Renewal of the United Nations Headquarters-administered health insurance programme, effective 1 July 2021 (Expired)

United Nations ST/IC/2021/10 Secretariat 31 May 2021 English only 21-06920 (E) 030621 *2106920* 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 2021 Contents Page General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Costing of United Nations Headquarters-administered health insurance plans . . . . . . . . . . . . . 4 Annual enrolment campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Coordination of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Fraud and abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Eligibility and enrolment rules and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Staff member married to another staff member and staff members who share responsibility for an eligible dependant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Changes between annual enrolment campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Staff on special leave without pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Staff on special leave with half or full pay and staff on part-time employment . . . . . . . . . . . . . 12 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 * Expiration date of the present information circular: 30 June 2022. ST/IC/2021/10 21-06920 2/62 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Procedures for exceptional reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Documentation required from plan participants requesting exceptional reimbursement . . . . . . 18 Additional procedures for Aetna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Websites of the Health and Life Insurance Section and the third-party administrators . . . . . . . 18 Annexes I. Premiums and contribution rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 II. United States-based medical benefits: plan comparison chart . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 III. Empire Blue Cross PPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 IV. Aetna Open Choice PPO/POS II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 V. HIP Health Plan of New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VI. Cigna US Dental PPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 VII. UnitedHealthcare Global Assistance and Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 VIII. ActiveHealth wellness programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 IX. UN Worldwide Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 X. Provider contact directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 XI. Basic responsibilities of plan enrollees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 XII. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 ST/IC/2021/10 3/62 21-06920 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 2021 administrative and plan changes, including premium and contribution rates changes. 2. Changes in the premium and contribution rates will take effect on 1 July 2021 for the following health insurance plans: (a) Aetna PPO/POS: no premium increase; (b) Empire Blue Cross PPO: no premium increase; (c) HIP Health Plan of New York: increase of 6.41 per cent; (d) UN Worldwide: no premium increase; (e) Cigna US Dental PPO plan: no premium increase. 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 2021: introduction of telephone and video consultations with in-network and out-of-network service providers. 4. The following plan benefit change will be implemented for the Empire Blue Cross PPO plan effective 1 July 2021: introduction of telephone and video consultations with in-network and out-of-network service providers. 5. The following plan benefit changes will be implemented for the UN Worldwide Plan effective 1 July 2021: (a) New coverage for smoking cessation; (b) Introduction of telephone and video consultations with in-network and out-of-network service providers. 6. Staff members and retirees currently enrolled in the UN Worldwide Plan who are considering coverage for family members residing in the United States of America or who intend to seek medical care in the United States on a regular basis are reminded that they should consider enrolling in one of the United States-based plans effective 1 July 2021, 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 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. Please refer to paragraph 43, in the section entitled “Special provisions for the UN Worldwide Plan”, of 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. It is also not possible to cover dependants only, nor is it possible to combine two United Nations Headquarters- administered medical insurance plans or to combine the Cigna Dental plan with the UN Worldwide Plan. 8. Staff members and retirees currently enrolled in the United Nations health insurance programme should note that the Health and Life Insurance Section is increasing communication to staff members and retirees to better inform them about their insurance and the spirit of the United Nations health insurance plans. Staff members and retirees should therefore expect to receive increased mailings and/or ST/IC/2021/10 21-06920 4/62 emails; they are expected to be fully informed of the requirements for availing themselves of the insurance benefits. Costing of United Nations Headquarters-administered health insurance plans 9. All health 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 health insurance plans. The cost of each plan 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 organizations are used to cover claim costs plus a fixed administrative fee per primary subscriber (i.e. staff member or retiree), which represents less than 3 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 based on “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 health providers in their networks. 11. Except for HIP, the United Nations Headquarters-administered health insurance plans are “experience-rated”. This means that each year’s plan 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 health care; (b) Continuing increases in prices for health care; (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 health 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. ST/IC/2021/10 5/62 21-06920 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 either the doctor or the patient. Participants are expected to be mindful of the cost of the services and treatments sought and to ensure that costs are given due consideration in making choices without necessarily sacrificing the quality and effectiveness of treatments. In the United States, the plans will cap reimbursements, based on a reasonable and customary rate and not the actual charges by the health care provider, so every effort should be made to select in-network providers. Out-of-network providers charge higher costs and may expose the patient to financial risk. 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, including 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, retirees and their eligible dependants use the condition management and wellness features available to Aetna and Empire Blue Cross participants through the ActiveHealth programme implemented in December 2008. In order to get maximum benefit s from both a health and wellness perspective and a plan cost perspective, plan participants are encouraged to make full use of the ActiveHealth programme, especially by accessing the MyActiveHealth website. 17. To improve access to care while safeguarding the financial viability of the United Nations Headquarters-administered health plans, all plan participants have the option to schedule a real-time audio or video consultation with a health practitioner through telemedicine services. Aetna participants have access to Teladoc, and Empire Blue Cross participants to LiveHealth Online, and UN Worldwide Plan provides telemedicine services through Cigna Global Telehealth. Annual enrolment campaign 18. The annual enrolment campaign for 2021 is being held from 1 to 30 June 2021 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. Staff members of other organizations that are not included in Umoja (e.g. the United Nations Development Programme (UNDP), the United Nations Children’s Fund (UNICEF) and the United Nations Office for Project Services (UNOPS)) should submit an application form to their organization requesting changes to their coverage during the annual enrolment campaign. Such actions should be completed by 30 June, as the system will automatically end the campaign period on that date and all changes will be effective 1 July 2021. After 30 June, no further actions can be completed ST/IC/2021/10 21-06920 6/62 without a qualifying work or life event. Additional information and answers to more specific questions regarding the United Nations Headquarters-administered health plans can be found on the health insurance website or directly from the staff of the Health and Life Insurance Section by email, telephone or fax as indicated below. Email: HLIS@un.org Website: www.un.org/insurance Tel.: 212 963 5804 Fax: 917 367 1670 19. The 2021 annual enrolment campaign is the only opportunity until the next annual enrolment campaign, in June 2022, 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, aside from the specific qualifying events, such as marriage, divorce, death, birth or adoption of a child or transfer within the United Nations system, for which special provisions for enrolment between annual enrolment campaigns are established. Paragraphs 38 and 39 of the present circular provide information on the qualifying events for enrolment and termination outside the annual enrolment campaign period. 20. A staff member enrolled in the United Nations Headquarters-administered health insurance programme must continue such coverage for at least 12 months before requesting to discontinue the coverage. Staff members enrolled in the UN Worldwide Plan who transfer to either the Aetna or the Empire Blue Cross plan must remain in the new plan for at least 12 months before their request to return to the UN Worldwide Plan will be accepted. 21. Individuals enrolled in United Nations Headquarters-administered after-service health insurance may transfer between United States-based plans once every two years only, in accordance with section 8.2 of administrative instruction ST/AI/2007/3, on after-service health insurance. 22. The effective date of insurance coverage for all annual enrolment campaign applications, whether for enrolment, change of plan or change of family coverage, is 1 July 2021. 23. Plan participants 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, under certain conditions, be credited with such deductible payment(s) under the new plan for the second six months of the year. The deductible credit will not occur automatically and can be implemented only if the plan participant: (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 plan participant 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). In order to receive the credit, participants must submit the completed form to the Section (not to Aetna or Empire Blue Cross) by email to HLIS@un.org, together with the relevant explanations of benefits, no later than 31 August 2021. ST/IC/2021/10 7/62 21-06920 Coordination of benefits 24. The United Nations health 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 participants covered by two or more plans, the United Nations health insurance programme coordinates benefits to ensure that the participant receives as much coverage as possible, but not in excess of expenses incurred. Plan participants covered under the United Nations health insurance programme are expected to advise the respective third-party administrator when a claim can also be made against another insurer. Aetna and Empire Blue Cross conduct exercises on coordination of benefits as part of the administrative servic es that they provide to the United Nations. Benefits are coordinated as follows: (a) Empire Blue Cross conducts its own exercises by mailing out annual questionnaires to participants; (b) 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 third-party administrators. Fraud and abuse 25. The responsibility for ensuring the proper use of the insurance rests with the plan participants and not with the Organization. The third-party administrators are responsible for conducting monitoring and compliance exercises to highlight potential fraud. Fraud or abuse of the plan by any participant (i.e. active staff members or retirees and their covered family members) will result in: (a) Immediate discontinuation of insurance for the participant and/or dependant(s) or suspension from receiving any subsidy from the Organization, as applicable; (b) Recovery of monies previously paid by the third-party administrators; (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. 26. Fraud or abuse of the plan by any provider will be handled according to the applicable procedures of the third-party administrators and may be referred to the local authorities and the Organization. Plan participants are required to revie w their explanation of benefits carefully to ensure that only services received from their provider are billed. Furthermore, it is the responsibility of plan participants to report any questionable charges to the third-party administrators so that they can be investigated. Eligibility and enrolment rules and procedures 27. All staff members holding appointments of three months or longer may enrol themselves and eligible family members in the United Nations health insurance programme. Eligibility for the United Nations health insurance programme is also based on location and is managed in conjunction with the administrative instruction on the medical insurance plan for locally recruited staff at designated duty stations away from Headquarters (ST/AI/2015/3). In addition, staff members holding temporary appointments with one or more extensions that, when taken cumulatively, will amount to three months or more of continuous service can enrol themselves and eligible family members from the beginning of the contract that will meet the three - month minimum threshold. ST/IC/2021/10 21-06920 8/62 28. Staff members holding temporary appointments of less than three months are eligible to enrol in the United Nations short-term medical insurance plan insured by Cigna on an individual basis only, based on availability. Information regarding the insurance programme for temporary appointments of less than three months can be obtained from the Health and Life Insurance Section website (www.un.org/insurance). Staff members enrolled in the short-term medical insurance plan will be required to transfer to one of the regular medical insurance plans upon extension of their temporary appointment beyond three months. Enrolment in a United Nations-administered health insurance plan beyond three months is not automatic and must be done through the Umoja self-service portal within 31 days of the contract extension date or by submitting an application form for staff members who are not in Umoja. 29. Individuals on a “when actually employed” appointment are not eligible to enrol in the United Nations health insurance programme. 30. Post-retirement appointees and surviving dependants (spouses and/or children) covered under the United Nations plans in accordance with the after-service health insurance provisions may continue such coverage, except when they are re-employed by the United Nations or employed by any other member organization of the United Nations Joint Staff Pension Fund and their service period requires re-entry or entry into the Pension Fund as a contributing participant. A post-retirement appointee who returns to service and re-enters the Pension Fund as a contributing participant, or a surviving dependant (spouse and/or child) who enters the Pension Fund as a contributing participant, must discontinue his or her after-service health insurance coverage and enrol in the health plan as an active staff member. If the staff member is employed by an organization that uses Umoja, enrolment must be carried out by submitting an application form to the Health and Life Insurance Section during the eligibility period. At that time, the staff member may retain his or her level of coverage or change the level of coverage if so desired. After-service health insurance coverage will resume upon separation from service and reapplication within 31 days of such separation, but at the level of coverage that existed on the initial after-service health insurance application. Failure to reapply within 31 days of separation will result in a gap in health insurance coverage for the post-retirement appointee, and reinstatement will be made only when all outstanding after-service health insurance contributions are paid in full. 31. “Eligible family members” referenced in the present circular do not include secondary dependants, family members of temporary staff members with appointments of less than three months or family members of occasional workers. The term “eligible family members” refers to a recognized spouse and one or more dependent children. The United Nations health insurance programme recognizes only one eligible spouse for coverage. A dependent child is one who meets the definition according to staff rules and is a household member in the Umoja system of the United Nations, the Atlas system of UNDP, the SAP system of UNICEF or the “oneUNOPS” system of UNOPS. 32. A child is eligible to be covered under the programme until the end of the calendar year in which he or she attains the age of 25, provided that the child is neither married nor employed full time. Children with disabilities may be eligible for continued coverage beyond the age of 25 if they are certified with a disability by the Division of Health-Care Management and Occupational Safety and Health, if the parent is an active staff member, or by the United Nations Joint Staff Pension Fund, if the parent is a retiree. 