Open Access Aetna Select Network Only Option
Summary plan description of the ExxonMobil Retiree Medical Plan - Open Access Aetna Select Network Only option as of January 2024
About the Retiree Medical Plan
This summary plan description (SPD) summarizes the ExxonMobil Retiree Medical Plan (the Plan) Open Access Aetna Select Network Only option. It does not contain all Plan details. The terms and conditions of the Plan are set forth in this SPD, the Plan Document, and the ExxonMobil Benefit Plans Common Provisions. Together, these documents are incorporated by reference into the Plan Document and constitute the written instruments under with the Plan is established and maintained. An amendment to one of these documents constitutes an amendment to the Plan. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate the Plan at any time. Where options are governed by federal laws, they will preempt state and local laws.
Unless otherwise noted, if there is a conflict between a specific provision under the Plan Document, the SPD or other written instrument, the Plan Document controls. If the Plan Document is silent on a specific issue, then the SPD controls on that issue, except where the SPD refers to a specific written instrument, in which case the specific written instrument will control. If both the Plan Document, ExxonMobil Benefit Plans Common Provisions, and SPD are silent, the terms of the Plan Document controls.
Open Access Aetna Select option is self-funded. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits.
Please read it carefully and refer to it when you need information about how the Plan works. If you cannot find the answer to your question(s) in this SPD, refer to the Information sources section, you will be able to find the appropriate contact to support your needs.
Information sources
Information sources for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option works
When you need information, you may need to contact one or more of the following sources. Please read carefully.
For claims administration and benefits information:
Contact Aetna for medical/surgical, behavioral health and substance use disorder benefits and claims information, including clinical guidelines, benefits predeterminations and providers in the Aetna Select network. Aetna also provides hospital precertification review for inpatient medical, behavioral health and substance use disorder services as well as for certain other medical services, tests, and equipment. Ask to speak to a health advocate nurse for ongoing consultation and referral services.
Contact Express Scripts for pharmacy benefits and claims information, including clinical guidelines, benefits predeterminations, and providers in the Express Scripts pharmacy network. Express Scripts also provides precertification review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for ongoing consultation and referral services.
Phone numbers and addresses:
Aetna Member Services
800-255-2386
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Central Time), except certain holidays
Automated Voice Response -
24 hours a day, 7 days a week
Aetna
PO Box 981106,
El Paso, TX 79998-1106
To visit Aetna’s website: www.aetna.com
Express Scripts
800-695-4116
800-497-4641 (international, use appropriate
country access code depending on country from which you are calling)
24 hours a day, 7 days a week
Express Scripts Home Delivery
P.O. Box 66577
St. Louis, MO 63166-65777
Direct Reimbursement Claim Form:
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to: 608 741-5475
To visit Express Scripts website: www.express-scripts.com.
ExxonMobil Benefits Service Center
Participants can enroll/change benefits on this portal and benefit representatives can provide specialized assistance.
Your Total Rewards portal: digital.alight.com/exxonmobil
Alight Mobile app (available through Apple App Store or Google Play)
Phone: 833-776-9966
Hours: 8am – 4pm CST, Monday through Friday, except certain holidays
Your Total Rewards portal: digital.alight.com/exxonmobil
Address:
Dept 02694, PO Box 64116, The Woodlands, TX, 77387-4116
ExxonMobil sponsored sites - Access to plan-related information including claim forms for retirees, survivors, and their family members.
- ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com.
- ExxonMobil Benefits Service Center Internet Site — Can be accessed by everyone at www.exxonmobil.com/benefits.
Eligibility and enrollment
Eligibility and enrollment details for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Most U.S. retirees, survivors and their eligible family members who reside in the Aetna Select service area are eligible to participate. The service area is determined by the retiree’s home address zip code.
Generally you are eligible if:
- You are a retiree.
- You are a survivor/surviving spouse, which means an eligible family member of a deceased employee or retiree.
- You are a Long Term Disability Retiree and are not eligible for Medicare Part A or B.
- You are a Long Term expatriate with U.S. Company-sponsored green card (also called permanent resident visas or PRVs) who retires/retired at the end of your current U.S. assignment on or after July 1, 2020 and remain in the U.S. with a valid PRV. If you choose not to enroll, there will be no opportunity to enroll at a later point in time during retirement.
You are not eligible if:
- You participate in any other employer medical plan to which ExxonMobil contributes.
- You are eligible for coverage under the ExxonMobil Medical Plan.
- You fail to make any required contribution toward the cost of the Plan.
- You fail to comply with general administrative requirements including but not limited to enrollment requirements.
- You lost eligibility as described under the Loss of eligibility section.
- You are eligible for Medicare as your primary plan.
Eligible family members
You may also elect coverage for your eligible family members including:
- Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married.
- Your child(ren) under age 26 (even if Medicare eligible). Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, call the Benefits Service Center.
- Your totally and continuously disabled child(ren) aged 26 or over incapable of self-sustaining employment by reason of mental or physical disability that occurred prior to otherwise losing eligibility, meets the Internal Revenue Service’s definition of a dependent, and is not eligible to be enrolled in Medicare as their primary medical plan.
- A child or spouse of a Medicare-eligible retiree or survivor enrolled in the Medicare Supplement Plan or Medicare Primary option, as long as that spouse or child (aged 26 or over) is not eligible for Medicare.
- If you, your dependent, or your spouse become eligible for Medicare, you need to give notice of this event to the ExxonMobil Benefits Service Center (EMBSC) for purposes of benefits coordination.
Effective January 1, 2019, a totally and continuously disabled child over age 26 of a retiree, deceased retiree, or deceased employee who is entitled to be enrolled in Medicare as their primary medical plan is not eligible for coverage under the ExxonMobil Retiree Medical Plan, or any other ExxonMobil health plan available to retirees (such as Dental and Vision coverage).
More complete definitions of Eligible Family Members and Child appear in the Key Terms section of this guide.
The Administrator-Benefits determination of eligibility is final and no appeals are available, including decisions regarding whether a child age 26 or older meets the clinical definition of totally and continuously disabled. All decisions by Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.
Suspended retiree
A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated, is a suspended retiree and not eligible for coverage until the earlier of the date the person:
- Reaches age 55, or
- Begins his or her benefit under the ExxonMobil Pension Plan at which time the person is again considered a retiree and may enroll.
The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:
- The date the suspended retiree would have attained age 55, or
- The date a survivor/surviving spouse begins receiving a benefit due to the suspended retiree’s accrued benefit from the ExxonMobil Pension Plan.
Special eligibility rules
A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person’s eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued.
Coverage Tiers
You can choose coverage as an:
- Individual Only (Retiree, Spouse, Surviving Spouse, Surviving Child),
- Retiree and spouse,
- Individual and child(ren), or
- Family.
There are also coverage tiers for surviving spouses and family members of deceased employees and retirees, and spouses and family members of retirees covered by the Medicare Primary Option and the Medicare Supplement Plan option.
Each class of coverage described in this section has its own contribution rate. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account.
Dual coverage
No one can be covered more than once in the Retiree Medical Plan. You and a family member cannot both enroll as retirees and elect coverage for each other as eligible family members. If you and your spouse or adult child are both retirees, you may both be eligible for coverage. Each of you can be covered as an individual retiree, or one of you can be covered as the retiree and the other can be an eligible family member. Also, if you and your spouse have children, each child can only be covered by one of you.
How to enroll
Retirees have three opportunities to enroll in the ExxonMobil Retiree Medical Plan:
- At retirement, or
- If you have waived coverage (see Other Employer Sponsored Coverage – Waiving EMRMP) and later lose coverage under another employer coverage, or
- When first eligible to be enrolled in Medicare as your primary plan.
There is no opportunity to enroll yourself in the Plan at any other time, including during annual enrollment. If you are under 65 at the time of your retirement or you are about to turn 65 while participating in the Retiree Medical Plan option, and have other employer coverage, you must waive coverage to maintain eligibility (please refer to the Other Employer Sponsored coverage – Waiving EMRMP section).
Eligible family members may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible family members cannot be added to your coverage at any other time, including during annual enrollment.
All enrollments must be completed within 30 days of the enrollment event. Coverage is effective the first of the month following receipt of your election by the ExxonMobil Benefits Service Center (EMBSC), except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption.
To enroll online visit Your Total Rewards portal.
You will be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g. marriage certificate, birth certificate). If you fail to provide such requested documents within the required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.
Changing your coverage
You may cancel your coverage at any time; however, you may not re-enroll unless you experience one of the enrollment opportunities listed above. Coverage will be terminated at the end of the month in which your elected change has been received.
Eligible family members may also be removed from your coverage at any time; however, they may not be reinstated unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above.
Note: You are required to remove family members who are no longer eligible3for coverage at the time of loss of eligibility. To remove an ineligible family member (a divorced spouse for example) you are required to notify the Benefits Service Center within 60 days of the loss of eligibility or your ineligible family members will not be entitled to COBRA benefits continuation. If you fail to notify the Benefits Service Center, you may also lose eligibility for yourself and your family under all ExxonMobil health plans. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s).
Post-Retirement changes in status
Event |
You are required/permitted to |
When |
Qualified status change |
||
Divorce Retiree and spouse enrolled in ExxonMobil Retiree Medical Plan |
You and your remaining eligible family members may change your medical plan option Note: You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility. |
You must make these changes within 60 days of your divorce and you are not required to show documentation to drop dependents. If you do not to notify the ExxonMobil Benefits Service Center within 60 days, this will result in your former spouse and stepchild(ren) not being entitled to elect COBRA. If you fail to remove your spouse and any stepchild(ren) within 60 days of the event:
|
Divorce Employee loses coverage under spouse’s medical plan. |
If you lose coverage under your spouse’s health plan because of divorce, you can sign up for medical coverage for yourself and your eligible family members. |
You must make these changes within 60 days following the date you lose coverage under your spouse’s plan. |
Death of a spouse or other eligible family member |
Death of a spouse: You are required to remove coverage for your former spouse but you may not remove coverage for yourself or other covered eligible family members. If you lose coverage under your spouse's health plan, you can sign up for medical plan coverage for yourself and your eligible family members. If you and your family members are enrolled in the ExxonMobil Retiree Medical Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator. Death of dependent child: You are required to remove coverage for deceased child but no other changes are allowed. |
You must provide notice of your spouse’s death within 30 days of the date of death. No other election changes will be permitted for those currently enrolled in the Plan. If you were covered on your spouse’s plan you must make an election within 30 days of the date of death. |
Other loss of family member's eligibility (e.g., sole managing conservatorship of grandchild ends) |
Coverage continues through their last day of eligibility for any event the participant reports. In some cases, continuation coverage under COBRA may be available. (See Continuation coverage for more details about COBRA.) |
You must notify the ExxonMobil Benefits Service Center as soon as a family member is no longer eligible. If you fail to notify the ExxonMobil Benefits Service Center within 60 days, the family member will not be entitled to elect COBRA. You remain responsible for ensuring that the dependent child is removed from coverage. If you fail to ensure that an ineligible family member is removed in a timely manner, there may be consequences for falsifying company records. |
Other qualified changes |
||
Another parent is ordered to provide coverage to your covered child through a QMSCO |
Revoke or decrease the affected child’s election if coverage actually provided. The effective date will be the date of qualification or end of month if termination date is not listed. |
Within 30 days following the date of the event |
You are ordered to provide coverage to your eligible child through a QMCSO |
If you’re currently enrolled, your child will be automatically covered under your current options. If not currently enrolled, you and the affected child will be covered automatically under the lowest cost option in the applicable plan(s). You can change your medical option. |
You must make these changes within 30 days of the event. |
Eligible dependent gains eligibility under another employer's plan
|
If the eligible dependent has or will obtain coverage under the other employer plan, remove them from coverage. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan. |
You must make these changes within 30 days of the event. |
A significant change in coverage or cost* of your, your spouse’s plan. *applies also to a significant increase in health care cost sharing.
|
Make a corresponding prospective change in your election:
|
Within 30 days following the date of the event. |
HIPAA special enrollment provisions |
||
Marriage |
|
Within 30 days following the date of the event. |
Gain a family member through birth, adoption or placement for adoption |
|
You must add the new family member within 30 days even if you already have family coverage. Coverage is effective on the date of birth, adoption, or placement for adoption. |
You or a family member loses eligibility under another employer's group health plan |
Enroll yourself and other family members who might have lost eligibility, add affected dependents and change medical plan option. |
You must make these changes within 30 days of the event. |
A family member’s employer contributions cease. |
|
You must make these changes within 30 days of the event. |
The participant or the participant’s dependent becomes eligible for premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP). |
If the participant is becoming eligible, they may drop coverage. If a dependent is becoming eligible, they may remove coverage for affected dependents only. |
Within 60 days of either:
|
Other Employer Sponsored coverage – Waiving EMRMP
A waiver process is in place to provide retirees and eligible family members with the option to waive coverage under the EMRMP when you or your eligible family members choose to participate in other employer-sponsored coverage. By completing the waiver, you will reserve your right to participate in the EMRMP at a later date upon proof of loss of coverage in the other employer’s plan, as long as the EMRMP is still available at that time. See scenarios below and how the waiver and reservation of rights apply:
How to Waive EMRMP Coverage at the Time of Your Retirement
If you have been actively participating in the ExxonMobil Medical Plan or the ExxonMobil International Medical and Dental Plan at the time of your retirement and you have access to other employer-sponsored coverage through either your own active employment or as a dependent of your spouse’s active employment, you/your spouse can choose to waive EMRMP coverage and reserve your right to participate upon the loss of such other coverage.
You must waive EMRMP coverage no later than 60 days from your retirement effective date. There are 2 ways to waive: you can contact the EMBSC at 1-833-776-9966 and indicate you want to waive, or you may also waive online in the EM Benefits portal by choosing the qualifying event named “Other Employer Sponsored Coverage”.
In order to enroll at a later date, you and/or your spouse will need to provide proof of loss of coverage and meet the following requirements:
- If you (and/or your spouse) lose other employer-provided coverage and you or your spouse are under 65 years of age, you have 60 days from loss of coverage to enroll in any of the Retiree Medical Plan options (Aetna POS II A or B, Aetna Select, Cigna OAPIN) of the EMRMP.
