19GE5020R0053.pdf

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30

1. REQUISITION NUMBER

5. SOLICITATION NUMBER

19GE5020R0053

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

07/20/2020

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME Wencke Jacobsen

b. TELEPHONE NUMBER (No collect calls)

c. EMAIL jacobsenw@state.gov

8. OFFER DUE DATE / LOCAL

TIME

CODE FRANK

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

FRANKFURT, 60435

GERMANY

9. ISSUED BY X UNRESTRICTED OR SET ASIDE: % FOR

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

10. THE ACQUISITION IS

SEE

SCHEDULE

11. DELIVERY FOR FOB DESTINATION

UNLESS BLOCK IS MARKED

12. DISCOUNT TERMS

13a. THIS CONTRACT IS

RATED ORDER UNDER DPAS

13b. RATING

RFQ IFB X RFP

14. METHOD OF SOLICITATION

LONDOCODE15. DELIVER TO

AMERICAN EMBASSY LONDON

33 Nine Elms Lane, SW11 7US

ATTN: RECEIVING OFFICE

LONDON

UNITED KINGDOM

CODE FRANK16. ADMINISTERED BY

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

FRANKFURT, 60435

GERMANY

FACILITY CODECODE

Contact Duns Telephone No.

17a. CONTRACTOR/OFFEROR LONDOCODE18a. PAYMENT WILL BE MADE BY

AMERICAN EMBASSY LONDON

33 Nine Elms Lane, London SW11 7US.

ATTN: FMC

LONDON, W1K 6AH

UNITED KINGDOM

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN

OFFER SEE ADDENDUM

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS

CHECKED

19. ITEM NO. 20. SCHEDULE OF SUPPLIES/SERVICES

(Use Reverse and/or Attach Additional Sheets as Necessary)

21. QUANTITY 22. UNIT 23. UNIT PRICE 24. AMOUNT

See Line Items Section

25. ACCOUNTING AND APPROPRIATION DATA

See Line Item Detail

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

X 27a. SOLICITATION INCORPORATES BY REFERENCES FAR 52.212-1, 52.212-4, FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA X ARE ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4, 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN ____ COPIES TO

ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH

OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE

TERMS AND CONDITIONS SPECIFIED.

29. AWARD OF CONTRACT: REF. OFFER DATED . YOUR OFFER ON

SOLICITATION (BLOCK 5) INCLUDING ANY ADDITIONS OR CHANGES WHICH

ARE SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF THE CONTRACTING OFFICER (TYPE OR PRINT)

Eric N. Moore 31c. DATE SIGNED 07/20/2020

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 02/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

19GE5020R0053

001 Private Medical Insurance

Under Age of 65 Inclusive of the following Sub CLINs:

0001A - 0001D as per attached Pricing Sheet

0.00 LT

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

002 Private Medical Insurance

Age 65+ Inclusive of the following Sub CLINs:

0002A - 0002D as per attached Pricing Sheet

0.00 LT

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

003 VAT / IPT (if applicable) 0.00 LT Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

19GE5020R0053

Line Item Summary

Solicitation Number:

19GE5020R0053

Contract Number: Title: UK-London Private Medical insurance

Date of Solicitation:

07/20/2020

Line Item No. Description Quantity Unit Unit Price Total Cost

19GE5020R0053 London, United Kingdom Private Medical Insurance Page 3 of 70

TABLE OF CONTENTS

Section 1 – The Schedule

SF 1449 cover sheet Continuation To SF-1449, Prices, Block 23 Continuation To SF-1449, Schedule Of Supplies / Services, Block 20 Description /

Specifications / Work Statement

Attachment 1 – Prices Attachment 2 – Contract Information / Experience Listing Attachment 3 – Form W-14

NOTE: Further contractor-provided attachments will be included after award

Section 2 – Contract Clauses

Contract Clauses Addendum to Contract Clauses - FAR and DOSAR Clauses not Prescribed in Part 12

Section 3 – Solicitation Provisions

Solicitation Provisions Addendum to Solicitation Provisions - FAR and DOSAR Provisions not Prescribed in Part 12

Section 4 – Evaluation Factors

Evaluation Factors Addendum to Evaluation Factors - FAR and DOSAR Provisions not Prescribed in Part 12

Section 5 – Representations and Certifications

Offeror Representations and Certifications Addendum to Offeror Representations and Certifications - FAR and DOSAR Provisions not

Prescribed in Part 12

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SECTION 1 – THE SCHEDULE

CONTINUATION TO SF-1449

PRICES – BLOCK 23

I BACKGROUND / SCOPE OF SERVICES

A. The Embassy of the United States of America in London, United Kingdom, requires Private

Medical Insurance for its Local Employees (LE). This shall be a commercial off-the-shelf-type insurance, not one specifically tailored to the Embassy’s requirements.

