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Defined Terms

As you read this SPD for the JPMorgan Chase Medical Plan, you'll come across some important terms related to the Plan. To help you better understand the Plan, many of those important terms are defined here.
Before-Tax Contributions
Before-tax contributions are contributions that are taken from your pay before federal (and, in most cases, state and local) taxes are withheld. Before-tax dollars are also generally taken from your pay before Social Security taxes are withheld. This lowers your taxable income and your income tax liability.
Your Medical Plan payroll contributions are taken on a before-tax basis.
Claims Administrator
The claims administrator is the company that provides certain claims administration services for the Medical Plan. If you elect Medical Plan coverage, your claims administrator is your health care company (Cigna or UnitedHealthcare, depending on your election).
Coinsurance
Coinsurance is the way you and the Plan share costs for certain covered health care services, generally after you pay any applicable deductible under the Medical and/or Prescription Drug Plan. For medically necessary covered in-network services, the Medical Plan pays a percentage of providers' negotiated fees and you pay the remainder. For medically necessary covered out-of-network services, the Medical Plan pays a percentage of the reasonable and customary (R&C) charges for services and you pay the remainder (you are responsible for paying any additional amount above R&C charges). The coinsurance percentage you pay depends on the type of covered service.
Coinsurance Maximum
The coinsurance maximum is a "safety net" that protects you from having to pay high expenses in the event of a serious medical situation. The coinsurance maximum is the most you would need to pay in a calendar year in addition to the deductible for medically necessary covered services under the Medical Plan. There are separate in-network and out-of-network coinsurance maximums.
Once the coinsurance maximum is reached, the Medical Plan will pay 100% of negotiated rates for medically necessary covered in-network care and 100% of reasonable and customary (R&C) charges for medically necessary covered out-of-network services for the rest of the year. Under the Medical Plan, amounts that you pay toward your medical deductible, amounts above R&C charges for out-of-network care, and your deductible, copayments, and coinsurance for prescription drugs do not count toward your medical coinsurance maximum.
There is a separate coinsurance maximum for the Prescription Drug Plan.
Please see "Right of Recovery" in the Plan Administration section for information on circumstances when you may be required to repay the benefits you've received under the Plan.
COBRA
The Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") is a federal law that allows you and/or your covered dependents to continue Medical Plan coverage on an after-tax basis (under certain circumstances) when coverage would otherwise end. The Health Care Participation section provides details on COBRA coverage.
Coordination of Benefits
Coordination of benefits rules are the rules that determine how benefits are paid when a patient is covered by more than one group plan. Rules include:
  • Which plan assumes primary liability;
  • The obligations of the secondary claims administrator or claims payer; and
  • How the two plans ensure that the patient is not reimbursed for more than the actual charges incurred.
In general, the following coordination of benefits rules apply:
  • As a JPMorgan Chase employee, your JPMorgan Chase coverage is considered primary for you.
  • For your spouse/domestic partner or child covered as an active employee and/or retiree of another employer, that employer's coverage is considered primary.
  • For children covered as dependents under two plans, the primary plan is the plan of the parent whose birthday falls earlier in the year (based on month and day only, not year).
Specific rules may vary, depending on whether the patient is:
  • An employee in active status (or the dependent of an employee).
  • Covered by Medicare.
If you or a dependent are eligible for Medicare because of disability or end-stage renal disease, please see "Coordination with Medicare" in the Plan Administration section for more information.
Copayment
A copayment (also known as a copay) is the fixed dollar amount you pay for certain medications under the Prescription Drug Plan. For example, copayments apply for generic drugs.
Covered Services
While the Plan provides coverage for numerous services and supplies, there are limitations on what's covered. For example, experimental treatments, most cosmetic surgery expenses, and inpatient private duty nursing are not covered under the Medical Plan. Medical procedures are generally reimbursable by the JPMorgan Chase Medical Plan only if they meet the definition of "Medically Necessary" (see the definition "Medically Necessary," below).
Custodial Care
Custodial care is medical or non-medical services that do not seek to cure, are provided during periods when the medical condition of the patient is not changing or does not require continued administration by medical personnel. An example of custodial care is assistance in the activities of daily living.
Deductible
The deductible is the amount you pay up front each calendar year for covered expenses before the Medical Plan generally begins to pay benefits for many expenses. There are separate in-network and out-of-network deductibles. Amounts in excess of reasonable and customary (R&C) charges and ineligible charges do not count toward the deductible. A separate deductible applies for the Prescription Drug Plan.
