Covered expenses

Covered expenses for the ExxonMobil Dental Plan

Q. What types of dental services are covered by the Plan?

A. The Plan divides dental services into four categories:

For all coverage, benefits are payable only for charges up to the reasonable and customary amount for similar services and supplies in the area. PPO dentists' charges are always within the reasonable and customary amount (see Adjustments to billed charges in the Payments section).

To be covered, an expense must be incurred by a plan participant for preventive dental care or for the care and treatment of dental disease or accidental injury and such service or treatment must be:

An expense or charge is generally considered incurred on the date the service is provided, with these exceptions:

  • Fixed bridges, crowns, inlays, onlays, or gold restorations are considered incurred on the first day of preparation of the tooth or teeth involved.
  • Full or partial dentures are considered incurred on the date the impression is taken.
  • Endodontics are considered incurred on the date the tooth is opened for root canal therapy
  • Dental implants are considered incurred on the date the implant post is inserted.  The implant crown is considered incurred on the date it is placed on the implant post.

Preventive services

To encourage good oral health and improve overall health of participants, the Plan pays 100% of covered charges for the following preventive services with no deductible and these expenses are not applied to the annual dental maximum:

  • Diagnostic oral examinations (up to four diagnostic oral examinations per calendar year)
  • Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year)
  • Diagnostic supplementary (bite-wing) X-rays (limited to four times each calendar year).
  • Periapical X-rays
  • Diagnostic full-mouth or panoramic X-rays* (limited to once in any three consecutive years).
  • Topical stannous fluoride application (limited to four times each calendar year).
  • Space maintainers and their insertion (limited to deciduous teeth whether primary or baby teeth and treatment for a covered family member under age 19).
  • Tooth sealants applied to a permanent molar (limited to one application per tooth in any three consecutive years).
  • Occlusal (night) guards for the treatment of bruxism (limited to one appliance in any two calendar-year period).

* Limitation does not apply to orthodontia treatment

Emergency treatment

The Plan also pays 100% of reasonable and customary covered charges for diagnostic x-rays and examination charges for problem focused limited oral exams. If you incur charges for urgent treatment on a day when you receive other dental services, such as a routine checkup or an extraction, the problem focus limited oral examination charges will be covered.

Example:

Suppose you see your dentist for an emergency toothache. Your dentist gives you an emergency examination, takes x-rays, and asks you to return for treatment at a later time. These costs are 100% reimbursable by the Plan.

If your dentist does an extraction in addition to the x-rays and emergency examination, these services are covered by the Plan, even if incurred on the same day. The emergency examination and x-rays would be covered at 100% and the extraction at 80%.

General services

After you meet an annual deductible of $50 per person (maximum of $150 per family), the Plan pays 80%, or as otherwise specified, of covered charges for the following services:

  • Care and treatment involving tooth extractions, fractures, and dislocations of the jaw, and cutting procedures in the oral cavity.
  • Root canals and other endodontic treatment.
  • General anesthetic in connection with oral surgery, periodontics, fractures, and dislocations if medically necessary according to Aetna guidelines.
  • Injection of antibiotics in conjunction with treatment of a covered dental expense if medically necessary according to Aetna guidelines.
  • Fillings, other than gold fillings. (For gold fillings, see Major services below.)
  • Repair and rebasing existing dentures or fixed bridges. (Replacing such dentures and fixed bridges is described under Major services below.)
  • Addition of teeth to existing denture or fixed bridges if required by loss of natural teeth.
  • Pre-surgery oral exams.
  • Crown build-ups, when approved.

Major services

After you meet the annual deductible of $50 per person (maximum of $150 per family), the plan pays 50% of covered charges for these services:

  • Full or partial dentures or fixed bridges or implants and their initial insertion. Replacement of existing devices can only be covered if such device cannot be made serviceable and is more than five years old. This includes any abutment to an implant and the crown over the implant.  The Plan does not cover charges for adjusting dentures or bridges within six months of installation. Such follow-up visits are normally included in initial charges.
  • Gold fillings and permanent crowns— or their replacement — necessary for restoration of tooth structure broken down by decay, injury or severe attrition.
  • Inlays and onlays as major services paid at 50%.

Separate charges for temporary fillings and crowns are not covered. If you are charged for both temporary and permanent crowns or dentures, only the charge for the permanent crown or denture is covered.

Orthodontic services

The Plan pays 50% of covered charges with no deductible up to the orthodontic lifetime limit of $2,000 per person for orthodontic services and supplies to correct malposed teeth. (See Orthodontia lifetime maximum in the Payments section for more information.)

When an employee is first eligible and enrolls in the Plan, orthodontic services and supplies will be covered even if the insertion of the first appliance occurs prior to becoming a covered person.

In addition to traditional orthodontia treatments, the Plan provides coverage for Invisalign however benefits are payable only for charges up to the reasonable and customary amount for similar services such as Comprehensive Orthodontic Treatment ("Braces"). This means that you are responsible for the excess amount.   As with other orthodontic treatments, these charges are subject to your orthodontia lifetime maximum.

The tool referenced below shows how benefits are paid from the ExxonMobil Dental Plan and reimbursements are made from your Health Care Flexible Spending Account. Refer to the Pre-Tax Spending Plan Summary Plan Description when using Pre-Tax Plan for orthodontia reimbursement.  Monthly reimbursements are based on your treatment plan (number of months braces are on the teeth), not your payment schedule. The orthodontia lifetime maximum benefit is $2,000 per covered person.

NOTE:  If you are paying your orthodontic services in full up front, contact Aetna member services for claim handling guidelines for your Health Care Flexible Spending Account.

The orthodontia calculator does not calculate correctly if orthodontia services are paid in full upfront. 

Go to

www.exxonmobil.com/Family-English/HR/Files/CALCULATOR_ORTHO2008_091907.xls

for the Orthodontia FSA Expenses Calculator.