The Contractor shall provide the medical Insurance services to employees of the Government of the United States of America in London, as described in Section 1.IV.A and B.

The groups of employees who shall be provided this insurance are listed in Section 1.IV.D.

This insurance shall be provided in accordance with Section 1.IV.A and B.

B. This is a fixed price requirements type contract.

The fixed prices / premium rates for the medical insurance services as specified in Section 1.IV. A and B are listed in Attachment 1 – Pricing.

II ACRONYMS AND ABBREVIATIONS

Acronym Definition

CLIN Contract Line Item Number

Contractor Insurance Company

CO

Contracting Officer

COR

Contracting Officer Representative

Dependent Dependents are defined as the covered employee’s legal spouse or civil partner as defined by law (limit one) or co-habiting partner (limit one), and children ( biological, adopted or for whom the employee is the legal guardian) who are unmarried and under age 24 at the renewal of the scheme. A child of a covered member's spouse, civil partner or co-habiting partner who is not the covered member's natural child, not adopted by the covered member or for whom the covered member is not the legal guardian is considered a child dependent if he/she fulfils the age and marital status criteria above and is part of the covered employee's household rather than the child's other parent.Parents, grandparents, siblings, and other relatives are not eligible dependents.

Employer

The United States Government = USG

Employee Staff member of the US Embassy London FMO Financial Management Officer

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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.

LS

Lump Sum

NHS National Health Service

PII

Personally Identifiable Information

Physician An individual who has graduated from an accredited medical school and is licensed to practice medicine in the jurisdiction in which the contract is to be performed. If the individual is a medical specialist, then he or she is Board Certified in that specialty

PMI Private medical insurance

QA

Quality Assurance

QC

Quality Control

QCP

Quality Control Plan

QTY

Quantity

SOW

Statement of Work

Surgical Procedure

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

TBD

To be determined

USG

U.S. Government

III PRICES

A.1 The contractor shall complete all work, including furnishing all labor, material, equipment and services, unless otherwise specified herein, required under this contract for the firm fixed unit prices indicated below and within the time specified herein. These individual prices shall include all labor, materials, profit, and, if applicable, value added tax (VAT) and

IPT.

Any costs not separately priced will be considered to be included in the individual prices as overhead or other indirect cost. No additional sums will be payable on account of any escalation in the cost of materials, equipment or labor, or because of the contractor's failure to properly estimate or accurately predict the cost or difficulty of achieving the results

Private Medical Insurance Page 6 of 70 required by this contract. Nor will the contract price be adjusted on account of fluctuations in the currency exchange rates.

A.2 The currency shall be fixed and cannot be changed by modification to the contract.

A.3 Premium Adjustment Based on Laws – The rates may 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(s). The contractor agrees to provide all documentation necessary to support any requested adjustment.

A.4 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 must include in its proposal for adjustment details setting forth how the pool impacts the request for equitable adjustment.

B. VAT – if applicable, the contractor shall be responsible for paying to the appropriate authority the applicable rate of Value Added Tax (VAT) and / or IPT (Insurance Premium Tax)..

Offerors shall identify the VAT/IPT as a separate line item. The VAT/IPT shall also be a separate cost item on all invoices submitted against task orders under the resulting contract.

The contractor will be reimbursed for VAT/IPT only up to the amount listed in each task order and upon presentation of proof that VAT/IPT has been paid to the host country government.

If the contractor receives a VAT/IPT refund from the host government, he shall re-pay the refund amount to the US Government.

C. Offeror, insert the currency of prices offered __________________

The fixed prices / premium rates for the health insurance services as specified in Section IV are as follows: see Attachment 1 - Pricing

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CONTINUATION TO SF-1449

SCHEDULE OF SUPPLIES / SERVICES, BLOCK 20

DESCRIPTION / SPECIFICATIONS / WORK STATEMENT

IV SPECIFICATIONS / STATEMENT OF WORK

IV.A PMI Services

The Government of the United States of America (USG) requires group PMI for a specific group of its employees in the UK as further described in Section 1.IV.B below to cover routine medical issues and medical emergencies.

The USG has determined that it will bear 100% of the cost of such insurance protection and will directly pay the premiums required. The specific health benefit coverage under the contract is set forth in this section.

The contractor shall ensure that health care under this contract does not exclude HIV / AIDS care. PMI shall be provided to employees as stated below for treatment of routine medical issues in the U.K. or outside the U.K. (i.e. while travelling).

