19BR2524R0001 - Mission Brazil LE Staff Health Dental insurance.pdf

Embassy of the United States of America

U.S. Embassy Brasilia

May 24th, 2024

Dear Prospective Offeror:

Subject: Request for Proposals number 19BR2524R0001

The Embassy of the United States of America invites you to submit a proposal for locally employed staff 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 June 05, 2024, at 03:30 pm (local time) at the US Embassy Brasilia, Brazil. Prospective offerors should contact Mr. Paulo Figueira, via e-mail brasiliagsoprocurementdl@state.gov for additional information or to arrange entry to the building.

Proposals are due by July 01st, 2024. No proposals will be accepted after this time. Proposals must be in English and incomplete proposals will not be accepted.

Your quotation must be submitted electronically to brasiliagsoprocurementdl@state.gov. It is important to make sure the submission is made in the specific size and format, using MS-Word

2007/2010 or MS-Excel 2007/2010 or Adobe Acrobat (pdf) file format. The file size must not exceed 30MB. If the file size should exceed the 30MB, the submission must be made in separate files and attached to separate emails with less than 30MB 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 mailto:brasiliagsoprocurementdl@state.gov mailto:brasiliagsoprocurementdl@state.gov

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, Jennifer Sheehan

Contracting Officer

Enclosure:

https://www.sam.gov/

SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING PAGE OF PAGES

03 | 91

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

3. SOLICITATION NO.

19BR2524R0001

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[X] NEGOTIATED (RFP)

5. DATE ISSUED

May 24, 2024

6. REQUISITION/PURCHASE NO.

7. ISSUED BY CODE 19BR25 8. ADDRESS OFFER TO (If other than item 7) U.S Embassy Brasilia, Brazil

General Services Office – Contracting Unit

Brasilia, Brazil

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

SOLICITATION

9. Sealed offers in original and 1 copies 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 July 01, 2024.

(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

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

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

X A SOLICITATION/CONTRACT FORM 3 X I CONTRACT CLAUSES 35-56

X B SUPPLIES OR SERVICE AND PRICES/COSTS 3-14 PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

X C DESCRIPTION/SPECS/WORK STATEMENT 15-25 X J LIST OF ATTACHMENTS 57-58

X D PACKAGING AND MARKETING 26 PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE 27-28 X K REPRESENTATIONS, CERTIFICATIONS, AND

X F DELIVERIES OR PERFORMANCE 29 OTHER STATEMENTS OF OFFERORS 59-81

X G CONTRACT ADMINISTRATION 30-31 X L INSTRS., COND., AND NOTICES TO OFFERORS 82-87

X H SPECIAL CONTRACT REQUIREMENTS 32-34 X M EVALUATION FACTORS FOR AWARD 88-91

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

14. ACKNOWLEDGMENT OF

AMENDMENTS

AMENDMENT NO. DATE AMENDMENT NO. DATE

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

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

AND

ADDRESS

OF

OFFEROR

TO SIGN OFFER (Type or print)

15B. TELEPHONE NO. (Include area code)

15C. CHECK IF REMITTANCE

ADDRESS [ ] IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

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

23. SUBMIT INVOICES TO ADDRESS SHOWN

IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTRATION BY (If other than Item 7)

CODE

25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

JENNIFER SHEEHAN

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 - PRICES

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide the Health and Dental Insurance services to employees of the

Government of the United States of America in Brazil and their eligible dependents as described in Section C. This insurance shall be provided in accordance with Section C.

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:

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.2.3 BASE YEAR OF CONTRACT:

B.2.3.1 Health Insurance Services:

Plan 1

Bi-Weekly Rates Per

Premium

Category Estimated # of

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 280

Self Plus One 890

Family (3 or more) 1060

Total 2230

Plan 2

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 2

Self Plus One 4

Family (3 or more) 3

Total 9

Total Price for Base Year: ________________________

B.2.3.2 Dental Insurance Services

Dental Plan 1

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 280

Self Plus One 890

Family (3 or more) 870

Total 2040

Total Price for Base Year: ______________________________

B.2.4 FIRST OPTION YEAR OF THE CONTRACT:

B.2.4.1 Health Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 240

Self Plus One 850

Family (3 or more) 1040

Total 2130

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 5

Self Plus One 8

Family (3 or more) 5

Total 18

Total Price for Option Year 1: __________________________

B.2.4.2 Dental Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 290

Self Plus One 899

Family (3 or more) 890

Total 2079

Total Price for Option Year 1: _____________________________

B.2.5 SECOND OPTION YEAR OF THE CONTRACT:

B.2.5.1 Health Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 220

Self Plus One 820

Family (3 or more) 1020

Total 2060

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 9

Self Plus One 16

Family (3 or more) 17

Total 42

Total Price for Option Year 2: _____________________

B.2.5.2 Dental Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 301

Self Plus One 905

Family (3 or more) 899

Total 2105

Total Price for Option Year 2: _____________________________

B.2.6 THIRD OPTION YEAR OF THE CONTRACT:

B.2.6.1 Health Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 190

Self Plus One 790

Family (3 or more) 990

Total 1970

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 12

Self Plus One 21

Family (3 or more) 26

Total 59

Total Price for Option Year 3: ________________________________

B.2.6.2 Dental Insurance Services

Category Estimated # of Premiums Rate per Premium Extended Bi-weekly

Total

Self-Only 320

Self Plus One 911

Family (3 or more)

Total 2141

Total Price for Option Year 3: ___________________________________

B.2.7 FOURTH OPTION YEAR OF THE CONTRACT:

B.2.7.1 Health Insurance Services

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 160

Self Plus One 715

Family (3 or more) 920

Total 1795

Premiums Rate per Premium

Extended Bi-weekly Total

Self-Only 18

Self Plus One 26

Family (3 or more) 31

Total 75

Total Price for Option Year 4: ____________________________

B.2.7.2 Dental Insurance Services

Category Estimated # of Premiums Rate per Premium Extended Bi-weekly

Total

Self-Only 333

Self Plus One 921

Family (3 or more)

Total 2172

Total Price for Option Year 4: ________________________

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.

B.2.8. Grand Total of Base plus All Option Years

Base Year Total

First Option Year Total

Second Option Year Total

Third Option Year Total

Fourth Option Year Total

Grand Total of Base plus All Option Years

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 premium rate 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 premium rate shall not be expressed in terms of a percentage of the premium.

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

Period of

Performance Self-Only

Self Plus One Family

Base Period

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.3.3 Bi-Weekly Retention Premium Rate per separate premium paid per single employee and per family plan.

Period of

Performance Self-Only

Self Plus One Family

Base Period

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.4. ECONOMIC PRICE ADJUSTMENT-HEALTH AND DENTAL INSURANCE

PREMIUMS

B.4.1. Premium Adjustment Based on Experience - For health and dental insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract. EPA adjustments will only be made to the contract line-item rate amount for each type of premium and cannot be collected as a lump sum adjustment based on the annual projected price. 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, ie 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.

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 and Dental Insurance coverage for its employees and dependents as described herein.

U.S. Embassy Brasilia, Brazil requires one health plan with two benefit levels and one dental plan with one benefit level. The health plan will provide coverage to current employees only

(Plan 1) and new employees only (Plan 2).

Plan 1 will be extended to current employees only and will include 100% benefit levels for both inpatient and outpatient services grandfathered from current contract per acquired rights.

All LE Staff covered under post’s medical benefit Plan 1 will pay a 10% share of the premium.

Plan 2 will be offered to new employees only and will be based on Global Medical Coverage

(GMC) benefit levels and amended to conform with National Health Agency (ANS) regulations. USG will pay 100% share of the premium for employees and 50% share of the premium for dependents.

The approved benefit levels and terms to be included in the solicitation are as outlined below for

Plan 1 and Plan 2. This is a supplemental medical benefit plan, meant to supplement those benefits and services available to local staff through the local social security system or available government health facilities and services. As such, although included in the request for proposal

(RFP), when preparing their bids and making a competitive proposal, local vendors should take into consideration those benefits that are provided by local government entities.

The benefit levels set forth are the minimum benefit levels acceptable for post’s health insurance contract. Post may accept offers of higher benefit levels as long as post complies with the applicable acquisition regulations. The GMC methodology encourages post to consider off-the-shelf insurance products which meet or exceed the minimum levels. Deviations are subject to review and approval by GTM/OE.

C.1.1 Employee and Dependent Health Dental Authorized Benefit Levels – PLAN 1

The benefit levels listed in Plan 1 must be provided to all current employees only at U.S. Mission

Brazil. New employees hired after the health insurance contract’s effective date do not qualify for the benefit levels in Plan 1. New employees qualify for Plan 2 only.

C.1.1.1 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 Brazil 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.

Retiree Coverage: Current retirees and current employees who per ANS rules incur rights to remain on the contract after retirement are grandfathered and eligible to continue coverage after retirement under a rider to the contract. The retired employees will pay 100% of the premium cost for themselves and their dependents.

C.1.1.2 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.1.1.3 Dependents:

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

Legal spouse: one legal spouse as defined by local law may be covered. LE Staff with more than one legal spouse must select only one spouse for coverage.

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

Dependent children: a child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE Staff. 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.

Parents, grandparents, siblings, and other relatives are not eligible dependents except those already enrolled in the current plan and grandfathered into the new contract.

