EXXONMOBIL DENTAL PLAN - SUMMARY PLAN DESCRIPTION 201
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ExxonMobil Dental Plan
Summary Plan Description
201
About Dental
- Information Sources ExxonMobil Dental Plan SPD
- Introduction As of January 2014
- Plan at a Glance
Eligibility and Enrollment
About The Dental Plan
Dental PPO 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
Covered Expenses
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
Exclusions
change benefits in any way or terminate any benefit at any time.
Payments
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.
Claims
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
Continuation Coverage by state insurance laws.
Administrative and ERISA
Notice: The Dental Plan is an excepted benefit under PPACA and is not minimum
Information
essential coverage.
Key Terms
Applicability to represented employees is governed by collective bargaining
agreements and any local bargaining requirements.
Benefit Summary
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: Address:
Aetna Member Services Aetna
800-255-2386 OR P. O. Box 14094
210-366-2416 (international, call collect) Lexington, KY 40512-
Monday - Friday 8:00 a.m. to 6:00 p.m. (Central Time), 4094
except certain holidays
Automated Voice Response - 24 hours a day, 7 days a
week2
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: Address:
Employees call: ExxonMobil Benefits
ExxonMobil Benefits Administration/Health Administration
Plan Services ExxonMobil BA BSC USBA
Monday - Friday 8:00 a.m. to 3:00 p.m. (Central 4300 Dacoma or "BH1"
Time), except certain holidays Houston, TX 77092
713-680-5858 (Houston)
713-680-7070 (international, call collect)
800-262-2363 (toll free outside Houston)
262-314-2752 (fax)
Retirees and Survivors call: ExxonMobil Benefits
ExxonMobil Benefits Service Center Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m. PO Box 199540
(Eastern Time), except certain holidays Dallas, TX 75219-9722
Toll-Free: 1-800-682-2847
or 800-TDD-TDD4 (833-8334) for hearing
impaired
ExxonMobil Sponsored Sites — Access to plan-related information including claim
forms for employees, retirees, survivors, and their family members.
z ExxonMobil Me, the Human Resources Intranet Site — can be accessed at
work by employees.
z ExxonMobil Family, the Human Resources Internet Site — can be
accessed from home by everyone at www.exxonmobilfamily.com.
z Retiree Online Community Internet Site — can be accessed from home by
retirees and survivors only at www.emretiree.com.
z 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.3
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:
z Plan at a Glance, a quick user's guide highlighting plan basics.
z Charts and tables throughout this SPD provide information, examples,
highlights of plan provisions, etc.
z References to sources of additional information.
z 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.4
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 page 7.
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 page 16.
Covered and Excluded Expenses
The Plan provides benefits for many, but not all, preventive, general, major and
orthodontic services. See pages 18-21 and 22-23.
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 page 24.
Claims
Dental PPO providers file claims for you. You are responsible for ensuring that claims
for non-network care are filed. See page 29.
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 page 33.
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 page 38.
Key Terms
This is an alphabetized list of words and phrases, with their definitions, used in this
SPD. See page 45.
Benefit Summary
A brief summary of benefits. See page 52.About Dental
Eligibility and Enrollment
Eligibility and Enrollment
- Eligible Family Members Q. What are the Plan's eligibility requirements?
- Suspended Retiree
- Special Eligibility Rules
A. Most U.S. dollar payroll regular employees of Exxon Mobil
- Classes of Coverage
Corporation and participating affiliates are eligible for this Plan.
- Double Coverage
- How to Enroll
- Changing Your Coverage Generally, you are eligible if:
- Changes in Status z You are a regular employee.
- Changes During the Year z You are an extended part-time employee.
- Other Changes That May Affect z You are a retiree.
Your Coverage z You are a survivor, which means an eligible family member of a deceased
- When Coverage Ends regular or extended part-time employee or retiree.
- Loss of Eligibility
You are not eligible if:
Dental PPO z You participate in any other employer dental plan to which ExxonMobil
contributes.
Covered Expenses z You fail to make any required contribution toward the cost of the Plan.
z You fail to comply with general administrative requirements including but not
Exclusions limited to enrollment requirements.
z You lost eligibility as described under the Loss of Eligibility section on page
Payments
14.
Claims
Eligible Family Members
Continuation Coverage
You may also elect coverage for your eligible family members including:
Administrative and ERISA
Information z Your spouse. When you enroll your spouse for coverage, you may be required
to provide proof that you are legally married.
Key Terms z Your child(ren) under age 26. Coverage ends at the end of the month in which
they reach age 26. If your situation involves a family member other than your
Benefit Summary biological or legally adopted child, call Benefits Administration.
z Your totally and continuously disabled child(ren) who is incapable of self-
sustaining employment by reason of mental or physical disability, that occurred
prior to otherwise losing eligibility and meets the Internal Revenue Service's
definition of a dependent.
z A child or spouse of a Medicare-eligible retiree enrolled in the ExxonMobil
Medicare Supplement Plan, as long as that spouse or child is not eligible for
Medicare.
