191D3222R0016 Jakarta LES Health Insurance Service - Solicitation.pdf

191D3222R0016 Health Insurance for LES U.S. Embassy Jakarta Page 1/72

SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING PAGE OF PAGES

1 | 72

2. CONTRACT (Proc. Inst. Ident.) NO.

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[x] NEGOTIATED (RFP)

5. DATE ISSUED 6. REQUISITION/PURCHASE NO.

191D3222R0016

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than item 7) Embassy of the United States of America Jl. Medan Merdeka Selatan 3-5, Jakarta 1010 Ph: 62-21 5083-1000 ext. 0

NOTE: In sealed bid solicitation "offer" and "offeror” mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and 2 copies for furnishing the supplies or services in the Schedule will be received at the place specified, in the depository located in Jakarta, until 12.00 noon local time on Thursday, September 15, 2022. CAUTION - LATE Submissions, Modifications, and Withdrawals:

10. FOR INFORMATION

CALL:

A. NAME

Arthur A. Dymond

B. TELEPHONE (NO COLLECT

CALLS)

AREA CODE NUMBER EXT

(62-21) 5083-1000 0

C.-E-MAIL ADDRESS

JakContractingOffice‐RFP@state.gov

11. TABLE OF CONTENTS

(x) SEC. DESCRIPTION PAGE(S) (x) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM 1 I CONTRACT CLAUSES 28

B SUPPLIES OR SERVICE AND PRICES/COSTS 2 PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

C DESCRIPTION/SPECS/WORK STATEMENT 7 J LIST OF ATTACHMENTS 44

D PACKAGING AND MARKETING 17 PART IV - REPRESENTATIONS AND INSTRUCTIONS

E INSPECTION AND ACCEPTANCE 18 K REPRESENTATIONS, CERTIFICATIONS, AND 47

F DELIVERIES OR PERFORMANCE 20 OTHER STATEMENTS OF OFFERORS

G CONTRACT ADMINISTRATION 21 L INSTRS., COND., AND NOTICES TO OFFERORS 63

H SPECIAL CONTRACT REQUIREMENTS 24 M EVALUATION FACTORS FOR AWARD 70

OFFER (Must be fully completed by offeror) NOTE: ITEM 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (120 calendar days unless a different period is inseted by the offer) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT SEE 14

(See section I, Clause No 52.232-8)

10 CALENDAR

DAYS

20 CALENDAR DAYS

30 CALENDAR

DAYS

CALENDAR DAYS

14. ACKNOWLEDGMENT OF

AMENDMENTS

AMENDMENT NO. DATE AMENDMENT NO. DATE

(The offeror acknowledges receipt of amendments to the solicitation and related documents ) numbered and dated:

15A. NAME CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED

AND ADDRESS

OF OFFEROR

TO SIGN OFFER (Type or print)

15B. TELEPHONE NO. (Include area code)

15C. CHECK IF REMITTANCE

ADDRESS [ ] IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN

COMPETITION:

[ ] 10 U.S.C. 2304(c)( ) [ ] 41 U.S.C. 253(c)( )

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTRATION BY (If other than Item 7)

CODE

25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

MICHAEL A. DELAUDER

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

IMPORTANT - Award will be made on this form, or on the Standard Form 26, or by other authorized official written notice.

NSN 7540-01-152-8064 STANDARD FORM 33 (REV 9-97)

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SECTION B

PRICE HEALTH INSURANCE

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide Health Insurance services to employees of the Government of the United States of America in Indonesia and their eligible dependents as described in Section C and the Exhibits in Section J. The groups of employees who shall be provided this insurance are listed in C.1.3 (Medical). This insurance shall be provided in accordance with Section C and the Exhibits in Section J.

B.1.1. Official Residence Expense (ORE) Staffs are included under this contract only as a rider; the Contractor shall bill the Chief of Mission, Deputy Chief of Mission, Consul General Surabaya, and/or Consulate Medan (for ORE Staff), at the rates specified below. See Section G for billing procedures.

B.1.2. Excess Coverage (C.1.1.21) is included under this contract only as rider benefits;

the Contractor shall bill the individual covered at the rates specified below. See Section G for billing procedures. Note that USG is not responsible, nor liable, for any riders.

B.2. PRICES

B.2.1 Value Added Tax.

The Government will not reimburse the Contractor for VAT under this contract. The Contractor shall not include a line item for VAT on Invoices as the U.S. Embassy has a tax exemption certificate with the host government.

B.2.2 Fixed Price.