- If you (and/or your spouse) lose coverage and are 65 years of age or over, you or your spouse will have 90 days from loss of coverage to enroll in the Medicare Primary Option (MPO) of the EMRMP. Please refer to section of Eligibility and Enrollment of the Medicare Primary Option for a list of the MPO requirements. You must meet each of the requirements within the 90 days from the loss of coverage.
If you do not meet all requirements to enroll in the applicable option by the deadlines above, you/your spouse will not be eligible to enroll in the EMRMP at a later date.
How to Waive EMRMP Coverage if you Acquire Other Employer-Sponsored Coverage After Retirement
If after you have begun participating in the EMRMP you acquire other employer sponsored health plan coverage through either your own active employment or as a dependent of your spouse’s active employment, you/your spouse can notify the EMRMP by contacting the EMBSC of your change in status and waive coverage under the EMRMP. There are 2 ways to waive: you can contact the EMBSC at 1-833-776-9966 and indicate you want to waive, or you may also waive online in the EM Benefits portal by choosing the qualifying event named “Other Employer Sponsored Coverage”. You must waive no later than 60 days from loss of coverage from the EMRMP.
You/your spouse can then enroll in the EMRMP at a later date when the other employer sponsored health plan ends, with proof of loss of coverage. As described in subsections 1 and 2, above.
Important note: A waiver form is different from a cancellation form, while the waiver form allows you to preserve your eligibility for future enrollment (if the EMRMP is still an available option at that time), the cancellation form is final and you will no longer be eligible to enroll in any of the EMRMP options at a later date.
Dependent Children/Disabled Dependents
If your dependent child is participating in other-employer sponsored coverage at the time of your retirement or during your retirement and the child is under the age of 26, this children will be eligible upon the proof of loss of coverage to participate in the EMRMP and no waiver form is needed, assuming the child meets eligibility criteria.
No waiver process is available for dependents who were participating the EMMP or EMRMP as a disabled dependent over the age of 26 and who terminate coverage anytime at or after your retirement. Once a disabled dependent’s coverage is terminated for loss of eligibility or otherwise, the over age 26 child will not be eligible to participate in the EMRMP at a later date.
Survivor Coverage
If you are a surviving spouse or surviving family member participating in the EMRMP, you are not eligible to waive coverage and reserve your right to participate at a later date when you acquire other employer-sponsored coverage or are hired by ExxonMobil.
Changes at retirement
If you were enrolled in the ExxonMobil Medical Plan, your enrollment and your covered family members will transfer to the ExxonMobil Retiree Medical Plan. If you were enrolled in the Aetna Select option as an employee, you will maintain claims, deductibles and out of pocket history as a retiree. However, as a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft.
If you are not covered by a medical plan to which ExxonMobil contributes and would like to enroll in the ExxonMobil Retiree Medical Plan, or if you would like to change your Retiree Medical Plan option, you may must do so within 60 days of your retirement date. Coverage is effective the first of the month following receipt of your election by the Benefits Service Center.
Annual enrollment
Each year, during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current Retiree Medical Plan option to another available option. Changes elected during annual enrollment take effect the first of the following year.
Retirees cannot enroll in health benefits or add eligible family members during annual enrollment. Eligible family members can only be added to your coverage at one of the enrollment opportunities listed above or if you experience a corresponding change in status.
Do not wait to remove a family member who loses eligibility; they should be removed as soon as their eligibility is lost. For consequences for covering an ineligible family member, see Loss of Eligibility.
If you do not want to make any changes, you don’t have to do anything during Annual Enrollment to continue with your current plan selection for the following year.
Changing your coverage
Changing your coverage on the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Other situations that may affect your coverage
Change in coverage costs or significant curtailment
If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. If you choose to cancel your elected coverage option, you may be able to elect coverage under another Plan option. This provision also applies to a significant increase in health care deductible or copayment.
If the cost for coverage under your spouse's medical plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for medical coverage for yourself and your eligible family members.
Transfer or change residence
If you move from one location to another, and the move makes you no longer eligible for the selected Retiree Medical Plan option (e.g., move out of the Aetna Select service area), you may change from your current Plan option to one that is available in your new location.
Addition or improvement of plan options
If a new Retiree Medical Plan option is added or if benefits under an existing option are significantly improved during a plan year, you may be able to cancel your current election in order to make an election for coverage under the new or improved option.
Loss of option
If a service area under the plan is discontinued, you will be able to elect either to receive coverage under another plan option providing similar coverage or to drop medical coverage altogether if no similar option is available. For example, if an option is discontinued, you may elect another option that has service in your area or you may elect to participate in the Aetna Select options. You may also discontinue medical coverage altogether.
If a covered family member lives away from home
Coverage depends on whether the plan option you are enrolled in as a retiree offers service in the area where you live. If your covered family member does not live with you (for instance, you have a child away at school), please contact Aetna Member Services to confirm whether service is available where your family member lives. (See service area in Key terms.)
If you or your covered spouse become eligible for Medicare
If you are a retiree, you and your family members who are not eligible for Medicare participate in the Retiree Medical Plan. When you (as a retiree) or a covered spouse of a retiree becomes eligible for Medicare as your primary plan, you or your spouse will no longer be eligible for the POS II, Aetna Select and Cigna OAPIN options in the Retiree Medical Plan, but you or your spouse may be eligible to enroll in the Medicare Primary Option (MPO). If you fail to enroll in the MPO when first eligible, or fail to waive coverage due to being enrolled in another employer sponsored health plan, then you will not be able to enroll at a later time without proof of having other employer provided medical coverage immediately prior to enrollment.
If you die
If you die while enrolled, your covered eligible family members can continue coverage through the Retiree Medical Plan. Eligibility continues for your spouse until your spouse remarries, or becomes eligible for Medicare. Upon eligibility for Medicare as their primary plan, your spouse can continue coverage through the Medicare Primary Option.
Children of deceased retirees may continue participation as long as they are an eligible family member and are not eligible to be enrolled in Medicare as their primary medical plan. If your surviving spouse remarries, eligibility for your stepchildren also ends. Special rules may apply to family members of individuals who become retirees due to disability. See Suspended Retiree below.
If you become a suspended retiree
If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan, you may continue coverage for yourself and all your family members who were eligible for Medical Plan participation before you became a suspended retiree for either 12 or 18 months.
Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan.
However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions.
Coordination of benefits
Coordination of benefits for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. Other group plans include any other plan coverage provided by:
- Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured, and
- No-fault and traditional fault auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.
Determination of primary plan
To find out if benefits under the EMRMP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:
- The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
- The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
- The plan that covers the person as a dependent of a working spouse will pay first,
- Medicare will pay second, and
- The plan that covers the person as a retired employee will pay third.
- Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
- When the parents of a child are divorced or separated:
- If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
- If a court decree gives financial responsibility for the child’s medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
- If there is no such court decree, the order of benefits will be determined as follows:
- the plan of the natural parent with whom the child resides,
- the plan of the stepparent with whom the child resides,
- the plan of the natural parent with whom the child does not reside, or
- the plan of the stepparent with whom the child does not reside.
- If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
- The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
- If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.
If it is determined that the other plan pays first, the benefits paid under the EMMP will be reduced. Aetna will calculate this reduced amount as follows:
- The amount normally reimbursed for covered benefits under the EMMP,
- Benefits payable from your other plan(s).
If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.
Calculation of Benefits
When EMRMP is your primary plan, EMRMP will pay your medical claims first, as if there is no other coverage. When EMRMP is your secondary plan, EMRMP will pay benefits after the primary plan, and that payment amount will be the lesser of:
- What EMRMP would have paid if it had been primary, or
- What EMRMP would have paid less the primary plan’s payment.
Incorrect computation of benefits
If you believe that the amount of benefit you receive from the ExxonMobil Retiree Medical Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services. If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. (See Claims and Administrative and ERISA information sections.)
Recovery of overpayment
Payments are made in accordance with the Provisions of the Plan. Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these overpayments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. The Plan Administrator may also make reasonable arrangements with you for repayment. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered. See Fraud against the plan section. In addition, the Plan has the right to engage an outside collection agency to recover overpayments on the Plan’s behalf if the Plan’s collection effort is not successful. The Plan may also bring a lawsuit to enforce its rights to recover overpayments.
Right of recovery (subrogation and/or reimbursement)
If you or a covered family member receives benefits from this plan as the result of an illness or injury caused by another person, the EMRMP has the right to be reimbursed for those benefits from any settlement or payment you receive from the person who caused the illness or injury. This means the EMRMP may recover costs from all sources (including insurance coverage) potentially responsible for making any payment to you or your covered family member as a result of an injury or illness, including:
- Uninsured motorist coverage,
- Underinsured motorist coverage,
- Personal umbrella coverage,
- Med-pay coverage,
- Workers’ Compensation coverage,
- No-fault automobile coverage, or
- Any first party insurance coverage.
What you need to know
Here are some important points about the right of subrogation:
The Plan has a lien on any payments you receive.
The EMRMP automatically has a lien, to the extent of any benefits it has paid, on any payment you’ve received from a third party, his/her insurer or any other source. The lien is in the amount of benefits paid by Aetna under this plan for treatment of the illness, injury or condition for which the other person is responsible.
Your cooperation is required.
You may not do anything to interfere or affect the EMRMP’s subrogation rights.
You also must fully cooperate with the EMRMP’s efforts to recover benefits it has paid. This includes providing all information requested by the Claims Administrator or its representatives. As part of this process, Aetna may ask you to complete and submit certain applications or other forms or statements. If you fail to provide this information, it will be considered a breach of contract and may result in the termination of your health benefits or the instigation of legal action against you.
You must notify Aetna.
If a lawsuit or any other claim is filed to recover damages due to injuries sustained by you or a covered family member, you must notify Aetna. This must be done within 30 days of the date the notice of the lawsuit or claim is given to a person, including an attorney.
The Plan is paid first.
The EMRMP’s subrogation rights are a first priority claim against all potentially responsible person(s), and must be paid before any other claim for damages.
The Plan is entitled to full reimbursement.
The EMRMP is entitled to full reimbursement first from any payments made by any responsible person(s). This reimbursement must be made, even if the payment is not enough to compensate you or your covered family member in part or in whole for damages. The terms of this plan provision apply and the EMRMP is entitled to full recovery whether or not any liability for payment is admitted by any potentially responsible person(s), and whether or not the settlement or judgment you receive identifies the medical benefits provided by the plan. The EMRMP may be reimbursed from any and all settlements and judgments, even those for pain and suffering or non-economic damages only.
Aetna chooses the court for any legal action.
Any legal action or proceeding with respect to this provision may be brought in any court of competent jurisdiction that Aetna selects. When you receive benefits under this plan, you agree to this rule and waive whatever rights you have by reason of your present or future place of residence.
The Plan is not responsible for your attorneys’ fees.
The EMRMP is not required to participate in or pay attorney fees to the attorney you hire to pursue your claim for damages.
Interpreting this provision.
If there is any question about the meaning or intent of this plan provision or any of its terms, the EMRMP will have the sole authority and discretion to resolve all disputes as to how this provision will be interpreted.
When coverage ends
Coverage for you and/or your family members ends on the earliest of the following dates:
The last day of the month in which:
- You die,
- A family member ceases to be eligible (for example, a child reaches age 26),
- You become a suspended retiree,
- You are no longer eligible for benefits under this Plan (e.g. as a surviving spouse, you re-marry),
- You, as a retiree, or your eligible family member becomes eligible for Medicare and for the Medicare Primary Option,
- Your former employer discontinues participation in the Plan,
OR
The effective date:
- You elect not to participate anymore (opt out)
- You do not make any required contribution (see additional details and grace period in Cancellation and Reinstatement Process below),
- You are rehired by Exxon Mobil Corporation after retirement as an employee or non-regular employee,
- The ExxonMobil Retiree Medical Plan ends,
- You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.
You are responsible for ending coverage with the Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 30 days for most changes in status (and 60 days in the case of divorce or if you, your spouse or your covered dependent gains or loses eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage, any contributions you make for ineligible family members will not be refunded.
Cancellation and Reinstatement Process
Cancellation of EMRMP due to non-payment of premiums:
Cancellations due to non-payment of plan premiums will be prospective, with a 3 month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3 month timeframe, coverage will be cancelled effective April 1.
How to Avoid Cancellation due to Nonpayment of Premiums
The ExxonMobil Benefits Service Center (EMBSC) offers the convenience of paying your benefits premiums through either direct debit or deduction from your monthly pension payment (if applicable). To set up either payment method, visit www.exxonmobil.com/benefits:
Direct Debit: click on “Health & Welfare,” then on “More,” and lastly on “Update Premium Payment Information.”
Monthly Pension Payment Deduction: click on “Library,” then on “Documents & Forms,” then on “Forms,” and lastly on “Pension Deduction Authorization Form. Return your completed form to the shown address.
For assistance, call the EMBSC at 1-833-776-9966
Reinstatement of EMRMP:
Once your coverage has been terminated, you can request to be reinstated upon showing good cause. The EMRMP (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.
Reinstatement for good cause will occur only when:
- Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
- The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
- Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).
If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the EMRMP. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the EMRMP.
Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:
- A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
- Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
- Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
- Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
- An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period.
There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.
Examples of circumstances that do not constitute good cause include:
- Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
- Authorized representative did not pay timely on member’s behalf;
- Lack of understanding of the ramifications of not paying plan premiums;
- Could not afford to pay premiums during the grace period; or
- Need for prescription medicines or other plan services.
The ExxonMobil Benefits Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations
Loss of eligibility
Fraud against the Plan
Any act, practice, or omission by a Plan participant that constitutes fraud or an intentional misrepresentation of material fact is prohibited by the Plan, and the Plan may rescind coverage retroactively as a result. Any such fraudulent statements, including on Plan enrollment forms and in electronic submissions, may invalidate any payment or claims for services and may be grounds for rescinding coverage. Everyone in your family may lose eligibility for Retiree Medical Plan coverage if you file claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Retiree Medical Plan on your behalf or that you recover from a third party. Additionally, coverage may be terminated if you fail to reimburse the Plan for any amount owed to the Plan, or if you receive and fail to report to the Claims Processor any discounts, write-offs, or other arrangements with providers that result in misrepresentation of your out-of-pocket costs. Your participation may be terminated if you fail to comply with the terms of the Retiree Medical Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g., spouse loses coverage. Termination may be retro-active to the date of coverage.
