* Expiration date of the present information circular: 30 June 2019



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ST/IC/2018/15






* Expiration date of the present information circular: 30 June 2019.

Information circular*
To: Members of the staff and participants of the after-service health insurance programme
From: The Controller
Subject: Renewal of the United Nations Headquarters-administered health insurance programme, effective 1 July 2018


Contents










Page

General

3

Costing of United Nations insurance programmes

4

Annual campaign

5

Coordination of benefits

6

Fraud and abuse

7

Eligibility and enrolment rules and procedures

7

Staff member married to another staff member

8

Enrolment between annual campaigns

9

Staff on special leave without pay

11

Staff on special leave with half or full pay and staff on part-time employment

11

Special provisions for the UN Worldwide Plan

12

Participant’s address for insurance purposes

13

Effective commencement and termination date of health insurance coverage

13

Employment-related illness or injury

13

Movement between organizations, breaks in appointment and movement between payrolling offices

13

Medical assistance service during personal travel

14

Cessation of coverage of the staff member and/or family members

14

Insurance enrolment resulting from loss of employment of a spouse

15

After-service health insurance

15

Conversion opportunity

16

Time limits for filing claims

16

Claim payments issued by cheque

16

Claims and benefit enquiries and disputes

16

Websites of the Health and Life Insurance Section and the insurance providers

17

Annexes




  1. Premiums and contribution rates

18

  1. United States-based medical benefits: plan comparison chart

20

  1. Empire Blue Cross PPO

23

  1. Aetna Open Choice PPO/POS II

29

  1. HIP Health Plan of New York

35

  1. Cigna US Dental PPO

38

  1. UnitedHealthcare Global Assistance and Risk

40

  1. ActiveHealth wellness programme

45

  1. UN Worldwide Plan

48

  1. Provider contact directory

53

  1. Basic responsibilities of plan enrolees

57

  1. Definitions

59


General
1. The purpose of the present circular is to provide information regarding health insurance plans administered by United Nations Headquarters and to announce the 2018 administrative and plan changes, including premium and contribution rates changes.

2. Changes in the premium and contribution rates will take effect on 1 July 2018 for the following health insurance programmes:

(a) Aetna PPO/POS: increase of 3.50 per cent;

(b) Empire Blue Cross PPO: increase of 4.75 per cent;

(c) HIP Health Plan of New York: increase of 9.17 per cent;

(d) Cigna US Dental PPO: increase of 2.50 per cent;

(e) UN Worldwide: increase of 2.50 per cent.

Please refer to annex I for more details.

3. The following plan benefit change will be implemented for the Aetna PPO plan effective 1 July 2018:

(a) Reduce benefits by $2,500 if plan members fail to obtain pre-authorization for inpatient hospitalization services. This will align the Aetna PPO plan with the Empire Blue Cross PPO plan and current market standards.

4. The following plan benefit change will be implemented for the Empire Blue Cross PPO plan effective 1 July 2018:

(a) Reduction in the reimbursement rate for out-of-network providers (except physical therapists) from 395 per cent of Medicare to 275 per cent to better align reimbursement practices with current market standards. Please remember that in 2017, there was a reduction in the reimbursement rate of out-of-network physical therapists from 395 per cent of Medicare to 250 per cent of Medicare to better align reimbursement practices with current market standards.

5. The following plan benefit changes will be implemented for the UN Worldwide Plan effective 1 July 2018:

(a) Increase of ceiling for annual check-ups from $750 to $1,050;

(b) Introduction of Cigna’s Global Telehealth service to all Cigna Worldwide Plan participants (for more information, see annex IX).

6. Staff members and retirees currently enrolled in the UN Worldwide Plan who are considering coverage for family members residing in the United States or who intend to seek medical care in the United States on a regular basis are reminded that they should consider enrolling in a United States-based plan effective 1 July 2018, given that the UN Worldwide Plan does not provide adequate coverage in the United States. In addition, the United Nations health insurance programme requires that staff members, retirees or covered dependants residing in the United States enrol in a United States-based plan. Staff members and retirees who choose to remain in the UN Worldwide Plan will also be subject to the increased limitations and restrictions that were implemented on 1 July 2017 for the Plan regarding expenses incurred in the United States. Benefit changes introduced in 2013 to deter plan members from receiving medical treatments in the United States proved ineffective. Please refer to the section on special provisions for the UN Worldwide Plan in the present circular.

7. It is not possible to cover staff members or retirees in one health insurance plan and cover their eligible dependants in another.