This is a fixed price with economic price adjustment requirements type contract under which will be issued firm, fixed-price task orders. The fixed prices/premium rates for the health insurance services as specified in Section C are as follows:

B.2.3 OFFERS AND PAYMENT IN LOCAL CURRENCY

All offers and payments shall be in local currency only, Indonesian Rupiah (IDR/ Rp) in accordance with the Bank Indonesia Regulation No. 17/3/PBI/2015. This applies to all firms and there are no exceptions.

JAMES ZADROGA 9/11 VICTIMS HEALTH AND COMPENSATION ACT OF 2010

NOTICE: UNLESS A WAIVER OR EXCEPTION APPLIES, PAYMENTS

SUBSEQUENT TO THIS PROCUREMENT ARE SUBJECT TO AN EXCISE TAX OF

2% PERSUANT TO 26 U.S.C. 5000C.

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B.2.4 BASE YEAR OF THE CONTRACT

Bi-Weekly Rates Per Premiums

Category Estimated Number of Premiums*

Rate per Premium Extended Bi-Weekly Total

a. Male Employee & Spouse

b. Female Employee & Spouse over 45 years old

c. Female Employee & Spouse under 45 years old

d. Child 1947 Subtotal (a+b+c+d) TOTAL PRICE FOR BASE YEAR(d x 26)**

*estimated number of premiums does not include any Riders (B.1.1) **does not include any premiums for Riders.

Rider Category*** Biweekly Rate per Premium C.1.1.21 Excess Coverage

***not included in the Total Price for Base Year Calculation

B.2.5 FIRST OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium Extended Bi-Weekly Total

e. Male Employee & Spouse

f. Female Employee & Spouse over 45 years old

g. Female Employee & Spouse under 45 years old

h. Child 1947 Subtotal (a+b+c+d) TOTAL PRICE FOR FIRST OPTION (d x 26)**

*estimated number of premiums does not include any Riders (B.1.1) **does not include any premiums for Riders.

***not included in the Total Price for First Option Year Calculation

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B.2.6 SECOND OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium

Extended Bi-Weekly Total

i. Male Employee & Spouse

j. Female Employee & Spouse over 45 years old

k. Female Employee & Spouse under 45 years old

l. Child 1947

TOTAL PRICE FOR SECOND OPTION (d x 26)**

***not included in the Total Price for Second Option Year Calculation

B.2.7 THIRD OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium

Extended Bi-Weekly Total

m. Male Employee & Spouse

n. Female Employee & Spouse over 45 years old

o. Female Employee & Spouse under 45 years old

p. Child 1947

TOTAL PRICE FOR THIRD OPTION (d x 26)**

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*** not included in the Total Price for Third Option Year Calculation

B.2.8 FOURTH OPTION YEAR OF THE CONTRACT

Category Estimated Number of Premiums*

Rate per Premium Extended Bi- Weekly Total

q. Male Employee & Spouse

r. Female Employee & Spouse over 45 years old

s. Female Employee & Spouse under 45 years old

t. Child 1947

TOTAL PRICE FOR FOURTH OPTION (d x 26)**

***not included in the Total Price for Fourth Option Year Calculation

B.2.9 GRAND TOTAL HEALTH INSURANCE FOR BASE PLUS ALL OPTION YEARS

Base Year Total First Option Year Total Second Option Year Total Third Option Year Total Fourth Option Year Total

Grand Total of Base Plus All Option Years

MINIMUM AND MAXIMUM AMOUNTS

During the Base Year of the contract, and during the option year that might be exercised, the United States Government (USG) shall place orders totaling a minimum of Rp.100,000,000. This reflects the contract minimum guarantee for each period of performance. The amount of all orders, for base and all option years shall not exceed Rp.385,000,000,000. This reflects the contract maximum.”

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B.3 ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the Contractor requests a price adjustment under B.4 below, the Contractor shall present cost experience data that includes the retention amount. For purposes of any economic price adjustment, this retention amount is a fixed amount that is a part of the premium amounts in B.2. This retention amount will not be adjusted for any reason.

The retention amount is part of the premium and may include, but not be limited to, such costs as overhead and general and administrative costs. It will also include any profit. Essentially, it includes all costs except the actual portion of the premium intended to fund claims paid to the health care provider/claimant. B.3.2 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

NOTE TO OFFEROR: Fill in the fixed bi-weekly retention amounts for each period of performance and for each category of premium. This fixed amount shall be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall not be expressed in terms of a percentage of the premium.