In the event a retiree is rehired and is eligible for the ExxonMobil Medical Plan, the retiree and eligible family members are no longer eligible for the EMRMP and coverage is rescinded for all periods during which the retiree is employed. The rehired retiree and eligible family members will be enrolled retroactively in the EMMP until the earlier of failure to comply with the administrative requirements of the EMMP or re-employment ends. Any claims paid during such periods of employment under the EMRMP will be reprocessed under the EMMP.
Continuation coverage
Continuation coverage on the ExxonMobil Retiree Medical Plan –Open Access Aetna Select Network Only option
Introduction
You are required to be given the information in this section because you are covered under a group health plan (the Retiree Medical Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.
The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rights Under the ExxonMobil Retiree Plan section.
Your spouse and your family members may have other options available when they lose group health coverage. For example, they may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, y the costs of monthly premiums may be lower. Additionally, they may qualify for a 30-day special enrollment period for another group health plan for which they are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
Determination of Benefits Administration Entity to Contact: current ExxonMobil retirees, their covered family members and former ExxonMobil Employees and their covered family members, who have elected and are participating through COBRA should all contact ExxonMobil Benefits Service Center at 1-833-776-9966 (Monday – Friday 8:00 a.m. to 4:00 p.m CST) or access Your Rewards portal
The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.
What is COBRA coverage?
COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section. If a specific qualifying event occurs and any required notice of that event is properly provided to the ExxonMobil Benefits Service Center, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary. You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.
Who is entitled to elect COBRA?
If you are the spouse of a retiree, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:
- The retiree dies,
- You become divorced from the retiree. Also, if the retiree reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.
A person enrolled as the retiree’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happens:
- The retiree dies,
- The child stops being eligible for coverage under the Plan as a child.
When is COBRA coverage available?
When the qualifying event is the death of a retiree, the Plan will offer COBRA coverage to qualified beneficiaries. You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.
For the other qualifying events, a COBRA election will be available to you only if you notify the ExxonMobil Benefits Service Center. You must notify the Benefits Service Center of the loss of your eligibility or your ineligible family members within 30 days from the date of the event except for the events of divorce or loss of Medicaid or Children’s Health Insurance Program (CHIP) coverage of you, your spouse or dependent for which you have up to 60 days to report. You may enroll in COBRA continuation coverage within 60 days from the later of the date coverage is lost or the date on the COBRA Election Notice statement. Current retirees or survivors may give notice of qualifying events by logging onto Your Total Rewards portal or by calling the ExxonMobil Benefits Service Center.
Please note: Notice is not effective until either a change is made on Your Total Rewards portal or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 30 or 60-day notice period depending on the change in status, then all qualified beneficiaries will lose their right to elect COBRA.
Election of COBRA
Each qualified beneficiary will have an independent right to elect COBRA. Covered retirees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.
How long does COBRA coverage last?
COBRA coverage is a temporary continuation of Plan coverage that lasts between 18-36 months depending on the qualifying event.
Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:
- You die;
- You and your spouse get a divorce; or
- An enrolled child no longer meets the definition of “child” under the terms of the Plan.
When COBRA Coverage Ends
COBRA coverage can end before the end of the maximum coverage period for several reasons:
- The premium for your continuation coverage is not paid on time.
- If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
- If after electing continuation coverage, you first become eligible for and enroll in Medicare Part A , Part B or both.
- Exxon Mobil Corporation no longer provides group health coverage to any of its eligible retirees.
Are there other coverage options besides COBRA continuation coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
More information about individuals who may be qualified beneficiaries during COBRA
A child born to, adopted by, or placed for adoption with a covered retiree during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered retiree is a qualified beneficiary, the covered retiree has elected COBRA coverage for himself or herself.
The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the retiree. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).
Cost of COBRA coverage
A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.
If you have questions
Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep your plan informed of address changes
In order to protect your family's rights, you should keep the Benefits Service Center informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Benefits Service Center.
Contacts for COBRA rights under the ExxonMobil Retiree Medical Plan
The following sets out the contact numbers based on your status under the Retiree Medical Plan. Failure to notify the correct entity could result in your loss of COBRA rights.
If your status is not listed, call the ExxonMobil Benefits Service Center.
Retirees and their covered family members, and former employees and family members who have elected and are participating through COBRA: |
|
Contact: |
Address: |
ExxonMobil Benefits Service Center Phone: 1-833-776-9966 Monday – Friday 8:00 a.m. to 4:00 p.m. (U.S. Central Time) Web: Your Total Rewards portal (digital.alight.com/exxonmobil) Alight Mobile app(available through Apple App Store or Google Play) |
ExxonMobil Benefits Service Center Address: Dept 02694 P.O. Box 64116 The Woodlands, TX, 77387-4116 |
FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS
Basic Plan features
Basic features of the ExxonMobil Retiree Medical Plan - Open Access Aetna Select Network Only option
The Plan generally covers only medically necessary care and services.
Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost effectiveness of treatment, office standards and ongoing training.
Although not required each participant in the Plan is encouraged to select a Primary Care Physician (PCP) when they enroll. When choosing a PCP, use the aetna.com website to select an individual physician.. Your PCP serves as your guide to care in today’s complex medical system and will coordinate and monitor your overall care or may provide treatment. They may also refer you to other network providers.
Participants may update their PCP by calling Member Services or through aetna.com.
Medically necessary
Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.
When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used. CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna website at www.aetna.com.
Precertification
Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf.
For more information on precertification for medical/surgical procedures and behavioral health and substance use disorder services, see the National Precertification List on the Aetna member website.
The Primary Care Physician
As a participant in the Plan, you will become a partner with a participating PCP in preventive medicine. The following physicians are considered PCPs: Internists, General Practitioners, Pediatricians, and Family Practitioners. Consult your PCP whenever you have questions about your health. Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other doctors or facilities for treatment.
Primary and preventive care
A PCP can provide preventive care and treat you for illnesses and injuries. The Plan covers routine physical exams, well-baby care, immunizations and allergy shots provided by your PCP.
You may also obtain routine vision exams and gynecological exams from in-network providers. You are responsible for the copayment stated in the Benefits summary.
Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.
Specialty and facility care
While your plan does not require a referral from a participating PCP to see specialty doctors, you will want to coordinate such care with your PCP. Your PCP may refer you to a specialist or facility for treatment or for covered preventive care services, when medically necessary.
When your PCP refers you to a participating specialist or facility for covered services, you will be responsible for the copayment shown in the Benefits summary.
To avoid costly and unnecessary bills, follow these steps:
- You are encouraged to consult your PCP first when you need routine medical care.
- Certain services require prior authorization from Aetna.
- All services provided by a non-network provider require prior authorization by Aetna.
Provider information
To find Aetna network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.
Your ID cards
Your cards identify you as a plan participant when you receive services from in-network providers or when you receive emergency services at non-network facilities.
Effective January 1, 2024, instead of receiving printed ID cards, they will be available on Aetna´s and ESI´s websites and apps so you can view them on your phone. You can download them and easily save, share, print or email them directly to providers.
You can also request a physical version any time via customer service, as well as through the apps or member websites.
Health Management Programs
Additional integrated programs are available to you and your family members to help you manage your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care. The Health Management tools and resources available to Aetna Select participants include a 24-Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, Expert Medical Opinion Services, and Centers of Excellence.
Health Management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor’s fees or facilities charges) are processed according to the Plan’s provisions.
24-Hour nurse line
Trained, licensed nurses are available by telephone at 1-800-556-1555, 24 hours a day, 7 days a week to answer routine questions about your health, or questions about a specific medical situation, condition or concern. However, these nurses cannot diagnose medical conditions, prescribe medication or give specific medical instruction. Topics discussed during your call may include services and expenses not covered under the Plan.
The nurse may refer you to a Health Advocate for a more detailed conversation if you face a health risk or serious medical condition.
Health Advocacy Program
The Health Advocate Program provides direct support to you, your family, and your treating physician(s) in the management of specific health care needs. The Health Advocate staff consists of registered nurses, supported by a medical director. Once you begin working with a Health Advocate, the nurse will work personally with you as long as you need support.
Health Advocates will assist you to coordinate a wide array of health care-related support and educational services. As situations require, your Health Advocate will assist you with admission, counseling, inpatient advocacy, discharge planning and home counseling. The nurse will also act as your proactive partner, working directly with you to help you navigate the health care delivery system by assisting with the coordination and management of your health care needs and collaborating with others involved in your treatment.
Some of the condition management programs available include but not limited to coronary artery disease (CAD), heart failure, diabetes –adult and pediatric, asthma –adult and pediatric, chronic obstructive pulmonary disease (COPD), chronic lower back pain, osteoporosis / osteoarthritis and peripheral artery disease. Contact Aetna to check if your chronic condition can be managed through the Health Advocate program.
Aetna Maternity Program
The AETNA Maternity Program provides free support and resources to help you have a healthy pregnancy. The program provides useful information about early labor symptoms, genetic counselling and screening, preeclampsia prevention and education and resources on caring for a newborn.
If your pregnancy is considered at-risk, nurse managers will be available to help you manage the risk, identify symptoms and understand treatment options.
Contact aetna.com for additional information.
Cancer Management Program
As a part of your coverage under this plan, Health Advocacy nurses are available to assist with newly diagnosed cancer, undergoing active treatment for cancer, or a recurrence, at no cost to you. The Health Advocacy team will support you in your cancer journey with case management and provide you with information on the many resources available to you including a personal navigator with experience in cancer diagnosis and treatments, who will provide you with personalized support whenever you need it, genetic counseling to help guide your treatment and assess your risk of developing other forms of cancer, and an extensive online cancer support center. If you would like to receive support from a Health Advocate, call 800-255-2386.
Musculoskeletal Conditions Support
As a part of your coverage under this plan, Hinge Health offers musculoskeletal conditions support at no cost to you, with programs relating to care for different joint and muscle pain needs, for example:
- Prevention (at risk): specific exercises and education
- Acute (recent injury): physical therapy video visits for every body part
- Chronic (high risk): exercise, education and behavioral change
- Surgery (pre & post rehab): pre and post rehabilitation continuity of care
Learn more about this program at www.hingehealth.com/exxonmobil or call 855-902-2777
Expert Medical Opinion Services
If you or a family member receive a diagnosis or treatment plan requiring complex medical care, you have access to expert medical opinion services through 2ndMD. Specialists who are recognized experts in their field will review medical records related to the diagnosis and provide an opinion on the recommended treatment, including a detailed report you can share with your physician or Health Advocate nurse. Expert opinion consults are available at no additional cost to you and can be accessed through a mobile application, web portal, or phone. Call 866-410-8649 or www.2ndMD.com/Aetna to initiate services.
Omada Programs for Diabetes, Hypertension, and Prevention (Weight Management)
Omada programs are available to eligible members (meeting certain medical criteria) via the application at www.omadahealth.com/exxonmobil. The programs offer real-time tips, health care equipment and support from care team coaches and specialists, and can help members feel better, manage medication and potentially reduce out-of-pocket health care costs.
ExxonMobil Centers of Excellence and Aetna Institutes
ExxonMobil Centers of Excellence (COEs) and Aetna Institutes offer access to networks of high-performing hospitals, clinics and health care facilities that offer specialized care where high-level knowledge and expertise provide better care and more likely positive outcomes. Aetna Institutes® include Institutes of Excellence® (IOE), Institutes of Quality (IOQ), and Gene-based, Cellular and Other Innovative Therapies (GCIT®) Designated Networks. For specific information regarding gene therapy and GCIT Designated Networks, refer to Specific Conditions.
COEs and Aetna Institutes® are not available for all diseases and all conditions or procedures relevant to a disease state. For instance, there are IOQs for bariatric, cardiac, orthopedic and applied behavioral analysis (ABA), while there are IOEs for transplant support and pediatric congenital heart Surgery and COEs for cardiac, cancer and some pediatric specialties. More information can be found at Aetna Institutes. If you would like to learn more about different COE/ Aetna Institutes® options, you will need to contact the 24-hour nurse line and ask to be put in contact with a Health Advocate who will be able to discuss different options with you.
Participation in a COE or Aetna Institutes® program is voluntary, and designed to direct participants to nationally recognized facilities with more positive outcomes. A COE or Aetna Institutes® recommended treatment plan, however, must meet the Plan provisions for medically necessary care in order for claims to be eligible for reimbursement.
Whenever clinically appropriate, you will be referred to a local COE or Aetna Institutes® If access to a clinically appropriate COE or Aetna Institutes® requires the patient to travel 100 or more miles, the Plan will reimburse reasonable transportation costs for you and a caregiver. The Plan will also provide a per diem for you and a caregiver to cover lodging and other expenses. If you become hospitalized, only your caregiver will receive the per diem, because food and lodging are already provided as part of the hospital charge. The per diem amounts are based on IRS guidelines. For 2024, the amount is $50 a day for one person, $100 a day for two people. This coverage also applies to living donor expenses ($50 per person per day, from time of travel up to 30 days past discharge if complications arise). There is also a $10,000 maximum reimbursement per occurrence.
If you decide not to use a COE or Aetna Institutes®, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan’s network. Note: this statement does not apply to GCIT services.
2024 Benefits summary
Benefits schedule for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
These charts provide only a brief summary of benefits under the Open Access Aetna Select option. They are not intended to include all provisions.
