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The Point-of-Service (POS) High and Low Options
The Point-of-Service (POS) High and Low Options are two of the options available under the JPMorgan Chase Medical Plan. Please Note: In some areas, your Medical Plan option administrator may refer to those options as a Preferred Provider Organization (PPO).
Depending upon your address on file with JPMorgan Chase, the POS Option in your location may be administered by:
  • UnitedHealthcare (UnitedHealthcare: Choice Plus POS);
  • Aetna (Aetna: Choice II POS);
  • Empire BlueCross BlueShield (Empire BlueCross BlueShield: PPO); or
  • Anthem BlueCross BlueShield (Anthem BlueCross BlueShield: POS).
Both the POS High and Low Options combine the advantages of traditional medical coverage with a cost-effective "managed care" arrangement that includes participating providers who have agreed to negotiated fees with the claims administrators. The POS High and Low Options help you manage your medical costs by giving you the flexibility to choose between in-network and out-of-network care for covered services.
Each of the network health care providers has agreed to accept negotiated rates, which are lower fees, when treating JPMorgan Chase Medical Plan participants. This means your out-of-pocket costs generally will be:
  • Lower when you receive your care from in-network providers; and
  • Higher when you receive your care from out-of-network providers.
High Option — If you are enrolled in this POS Option, you pay higher premiums but have lower deductibles and copayments for doctor's office visits and other services.
Low Option — If you are enrolled in this POS Option, you pay lower premiums but your deductibles and copayments for doctor's office visits and other services are higher.
At the time of hire (or plan eligibility) and during each annual benefits enrollment period, you'll have access to information about the POS High and Low Options' coverage provisions, including benefits and costs. Before enrolling for coverage, please review that information so that you can compare the key features of the POS High and Low Options and your other JPMorgan Chase Medical Plan Options.
With the POS High and Low Options...
  • Each time you need medical care, you can choose to use an in-network or out-of-network provider.
  • You do not need to designate a primary care physician (PCP). However, specialist copayments are higher than PCP copayments. Generally, PCPs include internists, general practitioners, family practice doctors, and pediatricians. Check with your administrator for details.
  • The plan offers 100% coverage for eligible in-network preventive medical care. Please Note: A service that is normally considered preventive may be classified and coded as diagnostic rather than preventive medical care by your physician in certain circumstances. A medical service will only be covered at 100% if it is coded as preventive. Before receiving any service, you should check with your physician to be sure a procedure is considered, and will be submitted to the claims administrator as a preventive medical care rather than as a diagnostic service. Please see "How the POS High Option Pays Benefits" and "How the POS Low Option Pays Benefits" to see how certain treatments and services are covered.
  • In-network physician and specialist office visits are covered after a copayment, while most other services are subject to coinsurance.
  • Out-of-network care is subject to an annual deductible, and expenses are generally covered at a lower percentage than in-network services.
  • If you use out-of-network providers, you generally need to notify your claims administrator before a hospital admission.
  • Claim forms are usually required for out-of-network care.
  • If you need specialist care, you may self-refer to an in-network provider and still receive a higher level of benefits.
How the POS High and Low Options Work
The POS Options have networks of participating physicians, hospitals, and other health care professionals who have agreed to a negotiated fee arrangement for covered health services.
The POS Options have different claims administrators based on geographic location:
  • United Healthcare for National (all states not listed below);
  • Empire BlueCross BlueShield in California, Louisiana, Michigan, western New York, and West Virginia;
  • Anthem BlueCross BlueShield in Indiana and Kentucky; and
  • Aetna in Arizona, Delaware, Maryland, Pennsylvania, Texas, and Washington, D.C.
Please Note: In some cases, your Medical Plan option administrator may refer to these options as a Preferred Provider Organization (PPO).
Where you live determines the POS network that you are able to access. If you're interested in enrolling in a POS Option, you may view an online provider directory by visiting the Benefits Web Center on My Rewards @ Work and going to Manage Your Health Care > Find a Doctor, or by directly visiting the option's web site. You may also request a print copy at any time by contacting the appropriate POS claims administrator and requesting information from a Service Representative.