Domestic Partner
You may cover a "domestic partner" as an eligible dependent under the Medical Plan if you're not currently covering a spouse.
  • You and your domestic partner must:
  • Be age 18 or older; and
  • Not be legally married to, or the domestic partner of, anyone else; and
  • Have lived together for at least the last twelve (12) months, are currently living together, and are committed to each other to the same extent as married persons are to each other, except for the traditional marital status and solemnities; and
  • Be financially interdependent (share responsibility for household expenses); and
  • Not be related to each other in a way that would prohibit legal marriage.
OR
  • Have registered as domestic partners pursuant to a domestic partnership ordinance or law of a state or local government, or under the laws of a foreign jurisdiction.
You must certify that your domestic partner meets the eligibility rules as defined under the Plan before coverage can begin. You may also be asked to certify that your domestic partner and/or your domestic partner's children qualify as tax dependent(s) as determined by the Internal Revenue Code (IRC) to avoid any applicable imputed income. Please see "Domestic Partners" in the Health Care Participation section for more information.
Eligible Dependents
Under the Medical Plan, your eligible dependents can include your spouse or domestic partner and your children. Please see the above definition of "Domestic Partner" and see "Eligible Dependents" in the Health Care Participation section for more information.
Experimental, Investigational, or Unproven Services
Experimental, investigational, or unproven services are medical, surgical, diagnostic, psychiatric, mental health, substance abuse and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the claims administrator makes a determination about coverage in a particular case, are determined to be:
  • Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use or not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; or
  • Subject to review and approval by any institutional review board for the proposed use; or
  • The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or
  • Not demonstrated through prevailing peer-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed.
The claims administrator, in its judgment, may determine an experimental, investigational or unproven service to be covered under the Medical Plan for treating a "life-threatening" sickness or condition if the claims administrator determines that a service:
  • Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use or not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use; or
  • Is safe with promising effectiveness;
  • Is provided in a clinically controlled research setting; and
  • Uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.
Please Note: For the purpose of this definition, the term "life-threatening" is used to describe sicknesses or conditions that are more likely than not to cause death within one year of the date of the request for treatment.
If services are denied because they are deemed to be experimental, investigational, or unproven, and the service is then considered an approved service by the claims administrator within six months of the date of service, you may resubmit your claim for payment.
Explanation of Benefits
An explanation of benefits (EOB) is a statement that the claims administrator prepares, which documents your claims and provides a description of benefits paid and not paid under the Medical Plan and through any related Medical Reimbursement Account and/or Health Care Spending Account.
Home Health Care
Home health care is an alternative to inpatient hospitalization during a patient's recovery period. If the attending physician believes that part-time care will suffice in treating the sickness or injury, the physician can prescribe a schedule of services to be provided by a state-licensed home health care agency. This schedule may include administration of medication, a regimen of physical therapy, suctioning or cleansing of a surgical incision, or the supervision of intravenous therapy.
Hospice Care Program
A hospice care program is a program that tends to the needs of a terminally ill patient as an alternative to traditional health care, while meeting medically necessary and acceptable standards of quality and sound principles of health care administration. The program must be a written plan of hospice care for a covered person, and it must be approved by the appropriate claims administrator.
Hospital
A hospital is an institution legally licensed as a hospital — other than a facility owned or operated by the United States government — that's engaged primarily in providing bed patients with diagnosis and treatment under the supervision of licensed physicians. The hospital must have 24-hour-a-day registered graduate nursing services and facilities for major surgery. Institutions that don't meet this definition don't qualify as hospitals.
Hospital Notification
Hospital notification refers to the requirement under the Medical Plan that you should notify the claims administrator in advance of a non-emergency hospital admission or if a maternity stay exceeds the guidelines. However, you will not be penalized under the Plan if you do not notify the claims administrator.
In-Network
"In-network" describes a covered service that is performed by a physician, hospital, lab, or other health care professional who is part of a health care company's network and who has agreed to pre-negotiated fees. When a service is performed in-network, benefits are generally paid at a higher level than they are when a service is performed out-of-network.
Medical Reimbursement Account
A Medical Reimbursement Account ("MRA," also known as a Health Reimbursement Account" or "HRA") is a tax-free account established on your behalf at your health care company when you enroll in the Medical Plan. You (and your covered spouse/domestic partner) can earn Wellness Rewards for your MRA by completing Initial Wellness Activities and Additional Wellness Activities. This account is JPMC-funded only; you cannot contribute to your MRA. You can use the funds in your MRA to pay for eligible out-of-pocket medical and prescription drug expenses (deductibles, coinsurance, and copayments).