33. Staff members who have no coverage under a United Nations plan or who are covered through another family member are strongly urged to obtain medical insurance coverage for themselves and their eligible family members during the ST/IC/2021/10 9/62 21-06920 annual enrolment campaign or after a qualifying event. This is especially the case given that the high cost of medical care could result in financial hardship for individuals who fall ill and/or are injured and have no such coverage. Injury or illness is not a qualifying event for enrolment in the United Nations health insurance programme. Staff member married to another staff member and staff members who share responsibility for an eligible dependant 34. In the case of a staff member married to another staff member, both staff members may either elect to maintain their own individual insurance coverage at the “staff member only” coverage level or elect “staff member plus spouse” or family insurance coverage. In the scenario where married staff members both maintain their own individual insurance coverage, are assigned to different duty stations and have a dependent child or children, the staff member in receipt of the dependency allowance must carry the insurance for the dependent child or children. In the case of staff members who are not married but share responsibility for an eligible dependent child or children, the staff member in receipt of the dependency allowance must carry the insurance for the dependent child or children. In the case of coverage at the two- person, i.e. “staff member plus spouse”, or family level, where both staff members are to be covered, such coverage must be carried by the higher-salaried staff member. 35. The determination of the higher-salaried staff member is based on the “medical net” salary of both staff members. “Medical net” salary is calculated as gross salary, less staff assessment, plus transitional allowance, single parent allowance, dependent spouse allowance, post adjustment, language allowance and non-resident allowance, as applicable. In the case in which both staff members in the same duty station belong to the same category and grade, the higher-salaried staff member will be the one who is at least two steps higher than the other; otherwise, either one may carry the two- person or family coverage. 36. The only exception to the policy above is in the case of a staff member on a temporary appointment of less than 364 days married to another staff member on a fixed-term, continuing or permanent appointment and belonging to the same category. In that case, the insurance coverage at the two-person or family level must be carried by the staff member whose appointment is not temporary. 37. It should also be noted that, if one spouse retires from service with the Organization before the other, the spouse who remains in active service must become the subscriber even if the retired spouse had been the subscriber up to the date of retirement and is eligible for after-service health insurance benefits following separation from service. The retiring staff member must nevertheless apply for after - service health insurance to the Health and Life Insurance Section in order to preserve his or her right to exercise the benefit in the future. Changes between annual enrolment campaigns 38. Between annual enrolment campaigns, staff members and their eligible family members may be allowed to enrol in the United Nations Headquarters-administered health insurance plans only if at least one of the following qualifying events occurs and enrolment is completed within 31 days of such an occurrence through the Umoja employee self-service portal, for United Nations staff, or through the submission of a completed application form, for staff of the United Nations agencies participating in the United Nations health insurance programme: (a) In respect of medical insurance coverage, upon receipt of an initial fixed - term or temporary appointment of at least three months’ duration at United Nations Headquarters or, in the case of temporary appointees, upon achieving a threshold ST/IC/2021/10 21-06920 10/62 duration of continuous active employment at a minimum of half-time for at least three months;1 (b) In respect of dental insurance coverage, upon receipt of an initial fixed - term or temporary appointment of at least three months’ duration at United Nations Headquarters;1 (c) Upon transfer or assignment of the staff member to a new duty station, even if of a temporary nature. For staff members with eligible family members who are residing in a different location, coverage must be init iated during the eligibility window, in alignment with the Umoja employee self-service enrolment period. In addition, dependants may be enrolled within 31 days of their initial United Nations - reimbursed travel date related to their installation at the duty station; (d) Upon reinstatement of appointment in accordance with staff rule 4.18; (e) Upon return from special leave without pay. Enrolment is automatic under the health insurance plan and coverage type in which the staff member was insured before commencing leave (i.e. no opportunity to enrol eligible family members if they were not covered before taking leave, with the exception of the events referred to in subparagraphs (g) and (h) below that occur during the period of special leave) ; (f) Upon marriage, in the case of spouses, provided that the staff member is currently enrolled; (g) Upon the birth or legal adoption of a child or children, provided that the staff member is currently enrolled; (h) Upon presentation of proof of loss of coverage by the staff member under a spouse’s health insurance plan, in accordance with paragraph 60 below; (i) Upon the provision of evidence that the staff member was on official travel or on an official leave (e.g. annual, sick or special) for the entire duration of the annual enrolment campaign and enrolment is completed through the Umoja employee self - service portal for United Nations staff or through the submission of a completed application for staff of United Nations agencies participating in the health insu rance programme within 31 days of his or her return to the duty station. 39. Staff members and their eligible dependants may terminate their coverage under the health plans between annual enrolment campaigns only if one of the following qualifying events occurs and if application for termination is made within 31 days of such an occurrence: (a) Upon divorce, in the case of a spouse; (b) Upon the death of a covered dependant; (c) Upon the marriage or full-time employment of a covered child; (d) Upon employment of a spouse with the Secretariat or a United Nations system organization through a non-temporary appointment at a higher grade and level and eligibility for medical insurance coverage. Employment of a spouse with any other employer will not be considered a qualifying event for termination from a United Nations health insurance plan; (e) Upon return from special leave without pay. Enrolment is automatic under the health insurance plan and coverage type in which the staff member was insured __________________ 1 If coverage for eligible family members is desired, such enrolment must be done at the same time as the staff member’s application, even if the dependants have not arrived at the duty station. ST/IC/2021/10 11/62 21-06920 before taking leave. The staff member can decide to terminate insurance upon return from special leave without pay. 40. In all the cases cited in the paragraphs above, enrolment, re-enrolment or termination must be completed within 31 days of the occurrence of the event. Enrolment between annual enrolment campaigns based on any other circumstances not listed in paragraphs 38 and 39 above or not processed through the employee self- service portal within 31 days of the event giving rise to eligibility will be den ied. Staff members who, for any reason, are uncertain as to the continuity of any outside coverage are urged to consider enrolling in a United Nations scheme during the current campaign period. Staff on special leave without pay 41. Staff members granted special leave without pay may retain coverage for health insurance during such periods or may elect to discontinue such coverage for the period of the special leave, under the following conditions: (a) Insurance coverage maintained during special leave without pay. If the staff member decides to retain coverage during the period of special leave without pay, the Health and Life Insurance Section must be informed by the staff member in writing of his or her intention at least 31 days in advance of the commencement of the special leave. At that time, the Section will require evidence of approval of the special leave, together with payment covering the full amount of the cost of the coverage(s) retained (i.e. both the staff member’s contribution and the Organization’s share, given that no subsidy is payable during such leave). If the leave period exceeds six months, premiums may be paid in instalments every six months. Failure to pay the required premiums in advance shall result in termination of coverage without further notice to the staff member concerned. Staff members may be allowed to transfer to a health insurance plan that is more appropriate to where they will reside during the period of special leave, provided that such leave is at least six month s in duration. However, staff members enrolled in the UN Worldwide Plan who will reside in the United States during the period of special leave, irrespective of the length of the leave, may enrol in either the Aetna or Empire Blue Cross or Cigna Dental plan; (b) Insurance coverage not maintained during special leave without pay. If a staff member going on special leave without pay has individual insurance coverage and is married to another staff member with separate individual insurance coverage, the staff member going on leave may not be covered under the policy of the spouse who remains in active service; (c) Insurance dropped while on special leave without pay . Should a staff member decide not to retain insurance coverage(s) while on special leave without pay, the staff member cannot re-enrol until he or she returns to work; (d) Re-enrolment upon return to duty following special leave without pay . Upon return to duty following special leave without pay, Umoja automatically reinstates coverage for United Nations staff members under the health insurance plan and coverage type in which the staff member was insured before taking the special leave without pay. For staff members of other United Nations organizations, re-enrolment in the health insurance plan and coverage type in which the staff member was insured before taking the special leave without pay should be done through the staff member’s human resources office in the respective organization. In case the United Nations staff member returning from special leave without pay wishes to drop insurance coverage, the staff member should request withdrawal from the plan within 31 days of the return from special leave without pay. Failure to withdraw within 31 days of the return from special leave without pay will result in the staff member ST/IC/2021/10 21-06920 12/62 being unable to withdraw until either the next annual enrolment campaign or another qualifying event. Staff on special leave with half or full pay and staff on part-time employment 42. Staff members on special leave with full or half pay shall continue to be covered through their health insurance plan in effect before the leave period. However, staff members with part-time employment status that involves a full calendar month shall be subsidized by the Organization at half the regular amount, and the staff member shall be responsible for the other half in addition to his or her regular insurance contribution. Special provisions for the UN Worldwide Plan 43. The UN Worldwide Plan covers current and former staff members who reside outside the United States. Current and former staff members and their dependants who reside in the United States are not eligible for coverage under the UN Worldwide Plan, given that it does not provide adequate coverage in view of the cost of health care in the United States. It is therefore expected that a request to change insurance plans will be initiated within 31 days of a situation change, pursuant to the appropriate procedure in place at the time of the event. Coverage through the UN Worldwide Plan is available only to staff members at duty stations outside the United States and to former staff members with a mailing address outside the United States. 44. The sole exception to this exclusion arises in the case of a dependent child who attends school or university in the United States and is required by the edu cational institution to enrol in its health insurance plan. In such a case, the student’s health insurance plan at the school or university will be primary and the UN Worldwide Plan will be secondary. It should be noted that the United States dental plan ( Cigna US Dental PPO) is separate from the United States medical plans (Aetna PPO and Empire Blue Cross PPO). United Nations staff may select the dental plan in the Umoja employee self-service portal and United Nations agency staff may fill out the dental portion of the group health insurance application form. 45. Plan participants covered under the UN Worldwide Plan should not seek medical care in the United States because the plan does not offer adequate medical protection owing to the annual reimbursement limit of $250,000 and the high cost of medical care in the United States, which is not reflected in the plan’s premiums. Participants who seek non-emergency medical care in the United States on a regular basis are required to transfer to a United States-based plan during the annual enrolment campaign. 46. Medical treatment obtained in the United States is subject to all the restrictions and limitations of the UN Worldwide Plan, and plan participants shall be responsible for the payment of all amounts that exceed benefit limits and annual maximums. Each plan participant will be responsible for the first $5,000 per person or $15,000 per family every year before the plan begins to pay for medical services received in the United States. Furthermore, expenses incurred in the United States will not be subject to the Major Medical Benefits Plan. Prior notification is mandatory and will allow the third-party administrator of the UN Worldwide Plan to propose alternatives and negotiate significant discounts. Participants who fail to receive prior approval from Cigna International for care in the United States will be subject to the deductibles and Major Medical Benefits Plan restrictions stated above. Staff members and their eligible family members cannot be covered under separate health insurance plans. 47. The claim costs in the UN Worldwide Plan are incurred in all parts of the world. Consequently, they reflect varying price levels. Three regional premium rate groups have been established to enable the determination of premiums that are broadly ST/IC/2021/10 13/62 21-06920 commensurate with the expected overall level of claims for the locations included within each rate group. The applicable rate group is based on the staff member’s duty station regardless of whether the covered family members are residing in the same duty station or if care is sought primarily outside the duty station. For retirees, the applicable rate group is based on the retiree’s mailing address. Neither the mailing address nor the duty station may be in the United States because the UN Worldwide Plan is not applicable for coverage in the United States. Participant’s address for insurance purposes 48. It is the responsibility of a staff member or retiree to ensure that his or her correct, complete and up-to-date mailing address is stored in the system of record of his or her organization (i.e. Umoja for the United Nations, Atlas for UNDP, SAP for UNICEF and oneUNOPS for UNOPS). Given that addresses are a part of a staff member’s personnel profile, United Nations staff members should update their address in the Umoja employee self-service portal, and UNDP, UNICEF and UNOPS staff should contact their respective service centres to provide or update their address. Retirees must email their address updates to ashi@un.org. The third-party administrators recognize only the addresses that are electronically transmitted to them by the United Nations from the above-mentioned systems. For those residing in the United States, it is also essential that the address bear the correct United States postal abbreviation for states (e.g. New York and New Jersey must be designated as NY and NJ, respectively) and zip codes. Incomplete address information will result in the third-party administrators rejecting the data transmission, as well as in misdirected mail and failure to receive important correspondence, identification cards or benefit cheques. Effective commencement and termination date of health insurance coverage 49. Provided that enrolment is completed within the prescribed 31-day time frame, coverage for a staff member newly enrolled in a health insurance plan begins on the first day of a qualifying contract or the first day of the following month. When a contract terminates before the last day of a month, coverage will remain in place until the last day of that month. As mentioned previously, premiums are not prorated. 