Please Note: Even though a network's service providers can change during the year, you won't be able to change to another option until the next annual benefits enrollment period, unless you experience a qualifying event.
How the POS High Option Pays Benefits
The way benefits are paid depends on whether you receive your care in-network or out-of-network. For additional information, please see "What Is Covered under All Medical Plan Options (Except the HMO Option)."
Benefit Provision
In-Network
Out-of-Network*
Annual Deductible
(No individual family member may satisfy more than the single deductible amount. Any amount paid toward in-network services is not applied to the out-of-network deductible.)
None
$600 individual
$1,200 individual + one
$1,200 individual + children
$1,800 family
Coinsurance Percentage
90%
70%
Annual Out-of-Pocket Maximum**
(No individual family member's covered expenses will exceed the individual out-of-pocket maximum.)
$1,200 individual
$2,400 individual + one
$2,400 individual + children
$3,600 family
$2,400 individual
$4,800 individual + one
$4,800 individual + children
$7,200 family
Lifetime Maximum
(Separate lifetime maximums apply to fertility services, substance abuse care, and skilled nursing facility.)
Unlimited
$2,000,000 per individual
Preventive Care
Routine Physical exams
Covered 100% at the following frequency:
  • From birth to 12 months: Seven exams
  • Age 13-24 months: Two exams
  • Age 24 months-18 years: One exam per year
  • Age 18-65: One exam every two years
  • Age 65 and over: One exam per year
70% coverage after deductible
Routine Gynecological Exams and Pap Smears
One exam and Pap smear per year (coverage includes related laboratory fees); check with your provider for age guidelines
70% coverage after deductible
Routine Mammography, Prostate Specific Antigen (PSA) Test, and Digital Rectal Exam
Age 40 and over: One exam per year
70% coverage after deductible
Fecal Occult Blood Test
Age 50 and over: One test per year
70% coverage after deductible
Sigmoidoscopy/Colonoscopy
Age 50 and over: One baseline screening and one follow-up screening every five years
70% coverage after deductible
Outpatient Services
Doctor's Office Visits
(Includes tests, supplies, and other services authorized by the plan and provided during the visit, consultations, specialist referrals, and second surgical opinions. Excludes eligible preventive care visits, which are covered 100% in-network.)
100% coverage after $20 primary care office visit copayment;*** $30 specialist office visit copayment
70% coverage after deductible
X-rays and Labs
(When performed to diagnose a medical problem or treat an illness or injury.)
90% coverage
70% coverage after deductible
Fertility Services
(Includes diagnostic procedures, in vitro fertilization, artificial insemination, etc.; limited to combined in-network and out-of-network maximum of $20,000/lifetime for each covered individual.****)
100% coverage after a $30 specialist office visit copayment; 90% coverage elsewhere (no copayment if in a facility)
70% coverage after deductible
Routine Eye Exams
Not covered
Not covered
Speech, Physical, or Occupational Therapy
(Combined in-network and out-of-network limit of 40 visits/ calendar year per therapy type.****)
90% coverage (no copayment if in a facility); 100% coverage after $30 office visit copayment (if in a doctor's office)
70% coverage after deductible
Chiropractic Care
(Must be medically necessary; coverage ends when medical recovery is achieved and treatment is for maintenance or managing pain; limited to 20 visits/calendar year****)
100% coverage after $30 per visit copayment
70% coverage after deductible
Mental Health Care
(Limited to combined in-network and out-of-network maximum of 40 visits/calendar year.****)
100% coverage after $30 per visit copayment
70% coverage after deductible
Substance Abuse Care
(Limited to combined in-network and out-of-network $20,000/lifetime maximum for inpatient and outpatient care for each covered individual.****)
100% coverage after $30 per visit copayment
70% coverage after deductible
Inpatient Services
Acute hospital care
(Based on hospital's standard rate for semi-private or common rooms, except for isolation of communicable diseases. Pre-certification requirements may apply.)
