Note on Health Insurance Schemes in the United Nations System

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1 JIU/NTE/77/2 Nte n ealth Insurance Schemes in the Unite Natins System reare by C. S. Jha an E. D. Shm Jint Insectin Unit Jint Insectin Unit Geneva June 977

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3 :u/nte/77/2 NTE N EALT INSURANCE SCEMES IN TE UNITED NATINS SYSTEM reare by.s. Jha an E.D. Shm Jint Insectin Unit Geneva GE

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5 FREWRD The rert n health insurance in the Unite Natins system invlve the cllectin f extensive ata frm varius rganizatins relating t the terms an cnitins f health insurance in its varius asects. Ts rve a timecnsuming exercise, ue t the absence f relevant ata n several ints frm sme rganizatins, wch increase the ifficulties f ealing with the subject. The ata reviewe ha t be checke by visits t the larger rganizatins in the curse f wch rtunity was taken t iscuss the issues with the rganizatins' fficials in charge f aministering health insurance schemes an with reresentatives f the staff assciatins. In view f the technical nature f the rert, it has been ecie t issue it as a 'nte. Given the imrtance f the subject, the Jint Insectin Unit hes that the nte will be cnsiere by the Aministrative Cmmittee fr Crinatin an that the results f their examinatin will be cmmunicate t the Internatinal Civil Service Cmmissin an als t the Jint Insectin Unit.

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7 Table f Cntents GLSSARY INTRDUCTIN I. KEY ISSUES F EALT INSURANCE RGRAMMES A. Tyes f Schemes B. Basic an Sulementary Schemes G. Cmulsry/Vluntary articiatin D. Gegracal Cverage E. Members F. AfterService Cverage G. Cverage f Families. Francse II. DESCRITIN F MAJR BENEFITS F EISTING SCEMES A. Dctrs' Services B. harmaceuticals G. sital Care D. Dental Care E. tical an earing Ais F. Disability (lss f earnings) Cverage III. FINANCIAL ASECTS A. General Situatin Table A Table B B. remiums their Structure an Artinment C. remiums fr AfterService Cverage D. Difficulties f AfterService Cverage IV. MANAGEMENT AND LICY MATTERS A. Aministratin f Schemes B. Reresentatin f Users G. Statistical Data D. Cnsumtin Restraints E. Fiel an rject ersnnel F. Majr Meical Exenses G. ServiceIncurre Illness aragrah 2 6 LA 83 M a^e iiiiv ^

8 il V. SUMMARY F CNCLUSINS A. B. C. D. E. F. G.. I. J. K. L. M. N. Annex I Annex Annex Annex. Tye f Scheme Basic an sulementary schemes Cmulsry/vluntary articiatin Active staff Cverage f families Francse sital care Dental care tical an hearing ais Disability (lss f earnings) cverage Financial asects f health insurance remiums, their structure an artinment Difficulties f afterservice cverage Reresentatin f Users Majr meical exenses RECMMENDATINS II III IV EALT INSURANCE SCEMES CMARATIVE TABLES CVERAGE F FAMILIES UNDER SME EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM FINANCIAL STATUS F EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM BENEFITS AND SERVICES UNDER EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM ara.gra.h ajsç Annex Annex Annex IV. IV. 2 IV,? BENEFITS AND SERVICES UNDER EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM BENEFITS AND SERVICES UNDER EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM BENEFITS AND SERVICES UNDER EALT INSURANCE SCEMES F TE UNITED NATINS SYSTEM

