RFQ_19BR2519R0003_-_Health_and_Dental-_FINAL.doc

U.S. Embassy Brasília

GSO Contracting Unit

April 30, 2019

Dear Prospective Offeror:

SUBJECT: Solicitation Number 19BR2519R0003 – Health and Dental Insurance for LES.

The Embassy of the United States of America invites you to submit a proposal for customized health and dental insurance for the locally employed staff for the U.S. Mission Brazil.

The Embassy intends to conduct a pre-proposal conference, and all prospective offerors who have received a solicitation package are invited to attend. See Section L of the attached Request for Proposals (RFP).

Your proposal must be submitted in a sealed envelope marked "Proposal Enclosed" to the Contracting Officer – Mr. Bart Stokes – U.S Embassy Brasilia , SES Qd 801 – Lote 03 – Av. Nações on or before May 30, 2019. No proposal will be accepted after this time.

In order for a proposal 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

3.

Section K, Representations and Certifications;

4.

Additional information as required in Section L.

Direct any questions regarding this solicitation to Mr. Paulo Figueira by email: figueirapf@state.gov or by telephone 61 3312-7201 during regular business hours.

Please note: proposals that contain more benefits (even if there is no increase in cost) or fewer benefits than those stated in the solicitation may be deemed technically unacceptable.

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.

Sincerely, G. Bart Stokes

Contracting Officer

UNDER DPAS (15 CFR 350)

2 | 74

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

3. SOLICITATION NO.

19BR2519R0003

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[X] NEGOTIATED (RFP)

5. DATE ISSUED

April 30, 2019

6. REQUISITION/PURCHASE NO.

7. ISSUED BY CODE

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

American Embassy

General Services Office – Contracting Unit

Brasilia, Brazil

Embaixada Americana – GSO/Contratos

SES – Quadra 801 – Lote 03

Brasília, DF 70403 900

Phone: (61) 3312 7201

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

SOLICITATION

9. Sealed offers in original and 1copies for furnishing the supplies or services in the Schedule will be received at the place specified, in the depository located in the American Embassy Brasilia until 16:30 local time May 30, 2019.

(hour)

(date)

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L. Provision No. 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR INFORMATION

CALL:

A. NAME

PAULO FIGUEIRA

B. TELEPHONE (NO COLLECT CALLS)

(61) 3312 7201

C. E-MAIL ADDRESS

figueirapf@state.gov

11. TABLE OF CONTENTS

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 inserted 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

(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

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

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)

G. BART STOKES

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.

SECTION B

PART I: PRICE - HEALTH INSURANCE

B.1 Health and Dental Insurance Services

The Contractor shall provide Health and Dental Insurance services to employees of the Government of the United States of America in Brazil including but not limited to employees located in Brasília, São Paulo, Rio de Janeiro, Recife and Belo Horizonte, 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 and C.4.3. The eligible family members who shall be provided this health insurance are listed in Sections C.1.5 and C.4.5.

This insurance shall be provided in accordance with Section C and the Attachments in Section J.

B.2 Prices 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:

The fixed prices/premium rates (in local currency) per capita for the standard category of health insurance services and Survivor Benefit (if applicable) for all plans as specified in Section C and Exhibit A of Section J are as follows:

Optional - Employees and dependents may elect any of the proposed plans. Numbers shown below correspond to current figures, however, they may vary, depending of the prices proposed for these categories. Employees/dependents will be able to decide on a plan category other than Standard by assuming/bearing the cost difference between plans.

The fixed prices/premium rates (in local currency) for the two additional categories of health insurance services as specified in Section C and Exhibit A of Section J are as follows:

B.2.1

BASE YEAR OF CONTRACT:

B.2.1.1 Health Insurance Services:

STANDARD

Per Month

SUBTOTAL:

SPECIAL

SUBTOTAL:

SUPERIOR

SUBTOTAL:

Total Price for Base Year: ________________________

B.2.1.2 Survivor Benefit for the period of 180 days.