90% coverage after $250 copayment per admission; waived if re-admitted for same or related condition within 14 days
70% coverage after deductible
Skilled Nursing Facility
(Must be ordered by physician as medically necessary; includes charges for services and supplies provided while patient is under continuous care and requires 24-hour nursing care and room and board; limited to combined in-network and out-of-network maximum of 365 days/lifetime for each covered individual.****)
90% coverage after $250 copayment per admission; waived if admitted from hospital
70% coverage after deductible
Hospice Care
90% coverage
70% coverage after deductible
Mental Health Care
(Limited to combined in-network and out-of-network maximum of 30 days/calendar year.****)
90% coverage after $250 copayment per admission
70% coverage after deductible
Substance Abuse Care
(Limited to combined in-network and out-of-network maximum of $20,000/lifetime for inpatient and outpatient care for each covered individual.****)
90% coverage after $250 copayment per admission
70% coverage after deductible
Other Services
Emergency Room
(For sudden and serious medical conditions approved by claims administrator as required for emergency care.)
100% after a $100 copayment per visit; waived if admitted
70% coverage if not considered an emergency
100% after a $100 copayment per visit; waived if admitted
70% coverage after deductible if not considered an emergency
Home Health Care
(Medically necessary only; may require pre-certification; limited to combined in-network and out-of-network maximum of 200 visits/calendar year; one visit = four hours.****)
90% coverage
70% coverage after deductible
Durable Medical Equipment and Prosthetics
90% coverage
70% coverage after deductible
Prescription Drugs
* Generally, all out-of-network expenses are subject to reasonable and customary (R&C) charges.
** Excludes annual deductible and copayments.
*** Generally includes doctors certified in family, general, internal medicine, or pediatrics. Check with your Medical Plan option's Member Services for details.
**** Combined in-network and out-of-network. All out-of-network expenses are subject to R&C charges. You should note that since in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.
How the POS Low Option Pays Benefits
Benefit Provision
In-Network
Out-of-Network*
Annual Deductible
(No individual family member may satisfy more than the single deductible amount. Any amount paid towards in-network services is not applied to the out-of-network deductible.)
None
$700 individual
$1,400 individual + one
$1,400 individual + children
$2,100 family
Coinsurance Percentage
80%
60%
Annual Out-of-Pocket Maximum**
(No individual family member's covered expenses will exceed the individual out-of-pocket maximum.)
$3,000 individual
$6,000 individual + one
$6,000 individual + children
$9,000 family
$6,000 individual
$12,000 individual + one
$12,000 individual + children
$18,000 family
Lifetime Maximum
(Separate lifetime maximums apply to fertility services, substance abuse care, and skilled nursing facility.)
Unlimited
$2,000,000 per individual
Preventive Care
Routine Physical exams
Covered 100% at the following frequency:
  • From birth to 12 months: Seven exams
  • Age 13-24 months: Two exams
  • Age 24 months-18 years: One exam per year
  • Age 18-65: One exam every two years
  • Age 65 and over: One exam per year
60% coverage after deductible
Routine Gynecological Exams and Pap Smears
One exam and Pap smear per year (coverage includes related laboratory fees); check with your provider for age guidelines
60% coverage after deductible
Routine Mammography, Prostate Specific Antigen (PSA) Test, and Digital Rectal Exam
Age 40 and over: One exam per year
60% coverage after deductible
Fecal Occult Blood Test
Age 50 and over: One test per year
60% coverage after deductible
Sigmoidoscopy/Colonoscopy
Age 50 and over: One baseline screening and one follow-up screening every five years
60% coverage after deductible
Outpatient Services
Doctor's Office Visits
(Includes tests, supplies, and other services authorized by the plan and provided during the visit, consultations, specialist referrals, and second surgical opinions. Excludes eligible preventive care visits, which are covered 100% in-network.)
100% coverage after $40 primary care office visit copayment; *** $50 specialist office visit copayment
60% coverage after deductible
X-rays and Labs
(When performed to diagnose a medical problem or treat an illness or injury.)