9 ll GLSSARY Unite i\gcinb_//^acuarters ealth lans Unite Nainb Blue Grss/AETNA/Majr Meileal N.. Unite Natins Blue Grss/ealth Insurance lan/majr Men:cal N. 2 Blue Crss is the sital Cmnent f bth lans Majr meical, cmmn t bth lans, is rvie by the AETNA Life an Casualty Insurance Cmany. AETNA rvies ne base cverage in the main lan, an tie ealth Insurance lan f Greater New Yrk (I) rvies it In the smaller lan. Dental cverage is rvie searately by ne lan ffere by Gru ealth Incrrate. The tr unite Natins lan is the Unite Natins Gru sital an Dentar Insurance Scheme (GMDIS), rvie by Cmmercial Insurer. Unite Natins, Geneva MISSA Mutual Insurance Sciety against Sickness an.accient 'sell finance) IL/lTU S~F Stall ealth insurance Fun (selffinance, M SI? Stall ealth Insurance lan (selffinance;. GMSE Caisse Malaie Suisse 'Entrerises (cmmercial gru schemej, ~ CT Caisse Malaie u ersnnel e la Cnfeeratin et es Inurrise^ Suisses e Transrt (nnrfit gru scheme), ZLQ. BMI? ~ Bas c Meical Insurance lan (vluntary cmmercial gru j^eme MMB Ma ""r Meical Benefits lan (vluntary cmmercial gru cheire. ENDEL? Lrte Nazinale e rvienza er Dienantl a 2m A i Divitt rujilc (sta^e scheme).

10 > /»S xi ü Vf c, " T=f FM CQ «3 a C T3 C I. t >»"«. s r ü B< M M a & Kl M Tj S 3 «4 ^ i""*s 3 g i Ü C Kl 43 Ü c 3 Ü Ctf ca M I W Ctf ca «5 i en 53 i!>> ft M Ü M Ü 3 Ü U ta Ü 3 g >> g 53 C c 3 i>» > ^ > Ü < ca is ü M Ü 3 ca M > i ) Ctf ta, t>i g 55 I ñ >> ri M Ê3 m M CJ A Ti S 3 < *"V I ta Ctf ta g S I C ta l K ta «C en!>> u ü ü u m S >* C M c i i!>* x ti > C ta >»«N l>» ü tt ta í>. l ca Q >» g C c f í>= > S2 * 3 ü ta ta «ti > => ta m i «s BU >*s S xl C Ü 3 CM g 55 xl ta ta ta Ctf ta M I W Ti N ta W i a? i c ta J2 ts Ctf c5 S i 6! Tj g I ta >J i>5 & & C ta cu

11 INTRDUCTIN All rganizatins an agencies in the Unite Natins syscem by their Staff Rules an Regulatins have an bligatin t rvie scial security rtectin fr its staff. 2. ealth insurance shul be seen as ne art f the ttal scial security arrangements fr Internatinal civil servants; the ther arts cmrise ensin, survivrs' benefits an cmensatin lans fr serviceincurre eath. Injury an illness» 3. Accring t the infrmatin receive by the Insectrs, there have been t ate nly tw systemwie stuies f the Unite Natins ealth Insurance Schemes; ne submitte in May 972 t the Secial Cmmittee fr the Review f the Unite Natins Salary System (A/AC5/CR.78) an the ther unertaken by the FICSA Staning SubCmmittee n ealth Insurance an submitte t its member bies in Aril 974 Bth went int the issues invlve an mae a number f cnstructive suggestins Incluing the establishment f a staning interrganizatin cnsultative by whse functin wul be t exchange infrmatin n licies an ractices as a first ste in eveling a cmmn health insurance scheme. As far as the Insectrs knw, nne f these rerts an recmmenatins have been fllwe u. In February 976, a cmarative stuy f the health insurance schemes In eratin in the Genevabase rganizatins unertaken by a cnsultant fr Wrl Intellectual rerty rganizatin (WI) ghlighte cntinuing ifferences. 4. ne f the ifficulties in a stuy f ts tye is the aarent lack f a cherent an unifrm scial licy an as a result each rganizatin has acte accring t its wn cnstraints, with the result that there are wie ifferences In the health insurance schemes in each rganizatin. Even In Geneva, there are fur searate schemes an these iffer substantially. 5 Due & saring health csts, the financial sitin f all these iniviual senenes Is becming increasingly vulnerable wch results in a tentially Increase buren fr all rganizatins an their staffs. 6 Anther ifficulty lies In the cmlexity f the schemes an the labyrinth f cmlex regulatins that frm the basis f the schemes. It is net the bject f ts rert t examine the varius regulatins in etail. Ts wul require as a rerequlsite ecisins n many questins f licy an rincile, as well as actuarial calculatins. Instea, the rert utlines the main rblems an ifferences an rses bra licies an a rceure fr their reslutin. The stuy cnclues with ne majr recmmenatin the creatin f an In teragency ealtn Insurance Cmmittee t examine the finings utline in ts rert an t evise a cmmn system fr health insurance wch might be intrice first in Geneva, an later extene t ther uty statins. A number f secific rsals are mae in ts rert fr cnsieratin by the rse InterAgency Cmmittee.