50. Any expenditure, including that related to ongoing treatment, incurred after the expiry of coverage will not be covered by the United Nations health insurance programme. Employment-related illness or injury 51. In the event of illness or injuries that may be attributable to the performance of official duties, the resulting medical and related expenses are payable under appendix D to the Staff Rules (rules governing compensation in the event of death, injury or illness attributable to the performance of official duties on behalf of the United Nations). In such cases, medical expenses can be paid initially under the health insurance plan of the affected staff member, subject to the subsequent offset by the United Nations of any amount payable under the provisions of appendix D. Nevertheless, staff members must still submit a claim addressed to the Secretary of the Advisory Board on Compensation Claims and the Claims Board. Movement between organizations, breaks in appointment and movement between payrolling offices 52. Coverage is terminated automatically but not restored automatically for staff members who are: (a) Separated from service; ST/IC/2021/10 21-06920 14/62 (b) Transferred between organizations under a loan, transfer or secondment arrangement (e.g. United Nations, UNDP and UNICEF); (c) Reappointed, regardless of whether there was a break in employment, or following a change in employment contract or appointment ; (d) Transferred to a non-Umoja payrolling organization. 53. Most individuals whose contracts end leave the United Nations common system. However, there are also insured staff members who are reappointed or transferred between the United Nations, UNDP and UNICEF. Those staff members must reapply for health insurance coverage within 31 days of the effective date of the reappointment or transfer. Strict attention to this requirement is necessary to ensure continuity of health insurance coverage because, as noted above, separation from an organization results in the automatic termination of insurance coverage at the end of the month. Staff members who transfer between organizations should also ensure that the receiving organization establishes their household members and mailing address in its database so that coverage can be reinstated under the receiving organization. Medical assistance service during personal travel 54. United Nations Headquarters-administered health insurance plans provide coverage to staff members while they are outside their duty station, including while on personal travel. For United States-based participants, enrolled under the Aetna and Empire Blue Cross plans, UnitedHealthcare Global Assistance and Risk provides emergency medical assistance when they are 100 miles or more away from home. 55. Staff members and retirees are reminded that, when they are undertaking personal travel, repatriation and evacuation costs are not covered under any of the United Nations Headquarters-administered health insurance plans or by UnitedHealthcare Global Assistance and Risk. Travellers should consider purchasing travel insurance that provides such benefits at their own cost. 56. For participants requiring a certificate of insurance coverage, such as that required for applications for visas to certain countries, a request for such a certificate may be sent to HLIS@un.org. Certain countries may not accept certifications by the United Nations and may require individuals to purchase travel insurance. Cessation of coverage of the staff member and/or family members 57. Staff members are required to immediately notify the Health and L ife Insurance Section of changes that result in a family member ceasing to be eligible for health insurance coverage, for example a spouse upon divorce or a child marrying or taking up full-time employment. As opposed to children who reach the age of 25 years, the responsibility for initiating the resulting change in coverage (e.g. from “staff member and spouse” to “staff member only” or from “family” to “staff member and spouse”) rests with the staff member. Discontinuation of coverage must be completed in the Umoja employee self-service portal within 31 days of the qualifying event. 58. A primary participant (e.g. a staff member, retiree, surviving dependant or the legal representative of the primary participant) wishing to discontinue his or her coverage, or that of an eligible family member, must communicate the instruction to the Health and Life Insurance Section in writing within 31 days of the qualifying event, even before the approval of the related personnel action. It is in the interest of staff members and retirees to process changes promptly to benefit from any reduction in premium contribution that may result. Irrespective of when a change is processed or when written notification is given, termination of coverage will be implemented on the first of the month after a family member ceases to be eligible for participation in the health insurance programme. No retroactive refund of contribution can be made ST/IC/2021/10 15/62 21-06920 as a result of a participant’s failure to take action or to provide timely notification of any changes to the Health and Life Insurance Section. 59. In the case of children with disabilities who are over the age of 25, eligibility for health insurance coverage shall cease as a result of emancipation, marriage, full-time employment, lapse of disability certification by the Division of Health-Care Management and Occupational Safety and Health or cessation of a pension or compensation benefit, whichever comes first. It is the staff member or retiree’s responsibility to ensure that disability certificat ions for his or her child or children with a disability are up to date. Such children will not be allowed to continue coverage under the health insurance plans while such certifications are being requested. Insurance enrolment resulting from loss of employment of a spouse 60. Loss of coverage by a staff member covered under a spouse’s health insurance plan owing to the spouse’s loss of employment beyond his or her control (i.e. layoffs, mandatory retirement, downsizing as a result of full or partial cessation of operations or relocation of offices, but not resignation or voluntary change to part -time employment) is considered a qualifying event for the enrolment of the staff member and his or her eligible dependants in a United Nations Headquarters-administered health insurance programme, provided that the staff member is otherwise eligible to participate in the programme. Application for enrolment in a United Nations plan under these circumstances must be made within 31 days of the qualifying event (th e qualifying event being the date of the spouse’s loss of employment) and must be accompanied by an official letter from the spouse’s employer certifying the reason for termination of employment and the effective and end dates and type of health insurance coverage. After-service health insurance 61. Staff members are reminded that, among the eligibility requirements for after- service health insurance coverage, the applicant must be enrolled in a United Nations scheme at the time of separation from service. Enrolment in the after-service health insurance programme is not automatic. Application for enrolment must be made within 31 days before or 31 days after the date of separation. Full details on the eligibility requirements and administrative procedures relating to after-service health insurance coverage are set out in administrative instruction ST/AI/2007/3, on after- service health insurance. In addition, staff members are reminded that if there is a delay in after-service health insurance deductions from a retiree’s pension benefit that results in arrears, then up to 70 per cent of the monthly pension benefit may be allocated to the arrears until the outstanding amount is paid. 62. In the case of the death of a staff member, information on continuation of coverage for a surviving spouse and/or dependent children can be found in administrative instruction ST/AI/2007/3. 63. In the case of subscribers to the after-service health insurance programme who: (a) elect to defer pension payments and have not yet reached the normal retirement age under the United Nations Joint Staff Pension Fund; or (b) receive monthly pension benefit payments that are insufficient to meet the cost of the participant’s monthly health insurance coverage, payment of the requisite contribution must be made in advance of the period of coverage under the applicable health insurance plan on a quarterly, semi-annual or annual basis. Contributions must be made in a currency acceptable to the Organization for the purposes of the insurance plan chosen. In the case of health insurance plans administered at Headquarters, the only acceptable currency is the United States dollar. At the normal retirement age, deductions must be ST/IC/2021/10 21-06920 16/62 made from the monthly pension benefit if the participant’s monthly pension benefit is sufficient to meet the cost of the monthly health insurance coverage. 64. Since 1 January 2011, United Nations Headquarters has required all former staff members and dependants (including surviving dependants) who are enrolled as participants in after-service health insurance and who qualify for participation in Medicare Part B, to enrol in the United States Medicare Part B programme. Those retirees who are eligible to enrol in Medicare Part B but choose not to do so will have their claims adjudicated as though they were enrolled, whereby the United Nations health insurance will become their secondary provider and only 20 per cent of their medical claims will be considered for reimbursement. Conversion opportunity 65. Following the passage of the Affordable Care Act in the United States and the offering of health insurance plans in the state or federal marketplace exchanges, the United States-based plans of the United Nations no longer offer private plans under what was previously referred to as the “conversion opportunity”. Staff members (subscribers) who cease employment with the United Nations and do not qualify for after-service health insurance benefits, or formerly covered spouses or children, are directed to the insurance exchanges operated by their states of residence or the federal Government to arrange for medical coverage under an individual contract. 66. The health insurance plans offered in the insurance exchanges do not require presentation of certification of medical eligibility (also referred to as “medical underwriting”). The exchanges offer different plans according to the needs of the individual. The Health and Life Insurance Section does not have information on individual plans offered in the various exchanges, nor can it provide advice on which plans are appropriate for a staff member or his or her family members’ needs. It is the staff member’s responsibility to assess the plans on offer. The plans are available only for residents of the United States. 67. Staff members and their family members who are covered under the UN Worldwide Plan may contact Cigna International directly to enquire about plans that they may purchase on their own, if available, following loss of coverage under the UN Worldwide Plan. Staff members must contact Cigna International as soon as coverage is terminated (normally within 31 days of such termination). Details on available plans should be obtained directly from Cigna International. Time limits for filing claims 68. Plan participants should note that claims for reimbursement of medical services under the Aetna plan (for in-network care only), the Empire Blue Cross plan and the UN Worldwide Plan must be received by the administrators of the plans no later than two years from the date on which the medical expense was incurred. Claims for reimbursement of all dental services under the Cigna US Dental plan as well as out-of- network services under the Aetna plan must be received no later than one year from the date on which the expense was incurred. Claims received by the third -party administrators after the above-mentioned grace periods will not be eligible for reimbursement. Claim payments issued by cheque 69. Subscribers who receive reimbursements by cheque are responsible for the timely cashing of those cheques. Neither the third-party administrators nor the Health and Life Insurance Section will reprocess uncashed cheques that are more than two years old. ST/IC/2021/10 17/62 21-06920 Claims and benefit enquiries and disputes 70. Claims questions must be addressed directly to the third-party administrators concerned. In the case of disputed claims, the staff member must exhaust the multilevel appeal process with the third-party administrator before requesting assistance from the Health and Life Insurance Section. The process is indicated in the explanation of benefits or denial letter mailed to the participant by the third -party administrator and the applicable benefits booklet. Plan participants must strictly observe the time limits for submitting appeals to the third -party administrators. The addresses and relevant telephone numbers of the third-party administrators are listed in annex X to the present circular. Appeals relating to costs in excess of reasonable and customary charges or maximum allowable amounts in accordance with the relevant insurance plan or use of an out-of-network provider in the case of United States-based plans shall not be considered by the Section. Appeals as a result of failure to submit requests to the third-party administrator or to observe time limits for submitting appeals likewise shall not be considered by the Section. 71. Information about the plans can be found in the plan outlines in the annexes to the present circular and the benefits booklets that can be found on the website of the Health and Life Insurance Section (www.un.org/insurance/circulars). Staff members are responsible for familiarizing themselves with the provisions of the plans in which they elect to enrol. More detailed descriptions of the benefits under the various plans in the United Nations Headquarters-administered health insurance programme, including most exclusions and limitations, can be found in the benefits booklets available on the Section’s website. In the event of a claim dispute, the resolution of such a dispute will be guided by the terms and conditions of the policy or contract in question. The final decision rests with the insurance company (in the case of HIP). Procedures for exceptional reimbursement 72. The procedures related to exceptional reimbursements under the United Nations Headquarters-administered health insurance plans follow a standard protocol. Those plans have annual maximums or other limitations in coverage for several health conditions. Claims within those maximums and limitations are processed in accordance with the standard protocol. Claims beyond the maximums and limitations or claims for covered services and treatments that are denied by third-party administrators can be referred to the United Nations for additional consideration in accordance with a set protocol for review and recommendation for exceptional approval. 73. In all cases, however, coverage under the programme is based on the underlying principle that the medical services must be medically necessary, and services must be a covered benefit within that specific plan. It should be noted that any claims for services and treatments not covered under the health insurance plan are not covered under this process. 74. Requests for exceptional reimbursement should be submitted to the Health and Life Insurance Section at HLIS@un.org. 75. When an exceptional claim is submitted, the relevant third-party administrator and the Health and Life Insurance Section assess whether the service is a covered benefit under the plan in question. 76. Once it is confirmed that this is a covered benefit, medical necessity is then requested from the relevant medical experts of the third-party administrators. Subsequently, the case is submitted to the Division of Health-Care Management and Occupational Safety and Health for review and advice on whether the treatment is medically necessary. If the Division decides that the services are not medically ST/IC/2021/10 21-06920 18/62 necessary, the request to exceptionally reimburse the claims will be denied. If the Division decides that the services are medically necessary, the request for exceptional approval is submitted to the Health and Life Insurance Committee for recommendation. 77. If the recommendation of the Health and Life Insurance Committee is positive, that recommendation is submitted to the Controller for approval. 78. The Health and Life Insurance Committee and the Controller consider the claim without knowing the name of the plan participant. Exceptional approvals are provided only for specific medical expenses and for treatments of a definite duration generally not exceeding six months. Unlimited approvals or blanket exceptions are never granted. Documentation required from plan participants requesting exceptional reimbursement 79. The following documentation is required from plan participants requesting exceptional reimbursement: • Letter stating the request and explaining the case history • Explanation of benefits provided by the third-party administrator denying reimbursement • Appeal letter(s) to the third-party administrator • Documentation issued by the health provider stating the following: o Diagnosis o Prognosis o Justification for the services provided o Cost of the medical services provided • Response to the letter of appeal given by the third-party administrator 80. Medical records should be submitted to the Division of Health-Care Management and Occupational Safety and Health (OSH@un.org). 