Medically Necessary
Medically necessary health care services and supplies are services or supplies that are determined by the claims administrator to be medically appropriate and:
  • Necessary to meet the basic health needs of the covered person;
  • Provided in the most cost-efficient manner and type of setting appropriate for the delivery of the service or supply;
  • Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies that are accepted by the claims administrator;
  • Consistent with the diagnosis of the condition;
  • Required for reasons other than the convenience of the covered person or his or her physician; and
  • Demonstrated through prevailing peer-reviewed medical literature to be either:
    • Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed. or
    • Safe with promising effectiveness:
      • For treating a life-threatening sickness or condition;
      • In a clinically controlled research setting; and
      • Using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health.
Please Note: For the purpose of this definition, the term "life-threatening" is used to describe sicknesses or conditions that are more likely than not to cause death within one year of the date of the request for treatment.
The fact that a physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or condition does not mean that it is a medically necessary service or supply as defined above. The definition of "medically necessary" used here relates only to coverage, and may differ from the way in which a physician engaged in the practice of medicine may define "medically necessary."
Finally, to be considered necessary, a service or supply cannot be educational or experimental in nature in terms of generally accepted medical standards.
Multiple Surgical Procedure Reduction Policy
The multiple surgical procedure reduction policy applies under the Medical Plan. Surgical procedures that are performed on the same date of service are subject to the multiple surgical procedure reduction policy. On an in-network basis, 100% of the negotiated charges are reimbursable for the primary/major procedure, 50% of negotiated charges are reimbursable for the secondary procedure, and 50% of negotiated charges are reimbursable for all subsequent procedures. On an out-of-network basis, 100% of the reasonable and customary (R&C) charges are reimbursable for the primary/major procedure, 50% of R&C charges are reimbursable for the secondary procedure, and 50% of R&C charges are reimbursable for all subsequent procedures. Participants undergoing surgery are urged to discuss this policy with their health care provider.
Non-Duplication of Benefits
Non-duplication of benefits is a provision that requires that the Medical Plan does not allow for duplication of benefits. If you and your eligible dependents are covered under more than one group plan, the primary plan (the one responsible for paying benefits first) needs to be determined. You are entitled to receive benefits up to what you would have received under the Medical Plan if it were your only source of coverage, but not in excess of that amount. If you have other coverage that is primary to the Medical Plan, the claims administrator will reduce the amount of coverage that you would otherwise receive under this plan by any amount you receive from your primary coverage. Please see the definition of "Coordination of Benefits" in this section.
Out-of-Network
"Out-of-network" describes a covered service that is performed by a physician, hospital, lab, or other health care professional who is not part of a health care company's network and who has not agreed to pre-negotiated fees. When a service is performed out-of-network, benefits are generally paid at a lower level than they are when a service is performed in-network and are generally limited to reasonable and customary charges.
Out-of-Pocket Expense
An out-of-pocket expense is the amount you pay for eligible expenses when you receive treatment. This includes your deductible, coinsurance, and copayments.
Out-of-Pocket Maximum
The out-of-pocket maximum, under the Prescription Drug Plan, is the maximum amount you would have to pay each year in copayments and coinsurance for prescription drugs. The annual out-of-pocket maximum does not include the deductible.
After you reach the annual out-of-pocket maximum, the Prescription Drug Plan would pay 100% of the cost of covered prescription drugs for the remainder of the year.
Please see "Right of Recovery" in the Plan Administration section for information on circumstances when you may be required to repay the benefits you've received under the Plan.
Primary Care Physician
A primary care physician ("PCP") is the network physician who provides or coordinates all the care you receive.
Primary care physicians include doctors who practice family medicine, internal medicine,* obstetrics/gynecology, and pediatrics. Care provided by an in-network primary care physician is covered at 90% of the pre-negotiated fee and is not subject to the deductible.
*Internists must be contracted with Cigna or UnitedHealthcare as Primary Care Physicians. (A list of doctors who are designated as Primary Care Physicians is available on Cigna or UnitedHealthcare's websites.)
Primary Plan
The primary plan is the plan that provides initial coverage to the participant. If the participant is covered under both a JPMorgan Chase Medical Plan option and another plan, the rules of the primary plan govern when determining the coordination of benefits between the two plans.
Specific rules may vary, depending on whether the patient is:
• An employee in active status (or the dependent of an employee); or
• Covered by Medicare.