12 2 I. KEY ISSUES F EALT INSURANCE RGRAMA 7. The rvisin f means bth t btain an ay fr quality health care where an when neee is wiely recgnize as a cmmunity resnsibility. In many cuntries, ts resnsibility is either assume by the state, by the emlyer, r by bth. Unless secial arrangements are mae t the cntrary, nrmally all staff members n becming Unite Natins emlyees, leave the scial security schemes f their hme cuntries. ne ntable excetin is the Unite States f America (USA), where Unite Natins emlyees may remain members f their scial security schemes. All the rganizatins in the "cmmn system" have sme kin f health insurance arrangements fr staff an their eenants, jintly finance by cntributins frm the rganizatins an the staff. Accring t the latest available statistics (975/976), the ttal Unite Natins health ulatin cvere by basic health insurance schemes was 86,3 ersns, excluing UN/Q/GMDIS (Van Brea) lan fr wch n ata was available. f these at least 35, were active staff members, 3, were ensiners an 47, were eenants (i.e., ver 5 er cent). At least 6l er cent (53,) f the ulatin belnge t selfaministere schemes, the rest being ivie between natinal, nnrfit r cmmercial schemes. These figures are arximate, ue t the inability f sme schemes t rvie the ata. A. Tyes f Schemes 8. The health insurance arrangements vary enrmusly between the rganizatins. Aenix I rvies in syntic frm a escritin f the schemes ffere. There are fur tyes f schemes: (a) Selffinance an selfmanage schemes The fllwing rganizatins run such schemes: Unite Natins ffice at Geneva (UNG) cvering Ecnmic Cmmissin fr Eure (ECE), General Agreement n Tariffs an Trae (GATT) Internatinal Trae Centre (itc), Unite Natins Cnference n Trae an Develment (UNCTAD), Unite Natins Develment rgramme (UND) (Geneva ffice), ffice f the Disaster Relief Crinatr (UNDR), Unite Natins igh Cmmissiner fr Refugees (UNCR) (fiel staff nly), Unite Natins Relief an Wrks Agency fr alestine Refugees (UNWRA) (Geneva ffice) an Wrl Meterlgical rganizatin (WM) (heaquarters staff nly). Unite Natins Eucatinal, Scientific an Cultural rganizatin (UNESC), cvering the Unite Natins Infrmatin ffice in aris an Internatinal Civil Aviatin rganizatin's (ICA) aris ffice. Internatinal Labur ffice (IL) Internatinal Telecmmunicatin Unin (ITU). Wrl ealth rganizatin (W).

13 3 (b) Schemes unerwritten by utsie carriers These are f tw tyes nnrfitmaking r rfitmaking schemes r a mixture f bth. The fllwing have schemes rganize by utsie carriers: Unite Natins eaquarters GMDIS lan wch cvers: all the rject ersnnel f the Unite Natins, WM, InterGvernmental Maritime Cnsultative rganizatin (IMC), ICAC. the majrity f IMC heaquarter staff (Lnn). F an Agriculture rganizatin f the Unite Natins (FA) General Service Staff an staff f the IL an Internatinal Atmic Energy Agency (IAEA) ste at Wasngtn an New Yrk. Internatinally recruite staff f UND an Unite Natins Clren's Fun (UNICEF). Unite Natins Envirnment rgramme (UNE), Ecnmic an Scial Cmmissin fr Asia an the acific (ESCA), an Ecnmic Cmmissin fr Western Asia (ECWA). Unite Natins Infrmatin Centres wrl\ri_e (excet aris). Unite Natins fiel staff an Unite Natins staff serving with fiel litical missins. fiel staff f FA an Unite Natins Inustrial Develment rganizatin (UNID). The ICA heaciarters staff may be members f a scheme sulementary t the state scheme, (c) Natinal r state schemes In Switzerlan, the Universal stal Unin (UU) an WI are affiliate t statesubsiize schemes. In Italy, the FA has sme categries f staff affiliate t a state scheme (ENEED), but, as the natinal scheme Is being rerganize, it may be that ts lcal staff will have t affiliate with the existing cmmercial schemes. In the Unite Kingm, the staff f IMC being resient are freely cvere by the British Natinal ealth Service, shul they wish t use the facilities. In Austria, UNID has certain categries f ersnnel wh are affiliate t the state scheme. In Canaa, all heaquarters staff f ICA are members f QII.

