ExxonMobil Employee Health Advisory Program
Summary Plan Description
201
About the Employee
Health Advisory Program
- How to Get the Care You
Need
- Information Sources
- Introduction
- Plan at a Glance
Eligibility and Enrollment
How the Plan Works
Continuation Coverage
Administrative and ERISA
Information
ExxonMobil EHAP SPD
As of January 2015
About EHAP
This summary plan description (SPD) of the ExxonMobil Employee Health Advisory
Program (EHAP) does not contain all the plan details. In determining your specific
benefits, the full provisions of the EHAP plan document, as they exist now or as they
may exist in the future, always govern. Copies of these documents are available for
your review.
Applicability to represented employees is governed by collective bargaining
agreements and any local bargaining requirements.
Grandfathered Plan Intent
Key Terms
ExxonMobil Corporation believes that EHAP is a "grandfathered health plan" under the
Patient Protection and Affordable Care Act (PPACA). As permitted by the Affordable
Care Act, a grandfathered health plan can preserve certain basic health coverage that
was already in effect on March 23, 2010.
Notice: EHAP 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.
Questions regarding which protections apply to the EHAP and what might cause the
EHAP to change from grandfathered health plan status can be directed to the Plan
Administrator at Administrator-Benefits, P.O. Box 2283, Houston, Texas 77252-2283.
You may also contact the Employee Benefits Security Administration, U.S.
Department of Labor at 1-866-444-3272
or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply to
grandfathered health plans.
How to Get the Care You Need
If you or an eligible family member needs help dealing with a mental health or
substance abuse problem or other personal issues, follow these steps to get the care
needed:

Step 1: Call Magellan Behavioral Health (Magellan) at 800-442-4123
and
select the appropriate option to get the name of an EHAP counselor who can
help you. An EHAP consultant -- a licensed counselor -- will ask you questions
so that he or she can assess your situation. Then, the EHAP consultant will
give you the names and telephone numbers of EHAP counselors in your area
who are part of the Magellan network.
2
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Step 2: Call the EHAP counselor to make an appointment. Mention that you're
a member of the Plan. After you have made your appointment, call Magellan to
confirm which EHAP counselor you have chosen.
Step 3: Go to your appointment. You don't have to file a claim form. (If you
need inpatient care or longer term treatment, your EHAP counselor, or EHAP
consultant, will make arrangements for you and tell you what you need to do.)
EHAP professional counselors are located away from your workplace location, and
Magellan does not reveal to the company the names of or reasons for individuals
seeking EHAP assistance.
You may also select an EHAP provider through the online self-referral process at
www.magellanhealth.com/member. To use the online self-referral process:
1.
2.
3.
4.
Enter the URL www.magellanhealth.com/member and sign in with your user
name and password (or follow the instructions for creating a user name and
password)
Follow the online directions.
Under "Online EHAP Referral" select "EAP Self Referral"
Follow the online directions.
At your request, Magellan will send you a hard copy of the directory information;
contact Magellan at 800-442-4123 . If there are no network EHAP counselors near
your home, Magellan will locate a qualified provider for you.
Information Sources
Care Manager — Arranges for and provides counseling services.
Phone Numbers:
Magellan Behavioral Health
800-442-4123
314-387-4700
(if international, call collect)
24 hours a day, seven days a week
Address:
Magellan Behavioral Health
14100 Magellan Plaza Drive
Maryland Heights MO 63043
Check Magellan's Web site at www.magellanhealth.com/member for Life Assistance
Resource information, such as community resources links, health and wellness tips,
and behavioral health Internet sites. Once you have accessed this site:

Sign in under Member Sign In (new users click on New or unregistered user)
Enter toll free number: 800-442-4123
(user ID and password not necessary)

At this point, you may register or continue as unregistered

Benefits Administration – Provides plan-related information.
Phone Numbers:
800-262-2363
(toll free outside Houston)
Monday - Friday 8:00 a.m. to 3:00 p.m. (U.S. Central
Time), except certain holidays
Address:
Benefits Administration
ExxonMobil BA BSC USBA
4300 Dacoma or "BH1"
Houston, Texas 77092
ExxonMobil Sponsored Sites — Provides employees and their family members
access to plan-related information.


ExxonMobil Me, the Human Resources Intranet Site — Can be accessed at
work by current employees.
ExxonMobil Family, the Human Resources Internet Site — Can be
accessed from home by everyone at www.exxonmobilfamily.com.
3
Introduction
EHAP Services
The ExxonMobil Employee Health Advisory Program (EHAP) offers professional
counseling in a confidential environment for personal problems requiring limited
intervention and referral services for more complicated problems. You may call the
service at any time, for any reason. Reasons for seeking assistance are as varied as
the individuals calling. Some of the types of problems for which you may seek help
include:

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Crisis in the family, such as balancing career and family responsibilities,
stress, relocation issues, divorce or separation, problems with children at
school, serious illness, family violence, child abuse, problems with the legal
system, death, or being a victim of crime.
Ongoing problems, such as chemical dependency, anxiety, depression,
family conflict, job dissatisfaction and single parent responsibilities.
Referral services to resources in your community that can help you find home
health care, nursing homes, legal services, consumer credit and financial
information are also available through Magellan's Life Assistance Resources.
Coverage is automatic for eligible employees and their eligible family members. The
company currently pays the full cost of this Plan.
EHAP is described in this SPD. These tools help you find specific information quickly
and easily.

