19BK8025R0001_Section_II_TAB_A_RFP_HealthInsurance_31Jan2025.pdf

Embassy of the United States of America Sarajevo, Bosnia and Herzegovina

Friday, January 31, 2025

Dear Prospective Offeror:

Subject: Request for Proposals number 19BK8025R0001

The Embassy of the United States of America invites you to submit a proposal for locally employed staff and eligible dependents health insurance coverage. The Embassy encourages prospective offerors to offer off-the-shelf plans that meet at least the minimum benefit levels required in this solicitation.

The U.S. Government intends to award a contract to the responsible company submitting an acceptable offer at the lowest price. We intend to award a contract based on initial proposals, without holding discussions, although we may hold discussions with companies in the competitive range if there is a need to do so.

The Embassy intends to conduct a pre-proposal conference at the site. The pre-proposal conference will be held on Tuesday, February 18, 2025, by 11:00 AM (local time) at the US Embassy in Sarajevo. Prospective offerors should contact Nedim Kapetanovic, Procurement Agent at the following e-mail address, KAPETANOVICN@STATE.GOV, by Thursday, February 13, 2025, by 12:00 AM (local time) for additional information or to arrange entry to the building.

Proposals are due by Tuesday, March 04, 2025, by 15:00 (local time). No proposals will be accepted after this time. Proposals must be in English and incomplete proposals will not be accepted.

Your proposal must be submitted in a sealed envelope marked "Proposal Enclosed for 19BK8024R0004 Health Insurance Services” for Daniel J. O’Rourke, Contracting Officer, to the address shown in block 7 on Standard Form SF-33.

Proposals submitted electronically to GSOPROCUREMENTSARAJEVO@STATE.GOV must be submitted before the date and time mentioned above (see also block 9 on SF-33). It is important to make sure the submission is made in the following specific size and format: in MS-Word 2007/2010 or MS-Excel 2007/2010 or Adobe Acrobat (pdf) file format. The file size must not exceed 50MB. If the file size should exceed 50MB, the submission must be made in separate files and attached to separate emails with less than 50MB each.

In order for a quotation to be considered, you must also complete and submit the following:

1. SF-33

2. Section B, Pricing Schedule.

3. Section B, Retention Amounts in B.3 and B.7.

4. Section K, Representations and Certifications; and

5. Additional information as required in Section L.

6. Proof of SAM Registration

Offerors shall be registered in the SAM (System for Award Management) database at https://www.sam.gov prior to submittal of their offer/proposal as prescribed under FAR 4.1102.

Failure to be registered at time of proposal submission may deem the offeror’s proposal to be considered non-responsible and no further consideration will be given. Therefore, offerors are highly encouraged to register immediately if they are interested in submitting a response to this requirement.

Sincerely, Daniel J. O’Rourke Contracting Officer

Enclosure:

Request for Proposal … 72 pages https://www.sam.gov/

SECTION

15A. NAME AND

ADDRESS

OF OFFEROR

SOLICITATION, OFFER, AND AWARD 1. This Contract is a Rated Order under the Defense Priorities and Allocations System (DPAS) - Code of Federal Regulations - at 15 CFR 700.

RATING PAGE OF PAGES

2. CONTRACT NUMBER 4. TYPE OF SOLICITATION 5. DATE ISSUED

CODE7. ISSUED BY

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

SOLICITATION

copies for furnishings the supplies or services in the Schedule will be received at the place specified in item 8, or if hand carried, in the depository located in

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision Number 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR

INFORMATION

CALL:

B. TELEPHONE (NO COLLECT CALLS)

AREA CODE NUMBER EXTENSION

C. EMAIL ADDRESS

11. TABLE OF CONTENTS

(X) DESCRIPTION PAGE(S) (X) SECTION PAGE(S)DESCRIPTION

A B C D E F G H

I

J

K

L

M EVALUATION FACTORS FOR AWARD

INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORS

PART IV - REPRESENTATIONS AND INSTRUCTIONS

LIST OF ATTACHMENTS

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

CONTRACT CLAUSESSOLICITATION/CONTRACT FORM

SUPPLIES OR SERVICES AND PRICES/COSTS

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

PACKAGING AND MARKING

INSPECTION AND ACCEPTANCE

DELIVERIES OR PERFORMANCE

CONTRACT ADMINISTRATION DATA

SPECIAL CONTRACT REQUIREMENTS

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT

(See Section I, Clause Number 52.232-8)

14. ACKNOWLEDGMENT OF AMENDMENTS

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

10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%)

DATEAMENDMENT NUMBERAMENDMENT NUMBER DATE

CODE FACILITY 16. NAME AND THE TITLE OF PERSON AUTHORIZED TO SIGN OFFER

(Type or print)

15B. TELEPHONE NUMBER

AREA CODE NUMBER EXTENSION

15C. CHECK IF REMITTANCE ADDRESS IS

DIFFERENT FROM ABOVE - ENTER

SUCH ADDRESS IN SCHEDULE.

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL OPEN COMPETITION UNDER THE

UNITED STATES CODE AT:

10 U.S.C. 3204(a) ( )41 U.S.C. 3304(a)

24. ADMINISTERED BY (If other than Item 7)

26. NAME OF CONTRACTING OFFICER (Type or print)

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

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

25. PAYMENT WILL BE MADE BY

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

CODE

ITEM

STANDARD FORM 33 (REV. 12/2022)

Prescribed by GSA - FAR (48 CFR) 53.214 (c)

SEALED BID (IFB) INVITATION FOR BID

NEGOTIATED (RFP) REQUEST FOR

PROPOSAL

(Hour) (Date)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

6. REQUISITION/PURCHASE NUMBER

8. ADDRESS OFFER TO (If other than item 7)

3. SOLICITATION NUMBER

9. Sealed offers in original and local time

A. NAME

2 - 8 9 - 18 20 - 21 23 - 24 25 - 27 70 - 72

62 - 69

42 - 44

28 - 41

45 - 61 until

1 72

19BK8025R0001 Jan 31, 2025

The Embassy of the United States of America Roberta C, Frasurea 1 71000 Sarajevo; Bosnia and Herzegovina

The Embassy of the United States of America Attn. Procurement and Contracting Office Roberta C, Frasurea 1; 71000 Sarajevo; Bosnia and Herzegovina

4 (four) see block 8 15:00 Mar. 04, 2025

Daniel J. O'Rourke +387(33) 704-489 X4489 ORourkeDJ@state.gov

SECTION B - PRICES

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.

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide Health Insurance services to employees of the Government of the United States of America in Bosnia and Herzegovina and their eligible dependents as described in Section C. This insurance shall be provided in accordance with Section C.

B.1.1. Official Residence Expense (ORE) Staff and Employee Association (EA) Employees may be covered under a rider to the contract. The employing officer/EA, not the U.S.

Government, is responsible for the employer’s share of the premium cots for ORE/EA employee at the rates specified below. Retirees are included under this contract only as riders; the Contractor shall bill the individual covered at the rates specified below. See Section G for billing procedures.

NOTE: The 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 for VAT on Invoices as the U.S. Embassy has a tax exemption certificate with the host government.

B.2.2. 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. PREMIUMS - BASE YEAR OF THE CONTRACT

The Contractor shall provide scheduled services for the base year of the contract starting on award date, block 18 Award Date on SF-33, and continuing for period of 12 consecutive months.

LE Staff covered under post’s medical benefit plan will pay a 10% share of the premium. Riders will pay 100% of insurance premiums as per clauses B.1.1.

CLIN INSURE CATEGORY Est. No. of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.3.a. SELF - ONLY:

1 covered individual 298

B.2.3.b. SELF PLUS ONE (two individuals) 60

B.2.3.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR BASE YEAR**

(MONTHLY SUBTOTAL x 12)

*Estimated number of Locally Employed Staff (LES). Does NOT include Riders.