14 4 In aitin t the state schemes, ersnal sulementary cmmercial schemes are available. () Meical assistance lans In small uty statins where n state health insurance scheme is available fr lcallyrecruite staff, the emlyer rganizatin nrmally ays 5 er cent f the csts f health care fr the staff member an s eenants, withut ayment f remium. The Unite Natins es ts thrugh a Meical Exense Assistance lan wch als ffers 8 er cent reimbursement fr maternity care. rganizatins that have ate cmmercial schemes an the cmanies cncerne state the avantages f such schemes t be as fllws: (a) Smaller rganizatins, with n cntingency reserves an n exerience, benefit frm the exerience f cmetent insurers; (b) rfessinal insurance cmanies are mre efficient an reimburse mre quickly than selfmanage schemes; (c) There are n irect management csts as they are inclue In remiums. Since salaries ai in cmmercial cmanies are usually lwer than Unite Natins salaries, an since cmmercial cmanies have mre exerience an larger vlume f business than iniviual Unite Natins rganizatins, their management csts may be lwer; () There are n "en" csts, whereas in selfaministere schemes, the aministrative csts wch are brne by the rganizatin cncerne are ifficult t Ientify; (in the UNESC scheme, art f its eficit is attributable t the aministrative csts f the scheme). (e) The aministratin f the scheme Is ineenent f bth the rganizatin an the staff member an tnis hels t avi cnflict in '"brerline" claims; (f) In certain regins, the health cverage is s cmlicate that nly rfessinal utsie carriers can ce, e.g., in the Unite States, where the nee fr esits befre entering a large number f hsitals, subsequent claims, verificatin rceures, cst cntrl rceures, actuarial stuies, etc., eman rfessinal cmetence. The isavantages f cmmercial schemes may be summarize as fllws: (a) remiums are gher in cmmercial schemes; (b) In the light f the evlutin f the lshy f scial security in recent years, articularly in Eure, where mst Unite Natins rganizatins have their heaquarters, there is a reluctance t accet schemes articularly fr health insurance, wch are rfitmaking.

15 5 (c) Exerience in certain rganizatins has sh^n Gnat >. year remiums are subsequently raise, smetimes substantially FA_ unite Natins eaquarters New Yrk an the UNESC sulementany schemes have all exerience ts: FA's remiums were increase in 975 by 23 er cent an Unite Natins eaquarters New Yrk by 69 er cent between January 974 an January 976, The IAEA an UNID cntracts with cmmercial insurers secify that remiums may be revise whenever rfits are less than 5 er cent, but increases are limite t 25 er cent in any ne year; () In a eficit year, it is extremely ifficult t seek better terms elsewhere; (e) Being gverne by a cntract, the cnitins are usually rigi an cannt take int accunt ersnal ifficulties; (f) rganizatins still have t rvie sme cstly aministrative services (in FA, a rtin f these csts are brne by the cmmercial Insurer).. As far as selfaministere schemes are cncerne, the avantages may be summarize as fllws: (a) Cntrl f the scheme rests In the hans f the rganizatin an staff; (b) remiums are lwer than fr cmmercial schemes; (c) Any rfits can be use t Imrve benefits,, cnitins r reserves, r t lwer remiums; () Benefits are In general better than fr a cmmercial scheme; (e) A mre ersnalize arach can be given t articular cases; (f) rblems can be srte ut quickly n the st.. The isavantages f a selfaministere scheme are as fllws: (a) Aministrative csts may be gh, either t an rganizatin wch bears the ttal csts r t tne scheme Itself (e.g., UNESC exerience); (b) A selfaministere scheme is nt ractical fr small rganizatins, ue t lack f risk sreaing; (c) It Is financially recarius unless there are substantial reserves r a reinsurance; (; Reimbursement elays may be lnger than in a cmmercial scheme, because f lack f exerience» lack f use f cmuters; etc.; (e) It is harer t evise an aly wrlvie stanars than It is fr a cmmercial insurer with eratins in many cuntries.