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
Information Sources, places where you can get more information.
Plan at a Glance, highlighting plan basics.
A list of Key Terms containing definitions of some words and terms used in
this SPD.
A careful review of this SPD will help you understand how the Plan works so you can
make the best use of it. You may obtain additional information through the sources
shown on page 2.
4
Plan at a Glance
Eligibility and Enrollment
You do not need to enroll — coverage begins for you and your eligible family members
as soon as you meet the eligibility requirements regardless of enrollment in the
ExxonMobil Medical Plan. See page 5.
How the Plan Works
This Plan helps pay for family counseling, and counseling to help you with
relationships and developmental or other personal issues. Benefits are paid for
outpatient counseling for you and your eligible family members. You can call Magellan
for a referral to an EHAP counselor. See page 7.
If you are not enrolled in the ExxonMobil Medical Plan, because of EHAP, you will
have access to a limited amount of benefits even though you are not enrolled in that
plan.
The Plan provides counseling and referral services for many types of personal
problems, including mental health, chemical dependency and work/family issues.
Services are arranged for and provided through Magellan. See page 8.
Administrative and ERISA Information
This Plan is subject to rules of the federal government, including the Employee
Retirement Income Security Act (ERISA), not state insurance laws. You and your
family members who lose eligibility may continue EHAP coverage for a limited time in
certain circumstances. See page 15.
Key Terms
This is an alphabetized list of words and phrases, with their definitions, used in this
SPD. These words are underlined and linked throughout the SPD for easy
identification. See page 22.
About the Employee Health
Advisory Program
Eligibility and Enrollment
Q. What are the Plan’s eligibility requirements?
Eligibility and Enrollment
- Eligible Family Members
- When Coverage Begins
- When Coverage Ends
A. Most U.S. dollar-paid employees of Exxon Mobil Corporation and
participating affiliates are eligible for EHAP. See eligible employees on
page 21 of the Key Terms section. Your eligible family members may
also participate. Coverage is automatic; you do not enroll.
How the Plan Works
Continuation Coverage
Administrative and ERISA
Information
Key Terms
Generally, you are eligible if:




You are a regular employee.
You are an extended part-time employee.
You are characterized as a trainee as described in the Key Terms section.
You are an expatriate employee inbound to the United States (including
service-oriented employees employed by non-U.S., non-participating
employers who are temporarily working in the United States).
Eligible Family Members
Your eligible family members include:



Your spouse.
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
biological or legally adopted child, call Benefits Administration.
Your totally and continuously disabled child(ren) who is incapable of selfsustaining 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.
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.
Refer to Key Terms for definitions of eligible family members, child, spouse and
Qualified Medical Child Support Order.
6
When Coverage Begins
Generally, your coverage begins on your first day of employment. Family members are
covered on the later of the date you begin employment or the date your family member
meets the eligibility requirements.
When Coverage Ends
Coverage for you and/or your family members ends on the earliest of the following
dates:
The last day of the month in which:



You terminate employment or are no longer classified as a regular employee of
a participating employer. Your employment is deemed to continue for purposes
of this Plan until the end of the period during which you are:
 Absent due to a leave of absence approved by your employer or
 Receiving short-term disability benefits under a disability income plan
sponsored by the company.
The date your family member ceases to be eligible.
The date:
 You (as a covered employee or family member) are no longer eligible
for benefits under this Plan.
 Your employer discontinues participation in the Plan.
 Your family member begins active duty in the armed forces of any
country, state or international organization, or becomes a member of
any civilian force auxiliary to any military force.
 The Plan is terminated.
 A Qualified Medical Child Support Order is no longer in effect for a
covered family member.
 A family member under a Qualified Medical Child Support Order
becomes eligible for benefits under another plan providing benefits
similar to this Plan.
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:



The disability must exist when your employment terminates.
The extension lasts only as long as the disability continues, but no longer than
12 months.
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 the Employee Health
Advisory Program
How the Plan Works
Eligibility and Enrollment
Q. What are the benefits of the Plan?
How the Plan Works
A. The Plan provides counseling visits and referral services as
described in this section. Up to eight counseling visits may be provided
at no cost to you, as clinically appropriate. All counseling services are
arranged by and provided through Magellan, the Care Manager for this
Plan.
- Private and Confidential
- Professional Counselors
- No Charge for EHAP Services
- After-Care Counseling
Continuation Coverage
Administrative and ERISA
Information
Key Terms
Private and Confidential
EHAP professional counselors are located away from your workplace location, and
Magellan does not reveal to the company the names of or reasons for individuals
seeking EHAP assistance. Unless your supervisor identifies and discusses with you a
situation where EHAP benefits would be beneficial, you tell others, or the law requires
disclosure, no one at the company will know that you are using the program. In
situations involving real or potential harm to individuals (for example, child abuse
cases or direct threats of violence against a person), laws require that certain
notifications be made. EHAP counselors will comply with these laws and disclose
required information.
Professional Counselors
Magellan makes available the counseling and referral services offered by EHAP
through a network of contracted EHAP counselors. Counselors include trained
psychologists, family and marriage counselors, social workers and therapists who
specialize in resolving personal problems.
8
No Charge for EHAP Services
Many problems can be resolved in just a few visits with an experienced counselor.
EHAP may provide you or your eligible family members with up to eight visits in a
calendar year for each problem.
If you need more counseling visits than are provided under EHAP - or if you need
services that are not provided by EHAP - the EHAP counselor will refer you to outside
services which may be a covered service under your medical plan. If the EHAP
counselor determines that more intense services are needed, you may be immediately
referred to an appropriate mental health provider. The cost of the additional or outside
services is not covered under EHAP but may be partly covered by your medical plan;
refer to the summary of benefits and coverage (SBC) for your medical plan or contact
Benefits Administration (see Information Sources at the front of this SPD) for
information.
After-Care Counseling Services
The Plan also provides chemical dependency support, counseling and monitoring
services for eligible employees who are actively at work following primary treatment for
chemical dependency. Magellan determines the extent to which after-care counseling
services are available to employees under this Plan.
About the Employee Health
Advisory Program
Eligibility and Enrollment
How the Plan Works
Continuation Coverage
Continuation Coverage
Q. Can coverage be continued after eligibility in this Plan ends?
A. Yes. The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) entitles you and your covered family members to extend
EHAP benefits beyond the date your coverage would normally end.
- Continuation Coverage Rights
under COBRA
- What is COBRA Coverage?
Administrative and ERISA
Information
Key Terms
Continuation Coverage Rights under
COBRA
This section contains important information about your right to COBRA continuation
coverage, which is a temporary extension of coverage under the Plan under certain
circumstances when coverage would otherwise end. This section generally explains
COBRA continuation coverage, when it may become available to you and your family,
and what you need to do to protect the right to receive it.
The right to COBRA coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become
available to you when you would otherwise lose your group health coverage. It can
also become available to your spouse and children, if they are covered under the Plan
when they would otherwise lose their group health coverage. For additional
information about your rights and obligations under the Plan and under federal law,
you should review this SPD or contact Benefits Administration at the telephone
numbers or address listed under Information Sources at the front of this SPD.
You may have other options available to you when you lose group health
coverage. For example, you may be eligible to buy an individual plan through the
Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you
may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.
Additionally, you may qualify for a 30-day special enrollment period for another group
health plan for which you are eligible (such as a spouse's plan), even if that plan
generally doesn't accept late enrollees.
What is COBRA Coverage?
COBRA coverage is a continuation of plan coverage when coverage would otherwise
end because of a life event known as a "qualifying event." Specific qualifying events
are listed later in this section. If a specific qualifying event occurs and any required
notice of that event is properly provided to Benefits Administration, COBRA coverage
must be offered to each person losing coverage who is a "qualified beneficiary." You,
your spouse, and your children could become qualified beneficiaries if coverage under
the Plan is lost because of the qualifying event. Certain newborns, newly adopted
children, and alternate recipients under QMCSOs may also be qualified beneficiaries.
This is discussed in more detail in separate paragraphs below. Under the Plan,
qualified beneficiaries who elect COBRA coverage may be required to pay the entire
cost for COBRA coverage.
10
Who is entitled to elect COBRA?
If you are an employee, you will be entitled to elect COBRA, if you lose your coverage
under the Plan because either one of the following qualifying events happen:


Your hours of employment are reduced; or
Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will be entitled to elect COBRA if you lose
coverage under the Plan because any of the following qualifying events happen:




Your spouse dies;
Your spouse's hours of employment are reduced;
Your spouse's employment ends for any reason other than his or her gross
misconduct;
You become divorced from your spouse. Also, if your spouse (the employee)
reduces or eliminates your group health coverage in anticipation of a divorce,
and a divorce later occurs, then the divorce may be considered a qualifying
event for you even though your coverage was reduced or eliminated before the
divorce.
A person enrolled as the employee's child will be entitled to elect COBRA if he or she
loses coverage under the Plan because any of the following qualifying events happen:




The parent-employee or parent-retiree dies;
The parent-employee's hours of employment are reduced;
The parent-employee's employment ends for any reason other than his or her
gross misconduct;
The child stops being eligible for coverage under the Plan as a child.
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after
Benefits Administration has been notified that a qualifying event has occurred.
Employer Gives Notice of Some Qualifying Events
When the qualifying event is the end of employment or reduction of hours of
employment, death of the employee, commencement of a proceeding in bankruptcy
with respect to the employer, the employer must notify Benefits Administration of the
qualifying event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or a child losing eligibility), a COBRA election
will be available to you only if you notify and provide the appropriate forms to Benefits
Administration within 60 days after the later of (1) the date of the qualifying event or (2)
the date on which the qualified beneficiary loses (or would lose) coverage under the
terms of the Plan as a result of the qualifying event. In providing this notice, you must
notify the correct Benefits Administration entity based on your status and follow the
procedures outlined in the next section. If these procedures are not followed or if the
wrong entity is notified during the 60-day notice period, THEN ALL QUALIFIED
BENEFICIARIES WILL LOSE THEIR RIGHT TO ELECT COBRA.
Notice Procedures for Qualifying Events
Notices of qualifying events from current employees must be made by logging onto
Employee Direct Access (EDA) located on the ExxonMobil Me HR Intranet site. Forms
are also available from ExxonMobil Benefits Administration/ Health Plan Services for
those individuals who do not have access to EDA. Notices of these qualifying events
from retirees and survivors must be made via the ExxonMobil Benefits Web or by
calling the ExxonMobil Benefits Service Center. Notice is not effective until either EDA
or the ExxonMobil Benefits Web change is made or the properly completed form is
received.
11
Election of COBRA
Each qualified beneficiary will have an independent right to elect COBRA. Covered
employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on
behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their
children. Any qualified beneficiary for whom COBRA is not elected within the 60day election period specified in the Plan’s COBRA election notice WILL LOSE
HIS OR HER RIGHT TO ELECT COBRA.
How long does COBRA coverage last?
COBRA coverage is a temporary continuation of coverage. When the qualifying event
is the death of the employee, the covered employee’s divorce or a child's losing
eligibility as a child, COBRA coverage under the Health Advisory Program can last for
up to a total of 36 months.
When the qualifying event is the end of employment or the reduction of the employee's
hours of employment, and the employee became entitled to Medicare benefits less
than 18 months before the qualifying event, COBRA coverage under the Health
Advisory Program for qualified beneficiaries (other than the employee) who lose
coverage as a result of the qualifying event can last until up to 36 months after the
date of Medicare entitlement. For example, if a covered employee becomes entitled to
Medicare 8 months before the date on which his employment terminates, COBRA
coverage for his spouse and children who lost coverage as a result of his termination
can last up to 36 months after the date of Medicare entitlement, which is equal to 28
months after the date of the qualifying event (36 months minus 8 months). This
COBRA coverage period is available only if the covered employee becomes entitled to
Medicare within 18 months BEFORE termination or reduction of hours.
Otherwise, when the qualifying event is the end of employment or reduction of the
employee's hours of employment, COBRA coverage under the Health Advisory
Program generally can last for only up to a total of 18 months.
The COBRA coverage periods described above are maximum coverage periods.
COBRA coverage can end before the end of the maximum coverage periods
described in this notice for several reasons.
There are two ways (described in the following paragraphs) in which the period of
COBRA coverage resulting from a termination of employment or reduction of hours
can be extended.
Disability Extension of COBRA Coverage
If a qualified beneficiary is determined by the Social Security Administration to be
disabled and you notify the correct Benefits Administration entity, in a timely fashion,
all of your qualified beneficiaries in your family may be entitled to receive up to an
additional 11 months of COBRA coverage, for a total maximum of 29 months. This
extension is available only for qualified beneficiaries who are receiving COBRA
coverage because of a qualifying event that was the covered employee’s termination
of employment or reduction of hours. The disability must have started at some time
before the 61st day after the covered employee’s termination of employment or
reduction of hours and must last at least until the end of the period of COBRA
coverage that would be available without the disability extension (generally 18 months,
as described above).
The disability extension is only available if you notify Benefits Administration in
writing of the Social Security Administration’s determination of disability within
60 days after the latest of:



The date of the Social Security Administration’s disability determination
The date of the covered employee’s termination or reduction of hours; and
The date on which the qualified beneficiary loses (or would lose) coverage
under the terms of the Plan as a result of the covered employee’s termination
of employment or reduction of hours.
12
You must also provide this notice within 18 months after the covered employee’s
termination of employment or reduction of hours in order to be entitled to a disability
extension, and you must notify the correct Benefits Administration entity at least 30
days before the end of the 18-month period. See the last page of this notice for the
listing of Benefits Administration entities. If these procedures are not followed or if the
notice to the correct Benefits Administration entity is not provided during the 60-day
notice period and within 18 months after the covered employee’s termination of
employment or reduction of hours, THEN THERE WILL BE NO DISABILITY
EXTENSION OF COBRA COVERAGE.
Second qualifying event extension of COBRA coverage
If your family experiences another qualifying event while receiving COBRA coverage
as a result of the covered employee’s termination of employment or reduction of hours
(including COBRA coverage during a disability extension as described above), the
covered spouse and children in your family can get up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months, if notice of the second
qualifying event is properly given to the correct Benefits Administration entity. This
extension may be available to the spouse and any children receiving COBRA
coverage if the employee or former employee dies, gets divorced, or if the child stops
being eligible under the Plan. This extension is not available under the Plan when a
covered employee becomes entitled to Medicare after his or her termination of
employment or reduction of hours.
This extension due to a second qualifying event is available only if you notify the
correct Benefits Administration entity within 60 days of the date of the second
qualifying event. See the last page of this notice for the listing of Benefits
Administration entities. If these procedures are not followed or if the notice to the
correct Benefits Administration entity is not provided during the 60 day notice period
and within 18 months after the covered employee’s termination of employment or
reduction of hours, THEN THERE WILL BE NO EXTENSION OF COBRA
COVERAGE.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other
coverage options for you and your family through the Health Insurance Marketplace,
Medicaid, or other group health plan coverage options (such as a spouse’s plan)
through what is called a “special enrollment period.” Some of these options may cost
less than COBRA continuation coverage. You can learn more about many of these
options at www.healthcare.gov.
More Information About Individuals Who May Be Qualified Beneficiaries
Children born to or placed for adoption with the covered employee during
COBRA coverage period
A child born to, adopted by, or placed for adoption with a covered employee during a
period of COBRA coverage is considered to be a qualified beneficiary provided that, if
the covered employee is a qualified beneficiary, the covered employee has elected
COBRA coverage for himself or herself. The child's COBRA coverage begins when
the child is enrolled in the Plan, whether through special enrollment or open
enrollment, and it lasts for as long as COBRA coverage lasts for other family members
of the employee. To be enrolled in the Plan, the child must satisfy the otherwiseapplicable Plan eligibility requirements (for example, regarding age).
Alternate recipients under QMCSOs
A child of the covered employee who is receiving benefits under the Plan pursuant to a
qualified medical child support order (QMCSO) received by Exxon Mobil Corporation
during the covered employee's period of employment with Exxon Mobil Corporation is
entitled to the same rights to elect COBRA as an eligible child of the covered
employee.
Cost of COBRA Coverage
A person who elects continuation coverage may be required to pay the group rate
premium for continuation coverage plus a 2% administration fee, if applicable, or
102% of cost to the plan to maintain the coverage, unless the person is entitled to
extended coverage due to disability. If the person becomes entitled to such extended
coverage, the person may be required to contribute up to 150% of contributions after
the initial 18-month's coverage until coverage ends. A person who elects continuation
coverage must pay the required contributions within 45 days from the date coverage is
elected retroactively to the date benefits terminated under the Plan.
13
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should
be addressed to the contact or contacts identified below. For more information about
your rights under the Employee Retirement Income Security Act (ERISA), including
COBRA, the Patient Protection and Affordable Care Act, and other laws affecting
group health plans, contact the nearest Regional or District Office of the U.S.
Department of Labor’s Employee Benefits Security Administration (EBSA) in your area
or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District
EBSA Offices are available through EBSA’s website.) For more information about the
Marketplace, visit www.HealthCare.gov.
Keep Your Plan Informed of Address Changes
In order to protect your family's rights; you should keep Benefits Administration
informed of any changes in your addresses as well as the addresses of family
members. You should also keep a copy, for your records, of any notices you send to
Benefits Administration.
Determination of Benefits Administration Entity to Contact:
IMPORTANT - "Benefits Administration" references throughout this notice change
depending on your status. Unless specifically stated otherwise, you should refer to the
correct Benefits Administration entity using the list below. If your status is not listed,
call ExxonMobil Benefits Administration/Health Plan Services for assistance.