Refer to Key Terms for definitions of eligible family members, child, suspended
retiree, spouse, and Qualified Medical Child Support Order.6
Suspended Retiree
A person who becomes a retiree due to incapacity within the meaning of the
ExxonMobil Disability Plan and who begins long-term disability benefits under that
plan, but whose benefits stop because the person is no longer incapacitated is
considered a suspended retiree and is not eligible for coverage until the earlier of the
date the person:
z Reaches age 55, or
z Begins his or her retirement benefit under the ExxonMobil Pension Plan, at
which time the person is again considered a retiree and may enroll.
The family members of a deceased suspended retiree will be eligible for coverage
under this Plan only after the occurrence of the earlier of the following:
z The date the suspended retiree would have attained age 55, or
z The date a survivor begins receiving a benefit due to the suspended retiree's
accrued benefit from the ExxonMobil Pension Plan.
Special Eligibility Rules
A person who otherwise is not a spouse but who, as a dependent of a former Mobil
employee who participated in or received benefits under a Mobil-sponsored plan or
program prior to March 1, 2000, is considered an eligible dependent as long as that
person's eligibility for coverage as a dependent under a Mobil-sponsored plan would
have continued.
Classes of Coverage
You can choose coverage as an:
z Employee or retiree only;
z Employee or retiree and spouse;
z Employee or retiree and child(ren).
There are also classes of coverage for extended part-time employees, surviving
spouses and family members of deceased employees and retirees and employees on
certain types of leaves of absence.
For employees on an approved leave of absence, their contribution rate will change
from the employee contribution rate to the Leave of Absence contribution rate as
shown in the table on the next page.7
Leave of Absence Contribution Rate begins
Type of Leave Immediately No later than No later than
after 6 months after 12 months
Military (voluntary) X
Civic Affairs X
Health / Dependent Care X
Education X
Personal X
Each class of coverage described in this section has its own contribution rate.
Employees contribute to the Dental Plan through monthly deductions from their pay on
a pre-tax or after-tax basis. Retirees and survivors receiving monthly benefit checks
from ExxonMobil pay by deductions from these checks on an after-tax basis. Other
retirees or survivors and participants with continuation coverage pay by check or by
monthly draft on their bank account.
Double Coverage
No one can be covered more than once in the Dental Plan . You and your spouse
cannot both enroll as employees (or retirees) and elect coverage for each other as
eligible family members. If you and your spouse work for the company or are both
retirees you may both be eligible for coverage. Each of you can be covered as an
individual employee (or retiree), or one of you can be covered as the employee (or
retiree) and the other can be an eligible family member. Also, if you have children,
each child can only be covered by one of you.
In addition a marriage between two ExxonMobil employees does not allow enrollment
or cancellation in any of the ExxonMobil health plans if either employee is then making
contributions on a pre-tax basis. In order to change your coverage you need to wait
until you experience a change in status that allows coverage changes or Annual
Enrollment.
How to Enroll
As a newly hired employee, if you enroll in the Dental Plan within 30 days of your start
date, coverage begins the first day of employment. If you enroll between 31 and 60
days of your date of hire, coverage will be effective the first day of the month following
receipt of the forms by Benefits Administration.
If you are eligible for the ExxonMobil Pre-Tax Spending Plan, you will be enrolled to
pay your monthly contributions on a pre-tax basis unless you annually decline this
feature. Your monthly pre-tax contributions and class of coverage must remain in
effect for the entire plan year, unless you experience a change in status. (See Annual
Enrollment and Changing Your Coverage sections.)
You can enroll eligible family members only if you are enrolled in this Plan. You can
enroll in the Plan using Employee Direct Access (EDA) available on the ExxonMobil
Me HR Intranet site. Enrollment forms are also available from Benefits Administration
for those individuals who do not have access to EDA.
You may be requested to provide documents at some future date to prove that the
family members you enrolled were eligible (e.g., marriage certificate, birth certificate).
If you fail to provide such requested documents within 90 days of the request,
coverage for the family members will be canceled the first of the following month and
you may be subject to discipline up to and including termination of employment for
falsifying company records.8
Under the Children's Health Insurance Program (CHIP) Reauthorization Act of 2009
you may change your Plan election for yourself and any eligible family members within
60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility,
or (2) becoming eligible for a state premium assistance program under Medicaid or
CHIP coverage. In either case, coverage is effective the first of the month following
receipt of the forms by Benefits Administration.
Annual Enrollment
Each year, usually during the fall, ExxonMobil offers an annual enrollment period.
During this time, you can switch from your current option to another available option.
This is also the time to make changes to coverage by adding or deleting family
members. Family members may be added or deleted for any reason but they must be
deleted if they are no longer eligible. Changes elected during annual enrollment take
effect the first of the following year.
Employees are automatically enrolled in the Pre-Tax Spending Plan to pay monthly
contributions on a pre-tax basis unless this feature is declined each time. This choice
is only available during the annual enrollment period or with a change in status.