80% coverage
60% coverage after deductible
Fertility Services
(Includes diagnostic procedures, in vitro fertilization, artificial insemination, etc.; limited to combined in-network and out-of-network maximum of $20,000/lifetime for each covered individual.****)
100% coverage after $50 specialist office visit copayment; 80% coverage elsewhere (no copayment if in a facility)
60% coverage after deductible
Routine Eye Exams
Not covered
Not covered
Speech, Physical, or Occupational Therapy
(Combined in-network and out-of-network limit of 40 visits/ calendar year per therapy type.****)
80% coverage (no copayment if in a facility); 100% coverage after $50 office visit copayment (if in a doctor's office)
60% coverage after deductible
Chiropractic Care
(Must be medically necessary; coverage ends when medical recovery is achieved and treatment is for maintenance or managing pain; limited to 20 visits/calendar year.****)
100% coverage after $50 per visit copayment
60% coverage after deductible
Mental Health Care
(Limited to combined in-network and out-of-network maximum of 40 visits/calendar year.****)
100% coverage after $50 per visit copayment
60% coverage after deductible
Substance Abuse Care
(Limited to combined in-network and out-of-network $20,000/lifetime maximum for inpatient and outpatient care for each covered individual.****)
100% coverage after $50 per visit copayment
60% coverage after deductible
Inpatient Services
Acute Hospital Care
(Based on hospital's standard rate for semi-private or common rooms, except for isolation of communicable diseases. Pre-certification requirements may apply.)
80% coverage after $500 copayment per admission; waived if readmitted for same or related condition within 14 days
60% coverage after deductible
Skilled Nursing Facility
(Must be ordered by physician as medically necessary; includes charges for services and supplies provided while patient is under continuous care and requires 24-hour nursing care and room and board; limited to combined in-network and out-of-network maximum of 365 days/lifetime for each covered individual.****)
80% coverage after $500 copayment per admission; waived if admitted from hospital
60% coverage after deductible
Hospice Care
80% coverage
60% coverage after deductible
Mental Health Care
(Limited to combined in-network and out-of-network maximum of 30 days/calendar year.****)
80% coverage after $500 copayment per admission
60% coverage after deductible
Substance Abuse Care
(Limited to combined in-network and out-of-network maximum of $20,000/lifetime for inpatient and outpatient care for each covered individual.****)
80% coverage after $500 copayment per admission
60% coverage after deductible
Other Services
Emergency Room
(For sudden and serious medical conditions approved by claims administrator as required for emergency care.)
100% after a $100 copayment per admission; waived if admitted
60% coverage if not considered an emergency
100% after a $100 copayment per admission; waived if admitted
60% coverage after deductible if not considered an emergency
Home Health Care
(Medically necessary only; may require pre-certification; limited to combined in-network and out-of-network maximum of 200 visits/calendar year; one visit = four hours.****)
80% coverage
60% coverage after deductible
Durable Medical Equipment and Prosthetics
80% coverage
60% coverage after deductible
Prescription Drugs
* Generally, all out-of-network expenses are subject to reasonable and customary (R&C) charges.
** Excludes annual deductible and copayments.
*** Generally includes doctors certified in family, general, internal medicine, or pediatrics. Check with your Medical Plan option's Member Services for details.
**** Combined in-network and out-of-network. All out-of-network expenses are subject to R&C charges. You should note that since in-network charges for covered services have been negotiated with the providers, those charges would always be within the R&C limits.
In-Network Benefits
Please Note
When you visit an in-network facility for a scheduled surgery, the POS High or Low Option will cover care provided by radiologists, anesthesiologists, and/or pathologists (RAPs) at the in-network percentage of the reasonable and customary (R&C) charge, even if the provider is considered an out-of-network provider. For example, assume you are enrolled in the POS High Option and visit an in-network facility for surgery and are treated by an out-of-network anesthesiologist whose charge is $500. If the R&C charge for the anesthesiologist's services is $400, the plan will reimburse you 90% of $400 ($360); you will be responsible for payment of the remaining $140. Fees for services provided by any other out-of-network specialists who attend to you while you are confined in an in-network facility will be paid at the out-of-network level of benefits. Services performed in an out-of-network facility will be paid at the out-of-network level of benefits, as explained in "Out-of-Network Benefits" on this page.
