overview of unhq health insurance programmes feb 2013 unhq... · un insurance pays = $65 un...
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UNHQ Programme27 February 2013
OVERVIEW OF UNHQ HEALTH INSURANCE PROGRAMMES
www.un.org/insurance
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Agenda
• High-level Overview
• Cost Containment
• Carrier Updates
• Eligibility Rules
www.un.org/insurance 2
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Health Insurance
• Self-funded (self-insured) programme– Risk responsibility
• General Assembly cost sharing mandate– US based plans: 33% (Staff) – 67% (the UN)
– Non-US based plan: 50% (Staff) – 50% (the UN)
– MIP plan: 25% (Staff) – 75% (the UN)
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– MIP plan: 25% (Staff) – 75% (the UN)
• Carriers importance– Administrative services such as claims processing
and staff member inquiries
– Provider networks and experts services
• Plan cycle– July to June cycle
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Cost Containment
www.un.org/insurance 4
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How Premiums are Determined
• CLAIMS + TREND = PROJECTED CLAIMS
• PROJECTED CLAIMS + FEES = TOTAL COST
• TOTAL COST = REQUIRED INCREASEPREMIUM
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How Premiums are Determined
Example
• Claims 1,000,000
• Trend at 10% +100,000
• Projected claims 1,100,000
• Administrative fees + 50,000• Administrative fees + 50,000
• Total Cost 1,150,000
• Current Premium 1,075,000
• Rate Increase 6.98%
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Cost Containment
• All participants share the responsibility to contain cost– Knowledgeable consumers are vital to containing
cost
– For Aetna and Empire Blue Cross participants, in-network doctor visits are less costly
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network doctor visits are less costly
• Wellness initiatives are another way to save cost– ActiveHealth participants are seeing health
improvements which lead to cost reductions
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In-network Benefits:Containing Costs in the US
• In-network visits are less costly for you and the UN – In-network providers deliver their services at
“discounted” rates
– Insurance generally picks up a larger portion of the bill
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bill
– Out-of-network provider usage exposes staff to high financial risk
– Use of in-network provider is encouraged
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Calculation of In-network (IN)vs.
Out-of-network (OON) Cost
In-network Out-of-network
Office visit charge $140 Office visit charge $140
Network discount - $60 Network discount - $0
Contracted rate = $80 Rate charged = $140
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Contracted rate = $80 Rate charged = $140
Your PCP co-pay - $15 You pay - $28
UN insurance pays = $65 UN insurance pays = $112
•For OON expenses, the staff pays 87% more and the UN reimburses 72% more. This example assumes that the charge of $140 is reasonable and customary.
•Cost incurred affect future premium. Therefore, the additional cost for OON care is passed on in the form of increased premiums.
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Carriers
www.un.org/insurance 10
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Aetna/Empire Blue Cross (PPO Plan)
• Members pay a co-pay for medical services received in-network
• Members pay an annual deductible, coinsurance, and out of pocket maximum for services received out-of-network
• Members pay a 20% co-payment or a
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• Members pay a 20% co-payment or a maximum of $20 per prescription for drugs
• Medical services covered worldwide
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Empire Blue Cross (PPO) Plan
In-network Out-of-network
Annual deductible $0 Annual deductible $200/$600
Office/Home visits $15/$20 Office/Home visits 80% after
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Office/Home visits $15/$20 Office/Home visits 80% after
Routine Physical $15 Routine Physical 80% after
Hospital: in-patient 100% Hospital: in-patient 80% after
Hospital: out-patient 100% Hospital: out-patient 80% after
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Aetna (PPO) Plan
In-network Out-of-network
Annual deductible $0 Annual deductible $175/$525
Office/Home visits $15/$20 Office/Home visits 80% after
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Office/Home visits $15/$20 Office/Home visits 80% after
Routine Physical $15 Routine Physical 80% after
Hospital: in-patient 100% Hospital: in-patient 80% after
Hospital: out-patient 100% Hospital: out-patient 80% after
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HIP (HMO Plan)
• In-network benefits and emergency only out-of-network benefits
• Members have no out-of-pocket cost for hospital and medical services received in-network
• Benefits include hospital services, physician services, behavioural health services, substance abuse services, occupational health services, prescription drug, vision
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occupational health services, prescription drug, vision and other health care benefits
• Members pay a $5 co-payment per prescription for drugs
• Fully insured program. Premiums set by HIP
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CIGNA (Dental PPO Plan)
• Members pay nothing for basic dental services provided by an in-network dentist
• Members pay an annual deductible and coinsurance of 10% to 30% for services received from an out-of-network dentist
• CIGNA covers dental services worldwide and
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• CIGNA covers dental services worldwide and benefits include diagnostic, preventive, restorative and orthodontic care
• Total reimbursements are capped but the maximum cap depends on you.– Minimum cap is $2,250 a year
– Maximum cap can increase to $2,550 a year
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Vanbreda International: Non-US Based Staff
• Comprehensive plan that covers medical and dental expenses for members outside of the US
• Members are reimbursed for medical and hospital treatment– Inpatient hospitalization: 100% subject to daily maximums