If you pay your monthly contributions on an after-tax basis and would like to continue
making contributions on an after-tax basis for the following year, you must elect to do
so during each Annual Enrollment and after each change in status. Otherwise, your
contributions will be switched to a pre-tax basis beginning the first day of the following
year. As a retiree, you will pay your contributions on an after-tax basis via payroll
deduction (if eligible), check, or bank draft
Changing Your Coverage
An employee may add a family member effective the first day of a month if required
contributions are made on a pre-tax basis and adding the family member does not
change the coverage level. If you are enrolled on an after-tax basis, you may add an
eligible family member to your existing option effective the first of the following month
following receipt of your written election by Benefits Administration.
To make a change to your coverage you may also wait until Annual Enrollment or until
you experience one of the following Changes in Status.9
Changes in Status
This section explains which events are considered changes in status and what
changes you may make as a result. If you have a change in status, you must complete
your change within 60 days. If you do not complete your change within 60 days,
changes to your coverage may be limited. If you fail to remove an ineligible family
member within 60 days of the event that causes the person to be no longer
eligible, (e.g., divorce) you must continue to pay the same pre-tax contribution
for coverage even though you have removed that ineligible person. The only
exception is death of an eligible family member. Your pre-tax contribution for
coverage will remain the same until you have another change in status or the
first of the plan year following the next annual enrollment period.
Your election made due to a change in status cannot be changed after the form is
received by Benefits Administration or the transaction is completed in EDA if it
changes your pre-tax elections. If you make a mistake in EDA, call Benefits
Administration at 1-800-262-2363 immediately or no later than the same day or first
work day following the day on which the mistake was made.
The following is a quick reference guide to the Changes in Status discussed in more
detail after the table.
Changes During the Year -
Medical/Dental/Vision (Health Plans)
If this event occurs... You may...
Marriage Enroll yourself and spouse and any new
eligible family members.
Divorce - Employee enrolled in Dental Change your level of coverage. You
Plan must drop coverage for your former
spouse but you may not drop coverage
for yourself or other covered eligible
family members.
Divorce - Employee loses coverage Enroll yourself and other family members
under spouse's dental plan that might have lost eligibility for
spouse's dental plans.
Gain a family member through birth, Enroll any eligible family members.
adoption or placement for adoption or
guardianship
Death of a spouse or other eligible Change your level of coverage. You may
dependent. not drop coverage for yourself or other
covered eligible family members.
Other loss of family member's eligibility Change your level of coverage. You may
(e.g. sole managing conservatorship of not drop coverage for yourself or other
grandchild ends) eligible family members.
You lose eligibility because of a change Your Dental Plan participation will
in your employment status, e.g., regular automatically be termed at the end of the
to non-regular month.
You gain eligibility because of a change Enroll yourself or any eligible family
in your employment status, e.g. non- members in the Dental Plan.
regular to regular
Termination of Employment by spouse or Enroll yourself and other eligible family
other family member or other change in members that may have lost eligibility
their employment status (e.g., change under the spouse's or family member's
from full-time to part-time) triggering loss plan in the Dental Plan.
of eligibility under spouse's or family
member's plan in which you or they were
enrolled10
If this event occurs... You may...
Your former spouse is ordered to provide End the family member's coverage,
coverage to your children through a change level of coverage and terminate
QMCSO their participation in the Dental Plan.
Commencement of Employment by End other family member's coverage and
spouse or other family member or other terminate their participation in the Dental
change in their employment status (e.g., Plan if the employee represents that they
change from part-time to full-time) have or will obtain coverage under the
triggering eligibility under another other employer plan. You may also
employer's plan cancel coverage for yourself, if health
care coverage is obtained through your
spouse’s employer plan.
Change in worksite or residence You may not drop coverage for yourself
affecting eligibility to participate in the or other eligible family members.
elected Dental Plan
Judgment, decree or other court order Change your Dental Plan level of
requiring you to cover a family member. coverage.
(Begin a QMCSO)
Termination of employment and rehire Dental Plan coverage is reinstated.
within 30 days or retroactive
reinstatement ordered by court
Termination of employment and rehire Enroll in the Dental Plan as a new hire.
after 30 days
You are covered under your spouse's Enroll yourself and eligible family
dental plan and plan changes coverage members in the Dental Plan.
to a lesser coverage level with a higher
deductible mid-year
You begin a leave of absence Call Benefits Administration
1-800-262-2363
You return from a leave of absence of Call Benefits Administration
more than 30 days (paid or unpaid). 1-800-262-2363
Changes will only be allowed if the medical/dental/vision enrollment form is
received within 60 days of the event by the Benefits Administration Office or the
change is made in EDA within 30 days. Unless otherwise noted, the effective date
will be the first of the month after the forms are received or the transaction is
completed in EDA.
Birth, Adoption or Placement for Adoption
If you gain a family member through birth, adoption, or placement for adoption you
may add the new eligible family member to your current coverage. You may also enroll
yourself, your spouse, and all eligible children. Coverage is effective on the date of
birth, adoption or placement for adoption. You must add the new family member within
60 days even if you already have family coverage. See the Changing your Coverage
section for additional circumstances in which changes can be made.