SUBTOTAL:

Total Price for Base Year: ___________________

B.2.1.3 Dental Insurance Services

STANDARD

Total Price for Base Year: ______________________________

B.2.2

FIRST OPTION YEAR OF THE CONTRACT:

B.2.2.1 Health Insurance Services

STANDARD

SUBTOTAL:

SUBTOTAL:

Total Amount

SUBTOTAL:

Total Price for Option Year 1: __________________________

B.2.2.2 Survivor Benefit for the period of 180 days.

Total Amount

SUBTOTAL:

Total Price for Option Year 1: ______________________

B.2.2.3 Dental Insurance Services

STANDARD

Total Price for Option Year 1: _____________________________

B.2.3

SECOND OPTION YEAR OF THE CONTRACT:

B.2.3.1 Health Insurance Services

STANDARD

SUBTOTAL:

SUBTOTAL:

SUBTOTAL:

Total Price for Option Year 2: _____________________

B.2.3.2 Survivor Benefit for the period of 180 days.

Total Amount

SUBTOTAL:

Total Price for Option Year 2: ___________________________

B.2.3.3 Dental Insurance Services

STANDARD

Total Price for Option Year 2: _____________________________

B.2.4

THIRD OPTION YEAR OF THE CONTRACT:

B.2.4.1 Health Insurance Services

STANDARD

SUBTOTAL:

Total Amount

SUBTOTAL:

SUBTOTAL:

Total Price for Option Year 3: ________________________________

B.2.4.2 Survivor Benefit for the period of 180 days.

Total Amount

SUBTOTAL:

Total Price for Option Year 3: ____________________________

B.2.4.3 Dental Insurance Services

STANDARD

Total Amount

Total Price for Option Year 3: ___________________________________

B.2.5

FOURTH OPTION YEAR OF THE CONTRACT:

B.2.5.1 Health Insurance Services

STANDARD

SUBTOTAL:

SUBTOTAL:

Total Amount

SUBTOTAL:

Total Price for Option Year 4: ____________________________

B.2.5.2 Survivor Benefit for the period of 180 days.

Total Amount

SUBTOTAL:

Total Price for Option Year 4: __________________________

B.2.5.3 Dental Insurance Services

STANDARD

Total Amount

Total Price for Option Year 4: ________________________

GRAND TOTAL - BASE PERIOD PLUS OPTION YEARS for Health Insurance Services: _____________________

GRAND TOTAL - BASE PERIOD PLUS OPTION YEARS for Survivor Benefit: _____________________ GRAND TOTAL - BASE PERIOD PLUS OPTION YEARS for Dental Insurance Services: _____________________

GRAND TOTAL - BASE PERIOD PLUS OPTION YEARS for Health Insurance Services and Dental Insurance: BRL ______________________

B.3 ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the Contractor requests a price adjustment under B.4 below, the Contractor must 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 must 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.

Base Period

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.4 Economic Price Adjustment

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. 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. Before any such adjustment is made, the contractor shall provide the Government a balance sheet (relatório de sinistralidade) showing two main components for the time period: (1) receipts (premiums received) minus the (2) claims paid (sinistro x prêmio), considering that the technical limit (limite técnico) is 75% of the premiums paid. The reevaluation of the premiums paid can be done every year. One of such adjustment (if approved) must coincide with the adjustment based on laws (B.4.2).

The Government reserves the right to have an independent third party review the balance sheet 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. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause - FAR 52.233-1, Disputes (Jul 2002) Alternate I (Dec 1991).

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. No adjustment shall be allowed during the first six months of the contract. After this period, the Contractor may request adjustment in premiums provided that the Contractor presents documentation that clearly supports the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract.

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

PART I - HEALTH INSURANCE

C.1 Health Insurance Services

The Government of the United States of America requires Health Insurance coverage for its employees and dependents as further described in C.1.1, in Brazil.

The Government has determined that the prevailing practice by employers in Brazil is to provide health insurance protection for their employees. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.1.

The enrollment in the health insurance plan is an option for employees who may elect any of the three proposed categories of health insurance plans. The cost of such insurance protection will be borne by both the employee and the employer. The Government shall pay a fixed amount (90%) of the standard plan for employees/dependents. The difference in costs for extended coverage plans will be at the employee’s personal expense, paid through the Government. The numbers provided in section B.2 correspond to the present number of employees and dependents enrolled in the current health plan. These numbers can either increase or decrease depending on proposed price and coverage.