B.3.2 Bi-Weekly Retention Amounts per separate premium paid per single employee and per family plan.

B.4. ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.4.1. Premium Adjustment Based on Experience - For health insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract, and it specifically excludes all riders in B.1.1. No adjustment will be allowed during the first twelve months. After such time, the Contractor or the Government may request an adjustment in premiums on an annual basis. Adjustments are not retroactive to previous contract terms.

Before any such adjustment is made, the Contractor agrees to provide the Government a balance sheet showing three main components for the time period:

(1) receipts (premiums received) minus the retention amount,

(2) number of insurance plans, and

(3) claims paid.

Period of Performance Male Employee/

Spouse

Female Employee/Spouse >

45 years old

Female Employee/Spouse <

45 years old Child

Base Period First Option Year

Second Option Year

Third Option Year

Fourth Option Year

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This information shall be provided per type of premium, i.e., per line item. The retention amount is not subject to adjustment. The Government reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract. Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.4.2. Premium Adjustment Based on Laws - The rates may also be adjusted during the performance period of the contract as a result of laws enacted by the host Government if such change in the laws has a direct impact on the cost to the Contractor to perform this contract at the contracted rate. In that event, the Contracting Officer may enter into negotiations with the Contractor to modify the contract to adjust the premium rate. The Contractor agrees to provide all documentation necessary to support any requested adjustment.

B.4.2.1 Employee Pool – This clause is only in effect if the Contractor included details in its offer regarding a pooling arrangement, of which this contract is a part.

Before any adjustment is made under this price adjustment clause, the Contractor shall include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

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SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America (“The Government”) requires Health Insurance coverage for its employees as further described in C.1.2 in Indonesia.

C.1.1 Employee and Dependent Health Service Benefits

The health benefits under this contract are as follows. Reimbursement of covered expenses is limited to the stated maximums and percentages of reasonable and customary costs. Proposals that contain more benefits (even if there is no increase in cost) or fewer benefits than stated in the solicitation may be deemed technically unacceptable.

Reimbursements or payments shall be made for the following covered benefits, subject to reasonable and customary costs in the locality where treatment was provided. The medical treatment must be prescribed or provided by a physician or nurse licensed in Indonesia, the United States, or in the country in which the treatment or prescription is received. Coverage of expenses will be provided in Indonesian Rupiah.

Contractor is encouraged to provide the off the shelf plan for each benefit level below.

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care): Minimum Coverage - 100%

Services and supplies provided during hospitalization including services provided by a licensed healthcare provider, bed, and board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, and general hospital nursing care, physical therapy, as well as drugs and medicines administered while in-patient. When private accommodations are provided, coverage will be limited to the cost of a semi-private room unless otherwise covered in an off the shelf plan. See Mental Health and Substance Abuse care (C.1.1.13) for details concerning inpatient psychiatric care.

See Mental Health and Substance Abuse Care (below) for details concerning inpatient psychiatric care.

See Outpatient Services (below) for details concerning professional services.

C.1.1.2 Emergency Services (Trips to Emergency Room): Minimum Coverage - 100%

Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.

C1.1.3 Ambulance: Minimum Coverage - 80%

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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.1.1.4 Outpatient Services: Minimum Coverage - 80%

Services provided by a licensed healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon’s fees and other medical services provided at a hospital, clinic, doctor’s office, medical facility, etc. Examples include, but are not limited to:

C.1.1.4.1 Professional services and treatment: doctors’ and surgeons' fees incurred at a hospital on an out-patient basis to include annual physical examination, at a clinic or doctor's office, at home, or via telemedicine consultation.

C.1.1.4.2 Specialist’s consultations and treatment, including second surgical opinion.

C.1.1.4.3 Minor surgical interventions.

C.1.1.4.4 Physiotherapist’s fee, chemotherapy, hemodialysis, and radiation treatments.

C.1.1.4.5 Vaccination (immunization) recommended by local authorities and/or the World Health Organization.

C.1.1.4.6 Medical services & expenses when not hospitalized such as, diagnostic tests, diagnostic imaging, laboratory test and x-rays.

See Rehabilitative and Habilitative Services and Devices (below) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (below) for details concerning psychiatric therapy.

C.1.1.5 Obstetric and Newborn Care: Minimum Coverage - Inpatient care 100% and Outpatient care 80%

Care and services that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and outpatient care for newborn babies. Hospitalization during pregnancy and/or delivery will be reimbursed as inpatient care. All other treatments will be considered outpatient services and will be reimbursed at that rate.

