If your duty station (for staff members) or legal place of residence (for other insured members) is outside the United States, specific rules apply when seeking medical care within the U.S. These rules are designed to ensure fair reimbursement and protect the financial sustainability of the UNSMIS health plan.

If you use medical services in the United States of America, due to the comparatively high cost of healthcare services and in accordance with the above paragraphs of our Internal Rules, UNSMIS may cap reimbursement at amounts significantly lower than the total invoice amount. This may result in substantial out-of-pocket costs. Therefore, before undergoing any planned medical procedure in the U.S., you are strongly advised to contact UNSMIS for confirmation so we can determine whether reimbursement will be capped.

Reimbursement and Prior Authorization Requirements

Pursuant to Rule VIII/4/f of our Internal Rules (available here), certain treatments received in the U.S. require prior authorization from UNSMIS’s Medical Adviser. This applies to treatments listed under benefits 2, 3, 5, 13, 16, 24, and 25 in Annex III, as well as any other treatments in Annex III that require prior authorization.

According to Rule VIII/4/c, to prevent excessive billing and protect the plan’s solvency, UNSMIS limits reimbursement to usual, reasonable, and customary (URC) charges in the region where care is received. As a result, reimbursement for the treatments listed above will be capped at the cost of equivalent care in the canton of Geneva. This ceiling will be specified in the prior authorization. Any expenses exceeding this amount will be your responsibility unless pre-approved by UNSMIS.

Treatments under Annex III that are not listed above do not require prior authorization and remain reimbursable under standard UNSMIS terms. However, they are also capped at the cost of equivalent care in the canton of Geneva.

Accidents and treatments classified as medical emergencies are reimbursed under standard UNSMIS terms. UNSMIS reserves the right to determine whether a case qualifies as a medical emergency and will assess claims accordingly.

To request prior authorization, you must submit your application at least 30 days before the scheduled treatment. It is essential to include a detailed description of the planned procedure and pre-operative medical report, when applicable.

You may be exempt from the above rules if your duty station is in the U.S. or if you are a U.S. resident. In such cases, UNSMIS may reimburse you at full, uncapped rates according to the standard terms and conditions outlined in Annex III of our Internal Rules. Additionally, U.S. citizens may be reimbursed for maternity and labor-related costs incurred in the U.S. at full, uncapped rates.

Billing and Payment

If a treatment is expected to be performed on an outpatient basis, you must request to be billed as a self-pay (i.e., uninsured) patient. This allows you to benefit from a discounted cash rate, which is usually lower than the rate charged to insurance companies. You must settle the bill yourself and submit it for reimbursement via eClaims, as usual. 

For very expensive outpatient treatments (e.g., oncology), direct payment may be arranged through UNSMIS’s local partner company. To request this, please email unsmis@un.org.

However, direct payment may not be granted for outpatient treatments with capped reimbursement. Please refer to Annex III of our Internal Rules for a list of these treatments.

If you expect to be hospitalized in the U.S., direct payment will be arranged through UNSMIS’s local assistant company. To request direct payment for planned medical procedures, please send all relevant medical documents and a preliminary quote from the provider to unsmis@un.org.