This information is applicable to all non-represented employees participating in the Plan. Applicability to represented employees is governed by local bargaining requirements
Type of Service or Supply |
Benefit Level |
Lifetime Maximum |
No lifetime maximum |
Individual Annual Out-of-Pocket Maximum (Includes Pharmacy) |
$3,000 |
Family Annual Out-of-Pocket Maximum Includes Pharmacy) |
$6,000 |
If a retiree and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%. |
|
Preventive Care |
|
Preventive Care Office Visits |
No charge |
Routine Physicals & Immunizations |
No charge |
Well Woman Care (including Pap Smear Test) |
No charge (direct access / no referral) |
Mammograms |
No charge |
Well Baby Care (including Immunizations) |
No charge |
Prostate Cancer Screening |
No charge |
Primary Care |
|
Non-routine PCP Office Visits – Including Telemedicine |
$25 copay per visit |
Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter |
$25 copay per visit |
Hearing Aids |
Up to $500 every 3 years for physician-prescribed hearing aids |
Specialty And Outpatient Care |
|
Specialist Office Visits- Including Telemedicine |
$45 copay per visit |
Walk in Clinic (Retail Clinic) |
$45 copay per visit |
Prenatal Care (applies to standard global maternity services and initial visit) |
$45 copay per visit (no referral required) |
Maternity (childbirth/delivery services) |
90% coverage |
Allergy Testing |
$25 copay at PCP / $40 copay at specialist per visit |
Imaging (CT/PET scans, MRIs) |
90% coinsurance |
Diagnostic X-rays and Outpatient Labs associated with an office visit |
No additional charge |
Therapy (speech, occupational, physical) |
$45 copay per visit |
Chiropractic Care Calendar Year Limit |
$45 copay per visit Up to 20 visits or $1,000 maximum |
Outpatient Rehabilitation |
$45 copay per visit |
Home Health Care |
90% coinsurance |
Skilled Nursing Care |
90% coverage |
Prosthetic Devices |
90% coinsurance |
To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website. |
|
Inpatient Services(Precertification required) |
|
Hospital Room and Board and Other Inpatient Services |
90% coverage |
Skilled Nursing Facilities |
90% coverage |
Hospice Facility |
90% coverage |
Surgery and Anesthesia |
|
Inpatient Surgery |
90% coverage |
Outpatient Surgery |
90% coverage |
Behavioral Health and Substance Use Disorder Treatment |
|
Office Visit |
$25 (PCP) or $45 (specialist) copay per visit |
Outpatient Services |
90% coverage |
Inpatient Treatment (including residential treatment centers) |
90% coverage |
Urgent and Emergency Care |
|
Urgent Care |
$60 copay per visit |
MinuteClinic® (includes walk-in visit and virtual visits) |
100% coverage Participating CVS/Target MinuteClinics |
Emergency Room |
$150 copay (waived if admitted) + 90% coverage |
Ambulance |
90% coverage |
Prescription Drugs through Express Scripts(No annual maximum benefit) |
|
Annual out-of-pocket maximum |
Combined with medical out-of-pocket maximum |
Short-term (30-day supply)* ** |
$15 copay – generic formulary drugs |
Long-term (90-day supply)* |
$30 copay – generic formulary drugs |
^ National Precertification List on the Aetna member website
* If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum.
** A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
*** Formulary means Express Scripts’ formulary of preferred prescription drugs.
Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked if you would like to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.
Note: effective January 1, 2024 the Plan will adopt standard concurrency rules: if you go to network providers, you will not be impacted. However, you may pay more for a second service during the same visit if you go to a non-network provider as the plan will cover 50% of the allowed amount for that second (non-preventive) service.
Eligible Health services under the Plan
Eligible services under the Plan on the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the Key Terms section for the definition of medically necessary.
Certain services must be pre-certified by Aetna. Your in-network provider is responsible for obtaining this approval.
Preventive care
Preventive care services billed by a network provider will be covered at 100% of the contracted rate. Most preventive care services billed by a not-network provider will be covered at 100% of the reasonable and customary rate.
Unless otherwise indicated, preventive care services covered at 100% include the following:
Preventive care immunizations
Eligible health services include immunizations for infectious diseases recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
Immunizations/vaccinations obtained outside of a physician's office or hospital:
Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.
During the emergency period, the ExxonMobil Retiree Medical Plan has covered COVID-19 vaccines/boosters at no cost to members. Starting May 12, 2023, these will be included as a preventive vaccine (such as the annual flu shot), which are also available to members at no cost only when using in-network providers.
Well woman preventive visits
Eligible health services include your routine:
- Well woman preventive exam office visit to a network, PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified illness or injury.
- Preventive care breast cancer (BRCA) gene blood testing by a physician and lab.
- Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the test results and evaluate treatment.
- Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy.
- Screening for urinary incontinence.
Preventive screening and counseling services
Eligible health services include screening and counseling by a network PCP for some conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer.
Routine cancer screenings
Eligible health services include the following routine cancer screenings:
- Mammograms
- Prostate specific antigen (PSA) tests
- Digital rectal exams
- Fecal occult blood tests
- Sigmoidoscopies
- Double contrast barium enemas (DCBE)
- Colonoscopies which includes removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
If you need a routine gynecological exam performed as part of a cancer screening, you may go directly to a network provider who is an OB, GYN or OB/GYN.
Prenatal care
Eligible health services include your routine prenatal physical exams as Preventive Care, which is the initial and subsequent history and physical exam such as:
- Maternal weight
- Blood pressure
- Fetal heart rate check
- Fundal height
You can get this care at your physician's, PCP’s, OB's, GYN's, or OB/GYN’s office.
Physicians and other health professionals
Physician services
Physician services include: non-routine office visits with a network PCP during both office and non-office hours - including Telemedicine, non-routine home visits by a network PCP, treatment for illness and injury and injections, including routine allergy desensitization injections at PCP's office, with or without physician encounter. All, subject to copay.
Physician services also include: routine physical exams. Eligible health services include office visits to your PCP and/or Obstetrician/Gynecologist for routine physical exams. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes:
- Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
- Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents.
- Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to:
- Screening and counseling services on topics such as:
- Interpersonal and domestic violence
- Sexually transmitted diseases
- Human immune deficiency virus (HIV) infections
- Screening for gestational diabetes for women
- High risk human papillomavirus (HPV) DNA testing for women age 30 and older
- Screening and counseling services on topics such as:
- Radiological services, lab and other tests given in connection with the exam.
For covered newborns, an initial hospital checkup
Telemedicine
Telemedicine services are available via phone, web, or mobile app, 24 hours/day, 7 days/week through the Plan’s designated service provider (Teladoc). Teladoc’s health care professionals can evaluate, diagnose, and treat non-emergency medical and behavioral health conditions, such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. To register for services, call 855-835-2362 or visit www.Teladoc.com/Aetna.
Hospital and other facility care
Hospital care
The types of hospital care services that are eligible for coverage include:
- Room and board charges up to the hospital’s semi-private room rate.
- Services of physicians employed by the hospital.
- Operating and recovery rooms.
- Intensive or special care units of a hospital.
- Administration of blood and blood derivatives, but not the expense of the blood or blood product.
- Radiation therapy.
- Cognitive rehabilitation.
- Speech therapy, physical therapy and occupational therapy.
- Oxygen and oxygen therapy.
- Radiological services, laboratory testing and diagnostic services.
- Medications.
- Intravenous (IV) preparations.
- Discharge planning.
- Services and supplies provided by the outpatient department of a hospital.
Alternatives to hospital stays
Outpatient surgery and physician surgical services
Eligible health services include services provided and supplies used in connection with outpatient surgery performed in a surgery center or a hospital’s outpatient department.
Home health care
Eligible health services include home health care provided by a home health care agency in the home, but only when all of the following criteria are met:
- You are homebound.
- Your physician orders them.
- The services take the place of your needing to stay in a hospital or a skilled nursing facility, or needing to receive the same services outside your home.
- The services are a part of a home health care plan.
- The services are skilled nursing services, home health aide services or medical social services, or are short-term speech, physical or occupational therapy.
- If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more information on the intermittent requirement.
- Home health aide services are provided under the supervision of a registered nurse.
- Medical social services are provided by or supervised by a physician or social worker.
Home health care services do not include custodial care.
Hospice care
Eligible health services include inpatient and outpatient hospice care when given as part of a hospice care program.
Outpatient private duty nursing
Eligible health services include private duty nursing care provided by an R.N. or L.P.N. for non-hospitalized acute illness or injury if your condition requires skilled nursing care and visiting nursing care is not adequate.
Residential Treatment facility
This is an institution that:
- Specializes in the treatment of psychological and social disturbances that are the result of behavioral health or substance use disorder conditions;
- Provides a sub-acute, structured, psychotherapeutic treatment program under the supervision of physicians;
- Provides 24-hour care, in which the patient lives in an open setting; and
- Is licensed as a residential treatment center in accordance with the laws of the appropriate legally authorized agency.
Skilled-nursing care
Skilled-nursing care is covered if medically necessary. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.
Skilled nursing facility
The types of skilled nursing facility care services that are eligible for coverage include:
- Room and board, up to the semi-private room rate
- Services and supplies that are provided during your stay in a skilled nursing facility
Skilled care
Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.
Emergency services and urgent care
Emergency care while traveling for business or a personal vacation:
If you require emergency medical care while traveling for business or a personal vacation, the Plan will cover your emergency treatment 24 hours a day, 7 days a week, anywhere in the world.
Covered expenses are subject to the Plan’s applicable coinsurance and copays
If you are traveling outside the United States, unless you have made other arrangements with the emergency medical providers, you will be required to pay the medical bills and then submit the claims to Aetna for reimbursement. The ExxonMobil Plans do not directly reimburse medical providers located outside the United States.
For reimbursement, submit the itemized bills along with a claim form. If the original bills are in a foreign language, you should obtain an English translation if possible. Bills must be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.
Follow-up care after emergencies
You must have approval from Aetna to receive follow-up care from a non network Provider. Suture removal, cast removal, X-rays, and clinic and emergency room revisits are some examples of follow-up care.
Urgent care
Treatment that you obtain outside of your service area for an urgent medical condition is covered if:
- The service is a covered benefit,
- You could not reasonably have anticipated the need for the care prior to leaving the network service area, and
- A delay in receiving care until you could return and obtain care from a participating network provider would have caused serious deterioration in your health.
Aetna has adopted the following definition of urgent medical condition:
- Urgent medical condition – means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from a network PCP.
- Some examples of urgent medical conditions are:
- Severe vomiting,
- Earaches,
- Sore throat, or
- Fever.
Follow-up care provided by a network PCP is covered, subject to the office visit copayment. Other follow-up care by participating specialists is subject to the specialist copay shown in the Benefits schedule. If you are in your service area, you must use an in-network urgent care center.
Telemedicine services
Telemedicine services are available through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, depression, stress and anxiety. Services are available 24/7 via phone or video chat. You pay a primary care visit copayment each time you use the service. Call 1-855-Teladoc (835-2362) or visit Teladoc.com/Aetna.
What to do outside your Aetna service area
Emergency care
If a participant goes to a hospital emergency room for an Emergency Medical Condition , any medical provider can be utilized and the emergency room copay will apply.
Urgent care
For urgent care, if you are out of your service area, participants can use a non-network urgent care provider or go to an emergency room. Non-emergency or non-urgent use of an urgent care provider is not covered. Urgent care may be obtained from a walk-in clinic, or an urgent care center. An urgent medical condition that occurs outside your Aetna service area can be treated in any of the above settings.
If, after reviewing information submitted to Aetna by the provider(s) who supplied your care, the nature of the urgent or emergency problem does not clearly qualify for coverage, it may be necessary to provide additional information.
Although the Aetna Select is a network only plan option, if you receive emergency services out-of-network, the out-of-network provider exceptions below will apply.
Protections against surprise bills: out-of-Network Provider Exceptions
Services rendered by a non-Participating Provider are subject to special payment rules described below when:
- You receive emergency services for an Emergency Medical Condition.
- You receive services by a non-Participating Provider in an In-Network facility.
- You receive covered air ambulance services.
Specifically, Covered Expenses rendered by a non-Participating Provider are generally paid at the “Surprise Billing Reimbursement Rate” (i.e., a rate calculated in accordance with ERISA § 716) when:
- You receive emergency services for an Emergency Medical Condition. In this case, the cost share will be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the Out-of-Network Providers cannot Balance Bill you.
- You receive certain items and services by an out-of-Network Provider in an In-Network facility. In this case, the cost share will generally be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will generally not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the out-of-Network Providers cannot Balance Bill you, unless you give written consent.
- You receive covered air ambulance services. In this case, the cost sharing will be based on the lesser of the qualifying payment amount (calculated in accordance with ERISA § 716) or the billed amount for the services. The cost share requirements will be the same requirements that would apply if the services were provided by an In-Network Provider of air ambulance services. If you receive these services, the out-of-Network Providers cannot Balance Bill you.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or Balance Billing.
For more information on your rights, please refer to the Surprise Medical Bills notice located in exxonmobilfamily.com
When Balance Billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost, such as the copayments and coinsurance, that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.
- You’re never required to give up your protections from balance billing. You also don’t have to get care out-of-network. You can choose a provider or facility in your plan’s network.
- You are protected from Balance Billing for:
- Emergency services
If you have an Emergency Medical Condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments and coinsurance. You can’t be Balance Billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be Balanced Billed for these post-stabilization services.
- Certain services performed by an out of network provider at an in-network hospital or ambulatory surgical center
When you get services from certain out-of-network providers at an in-network hospital or ambulatory surgical center, those out-of-network providers may not Balance Bill you or ask you to sign a written notice and consent form that allows Balance Billing. You pay only your plan’s in-network cost sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine, hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.
If you get other services from any other out-of-network providers at in-network hospital or ambulatory surgical center, these out-of-network providers can’t Balance Bill you, unless you sign a written notice and consent form that allows Balance Billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be Balance Billed for out-of-network services. You are not required to sign the notice and consent form.
You may seek care from an available in-network provider.
- Emergency services
- Air Ambulance
When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider. Any cost sharing will be based on rates that would apply if the services were supplied by an in-network provider.
Some states have surprise bill/balance billing laws. These laws apply to fully insured plans and may have impact to some self-funded plans, including state government or municipal plans and church plans.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your out-of-pocket limit.
How to handle services supplied based on inaccurate provider directory information?
If you relied on inaccurate information from our provider directories or website or that we verbally provided, we hold you harmless. For example, if you received services from a provider that you believed was in-network based on inaccurate information showing that the provider was in-network, but your claim was paid as out-of-network. In these situations, contact us and we will review the claim. After review, you may be responsible only for your in-network cost share.
Specific conditions
Autism spectrum disorder
Eligible health services include the services and supplies provided by a physician or behavioral health provider for the diagnosis and treatment of autism spectrum disorder. Applied Behavior Analysis (ABA) is not covered (see Exclusions).
Fertility Services
Infertility services to diagnose and treat the underlying medical cause of infertility, however, Comprehensive Infertility Services, fertility prescriptions, and Advanced Reproductive Technologies (ART) are not covered. You may obtain the following basic infertility services from a participating gynecologist or infertility specialist without a referral from your PCP:
- initial evaluation, including history, physical exam and laboratory studies performed at an appropriate participating laboratory,
- evaluation of ovulatory function,
- ultrasound of ovaries at an appropriate participating radiology facility,
- postcoital test,
- hysterosalpingogram,
- endometrial biopsy, and
- hysteroscopy,
- Semen analysis at an appropriate participating laboratory is covered for male plan participants; a referral from your PCP is necessary.