PMI shall be provided to employees as stated below:

a. Provider shall accept all existing members of current plan on no worse terms.

b. All new member coverage shall be fully medically underwritten by provider.

c. Scale of Cover – Open Referral – Network.

d. £100 excess (deductible) per 12 month rolling period.

IV.B Employee Health Services Benefits The maximum health benefits under this contract are as follows.

IB.B.1 Diagnostic and Out-Patient

Type of Cover Limits

Out-patient consultations, therapies and diagnostic tests.

Up to £1000 combined limit each year. For out-patient consultations with consultants who are not providerrecognized partnership consultants – up to the limit of the provider’s consultant fee schedule (up to £1,000 limit above).

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Out-patient complementary medicine (i.e. an acupuncturist, chiropractor or osteopath recognized by the insurer)

Up to £250 each year from within available out-patient consultations, therapies and diagnostic tests limit above

Out-patient MRI, CT and PET scans At provider-recognized facility – 100%

IV.B.2 Hospital Treatment

Consultants’ fees Provider-recognized partnership consultants in a provider-recognized facility – 100%

Consultants who are not providerrecognized partnership consultants – up to the limit of the provider’s consultant fee schedule

Facility access Provider-recognized facility only

Parent accommodation Up to age 16

Facility charges for surgical operations carried out as outpatient treatment

Provider-recognized facility – 100%

Facility charges for day-patient treatment and in-patient treatment

Provider-recognized facility within scale of cover – 100%

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IV.B.3 Cancer Treatment

Out-patient consultations, therapies and diagnostic tests

For out-patient consultations with consultants who are not providerrecognized partnership consultants

– up to the limit of the provider’s consultant fee schedule.

For out-patient consultations with provider-recognized partnership consultants – 100%

Out-patient complementary medicine 100%

Out-patient cancer drugs Provider-recognized facility – 100%

IV.B.4 Mental Health Treatment

Mental Health Treatment Up to a maximum of 90 days each year for mental health day-patient treatment and mental health in-patient treatment combined and not individually.

Consultants’ fees, mental health and wellbeing therapists’ fees and diagnostic tests for out-patient mental health treatment

Up to and from within available outpatient benefit limits

For out-patient consultations with consultants who are not providerrecognized partnership consultants

– up to the limit of the provider’s consultant fee schedule and up to the limit explained above

For out-patient consultations with consultants who are provider-recognized partnership consultants – 100% up to the limit explained above

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Consultants’ fees for mental health day patient treatment and mental health in-patient treatment

For provider-recognized partnership consultants in a provider-recognized facility – 100%

For consultants who are not providerrecognized partnership consultants in a provider-recognized facility – up to the limit of the provider’s consultant fee schedule

Facility charges for mental health day-patient treatment and mental health in-patient treatment

Provider-recognized facility within scale of cover – 100%l

IV.B.5 Additional Benefits

Treatment at home Only as agreed by provider

Home nursing Up to £600 per year

Private ambulance charges Up to £80 each single trip up to a maximum of £320 per year

IV.B.6 Overseas Emergency Treatment (Official Work Travel and Private Travel)

Out-patient treatment Paid up to and from within available limit for regular out-patient treatment

Out-patient MRI, CT, PET scans Up to £100 towards all the fees and charges

Consultants’ fees for outpatient surgical operations, day-patient and in-patient treatment

Paid up to the limit of the provider’s consultant fee schedule

Overseas facility charge Out-patient surgical operations up to £100, and day-patient and in-patient treatment up to £200 towards all the facility charges and not each charge individually

Note – This is not supposed to be a substitute for regular travel insurance.

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IV.B.7 Repatriation and Evacuation Assistance

Patient repatriation / evacuation 100%

Accompanying partner / relative Up to £750

IV.B.8 Cash Benefits

NHS cash benefit for NHS inpatient treatment

£50 each night up to a maximum of 35 nights in a year

NHS cash benefit for NHS inpatient stays when patient receives radiotherapy, chemotherapy or a surgical operation that is for cancer treatment

£100 per night

NHS cash benefit for NHS outpatient or day-patient treatment or NHS home treatment for cancer

£100 for each day the patient receives radiotherapy in a hospital setting

£100 for each day patient receives IVchemotherapy and for each threeweekly interval of oral chemotherapy or part thereof

£100 on the day of surgical operation

IV.B.9 Waiting Periods

Type of Cover Waiting Period

Mental health treatment No waiting period applies / waived

Treatment for caesarian sections No waiting period applies / waived

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IV.B.10 Exclusions This section does not apply to Cash benefits in B.8.

IV.B.10.1 Ageing, Menopause and Puberty

Treatment to relieve symptoms commonly associated with any bodily change arising from any physiological or natural cause such as ageing, menopause or puberty and which is not due to any underlying disease, illness or injury.