**TOTAL PRICE FOR BASE YEAR does NOT include any premiums for Riders.

EXCESS COVERAGE

Not included in the Total Price for Base Year Calculation

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.001 SELF - ONLY: 1 covered individual 1 a.002 SELF PLUS ONE (two individuals) 1 a.003 FAMILY (three or more individuals) 1

B.2.4. PREMIUMS - OPTION YEAR ONE OF THE CONTRACT

The Contractor shall provide the services for the premiums shown below for the Option Year

One period of the contract, starting one year (12 calendar months) after the contract award date, block 28 Award Date on SF-33, and continuing for a period of 12 months.

CLIN INSURE CATEGORY

Est. No.

of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.4.a. SELF - ONLY:

1 covered individual 298

B.2.4.b. SELF PLUS ONE (two individuals) 60

B.2.4.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR OPTION YEAR ONE**

(MONTHLY SUBTOTAL x 12)

**TOTAL PRICE FOR OPTION YEAR ONE does NOT include any premiums for Riders.

Not included in the Total Price for Option Year One Calculation

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.101 SELF - ONLY: 1 covered individual 1 a.102 SELF PLUS ONE (two individuals) 1 a.103 FAMILY (three or more individuals) 1

B.2.5. PREMIUMS - OPTION YEAR TWO OF THE CONTRACT

The Contractor shall provide the services for the premiums shown below for the Option Year

Two period of the contract, starting two years (24 calendar months) after the contract award date, block 28 Award Date on SF-33, and continuing for a period of 12 months.

CLIN INSURE CATEGORY

Est. No.

of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.5.a. SELF - ONLY:

1 covered individual 298

B.2.5.b. SELF PLUS ONE (two individuals) 60

B.2.5.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR OPTION YEAR TWO**

(MONTHLY SUBTOTAL x 12)

**TOTAL PRICE FOR OPTION YEAR TWO does NOT include any premiums for Riders.

Not included in the Total Price for Option Year Two Calculation

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.201 SELF - ONLY: 1 covered individual 1 a.202 SELF PLUS ONE (two individuals) 1 a.203 FAMILY (three or more individuals) 1

B.2.6. PREMIUMS - OPTION YEAR THREE OF THE CONTRACT

The Contractor shall provide the services for the premiums shown below for the Option Year

Three period of the contract, starting three years (36 calendar months) after the contract award date, block 28 Award Date on SF-33, and continuing for a period of 12 months.

LE Staff covered under post’s medical benefit plan will pay a 10% share of the premium. Riders will pay 100% of insurance premiums as per clauses B.1.1.

CLIN INSURE CATEGORY

Est. No.

of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.6.a. SELF - ONLY:

1 covered individual 298

B.2.6.b. SELF PLUS ONE (two individuals) 60

B.2.6.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR OPTION YEAR THREE**

(MONTHLY SUBTOTAL x 12)

*Estimated number of Locally Employed Staff (LES). Does NOT include Riders.

**TOTAL PRICE FOR OPTION YEAR THREE does NOT include any premiums for Riders.

EXCESS COVERAGE

Not included in the Total Price for Option Year Three Calculation

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.301 SELF - ONLY: 1 covered individual 1 a.302 SELF PLUS ONE (two individuals) 1 a.303 FAMILY (three or more individuals) 1

B.2.7. PREMIUMS - OPTION YEAR FOUR OF THE CONTRACT

The Contractor shall provide the services for the premiums shown below for the Option Year

Four period of the contract, starting four years (48 calendar months) after the contract award date, block 28 Award Date on SF-33, and continuing for a period of 12 months.

LE Staff covered under post’s medical benefit plan will pay a 10% share of the premium. Riders will pay 100% of insurance premiums as per clauses B.1.1.