If you enroll your new family member between 31 and 60 days from the birth or
adoption and your coverage level changes, you will pay the cost difference on a post-
tax basis until the end of the month in which the forms are received by Benefits
Administration. Beginning the first day of the following month your deduction will be
on a pre-tax basis.
Sole Legal Guardianship or Sole Managing Conservatorship
If you (or your spouse, separately or together) become the sole court appointed legal
guardian or sole managing conservator of a child and the child meets all other
requirements of the definition of an eligible family member, you have 60 days from the
date the judgment is signed to enroll the child for coverage. You must provide a copy
of the court document signed by a judge appointing you (or your spouse separately or
together) guardian or sole managing conservator.11 Marriage If you are enrolled in the Dental Plan, you can enroll your new spouse and his or her eligible family members (your stepchildren) for coverage. If you are not already enrolled for coverage, you can sign up for dental coverage for yourself, your new spouse, and your stepchildren. If you gain coverage under your spouse's dental plan, you can cancel your coverage. You must make these changes within 60 days following the date of your marriage or wait until Annual Enrollment or another change in status. Death of a Spouse If you lose coverage under your spouse's dental plan, you can sign up for Dental Plan coverage for yourself and your eligible family members. You must make these changes within 60 days following the date you lose coverage or wait until Annual Enrollment or another change in status. If you and your family members are enrolled in the ExxonMobil Dental Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator. When a Child is No Longer Eligible If an enrolled family member is no longer an eligible family member, coverage continues through the end of the month in which they cease to be eligible. In some cases, continuation coverage under COBRA may be available. (See page 33 for more details about COBRA.) You must notify and provide the appropriate forms to Benefits Administration as soon as a family member is no longer eligible. If you fail to notify and provide the appropriate forms to Benefits Administration within 60 days, the family member will not be entitled to elect COBRA. While we have an administrative process to remove dependents reaching the maximum eligibility age, you remain responsible for ensuring that the dependent is removed from coverage. If you fail to ensure that a family member is removed in a timely manner, there may be consequences for falsifying company records. Divorce In the case of divorce, your former spouse and any stepchildren are eligible for coverage only through the end of the month in which the divorce is final. You must notify and provide any requested documents to Benefits Administration as soon as your divorce is final. If you fail to notify and provide the appropriate forms to Benefits Administration within 60 days, the former spouse and family member will not be entitled to elect COBRA. There may also be consequences for falsifying company records. Please see the Continuation Coverage section of this SPD. You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility. If you lose coverage under your spouse's dental plan because of divorce, you can sign up for dental coverage for yourself and your eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until Annual Enrollment or another change in status. Leave of Absence If you are on an approved leave of absence, you can continue coverage by making required contributions directly to the Dental Plan by check. If you chose not to continue your coverage while on leave, your coverage ends on the last day of the month in which your leave began and you will be required to pay for the entire month's contributions. If you fail to make required contributions while on leave, coverage will end.
12 If the company should make any payment on your behalf to continue your coverage while you are on leave and you decide not to return to work, you will be required to reimburse the company for required contributions. If you are on an approved leave of absence and the Leave of Absence contribution rate begins, you may continue your coverage by making your required contribution. If you were on a leave that meets the requirements of the Family and Medical Leave Act of 1993 (FMLA) or the Uniformed Services Employment and Reemployment Rights Act (USERRA) and your coverage ended, re-enrollment is subject to FMLA or USERRA requirements. For more information, call Benefits Administration. Change in Coverage Costs or Significant Curtailment If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. This provision also applies to a significant increase in the dental deductible or co-payment. If the cost of coverage under your spouse's dental plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for dental coverage for yourself and any eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until Annual Enrollment or another change in status. Coverage due to a change in status will be effective as of the first of the month following your completion of the enrollment, or in the case of Annual Enrollment, the first of the following year. Addition or Improvement of Options If a new plan option is added or if benefits under an existing option are significantly improved during a plan year, you may be able to cancel your current election in order to make an election for coverage under the new or improved option. Loss of Option If the plan is discontinued, you will be able to elect either to receive coverage under another plan option providing similar coverage or to drop dental coverage altogether if no similar option is available. IMPORTANT REMINDER: If you pay your contributions on a pre-tax basis and you experience any of the events mentioned previously, or if you are newly eligible as a result of a change or loss of coverage under your spouse's dental plan, it is your responsibility to complete your change within 60 days of experiencing the event. If you miss the 60-day period, you will not be able to make changes until Annual Enrollment or until you experience another Changes in Status.
13
Other Changes That May Affect Your
Coverage
If You are a Retiree Not Yet Eligible for Medicare
If you are a retiree not eligible for Medicare, you and your family members who are not
eligible for Medicare can continue to participate in the Plan. When you (as a retiree) or
a covered family member become eligible for Medicare, Medicare will become the
primary plan and benefits will be coordinated.
If You are an Extended Part-Time Employee
If you terminate employment as an extended part-time employee, you are not eligible
to continue to participate in the Plan. You may be eligible to elect continuation
coverage for yourself and your eligible family members under COBRA provisions. See
page 33 for details.
