Q. How does the Plan work?
A. In addition to outpatient prescription drugs, the Plan covers certain other expenses. You and the Plan share costs for covered treatment and services. You must satisfy an annual deductible before the Plan considers expenses for payment. Once the annual deductible is met, the Plan's reimbursement level - when combined with Medicare - is 80% for the following expenses: covered charges that are paid by Medicare at less than 80%, claims from outside the U.S., and in-home skilled nursing care. The Plan also includes an annual out-of-pocket limit that includes your deductible. If you should meet your annual out-of-pocket limit, the Plan's reimbursement level — when combined with Medicare — is 100% of most covered charges for the rest of that calendar year. For examples, please see chart in the Benefit summary.
Each year you must meet the deductible before any expenses, other than outpatient prescription drugs, are eligible for reimbursement by the Plan.
You may become eligible for the Plan during a year in which you have met part or all of the deductibles under another medical plan to which ExxonMobil contributes. Those amounts apply to your deductible for the Plan, but do not apply to Medicare deductibles.
Annual out-of-pocket limit
The Plan protects you against most extremely high medical expenses. It does so by limiting your annual out-of-pocket payments for most covered expenses to $3,000 per person. Once you have spent $3,000 for covered expenses (including your deductibles), the Plan's reimbursement level when combined with Medicare is 100% for most covered charges during the remainder of that year.
For the year in which you become eligible for the Plan, this limit includes your out-of-pocket amounts for covered expenses while participating in any medical plan to which ExxonMobil contributes.
Certain expenses do not count toward this out-of-pocket limit, including:
- Your share of the costs of outpatient prescription drugs.
- Your share of the cost of in-home skilled nursing care.
- Charges above the Plan's reasonable and customary limits or the Medicare limiting charge.
- Charges not covered by the Plan, such as the difference in cost between a private and semiprivate hospital room.
To receive credit for medical deductibles and out-of-pocket expenses paid under another ExxonMobil plan, attach an explanation of benefits from that plan showing up-to-date information about your expenses when filing your first claim.
No lifetime limit
There is no lifetime maximum for the Plan.
Mental health treatment
Like other types of covered medical expenses where the Plan may provide a benefit even though Medicare does not, the Plan will reimburse 80% of reasonable and customary charges for covered mental health treatment.
Medicare only pays for outpatient mental health care and professional services when they are provided by a health care professional who can be paid by Medicare. You should ask your provider if they accept Medicare payment before you schedule treatment. If Medicare does not cover mental health treatment, the Plan will reimburse 80% of reasonable and customary charges. For example, mental health treatment rendered outside the U.S. is not covered by Medicare; however, it is covered under the Plan.
A transition benefit will be provided under the Plan when medically appropriate as determined by Aetna. A transition benefit will be provided:
- If such medical expenses were covered under a medical plan that was sponsored by ExxonMobil, and
- the covered person was participating in a medical plan sponsored by ExxonMobil that covered such care immediately prior to the covered person becoming Medicare eligible and moving into the Plan, and
- expenses for such care are excluded from coverage by Medicare; and
- a transition benefit request form is submitted to Aetna by the covered person's treating physician.
Example 1 — Care in a skilled-nursing facility and the annual out-of-pocket limit:
This example assumes you have met all Medicare and Plan deductibles when, following a period of hospitalization, you enter a Medicare-approved skilled-nursing facility. You remain there 100 days. The facility charges and Medicare approves $300 a day. The total bill is $30,000. It also assumes you have covered out-of-pocket expenses of $900 before you entered the skilled-nursing facility.
How the benefit is calculated
Example 2 — Major surgery:
This example assumes a seven-day hospital stay for major surgery. In addition to hospital charges, there are fees for a surgeon and an anesthesiologist. It also assumes you have not met the Part A deductible but that you have met the Part B and the Plan deductibles and that all providers accept Medicare assignment. Here is what such a procedure might cost:
How the benefit is calculated
- All of the Medicare-approved hospital charges except the Part A deductible $22,000 - $1,260 (Part A deductible) = $20,740
- 80% of surgeon's and anesthesiologist's Medicare-approved amount $1,875 x .80 = $1,500
The Plan starts with the total Medicare-approved amount.
