Annual Out-of-Pocket Limit - Expenses you pay for medical services apply towards the annual out-of-pocket maximum including both outpatient and inpatient mental health and substance abuse treatment. The annual out-of-pocket maximum is accumulated in the order the claims are processed. There is a separate $2,500 annual out-of-pocket maximum per member for prescription drugs.
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.
Benefits Administration - The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. It is your responsibility to contact the correct Benefits Administration entity with any required notices and address changes. If your status is not listed, call ExxonMobil Benefits Administration/Health Plan Services for assistance or contact them at email@example.com.
Benefits Administration / ExxonMobil Sponsored Sites — Access to plan-related information including claim forms for employees and their family members.
- ExxonMobil Me, the Human Resources Intranet Site — Can be accessed at work by employees.
- ExxonMobil Family, the Human Resources Internet Site — Can be accessed from home by everyone at www.exxonmobilfamily.com.
- ExxonMobil Benefits Service Center at Xerox Internet Site — Can be accessed from home by everyone at www.exxonmobil.com/benefits.
ExxonMobil Benefits Web (Single Sign On) – Can be accessed by U.S. dollar paid active employees without an SSN and PIN after authenticating to the ExxonMobil network from a Company issued PC, laptop or mobile device. Click here for access.
Magellan Behavioral Health is the Care Manager
A person under age 26 who is:
- A natural or legally adopted child of a regular employee or retiree;
- A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, retiree, or the spouse of a regular employee or retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator;
- A child for whom the regular employee or retiree has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee or retiree; or
- A stepchild of a regular employee or retiree.
Child does not include a foster child.
Co-payment (co-pay) - means the fee that must be paid by a plan participant to a participating provider at the time of service for certain covered expenses and benefits, as described in the “Co-payment Schedule.”
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 - means any service or supply, including room and board, which:
- Is furnished mainly to help you meet your routine daily needs; or
- Can be furnished by someone who has no professional health care training or skills; or
- Is at a level such that you have reached the maximum level of physical or mental function and are not likely to make further significant progress.
The amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount co-payments do not apply toward this amount. Outpatient prescription drug co-payments are not subject to nor do they count toward the annual deductible. The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill and retain proof of your payment, should you need to recover money from your provider.
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 disease or injury;
- Generally not useful in the absence of an illness or injury;
- Suitable for use while not confined in a hospital;
- Not for use in altering air quality or temperature; and
- Not for exercise or training.
Eligible employees - Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. The person must be classified on the employer’s books and records as an employee.
The following are not eligible to participate in the plan: leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the plan document. Generally, specialagreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.
Eligible family members
Eligible family members are generally your:
- 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; or
- is 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 or would have been covered as an eligible family member under this Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, or
- was covered as an eligible family member under a predecessor plan which provided for coverage of disability, if the disability occurred prior to the birthday on which the child's eligibility under that plan would have otherwise ceased, the child continued to be considered eligible for coverage because of such disability and the child had not lost eligibility under the predecessor plan; and
- the child is disabled before such birthday and has remained continuously disabled, and
- the child is recognized under a qualified medical child support order as having a right to coverage under this Plan.
A child who was disabled by reason of mental disability but who no longer meets the requirements of paragraphs 2(a) above, ceases to be an eligible family member 300 days following the date on which the applicable requirement is not met.
Please note: An eligible employee's parents are not eligible to be covered.
Emergency - means 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 a participating provider. All medically necessary procedures performed during the evaluation (triage and treatment of an emergency medical condition) are covered by the Plan.
Expatriate Employees - means service-oriented employees employed by non-U.S., non-participating employers who are temporarily working in the United States either under a visa that requires coverage by this plan of such employee while in the United States or in an assignment in the United States and the terms of the assignment require proof of adequate medical coverage. Expatriate employees include regular employees working on an assignment outside the United States where the terms of the assignment require proof of adequate medical coverage.
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 disease 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 Medical Plan - The plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible employees, and their family members and includes the Aetna Select option.
ExxonMobil Retiree Medical Plan (EMRMP)
The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the ExxonMobil Medicare Supplement Plan (MSP).
Retiree Medical Plan
A part of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members, and includes the Aetna Select option.
Home health services - means those items and services provided by participating providers as an alternative to hospitalization, and approved and coordinated in advance by Aetna.
Hospice care - means a program of care that is:
- Provided by a hospital, skilled nursing facility, hospice or duly licensed hospice care agency;
- Approved by Aetna; 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 - means
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 - means:
- 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 disease or injury 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 disease 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, mental 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 disease 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.
Mental health treatment facility - A facility that:
- meets licensing standards;
- mainly provides a program for diagnosis, evaluation and treatment of acute mental or nervous disorders;
- 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.
Mental or nervous condition - means a condition which manifests signs and/or symptoms that are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication. Mental or behavioral disorders and conditions include, but are not limited to:
- Affective disorders;
- Anxiety disorders;
- Personality disorders;
- Obsessive-compulsive disorders;
- Attention disorders with or without hyperactivity; and
- Other psychological, emotional, nervous, behavioral or stress-related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition.
Outpatient - means:
- 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 - means 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 - means 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 - means the medical services, hospital services, and other services and care to which a plan participant is entitled, as described in this booklet.
Plan participant - means an employee or covered family member.
Primary Care Physician (PCP) - means a participating physician who supervises, coordinates, and provides initial care and basic medical services as a general or family care practitioner or, in some cases, as an internist or a pediatrician, to Plan participants; initiates their referral for specialist care; and maintains continuity of patient care.
Provider - means 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.
Qualified Medical Child Support Order (QMCSO) - A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum:
- Name and address of the employee covered by the health plan.
- The name and address of each child for whom coverage is mandated.
- A reasonable description for the coverage to be provided.
- The time period of coverage.
- The name of each health plan to which the order applies.
You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.
Referral - means specific written or electronic direction or instruction from a Plan participant’s PCP, in conformance with Aetna’s policies and procedures, 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 longterm 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.
Self-insured (As used in the ExxonMobil Medical Plan) - 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 Aetna Select options under the EMMP are self-insured. 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) III-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 - means 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 - means 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 - means 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 abuse - means 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.
Trainee - A U.S.payroll employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school. This definition does not include an individual not on the U.S. payroll but in the U.S. on a training assignment that is not considered an expatriate assignment into the U.S. Such individuals are not eligible for the EMMP.
Terminal illness - means 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 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 your PCP.