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Defined Terms

As you read this summary of the JPMorgan Chase Expatriate Medical and Dental Plans, you'll come across some important terms related to each plan. To help you better understand the Plans, many of those important terms are defined here.
Alternate Benefits
If Cigna Global Health Benefits determines that a service less costly than the Covered Service the dentist performed could have been performed to treat a dental condition, the Plan will pay benefits based upon the less costly service if such service:
  • Would produce a professionally acceptable result under generally accepted dental standards; and
  • Would qualify as a Covered Service.
Before-Tax Contributions
U.S. home-based expatriate employees, and expatriate employees who are assigned to the United States, pay for coverage with before-tax dollars — contributions that are taken from your pay before U.S. federal (and, in most cases, state and local) taxes are withheld. Before-tax dollars are also generally taken from your pay before U.S. Social Security taxes are withheld. This lowers your U.S. taxable income and your U.S. income tax liability.
Claims Administrator
The claims administrator is the company that provides certain claims administration services for the Medical and Dental 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 and/or 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.
Non-U.S. home-based expatriate employees assigned outside the United States and their dependents are not eligible for COBRA continuation coverage.
Coinsurance
Coinsurance is the way you share costs for certain coverage options after you pay any applicable deductible. The Medical and Dental Plans 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.
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 Expatriate Medical Plan.
Once the coinsurance maximum is reached, the Expatriate 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. However, amounts that you pay toward your deductibles, copayments, and amounts above R&C charges for out-of-network care do not count toward your coinsurance maximum.
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) or covered by U.S. 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 details.
Copayment
A copayment (also known as a copay) is the fixed dollar amount you pay for certain covered services under the Expatriate Medical and Dental Plans. For example, the Expatriate Medical Plan requires a $150 copayment for an emergency room visit. The actual amount of the copayment will vary based on the services provided.
Covered Expenses
Covered expenses are the in-network negotiated fees or the reasonable and customary (R&C) charges for medically necessary covered services or supplies that qualify for full or partial reimbursement under the Expatriate Medical and/or the Expatriate Dental Plans.
Covered Services
While the Plans provide coverage for numerous services and supplies, there are limitations on what's covered.
For example, under the Expatriate Medical Plan, experimental treatments, most cosmetic surgery expenses, and inpatient and outpatient private duty nursing are not covered. Medical procedures are generally reimbursable only if they meet the definition of "Medically Necessary" (see "Medically Necessary," below).
Under the Expatriate Dental Plan, a crown, bridge, or gold restoration is not covered if a tooth was prepared for it before the person became covered under the Plan. So, while a service or supply may be necessary, it may not be covered under the Expatriate Dental Plan. Please see "What Is Covered" for more details.
Deductible
The deductible is the amount you pay up front each calendar year for covered expenses before the Expatriate Medical Plan and/or Expatriate Dental Plan generally begins to pay benefits for many expenses. Amounts in excess of reasonable and customary (R&C) charges and ineligible charges do not count toward the deductible.
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:
  • 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 Expatriate Medical Plan and the Expatriate Dental Plan.
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.
In-Network
"In-network" describes a covered service that is performed by a physician, dentist, 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.
Maximum Annual Benefit
The maximum annual benefit is the most the Expatriate Dental Plan will pay for covered preventive and restorative dental services for each participant in a year.
Maximum Lifetime Benefit
The maximum lifetime benefit is he most the Expatriate Medical Plan or Expatriate Dental Plan will pay for covered services in each participant's lifetime.
Maximum Lifetime Orthodontia Benefit
The maximum lifetime orthodontia benefit is the most the Expatriate Dental Plan will pay for covered orthodontia services for each participant's lifetime.
Any benefits that have been applied to a maximum provision under a U.S. domestic dental plan of your heritage organization will also be applied to the lifetime maximum for the Expatriate Dental Plan.
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.
Missing Tooth Exclusion
The missing tooth exclusion refers to an ineligible charge for a partial or full removable denture, removable bridge, or fixed bridgework if it includes replacement of one or more natural teeth missing before the person became covered under the Expatriate Dental Plan. This exclusion does not apply if the denture, bridge, or bridgework also includes replacement of a natural tooth that:
  • Is removed while the person is covered; and
  • Was not an abutment to a partial denture, removable, or fixed bridge installed during the prior five years.
Multiple Surgical Procedure Reduction Policy
The multiple surgical procedure reduction policy means that 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.
Necessary Services
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 Expatriate Dental Plan. Cigna International 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 Plans do 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 Expatriate Medical or Expatriate 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 expatriate 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.
Out-of-Network
"Out-of-network" describes a covered service that is performed by a physician, dentist, 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
Your out-of-pocket expense is the amount you pay for eligible expenses when you receive treatment. This includes your deductible, coinsurance and copayments.
Pre-Determination
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 $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 the Expatriate Dental Plan will pay.
Primary Plan
The primary plan is the plan that provides initial coverage to the participant. If the participant is covered under both the JPMorgan Chase Expatriate Medical Plan and/or Dental Plans 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 U.S. 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 details.
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.)
Please Note: Any changes you make during the year must be consistent with your QSC. Please see "Changing Your Coverage Midyear."
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 under the Expatriate Medical and/or Expatriate Dental Plans. 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, as determined in the sole discretion of the claims administrator. 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 Expatriate Medical Plan and/or Expatriate Dental Plans,, 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 coinsurance maximums.
Self-Insured
A self-insured plan is a plan where the sponsor (in the case of the Expatriate Medical Plan and the Expatriate Dental Plan, JPMorgan Chase) is responsible for the payment of medical and dental claims under the Plans. This makes these plans self-insured.
Spouse
The term "spouse" refers to any person to whom you are legally married as recognized by U.S. federal law.
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 Expatriate Health Benefits Resources.