Medical Plan Coverage Highlights
My Health is your central internal online resource for our healthcare plans. From My Health, you can easily connect to the Medical Plan claims administrators' websites to find in-network provider directories, access treatment cost estimators, check claims status, view Explanations of Benefits (EOBs), track your Medical Reimbursement Account balance, access your electronic ID card and much more. My Health also has benefits materials, tip sheets and other information on health and wellness.
Plan Option 1 and Plan Option 2 of the Medical Plan, each offered through Aetna and Cigna. The way you pay for covered services works the same way under both Plan Option 1 and Plan Option 2. For most in-network routine services, you will pay a copayment with no deductible. Less routine in-network services are subject to an annual deductible and coinsurance after you meet the deductible. Once you meet the Medical Plan's annual out-of-pocket maximum (with a combination of your deductible, coinsurance and copayments), the Plan covers eligible services at 100% for the remainder of the year. There are separate deductibles, out-of-pocket maximums, and coinsurance amounts for in-network and out-of-network services.
Both options cover the same medically necessary services and supplies, including prescription drugs and pre-existing conditions. However, Plan Option 1 has higher payroll contributions but generally lower deductibles, copays and out-of-pocket maximums, while Plan Option 2 has lower payroll contributions but generally higher deductible, copays and annual out-of-pocket maximums.
Plan Option 1 and Plan Option 2 benefits are offered through a network of participating healthcare providers (for example, doctors, hospitals, labs, and outpatient facilities that belong to Aetna and Cigna's networks).
You can visit any provider each time you need care, even if the provider is not in the network. But even though there is an out-of-network benefit available, you are strongly encouraged to stay in-network. Selecting out-of-network providers and services cost more for all employees and JPMorganChase. Selecting in-network providers and services will reduce your out-of-pocket costs.
- For most routine services, such as primary care and specialist office visits, basic lab services, urgent care, and emergency room care, you pay only the copayment — a fixed out-of-pocket amount — associated with each covered service.
- Less routine services, such as inpatient hospitalization or outpatient surgery, are subject to the annual deductible, then coinsurance once the deductible is met.
- You are not required to select or assign a Primary Care Physician.
- You do not need referrals to see a specialist.
- Important: Eligible in-network preventive care, including physical exams and recommended preventive screenings, is covered at 100% with no copays; and in-network primary care and mental healthcare office visits (psychologists, therapists, psychiatrists etc.) are covered after a $15 copayment. Primary Care Physicians include doctors who practice family medicine, internal medicine (and are contracted with Aetna or Cigna as Primary Care Physicians), obstetricians/gynecologists, and pediatricians. Visits to convenience care clinics, such as CVS Minute Clinic®, are also considered primary care visits.
The plan's out-of-pocket maximum — your financial "safety net" — limits the total amount you are required to pay out-of-pocket each year, including deductible, coinsurance and copayments. The out-of-pocket maximum includes medical services only; there is a separate out-of-pocket maximum for prescription drugs. Note that there are separate out-of-pocket maximums for in-network and out-of-network medical charges. The "per person" rule allows an employee or any covered dependent(s) to reach an individual out-of-pocket maximum, after which it is satisfied for the year for that person. See "Per Person Rule for Out-of-Pocket Maximums" for more information on the "per person" rule.
- You generally must meet an annual deductible before the coinsurance applies for covered services.
- Benefits for out-of-network care generally have a higher cost share (e.g., coinsurance) than for in-network care. Note, however, that benefits for emergency room and ambulance services are subject to the same copayments with in-network and out-of-network providers.
- There is a separate, higher out-of-pocket maximum for out-of-network charges.
- Benefits for out-of-network care are limited to reasonable and customary (R&C) charges after you meet the out-of-network deductible. These R&C charges are based on average claims data in your area and are determined by your healthcare company to be appropriate fees for medical services. You are responsible for any amount above the R&C charges.
- It's important to understand that if you are using out-of-network providers (doctors, facilities or other service providers), it is your responsibility to check with your healthcare company to see if there is a prior authorization or medical necessity requirement that you need to meet before receiving any out-of-network treatment, service or procedure. Otherwise, the treatment, service or procedure may not be covered by the Plan and you will be responsible for the full cost.
Prescription drug benefits are part of your coverage. The Prescription Drug Plan has a different plan design than other Medical Plan features, with copays based on the drug category and where you fill your prescription. Covered preventive generic and brand drugs are covered at 100% ($0 cost share), with no copay. There is no deductible for prescription drug coverage and a separate annual out-of-pocket maximum.
When you enroll in Plan Option 1 or Plan Option 2, you are eligible to receive funding in a tax-free account, the Medical Reimbursement Account (MRA), that you can use to pay for eligible medical and prescription drug out-of-pocket expenses. Your MRA is funded by JPMorganChase when you complete certain wellness incentive activities. You cannot contribute your own dollars. Your MRA account balance rolls over year to year.
Payroll contribution rates vary by the number and types of dependents whom you choose to cover — for example, a spouse/domestic partner vs. a child. You will be charged for up to a maximum of three children, regardless of how many additional children you choose to cover (you can cover all of your children, as long as they meet eligibility requirements). Contributions will also vary based on your Total Annual Cash Compensation, geographical location, Medical Plan option you select, you and your covered spouse's/domestic partner's tobacco user status, and you and your covered spouse's/domestic partner's completion of the wellness screening and assessment. The amount you pay does not differ depending on whether you choose Aetna or Cigna as your healthcare company.
More information is available on My Health.