Family planning services – other
Eligible health services include certain family planning services provided by your physician such as voluntary sterilization for males.
Gender affirming surgery
Gender affirming surgery is considered medically necessary when certain criteria are met. Please refer to Aetna’s Clinical Policy Bulletins for more information about the criteria relating to gender affirming surgery.
Insulin and diabetic supplies
Insulin and diabetic supplies are covered under the prescription drug plan through Express Scripts. They can be obtained through a retail pharmacy or through home delivery by paying your required coinsurance. In those rare instance where insulin or diabetic supplies are received in a doctor’s office, outpatient facility or hospital setting, they are covered as a medical expense.
Maternity and related newborn care
Eligible health services include prenatal and postpartum care and obstetrical services related to the pregnancy of a covered child, but not those related to the child born to the family member. After your child is born, eligible health services include:
- 72 hours of inpatient care in a hospital after a vaginal delivery
- 120 hours of inpatient care in a hospital after a cesarean delivery
- A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier
Oral and maxillofacial treatment (mouth, jaws and teeth)
Covered services include the following when provided by a physician, dentist and hospital:
- Dental work required by an accidental injury to sound, natural teeth or the mouth
Cutting out:
- Cysts, tumors, or other diseased tissues
- Cutting into gums and tissues of the mouth.
- Only when not associated with the removal, replacement or repair of teeth
- Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.
Reconstructive surgery and supplies
Eligible health services include all stages of reconstructive surgery by your provider and related supplies provided in an inpatient or outpatient setting only in the following circumstances:
- Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an implant and areolar reconstruction. It also includes surgery on a healthy breast to make it symmetrical with the reconstructed breast, treatment of physical complications of all stages of the mastectomy, including lymphedema and prostheses.
- Your surgery is to implant or attach a covered prosthetic device.
- Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:
- The defect results in severe facial disfigurement or major functional impairment of a body part.
- The purpose of the surgery is to improve function.
- Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or major functional impairment of a body part, and your surgery will improve function.
Transplant services
Eligible health services include transplant services provided by a physician and hospital.
This includes the following transplant types:
- Solid organ
- Hematopoietic stem cell
- Bone marrow
- CAR-T and T-Cell receptor therapy for FDA approved treatments
Network of transplant facilities
The amount you will pay for covered transplant services is determined by where you get transplant services. You can get transplant services from:
- An Institutes of Excellence™ (IOE) facility we designate to perform the transplant you need
- A Non-IOE facility
Your cost share will be lower when you get transplant services from the IOE facility we designate to perform the transplant you need. You may also get transplant services at a non-IOE facility, but your cost share will be higher.
The National Medical Excellence Program® will coordinate all solid organ, bone marrow and CAR-T and T-Cell therapy services and other specialized care you need.
Important note: If there is no IOE facility for your transplant type in your network, the National Medical Excellence Program® (NME) will arrange for and coordinate your care at an IOE facility in another one of our networks. If you don’t get your transplant services at the IOE facility we designate, your cost share will be higher.
Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.
Specific therapies and tests
Outpatient diagnostic testing
Diagnostic complex imaging services
Eligible health services include complex imaging services by a provider, including:
- Computed tomography (CT) scans
- Magnetic resonance imaging (MRI) including Magnetic resonance spectroscopy (MRS), Magnetic resonance venography (MRV) and Magnetic resonance angiogram (MRA)
- Nuclear medicine imaging including Positron emission tomography (PET) scans
Complex imaging for preoperative testing is covered under this benefit. Some services may require precertification.
Diagnostic lab work and radiological services
Eligible health services include diagnostic radiological services (other than diagnostic complex imaging), lab services, and pathology and other tests, but only when you get them from a licensed radiological facility or lab.
COVID-19 diagnostic tests (both administered in doctor’s offices or at pharmacies) and over-the-counter (OTC) COVID-19 tests have been covered by the Plan during the emergency period. Starting May 12, 2023, COVID-19 tests performed in doctor’s offices or at a pharmacy will be covered at the appropriate cost share for diagnostic tests. Please see the Benefit Summary for detailed information on cost share for diagnostic tests.
Starting May 12, 2023, COVID-19 OTC tests will not be covered at point of sale, but members that participate in the Health Care Flexible Spending Account (HC FSA) may request reimbursement for those tests, as long as they are considered eligible medical expenses. Inclusion of COVID-19 OTC tests as an eligible HC FSA expense is subject to IRS guidance, which may change in the future.
Chemotherapy
Eligible health services for chemotherapy depends on where treatment is received. In most cases, chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a cancer diagnosis during a hospital stay.
Chelation therapy
Chelation therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins.
Oral-motor therapy
Oral-motor therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins.
Outpatient infusion therapy
Eligible health services include infusion therapy you receive in an outpatient setting including but not limited to a free-standing outpatient facility, the outpatient department of a hospital, a physician in the office or a home care provider in your home.
Outpatient radiation therapy
Eligible health services include the following radiology services provided by a health professional:
- Radiological services
- Gamma ray
- Accelerated particles
- Mesons
- Neutrons
- Radium
- Radioactive isotopes
Short-term cardiac and pulmonary rehabilitation services
- Cardiac rehabilitation: includes cardiac rehabilitation services you receive at a hospital, skilled nursing facility or physician’s office, but only if those services are part of a treatment plan determined by your risk level and ordered by your physician.
- Pulmonary rehabilitation: includes pulmonary rehabilitation services as part of your inpatient hospital stay if it is part of a treatment plan ordered by your physician.
Short-term rehabilitation services
Short-term rehabilitation services help you restore or develop skills and functioning for daily living.
Eligible health services include short-term rehabilitation services your physician prescribes. The services have to be performed by:
- A licensed or certified physical, occupational or speech therapist
- A hospital, skilled nursing facility, or hospice facility
- A home health care agency
- A physician
Short-term rehabilitation services have to follow a specific treatment plan.
Outpatient cognitive rehabilitation, physical, occupational, and speech therapy
Eligible health services include:
- Physical therapy, but only if it is expected to significantly improve or restore physical functions lost as a result of an acute illness, injury or surgical procedure.
- Occupational therapy (except for vocational rehabilitation or employment counseling), but only if it is expected to:
- Significantly improve, develop or restore physical functions you lost as a result of an acute illness, injury or surgical procedure, or
- Relearn skills so you can significantly improve your ability to perform the activities of daily living.
- Speech therapy, but only if it is expected to:
- Significantly improve or restore the speech function or correct a speech impairment as a result of an acute illness, injury or surgical procedure, or
- Improve delays in speech function development caused by a gross anatomical defect present at birth.
- Cognitive rehabilitation associated with physical rehabilitation, but only when:
- Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or encephalopathy and
- The therapy is coordinated with us as part of a treatment plan intended to restore previous cognitive function.
If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy service beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found not to be medically necessary or rendered in connection with an IEP (Individualized Education Program) in a school setting. Visit limits do not apply to behavioral health services.
Outpatient physical, occupational, and speech therapy
Eligible health services include:
- Physical therapy (except for services provided in an educational or training setting), if it is expected to develop any impaired function.
- Occupational therapy (except for vocational rehabilitation or employment counseling), if it is expected to develop any impaired function.
- Speech therapy (except for services provided in an educational or training setting or to teach sign language) is covered provided the therapy is to:
- Restore speech after a demonstrated previous ability to speak is lost or impaired,
- Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
- Improve, develop, or maintain speech impaired as a result of delayed development, including autism spectrum disorder, down syndrome, cerebral palsy, fetal alcohol syndrome, and muscular dystrophy. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)
Vision therapy
Up to 12 medically necessary orthoptic vision therapy visits each calendar year to treat convergence insufficiency in accordance with Aetna’s Clinical Policy Bulletin. If you need more therapy, you can request more visits and your request will go through a medical review.
Other services
Acupuncture
Eligible health services include manual or electro acupuncture consistent with Aetna Coverage Policy Bulletins. Limited to a 10 visit max per year Chiropractic services
Chiropractic services will be covered only when performed by a licensed doctor or chiropractic who is acting within the scope of his or her license, limited to a 20 visit annual max.
Ambulance service
Eligible health services include transport by professional ground ambulance services:
- To the first hospital to provide emergency services.
- From one hospital to another hospital if the first hospital cannot provide the emergency services you need.
- From a hospital to your home or to another facility if an ambulance is the only safe way to transport you.
- From your home to a hospital if an ambulance is the only safe way to transport you. Transport is limited to 100 miles.
Your plan also covers transportation to a hospital by professional air or water ambulance when:
- Professional ground ambulance transportation is not available.
- Your condition is unstable, and requires medical supervision and rapid transport.
- You are travelling from one hospital to another and
- The first hospital cannot provide the emergency services you need, and
- The two conditions above are met.
Chiropractic services
Chiropractic services will be covered only when performed by a licensed doctor of chiropractic who is acting within the scope of his or her license, up to a 20-visit or $1,000 annual maximum.
Eligible health services include routine patient costs otherwise covered by the Plan that are associated with participation in phases I-IV of Approved Clinical Trials (as further defined in Key Terms) (i.e., clinical trials that are federally funded and certain drug trials) to treat cancer or other Life-Threatening Conditions, as determined by Aetna and as required by law. These costs will be subject to the Plan’s otherwise applicable cost-sharing requirements and limitations and do not include items that are provided for data collection or services that are clearly inconsistent with widely accepted and established standards of care or otherwise payable or reimbursable by another party..
Durable medical equipment (DME)
Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:
- It cannot be repaired
- Repairs would be more expensive than purchasing or renting replacement equipment
- The attending physician recommends replacement because of a change in the patient’s physical condition
Coverage includes:
- One item of DME for the same or similar purpose.
- Repairing DME due to normal wear and tear. It does not cover repairs needed because of misuse or abuse.
- A new DME item you need because your physical condition has changed. It also covers buying a new DME item to replace one that was damaged due to normal wear and tear, if it would be cheaper than repairing it or renting a similar item.
Your plan only covers the same type of DME that Medicare covers. But there are some DME items Medicare covers that your plan does not. We list examples of those in the exclusions section.
Extended-care facilities
An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:
- The inpatient stay must be medically necessary, and
- The inpatient stay has been pre-certified.
Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.
Gene-based, cellular and other innovative therapies (GCIT)
Covered services include GCIT provided by a physician, hospital or other provider.
GCIT covered services include:
- Cellular immunotherapies.
- Genetically modified oncolytic viral therapy.
- Other types of cells and tissues from and for use by the same person (autologous) and cells and tissues from one person for use by another person (allogenic) for certain therapeutic conditions.
- Human gene-based therapy that seeks to change the usual function of a gene or alter the biologic properties of living cells for therapeutic use.Examples include therapies using:
- Luxturna® (Voretigene neparvovec)
- Zolgensma® (Onasemnogene abeparvovec-xioi)
- Spinraza® (Nusinersen)
- Products derived from gene editing technologies, including CRISPR-Cas9.
- Oligonucleotide-based therapies. Examples include:
- Antisense. An example is Spinraza.
- siRNA.
- mRNA.
- microRNA therapies.
Facilities/provider for gene-based, cellular and other innovative therapies
We designate facilities to provide GCIT services or procedures. GCIT physicians, hospitals and other providers are GCIT-designated facilities/providers for Aetna and CVS Health.
Important note: You must get GCIT covered services from the GCIT-designated facility/provider. If there are no GCIT-designated facilities/providers assigned in your network, it’s important that you contact us so we can help you determine if there are other facilities that may meet your needs. If you do not get your GCIT services at the facility/provider we designate, they will not be covered services.
The following are not covered services unless you receive prior written approval from us:
- GCIT services received at a facility or with a provider that is not a GCIT-designated facility/provider
- All associated services when GCIT services are not covered. Examples include infusion, laboratory, radiology, anesthesia, and nursing services.
Key Terms- To help you understand this section, here are some key terms we use.
Cellular- Relating to or consisting of living cells.
GCIT- Any Services that are:
- Gene-based
- Cellular and innovative therapeutics
We call these “GCIT services”. They have a basis in genetic/molecular medicine and are not covered under the Institutes of Excellence™ (IOE) programs.
Gene- A unit of heredity which is transferred from a parent to child and is thought to determine some feature of the child.
Molecular- Relating to or consisting of molecules. A molecule is a group of atoms bonded together, making the smallest vital unit of a chemical compound that can take part in a chemical reaction.
Therapeutic- A treatment, therapy, or drug meant to have a good effect on the body or mind; adding to a sense of well-being
Hearing aids and exams
Benefits are provided up to a maximum of $2,500 after the deductible and coinsurance are paid for one or more hearing aids every rolling 36 months period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no Medical POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.
You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) Discount Program, the Hearing Care Solutions Discount Program, or LifeMart. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select “Hearing Discount Locations”. To compare costs, please call Amplifon Hearing Health Care at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member. To browse LifeMart discounts, register on their website via the link on the Aetna Member Website.
Preventive hearing exams are covered at no cost to members up to age 7.
Non-routine/non-preventive care hearing exams
Eligible health services for adults and children include charges for an audiometric hearing exam for evaluation and treatment of illness, injury or hearing loss, if the exam is performed by:
- A physician certified as an otolaryngologist or otologist
- An audiologist who is legally qualified in audiology; or holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and who performs the exam at the written direction of a legally qualified otolaryngologist or otologist.
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Non-routine/non-preventive care hearing exams are covered at the applicable cost share (depending if you go to an in-network or non-network provider.
Prosthetic devices
Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.
Coverage includes:
- Repairing or replacing the original device you outgrow or that is no longer appropriate because your physical condition changed
- Replacements required by ordinary wear and tear or damage
- Instruction and other services (such as attachment or insertion) so you can properly use the device
Behavioral health and substance use disorder care
Behavioral Health coverage
Covered services include the treatment of behavioral health disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider including:
- Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies related to your condition that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility
- Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:
- Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
- Individual, group, and family therapies for the treatment of behavioral health disorders
- Other outpatient behavioral health treatment such as:
- Partial hospitalization treatment provided in a facility or program for behavioral health treatment provided under the direction of a physician
- Intensive outpatient program provided in a facility or program for behavioral health treatment provided under the direction of a physician
- Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
- You are homebound
- Your physician orders them
- The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
- The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease
- Electro-convulsive therapy (ECT)
- Transcranial magnetic stimulation (TMS)
- Psychological testing
- Neuropsychological testing
- Observation
- Peer counseling support by a peer support specialist
Substance use disorder treatment
Covered services include the treatment of substance related disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider as follows:
- Inpatient room and board, at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility.
- Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:
- Office visits to a physician or behavioral health provider such as a psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
- Individual, group, and family therapies for the treatment of substance related disorders
- Other outpatient substance related disorders treatment such as:
- Partial hospitalization treatment provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
- Intensive outpatient program provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
- Ambulatory or outpatient detoxification which include outpatient services that monitor withdrawal from alcohol or other substances, including administration of medications
- Observation
- Peer counseling support by a peer support specialist
Behavioral health important note:
A peer support specialist serves as a role model, mentor, coach, and advocate. They must be certified by the state where the services are provided or a private certifying organization recognized by Aetna. Peer support must be supervised by a behavioral health provider.
Precertification
All inpatient and residential treatment for mental health and substance use disorder care must be pre-certified. The health care provider is responsible for obtaining pre-certification for network care.
Partial hospitalization, intensive outpatient and outpatient care do not require prior authorization/precertification. However, non-routine outpatient care, such as Transcranial Magnetic Stimulus –TMS, require prior authorization/precertification
Prescription drug program
Prescription drug program on the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
The Plan pays, subject to any limitations specified under Your Benefits, the cost incurred for outpatient prescription drugs that are obtained from a participating pharmacy. Express Scripts is the pharmacy benefit manager for your prescription drugs. You must present your Express Scripts or Medco ID card and make the copayment shown in the Benefits Summary for each prescription at the time the prescription is dispensed.
The Plan covers the costs of prescription drugs, in excess of the copayment, that are:
- Medically necessary for the care and treatment of an illness or injury, as determined by Express Scripts,
- Prescribed in writing by a physician who is licensed to prescribe federal legend prescription drugs or medicines, and
- Not listed under Prescription Drug Exclusions and Limitations, below.
Non-emergency prescriptions must be filled at a participating pharmacy. Generic drugs may be substituted for brand-name products where permitted by law.
Coverage is based upon Express Scripts’ formulary. The formulary includes both brand-name and generic drugs and is designed to provide access to quality, affordable outpatient prescription drug benefits. You can reduce your co-payment by using a covered generic or brand-name drug that appears on the formulary. Your co-payment will be highest if your physician prescribes a covered drug that does not appear on the formulary.
Long-term or maintenance medications
A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have generally used 75% of the previous prescription based on the prescribed dosage. During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.
Specialty medications
Specialty medications, including injectables and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.
Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider.
Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.
Emergency prescriptions
You may not have access to a participating pharmacy in an emergency or urgent care situation, or if you are traveling outside of the Plan’s service area. If you must have a prescription filled in such situations, the Plan will reimburse you as follows:
- Non-Participating Pharmacy – You must pay the pharmacy directly for the full cost of the prescription and you will be responsible for submitting a request for reimbursement in writing to the pharmacy benefit manager with a receipt for the cost of the prescription. The pharmacy benefit manager will directly reimburse the Member 100% of the prescription, less the applicable copay. Coverage for items obtained from non-participating pharmacies is limited to items obtained in connection with covered Emergency and Out-of-Area Urgent Care services. Contact Express Scripts Member Services for more information.
- Participating Pharmacy – When you obtain an emergency or urgent care prescription at a participating pharmacy (including an out-of-area participating pharmacy), you must pay the applicable copay. The pharmacy benefit manager will not reimburse claims submitted as a direct reimbursement request from a Member for a prescription purchased at a participating retail pharmacy except upon professional review and approval by the pharmacy benefit manager.
Covered drugs
The Plan covers the following:
- Outpatient prescription drugs when prescribed by a provider who is licensed to prescribe federal legend drugs or medicines, subject to the terms, limitations and exclusions described in this booklet.
- FDA-approved prescription drugs when the off-label use of the drug has not been approved by the FDA to treat the condition in question, provided that:
- the drug is recognized for treatment of the condition in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or
- the safety and effectiveness of use for the condition has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal.
- Diabetic supplies as follows:
- diabetic needles and syringes
- alcohol swabs
- test strips for glucose monitoring and/or visual reading
- diabetic test agents
- lancets (and lancing devices)
- insulin
- prescriptive and nonprescriptive oral agents for controlling blood sugar levels
- glucagon emergency kits
- Smoking Cessation aids and drugs prescribed by a physician.
- Oral and implantable contraceptive drugs and contraceptive devices.
- Injectable contraceptives (Depo-Provera).
- Growth hormone therapy, when pre-certified by Express Scripts
Prescription drug exclusions and limitations
Prescription drug exclusions
The following services and supplies are not covered by the Plan, and a medical exception is not available for coverage:
- Any drug that does not, by federal or state law, require a prescription order (such as an over-the- counter drug), even when a prescription is written.
- Any drug that is not medically necessary.
- Charges for the administration or injection of a prescription drug or insulin.
- Cosmetics and any drugs used for cosmetic purposes or to promote hair growth, including (but not limited to) health and beauty aids.
- Any prescription for which the actual charge to you is less than the copayment.
- Any prescription for which no charge is made to you.
- Insulin pumps or tubing for insulin pumps.
- Medication which is to be taken by you or administered to you, in whole or part, while you are a patient in a licensed hospital or similar facility.
- Take-home prescriptions dispensed from a hospital pharmacy upon discharge from the hospital, unless the hospital pharmacy is a participating retail pharmacy.
- Any medication that is consumed or administered at the place where it is dispensed.
- Immunization or immunological agents, including, but not limited to:
- biological sera.
- blood, blood plasma or other blood products administered on an outpatient basis.
- allergy sera and testing materials.
- Drugs used for the purpose of weight reduction, including the treatment of obesity.
- Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order.
- Drugs labeled Caution – Limited by Federal Law to Investigational Use and experimental drugs.
- Drugs prescribed for uses other than the uses approved by the FDA under the Food, Drug and Cosmetic Law and regulations.
- Medical supplies, devices and equipment, and non-medical supplies and substances, regardless of their intended use.
- Prescription drugs purchased prior to the effective date, or after the termination date, of coverage under this Plan.
- Replacement of lost or stolen prescriptions.
- Performance and athletic performance lifestyle-enhancement drugs and supplies.
- Smoking-cessation aids or drugs unless prescribed by a physician.
- Test agents and devices, except diabetic test strips.
- Needles and syringes, except diabetic needles and syringes.
- Any drug or device that terminates a pregnancy.
- Prophylactic drugs for travel.
- Nutritional supplements.
- Medication packaged in unit dose form (except those approved by payment by Express Scripts).
Prescription drug limitations
The following limitations apply to the prescription drug coverage:
- A participating retail or home delivery pharmacy may refuse to fill a prescription order or refill when, in the professional judgment of the pharmacist, the prescription should not be filled.
- Prescriptions may be filled only at a participating retail or home delivery pharmacy, except in the event of emergency or urgent care. Plan participants will not be reimbursed for out-of-pocket prescription purchases from a non-participating pharmacy in non-emergency, non-urgent care situations.
- Plan participants must present their ID cards at the time each prescription is filled to verify coverage. If you do not present your ID card, your purchase may not be covered by the Plan, except in emergency and urgent care situations, and you may be required to pay the entire cost of the prescription.
- The Plan is not responsible for the cost of any prescription drug for which the actual charge to the plan participant is less than the required copayment or for any drug for which no charge is made to the recipient.
- Plan participants will be charged the non-formulary prescription drugs copayment for prescription drugs covered on an exception basis.
- For maintenance medications (those taken on a regular basis to treat ongoing conditions like allergies, asthma, diabetes, heart conditions, etc.), the Plan will provide coverage for three fills at a retail pharmacy; for subsequent short-term fills, the participant will be responsible for 100% of the cost. Any long-term refill that is submitted to the Express Scripts home delivery pharmacy will be subject to long-term delivery pharmacy copayments.
- When a clinically equivalent generic is available, and a brand name drug is purchased, the copayment will be equal to the generic copayment amount plus the difference in the cost of the brand name drug and the generic. The difference in cost will not count toward the annual out-of-pocket maximum for prescription drugs.
- Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.
Advanced Utilization Management (AUM)
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.
As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review. If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.
Preferred drug step therapy rules
Preferred drug step therapy rules are used for certain therapeutic classes of drugs, to encourage the use of effective, lower-cost drugs initially by excluding some targeted medications from coverage unless prior authorization is provided by Express Scripts. Therapeutic classes, include: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, glaucoma, diabetes, respiratory allergy/asthma, anti-inflammatory and rheumatoid arthritis, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids, and stroke prevention. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic classes, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.
Prior authorization rules
Prior authorization rules apply to certain therapeutic classes of drugs; therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each class as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.
Therapeutic Resource Center
Plan participants and their physicians may receive outreach calls from Express Scripts Therapeutic Resource Center (TRC) pharmacists or healthcare specialists to offer personal over-the-phone guidance as well as other health management tools. You can also ask to speak to a TRC pharmacy specialist when you call Express Scripts.
Split-fill program
Express Scripts’ split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications, and manage specialty drug costs.
Exclusions
Exclusions for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Although the Plan covers many types of treatments and services, it does not cover all of them. Exclusions shall be interpreted and applied consistently with Clinical Policy Bulletins published by Aetna. These bulletins can be accessed on the Aetna website at www.aetna.com. See Basic Plan features for more information.
The Plan does not cover the following services and supplies:
General exclusions
- Any services or supplies that are not medically necessary, as determined by Aetna, even when medical provider has recommended/prescribed the services.
- Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law
- Charges for missed appointments, and/or completion of claim forms.
- Any claim submitted past the claim-filing deadline of 12 months from date of service.
- Court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding
- Payment for a portion of the charge that Medicare or another party is responsible for as the primary payer.
- Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered under clinical trial therapies (experimental or investigational) or covered under clinical trials (routine patient costs). See the Eligible health services under your plan – Other services section.
- Health services, including those related to pregnancy that are provided before your coverage is effective or after your coverage has been terminated.
- Treatment in a federal, state or governmental facility, including care and treatment provided in a nonparticipating hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws.
- Treatment of illnesses, injuries or disabilities related to military service for which you are entitled to receive treatment at government facilities that are reasonably available to you.
- Treatment of injuries sustained while committing a felony.
- Treatment of sickness or injury covered by a worker’s compensation act or occupational disease law, or by United States Longshoreman’s and Harbor Worker’s Compensation Act.
- Services or supplies covered by any automobile insurance policy, up to the policy’s amount of coverage limitation.
- Services provided by your close relative (your spouse, child, brother, sister, or the parent of you or your spouse) for which, in the absence of coverage, no charge would be made.
- Services required by a third party, including (but not limited to) physical examinations, diagnostic services and immunizations in connection with:
- obtaining or continuing employment,
- obtaining or maintaining any license issued by a municipality, state or federal government,
- securing insurance coverage,
- travel, and
- school admissions or attendance, including examinations required to participate in athletics, unless the service is considered to be part of an appropriate schedule of wellness services.
- Services you are not legally obligated to pay for in the absence of this coverage.
- Any expense incurred before you or your family members became covered under this option
- Any expenses that exceed reasonable and customary limits.
- Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem.
- Custodial care or maintenance care, even if ordered by a physician.
- Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services.
Physicians and other health professionals
- Any expense not recommended and approved by a physician acting within the scope of his or her license.
Hospital and other facility care
- Ambulance services, when used for non-emergency transportation.Any program or services performed in an experimental or investigational setting, per Aetna´s Clinical policy bulletins.
- Any outpatient disposable supply or device (except as described under Prescriptions Drugs) including, but not limited to: Sheaths, Bags, Elastic garments, Support hose, Bandages, Bedpans, Syringes, Blood or urine testing supplies, Other home test kits, Splints, Neck braces, Compresses, Other devices not intended for reuse by another patient.
- Private room rate above the hospital's most common semiprivate room rate, except when medically necessary.
- Care, services or supplies provided in:
- Rest homes
- Assisted living facilities
- Similar institutions serving as a persons’ main residence or providing mainly custodial or rest care
- Health resorts
- Spas or sanitariums
- Infirmaries at schools, colleges, or camps
- Outpatient supplies, including (but not limited to) outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic stockings and reagent strips, (except as described under Prescription Drugs).
Specific conditions
- Applied Behavior Analysis (ABA) for Autism spectrum disorder conditions.
- Any services and supplies related to births that take place in the home or in any other place not licensed to perform deliveries, including Home uterine activity monitoring.
- Biofeedback, except as specifically approved by Aetna.
- Blood, blood plasma, or other blood derivatives or substitutes.
- Breast augmentation and otoplasties, including treatment of gynecomastia.
- Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the condition or injury.
- Chiropractic services for therapeutic purposes in excess of 20 visits or $1,000 maximum per person per year and any maintenance chiropractic care.
- Concierge or annual fees. Any portion not related to medical care (such as a private waiting room, same-day appointments, extended time with physician) is excluded.
- Dental charges except as specifically provided in the Covered Expenses section.
- Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
- Services primarily of an educational nature or in an educational setting
- Non therapeutic or elective abortions.
- Fertility benefits provided by Progyny.
- Hair analysis
- Prosthetic devices:
- Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required for the treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of a covered leg brace
- Trusses, corsets, and other support items
- Repair and replacement due to loss, misuse, abuse or theft
- Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity.
- Nutritional programs, weight programs, and related food supplements, except for physician expenses and lab costs for treatment of morbid obesity, and for nutritional counseling performed by a licensed nutritionist or dietician, consistent with Aetna's Clinical Policy Bulletins.
- Nutritional supplements, even if prescribed by a physician, except for treatment of phenylketonuria (PKU).
- Hearing aids. Even though this Plan does not provide coverage for hearing aids, if you are considering the purchase of hearing aids, you may be able to lower your out-of-pocket expenses through the Amplifon Hearing Health Care (formerly HearPo) Discount Program or the Hearing Care Solutions Discount Program or Life Mart These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, you can visit www.aetna.com or call Amplifon Hearing Health Care (formerly HearPo) at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
- Household equipment, including (but not limited to) the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, is not covered. Improvements to your home or place of work, including (but not limited to) ramps, elevators, handrails, stair glides and swimming pools, are not covered.
