0001 Solicitation Pages.pdf

19GE5023R0005 Addis Ababa, Ethiopia

Locally Employed Staff Health Insurance Page 9 of 70

CONTINUATION TO SF-1449

SCHEDULE OF SUPPLIES / SERVICES, BLOCK 20

DESCRIPTION / SPECIFICATIONS / WORK STATEMENT

IV SPECIFICATIONS

A. HEALTH INSURANCE SERVICES

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

All LE Staff covered under post’s medical benefit plan will pay a 10% share of the 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)

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 employee’s share from the employee on a bi-weekly basis, via payroll deduction. Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

B. EMPLOYEE & DEPENDENT HEALTH SERVICE BENEFITS

B.1. MANDATORY/REQUIRED BENEFITS

B.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

Minimum Reimbursement Rate - 100% Coverage

Services and supplies provided during hospitalization including services provided by a licensed healthcare provider, bed and board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, and 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 (B.1.13) for details concerning inpatient psychiatric care.

B.1.2 Emergency Services (Trips to Emergency Room):

100% Coverage

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

Locally Employed Staff Health Insurance Page 14 of 70

C. Eligible Participants

C.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 Ethiopia 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.

Eligibility for Peace Corps personal services contractors not paid under the LCP; and Recreation Association employees is addressed in section C.3. below.

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

Official Residence Expense (ORE) and Employee Association (EA) employees shall be invoiced on a separated invoice

C.1.1. 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 bi-weekly basis. Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

C.2. 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.

Locally Employed Staff Health Insurance Page 15 of 70

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.2.1. Premium:

All LE Staff covered under post’s medical benefit plan will pay a 10% share of the 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)

Annual Maximum Limit

The maximum annual coverage per covered individual per contract year, not including expenses covered under B.1.15, HIV/AIDS benefits, is equivalent to 7000 USD.

C.2.2. Identification of Eligible Employees and Dependents:

U.S. Mission in Addis Ababa, Ethiopia will provide a list of all eligible employees and dependents with relationship to employee (self/spouse/child) and DOB for each. Updates will be provided to add or remove individuals on a bi-weekly basis.

C.2.3. Location of Employment:

The eligible employees covered by C.2.2. must be employed within the geographic boundaries of Ethiopia by:

• Department of State U.S. Embassy Addis Ababa (DOS)

• U.S. Mission to the African Union

• U.S Agency for International Development (USAID)

• Defense Attaché Office (DAO) and other components of the Department of Defense (DOD)

• Presidents Emergency Plan for AIDS Relief (PEPFAR)

• U.S. Department of Health and Human Services Centers for Disease Control (CDC).

• U.S. Foreign Agricultural Service

• U.S. Peace Corps

• U.S. Department of Justice

• U.S. Department of Commerce

• U.S. Department of Treasury

• U.S. Department of Homeland Security, and