If You Work Beyond When You Become Eligible for Medicare
If you continue to work for ExxonMobil, although you are eligible for Medicare, your
ExxonMobil coverage remains in effect for you and eligible family members and the
Plan is your primary plan.
If You or Your Covered Family Members Become Medicare Eligible for any
Reason
When a retiree or a covered eligible family member become eligible for Medicare,
benefits will be coordinated with Medicare.
If You Die
If you die while enrolled, your covered eligible family members can continue coverage.
Their eligibility continues with the company contributions for a specified amount of
time:
z If you have 15 or more years of benefit service at the time of your death,
eligibility continues until your spouse remarries or dies.
z If you have less than 15 years of benefit service, eligibility continues for twice
your length of Benefit Service or until the spouse remarries or dies, whichever
occurs first.
Children of deceased employees or retirees may continue participation as long as they
are an eligible family member. If your surviving spouse remarries, eligibility for your
children also ends. Special rules may apply to family members of individuals who
become retirees due to disability. (See Continued Coverage for suspended retirees
on page 33).
Eligible family members of deceased extended part-time employees are not eligible to
continue to participate in the Plan. These family members may be eligible to elect
continuation coverage under COBRA provisions. (See page 33 for details).14
If You Become a Suspended Retiree
If you are a retiree and you would otherwise lose coverage because you have become
a suspended retiree under the ExxonMobil Disability Plan (see page 6 for details), you
may continue coverage for yourself and your family members who were eligible for
plan participation before you became a suspended retiree for either 12 or 18 months.
Coverage continues for 12 months from the date coverage would otherwise end if you
received transition benefits under the ExxonMobil Disability Plan. However, if you did
not receive transition benefits under the ExxonMobil Disability Plan, coverage
continues for 18 months from the date coverage would otherwise end. The cost of this
continued coverage is 102% of the combined participant and company contributions.
When Coverage Ends
Coverage for you and/or your family members ends on the earliest of the following
dates:
z The last day of the month in which:
{ You terminate employment (except as a retiree or due to disability);
{ You elect not to participate;
{ A family member ceases to be eligible (for example, a child reaches
age 26); or
{ A retiree becomes a suspended retiree (see page 6).
{ You are no longer eligible for benefits under this Plan (e.g.,
employment classification changes from "regular employee" to "non-
regular employee" or from non-represented to represented where you
are no longer eligible for this Plan);
{ You do not make your required contribution;
{ A Qualified Medical Child Support Order is no longer in effect for a
covered family member;
OR
z The date:
{ You die;
{ The Plan ends;
{ Your employer discontinues participation in the Plan;
{ You enrolled an ineligible family member and in the opinion of the
Administrator-Benefits, the enrollment was a result of fraud or a
misrepresentation of a material fact.
You are responsible for ending coverage with Benefits Administration when
your enrolled spouse or family member is no longer eligible for coverage. If you
do not complete your change within 60 days, any contributions you make for ineligible
family members will not be refunded.
Loss of Eligibility
Everyone in your family may lose eligibility for plan coverage, and you may be subject
to disciplinary action up to and including termination of employment if you commit
fraud against the Plan, for instance, by filing claims for benefits to which you are not
entitled. Coverage may also be terminated if you refuse to repay amounts erroneously
paid by the Plan on your behalf or which you recover from a third party. Your
participation may be terminated if you fail to comply with the terms of the Plan and its
administrative requirements. You may also lose eligibility if you enroll persons who are
not eligible, for instance, by covering children who do not meet the eligibility
requirements or do not cancel coverage for family members at the time they are no
longer eligible, e.g. divorced spouse.15
Extended Benefits at Termination
You are entitled to extended coverage for as much as a year if you are terminated due
to disability with fewer than 15 years of service. This coverage is provided at no cost to
you. This is considered a portion of the COBRA continuation period. In order to assure
coverage beyond this extension period, you must elect COBRA upon termination of
employment.
Several conditions must be met:
z The disability must exist when your employment terminates.
z The extension lasts only as long as the disability continues, but no longer than
12 months.
z This extension applies only to the employee who is terminated because of a
disability. Continuation coverage for eligible family members may be available
through COBRA.About Dental
Dental PPO
Eligibility and Enrollment
Q1. Are my out-of-pocket costs different if I use a network dentist
Dental PPO versus a non-network dentist?
- Using the Dental PPO
- To Find a Dental PPO Provider A1. When you use a network dentist, you save money because these
- Pre-determination of Benefits participating providers have agreed to provide their services at
negotiated rates that are generally less than the rates charged by non-
Covered Expenses network dentists.
Exclusions Q2. Are my benefits different if I use a network dentist versus a non-
network dentist?
Payments
A2. The percent of eligible charges that the Plan pays is the same
Claims whether you use network or non-network providers. However, you may
be responsible for charges above the reasonable and customary (R&C)
Continuation Coverage limit for non-network providers (see Reasonable and Customary
Limits on page 26).
