Appendix_E_(Past_Requirements).pdf

Health and Life Services Contract No. 19EG3019C0001

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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 as further described in C.1.2 in Egypt. The Government has determined that the prevailing practice by employers in Egypt is to provide for their employees health insurance protection; that the cost of such insurance protection is usually borne by both the employee and the employer. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.2. The specific health benefit coverage under this contract is set forth in Section C and the Exhibits in Section J.

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.

C.1.1 Employee and Dependent Health Services Benefits

The health benefits under this contract 100% coverage for employee/dependents for in-network hospitalization and 70% for employee/dependents for out-of-network. Parents, grandparents, siblings, and other relative are not eligible dependents. Reimbursement of covered expenses is limited to the stated percentages of reasonable and customary costs. Proposals that contain more benefits (even if there is no increase in cost) or fewer benefits than stated in the solicitation may be deemed technically unacceptable.

C.1.1.1. Hospitalization:

Employee 100% / Dependent 100%

(70% employee &dependent if outside network or 100% with prior approval)

100% reimbursement of private room, a ward room or semi-private room. 100% reimbursement of hospital medical expenses including laboratory tests and x-rays, nursing care, operating room costs, intensive care, prescription medicines, and physical therapy. 100% reimbursement of ambulance service.

C.1.1.2 Professional services and treatment:

Employee 100% / Dependent 100%

(70% employee &dependent if outside network or 100% with prior approval)

100% reimbursement of doctors’ and surgeons’ fees incurred while hospitalized, at a hospital on an out-patient basis, at a clinic or doctor’s office, or at home. 100% reimbursement for medical services and expenses when not hospitalized such as laboratory tests and x-rays, prescription medicines, physical therapy, routine annual physical examination, and inoculations.

C.1.1.3. Prescription drugs and medicines:

Employee 90 % / Dependent 90%

Appendix E

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(70% employee &dependent if outside network or 90% with prior approval)

100% reimbursement when hospitalized, and 90% reimbursement when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required. 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.

C.1.1.4 For employees only: 100% reimbursement for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS; as well as brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee's child. The duration of this treatment is to be determined by the employee's physician following WHO or CDC guidelines.

The maximum limit for expenses reimbursed under section C.1.1.4 is limited to USD 10,000 per patient per contract year.

C.1.1.5 Obstetrical care:

Employee 100% / Dependent 100 %

(70% employee/dependent if outside network or 100% with prior approval per event)

100% reimbursement up to 6,000 local currency for normal delivery per event.

100% reimbursement up to 9,000 local currency for caesarean delivery per event

100% reimbursement up to 2,500 local currency for pre and post natal care per event.

C.1.1.6 Family planning:

Employee 0% / Dependent 0%

Not covered

C.1.1.7 Hearing aids:

(70% employee/dependent if outside network or 100% with prior approval)

100% reimbursement of the cost of a hearing aid apparatus and related examination. Limited to one apparatus per ear per patient in a three-year period.

C.1.1.8 Optical care:

Employee 100% / Dependent 100%

(0% employee/dependent if outside network)

100% reimbursement up to 800 local currency every two years for eye examination and treatment and prescription eyeglass, frames or contact lenses. Limited to two lenses per patient every two years. No reimbursement for nonprescription eyeglass frames, lenses, or tinting.

C.1.1.9 Dental care:

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Up to 1,000 local currency reimbursement per person per year of expenses for dental services including dentists’ fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, and bridges.

C.1.1.10. Physical therapy

Employee 100% Dependent 100%

(70% employee/dependent if outside network or 100% with prior approval)

C.1.1.11 Psychiatric treatment:

Employee 0% / Dependent 0%

Not covered

C.1.1.12 Medical expenses incurred out of country

Medical expenses incurred out of country will be covered for employees and dependents when (a) an illness or injury occurs when the individual is out of the country and treatment is medically necessary before the individual returns home or (b) the individual’s attending physician certifies and reports in advance that such treatment is medically necessary and unavailable locally. The report will be reviewed and prior approval must be obtained from the Embassy’s Medical Officer and the Insurance

Company’s representative. Reimbursement will be made at the same percentage rate and subject to the same annual maximum limit as for expenses incurred in country.