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.1.1.4 Premium:

Premiums will be based on the number of individuals covered:

-- Self-Only: 1 covered individual

-- Self Plus One: two individuals

-- Family: three or more individuals

C.1.1.5 Annual Maximum Limit:

The maximum annual coverage per covered individual per contract year, not including expenses covered under HIV/AIDS benefits if selected by post is BRL R$173,045.

C.1.1.6 MANDATORY/REQUIRED BENEFITS

C.1.1.6.1 Hospitalization (treatment in the hospital for inpatient care):

Services and supplies provided during hospitalization, including services provided by a licensed healthcare provider, bed & 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.

100% Coverage

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

C.1.1.6.2 Emergency Services (trips to emergency room):

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

C.1.1.6.3 Ambulance: No coverage per ANS regulations.

C.1.1.6.4 Outpatient Services:

Services provided by a certified healthcare provider on an ambulatory or outpatient basis

(without being admitted to a hospital), including surgeon’s fees and other medical services that may be provided in a hospital, clinic, doctor’s office, medical facility, etc. Examples include, but are not limited to:

-- Annual physical examinations

-- Specialist consultations and treatment, including second surgical opinion

-- Minor surgical interventions

-- Chemotherapy and radiation treatments

-- Immunizations recommended by local authorities and/or the World Health Organization

-- Diagnostic tests and diagnostic imaging

C.1.1.6.5 Obstetric and Newborn Care:

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.

Inpatient: 100% Coverage; Outpatient: 100% Coverage

C.1.1.6.6 Pediatric Services:

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

Inpatient: 100% Coverage; Outpatient: 100% Coverage

C.1.1.6.7 Prescription Drugs: No coverage per ANS regulations

C.1.1.6.8 Preventive and Wellness and Chronic Disease Management:

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but not limited to: physicals, immunization, hearing tests for diagnostic and preventative purposes, and cancer screenings.

C.1.1.6.9 Hearing Aids: No coverage per ANS regulations

C.1.1.6.10 Optical: No coverage per ANS regulations

C.1.1.6.11 Examinations and Treatment: 100% Coverage

C.1.1.6.12 Prescription lenses and frames or contact lenses: No coverage per ANS regulations

C.1.1.6.13 Reproductive Health:

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).

100% Coverage

C.1.1.6.14 Mental Health and Substance Abuse Care:

Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Services must be provided by a licensed psychiatrist, psychoanalyst, psychologist, or psychiatric social worker. Inpatient care for alcohol and substance abuse must be carried out at a facility licensed for detoxification and rehabilitation.

C.1.1.6.15 Rehabilitative and Habilitative Services:

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke) and habilitative services (e.g., developing skills, such as speech therapy for children) that help develop skills needed for everyday life.

100% Coverage

C.1.1.6.16 HIV/AIDS:

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.

100% up to USD 10,000 per contract year per covered individual

C.1.1.7 Dental:

C.1.1.7.1 Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges. The maximum coverage is USD

3,200 per covered individual per contract year. 100% Coverage; with annual cap

C.1.1.7.2 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 USD 2,400 lifetime limit. 100%

Coverage; with contract lifetime cap

C.1.1.8 180 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.1.1.9 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.1.2 Employee and Dependent Health Dental Authorized Benefit Levels – PLAN 2

The benefit levels listed in Plan 2 must be provided to all new employees hired at U.S. Embassy

Brazil after the new health insurance contract’s effective date.

C.1.2.1 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 Paraguay 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.1.2.2 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.1.2.3 Dependents:

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

Legal spouse: one legal spouse as defined by local law may be covered. LE Staff with more than one legal spouse must select only one spouse for coverage.

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

Dependent children: a child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE Staff. 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.1.2.4 Premium:

Premiums will be based on the number of individuals covered:

-- Self-Only: 1 covered individual

-- Self Plus One:two individuals

-- Family:three or more individuals

C.1.2.5 Annual Maximum Limit:

The maximum annual coverage per covered individual per contract year, not including expenses covered under HIV/AIDS benefits if selected by post, is BRL R$173,045.

C.1.2.6 MANDATORY/REQUIRED BENEFITS

C.1.2.6.1 Hospitalization (treatment in the hospital for inpatient care):

Services and supplies provided during hospitalization, including services provided by a licensed healthcare provider, bed & 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 (below) for details concerning inpatient psychiatric care.

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

C.1.2.6.2 Emergency Services (trips to emergency room):

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

C.1.2.6.3 Ambulance: No Coverage per ANS regulations

C.1.2.6.4 Outpatient Services:

Services provided by a certified healthcare provider on an ambulatory or outpatient basis

(without being admitted to a hospital), including surgeon’s fees and other medical services that may be provided in a hospital, clinic, doctor’s office, medical facility, etc. Examples include, but are not limited to:

-- Annual physical examinations

-- Specialist consultations and treatment, including second surgical opinion

-- Minor surgical interventions

-- Chemotherapy and radiation treatments

-- Immunizations recommended by local authorities and/or the World Health Organization

-- Diagnostic tests and diagnostic imaging

80% Minimum Coverage

C.1.2.6.5 Obstetric and Newborn Care:

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.

Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

C.1.2.6.6 Pediatric Services:

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

Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

C.1.2.6.7 Prescription Drugs: No Coverage per ANS regulations

C.1.2.6.8 Preventive and Wellness and Chronic Disease Management:

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but not limited to: physicals, immunization, hearing tests for diagnostic and preventative purposes, and cancer screenings.

80% Minimum Coverage

C.1.2.6.9 Hearing Aids: No coverage per ANS regulations

C.1.2.6.10 Optical: No Coverage per ANS regulations

C.1.2.6.11 Examinations and Treatment: 80% Minimum Coverage

C.1.2.6.12 Prescription lenses and frames, or contact lenses: No coverage per ANS regulations

C.1.2.6.13 Reproductive Health:

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).

80% Minimum Coverage

C.1.2.6.14 Mental Health and Substance Abuse Care:

Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Services must be provided by a licensed psychiatrist, psychoanalyst, psychologist, or psychiatric social worker. Inpatient care for alcohol and substance abuse must be carried out at a facility licensed for detoxification and rehabilitation.

50% Minimum Coverage

C.1.2.6.15 Rehabilitative and Habilitative Services:

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke) and habilitative services (e.g., developing skills, such as speech therapy for children) that help develop skills needed for everyday life.

50% Minimum Coverage

C.1.2.6.16 HIV/AIDS:

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.

100% up to USD 10,000 per contract year per covered individual

C.1.2.7 Dental:

C.1.2.7.1 Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges. The maximum coverage is USD

3,200 per covered individual per contract year. 80% Minimum Coverage; with annual cap

C.1.2.7.2 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 USD 2,400 lifetime limit. 80%

Minimum Coverage; with contract lifetime cap.

C.1.2.8 180 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.1.2.9 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.

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, Yahoo or Excite) to obtain the latest location of the most current FAR.

THE FOLLOWING FEDERAL ACQUISITION REGULATION CLAUSE(S) IS/ARE

INCORPORATED BY REFERENCE:

CLAUSE TITLE AND DATE

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

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

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

Government, is responsible for management and quality control to meet the terms of the contract.

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

Performance Objective

PWS

Paragraph Performance Threshold

Services

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

C.1.0 thru

C.1.6

All required services are performed and no more than sixteen (16)] customer complaint is received per month.

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

E.2.2 Standard. The performance standard is that the Government receives no more than sixteen (16) 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)

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 beginning on the effective date of the award with four 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:

U.S. Embassy Brasilia, Brazil

HR Office

SES – Quadra 801- Lote 3

Brasília, DF 70403 900 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 act for the Contracting Officer under this contract. This designee shall be identified as a Contracting Officer’s Representative (COR). Such designation shall specify the scope and limitations of the authority so delegated; provided, that the designee shall not change the terms or conditions of the contract, unless the COR is a warranted Contracting Officer, and this authority is delegated in the designation.

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

G.2 COR DUTIES

G.2.1 The COR is responsible for inspection and acceptance of services. These duties include review of Contractor invoices, including the supporting documentation required by the contract.

The COR may provide technical advice, substantive guidance, inspections, invoice approval, and other purposes as deemed necessary under the contract.

G.2.2 In addition, the COR shall maintain updated list of employees and dependents insured, which will supersede the initial list provided under this contract and as reported to the insurer 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 Brazilian REAL BRL – R$

G.4 SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted in an original and three (3) copies to the following address (designated billing office only for the purpose of submitting invoices):

BrasiliaDBO@state.gov mailto:BrasiliaDBO@state.gov

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 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.

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

G.5 REFUNDS TO THE GOVERNMENT

If at any time during performance of the contract the Government finds that the Contractor has been overpaid because the number of employees and/or dependents covered has decreased, the

Contracting Officer may either allow that overpayment to be credited to the Government’s account or require that the Contractor refund the overpayment. If the Contracting Officer requests a refund, the Contractor shall make that refund to the Government within ten calendar days of receipt of the request.

G.6 VALUE ADDED TAX

VALUE ADDED TAX (VAT). 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 on a [ ] monthly, [X ] quarterly basis. This new task order will include all changes made since the previous task order was issued and will include any increase or decrease in necessary funding. The changes to the list of eligible individuals will supersede the initial list provided under prior task orders without prejudice to the ineligibility clause. Task orders will indicate the effective date of employment, for purposes of calculating the premium due.

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

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. The Contractor shall establish procedures for handling medical insurance claims as follows:

(a) Administrative Records

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