Administrative and ERISA
Information
Using the Dental PPO
Key Terms
Using the Dental PPO is completely voluntary. The Dental PPO provides access to a
Benefit Summary network of dentists and dental specialists who have met Aetna's standards for
licensing, academics and service. Dental PPO providers' charges are always within
reasonable and customary limits. (See page 26.)
There are several advantages to using network providers:
z The discounts offered by network dentists generally lower your out-of-pocket
costs and allow you to cover more dental services for the annual benefit
maximum.
z Network dentists submit claims for you, so you do not have to complete claim
forms.
z Negotiated rates are within reasonable and customary limits, so you will not
have to pay charges above the limits. However, the alternative course of
treatment rules noted on page 27 apply.
To receive the benefit of negotiated rates, use network dentists and present your
Aetna Dental PPO ID card.17
To Find a Dental PPO Provider:
z Check DocFind® (www.aetna.com/docfind) on Aetna's Web site for the most
up-to-date list of dental PPO providers. The site is updated three times a week.
z Call Aetna Member Services for help with locating a PPO provider or to
request a printed listing of providers.
Confirm with Aetna Member Services and/or the dentist's office whether the dentist
participates in the network before the appointment, since network participation may
change.
If you or your covered family members need to see a dentist while away from home,
you can go to any licensed dentist. However, you may access the Aetna Web site or
contact Aetna Member Services to see if there is a network dentist in the area.
Pre-determination of Benefits
You are encouraged to submit a pre-determination of benefits before you begin
any complicated or expensive dental procedure to avoid unexpected expenses.
Generally, Aetna will tell you what benefits will be paid for the proposed treatment.
However, if a less expensive alternative course of treatment is available, Aetna will
advise you of the alternative course of treatment and tell you what benefits will be
paid. If you decide to have the more expensive proposed treatment, the Plan pays
benefits based on the cost of the alternative course of treatment.
Here is how the pre-determination process works:
z Indicate on a claim form (or in a letter) that you are seeking a pre-
determination of benefits. Give the form to your dentist.
z The dentist describes the suggested course of treatment, itemizing specific
services and charges. In some cases medical information, including x-rays,
may also be needed.
z The dentist submits the information to Aetna, which determines the Plan
benefits for the services outlined and notifies both you and the dentist. This
gives you a chance to discuss the work and charges with your dentist before
the work is performed.
If a lower cost alternative course of treatment would be medically appropriate, you
might decide to proceed with the original treatment, or you might opt for the alternative
course of treatment. That is a matter for you and your dentist to decide. Plan benefits
are based on the actual work done or on the Plan's requirements relating to alternative
course of treatment, not on the pre-determination. (See Alternative Course of
Treatment on page 27).
Note: A pre-determination is processed much like a claim. Plan accordingly and allow
sufficient time for that process to take place.About Dental
Covered Expenses
Eligibility and Enrollment
Q. What types of dental services are covered by the Plan?
Dental PPO
A. The Plan divides dental services into four categories:
Covered Expenses
- Preventive Services
z Preventive Services
- Emergency Treatment
z General Services
- General Services
z Major Services
- Major Services
z Orthodontic Services
- Orthodontic Services
Exclusions 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'
Payments charges are always within the reasonable and customary amount (see page 26).
Claims 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
Continuation Coverage such service or treatment must be:
Administrative and ERISA z Medically necessary
Information
z Performed or prescribed by a dentist or physician, and
z Not excluded under this Plan.
Key Terms
An expense or charge is generally considered incurred on the date the service is
Benefit Summary
provided, with these exceptions:
z Fixed bridges, crowns, inlays, onlays, or gold restorations are considered
incurred on the first day of preparation of the tooth or teeth involved.
z Full or partial dentures are considered incurred on the date the impression is
taken.
z Endodontics are considered incurred on the date the tooth is opened for root
canal therapy.
z Dental implants are considered incurred on the date the crown is placed on the
post and not when the post is inserted. In some cases, dental implant costs are
subject to an Alternative Course of Treatment limitation (see page 27).19
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:
z Diagnostic oral examinations
z Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar
year)
z Diagnostic supplementary (bite-wing) X-rays (limited to four times each
calendar year).
z Periapical X-rays
z Diagnostic full-mouth or panoramic X-rays* (limited to once in any three
consecutive years).
z Topical stannous fluoride application (limited to four times each calendar year).
z Space maintainers and their insertion (limited to deciduous teeth whether
primary or baby teeth and treatment for a covered family member under age
19).
z Tooth sealants applied to a permanent molar (limited to one application per
tooth in any three consecutive years).
z Occlusal (night) guards for the treatment of bruxism (limited to one appliance
every other year).
* 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%.20
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:
z Care and treatment involving tooth extractions, fractures, and dislocations of
the jaw, and cutting procedures in the oral cavity.
z Root canals and other endodontic treatment.
z General anesthetic and its administration in connection with oral surgery,
periodontics, fractures, and dislocations.
z Injection of antibiotics in conjunction with treatment of a covered dental
expense.
z Fillings, other than gold fillings. (For gold fillings, see Major Services below.)
z Repair and rebasing existing dentures or fixed bridges. (Replacing such
dentures and fixed bridges is described under Major Services below.)
z Addition of teeth to existing denture or fixed bridge if required by loss of natural
teeth.
z Pre-surgery oral exams.
