A physician who accepts Medicare assignment agrees to accept no more than the Medicare-approved amount as total payment for a service.
The amount on which Medicare bases its payments for a particular service.
A period beginning when you enter a hospital and ending after you have remained out of the hospital (or a skilled-nursing facility) for 60 consecutive days.
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 or 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.
A person specializing in clinical psychology who is licensed or certified by an appropriate governmental authority. If there is no licensing or certification in a particular area, he or she must be a member or fellow of the American Psychological Association.
The portion of covered expenses you pay. For some services the co-insurance will be a percentage of the cost of the service once the deductible has been satisfied. For outpatient prescription drugs there is a percentage co-payment.
Expenses that are eligible for reimbursement under the Plan. Some expenses must be Medicare-approved to be covered. All expenses must meet Plan requirements including medical necessity.
Care primarily helping meet personal needs and daily living activities such as walking, bathing, dressing, eating and giving medicine. Neither Medicare nor the Plan covers custodial care, even if ordered by a physician and provided by a licensed professional.
The amount of covered expenses you incur before a plan begins to pay. Medicare and the Plan have separate and different deductibles.
You may qualify for Social Security and Medicare by virtue of a disability, even if you are less than age 65.
Eligibility rule for participants of the Comprehensive Medical Expense Benefit Plan of Mobil Oil Corporation and the Superior Oil Medical Plan
If you or your family members were participating in the Comprehensive Medical Plan of Mobil Oil Corporation on March 31, 2004, and you were Medicare eligible, you are a participant in the Plan effective April 1, 2004. In addition, individuals who became your eligible family members (e.g., marriage) after March 31, 2004, are eligible.
Eligible family members are generally:
The spouse of an eligible retiree;
- The surviving spouse, who has not remarried, of a deceased eligible retiree;
- The surviving spouse, who has not remarried, of a deceased employee;
- The child of an eligible retiree;
- The child, whose surviving parent has not remarried, of a deceased employee or eligible retiree; or
- A person who becomes an eligible family member of an ExxonMobil eligible retiree by marriage after becoming eligible for Medicare. To participate in the Plan under this provision, prior group health coverage is not required. However, the person must be added as a covered family member within 30 days of becoming eligible.
In the Plan, an eligible retiree is a person who:
- Retired with retiree status from ExxonMobil;
- Retired with retiree status from Exxon;
- Retired with retiree status from Mobil or Superior Oil;
- Is a former Exxon or ExxonMobil employee who retired with retiree status from Exxon or ExxonMobil and is not currently working for ExxonMobil as a regular or non-regular employee
- Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this plan.
- A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if any of the following apply:
- The drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and, approval for marketing has not been given at the time it is furnished; Note: Approval means all forms of acceptance by the FDA.
- Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
- Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis. Reliable evidence shall mean only:
- Peer reviewed, published reports and articles in the authoritative medical and scientific literature;
- The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
- The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.
A statement summarizing charges and payments for medical services including the amount paid by Medicare or the Plan, and amounts remaining to be paid.
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 (or MSP) as constituent parts.
Medically necessary care and equipment provided at home by a Medicare-certified agency on a part-time or intermittent basis by skilled nurses, home-health aides, occupational, physical or speech therapists and those providing medical social services.
An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense which is:
- Accredited by the Joint Commission on Accreditation of Hospitals;
- A hospital, psychiatric hospital or a tuberculosis hospital, as those terms are defined in Medicare (or as may be amended by Medicare in the future), which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare; or
- An institution which:
- maintains on its premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians;
- continuously provides on its premises twenty four hour a day nursing service by or under the supervision of registered graduate nurses; and
- functions continuously with organized facilities for operative surgery on its premises.
The maximum amount (currently 115% of 95%, or 109.25% of the Medicare-approved amount) a physician may require a Medicare beneficiary to pay for a covered service if the physician does not accept assignment.
Services or supplies that are: legal; ordered by a physician or clinical psychologist; safe and effective in treating the condition for which ordered; part of a course of treatment generally accepted by the American medical community; of a proper quantity, frequency and duration for treating the condition for which ordered; not redundant when combined with other services and supplies used to treat the condition for which ordered; not experimental, meaning unproven by long-term clinical studies; and for the purpose of restoring health or extending life.
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 (4th ed. 1994) (DSM-IV), or its successor publication, and which is otherwise covered by Medicare. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.
See skilled-nursing care.
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).
Services and supplies provided by a hospital or skilled-nursing facility required to treat a patient. Excluded are fees for room and board and fees charged by physicians, private-duty or special nursing services.
A prescription drug or medicine obtained through either a retail pharmacy or through a mail order prescription service (including insulin and associated diabetic supplies if acquired through a prescription). A prescription drug or medicine, including injections, obtained or administered in a physician's office or in a hospital are not considered outpatient prescription drugs.
That part of Medicare which pays certain hospital and skilled-nursing facility bills.
That part of Medicare which pays certain physician and other medical bills.
That part of Medicare that provides Medicare Advantage plans.
That part of Medicare which pays certain outpatient prescription drug bills.
Physician means a person 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.
The participant whose Social Security number or Aetna Member Identification Number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's Social Security number or Aetna Member Identification Number to access all benefits.
An amount which is less than or equal to the most common charge for a particular medical service or supply in a particular geographic area. The Plan bases its payments on the lesser of the actual amount charged, the reasonable and customary amount, or the Medicare limiting charge, except when the provider accepts assignment under Medicare (then the Medicare-approved amount is used).
A Medicare term for available benefits after you use 90 days of hospital coverage in any benefit period. You have a lifetime maximum of 60 reserve days.
Generally, a person at least 55 years old who retires as a regular employee with 15 years of 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.
One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members.
Room, board, general-duty nursing and any other services regularly furnished by the hospital as a condition of being hospitalized. It does not include professional services of physicians or private-duty nursing.
Care requiring services only licensed medical professionals can provide in the home or in a skilled-nursing facility. Both Medicare and the Plan cover such care when prescribed by a physician and determined to be medically necessary. These types of services are sometimes called non-custodial nursing care.
A Medicare-approved institution meeting government-prescribed standards for skilled-nursing care or skilled-rehabilitation services. The Plan covers only Medicare-approved skilled-nursing facilities.
Services only licensed rehabilitation professionals can provide. Both Medicare and the Plan cover such care when prescribed by a physician and determined to be medically necessary.
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.
A surviving unmarried spouse of a deceased ExxonMobil regular employee or retiree.