IV.B.10.2 AIDS / HIV

Treatment for, related to, or arising from, AIDS or HIV, including any condition which is related to, or results from, AIDS or HIV.

Exception: Eligible treatment for or arising from AIDS or HIV if the patient became infected five years or more after their current continuous membership began

IV.B.10.3 Allergies or Allergic Disorders

Treatment to de-sensitise or neutralise any allergic condition or disorder.

IV.B.10.4 Benefits that are not covered and / or are above your benefit limits

Treatment, services or charges that are not covered under the policy. Treatment costs in excess of the amounts covered under the policy.

IV.B.10.5 Birth Control, Conception, Sexual Problems and Sex Changes

Treatment:

for any type of contraception, sterilisation, termination of pregnancy for any type of sexual problems (including impotence, whatever the cause) - for any type of assisted reproduction (eg IVF investigations or treatment), surrogacy, the harvesting of donor eggs or donor insemination where it relates solely to the treatment of infertility sex changes or gender reassignments or treatment for or arising from any of these.

IV.B.10.6 Chronic Conditions

Treatment of chronic conditions, i.e. a disease, illness or injury which has at least one of the following characteristics:

it needs ongoing or long-term monitoring through consultations, examinations, - check-ups and / or tests it needs ongoing or long-term control or relief of symptoms it requires rehabilitation or for you to be specially trained to cope with it - it continues indefinitely it has no known cure it comes back or is likely to come back.

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Exception: Eligible treatment arising out of a chronic condition, or for treatment of acute symptoms of a chronic condition that flare up. However, this is only covered if the treatment is likely to lead quickly to a complete recovery or to the patient being restored fully to his / her previous state of health, without having to receive prolonged treatment. For example, treatment following a heart attack arising out of chronic heart disease.

This exception does not apply to treatment of a mental health condition.

IV.B.10.7 Complications from Excluded Conditions, Treatment and Eexperimental Treatment

Treatment costs, including any increased treatment costs, incurred because of complications caused by a disease, illness, injury or treatment for which cover has been excluded or restricted from the policy.

(For example, if cover for diabetes is excluded by a special condition, and the patient has to spend any extra days in hospital or a treatment facility after an operation because he / she has diabetes, we would not pay for these extra days.)

Treatment costs the insured incurs because of any complications arising or resulting from experimental treatment that the insured receives or for any subsequent treatment the insured may need as a result of the patient undergoing any experimental treatment.

IV.B.10.8 Contamination, Wars, Riots and Terrorist Acts

Treatment for any disease, illness or injury arising directly or indirectly from: - war, riots, terrorist acts, civil disturbances, acts against any foreign hostility, whether war has been declared or not, or any similar event

- chemical, radioactive or nuclear contamination, including the combustion of chemicals or nuclear fuel, or any similar event.

IV.B.10.9Convalescence, Rehabilitation and General Nursing Care

Recognised facility accommodation if it is primarily used for any of the following purposes:

convalescence, rehabilitation, supervision or any purpose other than receiving eligible treatment receiving general nursing care or any other services which could have been provided in a nursing home or in any other establishment which is not a recognised facility receiving services from a therapist, complementary medicine practitioner or mental health and wellbeing therapist.

Exception: The PMI, at its discretion, may pay for eligible treatment for rehabilitation, i.e.treatment which is aimed at restoring health or mobility or to allow the patient to live an independent life, such as after a stroke. This will only be considered in cases where the rehabilitation:

is an integral part of in-patient treatment starts within 42 days from and including the date you first receive that in-patient treatment, and takes place in a recognised facility.

The patient must have the PMI’s written agreement before the rehabilitation starts and the PMI needs full clinical details from the patient’s consultant before we can give our decision. If the PMI agrees they pay for up to a maximum of 21 consecutive days’ rehabilitation.

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IV.B.10.10 Cosmetic, Reconstructive or Weight Loss Treatment

Treatment to change appearance, such as a remodeled nose or facelift whether or not it is needed for medical or psychological reasons. Breast enlargement or reduction or any other treatment or procedure to change the shape or appearance of your breast(s) whether or not it is needed for medical or psychological reasons, for example, for backache or gynaecomastia (which is the enlargement of breasts in males).

Treatment, including surgery:

which is for or involves the removal of healthy tissue (ie tissue which is not diseased), or the removal of surplus or fat tissue, or where the intention of the treatment, whether directly or indirectly, is the reduction or removal of surplus or fat tissue including weight loss (for example, surgery related to obesity including morbid obesity) whether or not the treatment it is needed for medical or psychological reasons. Treatment of keloid scars or scar revision.