- Hypnotherapy, except when approved in advance by Aetna.
- Incidental charges.
- Implantable drugs.
- Maintenance, replacement, or repair for continuously rented Durable Medical Equipment (DME), frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
- Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
- Radial keratotomy, including related procedures designed to surgically correct refractive errors.
- Recreational, educational and sleep therapy, including any related diagnostic testing.
- Religious, marital and sex counseling, including related services and treatment.
- Reversal of voluntary sterilizations.
- Routine hand and foot care services, including routine reduction of nails, calluses and corns.
- Routine eye examinations, eyeglasses, contact lenses, and orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
- Routine hearing exam.
- Self-treatment.
- Special education, including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired to function without that ability.
- Special medical reports, including those not directly related to the medical treatment of a plan participant (such as employment or insurance physicals) and reports prepared in connection with litigation.
- Specific injectable drugs, including:
- experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific condition or approved for a mode of treatment by the FDA and the National Institutes of Health,
- Needles, syringes and other injectable aids (except as described under Prescription Drugs),
- drugs related to treatments not covered by the Plan, and
- performance-enhancing steroids.
- Treatment, including therapy, supplies and counseling, for sexual dysfunctions.
- Jaw joint disorder treatment (TMJ) performed by prosthesis placed directly on the teeth, surgical and non-surgical medical and dental services, and diagnostic or therapeutics services related to TMJ
- Weight reduction programs and dietary supplements.
- Wigs or hairpieces for androgenic alopecia (male pattern baldness).
- Treatment of occupational illnesses or injuries sustained in situations covered by workers' compensation or a similar law
- Transportation or travel expenses except for:
- emergency transportation service by professional ambulance
- transportation costs to travel to a COE/IOE:
- if the distance is over 100 miles,
- and for Organ, Tissue, and Bone Marrow Transplants.
Concurrent Care Claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.
Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.
Adverse benefit determinations can be made for one or more of the following reasons:
- The individual is not eligible to participate in the Plan, or
- Aetna determines that a benefit or service is not covered by the Plan because:
- it is not included in the list of covered benefits,
- it is specifically excluded,
- a Plan limitation has been reached, or
- it is not medically necessary.
Medical claims and appeals
Filing claims for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select option
For most of your network claims for benefits, you do not need to submit a claim. This will be done automatically for you by the network provider. However for some network providers and out of network providers you will be required to file a claim for benefits.
All claims and appeals for benefits should be directed to the appropriate Claims fiduciary. Plan eligibility is determined by the Administrator-Benefits. The Administrator-Benefits determination of eligibility is final and no appeals are available.
How to file a Claim for benefits
If your providers do not file claims for benefits for you, follow the instructions on the claim forms, which are available at the Healthcare forms and useful links section ExxonMobil Family Internet site.
If you need to file a claim:
- Submit a completed claim form with necessary documentation within 12 months from the date the expense was incurred.
- Aetna will send you an explanation of benefits (EOB) for each claim. The EOB shows what service was performed, how much the provider charged, and what the covered charge was under the Plan. It shows if a deductible or copayment was involved, as well as the calculation used to determine your benefit.
- Keep the explanation of benefits for your records.
- You can review your EOB by going to Aetna’s website at www.aetna.com and following the instructions.
For prescription drug claims, refer to Short-term prescriptions in the Prescription Drug Program section.
Effective January 1, 2023, non-emergent care outside the U.S. will no longer be covered. If you paid for medical care received when traveling or working outside the United States prior to January 1, 2023, you have up to 12 months to request reimbursement by submitting an itemized bill along with a claim form. If the original bills are in a foreign language or paid in a foreign currency, you should obtain an English translation, if possible, of the services rendered and the claims administrator will convert the bill to U.S. dollars as of the date of service.
Initial Claim Review and Decision
When you file a claim, the claims administrator reviews the claim and makes a decision to either approve or deny the claim (in whole or in part). You will receive a written notice of the claim decision within the time limits described in the chart that follows. Those time limits are based on the type of claim and whether you submit a proper claim, including all necessary information.
Urgent, Pre-Service and Post-Service claims
Time limits |
|||
Urgent care claim |
Pre-service claim |
Post-service claim |
|
If the initial claim is properly completed: |
|||
Notice will be given to you not later than 72 hours after receiving the initial claim. Notice of initial benefits decision 24 hours in the case of a concurrent claim, if you request to extend the authorized treatment at least 24 hours before the existing authorization ends |
Notice will be given to you not later than 15 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 15 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision |
Notice will be given to you not later than 30 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 30 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision |
|
If the initial claim is not properly completed: |
|||
Notice will be given to you as soon as possible (but no more than 24 hours after Aetna receives the claim). You will have up to 48 hours to provide the additional information. |
Notice will be given to you 15 days of receipt of the claim.
You will have up to 45 days to provide the additional information. |
Notice will be given to you 30 days of receipt of the claim.
You will have up to 45 days to provide the additional information. |
|
If additional information is required: |
|||
The Plan´s benefit determination will be given to you not later than 48 hours after receiving additional information or upon the expiration of your 48-hour deadline to provide such information to complete the claim, whichever is earlier. |
The Plan´s benefit determination will be given to you not later than 15 days after receiving your additional information or upon the expiration of your 45-day deadline to complete the claim, whichever is earlier. |
Claim denial and reconsideration
If all or part of a claim is denied, Aetna Member Services will provide you with a written explanation supporting the denial and describing additional information, if any, that may improve the claim’s likelihood of being approved.
For Concurrent Care Claims Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.
Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.
Adverse benefit determinations can be made for one or more of the following reasons:
- The individual is not eligible to participate in the Plan, or
- Aetna determines that a benefit or service is not covered by the Plan because:
- it is not included in the list of covered benefits,
- it is specifically excluded,
- a Plan limitation has been reached, or
- it is not medically necessary.
How to appeal an Adverse Benefit Determination
Aetna will send you a written notice of an adverse benefit determination that will include the reason for the decision and will explain what steps you must take if you wish to appeal. The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. Appeals should be filed within 180 days from the date of the notice of Adverse Benefit Determination.
The following chart summarizes some information about how level one and level two appeals are handled for different types of claims. In certain situations, the time frames shown may be extended.
Type of Claim |
Level One Appeal |
Level Two Appeal |
Urgent care claim:a claim for medical care or treatment where delay could:
|
36 hours Review provided by Aetna personnel not involved in making the adverse benefit determination. |
36 hours Review provided by Appeals Committee. |
Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care. |
15 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination |
15 calendar days Review provided by Appeals Committee. |
Concurrent care claim extension: a request to extend a previously approved course of treatment. |
Treated like an urgent care claim or a pre-service claim depending on the circumstances |
Treated like an urgent care claim or a pre-service claim depending on the circumstances |
Post-service claim:a claim for a benefit that is not a pre-service claim. |
30 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination. |
30 calendar days Review provided by Appeals Committee. |
External review of Aetna’s final appeal determinations
The external review process is expanded to apply with respect to any adverse determination by a plan or issuer under the CAA, including grandfathered plans, and with respect to any item or service to which the No Surprises Act applies.
If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim.
An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, a rescission of coverage, or an adverse determination for surprise bills (medical and air ambulance bills, including a determination of whether an adverse determination is subject to surprise billing provisions) or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if
- You have received notice of the denial of a claim by Aetna, and
- Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and
You must submit the Request for External Review Form to Aetna within four months of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.
Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 45 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.
You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.
Nonalienation of Benefits
No benefit, right or interest of any Covered Person under the Plan shall be subject to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, including any liability for, or subject to, the debts, liabilities or other obligations of such person; and any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge, garnish, execute or levy upon, or otherwise dispose of any right to benefits payable hereunder or legal causes of action, shall be void. Notwithstanding the foregoing, the Plan may choose to remit payments directly to health care providers with respect to covered services, if authorized by the Covered Person, but only as a convenience to Covered Persons. Health care providers are not, and shall not be construed as, either “participants” or “beneficiaries” under this Plan and have no rights to receive benefits from the Plan or to pursue legal causes of action on behalf of (or in place of) Covered Persons under any circumstances.
Uncashed Checks
If a check to a Participant for benefits under the Plan remains uncashed for 5 years after issue, amounts attributable to such check shall remain in the Plan until the time the participant has requested these funds
The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.
End of the COVID-19 emergency periods
National Emergency (NE) and Public Health Emergency (PHE)
The COVID-19 “Outbreak Period” was anticipated to end 60 days after the end of emergency period. During that period, certain deadlines for the events outlined below were paused. The regular deadline timing for these events will resume starting on July 10, 2023. As these extended deadlines are applied on a case-by-case basis and if you have a question about the appropriate deadline for a particular claim or appeal, please contact the carrier (Aetna, Cigna, Express Scripts) directly for further assistance.
- Enrolling in a health plan upon a special enrollment event
- Electing COBRA continuation of coverage
- Making COBRA premium payments
- Notifying the plan of a COBRA qualifying event or determination of disability
- Filing an initial benefit claim or appeal of an adverse benefit determination for disability, retirement and other plans
- Filing an initial benefit claim, appeal of an adverse benefit determination and external review of certain claims for health plans
Administrative and ERISA information
Administrative and ERISA information for the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Basic Plan information
Plan name
The ExxonMobil Retiree Medical Plan
Plan sponsor and participating affiliates
The ExxonMobil Retiree Medical Plan is sponsored by:
Exxon Mobil Corporation
22777 Springwoods Village Parkway
Spring, TX 77389
All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Retiree Medical Plans. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.
Plan numbers
The ExxonMobil Retiree Medical Plan is identified with government agencies under two numbers:
The Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 540.
Plan administrators
The Plan Administrator for the ExxonMobil Retiree Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation.
Claims fiduciary and administrator
The Claims fiduciary has been delegated authority by the Administrator-Benefits to determine all claims and appeals for benefits. You may contact the claims fiduciary as follows:
Medical, Behavioral Health and Substance Use Disorders.
Aetna
P. O. Box 14463
Lexington KY 40512
Prescription Drugs:
Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Administrative Appeals Dept.
Forum and Venue
The exclusive forum and venue for any legal or equitable action relating to or arising under the plan shall be in the United States District Court for the Southern District of Texas, Houston Division, so long as the federal courts may assert subject matter jurisdiction over the action (unless the parties to the action have agreed otherwise). In the event the action is not subject to the subject matter jurisdiction of the federal courts, the exclusive forum and venue for such action shall be the district courts of Harris County, Texas (unless the parties to the action have agreed otherwise). Per the terms of the plan, you consent to the personal jurisdiction of these courts, as applicable, and waive any objections to personal jurisdiction or inconvenience of the forum and venue specified in this paragraph.
For service of legal process:
Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218
Authority of administrator-benefits
The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits, to construe and interpret the terms of the Retiree Medical Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.
Type of plan
The ExxonMobil Retiree Medical Plan is a welfare plan under ERISA providing medical benefits.
Plan year
The plan year is the calendar year.
Funding
The Plan is funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the ExxonMobil Retiree Medical Plan. These rates are based on past and projected plan experience. Participant contributions are paid to a Trustee who manages the funds under the terms of a Trust Agreement between ExxonMobil and the Trustee. The Trustee for the EMRMP Plan is:
The Northern Trust Company
50 S. LaSalle
Chicago, IL 6067
Claims processor
Aetna Life Insurance Company is the claims processor and claims fiduciary.
No implied promises
Nothing in this guide says or implies that participation in the ExxonMobil Retiree Medical Plan is a guarantee of continued employment with the company.
If the ExxonMobil Retiree Medical Plan is amended or terminated
The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the Retiree Medical Plan or any of its provisions. If any reductions in benefits are made in the future, you will be notified within sixty (60) days of the signing of the amendment. In the event the ExxonMobil Retiree Medical Plan is terminated, you will have the right to elect continuation coverage, as described in the COBRA section of this guide, in any other health plan maintained by Exxon Mobil Corporation or its controlled group.
Your rights under ERISA
As a participant in the ExxonMobil Retiree Medical Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall be entitled to:
Receive information about your plan and benefits
Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites, and union halls, all documents governing the ExxonMobil Retiree Medical Plan, including a copy of the latest annual report (Form 5500 Series) filed by the ExxonMobil Retiree Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Retiree Medical Plan including collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Descriptions. The Administrator may require a reasonable charge for the copies.
Receive a summary of the Plan’s annual financial report. (The Administrator-Benefits is required by law to furnish each participant with a copy of this Summary Annual Report.)
Prudent actions by plan fiduciaries
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries, of the ExxonMobil Retiree Medical Plan have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.
Enforce your rights
If your claim for a benefit is denied or ignored in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest Summary Annual Report from the Plan, and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
If you have a claim and an appeal for benefits, which are both denied or ignored, in whole or in part, you may file suit in a state or Federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. Any such lawsuits must be brought within one year of the date on which an appeal was denied.
The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance with your questions
If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.Federal notices
Federal notices related to the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Coverage for maternity hospital stay
Under federal law, the Plan may not restrict benefits for hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a caesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.
The Women’s Health and Cancer Rights Act
If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage copayment and deductibles which apply to other plan benefits:
- Reconstruction of the breast on which the mastectomy was performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance,
- Prostheses, and
- Services for physical complications in all stages of mastectomy, including lymphedema.
The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.
If you have any questions about your benefits please contact Aetna Member Services.
Key terms
A list of key terms in the ExxonMobil Retiree Medical Plan – Open Access Aetna Select Network Only option
Annual out-of-pocket limit
Expenses you pay for medical services apply towards the annual out-of-pocket maximum including both outpatient and inpatient behavioral health and substance use disorders treatment. The annual out-of-pocket maximum is accumulated in the order the claims are processed.
Approved Clinical Trial
A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening disease or condition and meets any of the following three conditions:
- Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
- The National Institutes of Health.
- The Centers for Disease Control and Prevention.
- The Agency for Health Care Research and Quality.
- The Centers for Medicare & Medicaid Services.
- Cooperative group or center of any of the entities described in clauses (a) through (d) or the Department of Defense or the Department of Veterans Affairs.
- A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.
- Any of the following if certain conditions are met:
- The Department of Veterans Affairs.
- The Department of Defense.
- The Department of Energy.
- The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
- The study or investigation is a drug trial that is exempt from having such an investigational new drug application.