C.1.1.13 Annual Maximum Limit - The maximum reimbursement per patient per contract year, not including expenses covered under C.1.1.4 is 200,000.00 EGP (Egyptian Pounds) and up to 400,000.00

EGP (Egyptian Pounds) for catastrophic treatment.

C.1.1.14 Ambulance Service

Employee 100% Dependent 100%

Of the customary and reasonable cost ambulance service.

C.1.2 Health Benefits Conditions and Limitations.

Conditions and limitations on the entitlement to health care under this contract are as follows:

C.1.2 Health Benefits Conditions and Limitations

There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures; massage;

exercise therapy; long term rehabilitative therapy; non-medical hospital charges such as telephones or television; home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

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 LES workers’ compensation program.

There is no reimbursement for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self-inflicted wound; or service in the armed forces of any country.

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C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - The employees eligible for the health insurance services include the following:

C.1.3.1.1 Locally Employed Staff who are (1) working on a full-time or part-time basis under non-temporary direct hire appointment 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.

C.1.3.1.2. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

C.1.3.2 Location of Employment

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

U.S. Department of State

U.S. Agency for International Development

U.S. Library of Congress

U.S. Foreign Agriculture Service

U.S. Foreign Commercial Service

U.S. Defense Intelligence Agency

U.S. Drug Enforcement Administration

U.S. Office of Military Cooperation

U.S. Army Corps of Engineers

U.S. Department of Defense

U.S. Department of Homeland Security

U.S. NAMRU 3

U.S Animal and Plant Health Inspection Services (APHIS)

U.S Department of Justice

U.S Department of Navy

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1 All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account (see separate rider, Exhibit B). All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.1.3.3.2 All current active employees of the Employee Association at U.S. Embassy Cairo are the responsibility of the Employee Association, not the U.S. Government.

C.1.3.4 Pre-existing conditions:

Employees employed by the embassy at the time the contract become effective and their dependent who may have pre-existing conditions shall be eligible for health coverage. Each new Employee upon entering on duty and his or her dependents who may have pre-existing conditions shall be eligible for

American Embassy Cairo, Egypt Page 14 of 43 health coverage during the performance period of their contract. Single employees and families with individuals having pre-existing conditions shall have the same premium levels (see B.2) as single employees and families with no individual having pre-existing conditions.

C.1.4 Individuals Not Eligible for Coverage

Individuals not eligible for coverage under this contract are non-personal services contract personnel;

employees working on a temporary basis; employees with an intermittent, seasonal, or WAE (when actually employed) schedule; and any other individual not falling within one of the categories of employees described in this clause.

C.1.5. Other Eligible Participants

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

o One spouse, o and up to 4 children to the age of 18, o unmarried children under 26 if a full time student o special needs children with no age limitation

C.1.5. Other Eligible Participants

Covered dependents include the participating employee’s spouse and children. A limit of one spouse per employee is covered. An eligible child is defined as the employee’s natural child, adopted child, stepchild, or foster child. The child must be unmarried, economically dependent upon the employee, and reside with the employee unless away at school. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 26 if a full time student. There is no age limit for a child who is physically or mentally handicapped so as to be unable to live independently. Max of

4 children.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee will be enrolled upon entering on duty with the United States Government. An employee is considered active

("on the rolls") whenever such employee is on approved leave, whether paid or unpaid. Medical coverage is authorized for up to 180 days to dependents in the event of an employee’s death within active service.

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.

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C.1.6.2. Period 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 (beyond one pay period) of Leave Without Pay or unpaid leave, 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 that employee prefers not to pay the premium.

C.1.7. BROCHURE REQUIREMENT.

C.1.7.1. The contractor shall provide a document (brochure/pamphlet/other written document) in

English and in Arabic that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made.

C.1.7.2.The contractor shall provide the document described in C.1.7.1 to the COR not later than 30 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.

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