Exception: Eligible surgical operation to restore your appearance after: - an accident, or if the benefits include cover for cancer treatment, as a direct result of surgery for cancer.

The PMI only pays if the accident or the cancer surgery takes place during the current continuous period of cover under this scheme and any of out schemes provided there has been no break in cover between this scheme and the other scheme. The PMI will only pay if this is part of the original eligible treatment resulting from the accident or cancer surgery and the patient has obtained the PMI’s written agreement before receiving the treatment.

IV.B.10.11 Deafness

Treatment for or arising from deafness caused by a congenital abnormality, maturing or ageing.

IV.B.10.12 Dental / Oral Treatment

Dental or oral treatment including:

the provision of dental implants or dentures, the repair or replacement of damaged teeth (including crowns, bridges, dentures, or any dental prosthesis made by a laboratory technician) the management of, or any treatment related to, jaw shrinkage or loss as a result of dental extractions or gum disease the treatment of bone disease when related to gum disease or tooth disease or damage.

Exception 1: Eligible surgical operation carried out by a consultant to:

put a natural tooth back into a jaw bone after it is knocked out or dislodged in an unexpected accidental injury treat a jaw bone cyst, but not if it is related to a cyst or abscess on the tooth root or any other tooth or gum disease or damage.

Exception 2: Eligible surgical operation carried out by a consultant to surgically remove a complicated, buried or impacted tooth root, such as an impacted wisdom tooth, but not if the purpose is to facilitate dentures or the acute condition relates to a pre-existing condition or a moratorium condition.

IV.B.10.13 Dialysis

Treatment for or associated with kidney dialysis (haemodialysis), meaning the removal of waste matter from your blood by passing it through a kidney machine or dialyser.

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Treatment for or associated with peritoneal dialysis, meaning the removal of waste matter from your blood by introducing fluid into your abdomen which acts as a filter.

Exception 1: Eligible treatment for short-term kidney dialysis or peritoneal dialysis if the dialysis is needed temporarily for sudden kidney failure resulting from a disease, illness or injury affecting another part of your body.

Exception 2: Eligible treatment for short-term kidney dialysis or peritoneal dialysis if you need this immediately before or after a kidney transplant.

IV.B.10.14 Drugs and Dressings for Out-Patient or Take-Home Use and Complementary and Alternative Products

Any drugs or surgical dressings provided or prescribed for out-patient treatment or for you to take home with you on leaving hospital or a treatment facility.

Any complementary or alternative therapy products or preparations, including but not limited to homeopathic remedies or substances, regardless of who they are prescribed or provided by or the type of treatment or medical condition they are used or prescribed for.

Exception: If the policy includes cover for cancer treatment ,out-patient common drugs, advanced therapies and specialist drugs for eligible treatment of cancer are covered.

IV.B.10.15 Excluded Treatment or Medical Conditions

NOT covered Treatment of any medical condition, or any type of treatment that is specifically excluded from the insured’s benefits.

IV.B.10.16 Experimental Drugs and Treatment

Treatment or procedures which, by reasonable definition, are experimental or unproved based on established medical practice in the United Kingdom, such as drugs outside the terms of their licence or procedures which have not been satisfactorily reviewed by NICE (National Institute for Health and Care Excellence).

Exception: An acute condition. However, the patient will need our written agreement before the treatment is received and we need full clinical details from the patient’s consultant before we can give our decision.

IV.B.10.17 Eyesight

Treatment to correct a patient’s eyesight, for example for long or short sight or failing eyesight due to ageing, including spectacles or contact lenses.

Exception: Eligible treatment for the patient’s eyesight if it is needed as a result of an injury or an acute condition, such as a detached retina.

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IV.B.10.18 Pandemic

Treatment for or arising from any pandemic disease and / or epidemic disease. Pandemic: the worldwide spread of a disease with epidemics occurring in many countries and most regions of the world.

Epidemic: more cases of a disease than would be expected for that disease in that area at that time.

IV.B.10.19 Intensive Care (Other than Routinely Needed After Private Day-Patient Treatment or In-Patient Treatment) Any intensive care if:

it follows an unplanned or an emergency admission to an NHS hospital or facility - it follows a transfer (whether on an emergency basis or not) to an NHS hospital or facility from a private recognised facility it follows a transfer from an NHS critical care unit to a private critical care unit - it is carried out in a unit or facility which is not a critical care unit.

if it is not routinely required as a medically essential part of the eligible treatment being carried out.

IV.B.10.20 Learning Difficulties, Behavioural and Developmental Problems

Treatment related to learning difficulties, such as dyslexia, or behavioural problems, such as attention deficit hyperactivity disorder (ADHD), or developmental problems, such as shortness of stature.

IV.B.10.21 Overseas Treatment

Treatment that received outside the United Kingdom.