At the time of a covered employee's death, his/her eligible dependents covered under post's medical plan and as designated in the official personnel file, are eligible to temporarily continue receiving the same level of medical coverage for up to 180 days. This continued coverage is limited to 180 days only, is subject to availability of the funds at post, and no extensions are possible.

The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care, unless exclusion has been authorized by HR/OE/CM.

The specific health benefit coverage under this contract is set forth in Section C and the Exhibits in Section J.

C.1.1 Employee and Dependent Health Services Benefits.

The health benefits under this contract, unless stipulated elsewhere in this contract, shall be in accordance with Law number 9.656/98 of the Brazilian Government, its amendments/updates as they occur and under the supervision of the Health Ministry through the National Health Agency - Agência Nacional de Saúde Suplementar (ANS) requirements and procedures. Any other laws related to health insurance services shall immediately be incorporated to this contract, except for reductions in benefits. In all cases, the contract prevails.

The health services benefits under this contract are the same for all eligible participants; however, accommodations, reimbursements and healthcare networks may be different, depending on the plan chosen by the employee among the three options below. Employees and dependents have to enroll in the same health plan category.

I.

Standard: Reference Plan, ward accommodation, i.e., a room in a hospital holding two or more patients, national healthcare network and free choice option with reimbursement within the terms of the contract.

II.

Special: Reference Plan, private room with escort, national healthcare network and free choice option with reimbursement higher than standard category, and within the terms of the contract.

III.

Superior: Reference Plan, private room with escort, national healthcare network and free choice option with reimbursement higher than the other two categories and within the terms of the contract.

Please describe conditions and limitations (if applicable) as per the following items, which shall be elucidated on C.1.2 and Exhibit A, section J.

All services listed below are covered in the three Health Plan categories for employees and dependents, in unlimited number of sessions or without limitation of any kind, unless otherwise described on clause C.1.2 - Health Benefits Conditions and Limitations.

C.1.1.1. Hospitalization including Intensive Care (UTI) C.1.1.2 Surgery;

C.1.1.3 Doctor Visits;

C.1.1.4 Maternity;

C.1.1.6 Outpatient care Services;

C.1.1.7 Emergency Services;

C.1.1.8 Therapies - Physiotherapy, radiotherapy, chemotherapy, sclerotherapy, etc;

C.1.1.9 Psychiatric Treatment;

C.1.1.10 Diagnosis/Control Exams;

C.1.1.11 Infectious/contagious diseases including Aids;

C.1.1.12 Special Events

Phonoaudiology, Psychomotricity, Acupuncture sections; laser eye corrective surgery, all kinds of transplants, medical specialties and highly complex procedures & treatments not included in the other categories;

C.1.1.13 Other Benefits: Transfer of patients to another hospital for medical reasons and expenses incurred by person accompanying patients under 18 or disabled patients, as per Brazilian law;

C.1.1.14 Medical expenses incurred out of country will not be covered, unless it is an emergency or urgency;

C.1.1.15 Transportation for out of country treatment;

Transportation for out of country treatment is not a covered expense.

C.1.1.16 Annual maximum limit: The USG will reimburse covered expenses up to a limit of 67,500 local currency per covered individual per contract year. Expenses incurred under section D of the plan are subject to a separate annual maximum limit of USD 10,000 per employee.

C.1.2 Health Benefits Conditions and Limitations:

· Hospitalization: 100% reimbursement of room and board for a ward room or semi-private room. 100% reimbursement of hospital medical expenses including laboratory tests, x-rays, nursing care, operating room costs, intensive care, and prescription medicines. 100% reimbursement for ambulance;

· Professional Services and Treatment: 100% reimbursement of surgeons, fees incurred while hospitalized, at a hospital on an out-patient basis, at a clinic. 100% reimbursement for medical services and expenses when not hospitalized including routine annual physical examination, and inoculations;

Doctors Outpatient is not covered; Doctors fee (hospital only): 90% reimbursement

· Prescription drugs and medicines: 100% reimbursement of the cost of medicines and drugs for which a prescription is legally required when hospitalized and 100% reimbursement when not hospitalized. Expenses incurred for medicines, vitamins, cold remedies, etc. that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician;

· Obstetrical care: 100% reimbursement of obstetrical related medical expenses;

· Physical Therapy: 80% reimbursement;

· Psychiatric Treatment: 80% reimbursement;

· Optical Care: 100% reimbursement for eye examination and treatment and prescription eyeglass or contact lenses. No reimbursement for frames, lenses, nonprescription lenses, or tinting;

· Hearing Aids: 80% reimbursement.