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:
z Full or partial dentures or fixed bridges or implants and their initial insertion.
Note: Dental implants are subject to the alternative course of treatment
provision. If you are considering an implant and you have multiple missing
teeth, the alternate course of treatment provision will most likely be deemed
appropriate. (See page 27 for information). Replacement of existing devices
can only be covered if such device cannot be made serviceable and is more
than five years old. 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.
z Gold fillings and permanent crowns — or their replacement — necessary for
restoration of tooth structure broken down by decay, injury or severe attrition.
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 on page 25 for more
information.)21 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 and supplies in the area. 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 upfront, contact Aetna member services for claim handling guidelines. 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.
About Dental
Exclusions
Eligibility and Enrollment
Q. Are there expenses which are not covered by the Plan?
Dental PPO
A. Although the Plan covers many types of dental treatments and
Covered Expenses services, it does not cover all of them
Exclusions No benefits are payable under the Plan for any charge incurred for:
Payments
z Treatment by a person other than a dentist or physician, except for services
performed by a licensed dental or medical professional under the direction of a
Claims dentist or physician.
Continuation Coverage
z Services not incident to and for the diagnosis or treatment of a condition,
disease or injury while a covered person.
Administrative and ERISA
Information
z Cosmetic services or supplies, except necessary reconstructive expenses in
connection with treatment of an accidental injury which begins within 90 days
Key Terms
after the accidental injury is sustained.
Benefit Summary
z Treatment covered by workers' compensation or similar law.
z Professional services rendered by the patient.
z Treatment of any condition with personally specialized or individually designed
services. For example, if you want a denture designed with a gap that
resembles a gap that existed in the natural teeth the denture is replacing, the
charge for creating that gap, or for personalizing the denture, is not covered.
z Facings on crowns behind the second bicuspid.
z Training in or supplies used for dietary counseling, oral hygiene or plaque
control.
z Procedures, restorations, and appliances to increase vertical dimension, to
restore occlusion and to repair attrition including, but not limited to, treatment
of Temporomandibular Joint Disorder (TMJ/TMD).23
z Services or supplies which are experimental according to accepted standards
of dental practice.
z Post-operative procedures or examinations for which an additional or separate
charge is made.
z Follow-up adjustments of dentures, fixed bridges, or implants within six months
of initial insertion for which an additional and separate charge is made.
z Temporary crowns or dentures, prior to installation of permanent devices, for
which an additional and separate charge is made.
z Treatment of any condition, disease or injury, including otherwise covered
dental expenses, if the person would not be required to pay charges had the
person not been covered under this Plan, including services provided in a
hospital operated by the United States or any of its agencies.
z Any charge for a service or supply not listed as a covered expense.About Dental
Payments
Eligibility and Enrollment
Q. How are payments determined?
Dental PPO
A. The Plan helps you and your family members with dental expenses.
Covered Expenses You and the Plan share costs for covered treatment and services. You
pay a percentage co-payment for most covered expenses. You must
Exclusions satisfy an annual deductible before the Plan starts paying on covered
non-preventive services. The Plan also has an annual maximum and a
Payments lifetime orthodontia maximum amount. Once the maximum lifetime
- Annual Maximum benefit maximum has been paid, no other benefits will be paid under
- Deductibles any circumstances. Once the Plan has paid charges for covered
- Percentage Co-payments expenses up to the maximum, you are responsible for all charges
- Orthodontia Lifetime Maximum above the maximum. See Adjustments to Billed Charges on page 26
- Adjustments to Billed Charges for other factors that may affect reimbursement.
Claims This section explains some of the terms and provisions you need to know to use the
Plan to your best advantage.
Continuation Coverage
Administrative and ERISA
Annual Maximum
Information
The annual maximum is $2,000, which is the amount of benefits payable under the
Key Terms Plan for covered dental expenses (other than preventive and orthodontic services)
each calendar year for each covered person. This annual maximum benefit is
Benefit Summary determined after you pay any necessary deductibles and co-payments. Orthodontic
expenses have a separate lifetime limit of $2,000.
Once the annual maximum benefit has been paid, no other benefits are available
under any circumstances. You are responsible for all charges above the annual
maximum benefit.
Example:
You have had several dental procedures totaling $1,800 between January 1st and July
31st. You have $200 remaining until you reach the annual maximum. On September
2nd, you have a dental procedure performed, and the cost to the Plan is $300. Since
the annual maximum is $2,000, the Plan will pay only $200 of the charge. You are
responsible for $100, and no benefits are available for dental services performed for
the remainder of the calendar year.
However, beginning January 1st of the following year, a new annual maximum benefit
will be available to pay charges for covered expenses incurred during that calendar
year.25
Deductibles
The deductible is the amount of covered expenses you must pay each calendar year
before the Plan begins sharing the cost. You do not pay a deductible for preventive
or orthodontic services. An annual deductible must be met for general and major
services. A $50 deductible applies to each covered person. Once deductibles for your
family reach $150, your family has satisfied the deductible requirements for the year.