16 6 2. The relative merits an emerits f selfaministere schemes cmare t cmmercial schemes are ifficult t assess because f the wie ifferences between schemes. wever, if selfaministere schemes cul be unifie in a single scheme, with variatins t accmmate lcal circumstances, their avantages wul rbably be ecisive. In Eure, the IL/lTU an UNG selfaministere schemes have aske fr bis base n the same cnitins they nw ffer an the rsals given were unaccetable, ffering fewer benefits r gher remiums, r bth. wever, the Insectrs cannt ignre either the fact that the g financial health f mst selfaministere schemes is ue t: (i) the fiel staff claim less than heaquarters staff, an therefre subsiize the schemes an; (ii) the rganizatins bear the ttal aministrative csts an the ne scheme that has nt ne s (UNESC) is In financial ifficulties artly fr ts reasn. At least tw selfaministere schemes (IL/lTU an W) seem t be able t rvie management that is just as ssticate an exert (in terms f claims, verificatin, analyses, etc.) as any cmmercial insurer. Mrever, the fact that relevant ata Is available n call t the rganizatin, its staff an the management f the scheme, Is a istinct avantage. Amng the Eureanbase rganizatins, there seems t be a istinct view that the margin f rfit f a cmmercial scheme r that f its brkers, cul be mre rfitably use by a selfaministere scheme t hl remiums an imrve benefits an cnitins. The situatin is the reverse In the Unite States f America, where the meical cst envirnment an aministrative csts invlve wul make a change at resent frm a cmmercial t a selfaministere scheme, if nt imssible, extremely ifficult. wever, the majrity f Unite Natins staff wrlwie is cvere by selfaministere schemes. 3 Wle the Insectrs wul nt wish t rnunce themselves categrically in favur f ne articular tye f scheme at ts stage withut further an etaile technical examinatin, they are f the efinite view that, fr the fllwing reasns, it is esirable fr the Unite Natins system t at selfaministere health insurance schemss n the wiest ssible basis: (a) The Unite Natins rganizatin cnstitutes a single family f natins. Staff members serving the varius rganizatins likewise cnstitute a single entity serving the internatinal cmmunity. Recgnitin has alreay been given t ts rincile in the evlutin f what is knwn as "the cmmn system", in wch salaries an emluments, graes an ensinary benefits f internatinal civil servants, irresective f the rganizatin f the Unite Natins family wch they serve, are gverne by the same r ientical regulatins. ealth Insurance benefits are a art f the verall scial security rvie t internatinal civil servants an there is n reasn why, as in the case f ensins, these als shul nt frm art f the cmmn system, ue regar being ai t the existence f ifferences in health cnitins in the milieus In wch they serve. Such unifrmity f treatment as regars health insurance can best be assure by having selfinsure r selfaministere schemes cvering many rganizatins an large numbers f internatinal civil servants;