There is no limitation of obstetrical care based on age or total number of prior deliveries per employees and/or spouse (for delivery expenses only).

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C.1.1.6 Pediatric Services: Minimum Coverage - Inpatient care 100% and Outpatient care 80%

Primary and preventive routine care services for covered dependent children, including, but not limited to physical examinations, developmental assessments, laboratory tests, and vaccinations (immunizations) recommended by local authorities and/or the World Health Organization.

C.1.1.7 Prescription Drugs: Minimum Coverage - Inpatient care 100% and Outpatient care 80%

Medications prescribed by a licensed health care provider that are medically required. Examples include but are not limited to prescription antibiotics to treat an infection, medication used to treat an ongoing condition, such as high cholesterol, prophylaxis, contraceptive medication.

Prescription medicines and drugs for which prescription is legally required. Expenses incurred for medicines, vitamins, cold remedies, etc., that are available over the counter without prescription will not be reimbursed even if prescribed by a physician.

C.1.1.8 Preventive and Wellness Services and Chronic Disease Management: Minimum Coverage - 80%

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes and covering pandemic associated cost but not covered by host-Government. Examples include, but are not limited to: physicals examination, vaccination/immunization, testing, and cancer screenings.

C.1.1.9 Hearing Aids: Minimum Coverage - 80% with annual cap, Maximum Rp.

22,500,000 covered individuals in three year period.

Examinations and Treatments.

Hearing Aid Apparatus: Limited to one apparatus per ear.

C.1.1.10 Optical Care: Minimum Coverage - 80% with Rp 4,500,00 covered individual in a two year period

Examinations and treatment.

Prescription lenses and frames or contact lenses.

C.1.1.11 Dental Care: Minimum Coverage – 80% with an annual cap of Rp 22,500,000 cover individual per contract year. Orthodontia: Minimum Coverage – 80% with a contract lifetime cap.

General Dental Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, inlays and onlays, extractions, false teeth, crowns, and bridges; expenses for professional dental treatment and services for fillings, examinations and treatment of abscesses

191D3222R0016 Health Insurance for LES U.S. Embassy Jakarta Page 11/72 and root canal, pins for cusp restorations, scaling, polishing, prophylaxis, expenses for dentures as result of loss of teeth, implant, dental treatment, and services which shall include periodontal surgery and other oral surgery.

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 Rp. 36,000,000 lifetime limit.

C.1.1.12 Reproductive Health: Minimum Coverage – 80%

Prescribed contraceptive devices, preventive care and routine examinations, voluntary sterilization, and diagnosis and treatment of conditions which may cause infertility.

Assisted reproductive technology (ART), fertility treatments, and reversal of sterilization are not covered (see Exclusions to Coverage).

C.1.1.13 Mental Health and Substance Abuse Care: Minimum Coverage – 50%

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 provided at a facility licensed for detoxification and rehabilitation.

C.1.1.14 Rehabilitative and Habilitative Services and Devices: Minimum Coverage – 50%

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke or physical therapy after an accident) and habilitative services (e.g., developing skills, such as speech therapy for children, etc.) 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.1.1.15 HIV/AIDS Expanded Coverage: Minimum Coverage – Rp 60,000,000 per covered individual per contract year.

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.1.1.16 Catastrophic Coverage: RESERVED

C.1.1.17 Out-of-Country Medical Treatment: RESERVED

C.1.1.18 Out-of-Country Medical Travel: RESERVED

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C.1.1.19 180 Day Coverage for Dependents After Employee’s Death: Minimum Coverage

– 100%

At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 180 days. This optional benefit is subject to availability of funds at post and no extensions are permitted.

C.1.1.20 Employee Assistance Program (EAP): RESERVED

C.1.1.21 Excess Coverage:

Additional coverage equal to 100% of the annual maximum or Rp.274,000,000 per covered individual per contract year. This excess coverage will be offered as an optional benefit to LE Staff. This can be used for any covered individual for any covered benefit that exceeds annual maximum, including to cover additional children (see C.1.4.1.1.2 for maximum number of children covered by U.S. Government). LE Staff must pay 100% of the premium if they elect Excess Coverage. The premium for this additional coverage is a rider to be paid by the employee to the vender directly and USG will not be responsible for collecting of these premium payments.