C.1.2.1 Excluded Procedures: Reserved.

In accordance with law 9.656/98.

C.1.2.2 Reserved.

C.1.3 Eligible Participants C.1.3.1 Eligible Employees

Eligible employees are Locally Employed Staff who are (1) working on a full-time or part-time basis under non-temporary direct hire appointments or under personal services agreements/contracts (PSA/PSC) that are not time limited to less than one year and (2) paid under the terms of the Local Compensation Plan.

In the event that employees hired under temporary appointments that are time limited less than one year, and only if its appointment be extended so that the total time limit exceeds one year, then there will be no probation or waiting period for employee and eligible dependents if the employee opts to enroll in the plan.

C.1.3.2 Location of Employment

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Brazil.

C.1.3.3

Reserved.

C.1.4 Individuals Not Eligible for Coverage

Not eligible are those working under temporary direct hire appointments; those working on When Actually Employed (WAE) schedules; those working under a PSC or PSA that is time limited to less than one year; nonpersonal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Brazil who provides services to other local organizations as well as to the U.S. Mission; employees of USAID institutional contractors; and Peace Corps personal services contractors as indicated in MS 743; and Recreation Association employees Official Residence Expense (ORE) and Employee Association (EA) employees may be covered under a rider to the contract. The employing officer/Employee Association, and not the USG, is responsible for the employer's share of the premium costs for an ORE/EA employee.

C.1.5 Dependent Coverage

Eligible employees may elect to enroll their eligible dependents. For the purposes of this plan, an employee's dependents are defined as the employee's legal spouse (limit one) and unmarried, economically dependent children who primarily reside with the employee unless away at school.

Child is defined as the employee's natural child, adopted child, stepchild, or foster child. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 24 if a full time student. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently. Parents, grandparents, siblings, and other relatives are not eligible dependents except those already enrolled in the former plan and grandfathered into the new contract.

C.1.5.5 Widowed mother, widowed father and widowed mother-in-law already enrolled to the Health Insurance Plan will remain and be considered as regular dependents, respecting the same prices and conditions established for all users under this contract. New additions in this category will not be permitted from the effective date of the contract.

C.1.6 Eligibility

C.1.6.1 Term of Eligibility and Effective Date

All current active participant employees are enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. New employees can either submit a health insurance election form upon entering on duty with the United States Government or within sixty-days from admission date with probation period free. Employees who submit the election form after sixty-days from admission date will have to fulfill the required probationary period in accordance with law 9.656/98. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

New-born babies of participant mothers will be automatically covered by the health insurance benefits during the first thirty-day period after birth. New-born babies should be enrolled in the plan during the first thirty-day period to be entitled for insurance services with no probation period. After this period, babies shall be included in the health insurance plan to be eligible for insurance coverage subject to the required probation period.

C.1.6.2 Period of Ineligibility

Employees and their dependents are not entitled to health insurance benefits during any period of employment for which premiums are not paid.

Additionally, employee's dependents are not entitled to health insurance benefits during any period of employment during which the employee was not eligible to participate.

During a period of Leave without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.

During a period of extended Leave without Pay (beyond one month period) or unpaid leave, the employee is responsible for the full cost of the insurance premiums for self and dependents. Alternatively, the employee may elect to have coverage ceased if that employee prefers not to pay the premium. In this case, upon return, employee/dependents have the option to be re-enrolled, subject to the required probation period.

During a period of extended Sick Leave, when the employee goes under INSS (Brazilian Social Security Institute) leave (longer than 15 days) the coverage under the health insurance contract will continue.