Exception: If the policy includes ‘Overseas emergency treatment’ we pay for eligible treatment needed as a result of a sudden illness or injury when you are travelling outside the UK.

IV.B.10.22 Physical Aids and Devices

Supplying or fitting physical aids and devices (e.g. hearing aids, spectacles, contact lenses, crutches, walking sticks, etc).

IV.B.10.23 Pre-Existing Conditions

For underwritten members, treatment of a pre-existing condition, or a disease, illness or injury that results from or is related to a pre-existing condition is not covered.

Exception: For underwritten members we pay for eligible treatment of a pre-existing condition, or a disease, illness or injury which results from or is related to a preexisting condition, if all the following requirements have been met:

the patient has been sent their membership certificate which lists the person with the pre-existing condition (whether this is the insured or a dependant) - the insured gave us all the information we asked for, before we sent the first membership certificate listing the person with the pre-existing condition for their current continuous period of cover under the scheme neither the insured nor the person with the pre-existing condition knew about it before we sent the first membership certificate which lists the person with the preexisting condition for their current continuous

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IV.B.10.24 Pregnancy and Childbirth

Treatment for:

pregnancy, including treatment of an embryo or foetus childbirth and delivery of a baby termination of pregnancy, or any condition arising from termination of pregnancy.

Exception 1: Eligible treatment of the following conditions:

miscarriage or when the foetus has died and remains with the placenta in the womb still birth hydatidiform mole (abnormal cell growth in the womb) foetus growing outside the womb (ectopic pregnancy) heavy bleeding in the hours and days immediately after childbirth (post-partum haemorrhage) afterbirth left in the womb after delivery of the baby (retained placental membrane) - complications following any of the above conditions.

Exception 2: We may pay for the delivery of a baby by caesarean section only when the life of the member (mother) is in immediate danger or would be put at direct risk by vaginal delivery. However, we need full clinical details from your consultant before we can give our decision.

Exception 3: We pay for eligible treatment of an acute condition of the member (mother) that relates to pregnancy or childbirth but only if all the following apply:

- the treatment is required due to a flare-up of the medical condition, and - the treatment is likely to lead quickly to a complete recovery or to you being restored fully to your state of health prior to the flare-up of the condition without you needing to receive prolonged treatment this section

IV.B.10.25 Screening, Monitoring and Preventive Treatment

Not covered:

health checks or health screening. Health screening: where the patient may not be aware you are at risk of, or are affected by a disease or its complications but are asked questions or have tests to find out if he /she are and which may lead to needing further tests or treatment routine tests, or monitoring of medical conditions, including:

routine antenatal care or screening for and monitoring of medical conditions of the mother or foetus during pregnancy routine checks or monitoring of chronic conditions such as diabetes mellitus or hypertension tests or procedures which, in our reasonable opinion based on established clinical and medical practice, are carried out for screening or monitoring purposes, such as endoscopies when no symptoms are present preventive treatment, procedures or medical services.

Exception: If the patient is being treated for cancer, hase strong direct family history of cancer and the consultant has advised that you receive a genetically-based test to evaluate future risk of developing further cancers, we may at our discretion cover this test as well as the recommended prophylactic surgery when it is recommended by your consultant. The patient must have our written agreement before you have tests, procedures or treatment and we will need full clinical details from the patient’s consultant before we can give our decision.

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IV.B.10.26 Sleep Problems and Disorders

Treatment for or arising from sleep problems or disorders such as insomnia, snoring or sleep apnoea (temporarily stopping breathing during sleep).

IV.B.10.27 Special Conditions

Treatment directly or indirectly relating to special conditions. The insured shall contact the provider for details.

IV.B.10.28 Speech Disorders

Treatment for or relating to any speech disorder, for example stammering.

Exception: At the PMI’s discretion: short-term speech therapy when it is part of eligible treatment. The speech therapy must be provided by a therapist who is a member of the Royal College of Speech and Language Therapists.

IV.B.10.29 Remote Consultations

Any remote consultations by telephone or any other remote medium with a consultant, therapist, mental health and wellbeing therapist or any other healthcare professional, unless such healthcare professional is at the time of the patient’s treatment recognised by the PMI to carry out remote consultations and is on the PMI’s list of recognised practitioners.

IV.B.10.30 Temporary Relief of Symptoms

Treatment, the main purpose or effect of which is to provide temporary relief of symptoms or which is for the ongoing management of a condition.

Exception: The PMI may pay for this type of treatment if it’s needed it to relieve the symptoms of a terminal disease or illness.

IV.B.10.31 Treatment in a Treatment Facility that is not a Recognised Facility

Consultants’ fees for treatment that the patient receives in a hospital or any other type of treatment facility that is not a recognised facility.