C.1.2 Annual Maximum Limit:

C.1.2.1 For section C.1.1.1 through C.1.1.14 and C.1.1.19 is Rp. 274,000,000 per covered individual per contract year

C.1.2.2 For section C.1.1.15. HIV/AIDS expanded coverage is Rp.60,000,000 per covered individual per contract year

C.1.2.3 For Section C.1.1.21 Excess Coverage is Rp. 274,000,000 per covered individual per contract year and must be paid by LE Staff directly to the vender.

C.1.3. Exclusions and Limitations

C.1.3.1. There is no coverage 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, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); Lasik or similar elective eye surgery; and/or services or supplies which have not been prescribed or approved by a certified health care provider;

C.1.3.2. There is no coverage for medical expenses incurred out-of-country. There is no reimbursement for out-of-country treatment

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C.1.3.3. There is no coverage 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.1.3.4. There is no coverage for infant tube technology, impotence, sex changes, and sexual transmitted disease.

C.1.3.5. There is no coverage for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient - e.g. not carrying the driver license while driving etc.; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self-inflicted wound; or service in the armed forces of any country; riot, civil war either announced or not; treatment and medication arising from participants in noncommercial/unscheduled flight; no reimbursement for cost resulting from participants driving on becoming passenger of vehicle used for safety impact, road, or speed trial.

C.1.3.6. There is no reimbursement for treatment or surgery due to obesity and/or thinness and baldness, or treatment to increase/reduce weight.

C.1.3.7. There is no reimbursement for medical or surgical services or procedures that are experimental or unrecognized as standard medical treatment by the medical profession e.g. ozone therapy, chelation therapy, iridology, cell implant therapy, laser therapy for refractive correction, other forms of exposure to cosmetics or aesthetics or medicine which has not been approved by the Ministry of Health of the Republic of Indonesia through the Directorate General of Drug and Food Control, including traditional medicine, alternative medicine, hyperbaric treatment, chiropractic treatment, and naturopathic treatment; all costs arising from the participant donating organs and/or blood, but if the Participant receives donations of organs and / or blood, then the fee paid is the Cost of Inpatient in accordance with the maximum limit received by the Participant, but excluding the cost of obtaining body organs and/or all previous examination fees.

C.1.3.8. There is no reimbursement for treatment and medication of effect of radiation, ionization, or contamination by radioactive material from any nuclear fuel or nuclear waste from the process of smelting nuclear material or from nuclear weapons materials.

C.1.3.9. There is no coverage for donation fees for social organization.

C.1.3.10. There is no coverage for expenses incurred after an employee leaves the service of the Bi-Mission.

C.1.3.11. Exclusions to coverage may be amended if provided in off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusions require prior authorization.

C.1.4 Eligible Participants

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C.1.4.1 Identification of Eligible Employees and Dependents: Bi-Mission Indonesia will provide a list of all eligible employees and dependents with relationship to employee (self/spouse/child) and DOB for each. Updates will be provided to add or remove individuals on a bi-weekly/monthly basis.

C.1.4.1.1 Definition of Dependents: LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

C1.4.1.1.1 Spouse: a limit of one legal spouse as defined by local law per employee will be covered. LE Staff with more than one legal spouse must select only one spouse coverage.

In cases where LE Staff and their legal spouse both work for the mission and both are eligible to participate in the medical plan, one will be designated as the lead for purposes of the medical plan, and the other will be considered a legal spouse.

C.1.4.1.1.2 Children: a 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, up to a maximum of three children. 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.

LE Staff with more than three legal children who are eligible to participate in the Bi-Mission medical plan can register their additional children. LE Staff must pay 100% of the premium for any covered benefits.

Parents, grandparents, siblings, and other relatives are not eligible dependents.

C.1.4.2. Location of Employment: The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Indonesia by:

U.S. Department of State –Jakarta U.S. Consulate – Medan U.S. Consulate General – Surabaya U.S. Consular Agency –Bali US Agency for International Development (USAID) Foreign Agriculture Service (FAS) Foreign Commercial Service (FCS) Library of Congress (LOC) Department of Justice (DOJ) Center for Disease Control (CDC) International Broadcasting Bureau/Voice of America (IBB/VOA) Defense Attaché Office (DOD-DAO) Immigration and Custom Enforcement (DHS-ICE) Drugs Enforcement Administration (DEA) International Narcotics and Law Enforcement Affairs (INL)

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Office of Defense Cooperation (DOD-ODC) Defense Threat Reduction Agency (DOD-DTRA) Facility Engineer Command (DOD-NAVFAC) Force Protection Detachment (DOD-FPD) Millennium Challenge Corporation (MCC)

C.1.4.3. Participants Covered Under a Rider: All current active ORE Staff personally employed by the Chief of Mission and the Deputy Chief of Mission and assigned to their respective official Government residences and paid under an ORE account. All costs for coverage of ORE Staff are the responsibility of the Chief of Mission and the Deputy Chief of Mission, not the U.S. Government.