C.1.7 Brochure Requirement

C.1.7.1.

The Contractor shall provide a brochure in Portuguese that sets forth a complete listing of the health insurance benefits to be provided under this contract and the accredited healthcare network. 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 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR’s request.

C.1.7.3.

The Contractor assumes full responsibility for ensuring that the document described in C.1.7.1 accurately reflects the requirements of the contract, as implemented by the Contractor’s technical proposal. In all cases, the contract shall take precedence. Should the COR discover that the brochure contains inaccuracies, the contractor will be notified in writing; however, failure on the part of the Government to notice any inaccuracies shall in no way limit, revise or otherwise affect the requirement under this contract for the contractor to fully comply with all contract terms.

C.1.8 Presentation Requirement

The Contractor shall make a presentation in each post to employees and dependents within 30 days of Contract award. This presentation shall demonstrate how the Contractor works, explain procedures and clarify doubts from users.

C.1.9 Identification Cards – Affinity cards The Contractor shall provide to the COR identification cards to each participant of the Health Insurance Plan before the contract is effective and during the whole period of the contract. Such cards shall be presented to the healthcare network by the participant. Participants shall always have a valid id card; it won’t be tolerable that participants are not accepted by the healthcare network due to an invalid card. Minimum validity period for such cards is 12 months.

Identification cards shall display “U.S. Embassy - Brazil”.

C.1.10 Probation Period

All plans are probation period free. This means that all current and future employees/dependents opting for the health insurance plan shall not be liable for any kind of probation, as long as they are enrolled during the implementation period of the contract (60 days) or within sixty-days from admission date.

C.1.11 Transference of Plans

Employees and dependents shall be allowed to transfer to a plan with greater benefits without problem or probation, provided that the transfer occurs during the open season. Transfer to an inferior plan is possible at any time, provided that there wasn’t hospitalization in the last six months. Transfer of plans beyond this period is subject to Contractor’s approval and shall suffer the probation in accordance with the law.

C. 1.12 Separation of the Health Plan The Contractor will be informed by the Human Resources Office on employees no longer enrolled to the health plan.

From that date on the Government will not be responsible or liable for any expenses made by these individuals (employees/dependents) after the date of separation in case of improper use of the identification cards.

C.1.13 Authorization for Certain Procedures Authorization for special procedures such as complex exams and surgeries shall not take longer than 72 hours to be approved by the Contractor., except for highly expensive surgical procedures. In that case the authorization might take up to 5 working days.

C.1.14 Reimbursement of Expenses

Beneficiaries of all plans shall be reimbursed for medical expenses when not using the accredited healthcare network, in accordance with the limits established in each health plan category. Reimbursement amounts shall be updated as per the Medical Association Table (or other – please describes and attached CD).

Standard Plan:

Special Plan:

Superior Plan:

C.1.14.1 Reimbursement time frame - Reimbursements shall be made to the participant through check or bank account deposit, no later than three weeks after submission. Please see clause H.4(a)(3).

C.2 Survivor Benefit

At the time of a covered employee's death, his/her eligible dependents covered under post's medical plan and as designated in the official personnel file, are eligible to temporarily continue receiving the same level of medical coverage for up to 180 days.

C.3 Definitions

Officer in charge for the contract. The Contracting Officer for this contract is the General Services Officer at the U.S. Embassy in Brasilia, Brazil.

COR

Contracting Officer's Representative (Human Resources Officer at the U.S. Embassy in Brasilia, Brazil).

Employer The United States Government.

Employee An individual currently or previously employed by the U.S. Government, as described in Section C.1.3.1.

Dependent U.S. Government employees’ protégées(s) as described in Section C.1.5 of this contract.

Health Insurance Plan Complete health plan which covers emergencies, doctor visits, diagnosis, hospitalization, surgery, ambulatorial services, diagnosis, treatment services etc.

Healthcare Network Hospitals, healthcare professionals, laboratories etc, affiliated to the company.

Hospital An institution established and operated for the care and treatment of sick and injured persons. It provides 24-hour nursing care and has diagnostic, laboratory, treatment, and surgical facilities. Any institution which does not meet this definition is not considered a hospital.