The POS High and Low Options' greatest financial advantages generally occur when you receive your care from a network provider.
When you receive in-network care through the POS High or Low Option:
  • You are covered 100% for eligible preventive medical care for several in-network screenings.
  • You pay a fixed copayment for office visits.
  • You usually don't have to file any claim forms; your network provider will usually file claims for you.
  • Your out-of-pocket expenses will be lower compared to your expenses for the same type of care on an out-of-network basis.
  • You don't have to pay any deductibles, except the inpatient hospital or skilled nursing facility copayment.
  • There's no lifetime dollar maximum covered benefit limit (except a $20,000 combined lifetime limit for covered fertility services and a $20,000 combined lifetime limit for substance abuse care). There is also a lifetime limit of 365 days for in- or out-of-network care in a skilled nursing facility.
Out-of-Network Benefits
Under both the POS High and Low Options, you have the option of visiting an out-of-network physician, hospital, or other provider at any time. For both options, if you choose to receive medically necessary covered services on an out-of-network basis:
  • Services performed by providers not participating in the network will be reimbursed at the out-of-network level of benefits, based on reasonable and customary (R&C) charges with respect to medically necessary covered services, you must meet your deductible before out-of-network benefits are paid.
  • You'll need to file a claim form to receive out-of-network benefits. See "How to File Claims" for more information.
  • Your own costs for medically necessary covered services generally will be higher than if you received in-network care.
  • There is a $2,000,000 per person lifetime benefit limit for out-of-network services. There is also a lifetime limit of 365 days for in- or out-of-network care in a skilled nursing facility.
Annual Deductible
Before you receive coverage for out-of-network benefits from either the POS High or Low Option, you need to satisfy an annual deductible. Only reasonable and customary (R&C) charges for medically necessary services will count toward the out-of-network deductible. Amounts above R&C charges do not count toward your deductible.
Under the POS High and Low Options, if you elect coverage for yourself or yourself plus one dependent:
  • Each covered person must pay all eligible expenses until the individual deductible is met. Then, eligible expenses are covered at the coinsurance indicated for that expense. Expenses for two covered individuals are not combined.
  • After a covered person meets the individual deductible amount, that person will pay no further deductible.
If you elect coverage for yourself plus two or more dependents:
  • All expenses incurred by you and/or your covered dependents combine to meet the appropriate total deductible (individual plus children or family deductible).
  • If no one person meets the individual deductible, but combined participant expenses meet the total deductible amount, no further deductible is required.
  • After a covered person meets the individual deductible amount, that person will pay no further deductible.
The maximum deductible any one covered person must pay is equal to the individual amount. After one person meets the individual deductible, that person will pay no further deductible, but other covered persons must continue to pay deductibles until the total is satisfied.
An Example: Amounts Applied Toward Out-of-Network Deductible
On behalf of you
$600
On behalf of your spouse/domestic partner
$500
On behalf of one child
$400
On behalf of a second child
$300
TOTAL
$1,800
In this example, one person has met the POS High Option of the $600 individual deductible (you), and the combined costs have reached $1,800. So any reasonable and customary (R&C) charges for medically necessary covered services would be reimbursable at 70% or until your out-of-pocket limit is met by the POS Option, even if they were on behalf of a person who has not yet met the $600 individual deductible. No other covered family members need to meet their individual deductible for the rest of the year.
Annual Out-of-Pocket Maximum
Under the POS High and Low Options, this is the maximum amount (excluding items such as annual deductible and copayments) you must pay in a calendar year toward each covered person's eligible expenses. Only reasonable and customary (R&C) charges for medically necessary services will count toward the annual out-of-pocket maximum. Amounts above R&C charges do not count toward your annual out-of-pocket maximum.
If you elect coverage for yourself or yourself plus one dependent:
  • Each covered person must pay all eligible out-of-pocket expenses until the individual maximum is met. Eligible out-of-pocket expenses are then covered at 100% for that person.