The deductible does not include any amounts above the reasonable and customary
limits (see Reasonable and Customary Limits section on page 26).
Percentage Co-payments
The co-payment is the percentage of the cost of covered dental treatment or services
that you pay. You pay a 20% co-payment for general services and a 50% co-payment
for major and orthodontic services.
Orthodontia Lifetime Maximum
The Plan pays up to $2,000 for covered orthodontic expenses for the lifetime of each
covered person. This is in addition to the annual maximum benefit for other types of
dental care.26
Adjustments to Billed Charges
When providers submit charges for payment, the following factors affect the amount
that will be considered eligible for reimbursement. References to these limitations may
appear on your explanation of benefits. Contact Aetna Member Services for more
information. A pre-determination of benefits is strongly recommended before you incur
any major or unusual expenses.
Reasonable and Customary Limits
Allowable amounts for services are determined by reasonable and customary (R&C)
limits. The Plan's claims administrator determines R&C limits. These limits are based
on data obtained from the Prevailing Healthcare Charges System owned by FAIR
Health. R&C limits for services are set at the 90th percentile of the range of charges
for a particular procedure in the same geographic area(s). R&C limits apply only to
non-network providers and services.
If any non-network provider charges a fee that exceeds the R&C limit, you are
responsible for the excess amount. The amount above the R&C limit does not apply
toward your annual deductible or your percentage co-payments. To find out if a
proposed charge is within R&C limits, contact Aetna Member Services. PPO provider
negotiated rates are always within R&C limits.
Example:
Assume that the R&C charge in your area for a tooth filling is $120, your non-network
dentist charges $140 to fill your tooth, and the network dentist's negotiated charge is
$100.
Network Non-Network
Tooth filling $100 $140
Covered amount $100 $120
You pay 20%* of covered amount $ 20 $ 24
You pay amount over R&C + 0 + 20
Your total cost $ 20 $ 44
*After deductible has been satisfied.
The summary on page 52 provides an overview of the ExxonMobil Dental Plan.
More detailed explanations of the expenses covered under each category
(preventive, general, major, and orthodontic) and expenses not covered are
provided beginning on pages 22-23 of this SPD.27
Alternative Course of Treatment
In situations where an alternative course of treatment would provide professionally
adequate (based on American Dental Association guidelines) results at a lower cost,
the lower-cost treatment is considered the covered expense.
The alternative course of treatment is determined either at the time a pre-
determination is made or when the claim is processed. Reimbursement and
subsequent repairs, replacement, or servicing is based on that alternative course of
treatment. Use the Plan's pre-determination of benefits feature to avoid unexpected
expenses.
If you incur a service that is eligible for an alternative course of treatment without a
pre-determination or you choose not to use the alternative course of treatment
identified during a pre-determination, you will be responsible for the following:
z Any reasonable and customary charges that you may incur while using a non-
PPO provider.
z The difference in cost between the alternative course of treatment and the
treatment performed.
z Your co-payment based on the alternative course of treatment, if your
deductible has been met.
Example:
Assume that you have a missing tooth and you would like it replaced with a dental
implant. Your provider is a Dental PPO network provider and the charge is $800.
When you submit your treatment plan for a pre-determination of benefits, Aetna
determines that a medically necessary, cost-effective alternative course of treatment is
available – a partial denture – that costs $500. The table below shows the cost you
would pay if you choose to proceed with a dental Implant instead of the partial
denture. Also, the table shows the cost if you use a non-network provider who charges
$1,000.
A B C D E F G
Dental R&C Cost in Covered Cost in Your co- Your
implant limit excess amount- excess payment total
of R&C cost of of the 50%* of cost
(A-B) partial covered covered (C+E+F)
denture amount amount
(B-D) (D* .5)
Network $ 800 $ 800 $0 $ 500 $ 300 $ 250 $ 550
Non- $ 1,000 $ 800 $ 200 $ 500 $ 300 $ 250 $ 750
Network
*After deductible has been satisfied.
The alternative course of treatment provisions will apply to any future treatment to
repair, service, or replace the implant. This means that if you have any covered
services performed on your implant, the Plan will calculate the benefits that are eligible
for reimbursement as though similar work was performed on a partial denture.28 Note: Installation of implants is a two-phase procedure. Phase one is the surgery to install the implant post. Phase two is the placement of the implant supported prosthetic (i.e., the tooth component of the dental implant) that is installed on the post. If there is an alternative course of treatment, you may still receive reimbursement for the dental implants, but the reimbursement is based on the assumption that you received the lower cost treatment (generally a bridge or denture), and that is considered the covered dental expense. You will not receive reimbursement until phase two when the charge for the prosthetic is submitted (generally when the impression for the tooth is made). Recovery of Overpayment If you or your beneficiary receives a distribution of any amount from the Plan to which you are not entitled, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The plan administrator may make reasonable arrangements with you for repayment.
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