- 80% of Medicare-approved hospital charges minus Medicare payment $22,000 x .80 =
$17,600 - $20,740 = $0
- 80% of surgeon's and anesthesiologist's bills minus Medicare payment $1,875 x .80 =
$1,500 - $1,500 = $0
- Medicare Part A deductible $1,260
- 20% of surgeon's and anesthesiologist's bills $1875 x .20 = $375
- Total = $1,635
In this example, the $23,875 in expenses is paid as follows:
Of the total charges, Medicare paid 93%, and you paid the remaining 7%. Because Medicare paid more than 80%, the Plan pays $0.
Example 3 — Traveling or living outside the United States:
Medicare does not generally cover medical care received while traveling or living outside the United States. The Plan pays for certain covered expenses at 80% after your annual medical deductible has been met. (See Expenses incurred outside the United States, for more information).
In this example, you incur $22,000 in covered medical expenses while vacationing in Europe.
How the benefit is calculated
Medicare does not cover these expenses.
- Plan deductible $300
- 20% of $21,700 = $4,340
- Total = $4,640
The actual results - applying your annual out-of-pocket limit
Because the Plan limits your annual out-of-pocket expenses to $3,000, the bill is paid as follows:
See the Claims section for information about filing a claim and the Coordination of Benefits section to learn how the Plan coordinates benefits.
In-home skilled-nursing care
With few exceptions, Medicare does not cover skilled-nursing care at home. If you need nursing care at home, there are two types of care — one is covered by the Plan and the other is not:
- Skilled-nursing care is care that only licensed medical professionals can provide. Feeding someone intravenously is an example of skilled-nursing care. This type of care is covered by the Plan but generally not by Medicare. However, Medicare does cover some intermittent short-term service if a homebound patient needs occasional skilled-nursing care but only in limited situations.
- Custodial care is care which primarily helps people meet personal needs and daily living activities — care which does not require the services of a licensed medical professional. Helping someone eat, walk, bathe and dress — even if ordered by a physician, and even if performed by a licensed professional — are examples of custodial care. Custodial care is not covered by either Medicare or the Plan.
A hospital, nursing home or other facility that mainly provides nursing or rehabilitation services cannot be considered your home.
If you think you need in-home skilled-nursing care, contact Aetna immediately. Aetna must pre-approve this care.
When considering whether nursing care is a covered expense, the critical question is: Does the care require the presence of licensed medical personnel to perform, observe, evaluate or teach?
If the answer is no, the Plan does not cover such care. The severity of a patient's condition is not a factor. A patient with an ongoing and steadily deteriorating condition may require constant attention, but may rarely require the services of a licensed medical professional. Only services requiring such a professional are covered.
If the answer is yes, the Plan covers in-home skilled-nursing care if you meet these conditions:
- Care has been approved in advance by Aetna. (See Information sources at the front of this SPD.)
- A physician must certify the care is medically necessary. The care given must actually be skilled-nursing care as described in this section below.
- A registered nurse, a licensed practical nurse or a licensed vocational nurse must provide the care.
- The Plan covers as much as 24-hour-a-day care for up to 30 days in any calendar year.
- The Plan covers up to 16 hours a day for as long as the care is needed.
None of the money you spend on in-home skilled-nursing care counts toward your annual out-of-pocket limit.
Example 1 — In-home skilled-nursing care:
In this example, you have satisfied plan requirements for in-home skilled-nursing care, and you have met the annual deductible. You have not had any other charges for in-home skilled-nursing care during this calendar year. You need such care for four hours a day for 42 days. Assuming this care costs $40 an hour, the daily cost is $160 a day. The cost for 42 days is $6,720.
How the benefit is calculated
Medicare does not pay for this type of service.
The Plan pays 80% of covered charges:
The $6,720 bill is paid as follows:
None of your share of the cost of in-home skilled-nursing care applies to your annual out-of-pocket limit. The Plan will never pay 100% of in-home skilled-nursing care expenses.