  • After a covered person meets the individual out-of-pocket maximum, that person will pay no further out-of-pocket expenses.
If you elect for yourself plus two or more dependents:
  • All eligible out-of-pocket expenses paid by you and/or your covered dependents combine to meet the appropriate total maximum amount (employee plus children or family).
  • If no one person meets the individual maximum, but combined participant out-of-pocket payments meet the total amount, eligible out-of-pocket expenses are then covered at 100%.
  • After a covered person meets the individual out-of-pocket maximum, that person will pay no further out-of-pocket expenses.
The maximum out-of-pocket expense any one covered person must pay is equal to the individual amount. After one person's expenses reach the individual out-of-pocket maximum, eligible out-of-pocket expenses are then covered at 100% for that person, but other covered persons must continue to pay out-of-pocket expenses until the total family out-of-pocket maximum is satisfied.
An Example: Amounts Applied Toward Out-of-Network Family Out-of-Pocket Maximum
On behalf of you
$2,400
On behalf of your spouse/domestic partner
$2,000
On behalf of one child
$2,000
On behalf of a second child
$800
TOTAL
$7,200
In this example, one person has met the $2,400 individual out-of-pocket maximum (you), and the combined out-of-pocket costs have reached $7,200. So, any reasonable and customary (R&C) charges for medically necessary covered services would be reimbursable at 100% by the POS High Option, even if they were on behalf of a person who has not yet met the individual out-of-pocket maximum. No other covered family members need to meet their individual out-of-pocket maximum for the rest of the year.
Maximum Lifetime Benefit
Important Note
Any benefits that have been applied to a lifetime maximum provision under a medical plan of your heritage organization, and as an active employee, will also be applied to the lifetime maximums of the JPMorgan Chase Medical Plan.
The maximum lifetime benefit for out-of-network care for each individual covered under the POS High and Low Option is $2,000,000. This includes the $20,000 lifetime fertility services maximum and the $20,000 lifetime substance abuse care maximum. There is also a lifetime limit of 365 days for in- or out-of-network care in a skilled nursing facility. The fertility services, substance abuse care, and skilled nursing facility lifetime maximum benefits apply to both in-network and out-of-network care. In addition, all benefits you receive under the POS High or Low Option, the Traditional Indemnity Option, the CDHO, and the Medicare Indemnity Options are added together for purposes of the lifetime maximums. The $20,000 lifetime fertility services benefit also includes services under the Exclusive Provider Organization (EPO) Option.
An Important Note on the Plan's Lifetime Maximum
The Medical Plan's lifetime maximum (overall, fertility services, substance abuse care, and skilled nursing facility care) reflects services received across the following plans:
  • POS High or Low Option
  • Consumer Driven Health Option (CDHO)
  • Traditional Indemnity Option
  • Medicare Indemnity Options
You do not gain a new maximum if you switch your coverage between these options. Once a participant reaches the plan's lifetime maximum, he or she may elect to enroll in an HMO or EPO Option by contacting the Benefits Call Center.
Hospital Notification
You must contact the claims administrator within 48 hours before all scheduled hospital admissions. In the event of an emergency, you can make this notification within 48 hours after your admission. You must also contact the claims administrator if a maternity stay will exceed 48 hours for the mother and newborn child following a vaginal delivery, or 96 hours for the mother and newborn child following a cesarean section delivery.
To provide notification, please contact your POS High or Low Option's claims administrator at the number listed in the "Claims Administrators' Contact Information."
If You Need Emergency Care
If you have a medical emergency that's sudden, urgent, and life-threatening, you should go to the nearest physician, hospital emergency room, or other urgent care facility. Your emergency care will be covered at 100% as if you received the care in-network as long as:
  • You, the physician, or a member of your family calls the POS High or Low Option claims administrator within 48 hours after the emergency; and
  • The POS High or Low Option claims administrator approves the care.
If you don't follow these guidelines to receive approval, your benefits will be paid as if you received the care out-of-network.

Benefits Effective January 1, 2008.