C.1.5. Eligibility

C.1.5.1. Term of Eligibility and Effective Date

Each current active eligible employee and their eligible dependents are enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee and eligible dependents 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.

C.1.5.2 Individuals Not Eligible for Coverage

Not eligible are those working under temporary appointments; those working under a PSC or PSA that is time limited to less than one year; non-personal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Indonesia who provides services to other local organizations as well as to the U.S. Mission; employees with an intermittent, seasonal, or WAE (when actually employed) schedule; employees of USAID institutional contractors; Peace Corps personal services contractors as indicated in MS 743;

Recreation Association employees; and any other individual not falling within one of the categories of employees described in this clause. There is no coverage for retired employees.

C.1.5.3 Periods 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 Leave Without Pay (LWOP) or unpaid leave beyond one pay period, 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 they prefer not to pay the premium.

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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 21 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) business 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, coverage, and contract terms 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 document contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the U.S. 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.

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SECTION D

PACKAGING AND MARKING

(RESERVED)

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SECTION E

INSPECTION AND ACCEPTANCE

E.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. In addition, the full text of a clause may be accessed electronically at: Acquisition.gov this address is subject to change.

If the Federal Acquisition Regulation (FAR) is not available at the location indicated above, use the Department of State Acquisition website at e-CFR to see the links to the FAR. You may also use an Internet “search engine” (for example, Google, Yahoo or Excite) to obtain the latest location of the most current FAR.

The following Federal Acquisition Regulation clause(s) is/are incorporated by reference:

CLAUSE TITLE AND DATE

52.246-4 INSPECTION OF SERVICES - FIXED PRICE (AUG 1996)

E.2. QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

This plan is designed to provide an effective surveillance method to promote effective Contractor performance. The QASP provides a method for the Contracting Officer's Representative (COR) to monitor Contractor performance, advise the Contractor of unsatisfactory performance, and notify the Contracting Officer of continued unsatisfactory performance. The Contractor, not the Government, is responsible for management and quality control to meet the terms of the contract.

The role of the Government is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective

PWS

Paragraph Performance Threshold

Services Performs all the insurance services set forth in the Performance Work Statement (PWS)

C.1.0 thru C.1.6

All required services are performed and no more than three (3) formal customer complaint are received per month

E.2.1 Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided. If appropriate, the COR will send the complaints to the Contractor for corrective action.

E.2.2 Standard. The performance standard is that the Government receives no more than three

(3) formal customer complaints per month. The COR shall notify the Contracting Officer of the

191D3222R0016 Health Insurance for LES U.S. Embassy Jakarta Page 19/72 complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR 52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of Services clause), if any of the services exceed the standard.

E.2.3 Procedures

(a) If any Government personnel observe unacceptable services, either incomplete work or required services not being performed, they should immediately contact the COR.

(b) The COR will complete appropriate documentation to record the complaint.

(c) If the COR determines the complaint is invalid, the COR will advise the complainant. The COR will retain the annotated copy of the written complaint for his/her files.

(d) If the COR determines the complaint is valid, the COR will inform the Contractor and give the Contractor additional time to correct the defect, if additional time is available. The COR shall determine how much time is reasonable.

(e) The COR shall, as a minimum, orally notify the Contractor of any valid complaints.

(f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR. The COR will review the matter to determine the validity of the complaint.

(g) The COR will consider complaints as resolved unless notified otherwise by the complaint.

(h) Repeat customer complaints are not permitted for any services. If a repeat customer complaint is received for the same deficiency during the service period, the COR will contact the Contracting Officer for appropriate action under the Inspection clause.

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SECTION F

DELIVERIES OR PERFORMANCE

F.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

they were given in full text. Upon request, the Contracting Officer will make their full text available. In addition, the full text of a clause may be accessed electronically at: Acquisition.gov this address is subject to change.

If the Federal Acquisition Regulation (FAR) is not available at the location indicated above, use the Department of State Acquisition website at e-CFR to see the links to the FAR. You may also use an Internet “search engine” (for example, Google, Yahoo or Excite) to obtain the latest location of the most current FAR.