Current ExxonMobil and XTO Employees or their covered family members
should use EDA or contact ExxonMobil Benefits Administration/ Health Plan
Services;
Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or
their covered family members contact ExxonMobil Benefits Service Center;
and
Former Exxon, Exxon Mobil or XTO Employees and Exxon and ExxonMobil
Retirees (who retired before October 1, 2005) and their Survivors or covered
family members, who have elected and are participating through COBRA,
contact ExxonMobil COBRA Administration.
The following sets out the contact numbers based on your status under the
ExxonMobil Medical Plan. Failure to notify the correct entity could result in your loss
of COBRA rights. If your status is not listed, call ExxonMobil Benefits
Administration/Health Plan Services for assistance.
14
Plan Contact Information
Phone Numbers:
Employees and their covered family members:
ExxonMobil Benefits Administration/Health
Plan Services
Monday - Friday except certain holidays
8:00 a.m. to 3:00 p.m. (U.S. Central Time)
800-262-2363
(toll free outside Houston)
Retirees, their survivors and covered family
members:
ExxonMobil Benefits Service Center
Monday – Friday except certain holidays
8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)
800-682-2847
(toll free)
800-TDD-TDD4
(833-8334) for the hearing
impaired
Address:
ExxonMobil Benefits
Administration ATTN: Health
Plan Services ExxonMobil BA
BSC USBA
4300 Dacoma BH-1
Houston, TX 77092
ExxonMobil Benefits Service
Center
P.O. Box 1014
Totowa, NJ 07512-1014
Former employees and retirees (who retired before October 1, 2005), their survivors
and family members who have elected and are participating through COBRA:
ExxonMobil COBRA Administration
Benefits Continuation Services,
Monday - Friday except certain holidays
Dept. 166 ADP National
8:00 a.m. to 7:00 p.m. (U.S. Central Time)
Accounts Services ExxonMobil
COBRA Administration
(800) 522-6621
(toll free)
P O Box 2968
Alpharetta, GA 30023-2968
Fax: (770) 619-7160
About the Employee Health
Advisory Program
Eligibility and Enrollment
How the Plan Works
Continuation Coverage
Administrative and ERISA
Information
- Basic Plan Information
- Benefit Claims
- Denied Claims
- Filing a Mandatory Appeal
- Legal Actions
- No Implied Promises
- Future of the ExxonMobil
Employee Health Advisory
Program
- Your Rights Under ERISA
Key Terms
Administrative and ERISA Information
Q. What other information do I need to know about the Plan?
A. This section contains technical information about the Plan and
identifies its administrator. It also contains a summary of your rights
with respect to the Plan and instructions about how you can submit an
appeal if your claim for benefits is denied.
The formal name of the Plan is the ExxonMobil Employee Health Advisory Program.
Plan Sponsor and Participating Affiliates
The ExxonMobil Employee Health Advisory Program is sponsored by:
Exxon Mobil Corporation
5959 Las Colinas Boulevard
Irving, Texas 75039-2298
All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates
participate in the ExxonMobil Health Advisory Program. A complete list of participating
affiliates is available from the Administrator-Benefits upon written request.
Certain employees covered by collective bargaining agreements do not participate in
the Plan.
Basic Plan Information
Plan Administrator
The Plan Administrator for the ExxonMobil Health Advisory Program is the
Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits
Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the
following address. Legal process may be served upon the Administrator-Benefits c/o
Exxon Mobil Corporation by serving the Corporation's Registered Agent for Service of
Process, Corporation Service Company (CSC).
Administrator-Benefits
ExxonMobil Medical Plan
P.O. Box 2283
Houston, Texas 77252-2283
For service of legal process:
Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218
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Authority of Administrator-Benefits
The Administrator-Benefits (and those to whom the Administrator-Benefits has
delegated authority) has the full and final discretionary authority to determine eligibility
for benefits, to construe and interpret the terms of the Employee Health Advisory
Program in its application to any participant or beneficiary, and to decide any and all
claim appeals.
Claims Fiduciary and Appeals
The Claims Fiduciary is the person to whom all appeals are filed. For the ExxonMobil
Employee Health Advisory Program, the Claims Fiduciary is the Care Manager,
Magellan Behavioral Health. The Care Manager will decide all appeals for denied
benefits. File any appeals with:
Magellan Behavioral Health
P.O. Box 2128
Maryland Heights MO 63043
Type of Plan
The ExxonMobil Employee Health Advisory Program is a welfare plan under ERISA
providing professional counseling for personal problems requiring limited intervention
and referral services for more complicated problems.
Plan Numbers
The ExxonMobil Employee Health Advisory Program is identified with government
agencies under two numbers: the Employer Identification Number 13-5409005 and the
Plan Number 609.
Plan Year
The Plan year is the calendar year, January 1 through December 31.
Plan Funding
Benefits are funded through employer contributions.
Benefit Claims
Magellan will generally make a determination on your request for EHAP services and
inform you of its determination in your initial telephone call to request services.
If Magellan cannot decide while on the initial call, Magellan will decide within five (5)
calendar days of your request for services or of notice to Magellan of a circumstance
that affects the availability of further EHAP services. Magellan will inform you by
telephone of its determination within one (1) business day after it decides. If you
consent to written notice, Magellan will send you written notice of its determination
within one business day of the telephonic notice.
If you are receiving an ongoing course of EHAP counseling, Magellan will notify you in
advance if it intends to terminate or reduce the number of EHAP sessions that can be
provided so that you will have an opportunity to appeal the decision before the
termination or reduction takes effect.
If Magellan determines that you need Urgent Care, Magellan will provide telephonic
crisis counseling and make an appropriate referral to your benefit plan and/or
emergency resources in the community.
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Because Magellan pays all EHAP providers directly, you should not make any
payment to a provider for EHAP services. In the event that you mistakenly pay a
provider for EHAP services, Magellan will make a determination on your request for
reimbursement within 15 days after receipt of the Claim (if EHAP services have not yet
been received) or with 30 days after receipt of the Claim (if the EHAP services have
already been received). Magellan will notify you of its determination telephonically,
and, if you consent to written notice, in writing, within the 15 day or 30 day period, as
applicable.
To use EHAP, call Magellan toll free. You do not pay for or file claim forms for your
EHAP counseling sessions. If you require additional services beyond that provided by
EHAP, those services may be provided under your medical plan.
If you have a problem with a plan benefit, contact Magellan. The Care Manager is
responsible for determining and informing you of your entitlement to a benefit.
The following categories of claims for benefits apply to the ExxonMobil Employee
Health Advisory Program, and according to the type of claim submitted, Magellan will
review your claim and respond within a designated response time. If Magellan needs
additional time (an extension) to decide on your claim because of special
circumstances, you will be notified within the claim response period.
Urgent care means care needed to avoid serious jeopardy to your life or health or to
regain maximum function (or required to avoid severe pain), as determined by
Magellan or your treating physician. Magellan does not make Claim determinations
relating to Urgent Care.
Pre-Service claims are any claims for benefits where the Plan provisions require
approval before care is obtained.
Post-service claims are claims made after care is received and apply to claims under
the ExxonMobil Employee Health Advisory Program.
Type of
Claim
Response
time
Extension
Urgent
claims
Not
applicable
Pre-service
claims
15 days
An additional 15 days. However, if an extension is
necessary due to incomplete information, you must
provide the additional information within 45 days from
the date of receipt of the extension notice.
Post-service 30 days
claims
An additional 15 days. However, if an extension is
necessary due to incomplete information, you must
provide the additional information within 45 days from
the date of receipt of the extension notice.
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Denied Claims
If your claim for benefits is denied completely or partially, and you authorize written
communication to you, Magellan will provide written notice to you, your beneficiary, or
designated representative. The notice will describe:






The specific reason(s) for the denial for the denial decision,
Identify Plan provisions on which the decision is based;
Describe any additional material or information necessary for an appeal review
and an explanation of why it is necessary;
Explain the review procedure, including time limits for appealing the decision
and to sue in federal court;
Identify your right to receive, free of charge, upon your request, any internal
rule, guidelines, protocol or similar criterion relied on in making the decision;
Identify your right to receive, free of charge, upon your request, an explanation
of the clinical judgment on which the decision is based (if the denial is based
on exclusion of experimental treatment services or because EHAP services
are not clinically appropriate).
If you do not authorize written notice, Magellan will furnish this information to you or
your Authorized Representative by telephone.
Filing a Mandatory Appeal
If you believe your Claim for EHAP benefits was denied in error, you may appeal the
decision. Your appeal must be submitted in writing to Magellan within 180 days
following your receipt of a denial notice.
Your appeal should state the reasons why you feel your Claim for EHAP benefits is
valid and include any additional documentation that you feel supports your Claim for
EHAP benefits. You can also include any additional questions or comments. You may
submit written comments, documents, records and other information relating to your
appeal, whether or not the comments, documents, records or information were
submitted in connection with the initial Claim for EHAP benefits. On your request,
Magellan will make relevant documents available to you.
The review of the initial decision will consider all new information, whether or not it was
presented or available for the initial decision. The person who conducts the appeal
review will be different from the person(s) who originally denied your Claim for EHAP
benefits and will not report directly to the original decision maker or prior reviewer.
You or your Authorized Representative will be notified of the appeal decision within the
following time frames:

If the case involves an adverse determination on a request for EHAP services
or a pre-service adverse determination relating to reimbursement, within thirty
(30) days of Magellan's receipt of the request for appeal;

If the case involves a post-service adverse determination relating to
reimbursement, within sixty (60) days of Magellan's receipt of the request for
appeal.
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If Magellan needs additional time to decide on your claim because of special
circumstances, you will be notified within the claim response period. However, an
extension may be requested, but the law stipulates that no additional time will be
allowed.
If you authorize written communication, Magellan will give you or your Authorized
Representative the decision on the appeal in writing. If the denial is upheld on appeal,
the notice will set forth:

The specific reason(s) for the denial and the Plan provisions upon which the
denial is based.

A statement that you are entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records and other
information relevant to the claim.

Notice of your right to receive, free of charge, upon your request, any internal
rule, guidelines, protocol or similar criterion relied on in making the decision.

Notice of your right to receive, free of charge, upon your request, an
explanation of the clinical judgment on which the decision is based (if the
denial is based on exclusion of experimental treatment services or because
EHAP services are not clinically appropriate).

A statement of your right to bring an action under section 502(a) of the
Employee Retirement Income Security Act (ERISA).
If you do not authorize written notification, Magellan will furnish this information to you
or your Authorized Representative by telephone.
If you do not agree with the final decision of Magellan, you may bring a lawsuit in
federal district court within one year of the final decision. You cannot bring legal action
unless your Claim has been reviewed and denied by Magellan.
Legal Actions
No action at law or in equity to recover benefits under the Plan shall be brought unless
the mandatory appeal process has been completed. In any event, no such action shall
be brought after the expiration of one year from the time an appeal is decided by
Magellan.
No Implied Promises
Nothing in the ExxonMobil Employee Health Advisory Program gives you a right to
remain in employment or affects ExxonMobil’s right to terminate your employment at
any time and for any reason (which is hereby reserved).
20
Future of the ExxonMobil Employee Health
Advisory Program
ExxonMobil expects to continue the Plan. However, ExxonMobil has the right to
change or terminate the Plan at any time and for any reason. A change also may be
made to required contributions and future eligibility for coverage, and may apply to
those who retired in the past, as well as those who retire in the future.
For health plans, certain rules apply regarding what happens when a plan is changed,
terminated or merged.
Claims incurred before the effective date of a plan change or termination will not be
affected. Claims incurred after a plan is terminated won't be covered.
Your Rights Under ERISA
As a participant in EHAP, you have certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a plan
participant, you shall be entitled to:
Receive Information About Your Plan and Benefits



Examine, without charge, at the office of the Administrator-Benefits and at
other specified locations, such as worksites and union halls, all documents
governing EHAP, including collective bargaining agreements, and a copy of
the latest annual report (Form 5500 Series) filed by EHAP with the U.S.
Department of Labor and available at the Public Disclosure Room of the
Employee Benefits Security Administration.
Obtain, upon written request to the Administrator-Benefits, copies of
documents governing the operation of EHAP, including collective bargaining
agreements, and copies of the latest annual report (Form 5500 Series) and
updated summary plan description. The administrator may require a
reasonable charge for the copies.
Receive a summary of EHAP's annual financial report. The AdministratorBenefits is required by law to furnish each participant with a copy of this
summary annual report.
Prudent Actions By EHAP Fiduciaries
In addition to creating rights for EHAP participants, ERISA imposes duties upon the
people who are responsible for the operation of the employee benefit plan. The people
who operate EHAP, called "fiduciaries", have a duty to do so prudently and in the
interest of you and other EHAP participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate
against you in any way to prevent you from obtaining a plan benefit or exercising your
rights under ERISA.
21
Enforce Your Rights