Hospital Patient An individual who has been admitted to a hospital, is assigned a bed, and is given diagnostic tests or receives treatment for a disease or an injury.

Surgical procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.

Claim Each and every use of the health benefits foreseen in this contract. Claims shall be paid directly by the Contractor to the service provider (i.e. hospitals, doctors, laboratories etc) or reimbursed to the beneficiary upon request.

Beneficiary Employees and dependents enrolled to the health plan.

Physical or Mental Incapacity A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions so as to be unable to live independently.

Open Season Is the period when employees have the option to move from one category to another. The changes are made effective on the anniversary date of the insurance policy.

C.4 Dental Insurance Services.

The Government of the United States of America requires Dental Insurance coverage for its employees and dependents as further described in C.4.1, in Brazil.

The Government has determined that the prevailing practice by employers in Brazil is to provide dental insurance protection for their employees. Dental insurance protection will be representative of locally prevailing compensation practice as further described in C.4.1.

The enrollment to the Dental Insurance plan is an option to employees, which may elect any of the three proposed categories of plans. The cost of such insurance protection will be borne by both the employee and the employer. The Government shall pay a fixed amount (90%) of the standard plan to employees/dependents. The difference in costs between plans or any additional coverage will be at the employee’s personal expenses, paid through the Government. The numbers provided in section B.2 correspond to the present number of employees and dependents enrolled to the current dental plan. These numbers can either increase or decrease depending on proposed price and coverage.

The specific dental benefit coverage under this contract is set forth in Section C. and the Exhibits in Section J.

C.4.1 Employee and Dependent Dental Services Benefits

The dental benefits under this contract, unless stipulated elsewhere in this contract shall be in accordance with Law number 9.656/98 of the Brazilian Government, its amendments/updates as they occur and under the supervision of the Health Ministry through the National Health Agency - Agência Nacional de Saúde Suplementar(ANS) requirements and procedures.

Any other laws related to health/dental insurance services shall immediately be incorporated to this contract, except for reduction in benefits. In all cases, the contract prevails.

The dental services benefits under this contract for eligible participants will depend on the plan chosen by the employee among the three options below. Employees and dependents will always be enrolled in the same dental plan category.

I.

Standard: Reference Plan, nationwide dental care network and free choice option with reimbursement within the limits described on clause C.4.14

II.

Special: Reference Plan plus additional coverage, large nationwide dental care network and free choice option with reimbursement within the limits described on clause C.4.14.

III.

Superior: Reference Plan plus additional coverage, comprehensive nationwide network and free choice option with reimbursement within the limits described on clause C.4.14.

Please describe conditions and limitations (if applicable) as per the following items, which shall be elucidated on C.4.2 and, section J.

All services listed below are covered in the three Dental Insurance Plan categories for employees and dependents, in unlimited number of sessions or without limitation of any kind, unless otherwise described on clause C.4.2 - Dental Benefits Conditions and Limitations.

C.4.1.1 Appointments and emergencies;

C.4.1.2 General dentistry;

C.4.1.3 X-rays;

C.4.1.4 Preventive dental care procedures such as protective sealant, fluorine, teeth cleaning etc;

C.4.1.6 Restorative dental work - fillings etc;

C.4.1.7 Pediatric dentist;

C.4.1.8 Surgeries and surgical extractions;

C.4.1.9 Endodontics;

C.4.1.10 Periodontics;

C.4.1.11 Annual maximum limit

· The overall annual maximum limit per patient is BRL R$ 67,500; however the recurring procedures table shall be followed.

C.4.2 Dental Benefits Conditions and Limitations

· Dental Care: 70% reimbursement of expenses for dental services including dentists, fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, bridges, and orthodontia treatment.

C.4.2.1 Reserved.

C.4.2.2 Reserved.

C.4.3 Eligible Participants

C.4.3.1 Eligible Employees.

The employees eligible for the dental insurance services include the following:

C.4.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Brazil, paid under the Local Compensation Plan and certified by the Contracting Officer, already enrolled in the current health plan.