The following Federal Acquisition Regulation clauses are incorporated by reference:

CLAUSE TITLE AND DATE

52.242-15 STOP WORK ORDER (AUG 1989)

52.242-17 GOVERNMENT DELAY OF WORK (APR 1984)

F.2 PERIOD OF PERFORMANCE. The performance period of this contract is one year beginning on date established in the Notice to Proceed (NTP) and continuing for twelve (12) months with four (4) one-year options to renew. This contract also includes an additional option under FAR 52.217-8.

F.3 OPTIONS

(a) The Government may extend this contract in accordance with the option clause at Section I, clause I.2, FAR Clauses Incorporated by Full Text (FAR 52.217-9, Option to Extend the Term of the Contract), which also specifies the total potential duration of the contract.

(b) The Government may exercise the option set forth at Section I, "FAR 52.217-8, Option to Extend Services".

F.4 REPORTS AND OTHER DELIVERABLES

All reports must be provided in electronic format to the COR in either PDF or XLSX (MS Excel) format, depending on the type of report. Any report including claims information must be submitted in XLSX format. All reports and other deliverables required under this contract shall be delivered to the following address:

Human Resources Office US Embassy Jakarta

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Jl. Medan Merdeka Selatan No. 3-5 Jakarta 10110 Remarks: LES Health Benefit Contract

Or via email: JakartaHROCBU@state.gov

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SECTION G

CONTRACT ADMINISTRATION DATA

G.1. 652.242-70 CONTRACTING OFFICER’S REPRESENTATIVE (COR) (AUG 1999)

(a) The Contracting Officer may designate in writing one Government employee, by name or position title, to take action for the Contracting Officer under this contract. This designee shall be identified as a Contracting Officer’s Representative (COR). Such designation shall specify the scope and limitations of the authority so delegated; provided, that the designee shall not change the terms or conditions of the contract, unless the COR is a warranted Contracting Officer, and this authority is delegated in the designation.

(b) The COR for this contract is the Human Resources Officer.

G.2 COR DUTIES

G.2.1 The COR is responsible for inspection and acceptance of services. These duties include review of Contractor invoices, including the supporting documentation required by the contract. The COR may provide technical advice, substantive guidance, inspections, invoice approval, and other purposes as deemed necessary under the contract.

G.2.2 In addition, the COR shall maintain updated list of employees and dependents insured, which will supersede the initial list provided under this contract and as reported to the insurer, without prejudice to the ineligibility clause.

G.2.3. The COR has the additional responsibility of maintaining the eligible listing of employees and dependents for insurance coverage.

G.2.4 The COR may not change the terms and conditions of the contract. While the COR is authorized to provide the Contractor with updated listings of eligible employees and dependents, only the Contracting Officer may modify existing task orders or issue new task orders, reflecting these changes, since only the Contracting Officer can obligate funding and commit the Government.

G.3. Payments: payments shall be made in Indonesian Rupiah (IDR), per the Bank Indonesia Regulation No. 17/3/PBI/2015.

G.4 SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices. All invoices for U.S. Government employees shall be submitted as one set of electronic copies (either in PDF or XLS format) to the Financial Management Office. The email address for the submission is JakartaFMCAccountants@state.gov.

G.4.2. Frequency of Payments. All funds under this contract will be obligated by issuance of task orders, as described in H.3. Each task order will fund a specific period of time and number of employees, and the task orders will be issued at the frequency described in H.3. All payments

191D3222R0016 Health Insurance for LES U.S. Embassy Jakarta Page 23/72 under this contract will be made at the conclusion of the period covered. Invoices may be submitted quarterly with payments being made quarterly by the Government.

G.4.3. U.S. Government Employees. The Government shall make payments directly to the Contractor for all Government employees, whether or not the employee is contributing to the basic premium amount.

G.4.4. Riders:

ORE. The Chief of Mission and/or Deputy Chief of Mission will make payment directly to the Contractor for the entire premium amount of the ORE staff, whether or not the ORE employee is contributing to the premium amount.

G.5 REFUNDS TO THE GOVERNMENT

If at any time during performance of the contract the Government finds that the Contractor has been overpaid because the number of employees and/or dependents covered has decreased, the Contracting Officer may either allow that overpayment to be credited to the Government’s account or require that the Contractor refund the overpayment. If the Contracting Officer requests a refund, the Contractor shall make that refund to the Government within ten calendar days of receipt of the request.

G.6 VALUE ADDED TAX (VAT)

As health insurance is not included as VAT object in Indonesia, no VAT will be billed or collected by Contractor.

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SECTION H

SPECIAL CONTRACT REQUIREMENTS

H.1 SECURITY. On occasion, a Contractor employee may require entry into U.S.