CLIN INSURE CATEGORY

Est. No.

of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.7.a. SELF - ONLY:

1 covered individual 298

B.2.7.b. SELF PLUS ONE (two individuals) 60

B.2.7.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR OPTION YEAR FOUR**

(MONTHLY SUBTOTAL x 12)

*Estimated number of Locally Employed Staff (LES). Does NOT include Riders.

**TOTAL PRICE FOR OPTION YEAR FOUR does NOT include any premiums for Riders.

EXCESS COVERAGE

Not included in the Total Price for Option Year Four Calculation

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.401 SELF - ONLY: 1 covered individual 1 a.402 SELF PLUS ONE (two individuals) 1 a.403 FAMILY (three or more individuals) 1

B.2.8. 52.217-8 OPTION TO EXTEND SERVICES (Term: Not to Exceed Six (6) Months)

Standard Routine Services. The firm fixed price for every monthly extension of the contract under FAR 52.217-8

CLIN INSURE CATEGORY

Est. No.

of Insures*

MONTHLY

PREMIUM RATE

EXTENDED MONTHLY

PREMIUM TOTAL

B.2.8.a. SELF - ONLY:

1 covered individual 298

B.2.8.b. SELF PLUS ONE (two individuals) 60

B.2.8.c FAMILY (three or more individuals) 79

MONTHLY SUBTOTAL FOR ALL INSURE CATEGORY

TOTAL PRICE FOR OPTION TO EXTEND SERVICES

(FAR 52.217-8)**

(MONTHLY SUBTOTAL x 6) *Estimated number of Locally Employed Staff (LES). Does NOT include Riders.

**TOTAL PRICE FOR OPTION TO EXTEND SERVICES pursuant to FAR 52.217-8, does NOT include any premiums for Riders.

EXCESS COVERAGE

Not included in the Total Price for Option To Extend Services pursuant to FAR 52.217-8

(See C.1.1.21. for clarification) Item Line Insure Category Per Category

(qty) Monthly Premium

Rate a.501 SELF - ONLY: 1 covered individual 1 a.502 SELF PLUS ONE (two individuals) 1 a.503 FAMILY (three or more individuals) 1

B.2.9. GRAND TOTAL

BASE YEAR TOTAL

OPTION YEAR ONE TOTAL

OPTION YEAR TWO TOTAL

OPTION YEAR THREE TOTAL

OPTION YEAR FOUR TOTAL

GRAND TOTAL (Base + all OPTION YEARS)

52.217-8 Price per Month

MINIMUM AND MAXIMUM AMOUNTS

During the Base Year of the contract, and during the option years that might be exercised, the United States Government (USG) shall place orders totaling a minimum of monthly insurance premiums for one (1) Locally Employed Staff, representing the total number of insures in all insure categories. 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 monthly insurance premiums for five hundred (500) Locally Employed Staff, total number of all insures in each insure category.

This reflects the contract maximum.

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 monthly 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. Monthly Retention Amounts per separate premium paid per single employee, self plus one and per family plan.

PERIOD OF

PERFORMANCE

SELF ONLY

(one covered individual)

SELF PLUS ONE

(two individuals)

FAMILY

(three or more individuals)

BASE YEAR

OPTION YEAR ONE

OPTION YEAR TWO

OPTION YEAR THREE

OPTION YEAR FOUR

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.

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.

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as described herein.

C.1.1. Employee and Dependent Health Service Benefits

C.1.1.1. Hospitalization (Treatment in the Hospital for Inpatient Care):

100% Coverage

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, 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 (see C.1.1.13.) for details concerning inpatient psychiatric care.

See Outpatient Services (see C.1.1.4.) for details concerning professional services.

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

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: 80% Minimum 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.1.1.4. Outpatient Services: 80% Minimum 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 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

100% coverage for Outpatient Services in accordance with local law on health insurance.

Services and treatments as listed in the legal opinion (from Maric & Co., dated 06/12/2024) to be exempted from paying copayments; are covered 100% (REF C). 80% Minimum coverage for rest of the outpatient services.

