Tirana HI Solicitation QA Responses cleared.docx

19AL6020R0001 Questions & Answers October 28, 2020

All Prospective Offerors

Re: Solicitation 19AL6020R0001: Health Insurance Contract

Dear Prospective Offerors:

In reference to this solicitation, we received many questions from prospective offerors. These questions are listed below, with responses embedded therein. We have combined some questions from perspective offerors because of their similarity. When appropriate to support our responses, we have included respective data.

Question No. 1: Please inform us if the documentation such as for ex. the balance sheet, or other certifications, have to be provided in English or in Albanian, as issued by the respective authorities.

Response No. 1: All documents shall be translated into English and certified by a notary.

Question No. 2: Please indicate whether the Declaration on the “probationary, disciplinary or actions taken upon the offeror, which are in force or are about to be imposed upon the offeror by the Government of Albania or its agents” should be in e form of self-declaration or an official document issued by the respective authorities.

Response No. 2: A self-declaration form will be sufficient.

Question No. 3: Please provide five years of loss data by year of account including annual net premium (for the same period), incurred claims and membership history. For membership history please provide the number of Employees with single coverage and with family coverage at the end of each year. Please do not include any confidential information, just the overall statistics for the group. Claims information is critical to our pricing and the relationship of claims to employee growth or shrinkage is part of the claims analysis.

Response No. 3: Since we are in the fifth year of the current contract, below is four years of loss data by year (including annual net premium paid by the Embassy and incurred claims by year). Fifth year calculations (1 April 2020 – 31 March 2021) are estimates based on previous trend and number of insured.

Total Gains/losses

· Membership history:

Question No. 4: We would like to know if you have been informed of Catastrophic cases, such as: Hemodynamics, Open Heart Surgery, Orthopedic Mayor Surgeries, Organ Transplant, Traumatic Accident, Cancer and Oncology Cases (Radio and Chemotherapy), and hospitalizations with more than 10 days

Response No. 4: From 2016 to 2020 YTD, there have been 31 cases of long-term sick leave at the Embassy. Long-term sick leave is connected with an extended illness that lasts over 14 calendar days. We do not have specific information about catastrophic cases.

Question No. 5 Please inform us on the no. of insureds whose have chronic conditions. Please provide statistical details and do not include any confidential information. How many insureds are actually chronically ill? Which is their average claim amount per year?

Response No. 5: Please refer to Response No. 4.

Question No. 6: What is the number of current pregnancies, as well as no. average annual pregnancies, based on your data?

Response No. 6: From 2016 to 2020 YTD, there have been 23 cases of pregnancy leave requests.

Question No. 7: What is the name if the insurance company that currently provides coverage?

Response No. 7: Eurosig Sh.a is the Embassy’s current health insurance provider.

Question No. 8: Is there a preferred list of Hospitals, Clinics or other Medical Facilities that the Embassy employees prefer? If yes, please provide a list of these facilities

Response No. 8: Embassy employees generally prefer the major medical facilities located in Albania: American Hospitals 1, 2, 3; Hygeia; Salus; German Hospital; Amavita; Continental; ABC Clinic; Pro-Life; Laboratory Genius; Intermedica. However, the offeror should provide a closed list of in-network hospitals and other medical facilities

Question No. 9: Would U.S. Embassy in Tirana accept a consortium of insurance companies that intend to submit a proposal for customized health insurance for locally engaged employees and their dependents?

a) the consortium may be composed by insurance companies registered and authorized by the Government of the Republic of Albania

b) the consortium may be composed one insurance company registered and authorized by the Government of the Republic of Albania and another insurance company registered and authorized by the by a government other than Albania.

Response No. 9: The HI Solicitation is clear in its requirements, and the U.S. Embassy in Tirana invites all prospective offerors to structure their responses to the HI Solicitation as they deem best. Each prospective offeror can propose a response to the HI Solicitation, pursuant to its best judgment, operational structure, and business. All proposals will be evaluated openly and fairly by defined criteria.

Question No. 10: we reserve the right to make other additional questions that may arise, and we are conscious that may not receive the reply immediately in the meeting, but later on in the coming days by email.

a. Please explain us the aim of the provision: “Indemnification and Medical Liability Insurance”?

Response 10 (a): Per Section 52.237-7: (a)It is expressly agreed and understood that this is a nonpersonal services contract, as defined in Federal Acquisition Regulation (FAR) 37.101, under which the professional services rendered by the Contractor are rendered in its capacity as an independent contractor. The Government may evaluate the quality of professional and administrative services provided, but retains no control over professional aspects of the services rendered, including by example, the Contractor’s professional medical judgment, diagnosis, or specific medical treatments. The Contractor shall be solely liable for and expressly agrees to indemnify the Government with respect to any liability producing acts or omissions by it or by its employees or agents. The Contractor shall maintain during the term of this contract liability insurance issued by a responsible insurance carrier of not less than the following amount(s) per specialty per occurrence: $750,000.00 (b)An apparently successful offeror, upon request by the Contracting Officer, shall furnish prior to contract award evidence of its insurability concerning the medical liability insurance required by paragraph (a) of this clause.