Government-owned or -operated facilities. If so, the Contractor should be prepared to provide the necessary identification to permit escorted access within that facility.

H.2 STANDARDS OF CONDUCT. The Contractor shall maintain satisfactory standards of employee competency, conduct, cleanliness, appearance, and integrity and shall be responsible for taking such disciplinary action with respect to employees as may be necessary. Each Contractor employee is to adhere to standards that reflect credit on themselves, their employer, and the United States Government.

H.3 ORDERING PROCEDURES. The Government will issue a task order within 90 days after contract award to identify all employees to be covered by the insurance described in this contract and the coverage selected by each employee, including dependents to be covered. The COR will make subsequent additions or deletions to this list in writing and provide the revised list to the Contractor. All such revisions shall be consolidated, and a new or modified task order will be issued by the Contracting Officer. If any changes have been made to the coverage listing, the Government anticipates issuance of a new task order on a quarterly basis (i.e., once every 3 months). This new task order will include all changes made since the previous task order was issued and will include any increase or decrease in necessary funding. The changes to the list of eligible individuals will supersede the initial list provided under prior task orders without prejudice to the ineligibility clause. Task orders will indicate the effective date of employment, for purposes of calculating the premium due.

H.3.1. Riders are not included under the task orders issued by the Contracting Officer. Because their coverage is under a rider, their employer are themselves are responsible for directly interacting with the Contractor to order any coverage. When contacted, the Contractor shall advise the person of the paperwork and payment that will be necessary to order coverage for the identified individuals. The Contractor may be contacted by more than one individual. Because more than one employer may have ORE staff, the Contractor may be contacted by more than one employer (typically the Chief of Mission, Deputy Chief of Mission and Consul General Surabaya.)

H.4. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS

General.

The Contractor shall be responsible for all planning, estimating, programming, project management, scheduling, dispatching, supervision, and inspection of work. The Contractor shall maintain his own reference library of technical reference works and local laws and regulations, including current tariffs and registries. The Contractor shall treat the information provided by the Embassy concerning employee' personal data, medical information, and salaries as highly

191D3222R0016 Health Insurance for LES U.S. Embassy Jakarta Page 25/72 sensitive and not divulge any employee information to unauthorized persons. The Contractor shall establish procedures for handling medical insurance claims as follows:

(a) Administrative Records

(1) The Contractor shall maintain medical insurance files for each covered employee and each covered dependent including receipts and proof of paid claims, requests for claim reimbursements, and accounting of paid benefits with balances of amounts remaining in the annual per person reimbursement ceiling.

(2) The Contractor shall provide the COR with the necessary claim forms for each type of benefit that can be claimed under the contract. These forms shall specify a list of documents required to be appended to each claim and otherwise provide instructions for claim filing.

(3) The Contractor shall use the English spelling of the employees' names in all transactions, including reimbursement checks.

(4) The Contractor shall send employee claim reimbursement checks to employees not later than two weeks after a claim is submitted.

(b) Medical Insurance Claims. Settlement of medical insurance shall be completed as follows:

(1) All medical claims shall be submitted directly to the Contractor by employees, through a drop box in the COR's office. The claims shall be picked up from the COR each Tuesday.

(2) The Contractor shall date stamp and screen all claims submitted on the day of receipt. If there are any missing documents or information thereby disallowing said claim to be payable, the Contractor shall notify the employee within two days, with a copy to the COR (if notification is written).

(3) The Contractor shall settle the claims no later than two weeks from the date the claim is submitted to the Contractor.

(4) Settlement shall be by issuance of checks in the name of the employee for each claim submitted. Each check shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any.

(5) The Contractor shall accept the employee's or dependent's choice to go for surgery to hospitals designated by the Contractor in order that the Contractor will pay the expenses directly to the hospitals.

H.5. REPORT REQUIREMENTS.

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(a) The Contractor shall provide the following monthly report. The report shall be received by the COR no later than the 10th day of each month. The report shall report on the previous month's activities.

(b) Employee Claims Report. The report shall list all claims paid by the Contractor to a claimant, including the name of the claimant, date claim is received by the Contractor, and the amount claimed. This report shall also include all outstanding claims and a brief description of why claim has not been paid. The report shall not include any claims information for riders.

H.6. MISCELLANEOUS CONTRACTOR REQUIREMENTS

H.6.1. General. The Contractor shall take all such steps as are necessary, and obtain and pay for all permits, taxes and fees as are required by…