8. Staff members and retirees currently enrolled in the United Nations health insurance programme should note that all carriers are increasing communication to staff members and retirees in an effort to improve their understanding of insurance. Staff members and retirees should therefore expect to receive increased mailings and/or emails.


Costing of United Nations insurance programmes
9. All plans administered by United Nations Headquarters, other than the HIP Health Plan of New York, are self-funded health benefit plans; they are not insured programmes. The cost of the programme is based primarily on the medical services provided to plan participants and directly reflects the level of utilization of the plan benefits by its participants. The yearly contributions paid by the participants and the portion of the premium paid by participating United Nations entities are used to cover claim costs plus a fixed administrative fee per primary subscriber (i.e. staff member or retiree), which represents less than 4 per cent of the total programme cost for the United States-based plans and about 8 per cent for the UN Worldwide Plan. Costs are borne by the plan participants and the Organization as follows:

(a) For United States-based plans, the United Nations and plan participants bear the costs collectively through a “two thirds to one third” cost-sharing arrangement approved by the General Assembly;

(b) For the UN Worldwide Plan, costs are borne by the United Nations and by plan participants collectively through a 50/50 cost-sharing arrangement approved by the General Assembly;

(c) Neither the portions of the monthly premium of plan participants nor those of the organizations are prorated. The full monthly premium amount will be collected regardless of the date on which coverage begins within a month.

10. Aetna, Empire Blue Cross and Cigna provide administrative services to the United Nations on the basis of “administrative services only” agreements entered into by the United Nations with those carriers. Those arrangements make it possible for the United Nations to use the carrier’s eligibility and claim-processing expertise, and benefit from the direct billing and discounted services that the carriers have negotiated with medical providers in their networks.

11. Except for HIP, the United Nations medical insurance and dental insurance programmes are “experience-rated”. This means that each year’s premiums are based on the cost of medical or dental treatment received by United Nations participants in prior years, plus the expected effect of higher utilization and medical inflation, plus the appropriate allowance for administrative expenses for the new plan year. The underlying elements in the increasing cost of health insurance for participants are therefore:

(a) Continuing growth in utilization of services and medications;

(b) Continuing increases in prices for services and medications;

(c) Expenses that are incurred in high-cost health-care markets.

12. In a year following periods of heavy utilization, premium increases are likely to be relatively high. Conversely, if utilization in the prior year has been moderate, the premium increase in the subsequent year is also likely to be moderate. The yearly premiums are calculated to meet medical expenses and administration costs in the forthcoming 12-month contract period. Each year the expected overall costs of the programme are first expressed as premiums and then borne collectively by the participants and by the Organization in accordance with the cost-sharing ratios set by the General Assembly.

13. To contain premium increases, all participants of the United Nations health insurance plans are expected to be educated consumers. Expenses must be incurred for medically necessary services and treatments, and not for the convenience of the doctor or patient. Participants are expected to be mindful of the cost of the services and treatments being sought and to ensure that costs are given due consideration in making medical choices without necessarily sacrificing the quality and effectiveness of treatments. In the United States, it means that every effort should be made to select in-network providers, given that out-of-network providers charge higher costs and expose the patient to financial risk, since the plans will cap reimbursements on the basis of a reasonable and customary rate and not the actual provider’s charges.

14. The HIP plan is “community-rated”. This means that HIP premiums are based on the average medical cost of all employers that purchase the same kind of coverage from HIP and not just that of United Nations participants. The New York State Insurance Department regulates the premium rates for community-rated programmes, such as HIP.

15. Each plan in the United Nations Headquarters health insurance programme provides protection against the high cost of health care, whether it involves preventive care, management of chronic conditions, serious illness or injury. Premiums collected are pooled together, from which the claims are paid. To ensure the viability and affordability of the plans, subscribers are expected to participate and contribute to the plan through the regular payment of premiums, regardless of their current health condition and need for coverage. Strict rules for enrolment in, and termination from, the plan have been put in place to prevent abuse and participation on an “as needed” basis only. Rebates based on a person’s consumption are not permitted.

16. Cost containment is also available through wellness initiatives. Health improvements and cost reductions have begun to become apparent as staff and retirees use the condition management and wellness features available to Aetna and Empire Blue Cross participants through the ActiveHealth programme implemented in December 2008. Plan participants are encouraged to make full use of the ActiveHealth programme, especially by accessing the MyActiveHealth website, so as to obtain maximum benefits from both a health/wellness perspective and a plan cost perspective.