If this facility access is partnership facility, the PMI will not pay for facility charges for treatment that the patient receives in a hospital or any other type of treatment facility that is not a recognised facility.

Exception: The PMI may pay consultants’ fees and facility charges for eligible treatment in a treatment facility that is not a recognised facility when the proposed treatment cannot take place in a recognised facility for medical reasons. However, the patient will need the PMI’s written agreement before the treatment is received and the PMI needs full clinical details from the consultant before a decision.

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IV.B.10.32 Unrecognised Medical Practitioners, Providers and Facilities

Treatment if the consultant who is in overall charge of treatment is not recognised by the PMI.

Treatment if any of the following apply:

the consultant, medical practitioner, therapist, complementary medicine practitioner, mental health and wellbeing therapist or other healthcare professional is: - not recognised by our company for treating the medical condition you have and / or for providing the type of treatment you need, and / or is not in the list of recognised practitioners that applies to your benefits - the hospital or treatment facility is:

not recognised by our company for treating the medical condition you have and / or for providing the type of treatment you need, and / or is not in the facility access list that applies to your benefits the hospital or treatment facility or any other provider of services is not recognised by the PMI and/or the PMI has sent a written notice saying that they no longer recognise them for the purpose of the private medical insurance schemes.

The PMI does not recognise consultants, therapists, complementary medicine practitioners, mental health and wellbeing therapists or other healthcare professionals in the following circumstances:

where the PMI does not recognise them as having specialised knowledge of, or expertise in, the treatment of the disease, illness or injury being treated - where the PMI does not recognise them as having specialised expertise and ongoing experience in carrying out the type of treatment or procedure needed - where the PMI has sent a written notice to them saying that they no longer recognize them for the purposes of their schemes.

IV.B.10.33 Moratorium Conditions

For moratorium members the PMI does not pay for treatment of a moratorium condition, or a disease, illness or injury that results from or is related to a moratorium condition.

Exception: If the insured applies to add its newborn baby as a dependant under its membership and the baby’s membership would be as a moratorium member the PMI will not apply this exclusion to the baby’s cover if the insured has been a member under this scheme (and if applicable previous scheme) for at least 12 continuous months before the baby’s birth and the insured includes the baby as a dependant within three months of their birth.

IV.B.10.34 Chronic Mental Health Conditions

Any mental health treatment for any member who has suffered from or is suffering from a chronic mental health condition.

IV.B.11 Eligible Employees Employees eligible for the PMI services under this contract are:

a. LE Staff employees of the U.S. Embassy in London and its constituent posts and outlying offices, who are paid under the Local Compensation Plan and who work on a full-time, part-time or intermittent basis under a direct-hire appointment or personal services agreement/contract;

b. LE Staff employees of OSC Caversham paid under OSC’s local compensation plan and who work on a full-time, part-time or intermittent basis under a direct-hire appointment or personal services agreement/contract;

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c. Official Residence Expense (ORE) staff employee under a contract subject to the employing officer being responsible for the employer’s share of costs

d. Employees of the American Embassy Employees’ Association (AEEA) who are paid in local currency and employed under a contract subject to the AEEA being responsible for the employer’s share of costs

e. An employee is also considered active ("on the rolls") whenever such employee is on annual or sick leave, or leave without pay. During a period of Leave Without Pay coverage will apply provided the employee makes his / her contributions in that period.

f. Pre-existing Conditions: Employees employed by the Embassy at the time the contract becomes effective who may have pre-existing conditions shall be eligible for health coverage.

Each new employee upon entering on duty who may have preexisting conditions shall be eligible for health coverage during the performance period of this contract.

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

IV.B.12 Pools and current employee count

Under age 65 Single 74 Couple 51 Family 56 Single Parent Family 15

Over age 65 Single 2 Couple 4 Family 0 Single Parent Family 0

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C. DELIVERABLES

C.1 The Contractor shall provide a document (brochure/pamphlet/other written document) 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.

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

The Contractor assumes full responsibility for ensuring that the document described in C.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.2 The Contractor shall provide the following summary reports monthly. All reports must be received by the COR no later than the 10th day of each month. These reports shall report on the previous month's activities. No PII information will be included in the report.

Employee Claims Report. The report will list all claims paid by the Contractor to a claimant, including the name of the claimant, date claim is received by the Contractor, and the amount claimed. This report shall also include all outstanding claims and a brief description of why claim has not been paid.

Demographic Information Report to include employee age distribution, dependent distribution, member movement, and distribution of benefits.

Benefits utilization information to include hospital benefit statistics, chronic illness statistics, claims expenditure distribution, and health promotion utilization.