81. Upon approval by the Controller, the Health and Life Insurance Section will request the third-party administrator to pay the claim. Additional procedures for Aetna 82. For plan participants enrolled in the Aetna plan, funds are transferred separately to Aetna for each approved case so that Aetna can issue a cheque to the provider or, if the provider has already received payment, to the plan participant. Aetna is informed of the transfers. When the amount of each transfer is reflected in their records, Aetna will issue a cheque and mail it to the participant. 83. Neither the Controller’s office nor any other United Nations office can make these payments, because all insurance-related payments are to be made by third-party administrators. Websites of the Health and Life Insurance Section and the third-party administrators 84. The website of the Health and Life Insurance Section can be accessed at www.un.org/insurance. It provides information about the United Nations Headquarters-administered health insurance programme, as well as the relevant forms. ST/IC/2021/10 19/62 21-06920 Detailed descriptions of the Aetna, Empire Blue Cross, Cigna US Dental , UN Worldwide and ActiveHealth plans are also posted there. 85. Each third-party administrator in the United Nations health insurance programme has its own website providing a wide range of information about the plan, such as: (a) Healthcare providers; (b) Physicians; (c) Participating hospitals; (d) Pharmacies; (e) Vendors of prosthetics, orthotics, durable medical equipment and medical supplies; (f) Dentists; (g) Health education; (h) Covered services; (i) Replacement insurance cards; (j) Explanations of benefits or claims processed; (k) Mobile applications available for download to a plan participant’s smartphone. The provider contact directory contained in annex X provides the Internet address of each carrier, as well as related instructions. ST/IC/2021/10 21-06920 20/62 Annex I Premiums and contribution rates Headquarters-administered medical and dental insurance schedule of monthly premiums* and contribution rates** (Effective 1 July 2021) (Premium rates in United States dollars ) Type of coverage Aetna Open Choice PPO POS II Empire Blue Cross PPO HIPa Cigna US Dental PPO with Aetna, Empire Blue Cross or HIP Cigna US Dental PPO alone 2020 rates 2021 rates 2020 rates 2021 rates 2020 rates 2021 rates 2020 rates 2021 rates 2021 rates Staff member only Premium rate 1 205.33 1 205.33 895.55 895.55 1 183.14 1 258.98 65.63 65.63 65.63 Contribution rate (percentage) 6.36 6.36 4.09 4.09 13.72 20.95 0.32 0.32 0.45 Staff member and one child Premium rate 2 407.11 2 407.11 1 787.53 1 787.53 2 160.40 2 298.87 131.26 131.26 131.26 Contribution rate (percentage) 11.13 11.13 7.24 7.24 20.98 32.03 0.56 0.56 0.79 Staff member and spouse Premium rate 2 407.11 2 407.11 1 787.53 1 787.53 2 160.40 2 298.87 131.26 131.26 131.26 Contribution rate (percentage) 11.13 11.13 7.24 7.24 20.98 32.03 0.56 0.56 0.79 Staff member and two or more eligible family members Premium rate 3 011.58 3 011.58 2 595.58 2 595.58 3 439.39 3 659.84 211.95 211.95 211.95 Contribution rate (percentage) 12.43 12.43 9.23 9.23 29.43 44.94 0.86 0.86 1.35 a Effective 1 July 2013, the HIP Health Plan of New York was closed to new subscribers (i.e. staff members or retirees). Subscribers who are currently covered may remain in the plan, and any changes related to eligible household members will be accepted. However, a current subscriber who transfers to another United States plan during the 2021 annual enrolment campaign will not be allowed to return to the HIP plan in future annual enrolment campaigns. __________________  The cost of the medical and dental insurance plans at Headquarters is shared between the participants and the Organization. ** Staff members may determine their exact contribution by multiplying their “medical net” salary by the applicable contribution rate above. “Medical net” salary for insurance contribution purposes is calculated as gross salary, less staff assessment, plus transitional allowance, single parent allowance, dependent spouse allowance, post adjustment, language allowance and non-resident allowance. Actual contributions are capped at 85 per cent of the corresponding premium. ST/IC/2021/10 21/62 21-06920 UN Worldwide health insurance schedule of monthly premiums*** and contribution rates**** (Effective 1 July 2021) Type of coverage Monthly premium (United States dollars) Contribution rate (percentage) Effective Effective July 2020 July 2021 July 2020 July 2021 Rate group 1a Staff member only 170.00 170.00 1.51 1.51 Staff member and one family member 362.00 362.00 2.33 2.33 Staff member and two or more eligible family members 597.00 597.00 3.67 3.67 Rate group 2b Staff member only 292.00 292.00 2.31 2.31 Staff member and one family member 615.00 615.00 3.73 3.73 Staff member and two or more eligible family members 1 016.00 1 016.00 5.86 5.86 Rate group 3c Staff member only 281.00 281.00 2.41 2.41 Staff member and one family member 592.00 592.00 3.88 3.88 Staff member and two or more eligible family members 974.00 974.00 6.11 6.11 a Rate group 1 includes all locations outside the United States of America other than those listed under rate groups 2 and 3. b Rate group 2 includes Chile and Mexico. c Rate group 3 includes Andorra, Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingd om of Great Britain and Northern Ireland. __________________ *** The cost is shared between the participants and the Organization. **** Staff members may determine their exact contribution by multiplying their “medical net” salary by the applicable contribution rate above. “Medical net” salary is calculated as gross salary, less staff assessment, plus transitional allowance, single parent allowance, dependent spouse allowance, post adjustment, language allowance and non-resident allowance, as applicable. The applicable rate group is based on the staff member’s duty station. Actual contributions are capped at 85 per cent of the corresponding premium. ST/IC/2021/10 21-06920 22/62 Annex II United States-based medical benefits: plan comparison chart* Benefits In-network Out-of-network HIP Health Plan of New York (in-network only) Aetna Empire Blue Cross Aetna Empire Blue Cross Annual deductible $0.00 $0.00 $0.00 Individual: $250 Family: $750 Individual: $250 Family: $750 Insurance coverage 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Annual out-of- pocket maximum Not applicable Individual: $1,000 Family: $3,000 Not applicable Individual: $1,500 Family: $4,500 (with deductible) Individual: $1,250 Family: $3,750 (with deductible) Lifetime maximum Unlimited Unlimited Unlimited Unlimited Unlimited Claim submission Provider files Provider files Provider files You file You file Hospital benefits Inpatient Pre-registration required 100 per cent 100 per cent 100 per cent 100 per cent United States: 80 per cent after deductible International: 100 per cent Outpatient 100 per cent 100 per cent 100 per cent 100 per cent United States: 80 per cent after deductible International: 100 per cent Emergency room (initial visit) 100 per cent accidental injury; sudden and serious medical condition 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) Emergency room visit (for non-emergency care) Not covered but 100 per cent after $0/$35 co-pay at urgent care centres in the United States Not covered Not covered Not covered Not covered * A more detailed summary of benefits for each plan is contained in the succeeding annexes and applicable summary plan descriptions available at www.un.org/insurance/circulars. ST/IC/2021/10 23/62 21-06920 Benefits In-network Out-of-network HIP Health Plan of New York (in-network only) Aetna Empire Blue Cross Aetna Empire Blue Cross Medical benefits Office/home visits 100 per cent 100 per cent after $15/$20 primary care physician/ specialist co-pay 100 per cent after $15/$20 primary care physician/ specialist co-pay 80 per cent after deductible 80 per cent after deductible Routine physical 100 per cent once every 12 months 100 per cent after $15 co-pay once every 12 months 100 per cent after $15 co-pay once every 12 months 80 per cent after deductible once every 12 months 80 per cent after deductible once every 12 months Surgery 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Prescription drugs Pharmacy $5.00 for generic/brand per 30-day supply 20 per cent co-pay up to $20 per 30-day supply for generic 25 per cent co-pay up to $30 per 30-day supply for brand name 20 per cent co-pay up to $20 per 30-day supply for generic 25 per cent co-pay up to $30 per 30-day supply for brand name United States: 60 per cent after deductible International: 80 per cent after deductible United States: 60 per cent after deductible International: 80 per cent after deductible Mail order $2.50 for generic/brand per 30-day supply 100 per cent after $15 co-pay per 90-day supply 100 per cent after $15 co-pay per 90-day supply Not applicable Not applicable Behavioural health-care benefits (must be pre-certified; benefit maximum for in-network and out-of- network combined) Inpatient mental health care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible Outpatient mental health care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Inpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible Outpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible ST/IC/2021/10 21-06920 24/62 Benefits In-network Out-of-network HIP Health Plan of New York (in-network only) Aetna Empire Blue Cross Aetna Empire Blue Cross Vision care Eye exam 100 per cent 100 per cent after $20 co-pay 100 per cent after $15 co-pay 80 per cent $40 allowance One exam every 12 months One exam every 12 months One exam every 12 months One exam every 12 months One exam every 12 months Frames and optical lenses $45 every 24 months for frames and lenses from select group $100 allowance, then savings of up to 35 per cent at participating centres $130 allowance, then 20 per cent discount on remaining balance for frames, $10 co-pay for lenses 80 per cent up to $100 per year $45 for frames $25/pair single vision $40/pair bifocal lenses $55/pair trifocal lenses (amounts listed are allowances provided by insurance) Other benefits Physical and other inpatient therapy 100 per cent 100 per cent 100 per cent 80 per cent 80 per cent after deductible 90 visits 60 visits 60 visits Physical and other outpatient therapy 100 per cent 100 per cent 100 per cent after $20 co-pay 80 per cent after deductible 80 per cent after deductible 90 visits 60 visits 60 visits Durable medical equipment 100 per cent 100 per cent 100 per cent 80 per cent Not covered ST/IC/2021/10 25/62 21-06920 Annex III Empire Blue Cross PPO Plan outline The Empire Blue Cross PPO plan provides worldwide coverage for hospitalization and surgical, medical, vision and prescription drug expenses. Under this plan, medically necessary treatment for a covered illness or injury may be obtained at a hospital or from a physician of one’s own choosing, whether an in-network or out-of-network provider. The present annex provides a high-level summary chart of the plan. For detailed information, staff members must review the Empire Blue Cross PPO plan description document available on the Health and Life Insurance Section website (www.un.org/insurance). In addition, participants of the Empire Blue Cross plan have access to UnitedHealthcare Global Assistance and Risk and ActiveHealth as part of their participation in the plan. Coverage when travelling or living outside the United States of America is handled by Blue Cross Blue Shield Global Core. Details can be found in the Empire Blue Cross PPO plan description document. Empire Blue Cross PPO summary of benefits Benefits In-networka Out-of-network Annual deductible Individual $0 $250 Family $0 $750 Insurance coverage (percentage at which the plan pays benefits) 100 per cent 80 per cent Annual out-of-pocket maximum Individual Family $0 $0 $1,250 $3,750 (includes annual deductible; network and prescription drug co-pays do not count towards the out-of-pocket limit) Lifetime maximum Unlimited Dependent children Covered to end of calendar year in which child reaches age 25 Claim submission Provider files claims You file claims Hospital services and related care coverage Inpatientb – Unlimited days – semi-private room and board – Hospital-provided services – Routine nursery care 100 per cent 80 per cent after deductible within the United States 100 per cent outside the United States ST/IC/2021/10 21-06920 26/62 Benefits In-networka Out-of-network Outpatient – Surgery and ambulatory surgeryb – Pre-surgical testing (performed within seven days of scheduled surgery) – Blood – Chemotherapy and radiation therapy – Mammography screening and cervical cancer screening 100 per cent 80 per cent after deductible within the United States 100 per cent outside the United States Mandatory pre-registrationb (1 800 982 8089) Pre-registrations are your responsibility Pre-registrations are your responsibility (For emergency admission, call within 48 hours or the next business day if admitted on a weekend) Hospital emergency roomc (initial visit) – Accidental injury – Sudden and serious medical condition 100 per cent, including physician’s charges, after $75 co-pay (waived if admitted within 24 hours) 100 per cent, including physician’s charges, after $75 co-pay (waived if admitted within 24 hours) Emergency room visit for non-emergency care is not covered Urgent care 100 per cent after $15/$20 co-pay Subject to deductible and co-insurance Ambulance 100 per cent up to the allowed amount Air ambulance (to nearest acute care hospital for emergency inpatient admissions) 100 per cent Home health careb ,d – Up to 200 visits per calendar year 100 per cent 80 per cent after deductible within the United States 100 per cent outside the United States – Home infusion therapy 100 per cent Covered in-network only Outpatient kidney dialysis Home, hospital-based or free- standing facility treatment 100 per cent 80 per cent after deductible Skilled nursing facilityb Up to 120 days per calendar year 100 per cent Covered in-network only within the United States 80 per cent after deductible outside the United States ST/IC/2021/10 27/62 21-06920 Benefits In-networka Out-of-network Hospiceb Participants will have Unlimited Days if life expectancy is up to 12 months and continue disease- modifying treatments after Hospice engagement has begun. 100 per cent Covered in-network only Physician services and other medical benefits (excluding behavioural health and substance abuse care) Office/home visits/office consultations 100 per cent after $15/$20 primary care physician/specialist co-pay 80 per cent after deductible Telemedicine (LiveHealth Online) covered in-network only 100 per cent after $15 primary care physician co-pay Covered in-network only Surgery 100 per cent 80 per cent after deductible Surgical assistant 100 per cent 80 per cent after deductible Anaesthesia 100 per cent 80 per cent after deductible Inpatient visits/consultations 100 per cent 80 per cent after deductible Maternity care 100 per cent after initial visit 80 per cent after deductible Diagnostic X-rays 100 per cent 80 per cent after deductible Laboratory tests 100 per cent 80 per cent after deductible Chemotherapy and radiation therapy Hospital outpatient or physician’s office 100 per cent 80 per cent after deductible MRIs/MRAs, PET/CAT scans and nuclear cardiology scansb 100 per cent 80 per cent after deductible Cardiac rehabilitation 100 per cent after $20 specialist co-pay 80 per cent after deductible Second surgical opinione 100 per cent after $20 specialist co-pay 80 per cent after deductible Second medical opinion for cancer diagnosis 100 per cent after $20 specialist co-pay 80 per cent after deductible f Allergy testing and allergy treatment 100 per cent after $20 specialist co-pay per office visit for testing 100 per cent for treatment visits 80 per cent after deductible Prosthetic, orthotics, durable medical equipmentg 100 per cent Covered in-network only Medical supplies 100 per cent 100 per cent up to the allowed amount Preventive care Annual physical exam 100 per cent after $15 co-pay 80 per cent after deductible Diagnostic screening tests 100 per cent 80 per cent after deductible Prostate-specific antigen (PSA) test 100 per cent 80 per cent after deductible ST/IC/2021/10 21-06920 28/62 Benefits In-networka Out-of-network Well-woman care 100 per cent after $15 co-pay 80 per cent after deductible Mammography screening 100 per cent 80 per cent after deductible Well-child care (including recommended immunizations)d – Under 1 year of age: seven visits – 1–4 years old: seven visits – 5–11 years old: seven visits – 12–17 years old: six visits – 18 years old to 19th birthday: two visits 100 per cent 100 per cent Physical therapy and other skilled therapies Physical therapyb – 60 inpatient visits, and – 60 visits combined in home, office or outpatient facility 100 per cent 100 per cent after $20 specialist co-pay 80 per cent after deductible 80 per cent after deductible Pre-certification not required for out-of-network Occupational, speech, visionb 60 visits combined in home, office or outpatient facility 100 per cent after $20 specialist co-pay 80 per cent after deductible Behavioural health and substance abuse servicesh Inpatient mental health care 100 per cent 80 per cent after deductible Outpatient mental health care 100 per cent (LiveHealth Online behavioural health) covered in-network only 80 per cent after deductible Inpatient alcohol and substance abuse 100 per cent 80 per cent after deductible Outpatient alcohol and substance abuse 100 per cent 80 per cent after deductible Prescription drug benefits Card programme 30-day supply 800 342 9816 Generic: 20 per cent co-pay with $5 minimum and up to a maximum of $20 per prescription Brand name: 25 per cent co-pay up to a maximum of $30 per prescription Within the United