Key terms

List of key terms in the ExxonMobil Employee Medical HMO - Cigna OAPIN Plan

Bed and board

The term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general services and activities needed for the care of registered bed patients.

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, as 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 Benefits Administration 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 hr.medical.dental.questions@exxonmobil.com

Access to medical plan-related information including claim forms for employees, retirees, survivors, and their family members.

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.

Charges

The term "charges" means the actual billed charges; except when the provider has contracted directly or indirectly with Cigna for a different amount.

Child

A person under age 26 who is:

  • A natural or legally adopted child of a regular employee;
  • A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, or the spouse of a regular employee (separately or together) is the sole court appointed legal guardian or sole managing conservator;
  • A child for whom the regular employee has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee; or
  • A stepchild of a regular employee.
  • Child does not include a foster child.

Co-payment

Your share of medical (including out-patient prescription drugs) and mental health and chemical dependency expenses. For some services, such as hospital stays, the co-insurance will be a percentage of the cost of the service once the deductible has been satisfied. For other services, such as routine office visits to a POS II provider, the co-payment will be a fixed amount. For outpatient prescription drugs there is a percentage co-payment.

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 Cigna OAPIN Option.

Deductible

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.

Durable medical equipment

Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines.

Eligible employees

Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. The person must be on the employer's books and records as an employee.

The following are not eligible to participate in the Medical Plan: leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the Medical Plan document. Generally, special-agreement 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:

  • 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; 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
  • either
  • 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. A child who is not legally present in the United States or a child who resides outside the United States and is not a citizen who doesn’t usually reside with the Employee is not an Eligible Family Member.

Emergency services

Emergency services are medical, psychiatric, surgical, hospital, and related health care services and testing, including ambulance service, which are required to treat a sudden, unexpected onset of a bodily injury or serious sickness which could reasonably be expected by a prudent layperson to result in serious medical complications, loss of life or permanent impairment to bodily functions in the absence of immediate medical attention. Examples of emergency situations include uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, burns, cuts and broken bones. The symptoms that led you to believe you needed emergency care, as coded by the provider and recorded by the Hospital on the UB04 claim form, or its successor, or the final diagnosis, whichever reasonably indicated an emergency medical condition, will be the basis for the determination of coverage, provided such symptoms reasonably indicate an emergency.

Employer

The term Employer means Exxon Mobil Corporation and participating affiliated companies, who are selffunding the benefits described in this SPD, on whose behalf Cigna is providing claim administration services.

Expense incurred

An expense is incurred when the service or the supply for which it is incurred is provided.

Extended part-time employee

An employee who is designated as a non-regular employee but who has been designated as an Extended PartTime employee under his or her employer's employment policies relating to flexible work arrangements.

ExxonMobil Medical Plan (medical plan)

The plan sponsored by Exxon Mobil Corporation, which provides medical benefits for eligible employees and their family members and includes as one option the Cigna OAPIN Option.

ExxonMobil Retiree Medical Plan (retiree medical plan)

The Plan sponsored by Exxon Mobil Corporation, which provides medical benefits for eligible retirees, survivors and their family members and includes as one option the Cigna OAPIN Option.

Formulary

Listing of approved drugs and medications approved in accordance with parameters established by the Pharmacy and Therapeutics Committee. This list is subject to periodic review and updates.

Free-standing surgical facility

The term Free-Standing Surgical Facility means an institution which meets all of the following requirements:

  • It has a medical staff of Physicians, Nurses and licensed anesthesiologists;
  • It maintains at least two operating rooms and one recovery room;
  • It maintains diagnostic laboratory and x-ray facilities;
  • It has equipment for emergency care;
  • It has a blood supply;
  • It maintains medical records;
  • It has agreements with Hospitals for immediate acceptance of patients who need Hospital Confinement on an inpatient basis; and
  • It is licensed in accordance with the laws of the appropriate legally authorized agency.

Home health aide

The term Home Health Aide means a person who: (a) provides care of a medical or therapeutic nature; and (b) reports to and is under the direct supervision of a Home Health care Agency.

Home health care agency

The term Home Health Care Agency means a Hospital or a non-profit or public home health care agency which:

  • Primarily provides skilled nursing service and other therapeutic service under the supervision of a Physician or a Registered Graduate Nurse;
  • Is run according to rules established by a group of professional persons;
  • Maintains clinical records on all patients;
  • Does not primarily provide custodial care or care and treatment of the mentally ill; but only if, in those jurisdictions where licensure by statute exists, that Home Health Care Agency is licensed and run according to the laws that pertain to agencies which provide home health care.

Home health care plan

The term Home Health Care Plan means a plan for care and treatment of a person in his home. To qualify, the plan must be established and approved in writing by a Physician who certifies that the person would require confinement in a Hospital or Skilled Nursing Facility if he did not have the care and treatment specified in the plan.

Hospice care program

The term Hospice Care Program means:

  • A coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and their families;
  • A program that provides palliative and supportive medical, nursing and other health services through home or inpatient care during the illness;
  • A program for persons who have a Terminal Illness and for the families of those persons.

Hospice care services

The term Hospice Care Services means any services provided by: (a) a Hospital, (b) a Skilled Nursing Facility or a similar institution, (c) a Home Health Care Agency, (d) a Hospice Facility, or (e) any other licensed facility or agency under a Hospice Care Program, and is a Medicare approved Hospice Care Program.

Hospice facility

The term Hospice Facility means an institution or part of it which:

  • Primarily provides care for Terminally Ill patients;
  • Is accredited by the National Hospice Organization;
  • Meets standards established by Cigna; and
  • Fulfills any licensing requirements of the state or locality in which it operates.