D.1 Eligibility

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

Family – the member plus his / her adult partner plus unmarried children of either up to the age of 24 Single Parent Family – the member plus his / her unmarried children up to the age of 24

D.2. Dependents / other eligible participants:

Dependents are defined as the covered employee’s legal spouse or civil partner as defined by law (limit one) or co-habiting partner (limit one), and children (biological, adopted or for whom the employee is the legal guardian) who are unmarried and under age 24 at the renewal of the scheme.

A child of a covered member's spouse, civil partner or co-habiting partner who is not the covered member's natural child, not adopted by the covered member or for whom the covered member is not the legal guardian is considered a child dependent if he/she fulfils the age and marital status criteria above and is part of the covered employee's household rather than the child's other parent.

Parents, grandparents, siblings, and other relatives are not eligible dependents.

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V CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

V.1 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 USG, is responsible for management and quality control to meet the terms of the contract. The role of the USG is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective Performance Threshold

Timely payment of benefits (within 21 calendar days)

No more than one (1) customer complaint is received per month.

No incorrectly denied claims

No more than one (1) customer complaint is received per month.

V.1.1 Surveillance – The COR will receive and document all complaints from USG personnel regarding the services provided. If found valid, the COR will send the complaints to the contractor for corrective action.

V.1.2 Standard – The performance standard is that the USG receives no more than one (1) customer complaint per month. The COR shall notify the Contracting Officer of the complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR 52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of Services clause), if any of the services exceed the standard.

V.1.3 Complaint Procedures

a. If USG personnel observe unacceptable services such as but not limited to lack of coordination during medical evacuation, extended referral periods, delays in receipt of payment, etc., they will 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, provide e-mail notification informing the contractor of any valid complaints.

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f. If the contractor disagrees with the complaint and challenges the validity of the complaint, the contractor shall notify the COR by e-mail. 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 complainant.

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.

V.1.4 Employee Claims Report

The contractor shall provide a monthly Employee Claims Report. The report shall be received by the COR no later than the 10th calendar day of each month. The report shall list all claims paid by the contractor to a claimant, including the name of the claimant, date claim is received by the contractor, and the amount claimed. This report shall also include all outstanding claims and a brief description of why claim has not been paid.

V.2 REPORTS AND OTHER DELIVERABLES

All reports and other deliverables required under this contract shall be delivered by email to the COR and mailed to the following address:

US Embassy London

ATTN: HR

Ms. Laura Dawkin London, UK

NOTE: Any and all costs for the preparation, handling, mailing and submission of progress reports or any other required reports and documentation shall be included in the total price of each delivery order.

Description QTY Submission Date Deliver to and how:

Reference para IV C Brochures

1 per current members (and members at renewal) plus and exra 20 Pus a soft copy for electronic distribution on requesr

For review 30 days after contract award

After review by the

COR

Within 10 calendar days of the COR’s request

COR

hard copy

Private Medical Insurance Page 24 of 70 para IV.C.2 Employee claims report 1 ea No later than the 10th calendar day of each month

COR

e-mail, pdf document para V.7 Draft version of Management

Plan 1 ea As part of the offer CO para V.7 Final version of Management

Plan 1 ea 15 calendar days after receipt of contract award

COR

V.3 Contractor Responsibility in Claims and Reimbursement to Claims

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 employees' 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 eligible employee 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 employee per year reimbursement ceiling.

(2) The contractor shall provide the COR with the necessary claim forms for each type of benefit that can be claimed under the contract. These forms shall specify a list of documents required to be appended to each claim and otherwise provide instructions for claim filing.

(3) The contractor shall use the English spelling of the employees' names in all transactions, including reimbursement checks.

(4) The contractor shall provide employee claim reimbursement checks to the COR for disbursement to the employee not later than the Tuesday, which is two weeks after the claim has been submitted.

b.. Pre-Treatment / Preparatory Procedures

In advance of any consultation, treatment or procedure, the insured contacts the contractor to discuss the potential claim in order to get prior approval of the claim from the contractor. If the consultation, treatment or procedure is covered, and

Private Medical Insurance Page 25 of 70 the contractor agrees the provider, the contractor will provide the insured with a pre-authorization code number. The insured will give this number to the provider and the provider will invoice the contractor directly. If the provider invoices the insured, the insured will pass the invoice to the contractor for settlement.

The contractor shall pay the provider’s invoice no later than three weeks from the date a complete invoice is submitted to the contractor.

The contractor will provide the insured with a statement summarizing the invoice and treatment details and payments made, together with notification of any amount payable by the member directly to the provider and the reason for this direct payment.

V.4 Miscellaneous Contractor Requirements

A contract with the U.S.