Annual campaign
17. The annual campaign for 2018 is being held from 31 May to 30 June 2018 and is open to active staff members only. Staff members may log on to the Umoja employee self-service portal to make changes to their coverage, which may include changing health insurance plan, adding a family member who was not previously covered or terminating coverage for a currently covered family member. Such action should be completed by 30 June, as the system will automatically end the campaign period on that date. After 30 June, no further actions can be completed without a qualifying work or life event. The staff members of the Health and Life Insurance Section are available to provide information and answer specific questions regarding the health plans being offered to staff, by email or in person, every day through the Insurance and Disbursement Service client services at the location and hours indicated below:

Room FF-300, 304 East 45th Street, New York, New York 10017

Client service hours: 1–4 p.m., Monday through Friday

Email: ids@un.org

Website: www.un.org/insurance

Tel.: 212 963 5804 (for general enquiries)

Fax: 917 367 1670

18. The 2018 annual campaign is the only opportunity until the next annual campaign, in June 2019, to: (a) enrol or terminate enrolment in the United Nations Headquarters-administered insurance programme; (b) change to another plan; and/or (c) add or terminate coverage for eligible dependants from their plan, aside from the specific qualifying events, such as marriage, divorce, death, birth or adoption of a child and transfer within the United Nations system, for which special provisions for enrolment between campaigns are established. Paragraphs 37 and 38 of the present circular provide information on the qualifying events for enrolment and termination outside the annual campaign period.

19. A staff member enrolled in any of the health insurance plans must continue such coverage for at least 12 months before elections for discontinuation of coverage during the annual campaign will be accepted. Staff members enrolled in the UN Worldwide Plan who transfer to the Aetna or Empire Blue Cross plan as a result of covered family members residing in the United States must remain in the new plan for at least 12 months before elections to return to the UN Worldwide Plan will be accepted.

20. Individuals enrolled in the Headquarters-administered after-service health insurance may make a change between either United States-based plan once every two years only, in accordance with section 8.2 of administrative instruction ST/AI/2007/3 on after-service health insurance.

21. The effective date of insurance coverage for all campaign applications, whether for enrolment, change of plan or change of family coverage, is 1 July 2018.

22. Staff members who switch coverage between the Aetna and Empire Blue Cross plans and who have met the annual deductible or any portion thereof under either of those plans during the first six months of the year may be credited with such deductible payment(s) under the new plan for the second six months of the year, under certain conditions. The deductible credit will not occur automatically and can be implemented only if the staff member:

(a) Formally requests the deductible credit on the special form designed for that purpose;

(b) Attaches the original explanations of benefits attesting to the level of deductibles met for the calendar year by the staff member and/or each eligible covered dependant.

The deductible credit application form may be obtained from the website of the Health and Life Insurance Section (www.un.org/insurance/forms). The completed form must be submitted to the Section (not to Aetna or Empire Blue Cross) by email to ids@un.org, together with the relevant explanations of benefits, no later than 31 August 2018 in order to receive such deductible credit.
Coordination of benefits
23. The United Nations insurance programme does not reimburse the cost of services that have been or are expected to be reimbursed under another insurance, social security or similar arrangement. For those members covered by two or more plans, the United Nations insurance programme coordinates benefits to ensure that the member receives as much coverage as possible, but not in excess of expenses incurred. Members covered under the United Nations insurance programme are expected to advise the insurance carriers when a claim can also be made against another insurer. Benefits are coordinated as follows:

(a) Aetna and Empire Blue Cross conduct coordination of benefits exercises as part of the administrative services that they provide to the United Nations;

(b) Empire Blue Cross conducts its own exercises by mailing out annual questionnaires to members, and Aetna uses the services of the Rawlings Company to conduct its exercises.

Plan participants are required to complete and return all questionnaires sent to them by insurance carriers.


Fraud and abuse
24. The responsibility for ensuring the proper use of the insurance rests with the plan member and not with the Organization. The insurance carriers are responsible for conducting monitoring and compliance exercises to highlight potential fraud. Fraud or abuse of the plan by any member (i.e. active staff members or retirees and their covered family members) will result in:

(a) Immediate discontinuation of insurance for the member and/or dependant(s) or suspension from receiving any subsidy from the Organization, as applicable;

(b) Recovery of monies previously paid by the insurance carrier;

(c) Any other administrative and/or disciplinary measures, in accordance with staff rule 10.2 and other administrative directives, including dismissal for misconduct;

(d) Referral to the relevant national authorities by the Organization.

25. Fraud or abuse of the plan by any provider will be handled according to the applicable procedures of the insurance carrier and may be referred to the local authorities and the Organization. Members are strongly encouraged to review their explanation of benefits or claim statement carefully in order to ensure that only services received from their provider are billed and to report any questionable charges to the insurance carriers so that those can be investigated.



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