As you read this summary of the JPMorgan Chase Dental 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 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, Dental, Vision and Spending Accounts Plans' payroll contributions are generally taken on a before-tax basis.
The claims administrator(s) are the company(ies) that provide certain claims administration services for the Plan and its options.
Coinsurance is the way you share costs for certain coverage options after you pay any applicable deductible. Certain Dental Plan options pay either a percentage of reasonable and customary (R&C) charges or a percentage of the in-network dentist's negotiated fees for covered services, and you pay the remainder. The actual percentage depends on the option you've chosen and the type of covered service.
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a federal law that allows you and/or your covered dependents to continue Dental Plan coverage on an after-tax basis (under certain circumstances) when coverage would otherwise have ended. 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 him or her.
- 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). 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 details.
In addition, these rules do not apply to the Dental Maintenance Organization (DMO)/Dental Health Maintenance Organization (DHMO), which have their own coordination of benefits provisions. If you are covered by a DMO/DHMO, please check with your Dental Plan carrier to learn how it handles coordination of benefits.
The in-network negotiated fees or reasonable and customary (R&C) charges for out-of-network services if allowed for under an option for necessary covered services or supplies that qualify for full or partial reimbursement under the Dental Plan.
Covered services are services and procedures generally reimbursable by the Plan when they are "necessary." (See the definition of "Necessary Services" in this section.) While the Plan provides coverage for numerous services and supplies, there are limitations on what's covered. So, while a service or supply may be necessary, it may not be covered under the JPMorgan Chase Dental Plan. Please see "What Is Covered" for more details.
The deductible is the amount you pay in a calendar year for covered expenses before the Preferred Dentist Program (PDP) Option begins to pay benefits. Amounts in excess of reasonable and customary (R&C) charges do not count toward the deductible.
Under the Plan, your eligible dependents can include your spouse or domestic partner and your children. Please see "Your Eligible Dependents" in the Health Care Participation section for more information.
Explanation of Benefits (EOB)
An explanation of benefits (EOB) is a statement that the claims administrator prepares, which documents your claim and provides a description of benefits paid and not paid under the Dental Plan.
Dental Plan options for which the benefit payments are the responsibility of the insurance carrier (DMO and DHMO).
"In-network" and "out-of-network" are terms referring to whether a covered service is performed by a dentist who is part of the network associated with the Dental Plan (in-network) or by a dentist who is not part of the network (out-of-network). 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.
Maximum Annual Benefit
The maximum annual benefit is the most the Preferred Dentist Program (PDP) Option will pay for covered preventive and restorative services for each participant in a year.
Necessary services are services or supplies that are accepted and used by the dental community as appropriate for the condition being treated or diagnosed. The services or supplies also must be prescribed by a dentist for the diagnosis or treatment of the condition to be considered necessary. Some prescribed services may not be considered necessary and may not be covered under the JPMorgan Chase Dental Plan. The claims administrator will determine whether a service or supply is necessary.
Finally, to be considered necessary, a service or supply cannot be cosmetic, educational, or experimental in nature and must be in accordance with generally accepted dental standards.
Non-Duplication of Benefits
Non-duplication of benefits is a provision that requires that the Dental 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 JPMorgan Chase Dental 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 JPMorgan Chase Dental 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 for more information.
Pre-determination is an itemization of the proposed course of treatment (including recent pre-treatment X-rays), which you should submit before work is begun, if you anticipate that charges will be more than approximately $300. A dental consultant will review the proposed treatment before work begins and the claims administrator will inform you and your dentist of the amount of covered charges. That way, you'll understand the benefits that will be paid before treatment begins. Benefits will be paid according to the Plan provisions in effect when the services are actually rendered. The amount may change if the treatment changes from that which was predetermined or if frequency limits apply. Except in the case of an emergency, you may not want to begin the course of treatment until you know what amount your JPMorgan Chase Dental Plan option will pay.
Reasonable and Customary (R&C) 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 under the Dental Plan. 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 eligible expenses. Therefore, they don't count toward your deductible, benefit limits, or maximums.
A self-insured option is an option where the sponsor (in the case of the PDP option, JPMorgan Chase) is responsible for the payment of dental claims under the Dental Plan. This makes the option self-insured. JPMorgan Chase is responsible for the payment of dental claims under the PDP Option.