C.4.3.1.2 Locally Employed Staff who are working on a full-time or part-time basis under non-temporary direct hire appointments or under personal services agreements/contracts (PSA/PSC) that are not time limited to less than one year and paid under the terms of the Local Compensation Plan;

C.4.3.1.3 Locally hired resident U.S. citizens working on a full-time or part-time basis under non-temporary direct hire appointments or under personal services agreements/contracts (PSA/PSC) that are not time limited to less than one year and paid under the terms of the Local Compensation Plan.

C.4.3.1.4 Retired employees and dependents enrolled in the current dental plan have the option to continue, provided that he/she pays the entire cost of the premium (both employer and employee share) directly to the Contractor in accordance with Brazilian law.

C.4.3.1.5 Employees enrolled in the dental plan who during the performance of the contract choose to resign and are already retired by the local social security system have the option to continue (dependents included), provided that he/she pays the entire cost of the premium (both employer and employee share) directly to the Contractor in accordance with Brazilian law.

C.4.3.1.6 Employees (and dependents) separated without cause may continue to be enrolled in the dental plan provided that he/she pays the entire cost of the premium (both employer and employee share) directly to the Contractor in accordance with Brazilian law.

C.4.3.1.7 Employees (and dependents) separated “with cause” do not have the option to continue enrollment in the dental plan and will be removed from the insurance policy.

C.4.3.1.8 Resigned employees (and dependents) do not have the option to continue enrollment in the dental plan and will be removed from the insurance policy, except those who meet the criteria under C.4.3.1.5.

C.4.3.2 Location of Employment.

The individuals covered by C.4.3.1 must be employed within the geographic boundaries of Brazil.

C.4.3.3

Reserved.

C.4.4 Individuals Not Eligible for Coverage

Individuals not eligible for coverage under this contract are non personal services contract personnel and any other individual not falling within one of the categories of employees described in this clause.

C.4.5 Other Eligible Participants.

The following additional categories of persons are covered by this insurance:

C.4.5.1 Spouse or partner, with proof of stable relationship through the appropriate documents.

C.4.5.2 Single children up to 18 years old or 24 if a full time student.

C.4.5.3 Single children over 24, with any mental or physical incapacity, unable to live independently.

C.4.5.4 Minors under legal guardianship or tutelage and stepchildren.

C.4.5.5 Widowed mother, widowed father and widowed mother-in-law already enrolled to the Dental Insurance Plan will remain and be considered as regular dependents, respecting the same prices and conditions established for all users under this contract. New additions in this category will not be permitted from the effective date of the contract.

C.4.6 Eligibility

C.4.6.1 Term of Eligibility and Effective Date

All current active participant employees are enrolled for dental benefits under this contract upon award and thereafter during the performance period of this contract. New employees can either submit a dental insurance election form upon entering on duty with the United States Government or within sixty-days from admission date with probation period free. Employees who submit the election form after sixty-days from admission date will have to fulfill the required probation period. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

New-born babies of participant mothers will be automatically covered by the dental insurance benefits during the first thirty-day period after birth. New-born babies should be enrolled in the plan during the first thirty-day period to be entitled for insurance services with no probation period. After this period, babies shall be included in the dental insurance plan to be eligible for insurance coverage subject to the required probation period.

C.4.6.2 Period of Ineligibility

Employees and their dependents are not entitled to dental insurance benefits during any period of employment for which premiums are not paid.

Additionally, employee's dependents are not entitled to dental insurance benefits during any period of employment during which the employee was not eligible to participate.

During a period of Leave without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.

During a period of extended Leave without Pay (beyond one month period) or unpaid leave, the employee is responsible for the full cost of the insurance premiums for self and dependents. Alternatively, the employee may elect to have coverage ceased if that employee prefers not to pay the premium. In this case, upon return, the employee/dependents have the option to be re-enrolled, subject to the required probation period.

During a period of extended Sick Leave, when the employee goes under INSS (Brazilian Social Security Institute) leave (longer than 15 days) the coverage under the dental insurance contract will continue.

C.4.7 Brochure Requirement

C.4.7.1.