(c)Liability insurance may be on either an occurrences basis or on a claims-made basis. If the policy is on a claims-made basis, an extended reporting endorsement (tail) for a period of not less than 3 years after the end of the contract term must also be provided.

(d)Evidence of insurance documenting the required coverage for each health care provider who will perform under this contract shall be provided to the Contracting Officer prior to the commencement of services under this contract. If the insurance is on a claims-made basis and evidence of an extended reporting endorsement is not provided prior to the commencement of services, evidence of such endorsement shall be provided to the Contracting Officer prior to the expiration of this contract. Final payment under this contract shall be withheld until evidence of the extended reporting endorsement is provided to the Contracting Officer.

(e)The policies evidencing required insurance shall also contain an endorsement to the effect that any cancellation or material change adversely affecting the Government’s interest shall not be effective until 30 days after the insurer or the Contractor gives written notice to the Contracting Officer. If, during the performance period of the contract the Contractor changes insurance providers, the Contractor must provide evidence that the Government will be indemnified to the limits specified in paragraph (a) of this clause, for the entire period of the contract, either under the new policy, or a combination of old and new policies.

(f)The Contractor shall insert the substance of this clause, including this paragraph (f), in all subcontracts under this contract for health care services and shall require such subcontractors to provide evidence of and maintain insurance in accordance with paragraph (a) of this clause. At least 5 days before the commencement of work by any subcontractor, the Contractor shall furnish to the Contracting Officer evidence of such insurance.

b. Please inform us if there will be a request for the Financial Statements?

Response 10 (b):Yes, please refer to Section L.9 in the solicitation

c. Please indicate if this provision is applicable for Albania “The small business size standard is __38,500,000 million dollars”.

Response 10 (c): No. This is for U.S. companies.

d. Profit sharing credit plan?

Response 10 (d): The HI Solicitation is clear in its requirements as set forth in L.4.3.3 Each prospective offeror can propose a response to the HI Solicitation, pursuant to its best judgment, operational structure, and business. All proposals will be evaluated openly and fairly by defined criteria.

e. Employee pool?

Response 10 (e): For quantity of plans and cost estimates, please refer below:

· Self-Only: one covered individual – 55 plans

· Self Plus One: two individuals – 62 plans

· Family: three or more individuals – 148 plans

Question No. 11: List of Items, Schedule of Requirements, Scope of Work, Terms of Reference, Bill of Materials required

Response No. 11: All information is included in the Solicitation document published in Beta.Sam.Gov.

Question No. 12: Soft Copy of the Tender Document through email

Response No. 12: Solicitation document can be downloaded from Beta.Sam.Gov.

Question No. 13: Names of countries that will be eligible to participate in this tender

Response No. 13: The procedure is Full and Open Competition

Question No. 14: Information about the Tendering Procedure and Guidelines Response No. 14: Answer: This is based on Procurement guidance and/or prevailing practice in contracting process.

Question No. 15: Estimated Budget for this Purchase Response No. 15: Answer: This is based on Procurement guidance and/or prevailing practice in contracting process.

Question No. 16: Any Extension of Bidding Deadline?

Response No. 16: There is no Extension of bidding deadline. Current due date is November 16, 2020, at Tirana local time (1630 hours) when proposals are due.

Question No. 17: Any Addendum or Pre Bid meeting Minutes?

Response No. 17 Q&A and Pre-Bid meeting Minutes will be published on Beta.Sam.Gov.

Question No. 18: Could you please provide information about the claims you have had outside of Albania during your current coverage?

Response No. 18: The amount of claims paid out for services outside of Albania from 2016 until YTD is 10,035,987.69 ALL.

Question No. 19: Could the price proposal be in USD?

Response No. 19: The proposal must be in ALL as the contract is paid in ALL. Even though the awarded prices and payments will be in local currency, the solicitation does allow for proposals to be submitted in more than one currency.

52.225-17 EVALUATION OF FOREIGN CURRENCY OFFERS (FEB 2000):

If the Government receives offers in more than one currency, the Government will evaluate offers by converting the foreign currency to United States currency using the exchange rate used by the Embassy in effect as follows:

(a) For acquisitions conducted using sealed bidding procedures, on the date of bid opening.

(b) For acquisitions conducted using negotiation procedures—

(1) On the date specified for receipt of offers, if award is based on initial offers; otherwise

(2) On the date specified for receipt of proposal revisions.

Question No. 20: What does the annual cap term, stand for, and please give an example?

