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Special Medical Plan Options If You're Disabled and Eligible for Medicare
If you (or a covered dependent) become entitled to Medicare because of a qualifying disability, Medicare becomes the primary source of medical coverage for the disabled individual 29 months after the disability determination date. (Please see " Determining Primary Coverage" for more information on coordination of benefits with Medicare.) In addition, you are eligible to participate in the same Medical Plan options that are available to JPMorgan Chase Medicare-eligible retirees. These include the:
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Medicare Indemnity High Option;
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Medicare Indemnity Low Option;
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Medicare Advantage Health Maintenance Organization (HMO) Option, if available; and
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Medicare Supplement Health Maintenance Organization (HMO) Option, if available.
In general, you and your dependents must be enrolled in the same Medical Plan option. However, you and your dependents may be covered under separate Medical Plan options if one individual is disabled and eligible for Medicare and the others are not. This is called "split coverage." However, at all other times everyone must be covered under the same option.
If you are eligible for the Medicare options listed above, you will be notified.
Medicare Indemnity High Option
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 be applied to the lifetime maximums of the JPMorgan Chase Medical Plan.
With this option, you must first meet an annual deductible, then the plan pays 90% of medically necessary covered expenses (up to Medicare-allowable charges), subject to certain annual and lifetime maximums. You can choose to use any physician you like. See the chart under " How the Medicare Indemnity Options Pay Benefits" to compare the key provisions of the two Medicare Indemnity Options.
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:
You do not gain a new maximum if you switch your coverage between options. Once a participant reaches the plan's lifetime maximum, he or she may elect to enroll in an HMO or EPO Option, if available, by contacting the Benefits Call Center.
Medicare Indemnity Low Option
This option differs from the Medicare Indemnity High Option in the amount of your contributions, your deductibles, and some covered expenses. Under the Medicare Indemnity Low Option, your contributions for coverage are lower than under the Medicare Indemnity High Option. However, you have higher deductibles and out-of-pocket maximums, and the plan reimburses a lower percentage of eligible expenses.
After you pay the deductible, the plan pays 85% of medically necessary covered expenses (up to Medicare-allowable charges), subject to certain annual and lifetime maximums. You can use any physician you like and still receive benefits. Please see the chart under " How the Medicare Indemnity Options Pay Benefits" to compare the key provisions of the two Medicare Indemnity Options.
Medicare Indemnity High and Low Options
Here are some highlights for the Medicare Indemnity High and Low Options:
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You can use any doctor you like at any time and still receive benefits for covered services.
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Benefits begin after you meet an annual deductible.
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You must notify the claims administrator before a non-emergency hospital admission.
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Claim forms are required.
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There are limits on your annual out-of-pocket expenses.
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When you participate in the Retiree Medical Plan and become eligible for Medicare, Medicare becomes the primary payer of benefits. This means that JPMorgan Chase will determine how much it will pay, based on what Medicare would have paid, even if Medicare does not pay a portion of the cost. Please see "Determining Primary Coverage" for more information on coordination of benefits with Medicare.
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Under the Medicare Indemnity High Option: Preventive care benefits are provided up to $200 per year without paying a deductible.
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Under the Medicare Indemnity Low Option: Your contributions for coverage are lower than under the Medicare Indemnity High Option. However, you have higher deductibles and out-of-pocket maximums, and the plan reimburses a lower percentage of eligible expenses.
How the Medicare Indemnity Options Pay Benefits
The Medicare Indemnity High and Low Options pay benefits as follows:
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Benefit Provision
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Medicare Indemnity High Option
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Medicare Indemnity
Low Option
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$1,000 individual + children
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$3,000 individual + children
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Annual Out-of-Pocket Maximum
(Excludes annual deductible.)
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$5,000 individual + adult
$5,000 individual + children
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$10,000 individual + adult
$10,000 individual + children
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(Separate lifetime maximums apply to fertility services, substance abuse care, and skilled nursing facility.)
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$2,000,000 per individual
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$2,000,000 per individual
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100% coverage; maximum $200 per year; combined maximum with well-child care; not subject to deductible
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100% coverage; maximum $200 per year; combined maximum with routine exams; not subject to deductible
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85% coverage after deductible
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(Includes tests, supplies, and other services authorized by the plan and provided during the visit, consultations, specialist referrals, and second surgical opinions.)
