Dental Plan

Summary plan description of the ExxonMobil Dental Plan as of January 2017

About the Dental Plan

This summary plan description (SPD) is a summary of the ExxonMobil Dental Plan. It does not contain all the Plan details. In determining your specific benefits, the full provisions of the formal documents, as they exist now or as they may exist in the future, always govern. You may obtain copies of these documents by making a written request to the Administrator-Benefits. Exxon Mobil Corporation reserves the right to change benefits in any way or terminate any benefit at any time.

The Dental Plan is self-insured. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. These options are governed by federal laws, not by state insurance laws.

Notice: The Dental Plan is an excepted benefit under PPACA and is not minimum essential coverage. Since it is not minimum essential coverage, you may not treat it as required coverage when filing your U.S. Federal Income Tax return.

Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.

Information sources

When you need information, you may contact:

Claims and dental Preferred Provider Organization (PPO) administrator

Provides claim payment information, Aetna Dental PPO provider and claim forms.

Phone numbers:

Aetna Member Services
800-255-2386 OR
210-366-2416 (international, call collect)
Monday - Friday 8:00 a.m. to 6:00 p.m. (Central Time), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week

Address:

Aetna 
P. O. Box 14094 
Lexington, KY 40512-4094

Benefits Administration

Customer Service Representatives can provide specialized assistance. References to Benefits Administration throughout this SPD refer to either ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed below. Depending on your status (employee, retiree, or survivor), you should contact the appropriate service center.

Employees can enroll/change benefits on the ExxonMobil Me HR Intranet site through Employee Direct Access (EDA) when a change in status occurs. Enrollment forms are also available through ExxonMobil Benefits Administration for those without access to EDA.

Phone numbers:
Employees call:

ExxonMobil Benefits Administration/Health Plan Services
Monday - Friday 8:00 a.m. to 3:00 p.m. (Central Time), except certain holidays
800-262-2363 (toll free outside Houston)
262-314-2752 (fax)
hr.medical.dental.questions@exxonmobil.com (E-mail)

Retirees and Survivors call:
ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m.
(Eastern Time), except certain holidays 
Toll-Free: 1-800-682-2847
or 800-TDD-TDD4 (833-8334) for hearing impaired

Address:
ExxonMobil Benefits Administration
ExxonMobil BA BSC USBA 
P.O. Box 64111
Spring, TX 77387-4111

ExxonMobil Benefits Service Center
P.O. Box 18025
Norfolk, VA 23501-1867

ExxonMobil Sponsored Sites - Access to plan-related information including claim forms for employees, retirees, survivors, 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.
  • Retiree online community internet site - can be accessed from home by retirees and survivors only at www.emretiree.com.
  • ExxonMobil benefits service center at Xerox internet site - can be accessed from home by everyone at www.exxonmobil.com/benefits.

Aetna does not render dental services or treatments. Neither the Plan nor Aetna is responsible for the services that are delivered by providers participating in the Aetna Dental PPO and those providers are solely responsible for the dental services they deliver. Providers are not the agents nor employees of the Plan or Aetna.

Introduction

The ExxonMobil Dental Plan (the Plan) encourages good dental health by paying, within plan limits, for 100% of the cost of preventive services and part of the cost of other general and major services, including orthodontia. The Plan offers you the opportunity to use the Aetna Dental PPO Network, a voluntary PPO.  Because participating dentists and dental specialists have agreed to provide their services at negotiated rates, you will save money and maximize your annual Plan benefits when you choose to receive care from a participating dentist.  ExxonMobil's dental plan is described in detail in this SPD. These tools help you find specific information quickly and easily:

  • Plan at a glance, a quick user's guide highlighting plan basics.
  • Charts and tables throughout this SPD provide information, examples, highlights of plan provisions, etc.
  • References to sources of additional information.
  • Key terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification.

A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions.

Plan at a glance

Enrolling

You may enroll yourself and your eligible family members within your first 60 days of employment or within 60 days of a subsequent change in status or at Annual Enrollment. See How to enroll

The Dental PPO

You can visit any dentist – but save when you choose a dentist who participates in the Aetna Dental PPO network. The negotiated rates for the dentist's services are always within reasonable and customary (R&C) limits and generally lower than rates charged by non-network dentists which helps you maximize your annual plan benefit by paying less out of pocket for covered services. See Dental PPO

Covered and excluded expenses

The Plan provides benefits for many, but not all, preventive, general, major and orthodontic services. See the Covered expenses section.

Payments

You and the Plan share the costs for covered treatments and services. You pay a deductible before the Plan begins paying for certain benefits. For each covered person, the Plan pays up to $2,000 each calendar year for covered dental expenses (other than preventive and orthodontic services) and up to a $2,000 lifetime maximum benefit for covered orthodontic expenses. See Payments.

Claims

Dental PPO providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See Claims.

Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)

You and your family members who lose eligibility may continue dental coverage for a limited time in certain circumstances. See Continuation coverage

Administrative and ERISA information 

This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, (ERISA) as amended, not state insurance laws. See Administrative and ERISA information.

Key terms 

This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See Key terms

Benefit summary 

A brief summary of benefits. See Benefit summary