Health Insurance Services for American Embassy Lilongwe

DESCRIPTION/SPECIFICATION/WORK STATEMENT PART I - HEALTH INSURANCE C.1. HEALTH INSURANCE SERVICES The Government of the United States of America requires Health Insurance coverage for its employees as further described in C.1.2 in Lilongwe, Malawi. The Government has determined that the prevailing practice by employers in Malawi is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by both the employer and the employee on a 90% - 10% basis, respectively. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.2. The specific health benefit coverage under this contract is set forth in Section C. The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care. C.1.1 Employee and Dependent Health Services Benefits The health benefits under this contract are as follows. Reimbursement of covered expenses is limited to the stated percentages of reasonable and customary costs. Reimbursements or payments shall be made for the following covered benefits, subject to reasonable and customary costs in the locality where treatment was provided. C.1.1 Employee and Dependent Health Services Benefits C.1.1.1. Hospitalization: 100% coverage. Services and supplies provided during hospitalization, including services provided by a certified healthcare provider, bed and board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, general hospital nursing care, and drugs and medicines administered while in the hospital. When private accommodations are provided, coverage will be limited to the cost of a semi-private room. C.1.1.2 Outpatient Services: 80% coverage. Services provided by a certified healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon's fees and other medical services that may be provided in a hospital, clinic, doctor's office, medical facility, etc. Examples include, but are not limited to: - Annual physical examinations - Specialist consultations and treatment, including second surgical opinion - Minor surgical interventions - Chemotherapy and radiation treatments - Immunizations recommended by local authorities and/or the World Health Organization - Diagnostic tests and diagnostic imaging . C.1.1.3. Prescription Drugs and Medicines: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized. Medications that are prescribed by a certified health care provider that are medically necessary to treat a specified diagnosis. Examples include, but are not limited to: prescription antibiotics to treat an infection; medication used to treat an ongoing condition, such as high cholesterol; or contraceptive medication. C.1.1.4 HIV/AIDS: 100% up to USD 10,000 per year/ covered individual. Medications to suppress opportunistic infections (such as tuberculosis or toxoplasmosis for covered individuals who have HIV/AIDS). Brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV/AIDS to the child. Generally excludes medication for the long-term suppression of HIV/AIDS through the combination of anti-retroviral drugs in locations with inadequate local healthcare infrastructures. C.1.1.5 Obstetrical and new born Care: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized. Care and services that women receive during pregnancy (prenatal care), throughout labor and delivery, and post-delivery, and outpatient care for newborn babies. Hospitalization during pregnancy and/or delivery will be reimbursed as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services (see above). C.1.1.6 Hearing Aids: 80% Coverage. Hearing aid apparatus and related examinations. Limited to one apparatus per ear up to a maximum of USD 1,500 per covered individual per three-year period. C.1.1.7 Optical Care: 80% Coverage. Eye examination, treatment, and prescription lenses and frames or contact lenses up to a maximum of USD150 per covered individual per contract year. C.1.1.8 Dental Care: 80% Coverage. Dentist's fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges per covered individual up to a maximum of USD3200 per contract year. Orthodontia treatment is covered only if treatment begins before age 18, or if required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per covered individual up to a maximum of USD2400 lifetime limit. C.1.1.9 Rehabilitative and Habilitative Services and Devices: 50% Coverage. Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke) and habilitative services (e.g., developing skills, such as speech therapy for children) that help develop skills needed for everyday life. Devices to help gain or recover mental or physical skills lost due to injury, disability or a chronic condition, and devices needed for habilitative reasons. C.1.1.10 Medical Expenses Incurred Out of Country: Medical expenses incurred out-of-country will be covered at the same benefit levels and subject to the same total maximum annual limit as medical expenses incurred in-country. C.1.1.11 Out of Country Medical Travel Transportation for out-of-country medical treatment will be a covered expense for covered employees and eligible family members. To be considered a covered expense, the attending certified health care provider must certify in advance that the treatment is medically necessary and unavailable locally. 80% of covered individual's transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be covered. 80% of the transportation expenses of an attendant will also be covered, but only if the covered individual's attending certified health care provider certifies that an attendant for the patient is necessary, (e.g., a parent in the case of a patient who is a minor, or a family member to make medical decisions in the case of a patient who is unwell or unconscious). All coverage for transportation for out-of-country medical treatment is subject to the total maximum annual limit. Transportation to a neighboring country without the attending certified health care provider certifying that the treatment is medically necessary and unavailable locally will not be covered. C.1.1.12 Annual Maximum Limit - The maximum annual reimbursement per patient per contract year, not including expenses covered under c.1.1.4, is $25,682.00 per patient per contract year. C.1.1.13 Ambulance: 80% Coverage. Professional ground transport to move a patient from the place where s/he is injured or becomes ill to the nearest hospital able to provide treatment or to move a patient from one medical facility to another. C.1.1.14 Emergency Services: 100% coverage. Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. C.1.1.15 Pediatric services: In-patient: 100%. Out-patient: 80% coverage. Primary and preventive routine care services for covered dependent children, including, but not limited to: physical examination, developmental assessment, laboratory tests, and immunizations recommended by local authorities or the World Health Organization. C.1.1.16 Preventative and Wellness Services and Chronic Disease Management: 80% Coverage. Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but are not limited to: physicals, immunizations, and cancer screenings. C.1.1.17 Family planning: 80% coverage. Prescribed contraceptive devices, voluntary sterilization, and diagnosis and treatment of infertility. C.1.1.18. Mental, Nervous, and Substance Abuse Care: 50% Coverage. Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Services must be provided by a licensed psychiatrist, psychoanalyst, psychologist, or psychiatric social worker. Inpatient care for alcohol and substance abuse must be carried out at a facility certified for detoxification and rehabilitation. C.1.1.19 Catastrophic Coverage: Additional coverage equal to USD 26,000 per person per contract year. Catastrophic conditions shall be defined as major medical conditions occurring as a result of a single/illness/accident or closely related set of major illnesses (or conditions relating to a single accident) that exceed the standard maximum coverage limit. C.1.1.20 Excess Coverage: Additional coverage equal to 100% of the annual maximum USD 26,000 to be applied to any covered individual to any covered benefit. LE Staff must pay 100% of the premium if they elect Excess Coverage. Not applicable to direct reimbursement posts. This can be used for any coverage individual for any covered expense that exceed annual maximum. C.1.1.21 Exclusions to Coverage: There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, artificial insemination, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider. Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusion requires prior authorization. There is no reimbursement for expenses that will be reimbursed or paid directly under a host country medical program or workers' compensation program, the U.S. workers' compensation program, or post's LE Staff workers' compensation program. C.1.3 Eligible Participants C.1.3.1 Eligible Employees - The employees eligible for the health insurance services include the following: C.1.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Lilongwe Malawi paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include C.1.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts (PSCs); C.1.3.1.3. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs. C.1.3.2 Location of Employment The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Lilongwe, Malawi by: United States Department of State (DOS) United States Agency for International Development (USAID) United States Centre for Disease Control (CDC) United States Department of Defense (DOD) C.1.3.3 Participants Covered Under a Rider C.1.3.3.1 All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account (see separate rider). All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government. All costs for C.1.1.19 (Catastrophic Coverage) and C.1.1.20 (Excess Coverage) are the responsibility of the employee. C.1.3 Individuals Not Eligible for Coverage Individuals not eligible for coverage under this contract are non-personal services contract personnel; employees working on a temporary basis; employees with an intermittent, seasonal, or WAE (when actually employed) schedule; and any other individual not falling within one of the categories of employees described in this clause. C.1.4 Other Eligible Participants Covered dependents include the participating employee's one legal spouse and unmarried children to 26, or disabled. . An eligible child is defined as the LE Staff's natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE Staff. A child will be covered until the end of the contract year in which s/he reaches age 26. An unmarried child determined to be incapable of self-support due to a physical or mental condition will continue to be eligible to participate in the medical plan as long as the condition persists, the child remains unmarried, and the LE Staff maintains coverage There is no limit on the number of children covered per employee. C.1.5. Eligibility C.1.5.1. Term of Eligibility and Effective Date Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee will be enrolled upon entering on duty with the United States Government. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid. During a period of Leave without Pay (LWP) or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the Contractor. The employee's share of the premium will be collected through payroll deduction in that or the subsequent pay period. C.1.5.2. Period of Ineligibility Employees and their dependents are not entitled to health benefits during any period of employment for which premiums are not paid. Additionally, employee's dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate. During a period of extended (beyond one pay period) of Leave Without Pay (LWP) or unpaid leave, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the Contractor, and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if that employee prefers not to pay the premium. C.1.6. BROCHURE REQUIREMENT C.1.6.1. The Contractor shall provide a document (brochure/pamphlet/other written document) in English that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The Contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made. C.1.6.2. The Contractor shall provide the document described in C.1.6.1 to the COR not later than thirty days (30) after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR's request. C.1.6.3. The Contractor assumes full responsibility for ensuring that the document described in C.1.6.1 accurately reflects the requirements of the contract, as implemented by the Contractor's technical proposal. In all cases, the contract shall take precedence. Should the COR discover that the brochure contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the Government to notice any inaccuracies shall in no way limit, revise or otherwise affect the requirement under this contract for the Contractor to fully comply with all contract terms.