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90% coverage after deductible
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85% coverage after deductible
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(When performed to diagnose a medical problem or treat an illness or injury.)
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90% coverage after deductible
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85% coverage after deductible
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(Check with claims administrator for age and frequency limitations.)
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100% coverage; maximum one per calendar year
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100% coverage; maximum one per calendar year
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(Includes diagnostic procedures, in vitro fertilization, artificial insemination, etc.; limited to maximum of $20,000/lifetime for each covered individual.)
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90% coverage after deductible
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85% coverage after deductible
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Speech, Physical, or Occupational Therapy
(Limited to a maximum of 40 visits/calendar year per therapy type.)
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90% coverage after deductible
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85% coverage after deductible
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(Must be medically necessary; coverage ends when medical recovery is achieved and treatment is for maintenance or managing pain; limited to a maximum of 20 visits/calendar year.)
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90% coverage after deductible
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85% coverage after deductible
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(Limited to Maximum of 40 visits/calendar year.)
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90% coverage after deductible
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85% coverage after deductible
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(Limited to $20,000/lifetime maximum for inpatient and outpatient care for each covered individual.)
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90% coverage after deductible
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85% coverage after deductible
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90% coverage after deductible
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85% coverage after deductible
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(Limited to maximum of 120 days/lifetime for each covered individual.)
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90% coverage after deductible
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85% coverage after deductible
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90% coverage after deductible
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85% coverage after deductible
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(Limited to a maximum of 30 days/calendar year.)
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90% coverage after deductible
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85% coverage after deductible
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(Limited to a maximum of $20,000/lifetime for inpatient and outpatient care for each covered individual.)
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90% coverage after deductible
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85% coverage after deductible
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(For sudden and serious medical conditions approved by claims administrators as required for emergency care.)
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90% coverage after deductible
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85% coverage after deductible
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(Medically necessary only; may require pre-certification; limited to maximum of 200 visits/calendar year; one visit = four hours.)
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90% coverage after deductible
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85% coverage after deductible
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Durable Medical Equipment and Prosthetics
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90% coverage after deductible
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85% coverage after deductible
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All percentages above generally apply to reasonable and customary (R&C) charges and Medicare allowable charges. You are responsible for 100% of all expenses above R&C charges.
Other Provisions
Medicare HMOs for Medicare-Eligible Retirees
JPMorgan Chase offers a number of HMOs and EPOs that provide coverage for participants who are Medicare-eligible. Most of these HMOs and EPOs are designed to coordinate benefits with Medicare. (Please see " Determining Primary Coverage.") There are two kinds of HMO-type plans offered to Medicare-eligible retirees:
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Medicare Advantage Plans; and
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Medicare Supplement Plans.
Medicare Advantage Plans (Medicare Part C)
Medicare Advantage Plans (Medicare Part C) are managed care plans offered by private health insurance companies across the country. Most Medicare Advantage Plans are Medicare Health Maintenance Organizations (HMOs). This means they work much like regular HMOs — you must use the HMO's network of providers to receive benefits (except in an emergency). However, in return, you can usually receive a higher level of benefits than under Original Medicare.
The federal government helps to fund Medicare Advantage Plans by paying a set amount of money to the health insurance companies that offer these types of plans for each participant who enrolls. Because of this funding, Medicare Advantage Plans cover the same services as Original Medicare, plus they sometimes offer enhanced benefits for vision, hearing, and prescription drugs.
You must be enrolled in Medicare Part A and paying Medicare Part B premiums to participate in a Medicare Advantage Plan.
JPMorgan Chase offers Medicare Advantage HMOs to Medicare-eligible individuals in certain locations.
Medicare Supplement Plans (HMO)
The Medicare Supplement Plans (HMO and EPO) supplement the benefits of Original Medicare (Medicare Part A and Part B). These options are designed to coordinate benefits with Medicare and typically provide additional benefits in areas where Medicare has limited coverage (such as hospital deductibles and prescription drug coverage).
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