States: 60 per cent after deductible Outside the United States: 80 per cent after deductible (Express Scripts prescription drug claim form must be filed for reimbursement) The co-insurance will not count towards the $1,250/$3,750 out-of- pocket limit ST/IC/2021/10 29/62 21-06920 Benefits In-networka Out-of-network Ingenio Rx (Pharmacy Member Services) 833 271 2374 100 per cent after $15 co-pay for up to a 90-day supply from participating mail order vendor When a brand name drug is dispensed and an equivalent generic is available, the participant will pay the tier 2 co-pay plus the difference in cost between the generic and the brand name drug . For medications taken regularly, participants can choose, or opt out of, home delivery. If they opt out, they can remain at their retail pharmacy. Plan participants are advised of this requirement at their pharmacy, followed by a letter when their retail courtesy fills run out. There is no penalty for continuing with the participant’s retail pharmacy after opting out of home delivery. Plan participants can also choose to get a 90-day supply at any CVS pharmacy for many maintenance and non-maintenance drugs on their drug list at the same cost as home de livery. For questions or to opt out of home delivery, participants should call the pharmacy member services number on their ID card. Vision care programme Blue View Vision 866 723 0515 (Eye Med in New Jersey) Routine eye exam (once every 12 months) $15 co-pay $40 allowance Eyeglass frames (once every 12 months) $130 allowance, then 20 per cent off balance $45 allowance Eyeglass lenses Single $10 co-pay, then covered in full $25 allowance Bifocal $10 co-pay, then covered in full $40 allowance Trifocal $10 co-pay, then covered in full $55 allowance Eyeglass lens upgrades UV coating Tint (solid and gradient) Standard scratch-resistance Standard polycarbonate Standard progressive Standard anti-reflective coating Other add-ons and services $15 member cost $15 member cost $15 member cost $40 member cost $65 member cost $45 member cost 20 per cent off retail price $0 $0 $0 $0 $0 $0 $0 Contact lenses Elective conventional $130 allowance, then 15 per cent off balance $105 allowance Elective disposable $130 allowance $105 allowance Non-elective Covered in full $210 allowance ST/IC/2021/10 21-06920 30/62 Benefits In-networka Out-of-network Contact lens fitting Standard fitting Premium fitting Up to $55 10 per cent off retail price $0 $0 In addition, Blue View Vision gives participants 40 per cent off an additional pair of complete eyeglasses, 15 per cent off the retail price of conventional contact lenses, and 20 per cent off the retail price of eyewear accessories (some non-prescription sunglasses, lens cleaning supplies, contact lens solutions and eyeglass cases) . Other health care Acupuncture 100 per cent after $20 co-pay 80 per cent after deductible $1,000 annual limit on combined in- and out-of-network benefits Chiropractic care 100 per cent after $20 co-pay 80 per cent after deductible $1,000 annual limit on combined in- and out-of-network benefits Hearing exam (every three years) 100 per cent after $20 specialist co-pay 80 per cent after deductible Hearing appliance 100 per cent up to $750 maximum benefit per hearing device per ear every three years covered 80 per cent after deductible, up to $750 maximum benefit per hearing device per ear every three years a In-network services (except mental health or alcohol/substance abuse) are those from a provider that participates with Empire or another Blue Cross Blue Shield plan through the BlueCard Program, or a participating provider with another Blue Cross Blue Shield plan that does not have a PPO network and does accept a negotiated rate arrangement as payment in full. b The Medical Management Program must pre-approve or benefits will be reduced by 50 per cent up to $2,500. c If admitted, the Medical Management Program must be called within 24 hours or as soon as reasonably possible. d Combined maximum visits for in-network and out-of-network services. e Charges to participants do not apply if the second surgical opinion is arranged through the Medical Management Program. f If arranged through the Medical Management Program, services provided by an out -of-network specialist will be covered as if the services had been in-network (i.e. subject to the in-network co-payment). g In-network vendor must call the Medical Management Program to pre -certify. h Empire Behavioral Health Services must pre-approve or benefits will be reduced by 50 per cent up to $2,500. Out-of-network mental health care does not require pre-certification; however, outpatient alcohol and substance abuse visits must be pre-certified. In-network mental health services are those from providers that participate with Empire Behavioral H ealth Services. ST/IC/2021/10 31/62 21-06920 Annex IV Aetna Open Choice PPO/POS II Plan outline The Aetna Open Choice PPO/Aetna Choice POS II plan offers worldwide coverage for hospitalization and surgical, medical, vision and prescription drug expenses. Under this plan, medically necessary treatment for a covered illness or injury may be obtained at a hospital or from a physician of one’s own choosing, whether an in-network or out-of-network provider. The Aetna Open Choice PPO/POS II plan includes automatic enrolment in the Aetna International programme for plan participants who are active staff members at duty stations outside the United States of America and for retirees with a mailing address outside the United States. All correspondence relating to the Aetna International programme (identification cards, explanations of benefits, reimbursement cheques and any other materials) will continue to be sent to the mailing address on record in the personnel system. The Aetna International programme provides for admission, on a direct-pay basis, to hospitals outside the United States with which Aetna International has negotiated such arrangements. The current list contains more than 600 such hospitals outside the United States and more hospitals are being added. For active staff members at duty stations overseas and for retirees with an overseas mailing address, hospitals associated with Aetna International have agreed to direct-pay arrangements with Aetna International. Therefore, an upfront deposit upon admission is not required and the bill does not become due upon discharge, with the exception of the deductible and any co-insurance that may be required. At present, bills for physicians’ services must be settled directly and then remitted to Aetna International for reimb ursement. If you do not wish to use a provider contracted by Aetna International, you are free to seek medical services from another facility or medical professional of your choice. In that case, direct-pay assistance may not be available. The present annex provides a high-level summary chart of the plan. For detailed information, staff members may review the Aetna Open Choice PPO/POS II plan description document available at www.un.org/insurance. In addition, participants of the Aetna plan have access to UnitedHealthcare Global Assistance and Risk and ActiveHealth as part of their participation in the plan. Aetna Open Choice PPO/POS II summary of benefits Benefits In-network Out-of-network Annual deductible Individual $0 $250 for Aetna (domestic) only Family $0 $750 for Aetna (domestic) only Insurance coverage (percentage at which the plan pays benefits) 100 per cent except where noted 100 per cent hospital; 80 per cent all other, except where noted ST/IC/2021/10 21-06920 32/62 Benefits In-network Out-of-network Annual out-of-pocket maximum Individual $1,000 for Aetna (domestic and international) $1,500 for Aetna (domestic and international) Family $3,000 for Aetna (domestic and international) $4,500 for Aetna (domestic and international) (includes annual deductible; network and prescription drug co-pays do not count towards the out-of-pocket limit) Lifetime maximum Unlimited Unlimited Dependent children Covered to end of calendar year in which child reaches age 25 Claim submission Provider files claims You file claims Hospital services and related care coveragea Inpatient coverage Outpatient coverage 100 per cent 100 per cent 100 per cent 100 per cent Mandatory pre-certification/ pre-registrationa (1 888 632 3862) Mandatory. Applies to inpatient hospital only. Strongly recommended for skilled nursing facility, home health care, hospice care and private duty nursing care. No penalty applies Provider is responsible You or the provider are responsible. For failure to obtain pre-certification, $2,500 penalty applies (For emergency admission, call within 48 hours or next business day if admitted on weekend) Hospital emergency room Based on symptoms, i.e. constituting a perceived life-threatening situation 100 per cent, including physician’s charges, after $75 co-pay (waived if admitted within 24 hours) 100 per cent, including physician’s charges, after $75 co-pay (waived if admitted within 24 hours) Hospital emergency room For non-emergency care (examples of conditions: skin rash, earache, bronchitis, etc.) Not covered Not covered Ambulance [there are no network providers for these services at the present time] 100 per cent Skilled nursing facility 100 per cent Up to 365 days per year for restorative care as determined by medical necessity ST/IC/2021/10 33/62 21-06920 Benefits In-network Out-of-network Private duty nursing (in-home only) 100 per cent, subject to yearly limits of $5,000 and 70 “shifts” as well as $10,000 lifetime Must be determined to be medically necessary and supported by a doctor’s prescription/medical report. Pre-certification is strongly recommended Home health carea Up to 200 visits per year 100 per cent Must be determined to be medically necessary and supported by a doctor’s prescription/medical report. Pre-certification is strongly recommended. Hospicea (210 days) Plus 5 days’ bereavement counselling 100 per cent, deductible does not apply Physician services Office visits For treatment of illness or injury (non-surgical) 100 per cent after $15/$20 primary care physician/specialist co-pay 80 per cent after deductible Telemedicine 100 per cent after $15 primary care physician co-pay 80 per cent after deductible Maternity (includes voluntary sterilization and voluntary abortion; see family planning) 100 per cent after $15 co-pay 80 per cent after deductible Physician in-hospital services 100 per cent 80 per cent after deductible Other in-hospital physician services (e.g. attending/independent physician who does not bill through hospital) 100 per cent 80 per cent after deductible Surgery (in hospital or office) 100 per cent 80 per cent after deductible Second surgical opinion 100 per cent 100 per cent after deductible Anaesthesia 100 per cent (if participating hospital) 80 per cent after deductible Allergy testing and treatment (given by a physician) 100 per cent after $20 specialist co-pay 80 per cent after deductible Allergy injections (not given by a physician) 100 per cent 80 per cent after deductible Preventive care Routine physicals and immunizations – Children aged 7+ and adults: 1 routine exam every 12 months 100 per cent after $15 co-pay 80 per cent after deductible ST/IC/2021/10 21-06920 34/62 Benefits In-network Out-of-network Well-child care and immunizations Well-child care to age 7: – Six visits per year, age 0–1 – Two visits per year, age 1–2 – One visit per year, age 2–7 100 per cent Routine OB/GYN exam 1 routine exam per calendar year, including 1 Pap smear 100 per cent after $15 co-pay 80 per cent after deductible Family planning – Office visits, including tests and counselling 100 per cent after $20 specialist co-pay 80 per cent after deductible – Surgical sterilization procedures for vasectomy/tubal ligation (excludes reversals) 100 per cent 80 per cent (deductible waived) Infertility treatment – Office visits, including testing and counselling 100 per cent after $20 specialist co-pay 80 per cent after deductible – Artificial insemination limited to six treatments per lifetime 100 per cent 80 per cent after deductible – Advanced reproductive technology limited to $25,000 per lifetime for medical expenses and $10,000 per lifetime for pharmacy expenses 100 per cent 80 per cent after deductible Routine mammogram (no age limit) 100 per cent 80 per cent after deductible 100 per cent if performed on an inpatient basis or in the outpatient department of a hospital Annual urological exam by urologist 100 per cent 80 per cent after deductible Behavioural health and substance abuse services Mental health inpatient services (1 800 424 1601) 100 per cent 100 per cent after deductible Inpatient coveragea These services are provided by Aetna Behavioural Health. Pre-registration of inpatient confinements is required. For in-network services, the network provider is responsible for pre-registration. For out-of-network inpatient services, either the physician or the participant must pre-register the confinement, or the penalty may applyb Outpatient coverage 100 per cent 80 per cent after deductible For out-of-network outpatient behavioural health and substance abuse benefits; the patient co-insurance does not count towards meeting the annual out-of-pocket limits ST/IC/2021/10 35/62 21-06920 Benefits In-network Out-of-network Crisis intervention Autism and applied behavioural analysis (ABA) 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Alcohol/drug abuse Inpatient coveragea 100 per cent 100 per cent after deductible Outpatient coverage 100 per cent 80 per cent after deductible Prescription drug benefits Aetna Retail Rx (1 800 784 3991) Aetna International Retail Rx (1 800 231 7729) Retail means regular 30-day supply Generic: 80 per cent up to $5 minimum co-pay with a $20 maximum co-pay per prescription; 100 per cent thereafter per one- month supply Brand name: 80 per cent up to $5 minimum co-pay with a $20 maximum co-pay per prescription; 100 per cent thereafter per one- month supply Within the United States: 60 per cent after deductible Outside the United States: 80 per cent after deductible The co-insurance will not count towards $1,250/$3,750 out-of- pocket limit Aetna Mail Order Rx (1 888 792 3862) Aetna International Mail Order Rx (1 800 231 7729) Mail order means 90-day supply 100 per cent after $15 co-pay for up to a 90-day supply from participating mail order vendor Prescriptions for retail/mail order programme: when a brand name drug is dispensed and an equivalent generic is available, the participant will pay the co-pay plus the difference in cost between the generic and the brand name drug unless the doctor specifies the brand name drug by writing “DAW” or “Dispense as written” on the prescription. In that event, you pay the normal co-pay only Vision and hearing care Eye exam (once every 12 months) 100 per cent 80 per cent, deductible does not apply Optical lenses (including contact lenses once every 12 months) $100 maximum for lenses and frames purchased in a 12-month period Aetna Vision Discount programme (1 800 793 8616) Discount information for laser surgery (1 800 422 6600) Save up to 35 per cent on frames and about 15 per cent for non-disposable contact lenses at participating EyeMed centres. Discounts available for laser surgery Hearing exam Evaluation and audiometric exam 100 per cent after $20 co-pay (one exam every three years; exam must be performed by otolaryngologist or state-certified audiologist) 80 per cent after deductible (one exam, limited to $100 reimbursement every three years; exam must be performed by otolaryngologist or state-certified audiologist) ST/IC/2021/10 21-06920 36/62 Benefits In-network Out-of-network Hearing device [there are no network providers for these services at the present time] 80 per cent, deductible does not apply; $750 maximum benefit per hearing device per ear every three years Other health care Physical and occupational therapy 100 per cent 80 per cent after deductible Laboratory tests, diagnostic X-rays 100 per cent 80 per cent after deductible Speech therapy 80 per cent after deductible for out-of-network services (where services are rendered by a participating provider, 100 per cent reimbursement applies after $20 co-pay) Outpatient diabetic self-management education programme 80 per cent, deductible does not apply If services are rendered in a hospital, 100 per cent reimbursement applies with no co-pay. If rendered in a network doctor’s office, 100 per cent reimbursement with $20 specialist co-pay applies Durable medical equipment 80 per cent, deductible does not apply If services are rendered by a network provider or within a hospital setting, 100 per cent reimbursement applies with no co-pay Acupuncture 100 per cent after $20 co-pay up to a maximum benefit of $1,000 per year 80 per cent after deductible up to a maximum benefit of $1,000 per year In-network and out-of-network benefits are combined for a maximum of $1,000 per calendar year Chiropractic care 100 per cent after $20 co-pay up to a maximum benefit of $1,000 per year 80 per cent after deductible up to a maximum benefit of $1,000 per year In-network and out-of-network benefits are combined for a maximum of $1,000 per calendar year a The Medical Management Program must pre-approve, or benefits will be reduced by 50 per cent, up to $2,500. If admitted, the Medical Management Program must be called within 24 hours or as soon as is reasonably possible. b The Medical Management Program must pre-approve inpatient hospital services when you go to an out-of-network provider. It is your responsibility to obtain pre-certification from Aetna for any hospital services. If you do not obtain pre -certification, the $2,500 penalty will apply. To obtain pre-certification, call Aetna on the telephone number listed on your ID card. ST/IC/2021/10 37/62 