The Contractor shall provide a brochure in Portuguese that sets forth a complete listing of the dental insurance benefits to be provided under this contract and the accredited dental care network. 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.4.7.2.

The Contractor shall provide the document described in C.1.7.1 to the COR not later than 30 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR’s request.

C.4.7.3.

The Contractor assumes full responsibility for ensuring that the document described in C.1.7.1 accurately reflects the requirements of the contract, as implemented by the Contractor’s technical proposal. In all cases, the contract shall take precedence. Should the COR discover that the brochure contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the Government to notice any inaccuracies shall in no way limit, revise or otherwise affect the requirement under this contract for the contractor to fully comply with all contract terms.

C.4.8 Presentation Requirement

The Contractor shall make a presentation in each post to employees and dependents within 30 days of Contract award. This presentation shall demonstrate how the Contractor works, explain procedures and clarify doubts from users.

C.4.9 Identification Cards The Contractor shall provide to the COR identification cards to each participant of the Dental Insurance Plan before the contract is effective and during the whole period of the contract. Such cards shall be presented to the dental care network by the participant. Participants shall always have a valid id card; it won’t be tolerable that participants are not accepted by the dentalcare network due to an invalid card. Minimum validity period for such cards is 12 months.

Identification cards shall display “U.S. Embassy - Brazil”.

C.4.10 Probation Period

All plans are probation period free. This means that all current and future employees/dependents opting for the dental insurance plan shall not be liable for any kind of probation, as long as they are enrolled during the implementation period of the contract (60 days) or within sixty-days from admission date.

C.4.11 Transference of Plans

Employees and dependents shall be allowed to transfer to a plan with greater benefits without problem or probation, provided that the transfer occurs during the open season. Transfer to an inferior plan is also possible during the open season, provided that there wasn’t any treatment specific to the higher category in the six months prior to the transfer. Transfer of plans beyond this period is subject to Contractor’s approval and shall suffer the probation in accordance with the law.

C. 4.12 Separation of the Dental Insurance Plan The Contractor will be informed by the Human Resources Office on employees no longer enrolled to the dental insurance plan. From that date on the Government will not be responsible or liable for any expenses made by these individuals (employees/dependents) after the date of separation in case of improper use of the identification cards.

C.4.13 Authorization for Certain Procedures Authorization for special procedures such as complex exams and surgeries shall not take longer than 72 hours to be approved by the Contractor.

C.4.14 Reimbursement of Expenses

Beneficiaries of all plans shall be reimbursed for dental expenses when not using the accredited Dental Insurance network, in accordance with the limits established in each dental plan category. Reimbursement amounts shall be updated in accordance with references of the Dental Association Table attached on Section J.

C.4.14.1 Reimbursement time frame - Reimbursements shall be made to the participant through check or bank account deposit, no later than three weeks after submission. Please see clause H.4(a)(3).

C.5 Definitions

Officer in charge for the contract. The Contracting Officer for this contract is the General Services Officer at the U.S. Embassy in Brasilia, Brazil.

COR

Contracting Officer's Representative (Human Resources Officer at the U.S. Embassy in Brasilia, Brazil).

Employer The United States Government.

Employee An individual currently or previously employed by the U.S. Government, as described in Section C.1.3.1.

Dependent U.S. Government employees’ protégées(s) as described in Section C.1.5 of this contract.

Dental Insurance Plan Complete dental plan which covers emergencies, appointments, diagnosis, preventive dental care, restorative dental work, surgeries, Endodontics, Periodontics, treatments etc.

Dentalcare Network Clinics, dental care professionals, laboratories etc, affiliated to the company.

Surgical procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.

Claim Each and every use of the dental benefits foreseen in this contract. Claims shall be paid directly by the Contractor to the service provider (i.e. hospitals, doctors, laboratories etc) or reimbursed to the beneficiary upon request.

Beneficiary Employees and dependents enrolled in the dental insurance plan.

Physical or Mental Incapacity A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions so as to be unable to live independently.

Open Season Is the period when employees have the option to move from one category to another. The changes are made effective on the anniversary date of the insurance policy.

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 the following 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. Also, the full text of a clause may be accessed electronically at this address:

http://www.acquisition.gov/far/…