Hospital

The term Hospital means:

  • An institution licensed as a hospital, which: (a) maintains, on the premises, all facilities necessary for medical and surgical treatment; (b) provides such treatment on an inpatient basis, for compensation, under the supervision of Physicians; and (c) provides 24-hour service by Registered Graduate Nurses;
  • An institution which qualifies as a hospital, a psychiatric hospital or a tuberculosis hospital, and a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals; or
  • An institution which: (a) specializes in treatment of mental illness, alcohol or drug abuse or other related illness; (b) provides residential treatment programs; and (c) is licensed in accordance with the laws of the appropriate legally authorized agency.

The term Hospital will not include an institution, which is primarily a place for rest, a place for the aged, or a nursing home.

Injury

The term Injury means an accidental bodily injury.

Medicaid

The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medicare

The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.

Mental illness

The term "mental illness" means any disorder, other than a disorder induced by alcohol or drug abuse, which impairs the behavior, emotional reaction or thought process of a person, regardless of medical origin. In determining benefits payable, charges made for the treatment of any physiological symptoms related to a mental illness will not be considered to be charges made for treatment of a mental illness.

Necessary services and supplies

The term Necessary Services and Supplies includes any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during Hospital Confinement. The term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees.

Network

Providers and facilities that participate in a health maintenance organization available under this Cigna OAPIN Option.

Nurse

The term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation "R.N.," "L.P.N." or "L.V.N."

Outpatient mental illness services

Outpatient Mental Illness Services are services of providers who are qualified to treat mental illness when treatment is provided on an outpatient basis, while you or your eligible/covered Family Member is not confined in a Hospital, in an individual, group or structured group therapy program. Covered Services include, but are not limited to, outpatient treatment of conditions such as: anxiety or depression which interferes with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic mental illness conditions (crisis intervention and relapse prevention) and outpatient testing and assessment.

Participating pharmacy

The term Participating Pharmacy means a retail pharmacy or mail-order pharmacy with which Cigna has contracted, either directly or indirectly, to provide prescription services to its plan participants.

Participating provider

The term Participating Provider means:

  • An institution, facility, agency or healthcare professional which has contracted directly or indirectly with Cigna.

The providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers will be provided with this booklet.

Pharmacy & Therapeutics (P&T) Committee

A committee of Provider Organization members comprised of Medical providers, Pharmacists, Medical Directors and Pharmacy Directors, which reviews medications for safety, efficacy, cost effectiveness and value. The P & T Committee evaluates medications for addition to or deletion from the Formulary and may also set dispensing limits on medications. Related Services are also reviewed & evaluated.

Physician

The term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the services are received if he is:

  • Operating within the scope of his license; and
  • Performing a service for which benefits are provided under this Cigna OAPIN Option when performed by a Physician.

Prescription drug

Prescription Drug means; (a) a drug which has been approved by the Food and Drug Administration for safety and efficacy; or (b) certain drugs approved under the Drug Efficacy Study Implementation review; or (c) drugs marketed prior to 1938 and not subject to review, and which can, under federal or state law, be dispensed only pursuant to a prescription order; or (d) injectable insulin

Primary Care Physician

The term Primary Care Physician means a Physician: (a) who qualifies as a Participating Provider in general practice, internal medicine, family practice or pediatrics; and (b) who has been selected by you, as authorized by the Provider Organization, to provide or arrange for medical care for you or any of your covered Family Members.

Provider organization

The term Provider Organization refers to a network of Participating Providers.

Psychologist

The term Psychologist means a person who is licensed or certified as a clinical psychologist. Where no licensure or certification exists, the term Psychologist means a person who is considered qualified as a clinical psychologist by a recognized psychological association. It will also include: (1) any other licensed counseling practitioner whose services are required to be covered by law in the locality where the services are received if he is: (a) operating within the scope of his license; and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist; and (2) any psychotherapist while he is providing care authorized by the Provider Organization if he is: (a) state licensed or nationally certified by his professional discipline; and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist.

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 Medical Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.

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

One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare Eligible retirees, survivors and their family members.

Self-funded plan

A self-funded plan option, under the 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 these self-funded options, they may look just like fully-insured plans. For example, the Cigna OAPIN option under the Medical Plan is a self-funded plan.

Cigna is responsible for only administering the plan. (i.e., Cigna is the claims processor for the self-insured plan.) ExxonMobil is responsible for funding the plan to pay health claims. This does not impact the benefits provided under the Cigna OAPIN Option under the Medical Plan. The U.S. Department of Labor regulates selffunded plans, not the state insurance department.

You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.

Service area

The geographic area designated by the Cigna OAPIN Option in which an individual must live in order to be an eligible member. This area is determined by the participant's home address zip code.

Sickness - for medical coverage

The term Sickness means a physical or mental illness. It also includes pregnancy. Covered Expenses incurred for routine Hospital and pediatric care of a newborn child prior to discharge from the Hospital nursery will be considered to be incurred as a result of Sickness.

Skilled nursing facility

The term Skilled Nursing Facility means a licensed institution (other than a Hospital) which specializes in:

  • Physical rehabilitation on an inpatient basis; or
  • Skilled nursing and medical care on an inpatient basis;

but only if that institution (a) maintains on the premises all facilities necessary for medical treatment; (b) provides such treatment, for compensation, under the supervision of Physicians; and (c) provides Nurses' services.

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.

Terminal illness

A Terminal Illness will be considered to exist if a person becomes terminally ill with a prognosis of six months or less to live, as diagnosed by a Physician.

Trainee

An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.

Urgent care

Urgent Care is medical, surgical, Hospital or related health care services and testing which are not Emergency Services, but which are determined by Cigna, in accordance with generally accepted medical standards, to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or were scheduled to receive services. Such care includes, but is not limited to, dialysis, scheduled medical treatments or therapy, or care received after a Physician's recommendation that the covered person should not travel due to any medical condition.