17 7 (b) It is the cmmn ractice amng gvernments that being large wners f rerty, they nt insure gvernment rerty; an they als unertake ther frms f selfinsurance, n the rincile that gvernments becme their wn insurers an instea f aying large remiums t insurance cmanies they in effect ay these t themselves. Thugh the analgy is nt cmlete, the alicatin f similar rincile in the case f health insurance will nt be inarriate, rvie that Unite Natins rganizatins get tgether an members f the insure is sufficiently large t lace the selfaministere scheme n ar with that aministere by a cmmercial insurance cmany; (c) The ifferences in the secialize internal rceures f rganizatins f the Unite Natins system shul nt be an bstacle t a cmmn arach t health insurance, just as they are n bstacle t a cmmn system. Inee, the jining tgether f as many rganizatins f the Unite Natins system as ssible t establish a health insurance scheme fr their ersnnel wul be a esirable an even essential emnstratin f the neness f the Unite Natins family an a further extensin f the cmmn system t wch they have alreay subscribe; () rvie the number f ersns cvere by a selfaministere Unite Natins health scheme is large an the scheme Is aministere efficiently with a small but traine staff an with the hel f cmuters, there is n reasn why a selfinsure scheme shul be mre exensive r mre ilatry in rviing the services than a cmmercial scheme. Inee, It shul be less exensive, since, unlike cmmercial rganizatins, it cul lugh back what wul be rfits in a cmmercial scheme, int the selfaministere scheme, s as t reuce remiums an/r increase benefits. The exerience f the IL/lTU an W schemes shws that selfaministere schemes can be aministere in an efficient an ssticate manner; (e) The Insectrs wul regar it as a esirable aim that there shul be a single scheme cvering all Internatinal civil servants belnging t all Unite Natins rganizatins (an nnunite Natins gvernmental rganizatins wh may wish t jin) whether ste at the heaquarters f the rganizatins r in the fiel. wever, ts fr sme time at any rate can nly remain an ieal, as ractical rblems have t be taken int cnsieratin. Fr examle, the meical an articularly the hsitalizatin situatin in New Yrk is such that Unite Natins eaquarters an ther Unite Natins bies lcate in New Yrk an ther laces in the Unite States have t have a searate health insurance scheme fr their staff members. Likewise, the smaller rganizatins, situate in centres where there is nt a large cnglmeratin f internatinal civil servants, may refer t remain uner the natinal health scheme r a cmmercial scheme until sach time as a single wrlwie health insurance scheme becmes a realistic ssibility in the Unite Natins system; (f) The Insectrs wul suggest that as a first ste the Genevabase rganizatins cmbine an evlve a single health insurance scheme fr all ersnnel serving these rganizatins in Geneva an in the fiel, an the ersnnel f such nnunite Natins rganizatins in Geneva as may care t jin such a scheme. They cnsier that a selfaministere scheme fr Genevabase staff Is racticable; it wul cver ver 4, ersns, an If Genevabase nnunite Natins rganizatins jin in, then the number wul be much larger;

18 (g) The health scheme fr Genevabase fficials in the Unite Natins system if successful cul becme the nucleus f a much larger scheme t wch later ther rganizatins lcate elsewhere cul subscribe. The success f any such scheme wul een n the willingness f the rganizatins t jin tgether with thers in a cmmn scheme an t give u their articular schemes; (h) The Insectrs wul urge the accetance in rincile f the suggestin fr a single health scheme fr all ersnnel f the Unite Natins system lcate in Geneva, t be fllwe by an exert stuy t wrk ut the etails f such a scheme, Incluing the fixatin f remiums an benefits n a unifrm basis. B. Basic an Sulementary Schemes 4. All the health schemes f the Unite Natins system rvie fr bth basic an sulementary benefits. The latter are esigne t cver majr meical exenitures, whether fr chrnic illness r emergency care, r t rvie r imrve un benefits nt cvere by basic schemes. 5. Five sulementary cmmercial schemes FA, IAEA, UNID, UU an WI require aitinal remiums. UNESC ha, until ctber 976, a cmmercial sulementary licy wch may be renegtiate an feels strngly that the wr "sulementary" shul aly nly t an aitinal, searate, usually cmmercial scheme. With the excetin f the five rganizatins mentine abve, in all ther schemes, the sulementary benefits frm an integral art f the majr scheme. 6. nly the IL/lTU scheme alies its sulementary benefits t all categries f care withut excetin (witn iniviual maxima In certain cases). All ther schemes restrict sulementary benefits t a mre r less cmrehensive list f categries. 7. The cver rvie an the alicatin f the benefits vary wiely frm scheme t scheme: (a) In the UNG scheme, nce csts excee SF 2, (er categry f care/ttal er annum) 8 er cent f the remainer t an annual maximum f SF 25, Is reimburse. Ts amunt is renewable uner certain cnitins but in fact there has never been a request fr such a renewal ; (b) The IL/lTU an W selfaministere schemes an the IAEA an UNID cmmercial schemes reimburse er cent f the amunt nt refune by the basic scheme whenever ts amunt excees 5 er cent f the net annual salary f the staff member, u t $ 35, er family er year, renewable; (c) The UNESC scheme reimburses er cent f the amunt nt refune uner a basic scheme when such exenses excee a given rrtin f such salary, accring t a sliing scale, with n uer limits; () The FA scheme reimburses 8 er cent f extra csts after the basic reimbursement, u t a maximum f $ 5, er ersn in any 2 successive mnths;