21-06920 Benefits Aetna Vision Discount discounted fee Frames Priced up to $60.99 retail 35 per cent off retail Priced from $61.00 to $80.99 retail 35 per cent off retail Priced from $81.00 to $100.99 retail 35 per cent off retail Priced from $101.00 and up 35 per cent off retail Lenses: per pair (uncoated plastic) Single vision $40 Bifocal $60 Trifocal $80 Standard progressive (no-line bifocal) $125 Lens options: per pair (add to lens prices above) Polycarbonate $40 Scratch-resistant coating $15 Ultraviolet coating $15 Solid or gradient tint $15 Glass 20 per cent off retail Photochromic 20 per cent off retail Anti-reflective coating $45 ST/IC/2021/10 21-06920 38/62 Annex V HIP Health Plan of New York Plan outline The HIP plan is a health maintenance organization (HMO) and follows the concept of total prepaid group practice hospital and medical care. This means that there is no out-of-pocket cost to the staff member for covered services at numerous participating medical groups in the greater New York area. In addition, prescription drugs (a $5 co-payment applies) and medical appliances (in full) are covered when obtained through HIP participating pharmacies and are prescribed by HIP physicians or any physician in a covered emergency. The present annex provides a high-level summary chart of the plan. For detailed information, staff members must review the HIP Health Plan of New York plan description document available at www.un.org/insurance. As from 1 July 2013, the HIP plan is closed to new subscribers (i.e. staff members or retirees). Subscribers who are currently covered may remain in the plan, and any changes related to eligible household members will be accepted. However, a current subscriber who transfers to another United States of America plan during the 2021 annual enrolment campaign will not be allowed to return to the HIP plan in future annual enrolment campaigns. HIP Health Plan of New York summary of benefits Benefits Coverage Hospital services and related care Inpatient – Unlimited days: semi-private room and board – Hospital-provided services – Routine nursing care 100 per cent Outpatient – Surgery and ambulatory surgery – Pre-surgical testing (performed within seven days of scheduled surgery) – Chemotherapy and radiation therapy – Mammography screening and cervical cancer screening 100 per cent Emergency room/facility (initial visit) – Accidental injury – Sudden and serious medical condition 100 per cent Ambulance 100 per cent Home health care – Up to 200 visits per calendar year 100 per cent – Home infusion therapy 100 per cent ST/IC/2021/10 39/62 21-06920 Benefits Coverage Outpatient kidney dialysis Home, hospital-based or free-standing facility treatment 100 per cent after $10 co-pay Skilled nursing facility Unlimited days per calendar year 100 per cent Hospice Up to 210 days per lifetime 100 per cent Physician services Office or home visits/office consultations 100 per cent Surgery 100 per cent Surgical assistant 100 per cent Anaesthesia 100 per cent Inpatient visits/consultations 100 per cent Maternity care 100 per cent Artificial insemination/unlimited procedures based on New York State mandate 100 per cent Diagnostic X-rays, MRI, CAT scans 100 per cent Laboratory tests 100 per cent Inpatient hospital private duty nursing 100 per cent Cardiac rehabilitation 100 per cent Second surgical opinion 100 per cent Second medical opinion for cancer diagnosis 100 per cent Allergy testing and allergy treatment 100 per cent Prosthetic, orthotic and durable medical equipment 100 per cent Medical supplies 100 per cent Preventive care Annual physical exam 100 per cent Diagnostic screening test 100 per cent Prostate-specific antigen (PSA) test 100 per cent Well-woman care (no referral needed) 100 per cent Mammography screening/Pap smears 100 per cent ST/IC/2021/10 21-06920 40/62 Benefits Coverage Well-child care (including recommended immunizations) 100 per cent – Newborn baby One in-hospital exam at birth – Birth to 1 year of age Six visits – 1–2 years of age Three visits – 3–6 years of age Four visits – 7 years of age up to 19th birthday Six visits Physical therapy and other skilled therapies Physical therapy Up to 90 inpatient days per calendar year 100 per cent Physical therapy (benefit combined with occupational, respiratory and speech) – 90 inpatient visits 100 per cent – 90 outpatient visits 100 per cent Occupational, respiratory, speech (benefit combined with physical therapy) – 90 inpatient visits 100 per cent – 90 outpatient visits 100 per cent Behavioural health and substance abuse services Mental health care 100 per cent Outpatient alcohol and substance abuse 100 per cent Inpatient alcohol and substance abuse/rehab 100 per cent Prescription drug benefits Pharmacy 100 per cent after $5 co-pay for generic/brand, 30-day supply Mail order programme 100 per cent after $2.50 co-pay for generic/brand, 30-day supply Vision care programme Through a designated group of providers 100 per cent for one exam every 12 months 100 per cent after $35 co-pay for standard corrective lenses and $80 allowance for one pair standard frames from a select group every 24 months Other health care Acupuncture/yoga/massage Discounted rates Chiropractic care (no referral needed) 100 per cent ST/IC/2021/10 41/62 21-06920 Annex VI Cigna US Dental PPO Plan outline The dental PPO programme offers a large network of participating providers in the greater New York metropolitan area and nationally. A dental PPO functions like a medical PPO: the network of dentists who participate in the Cigna US Dental PPO plan accept as payment a fee schedule negotiated with Cigna. When covered services are rendered by an in-network provider, Cigna reimburses the dentist according to the schedule and the participant normally has no out-of-pocket expenses. The present annex provides a high-level summary chart of the plan. For detailed information, subscribers must review the Cigna US Dental PPO plan description document available at www.un.org/insurance. Cigna US Dental PPO summary of benefits Benefits In-network Out-of-network Plan year maximum – 1 July 2020–30 June 2021 (Class I, II and III expenses) Year 1: $2,250 Year 1: $2,250 Year 2: $2,350 Year 2: $2,350 Year 3: $2,450 Year 3: $2,450 Year 4: $2,550 Year 4: $2,550 Maximum amounts in years 2–4 are dependent on Class I services being rendered Plan year deductible – 1 July 2020–30 June 2021 $0 $50 per person $150 per family Reimbursement levels Based on reduced contracted fees Based on reasonable and customary allowances Plan pays You pay Plan pays You pay Class I – Preventive and diagnostic care 100 per cent No charge 90 per cent 10 per cent Oral exams/routine cleanings Full mouth X-rays Bitewing X-rays Panoramic X-rays Periapical X-rays Fluoride application Sealants space maintainers Emergency care to relieve pain Histopathologic exams ST/IC/2021/10 21-06920 42/62 Plan pays You pay Plan pays You pay Class II – Basic restorative care 100 per cent 0 per cent 80 per cent 20 per cent Fillings/root canal therapy/endodontics Osseous surgery Periodontal scaling and root planning Denture adjustments and repairs Oral surgery – simple extractions Oral surgery – all except simple extractions Anaesthetics: surgical extractions of impacted teeth Repairs to bridges, crowns and inlays Class III – Major restorative care 100 per cent 0 per cent 80 per cent 20 per cent Crowns Surgical implants Dentures Bridges inlays/onlays Prosthesis over implant Class IV – Orthodontia lifetime maximum 100 per cent $2,250 dependent children up to age 19 0 per cent 70 per cent $2,250 dependent children up to age 19 30 per cent Note: This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in the insurance certifica te or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. Cigna Dental refers to the following operating subsidiaries of Cigna Corporation: Connecticut General Life Insurance Company, and Cigna Dental Health, Inc., and its operating subsidiaries and affiliates. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc., Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc. and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by Connecticut General Life Insurance Company or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. The Cigna Dental PPO is underwritten and/or administered by Connecticut General Life Insurance Company, with network management services provided by Cigna Dental Health, Inc. For Arizona/Louisiana residents the dental PPO plan is known as CG Dental PPO. In Texas, Cigna Dental’s network-based indemnity plan is known as Cigna Dental Choice. The Cigna Dental Traditional plan is underwritten or administered by Connecticut General Life Insurance Company. In Arizona and Louisiana, the Cigna Dental Traditional plan is referred to as CG Traditional. ST/IC/2021/10 43/62 21-06920 Annex VII UnitedHealthcare Global Assistance and Risk UnitedHealthcare Global Assistance and Risk is a service available to Aetna and Empire Blue Cross subscribers. The 2021 monthly cost per subscriber is $0.24 and is built into the premium schedule for Aetna and Empire Blue Cross as set out in annex I of the present information circular. UnitedHealthcare Global Assistance and Risk is a programme providing emergency medical assistance management, including coordinating emergency evacuation and repatriation, and other travel assistance services when the staff member is 100 or more miles from home. Below is a summary of the management coordination services provided. Medical assistance services Worldwide referrals: Worldwide medical and dental referrals are provided to help the participant to locate appropriate treatment or care. Monitoring of treatment: UnitedHealthcare Global Assistance and Risk coordinators will continually monitor the participant’s case and UnitedHealthcare Global Assistance and Risk physician advisers will provide the participant with consultative and advisory services, including the review and analysis of the quality of medical care being received. Facilitation of hospital payment: Upon securing payment or a guarantee to reimburse, UnitedHealthcare Global Assistance and Risk will either wire funds or guarantee the required emergency hospital admittance deposits. Transfer of insurance information to medical providers : UnitedHealthcare Global Assistance and Risk will assist the participant with hospital admission, such as relaying insurance benefit information, to help to prevent delays or denials of medical care. UnitedHealthcare Global Assistance and Risk will also assist with discharge planning. Medication and vaccine transfers: In the event medication or vaccine products are not available locally, or a prescription medication is lost or stolen, UnitedHealthcare Global Assistance and Risk will coordinate their transfer to the participant upon the prescribing physician’s authorization, if it is legally permissible. Replacement of corrective lenses and medical devices: UnitedHealthcare Global Assistance and Risk will coordinate the replacement of corrective lenses or medical devices if they are lost, stolen or broken during travel. Dispatch of doctors/specialists: In an emergency where the participant cannot adequately be assessed by telephone for possible evacuation, or cannot be moved, and local treatment is unavailable, UnitedHealthcare Global Assistance and Risk will send an appropriate medical practitioner to the participant. Medical records transfer: Upon the participant’s consent, UnitedHealthcare Global Assistance and Risk will assist with the transfer of medical information and records to the participant or to the treating physician. Continuous updates to family, employer and physician: With the participant’s approval, UnitedHealthcare Global Assistance and Risk will provide case updates to appropriate individuals designated in order to keep family, employer and physicians informed. ST/IC/2021/10 21-06920 44/62 Hotel arrangements for convalescence: UnitedHealthcare Global Assistance and Risk will assist with the arrangement of hotel stays and room requirements before and after hospitalization. The following services do not fall within the purview of health insurance but are, nevertheless, included in the monthly UnitedHealthcare Global Assistance and Risk fee paid by participants in the Aetna and Empire Blue Cross plans. Travel assistance services Emergency travel arrangements: UnitedHealthcare Global Assistance and Risk will make new reservations for airlines, hotels and other travel services in the event of an illness or injury. Transfer of funds: UnitedHealthcare Global Assistance and Risk will provide an emergency cash advance subject to UnitedHealthcare Global Assistance and Risk first securing funds from the participant or participants. Replacement of lost or stolen travel documents: UnitedHealthcare Global Assistance and Risk will assist in taking the necessary steps to replace passports, tickets and other important travel documents. Legal referrals: Should legal assistance be required, UnitedHealthcare Global Assistance and Risk will direct the participant to an attorney who will assist in securing a bail bond. Interpretation services: UnitedHealthcare Global Assistance and Risk’s multilingual assistance coordinators are available to provide immediate verbal interpretation assistance in a variety of languages in an emergency; otherwise, UnitedHealthcare Global Assistance and Risk will provide referrals to local interpreter services. Message transmittals: The participant may send and receive emergency messages toll-free, 24 hours a day, through the UnitedHealthcare Global Assistance and Risk emergency response centre. Online services Global Intelligence Centre: Participants have access to the UnitedHealthcare Global Assistance and Risk member centre, which includes detailed information on the UnitedHealthcare Global Assistance and Risk programme, as well as medical and security information for more than 230 countries and territories around the world. To activate the member centre account: 1. Visit https://members.uhcglobal.com. 2. In the login box, select “create user”. 3. Enter the UnitedHealthcare Global Assistance and Risk ID number for the United Nations (33211). 4. Accept the user agreement. 5. Enter in your personal account information to designate yourself a unique username and password. Medical Intelligence Reports: The participant will have online access to continuous updates on health information pertinent to the destination(s) of travel, such as immunizations, vaccinations, regional health concerns, entry and exit requirements and transportation information. Risk ratings are provided for each country ranking the severity of the risk concerning disease, quality of care, access to care and cultural challenges. ST/IC/2021/10 45/62 21-06920 World Watch global security intelligence: The participant will have online access to the latest authoritative information and security guidance for over 170 countries and 280 cities. Information includes the latest news, alerts, risk ratings and a broad array of destination information, including crime, terrorism, local hospitals, emergency phone numbers, culture, weather, transportation information, entry and exit requirements and currency. The UnitedHealthcare Global Assistance and Risk global security and medical databases are continuously updated and include intelligence from thousands of worldwide sources. This information is also available upon request by calling the UnitedHealthcare Global Assistance and Risk emergency response centre. Custom travel reports: Using the Medical Intelligence Reports and World Watch online intelligence tools, the participant is able to create customized, printable health and security profiles by destination. Hotspots travel alerts: Subscribe through the member centre to receive a free weekday email snapshot of security events from around the world. This bulletin provides a quick review of events, listed by region and destination, that could have a significant impact on travellers. Each event summary includes country threat levels and significant dates. Conditions and limitations The services described above are available to the participant only during the participant’s enrolment period and only when the participant is 100 or more miles away from his or her residence. How to use UnitedHealthcare Global Assistance and Risk access services 24 hours a day, seven days a week, 365 days a year If participants have a medical problem, they should call the toll -free number of the country in which they are located (see list below), or call the 24-hour UnitedHealthcare Global Assistance and Risk emergency response centre in Baltimore, Maryland: Phone: 1 410 453 6330 Website: www.uhcglobal.com Email: Assistance@uhcglobal.com A multilingual assistance coordinator will ask for your name, your company or group name, the United Nations UnitedHealthcare Global Assistance and Risk ID number (33211) and a description of your situation. If the condition is an emergency, go immediately to the nearest physician or hospital without delay and then contact the UnitedHealthcare Global Assistance and Risk emergency response centre. It will then take the appropriate action to provide assistance and monitor care. In Italy, operator-assisted calls can be made by dialling 170. This will give you access to the international operator. If calling from Mexico on a payphone, the payphone must be a La Date payphone. When calling the phone numbers in China, please dial as follows: Northern regions – first dial 10888, then wait a second to be connected. After being connected, dial the remaining numbers. ST/IC/2021/10 21-06920 46/62 Southern regions – first dial 10811, then wait a second to be connected. After being connected, dial the remaining numbers. When calling the phone numbers in Egypt, please dial as follows: Inside Cairo – first dial 510 0200, then wait a second to be connected. After being connected, dial the remaining numbers. Outside Cairo – first dial 02 510 0200, then wait a second to be connected. After being connected, dial the remaining numbers. International callers who are unable to place toll-free calls to UnitedHealthcare Global Assistance and Risk Many telephone service providers, such as cell phones, payphones and other commercial phone venues, charge for, or outright bar, toll-free calls on their networks. In such cases, callers should call the UnitedHealthcare Global Emergency Response Center directly. Charges may be incurred on the initial call . However, if the member provides a contact number, the Emergency Response Center will call back immediately to mitigate additional charges. ST/IC/2021/10 47/62 21-06920 Annex VIII ActiveHealth wellness programme The ActiveHealth wellness programme provides confidential health and wellness support to Aetna and Empire Blue Cross health insurance plan participants. Participants can access a variety of tools and resources to help them achieve their health goals. ActiveHealth may contact you about participating in the wellness programme. You can also self-refer. You can enrol by visiting www.myactivehealth.com/unitednations or by calling 800 778 8351. Programme features Personal health website The well-being engagement platform, available at www.myactivehealth.com/ unitednations, can help participants to eat better, be more active and better manage a health condition. It allows users to track health, look up symptoms and find healthy recipes. The following tools and resources are available on the platform: • Health assessment: helps you build a picture of your overall health • Your personal health record: shows your health data, claims, tests and more • Digital coaching support: lets you work on your health goals 24 hours a day, seven days a week • Challenges: inspires you to achieve your health goals with fun adventure themes • Resources: helps you find a wide range of information • Social communities: lets you contact others facing similar health issues • Trackers: connects with your favourite health applications and devices and then synchronizes your data You can download the ActiveHealth mobile application by searching for “ActiveHealth”. Whether you use the mobile application or log in using a desktop computer, ActiveHealth synchronizes your data. Personalized “Health Actions” ActiveHealth’s patented CareEngine technology takes in a large pool of participant data, ranging from claims and lab data to self-reported information, from the health assessment. It compares the data to thousands of clinical rules based on the latest medical information and treatment guidelines to find opportunities to improve health. These alerts, “Health Actions”, are all peer-reviewed by top clinical faculty at Harvard Medical School. You can find a prioritized list of your Health Actions on the home page of the well-being engagement platform. They can range from simple reminders for preventive care to notifications about serious issues, such as possible drug interactions. ActiveHealth will also send you Health Actions related to clinically urgent gaps in care, such as missing lab tests, or drug interactions in the mail. They will also mail or fax them to treating health care providers. ActiveHealth’s goal is to provide health-care providers and patients with information about possible ways to improve health. Final health-care and treatment decisions remain between you and your health-care provider. ST/IC/2021/10 21-06920 48/62 Coaching support for chronic condition management Support is available for learning how to manage a new diagnosis or managing a chronic condition. The following are available: • Digital coaching: work on your health goals whenever and wherever you want. Fun daily activities keep you moving forward • Group coaching: experienced coaches lead live, online group coaching sessions. These interactive sessions let you work on your health with others working towards similar goals • One-on-one coaching: connect over the phone with a trusted coach who can help you manage your condition. You can learn more about your condition and how to make the most of your time with your health-care provider. You can expect to have an enthusiastic coach motivating you to take control of your health The programme offers support for 19 primary conditions: • Asthma1 • Chronic back and neck pain • Chronic hepatitis (B and C) • Chronic kidney disease • Chronic obstructive pulmonary disease (COPD) • Coronary artery disease • Depression2 • Diabetes1 • End-stage renal disease • Heart failure • High blood pressure1 • High cholesterol • Migraines • Osteoarthritis • Rheumatoid arthritis • Seizures • Systemic lupus erythematosus • Ulcerative colitis/irritable bowel disease/Crohn’s • Weight management1 Once you enrol in the programme, you can work with your coach on lifestyle habits that can affect your condition, such as managing your stress and being m ore active. 24-hour nurse line Registered nurses are available by telephone 24 hours a day, seven days a week, at 800 556 1555. Nurses can offer support on thousands of topics, such as common conditions, gender- and age-specific issues, dental care, mental health, weight loss and much more. They can refer you to support from the condition management programme and to other support available through United Nations programmes. __________________ 1 Adult and paediatric programmes. 2 Addressed as a co-morbid condition. ST/IC/2021/10 49/62 21-06920 Annex IX UN Worldwide Plan Plan benefits summary The UN Worldwide Plan, administered by Cigna International Health Services, indemnifies participants, within the limits of the plan, for reasonable and customary charges in respect of medical, hospital and dental treatment for illness, an accident or maternity. Additionally, the plan provides cover for some aspects of preventive care. The aggregate reimbursement in respect of the total expenses covered by the plan that are incurred by an insured participant shall not exceed $250,000 in any calendar year. The provisions set forth below are subject to this limitation. In addition to the maximum reimbursement per calendar year, certain maximums per treatment, procedure, supplies or other services may also apply, depending on the type of service. The present annex provides a high-level summary chart of the plan. For detailed information staff members must review the UN Worldwide Plan description of benefits available at www.un.org/insurance or access the UN Worldwide Plan’s website (www.cignahealthbenefits.com). General cover – outpatient expenses Basic Medical Insurance Plan (BMIP) BMIP+Major Medical Benefits Plan (MMBP) Outpatient costs for the services listed below 80 per cent (see below for restrictions for services received in the United States) 96 per cent (after yearly out of pocket of $200 per person per calendar year or $600 per family per calendar year has been filled, only for services received outside the United States) Doctors’ fees (GP and specialists) 80 per cent MMBP applicable Paramedical fees 80 per cent – paramedical benefits are capped at 60 sessions annually Pharmacy Laboratory and medical imaging Mental health Prior approval for mental health care is required after 30 sessions Outpatient costs in the United States (please see below for chemotherapy, haemodialysis and radiological treatments) 80 per cent (yearly deductible of $5,000 per person per calendar year or $15,000 per family per calendar year) No MMBP Note: Some treatments are subject to prior approval. Please refer to the description of benefits at www.cignahealthbenefits.com for more information. ST/IC/2021/10 21-06920 50/62 Specific treatments Benefits Remarks Chemotherapy 100 per cent Doctors’ fees at 80 per cent plus MMBP Radiotherapy 100 per cent Doctors’ fees at 80 per cent plus MMBP Haemodialysis 100 per cent Doctors’ fees at 80 per cent plus MMBP Fertility treatments 100 per cent Doctors’ fees at 80 per cent plus MMBP General cover – hospitalizations (subject to prior approval) Benefits Remarks Bed and board 100 per cent up to a maximum per day The maximum per day varies depending on the region Cover restricted to 100 per cent of a semi-private room (two patients) or ward (more than two patients) for specific areas See details in the plan description on our website Other hospital expenses 100 per cent Doctors’ fees 80 per cent plus MMBP Personal expenses Not covered Covered expenses incurred in the United States of America Benefits Remarks Increased deductible $5,000 per person per calendar year or $15,000 per family per calendar year No MMBP Strict enforcement of prior approval for: 80 per cent (yearly deductible of $5,000 per person per calendar year or $15,000 per family per calendar year) No MMBP – Planned hospitalization – Selected outpatient treatments (chemo and radiotherapy, haemodialysis) For more information, please check the website. ST/IC/2021/10 51/62 21-06920 General cover – benefits with ceilings Benefits Ceiling Dental 80 per cent – $1,000 per person per calendar year – Carry over from previous year’s balance Optical 80 per cent $250 per period of 24 months (counted as of date of purchase). Participation of 12 months in the scheme is required for reimbursement Medical check-up/ preventive care 100 per cent $1,050 per person per calendar year Home hospitalization 100 per cent $5,000 per illness Exclusions • Insured participants who are mobilized or who volunteer for medical service in time of war • Injuries resulting from motor-vehicle racing or dangerous competitions in respect of which betting is allowed (normal sports competitions are covered) • The consequences of insurrections or riots if, by taking part, the plan participant has broken the applicable laws; and the consequences of brawls, except in cases of self-defence • Non-medical expenses, including spa cures, rejuvenation cures or cosmetic treatment (reconstructive surgery is covered where it is necessary as the result of an accident or illness for which coverage is provided) • The direct or indirect results of explosions, heat release or irradiation produced by transmutation of the atomic nucleus or by radioactivity or resulting from radiation produced by the artificial acceleration of nuclear particles • Costs exceeding the reasonable and customary limit for the area in which they are incurred • Preventive care, other than medical check-up and certain vaccinations • Costs of travel or transportation (except for professional ambulance service to the first hospital where adequate care can be given in case of emergency) • Medical care that is not medically necessary • Medical care that is not medically recognized as a treatment for the diagnosis provided • Long-term care • Products whose effectiveness has not been sufficiently proved scientifically and which are not generally medically recognized in the medical world (e.g. products containing glucosamine or chondroitin sulphate) • Elective surgery not resulting from illness, an accident or maternity ST/IC/2021/10 21-06920 52/62 Cigna health and well-being services With more than 20 years of experience in health and well-being, Cigna offers engaging, flexible and global customized health and well-being solutions that can improve personal performance and support global organizations such as the United Nations. The programmes are built and focused on the theme “Three pillars of health”: access to care, managing care and positive lifestyle and behaviour changes. Cigna Wellbeing application The Cigna Wellbeing application connects participants to a new dimension of health. Preventing illness through health and well-being-related services is part of the Cigna-United Nations strategy supporting UN Worldwide Plan participants. The Cigna Wellbeing application provides all eligible plan participants with access to clinical and well-being-related services and tools through access to telephone and video consultations with a doctor using Cigna Global Telehealth, and an online assessment, followed by lifestyle coaching on the basis of a personality questionnaire and a focus on health improvement. All eligible plan participants over the age of 18 have access to these services through a secured and personalized account. The Cigna Wellbeing application can be downloaded for free from the App Store (iOS) and Google Play (Android). Global Telehealth Cigna’s Global Telehealth service connects patients to licensed doctors around the world – by telephone or video – for non-emergency health issues. The service can be accessed 24 hours a day, seven days a week, and appointments with general practitioners set within 48 hours. Within five days of the initial consultation, the general practitioner can schedule a follow-up consultation with a specialist, when and where appropriate. The Global Telehealth doctor is assigned on the basis of the date, time and language preference in your time zone. Currently, video consultations are available in English and Spanish, while telephonic consultations are available in English, Spanish, French, German, Portuguese, Mandarin Chinese, Japanese, Hindi and Arabic. To ensure the shortest waiting period for appointments, a plan participant may be paired with a different doctor for each consultation. However, all doctors will be able to review notes from previous Global Telehealth consultations, allowing for a shared and comprehensive patient file, which provides consistency and ensures that all users receive optimal care. How can Global Telehealth help you? Global Telehealth doctors will listen to your specific concerns and provide clear advice and guidance on the best steps to take. You will be able to share documents, images and files to help explain your symptoms and condition. The doctors can also help you to understand the local health-care system. They’ll tell you how to organize any potential upcoming doctor appointments. ST/IC/2021/10 53/62 21-06920 What services are provided through Global Telehealth? Global Telehealth provides access to clinical guidance from doctors by phone or video. You may: • Access a trusted doctor, including specialists, for a medical consultation, even when based in a remote location • Discuss pressing medical symptoms, such as a fever, a rash and aches and pains • Receive a working diagnosis when enough medical information is available • Discuss a medical report, test results or treatment plans • Prepare for upcoming consultations, treatment and hospitalizations • Get support for navigating the local health-care system • Obtain referrals to in-network Cigna health-care providers What if there is an emergency? Cigna’s Global Telehealth is not for medical emergencies. In those cases, patients are advised to reach out to their local emergency service. Clinical services Cigna wants to offer you the necessary coaching and support at critical times of acute medical need, so all UN Worldwide Plan participants are offered access to the following Cigna clinical services: Clinical case management Cigna’s trained nurses will get in touch with patients for regular follow-up to treatment and in order to ensure their well-being or that of their family members. Decision support The Cigna Decision Support programme helps plan participants to make informed decisions about the correct diagnosis and treatment options available to them. Plan participants receive independent medical advice on the basis of the expert opinions of prominent physicians worldwide. The programme is used in the diagnosis of health concerns that include breast cancer, prostate cancer, back surgery, brain tumours, colon cancer, hip replacement surgery and knee surgery. Chronic condition management For patients diagnosed with diabetes or cardiovascular conditions, Cigna has a voluntary Chronic Condition Management programme in place, through which clinical case managers (nurses) guide patients in order to ensure that they receive appropriate care. ST/IC/2021/10 21-06920 54/62 Annex X Provider contact directory Websites Online provider directories Instructions 1. Aetna (domestic) Aetna International (active staff at duty stations and retirees residing outside the United States) www.aetna.com/docfind/index.html www.aetnainternational.com/members/login.do (a) Log in using your member ID and password (b) Click on “find healthcare” link on the left of your screen (c) Click on the destination of your choice (d) Begin search 2. Empire Blue Cross www.empireblue.com/health-insurance/provider- directory/searchcriteria Global Core Services http://bcbsglobalcore.com (a) Accept terms and conditions of site use agreement (b) Type in YLD in the cell below the agreement (c) Click “Login” 3. HIP (Emblem) Health Plan of New York www.emblemhealth.com/find-a-doctor 4. Cigna Dental www.cigna.com/web/public/hcpdirectory 5. UN Worldwide Plan www.cignahealthbenefits.com (a) Log in using your personal reference number and password (b) Click on “provider search” Note: Staff members are strongly encouraged to establish usernames and passwords to access the member websites of the third- party administrators to obtain information on the status of claims, view benefits, request identification cards and print temporary identification cards, among others. Addresses and telephone numbers of United States-based third-party administrators for claims and benefit enquiries I. Aetna PPO/POS II Aetna Inc. P.O. Box 981106 El Paso, TX 79998-1106 Tel.: 800 784 3991 Member services (benefit/claim questions) Tel.: 800 333 4432 Pre-registration/pre-certification of hospital/institutional services Tel.: 800 872 3862 Tel.: 800 272 3631 Aetna PPO/POS II members on travel Aetna Maternity Management Tel.: 800 784 3991 Participating pharmacy referral ST/IC/2021/10 55/62 21-06920 