The conditions for this clause (g) are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary of Health and Human Services determines: to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
- The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
- The study or investigation is a drug trial that is exempt from having such an investigational new drug application.
Balance Bill
The difference between the Plan’s reimbursement for out-of-Network services and what the Provider charges
Behavioral health condition
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-V), or its successor publication, and which is appropriately treated by the Behavioral health Network. Such a condition will be considered a behavioral health condition, regardless of any organic or physical cause or contributing factor
Behavioral health provider
A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist, or other clinician with at least a master's degree, who provides inpatient or outpatient treatment for a behavioral health condition, who is licensed in the state of practice and who is acting within the scope of that license (if applicable). If the person is not subject to a licensing requirement, the person must provide treatment consistent with that which would be provided by the type of providers listed above.
Behavioral health treatment facility
A facility that:
- meets licensing standards,
- mainly provides a program for diagnosis, evaluation and treatment of behavioral health conditions,
- prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs,
- provides all normal infirmary level Medical Services or arranges with a Hospital for any other Medical Services that may be required,
- is under the supervision of a psychiatrist, and
provides skilled nursing care by licensed nurses who are directed by a registered nurse.
Benefit service
Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:
- unauthorized absences,
- leaves of absence of over 30 days (except military leaves or leaves under the Federal Family and Medical Leave Act),
- certain absences from which you do not return,
- periods when you work as a non-regular employee, a special-agreement person in a service station, car wash, or car-care center operations, or
- when you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.
The Benefits Service Center
The following sets out the contact numbers based on your status under the ExxonMobil Retiree Medical Plan. It is your responsibility to contact the correct Benefits Service Center entity with any required notices and address changes. If your status is not listed, call the ExxonMobil Benefits Service Center for assistance at 1-800-682-2847.
Phone Numbers:
Retirees and Survivors call:
ExxonMobil Benefits Service Center
Monday - Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time),
except certain holidays
Toll-Free: 1-800-682-2847 or 800-TDD-TDD4 (833-8334) for hearing impaired
Address:
ExxonMobil Benefits Service Center
P.O. Box 18025, Norfolk, VA 23501-1867
Effective January 2, 2024, Alight will be the new administrator of ExxonMobil’s health, life insurance, and pension plans. If you need assistance, please contact:
ExxonMobil Benefits Service Center
Phone: 833-776-9966
Hours: 8am – 4pm CST, Monday through Friday, except certain holidays
Your Total Rewards portal: digital.alight.com/exxonmobil
Alight Mobile app (available through Apple App Store or Google Play)
Address:
Dept 02694, PO Box 64116, The Woodlands, TX, 77387-4116
Benefits administration / ExxonMobil sponsored sites
Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.
- ExxonMobil Family, the Human Resources Internet Site — Can be accessed from home by everyone at www.exxonmobilfamily.com.
- Retiree Online Community Internet Site — Can be accessed from home by retirees and survivors only at www.emretiree.com.
- ExxonMobil Benefits Service Center Internet Site — Can be accessed from home by everyone at www.exxonmobil.com/benefits.
Child
A person under age 26 who is:
- A natural or legally adopted child of a retiree,
- A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a retiree, or the spouse of a retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator,
- A child for whom the retiree has assumed a legal obligation for support immediately prior to the child's adoption by the retiree, or
- A stepchild of a retiree.
Claims administrator / processor
Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.
Claims fiduciary
For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.
Concurrent care claims
Concurrent claims are any claims that involve an ongoing approved course of treatment. Typically, concurrent claims will be handled as either a pre-service claim or urgent care claim, depending on the circumstances.
Copayments and coinsurance
Your share of covered services (including out-patient prescription drugs and behavioral health and substance use disorders expenses). For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service. For other services, such as routine office visits to an Open Access Aetna Select provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.
Cosmetic surgery
Means any surgery or procedure that is not medically necessary and whose primary purpose is to improve or change the appearance of any portion of the body to improve self-esteem, but which does not:
- Restore bodily function,
- Correct a diseased state, physical appearance or disfigurement caused by an accident or birth defect, or
- Correct or naturally improve a physiological function.
Covered services and supplies (covered expenses)
Means the types of medically necessary services and supplies described in Your Benefits.
Custodial care
Care that helps meet personal needs and daily living activities. Such care, even if ordered by a doctor and performed by a licensed medical professional such as a nurse, is not covered by the Plan. Examples are:
- Routine patient care such as changing dressings, periodic turning and positioning in bed
- Administering oral medications
- Care of a stable tracheostomy (including intermittent suctioning)
- Care of a stable colostomy/ileostomy
- Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
- Care of a bladder catheter (including emptying/changing containers and clamping tubing)
- Watching or protecting you
- Respite care, adult (or child) day care, or convalescent care
- Institutional care. This includes room and board for rest cures, adult day care and convalescent care
- Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
- Any other services that a person without medical or paramedical training could be trained to perform
- Any service that can be performed by a person without any medical or paramedical training
Detoxification
Means the process whereby an alcohol-intoxicated, alcohol-dependent or drug-dependent person is assisted in a facility licensed by the state in which it operates, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factor, or alcohol in combination with drugs as determined by a licensed physician, while keeping physiological risk to the patient at a minimum.
Durable medical equipment (DME)
Means equipment determined to be:
- Designed and able to withstand repeated use,
- Made for and used primarily in the treatment of a condition or injury,
- Generally not useful in the absence of an illness or injury,
- Suitable for use while not admitted in a hospital,
- Not for use in altering air quality or temperature, and
- Not for exercise or training.
Eligible family members
Eligible family members are generally your:
- Spouse
- A child who is described in any one of the following paragraphs (1 through 3):
- has not reached the end of the month during which age 26 is attained (even if Medicare eligible), or
- is aged 26 or over and totally and continuously disabled and incapable of self-sustaining employment by reason of mental or, physical disability, provided the child:
- meets the Internal Revenue Service's definition of a dependent, and
- was covered as an eligible family member under this Plan or the ExxonMobil Medical Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, and
- met the clinical definition of totally and continuously disabled before such birthday and continues to meet the clinical definition through subsequent periodic reassessment reviews, and
- is not eligible to be enrolled in Medicare as their primary medical plan, or
- is recognized under a qualified medical child support order as having a right to coverage under this Plan.
A child aged 26 or over who was disabled but who no longer meets the requirements of paragraph (2) above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.
Please note: An eligible retiree's parents are not eligible to be covered.
Emergency
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
- Serious impairment to bodily function, or
- Serious dysfunction of any bodily organ or part.
- With respect to emergency services furnished in a hospital emergency department, the Plan does not require prior authorization for such services if you arrive at the emergency medical department with symptoms that reasonably suggest an emergency condition, based on the judgment of a prudent layperson, regardless of whether the hospital is an in-network provider.
- The plan covers medically necessary emergency services including the following:
- Initial services. A medical screening examination within the capability of a hospital emergency department or freestanding independent emergency department, including ancillary services routinely available in the emergency department, to determine whether an “emergency medical condition” exists.
- Post-stabilization services. Additional services covered under the plan that are furnished by a nonparticipating provider or nonparticipating emergency facility after a participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the initial services were provided
Experimental or investigational
Means services or supplies that are determined by Aetna to be experimental. A drug, device, procedure or treatment will be determined to be experimental if:
- There are not sufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the condition or injury involved, or
- Required FDA approval has not been granted for marketing, or
- A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes, or
- The written protocol(s) used by the treating facility or the protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes, or
- It is not of proven benefit for the specific diagnosis or treatment of your particular condition, or
- It is not generally recognized by the medical community as effective or appropriate for the specific diagnosis or treatment of your particular condition, or
- It is provided or performed in special settings for research purposes.
ExxonMobil Retiree Medical Plan (EMRMP)
The Plan sponsored by ExxonMobil which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP), the Medicare Primary Option (MPO) and the Medicare Supplement plan (or MSP).
Home health services
Means those items and services provided by participating providers as an alternative to hospitalization.
Hospice care
A program of care that is:
- Provided by a hospital, skilled nursing facility, hospice or duly licensed hospice care agency, and
- Focused on palliative rather than curative treatment for a plan participant who has a medical condition and a prognosis of less than 6 months to live.
Hospital
Means an institution rendering inpatient and outpatient services, accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.
Incidental Charges
Charges for services that are considered an integral component of the primary procedure. Aetna’s standard for determining incidental charges is based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association. CPT coding is the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures, including guidelines explaining that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure. Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure. For example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot.
An immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid. Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a pre-authorized non-participating provider or if you have signed a statement in the provider's office saying you will be responsible for incidental charges.
Infertility
- For a female who is under age 35, the inability to conceive after one year or more without contraception or 12 cycles of artificial insemination.
- For a female who is age 35 or older, the inability to conceive after six months without contraception or six cycles of artificial insemination.
Medical services
Means those professional services of physicians or other health professionals, including medical, surgical, diagnostic, therapeutic and preventive services authorized by Aetna.
Medically necessary
Means services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards, as described in the Your Benefits section of this booklet. To be medically necessary, the service or supply must:
- Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness, injury, or mental health condition involved and your overall health condition,
- Be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well-baby care, as determined by Aetna,
- Be a diagnostic procedure, indicated by the health status of the plan participant, and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness or injury involved and your overall health condition,
- Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a physician’s office, on an outpatient basis, or in any facility other than a hospital, when used in relation to inpatient hospital services, and
- As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests.
In determining whether a service or supply is medically necessary, Aetna will consider:
- Information provided on your health status,
- Applicable standard of care,
- Aetna's Clinical Policy Bulletin's and other non-case specific materials, which shall be based on medical and Scientific Evidence,
- Reports in peer reviewed medical literature,
- Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data,
- Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment,
- The opinion of health professionals in the generally recognized health specialty involved,
- The opinion of the attending physicians, which has credence but does not overrule contrary opinions, and
- Any other relevant information brought to Aetna’s attention
In no event will the following services or supplies be considered medically necessary:
- Services or supplies that do not require the technical skills of a medical, behavioral health or dental professional,
- Custodial care, supportive care or rest cures,
- Services or supplies furnished mainly for the personal comfort or convenience of the patient, any person caring for the patient, any person who is part of the patient’s family or any health care provider,
- Services or supplies furnished solely because the plan participant is an inpatient on any day when their illness or injury could be diagnosed or treated safely and adequately on an outpatient basis,
- Services furnished solely because of the setting if the service or supply could be furnished safely and adequately in a physician’s or dentist’s office or other less costly setting, or
- Experimental services and supplies, as determined by Aetna.
Medicare
The program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
Outpatient
- A plan participant who is registered at a practitioner’s office or recognized health care facility, but not as an inpatient, or
- Services and supplies provided in such a setting.
Participating provider
A provider that has entered into a contractual agreement with Aetna to provide services to plan participants.
Pharmacy benefit manager
Express Scripts is the pharmacy benefit manager for prescription drugs.
Physician
Acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is duly licensed as an Orthoptist, a Physician Assistant or Nurse Practitioner. Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.
Plan benefits
The medical services, hospital services, and other services and care to which a plan participant is entitled, as described in this booklet.
Plan participant
A retiree or covered family member.
Post-service claims
All claims for benefits after medical services have been provided, such as requests for reimbursement or payment for the provided services.
Pre-service claims or Pre-determination
Requests for approval required before medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary. A written pre-determination request will result in a detailed response as to whether a treatment or service is covered under the Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a pre-determination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.
Primary Care Physician (PCP)
A Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons, initiates their referral for specialist care, and maintains continuity of patient care. Physician groups, nurse practitioners and physician assistants cannot be PCPs.
Private duty nursing
Continuous, substantial and complex skilled in-home nursing care in the home requiring services that can only be provided by a licensed medical professionals can provide, has been as prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.
Provider
A physician, health professional, hospital, skilled nursing facility, home health agency, or other recognized entity or person licensed to provide hospital or medical services to Plan participants.
Reciprocity
The Plan allows full reciprocity between Aetna Select networks, when members follow all administrative requirements such as obtaining authorizations.
Referral
Specific written or electronic direction or instruction from a Plan participant’s PCP, , which directs the plan participant to a participating provider for medically necessary care.
Retiree
Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age.
Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.
Retiree Medical Plan (RMP)
One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes Retiree Medical Plan Open Access Aetna Select Option (as described in this SPD) and other self-funded options.
Self-funded
(As used in the ExxonMobil Medical Plan) A self-funded option is an option set up by ExxonMobil to set aside funds to pay employees’ health claims. Because ExxonMobil has hired insurance companies to administer the claims for these plans, they may look just like fully insured plans but they are funded by ExxonMobil. For example, all Open Access Aetna Select options under the EMMP and EMRMP are self-funded. Aetna is responsible for processing claims and is the claims fiduciary (i.e., Aetna makes the final decision on claims under those plans). ExxonMobil is responsible for providing the funds to the Plan to pay health claims. This does not impact the way that your plan operates. The U.S. Department of Labor regulates self-funded plans, not the state. You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.
Serious Mental Illness
The following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) V-R: schizophrenia; paranoid and other psychotic disorders; bipolar disorders (hypomanic; mixed, manic and depressive); major depressive disorders (single episode or recurrent); schizo-affective disorders (bipolar or depressive); pervasive developmental disorders; obsessive-compulsive disorders and depression in childhood and adolescence.
Service area
The geographic area, established by Aetna and approved by the appropriate regulatory authority, in which a Plan participant must live or otherwise meet the eligibility requirements in order to be eligible as a participant in the Plan. Eligibility is determined by the participant's home address zip code.
Skilled nursing facility
An institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a skilled nursing facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna to meet the reasonable standards applied by any of the aforesaid authorities.
Specialist
A physician who provides medical care in any generally accepted medical or surgical specialty or sub-specialty.
Spouse; marriage
All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.
Substance use disorder
Any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning, or which produces physiological dependency evidenced by physical tolerance or withdrawal.
Survivor/ surviving spouse
A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.
Suspended retiree
A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person:
- Reaches age 55, or
- Begins his or her benefit under the ExxonMobil Pension Plan, at which time, the person is again considered a retiree.
The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:
- The date the suspended retiree would have attained age 55, or
- The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.
Terminal illness
An illness of a Plan participant, which has been diagnosed by a physician and for which they have a prognosis of six (6) months or less to live.
Urgent care claims
Special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.
Urgent medical condition
A medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from your PCP.