– Other expenses: Up to 96% of “Reasonable and Customary”
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– Other expenses: Up to 96% of “Reasonable and Customary” services
– Annual maximum reimbursement: $250,000
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Vanbreda Policy for Short-term Staff
• Covers emergency or immediate medical treatment for staff members only, including in the US
• Members pay a $100 annual deductible and are reimbursed 80 percent of reasonable and customary fees
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customary fees
• Yearly reimbursements are capped at $30,000
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ActiveHealth
• Confidential health management service– Medical Professionals w/ at Least a 4-yr Degree
• Disease management and wellness– Aetna
– Empire Blue Cross
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• Services– CareEngine and Care Considerations
– Nurse Care Program
– ActivePHR
– 24-hour Informed Health Line
– NuVal
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FrontierMEDEX
• Available to Aetna and Empire Blue Cross participants 100 or more miles from home
• Coordinates delivery of care, emergency evacuations, and repatriations
• FrontierMEDEX does not pay the cost of evacuation and/or repatriation
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evacuation and/or repatriation
• List of country specific telephone numbers on our website (www.un.org/insurance)
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Life Insurance
• Life insurance plan provides term insurance coverage
• No cash value
• Participation is voluntary
• No UN subsidy for coverage
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– Participating staff members finance
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Eligibility Rules
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Eligibility: Medical and Dental Plans
Eligible to join when the following events occur:
• Initial appointment of three months or longer • Upon transfer from/to Headquarters from
another duty station• Vanbreda Short-term insurance plan: staff
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• Vanbreda Short-term insurance plan: staff members are eligible to join the plan if they receive the following:– Temporary appointment of less than three months
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Health Insurance Enrolment Rules and Procedures
Enrolment must be done:
• Within 31 days of employment (reappointment) or
• During annual campaign
Changes due to an event below must be done:
• Within 31 days of the event:•Marriage/Divorce •Birth/legal adoption of a
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•Marriage/Divorce •Birth/legal adoption of a child
•Reassignment/change of duty station to/from HQ
•Upon return from Special Leave without Pay (SLWOP)
•Upon assignment to a mission in the field
•Upon an inter-agency transfer
•Upon evidence of absence for enrolment
•Change in dependent status
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Documents/Information Required for Enrolment
• Approved Personnel Action (PA)
• Dependents reflected in IMIS/SAP/ATLAS as household members
• Certified disabled status for all disabled dependents over 25
• Valid address in “mailing address” field in
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• Valid address in “mailing address” field in IMIS/SAP/ATLAS
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Eligibility: Life Insurance Plan
Eligible to join when the following events occur:
• Contract for six months or longer – Must have received medical clearance upon
appointment
• Automatic enrolment if application is submitted within 60 days of appointment
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within 60 days of appointment• Evidence of Insurability (EOI) required if staff
apply 60 days after appointment
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Cessation of Coverage
• Coverage automatically terminates when a separation PA is approved. – Changes in contract type often trigger a separation
PA • A move from Temporary contract to Fixed-term contract
• For events that provide staff members a chance to change coverage (i.e. divorce)
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chance to change coverage (i.e. divorce)– The coverage is terminated upon the receipt of a
written request from staff member. – The change becomes effective 1st of the month
following receipt of the request to terminate.
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Special Leave Without Pay (SLWOP)
Staff members: • Can continue coverage• Should provide evidence of the approval • Must submit advance payment covering the
full premium• Must submit a new application within 31 days
of return
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of return• Who drop coverage while on SLWOP may
reapply for coverage– For Life insurance must provide an EOI
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ASHI Eligibility
Eligible to join ASHI medical when the following events occur:
• At least 55 years old at time of retirement
• Participation in a UN sponsored health plan– For at least 5 yrs for unsubsidized coverage and 10 years for
subsidized coverage if hired prior to 1 July 2007
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subsidized coverage if hired prior to 1 July 2007
– For 10 years if hired after 1 July 2007
• Election to receive or be receiving a pension benefit from UNJSPF
• Granted a disability benefit by UNJSPF or under appendix D
• ST/AI/2007/3, dated 1 July 2007 provides ASHI details
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Relevant documents
• ST/AI/343 – Medical Insurance Plan (MIP) for locally recruited staff at designated duty stations away from Headquarters
• ST/AI/2007/3 – After-service health insurance coverage
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coverage• ST/IC/2012/16 - UNHQ administered plans• ST/IC/2005/55 – Aetna Global for services rendered
outside the United States
• ST/AI/2002/6 – Life insurance• ST/IC/2002/63 – UN group life insurance plan
www.un.org/insurance
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Questions
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Contact Health and Life Insurance SectionEmail: [email protected]
Website: www.un.org/insurance