Tel.: 888 792 3862 Aetna Rx Home Delivery (mail order drugs) P.O. Box 417019, Kansas City, MO 64179-9892 Tel.: 888 792 3862 Maintenance drug automated refills (credit card) Tel.: 800 424 1601 Aetna Behavioral Health Tel.: 800 793 8616 Vision One Tel.: 800 422 6600 Discount information on Lasik surgery II. Aetna International PPO Aetna International/Aetna P.O. Box 981543 El Paso, TX 79998-1543, United States Tel.: 1 800 231 7729 or 1 813 775 0190 (call collect from outside the United States) Member services (benefit/claim questions) Tel.: 1 800 231 7729 or 1 813 775 0190 (call collect from outside the United States) Pre-registration of hospital/institutional services Tel.: 1 800 231 7729 or 1 813 775 0190 (call collect from outside the United States) Participating pharmacy referral Other numbers Same as for Aetna PPO/POS II above III. Empire Blue Cross PPO Empire Blue Cross Blue Shield PPO Member Services P.O. Box 1407 Church Street Station New York, NY 10008-1407 Tel.: 855 519 9537 Member services (benefit/claim questions) Tel.: 855 519 9537 Medical Management Program (pre-certification for hospital admissions, elective surgery, home care, skilled nursing facilities, second opinion referrals) Tel.: 855 519 9537 Empire Behavioral Health Services (prior approval of mental health/substance abuse care) Tel.: 833-252- 0325 Empire Pharmacy Management Program/Ingenio Rx (prescription card programme and pharmacy network and maintenance drug mail order drug information) IV. Empire Blue Cross (international benefits and claims) Global Core Service Center, P.O. Box 2048 – Southeastern, PA 19399 or claims@bcbsglobalcore.com Tel.: 1 855 327 1444 1 312 935 1721 (call collect from outside the United States) Global Core Services (international benefits and claims services) ST/IC/2021/10 21-06920 56/62 Tel.: 1 866 723 0515 Blue View Vision Attn: Out Of Network (OON) Claims P.O. Box 8504 Mason, OH 45040 V. HIP HIP Member Services Department 7 West 34th Street New York, NY 10001 Tel.: 800 HIP TALK (800 447 8255) HIP Member Services Dept. (walk-in service available) 6 West 35th Street New York, NY 10001 Tel.: 888 447 4833 Hearing-/speech-impaired Tel.: 877 774 7693 Chiropractor hotline Tel.: 888 447 2526 Mental health hotline Tel.: 800 290 0523 Dental hotline Tel.: 800 743 1170 Lasik surgery (Davis Vision) hotline VI. Cigna US Dental PPO plan Cigna Dental P.O. Box 188037 Chattanooga, TN 37422-8037 Tel.: 800 747 UNUN or 800 747 8686 Claim submission, identification card requests and customer service Tel.: 888 DENTAL8 or 888 336 8258 For participating provider referrals VII. UnitedHealthcare Global Assistance and Risk UnitedHealthcare Global Assistance and Risk Assistance 10175 Little Patuxent Parkway, 5th Floor Columbia, MD 21044 Tel.: 800 527 0218 Within the United States Tel.: 410 453 6330 UnitedHealthcare Global Assistance and Risk emergency response centre, Baltimore, MD VIII. ActiveHealth ActiveHealth Management 1333 Broadway New York, NY 10018 Tel.: 212 651 8200 Corporate headquarters Tel.: 800 778 8351 ActiveHealth nurse care manager programme Tel.: 800 556 1555 24-hour nurse line www.myactivehealth.com/ unitednations MyActiveHealth website IX. UN Worldwide Plan You can reach customer service for Cigna 24 hours a day, seven days a week, 365 days a year. In case of emergency or if you simply have a question, you can contact Cigna’s multilingual staff in several ways. The contact details are also mentioned on your personal web pages and on your membership card. ST/IC/2021/10 57/62 21-06920 Antwerp office Kuala Lumpur office Florida office www.cignahealthbenefits.com For claims: un.wwp@cigna.com For membership: clientservice1@cigna.com For guarantees of payment: admissions@cigna.com Please mention your Cigna reference number in the email subject 32 3 217 68 42 60 3 2178 05 55 1 305 908 9101 Cigna P.O. Box 69 2140 Antwerpen Belgium Cigna P.O. Box 10612 50718 Kuala Lumpur Malaysia P.O. Box 451989 33345 Sunrise, Florida United States of America Free communication channels As a UN Worldwide Plan participant, you can use the “call me back” functionality on your personal web pages. You can also contact Cigna on Skype by adding “Cigna Health Benefits” to your contact list. More details can be found in the Contact section of your personal web pages. Wherever feasible, you can also call Cigna for free through a toll-free number. If there is no toll-free number available for your country of stay, you can use the United Nations-dedicated phone number, which is also mentioned on your membership card. You can find the full list of available toll-free numbers per country on your personal web page. Disclaimer: This circular provides only a summary of the benefits covered under the United Nations Headquarters insurance programme. Detailed benefit descriptions can be obtained from the website of the Health and Life Insurance Section. ST/IC/2021/10 21-06920 58/62 Annex XI Basic responsibilities of plan enrollees In an effort to assist staff members, retirees, surviving dependants, and dependants covered under insurance administered by the United Nations, the present annex provides a helpful list of basic responsibilities relating to insurance. While the list is not exhaustive, it should be useful in reminding each covered staff member, retiree, surviving dependant (spouse and/or child), and/or dependant of his or her basic responsibilities. The list is broken down into three primary categories: (a) Plan enrolment; (b) Plan knowledge; (c) Fraud prevention. Plan enrolment If a staff member, retiree or surviving dependant desires insurance coverage for his or her eligible dependants, he or she is responsible for ensuring that the required processes are followed within the allotted time frame for their specific situation. The staff member or retiree must ensure that he or she and his or her desired dependants who are eligible are enrolled in the plan if coverage is desired. In order to ensure that information is provided to the staff member, retiree or surviving dependant in a timely manner, the staff member, retiree or surviving dependant (spouse and/or children) must ensure that his or her contact details (e.g. mailing and email addresses) are always up to date in the relevant United Nations systems (Umoja, etc.). Active staff members may confirm their enrolment by reviewing their monthly payslips or by accessing the relevant systems of their organizations to confirm coverage for themselves and their dependants. It is the decision of the staff member, retiree or surviving dependent spouse to enrol or not enrol his or her eligible dependants. It is imperative that staff members, retirees and surviving dependants (spouse and/or children) review the present information circular in its entirety to ensure that the ramifications of not enrolling are well understood. Plan knowledge There are several avenues for staff members, retirees and surviving dependants (spouse and/or children) to obtain additional information regarding insurance provided by the United Nations. It is the responsibility of staff members, retirees and surviving dependants to avail themselves of the information necessary to understand how the plan works and how they can seek assistance. Below are several ways in which information regarding process, procedures, coverage and reimbursement may be found: (a) Online registration on the third-party administrators’ websites; (b) Exploration of the United Nations website dedicated to insurance, www.un.org/insurance; (c) Review of the insurance plan’s applicable information circular; (d) Review of the explanation of benefits to understand what was reimbursed, why it was reimbursed and what, if any, financial responsibility the staff member, retiree or surviving dependents have. ST/IC/2021/10 59/62 21-06920 Fraud prevention It is up to each staff member, retiree, surviving dependant (spouse and/or children), and covered eligible dependant to ensure that: (a) Submitted claims are processed correctly by reviewing all explanations of benefits received; (b) Insurance cards are only utilized by the appropriate individual, which means that it is vital that insurance cards be kept secured; (c) Third-party administrators are notified immediately when fraud is suspected; (d) Patient portions for all treatments are paid when due, without exception; (e) The consequences of fraud are understood. Those who engage in fraud will be reported to the authorities within the United Nations and the country in which the fraud occurred for appropriate action, such as non-payment of suspected fraudulent claims, suspension of any subsidy, termination of coverage, criminal investigation and other administrative actions, including termination of employment, for any staff member involved. It is imperative that each staff member, retiree, surviving dependant (spouse and/or children) and covered eligible dependant is conscious of the costs of fraud, since the United Nations plans are self-funded, which means that fraud affects the Organization, staff members and retirees. The Organization and primary subscribers, not the third-party administrators, cover all associated costs of the insurance plans. ST/IC/2021/10 21-06920 60/62 Annex XII Definitions The following definitions are intended to clarify the meaning of certain terms that are used throughout the present circular: Accident: The sudden action of an external force causing impairment of physical integrity. Administering office: The office that has the responsibility for the day-to-day operation of the plan (for example, enrolment, collection of contributions from active and former staff members, premium accounting) at a given duty station. After-service participant: Retirees, participating survivors and recipients of a periodic disability benefit from the United Nations Joint Staff Pension Fund and/or appendix D to the Staff Rules (rules governing compensation in the event of death, injury or illness attributable to the performance of official duties on behalf of the United Nations). Annual enrolment campaign: Period during the year when a subscriber can enrol or terminate coverage for eligible family members after the original 31 -day period following a qualifying event; the annual enrolment campaign takes place during a set period every year with the effective date of coverage being 1 July. Co-insurance: A subscriber’s share of the cost of a covered health-care service or expense that is usually calculated as a percentage of the allowed amount for a service. For example, if the plan covers 80 per cent of the reasonable and customary cost of a service, the co-insurance is 20 per cent or the share that the subscriber is responsible for. Coordination of benefits: The settlement of reimbursable medical expenses where more than one medical insurance scheme covers a subscriber and/or his or her eligible family members (the instances when a health insurance plan of the United Nations health insurance programme is considered the secondary plan are described in paras. 24 and 44 of the main text). Dental services: Services performed by a dental practitioner or a dentist who is licensed to practise dentistry in the country in which he or she practises the profession. Diagnosis: The identification by a licensed physician of an illness or nature of a disease. Eligibility file: A file that is sent electronically to the third-party administrator that contains information on all active or retired staff members and their elig ible family members who are covered under the plan; this file is the basis on which the third - party administrator determines who is eligible for coverage under the United Nations health insurance programme. Eligible family members: A subscriber’s recognized spouse and one or more dependent children, as defined in staff rule 3.6 (a) (iii). The United Nations health insurance programme recognizes only one eligible spouse. A subscriber’s children who meet the criteria for a dependent child under staff rule 3.6 (a) (iii), but for whom the staff member does not receive a dependency allowance owing to local limits on the number of children for whom a dependency allowance is payable, may also be considered as an eligible family member for the purpose of enrolment in the plan. In the case of an after- service subscriber, eligible family members are defined as the spouse and children already enrolled at the time of separation from service and any child born within ST/IC/2021/10 61/62 21-06920 300 days of separation. A staff member’s parents, brothers and sisters, whether or not recognized as secondary dependants, are not eligible for the plan. Emergency medical care: Medical treatments that are undertaken owing to an unplanned, sudden and acute illness or injury and which, for medical reasons, ca nnot be delayed or postponed. Enrolled family member: An eligible family member who is enrolled in the United Nations health insurance programme. Explanation of benefits: A statement that is sent to a subscriber by the third-party administrator that shows medical expenses claimed, reimbursement by the plan and any balances that are the responsibility of the subscriber. It may be sent by mail or email or as a downloadable document from the third-party administrator’s website. Hospital: An institution licensed by the Government to provide medical and surgical treatment and nursing care for sick or injured persons. Such care normally involves overnight stay (or inpatient care), thus requiring such facilities to have inpatient beds and continuous physician and nursing services under the supervision of licensed professionals. These facilities may also provide same-day treatments (outpatient care). Inpatient care/treatment: Services provided to a person who has been admitted to a hospital and will stay one or more nights. Medical information: Any information acquired by medical personnel, whether orally or in writing, relating to the physical or mental condition of any ind ividual covered under a health insurance plan. For purposes of the proper review and administration of claims, such information may include, but not be limited to, diagnosis, physician’s medical reports, results of diagnostic tests, treatment plans, prescr iptions, etc. Medical management/pre-certification: Processes whereby the administrator of the medical plan is contacted before certain services, such as hospitalization and outpatient surgery, are provided. Medical necessity (or medically necessary): All health-care services (that is, procedures, treatments, supplies, devices, equipment, facilities or drugs) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, d iagnosing or treating an illness, injury or disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual’s illness, injury or disease; (c) not primarily for the convenience of the covered individual, physician or other health-care provider; and (d) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered individual’s illness, injury or disease. Out-of-pocket amount or expenses: The unreimbursed portion of recognized medical expenses (or co-insurance) that are taken into account in determining the application of the hardship provisions. Outpatient care/procedures: Services provided to a person in a clinic, emergency room, hospital, medical or surgery centre or other facilities that do not involve an overnight stay in the facility. The patient receives care and returns home without being admitted. Participating survivor: An eligible family member who survives a subscriber. Physician: A person who is licensed to practise medicine by the authorit ies responsible for the territory in which he or she is practising. ST/IC/2021/10 21-06920 62/62 POS: A point of service (POS) plan is a type of managed care health insurance plan in the United States of America. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO). It provides health-care services at a lower overall cost. The United Nations POS plan with Aetna also allows plan participants to visit any in-network physician or health-care provider without first requiring a referral from a primary care physician. PPO: A preferred provider organization (PPO) is a medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO medical and health-care providers are known as “preferred providers”. PPO plans allow participants to visit any in-network physician or health-care provider they wish without first requiring a referral from a primary care physician. Prognosis: A description of the likely course of a disease or illness provided by a physician, including the patient’s chances for recovery. Reasonable and customary: The prevailing pattern of charges for professional and other health services at the staff member’s duty station or the approved lo cation (for example, the place of approved medical evacuation or regional area of care) where the service is provided. Recognized expenses: The expenses for services claimed, provided they are found to be reasonable and customary at the duty station or, when obtained elsewhere in the country or at an approved medical evacuation location or regional area of care, at the place provided. If the expenses claimed are found to be above what is considered reasonable and customary, then the recognized amount for the purpose of calculating reimbursement is the reasonable and customary amount as reasonably determined by the third-party administrator. Subscriber: An active or after-service participant enrolled in the United Nations health insurance programme or, upon the death of the former or the latter, the surviving spouse (if any) or the eldest eligible child recognized and receiving a monthly benefit from the United Nations Joint Staff Pension Fund. Third-party administrator: An outside entity engaged by the United Nations for the processing and payment of United Nations health insurance programme claims.