If your claim for a benefit is denied or ignored, in whole or in part, you have a
right to know why this was done, to obtain copies of documents relating to the
decision without charge, and to appeal any denial, all within certain time
schedules.
Under ERISA, there are steps you can take to enforce the above rights. For
instance, if you request a copy of EHAP documents or the latest summary
annual report from the EHAP and do not receive them within 30 days, you may
file suit in a Federal court. In such a case, the court may require the
Administrator-Benefits to provide the materials and pay you up to $110 a day
until you receive the materials, unless the materials were not sent because of
reasons beyond the control of the administrator.
If you have a claim and an appeal for benefits, which are denied or ignored, in
whole or in part, you may file suit in a state or Federal court. Any such lawsuits
must be brought within one year of the date on which an appeal was denied.
Such lawsuit must be filed in the United States District Court for the Southern
District of Texas, Houston, Texas, or in the United States District Court for the
federal judicial district where the employee currently works. If a retiree or
terminee, the suit must be filed in the last location worked prior to termination
of employment. Beneficiaries must also file in the same federal judicial district
that the employee or retiree would be required to file. The court will decide who
should pay court costs and legal fees. If you are successful, the court may
order the person you have sued to pay these costs and fees. If you lose, the
court may order you to pay these costs and fees, for example, if it finds your
claim is frivolous.
Assistance with Your Questions
If you have any questions about EHAP, you should contact the Care Manager or call
Benefits Administration. If you have any questions about this statement or about your
rights under ERISA, or if you need assistance in obtaining documents from the
Administrator-Benefits, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor, listed in your telephone directory or
the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue N.W.,
Washington, D.C. 20210. You may also obtain certain publications about your rights
and responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
About the Employee Health
Advisory Program
Eligibility and Enrollment
How the Plan Works
Continuation Coverage
Administrative and ERISA
Information
Key Terms
Key Terms
Barred Employee
An employee who is covered by a collective bargaining agreement except
to the extent participation is provided under such agreement.
Care Manager
Magellan Behavioral Health or its successor as designated by
ExxonMobil Corporation.
Child
A person under age 26 who is;




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A naturally or legally adopted child of a regular employee or
retiree;
A grandchild, niece, nephew, cousin, or other child related by
blood or marriage over whom a regular employee, retiree, or the
spouse of a regular employee or retiree (separately or together) is
the sole court appointed legal guardian or sole managing
conservator;
A child for whom the regular employee or retiree has assumed a
legal obligation for support immediately prior to the child's
adoption by the regular employee or retiree; or
A stepchild of a regular employee or retiree.
Child does not include a foster child.
Eligible Employees
Most U.S. dollar-paid employees of Exxon Mobil Corporation and
participating affiliates are eligible. Full-time employees not hired on a
temporary basis (also called "regular employees") are eligible. Extended
part-time employees, as classified on the employer's books and records,
are also eligible.
The following are not eligible to participate in the Plan: employees of
Station Operators, Inc. (SOI), leased employees as defined in the Internal
Revenue Code, barred employees, or special agreement persons as
defined in the plan document. Generally, special-agreement persons are
persons paid by the company on a commission basis, persons working
for an unaffiliated company that provides services to the company, and
persons working for the company pursuant to a contract that excludes
coverage of benefits.
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Eligible Family Members
Eligible family members are generally your:


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Spouse.
A child who is described in any one of the following paragraphs (1)
through (3):
(1) has not reached the end of the month during which age 26 is
attained; or
(2) is totally and continuously disabled and incapable of self-sustaining
employment by reason of mental or physical disability, provided the
child:
(a) meets the Internal Revenue Service's definition of a dependent
and,
(b) either
(i) was, or would have been, covered as an eligible family member
under this Plan immediately prior to the birthday on which the child's
eligibility would have otherwise ceased, or
(b) either
(i) was, or would have been, covered as an eligible family member
under this Plan immediately prior to the birthday on which the
child's eligibility would have otherwise ceased, or
(ii) was covered as an eligible family member under a predecessor
plan which provided for coverage of disability, if the disability
occurred prior to the birthday on which the child's eligibility under
that plan would have otherwise ceased, the child continued to be
considered eligible for coverage because of such disability and
the child had not lost eligibility under the predecessor plan; and
(c) the child is disabled before such birthday and has remained
continuously disabled, and
(3) the child is recognized under a qualified medical child support
order as having a right to coverage under this Plan.
A child who was disabled by reason of a mental disability but
who no longer meets the requirements of paragraph 2(a)
above ceases to be an eligible family member 300 days
following the date on which the applicable requirement is not
met.
Please note: An eligible employee or retiree's parents are not eligible to be covered.
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Extended Part-Time Employee
An employee who is classified as a non-regular employee, but who has
been designated as an Extended Part-Time employee under his or her
employer's employment policies relating to flexible work arrangements.
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Qualified Medical Child Support Order
A Qualified Medical Child Support Order (QMCSO) is a court decree
under which a court order mandates health coverage for a child. A
QMCSO must include, at a minimum:
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




Name and address of the employee covered by the health plan.
The name and address of each child for whom coverage is
mandated.
A reasonable description for the coverage to be provided.
The time period of coverage.
The name of each health plan to which the order applies.
You may obtain, without charge, a copy of the Plan's procedures
governing QMCSO determinations by written request to the
Administrator-Benefits.
Regular Employee
An employee of a participating employer, whether or not the person is a
director, who, as determined by the participating employer, regularly
works a full-time schedule, and is not employed on a temporary basis.
The definition includes a person who regularly works a full-time schedule
but who, for a limited period of time, is approved for a part-time regular
work arrangement under the participating employer’s work rules relating
to part-time work for regular employees.
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Spouse; Marriage
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.
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Trainee
An employee who is classified as a non-regular employee, but who has
been characterized as a Trainee and has graduated from high school.
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