19 9 (e) All Unite Natins eaquarters schemes, after a francse (euctin) f $ 75 er atient er year reimburse 8 er cent ( er cent fr inhsital care) f csts u t a lifetime maximum f $ 25, er atient. In the Unite Natins GMDIS lan, the annual maximum is $ 3, er atient, renewable. 8. The questin f reinsuring r "st lss" insurance fr majr meical exenses rvie fr by sulementary schemes, has been examine by sme rganizatins fr claims exceeing a certain annual aggregate (UNG: SF 6,; IL/lTU: $ 46,) but the terms ffere by cmmercial insurers have been rbitive. In the IL/ITU scheme, as a ercentage f ttal reimbursements, sulementary benefits amunte t: $ In the W scheme the figures were: $ Thse schemes that rvie merely fr an initial r annual francse seem t be caable f making ayments f sulementary benefits mre quickly than thse that require an exeniture f 5 er cent r mre f annual Incme befre a ayment is ue, althugh they may reimburse less generusly than the latter schemes. 9. The evience suggests that sulementary schemes are rarely utilize, but they rvie essential insurance. There wul be therefre a case fr sulementary benefits frming an integral art f the basic schemes with a ttal ceiling er ersn er year r case, withut causing an extra financial buren. The questin f abuses, francse, etc., will be ealt with later. G Cmulsry/Vluntary articiatin 2. articiatin Is cmulsry in the fllwing schemes: IL/lTU, UU, UNESC, W, FA (basic lan), IAEA, UNID (rject ersnnel) WI an ICA (QI). Mst rganizatins exemt staff members frm cmulsry Insurance in excetinal cases if they have alternative cmarable cverage. IAEA an UNID exemt thse staff wh are affiliate t the Austrian natinal scheme. IAEA, IL an FA allw their staff wrking in New Yrk t jin ne f the Unite Natins eaquarters lans whse cverage, esecially fr hsital care, is suerir t their wn. W allws fr n such exemtins frm members, an ays the balance f amunts nt therwise reimburse. 2. articiatin is vluntary in the UNG selfaministere scheme an in the cmmercial schemes in Unite Natins eaquarters (GMDIS), the basic an sulementary cnstituting fr ts urse a single scheme.

20 22. articiatin is vluntary in sulementary schemes, even if cmulsry in the basic schemes in the WI, UÜ, FA/MMB, IAEA/SNI + TD an UNID 3MI + TD (the IAEA an UNID schemes being alie t lcal staff affiliate with the Austrian natinal scheme), ICA/Great West, IMC/BUA, IMC/GMDIS. In aitin, fr all schemes, the articiatin f ensins in bth basic an sulementary schemes, is vluntary. 23. nly the Unite Natins eaquarters an Geneva ermits Its staff the tin f being insure r nt. Mst f the schemes ate by the rganizatins in Eure reflect the scial legislatin in the cuntries in Eure where they have their heaquarters an where affiliatin with scial security an health insurance schemes has been manatry fr many years. The Unite Natins vluntary scheme has the avantage f aviing uble ayment by staff wh are insure elsewhere r by suses wh wrk utsie the Unite Natins an are cvere by their suse's utsie emlyer. 24. Since well ver 9 er cent f the Unite Natins eaquarters staff an 92 er cent f UNG's staff with cntracts f six mnths r mre are affiliate t their resective schemes an cmulsry insurance ensures a greater sreaing f risks, members f health insurance schemes f Unite Natins rganizatins shul be cmulsry with the inbuilt rvisin f exemtin if the staff member can rvie rf f aequate cver in anther cmarable scheme. The fact that members in Unite Natins Jint Staff ensin Fun (UNJSF) is cmulsry fr all staff members wh qualify lens surt t cmulsry members f health insurance schemes. D. Gegracal Cverage 25. With tw excetins UNG an WI all health Insurance schemes f the Unite Natins system, whether they be selfaministere r cmmercial, have wrlwie gegracal cverage. In rincile, the UNG scheme is wrlwie, but it bases its hsitalizatin benefits n Geneva rates, using its sulementary benefits scheme fr any excess csts. Fr WI, wrlwie cverage is ssible but necessitates the ayment f an extra remium. The Insectrs believe that realistic wrlwie cverage is essential fr all schemes f the Unite Natins system. 'E. Members _(a) Active Staff 26. The criteria fr articiatin In health insurance schemes are very isarate bth in terms f the minimum eri f aintment necessary t qualify fr articiatin an f the categries f staff (regular staff, shrtterm staff, rject ersnnel, etc.), an in the tye f benefit available t them. 27. The shrtest qualifying eri fr members f a health scheme is three mnths in WI, UNID an Unite Natins eaquarters. In UNG six mnths an in IL/lTU, W, FA, UU, UNESC an IAEA It is ne year.