These rules do not apply to any private insurance you may have. Please see "If You Are Covered by More Than One Plan" in the Plan Administration section for more information.
Qualified Status Change
The JPMorgan Chase benefits you elect during each Annual Benefits Enrollment will generally stay in effect throughout the plan year, unless you elect otherwise, because of a Qualified Status Change (QSC). If you have a QSC, you have 31 days from the qualifying event to make benefits changes; 90 days from the qualifying event if the event is the birth or adoption of a child. The benefits you elect will be effective the date of the event if you make the elections timely. (Please Note: You will have 90 days from the QSC date to add any newly eligible dependents to the JPMC Medical Plan should that dependent pass away within this 90-day period.)
Any changes you make during the year must be consistent with your QSC. Please see "Changing Your Coverage Midyear," in the Health Care Participation section for more information.
Please Note: Regardless of whether you experience a QSC, you cannot change your health care company during the year.
Reasonable and Customary Charges
Reasonable and customary charges ("R&C charges," also known as "eligible expenses") are the actual charges that are considered for payment when you receive medically necessary care for covered services from an out-of-network provider. R&C means the prevailing charge for most providers in the same or a similar geographic area for the same or similar service or supply. These charges are subject to change at any time without notice.
Reimbursement is based on the lower of this amount and the provider's actual charge.
If your provider charges more than the R&C charges considered under the Plan, you'll have to pay the difference. Amounts that you pay in excess of the R&C charge are not considered covered expenses.
Therefore, they don't count toward your deductible, benefit limits, or coinsurance maximums.
Regional Cost Category
The regional cost category is the category that is assigned to a state or region based on the cost of health care for that region in relation to the national average. The Regional Cost Category is used to determine your Medical Plan contributions and is based on your home address.
Self-Insured
A self-insured plan is a plan where the sponsor (in the case of the Medical Plan, JPMorgan Chase) is responsible for the payment of medical claims under the Medical Plan, including the Prescription Drug Plan. This makes the Plan self-insured.
Skilled Nursing Facility
A skilled nursing facility is an institution that primarily provides skilled nursing care and related services for people who require medical or nursing care, and that rehabilitates injured, disabled, or sick people.
Spouse
Your spouse is the person to whom you are legally married as recognized by U.S. federal law, if you are legally married.
If JPMorgan Chase employs your spouse, domestic partner, or child, he or she can enroll in coverage as an employee or as your dependent, but not as both. If you want to cover your eligible child(ren), you or your spouse/domestic partner may provide this coverage. If you are covering a spouse/domestic partner who is also a JPMorgan Chase employee (i.e., company couple), you should update the "dependent is also an employee" indicator on the Dependent Enrollment page of the Benefit Web Center, available through My Health.
Tobacco-User Surcharge
The tobacco-user surcharge refers to additional Medical Plan contribution costs for employees and covered spouses/domestic partners who use tobacco products. Eligible employees and covered spouses/domestic partners who do not use tobacco products pay less for coverage under the Medical Plan than those who use tobacco products.
A "tobacco user" (for a plan year), as defined in the Medical Plan, is any person who has used any type of tobacco products (for example, cigarettes, cigars, pipes, chewing tobacco, snuff, or a pipe) regardless of the frequency or location (this includes daily, occasionally, socially, at-home only, etc.) in the 12 months preceding January 1 of the plan year. Tobacco users may be able to qualify for lower non-tobacco user rates by completing a tobacco cessation program (see "Tobacco Cessation Program").
Total Annual Cash Compensation
Total Annual Cash Compensation ("TACC") is your annual rate of base salary/regular pay plus any applicable job differential pay (e.g., shift pay) as of each August 1, plus any cash earnings from any incentive plans (e.g., annual incentive, commissions, draws, overrides and special recognition payments or incentives) that are paid to or deferred by you for the previous 12-month period ending each July 31. Overtime is not included. It is recalculated as of each August 1 to take effect the following January 1 and will remain unchanged throughout the year. For most employees hired on or after August 1, it will be equal to your annual rate of base salary/regular pay plus applicable job differentials.
Total Annual Cash Compensation is used for purposes of determining your Medical Plan contribution pay tier, deductible and in-network coinsurance maximum.
Visit
A visit is an encounter with a provider involving direct patient contact. Some benefit provisions limit the number of covered visits. Unless a visit is defined for a particular benefit provision (such as home health care), each procedure code billed counts as a visit toward the limit. The length of a visit may vary by procedure code.