“Prescription lenses and frames, or contact lenses: Covered up to a maximum of 31,734 ALL per covered individual every two years. 80% Minimum Coverage; with annual cap.”

“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 253,872 ALL lifetime limit. 80% Minimum Coverage; with contract lifetime cap”.

Response No. 20: The annual cap refers to the maximum amount of coverage for the service taken, per individual per contract year or as otherwise stated in the solicitation.

As set forth in C.1.1.10 Optical Care, this cap is applicable per covered individual every two years. Per C.1.1.11 Dental Care under Orthodontia: this cap is applicable per covered individual up to a maximum of 253,872 ALL for four years.

Question No. 21: What does the lifetime cap term, stand for, please give an example. Is this a 5 year limit of coverage?

C.1.1.11Dental Care: Minimum Coverage – 80% 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 253,872 ALL lifetime limit. 80% Minimum Coverage; with contract lifetime cap.

Response No. 21: According to C.1.1.11, the maximum of 253,872 ALL per individual of four years of orthodontia treatment cannot be exceeded.

Question No. 22: Should the Insurer create a list of covered examinations? Does highlighted section above, belong here? or does it also refer to Outpatient Services?

Response No. 22: As set forth in C.1.1.4, the insurer should create a list of covered examinations “Annual physical examinations. The Contractor shall provide a check-up list of covered services and tests by gender and age group. “

Question No. 23: C.1.1.18&20 Reserved. What does this cover stands for?

Response No. 23: These are sections covering optional benefits that do not apply to this contract.

Question No. 24: Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest cost and technically acceptable. Please give an interpretation of this sentence.

Response No. 24: If an off-the-shelf health plan includes for example "massage" therapy," the Embassy would consider deleting massage therapy from the "exclusion" list" accepting that benefit if the proposal is otherwise lowest cost, technically acceptable.

Question No. 25: Network providers. Will the insured be entitled to receive treatment only in Insurer's medical providers, or the network providers shall not be considered?

Response No. 25: No. The insured is free to choose whether to go to the in-network providers or out-of-network ones.

Question No. 26: Liability insurance 175,000 USD per provider or per insurer?

Response No. 26: Per 52.237-7, “The Contractor shall maintain during the term of this contract liability insurance issued by a responsible insurance carrier of not less than the following amount(s) per specialty per occurrence: USD 175,000... Liability insurance may be on either an occurrences basis or on a claims-made basis. If the policy is on a claims-made basis, an extended reporting endorsement (tail) for a period of not less than 3 years after the end of the contract term must also be provided.”

Question No. 27: In the third year there is a reduction of claims with 50%. Which were the reasons behind this reductions, to what service not being used, is this reduction mainly related to?

Response No. 27: Claims have been quite unpredictable due to usage and some high value incidents.

Question No. 28: Additional cover, for those choosing the rider tariff, will there be sublimit for services like for example dental and optical?

Response No. 28: No. For the participants in the plan covered under a Rider, the service levels are the same as for the primary participants (U.S. Embassy locally employed staff).

Question No. 29: How many insured are being treated for malignant cancer Response No. 29: Please refer to Response No. 4.

Question No. 30: What is the procedure we should follow for the 2% tax on each invoice to be retained by the Government?

Response No. 30: While there is no separate CLIN for this since the winning proposal may qualify for an exemption, please reference details on the Zadroga Act from the two FAR referenced contained in the RFP.

Question No. 31: In case two companies will be joined together to offer health insurance services, what is the technical procedure required to be followed? How should we submit the documentation?

Response No. 31: The HI Solicitation is clear in its requirements, and the U.S. Embassy in Tirana invites all prospective offerors to structure their responses to the HI Solicitation as they deem best. All documentation should be submitted in accordance to solicitation. Each prospective offeror can propose a response to the HI Solicitation, pursuant to its best judgment, operational structure, and business. All proposals will be evaluated openly and fairly by defined criteria.

Question No. 32 Can you clarify the Reasonable and Customary costs disposition? Do we need to share the prices provided by the medical providers in Albania?

Response No. 32: Yes. We are not only asking you to provide a closed list of these reasonable and customary costs, but we request as well to share with us the standard you have used to come up with these reasonable and customary costs.

Question No. 33 Can we add in the brochure the services that require pre-approval from the insurer?

Response No. 33: Yes. Please add those in the brochure and explain the pre-approval procedure to be followed as well.

Question No. 34: Under the exclusion disposition the long-term rehabilitative therapy is excluded from coverage, while in C.1.1.14 Rehabilitative and Habilitative Services and Devices are covered at 50%. How should the offeror understand this? What do you consider as long-term rehabilitative therapy?