See Rehabilitative and Habilitative Services and Devices (see C.1.1.14.) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (see C.1.1.13.) for details concerning psychiatric therapy.

C.1.1.5. Obstetric and Newborn Care: Inpatient: 100% Coverage; Outpatient:

80% Minimum Coverage

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 covered as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services.

C.1.1.6. Pediatric Services: Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

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

C.1.1.7. Prescription Drugs: Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

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; or contraceptive medication.

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. Examples include, but are not limited to: physicals, immunizations, and cancer screenings.

C.1.1.9. Hearing Aids:

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear. The maximum coverage is EUR 1,442.00 per covered individual per three-year period. 80% Minimum Coverage: with applicable cap.

C.1.1.10. Optical:

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames, or contact lenses: The maximum coverage is EUR 288.00 per covered individual every two years. 80% Minimum Coverage; with applicable cap.

C.1.1.11. Dental:

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges. The maximum coverage is EUR 3,075.00 per covered individual per contract year. 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. The maximum coverage is EUR 2,307.00 lifetime limit. 80% Minimum Coverage; with contract lifetime cap.

C.1.1.12. Reproductive Health: 80% Minimum Coverage

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: 50% Minimum 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 provided at a facility licensed for detoxification and rehabilitation.

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

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: 100% up to EUR 9,610 per contract year per 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.1.1.16. Catastrophic Coverage

Additional coverage equal to EURO 73,200.00 per covered individual 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.1.1.17. Out-of-Country Medical Treatment:

Medical expenses incurred out-of-country will be covered, but coverage will be the same and subject to the same total maximum annual limit as for medical expenses incurred in-country.

C.1.1.18. Out-of-Country Medical Travel: 80% Reimbursement

Transportation for out-of-country medical treatment will be a covered expense for LE Staff 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.1.1.19. 180 Day Coverage for Dependents After Employee’s Death

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. [Reserved]

C.1.1.21. Excess Coverage

Additional coverage equal to EURO 73,200.00 per covered individual per contract year. This excess coverage will be offered as an optional benefit to LE Staff. LE Staff must pay 100% of the premium if they elect Excess Coverage.

This excess coverage will be offered as an optional benefit to LE Staff. This can be used for any covered individual for any covered expense that exceeds annual maximum. 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

The maximum annual reimbursement per covered individual per contract year, not including expenses defined under C.1.3. Exclusions to Coverage and C.1.1.16. Catastrophic Coverage, or those covered under C.1.1.15. HIV/AIDS, and C.1.1.21. Excess Coverage is equivalent to EURO 73,200.00

C.1.3 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, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, 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 exclusions require 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.1.4. ELIGIBLE PARTICIPANTS

C.1.4.1. Identification of Eligible Employees and Dependents:

U.S. Mission in Sarajevo Bosnia and Herzegovina 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. Dependents:

LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

C.1.4.1.1.1. Legal spouse or domestic partner, to include same-sex domestic partners, as certified by COM: one legal spouse as defined by local law or one domestic partner may be covered. LE Staff with more than one legal spouse or domestic partner must select only one individual for coverage.

In cases where LE Staff and their legal spouse or domestic partner 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 or domestic partner.

C.1.4.1.1.2. Dependent children: a child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. Any child of a recognized domestic partner shall be deemed a stepchild of the employee. Children 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.

C.1.4.2. Location of Employment: The eligible employees covered by C.1.4.1. must be employed within the geographic boundaries of Bosnia and Herzegovina by: Department of State, Department of Defense, Department of Justice, International Narcotic and Law Enforcement (INL), United States Agency for International Development, Department of Agriculture, Federal Bureau of Investigation, and the Department of Homeland Security.

C.1.4.3. Participants Covered Under a Rider

(a) Official Residence Expense (ORE) and Employee Association (EA) employees may be covered under a rider to the contract. The employing officer/EA, not the U.S. Government, is responsible for the employer's share of the premium costs for an ORE/EA employee.