21 28. Fr shrtterm staff wh nt qualify fr articiatin, W, WM, UNESC, IL/lTU, FA, IAEA an UNID use utsie cmmercial schemes. UNG allws its shrtterm staff t jin Its main scheme (MISSA) but exclues them frm sulementary benefits an accient cver. IAEA an UNID rvie a searate Van Brea scheme fr nnaustrian shrtterm staff. The Austrian shrtterm staff are cvere by the natinal scheme, althugh they may becme members f the sulementary scheme. 29. rject ersnnel: all rganizatins rvie sme scheme fr rject ersnnel with cntracts f ne mnth r mre (Unite Natins eaquarters anfa) r u t ne year (IL/lTU). The cst f cverage varies wiely an the cmmercial (Van Brea) schemes f FA, IMC an Unite Natins eaquarters (als cvering UNID rject ersnnel) wch are available als t ther categries f ersnnel in ther rganizatins, are mre cstly t the exert than sme f the schemes f ther agencies. 3. There is a similar variety f arrangements fr health insurance cverage f staff n leave withut ay r transferre t an frm ther rganizatins. 3. The abve shws that these isarities, even between rganizatins lcate in the same city (Geneva, Vienna) an even using the same cmmercial brker (IAEA an UNID), cannt be cnucive t harmnius interagency staff relatins in the fiel, nr inee witn the same rganizatin, where sme categries f staff have mre avantageus treatment. The simlest an best slutin wul be t fllw the examle f the IL/lTU scheme an t rvie that nce a articiant has jine the scheme, there be n iscriminatin in terms f benefits r remiums. The Insectrs cnsier that staff members shul have cntracts f at least six mnths' uratin t be eligible t jin the ealth Insurance Scheme. F. AfterService Cverage 32. All health insurance schemes f the Unite Natins system rvie fr the cntinuatin f subsiize health insurance withut reuctin f cverage fr thse wh retire (at age 55 r mre), fr their eligible family members, fr the survivrs f staff members wh ie in service r wh ie as a ensiner, rviing such staff members r ensiners were insure fr a given eri befre searatin, nrmally ten years. Uner the Unite Natins eaquarters schemes, hwever, such afterservice cverage fr lcallyrecruite General Service staff, their families r survivrs, alies nly in Geneva, Lnn, aris, Rme, New Yrk, Wasngtn, an in Ecnmic Cmmissin fr Asia an the Far East (ECAFE) an Ecnmic Cmmissin fr Latin America(ECLA). Thse wrking in many Unite Natins Infrmatin Centres, in fiel uty statins f UND an UNICEF an certain ther areas, have n such afterservice cverage. 33 Where the minimum eri f members is nt serve, there is usually sme rvisin fr cntinuus, but unsubsiize cverage with either reuce benefits r severely limite in time withut reuce benefits, usually between three an six mnths. The same tye f afterservice cverage is available fr staff members wh retire regarless f age with a isability ensin frm the UNJSF an/r with a eriic cmensatin benefit ayable as a result f a serviceincurre Injury, accient r illness. In the IL/ITU an UNESC schemes, n qualifying eri f members is require where a isability ensin r eriic benefit is ayable. In FA, n the ther han, the qualifying eri in these cases is three years an at UNG an Unite Natins eaquarters, five years.

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