Response No. 34:

Rehabilitative services as defined in C.1.1.14 is a beneficial but temporary solution to help a patient who is unable to perform daily tasks during the healing period following a surgery, illness, or other medical condition that is expected to improve. In other words, the problem is not permanent. Generally, the hospital or health care provider determines how much rehabilitative services is needed to improve the condition. For example, a person breaks a leg or has knee surgery and is given 6 weeks of rehabilitative services or physical therapy after being released from a hospital after surgery. Sometimes this care happens in the rehabilitative section of a hospital or at a post-hospital, rehabilitative facility. Another example is a patient who is recovering from a stroke and is transferred to a rehabilitative facility where the patient receives skilled nursing care until they can regain strength, relearn skills for walking, talking, and eating. After a set time, they are released home.

Long-term rehabilitative therapy, which is excluded from coverage, involves medical, therapeutic, and personal care services for those with chronic or progressive medical conditions that limit their ability to function independently on a permanent basis. For example, a person is diagnosed with Parkinson’s disease, permanent disabilities, or dementia, and requires skilled nursing care in a nursing facility.

Question No. 35: Please provide information on the basis of reasonable and customary prices to be used from the Provider when calculation the claims value for:

a. Hospital Treatment

b. Ambulatory Treatment Response No. 35: As mentioned during the pre-proposal conference held on 10/20/2020 at 11:00 a.m. with possible bidders, this information is required to be provided by the insurer to the Embassy as part of the solicitation package.

Question No. 36: Please provide information on the basis of reasonable and customary prices, for specific treatment required under the solicitation as follows:

a. Optical care – on what basis the reasonable and customary prices shall be calculated for frames when compared to glasses i.e. any percentage of costs of frames toward the overall limit to be covered for frames. Question raised as luxury frames are often many times higher when compared to the cost of the optical glasses/lenses.

b. Dental treatment - on what basis the reasonable and customary will be calculated for specific treatment such as implants.

Response No. 36: As mentioned during the pre-proposal conference held on 10/20/2020 at 11:00 a.m. with possible bidders, this information is required to be provided by the insurer to the Embassy as part of the solicitation package.

Question No. 37: Please provide additional information on the limitation set on the solicitation “country medical program”. What types of country medical programs does the Embassy intend to take in consideration for the limitation, please provide a list of these medical programs and services covered by them.

Response No. 37: This is medical market research, and it is recommended that the insurer makes the list of services covered under the country medical program, and then includes it in the solicitation package.

Question No. 38: Please confirm that the Embassy has the information of claims paid for the first contractual year amount to 47,682,361.42, as the information is not included on the tender documentation, meanwhile the contract is in force since 01.04.2016.

Response No. 38: Yes. The Embassy has this information, but as per RFP regulation under EXHIBIT F it is only required to provide paid claims data for the last three years.

Question No. 39: Please confirm that the Embassy has the information that the existing provider reimbursed for dental coverage amount of ALL 6,047,505 only for the period 01.01.2016-31.03.2017, meanwhile for the last 3 years reimbursed an amount of ALL 11,953,179.90. The rate of reimbursement at 55% Response No. 39: Yes. The Embassy has this information, but the current rate of reimbursement as per contract in force is 45% of coverage for all dental services.

Question No. 40: Please provide additional information for the coverage to be provided under the terms of the solicitation will cover any medical expenses for any employee traveling abroad not for working purpose.

Response No. 40: Please refer to C.1.1.17 Out-of-Country Medical Treatment, which covers medical expenses incurred out-of-country, regardless of official or personal purpose. However, out-of-country medical travel and transportation is not a covered benefit.

Question No. 41: Please provide additional information on the request for coverage for “Rehabilitative and habilitative services and devices” as specified under C.1.1.4 Response No. 41: As set forth in HI Solicitation paragraph C.1.1.14 Rehabilitative and Habilitative Services and Devices quotes: “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.”

Question No. 42: Has there been any changes to the Table of Benefits over the past 5 years?

Response No. 42: No. Table of benefits has remained the same.

Question No. 43: Can you share the number of employees/dependents who subscribed to the Excess Coverage as well as their date of birth and gender?

Response No. 43: No employee has subscribed to the excess coverage. This benefit is a new covered benefit and is not part of our current contract.

Question No. 44: C.1.1.17 Out-of-Country Medical Treatment, page 13 in the PDF file:

Is it possible to add a maximum covered period for this benefit? 90 days?

Response No. 44: No, it is not.

Question No. 45: C.1.1.13 Mental Health and Substance Abuse Care (page 12): “Inpatient care for alcohol and substance abuse must be provided at a facility licensed for detoxification and rehabilitation.” Can we get claims experience associated with these conditions?

Response No. 45: No, mental health and substance abuse care is not covered under the terms of our current contract. This benefit is a new covered benefit and is not part of our current contract.

Thank you for your interest in this solicitation.

Sincerely, Sally B. Lewis