(a) Coverage After Retirement: Employees who were covered under the medical insurance plan at the time of retirement may elect to continue coverage, for themselves and dependents, under rider to the contract. The retiree, not the USG, is responsible for 100% of the premium costs associated with the plan. The administration of the plan is handled by retiree and insurance provider.

C.1.5 Eligibility

To be eligible to participate in the medical plan, LE Staff must be:

- Paid under the terms of the Local Compensation Plan (LCP); and –

- Under a non-temporary direct hire appointment, personal services agreement (PSA), or personal services contract (PSC); or

- Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

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 Bosnia and Herzegovina, who provides services to other local organizations as well as to the U.S. Mission;

employees working on an intermittent or When Actually Employed (WAE) schedule; employees of USAID institutional contractors; Peace Corps personal services contractors as indicated in MS 743;

and Recreation Association employees.

C.1.6. 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.

C.1.7. Brochure Requirement

C.1.7.1. The Contractor shall provide a document (brochure/pamphlet/other written document) in the English and Bosnian language 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.1.7.2. The Contractor shall provide the document described in C.1.7.1 to the COR not later than 30 calendar 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.1.7.3. The Contractor assumes full responsibility for ensuring that the document described in C.1.7.1 accurately reflects the requirements, coverage, and 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.

SECTION D

PACKAGING AND MARKING

(RESERVED)

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 or Bing) 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 one

(1) customer complaint is 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.

https://acquisition.gov/browse/index/far https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

E.2.2. Standard. The performance standard is that the Government receives no more than one (1) customer complaint per month. The COR shall notify the Contracting Officer of the 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.

SECTION F

DELIVERIES OR PERFORMANCE

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

available. In addition, the full text of a clause may be accessed electronically at: Acquisition.gov this address is subject to change.

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

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 upon award with four (4) one-year options to renew.

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 and other deliverables required under this contract shall be delivered to the following address:

The Embassy of the United States of America in Sarajevo Attn. Contracting Officer Representative Roberta C. Frasurea 1 71000 Sarajevo, Bosnia and Herzegovina https://acquisition.gov/browse/index/far https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

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 Assistant.

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 an updated list of employees and dependents insured, which will supersede the initial list provided under this contract and as reported to the insurer or through the broker, 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. Payment shall be made in the currency of awarded contract.

G.4. SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees may be submitted electronically via e-mail to the following e-mail address, SARAJEVOINVOICES@STATE.GOV, in Portable Document Format (pdf) format not exceeding 30MB. Originals of the invoice shall be submitted to the following address (designated billing office only for the purpose of submitting invoices):

The Embassy of the United States of America in Sarajevo Financial Management Office Roberta C. Frasurea 1 71000 Sarajevo, Bosnia and Herzegovina

G.4.2. Frequency of Payments. All funds under this contract for non-rider coverage 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 under this contract will be made at the conclusion of the period covered.

Invoices may be submitted monthly with payments being made monthly by the Government.

Coverage is provided in accordance with FAR 32.404.

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:

a. 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.

b. EAE Staff. The Employee Association will make payment directly to the Contractor for the entire premium amount of the EA employee, whether or not the EA employee is contributing to the premium amount.

c. Retirees. The retiree will make payment directly to the Contractor for the entire premium amount.

G.5. [Reserved]

G.6. VALUE ADDED TAX

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

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 as soon as possible 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 or modification to the task order on a monthly, quarterly basis.

This new or modified 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. 15/30 Rule.

Employees, eligible dependents, and new family members, if added or removed to/from the list of insures by the 15th day of the monthly coverage period, from the first day of coverage period stated on task order, shall be charged for entire month. Modification to task order shall be issued.

Employees, eligible dependents, and new family members, if added or removed to/from the list of insures after the 15th day of the monthly coverage period, shall not be charged. Modification to the task order shall not be issued.

H.3.2. Riders are not included under the task orders issued by the Contracting Officer.

Because their coverage is under a rider, their employer or 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.

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 sensitive and not divulge any employee information to unauthorized persons.