A0001 updated Benefit Levels.pdf

19GE5023R0033 Harare, Zimbabwe

Locally Employed Staff Health Insurance Page 10 of 77

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.

-- Self-Only: 1 covered individual -- Self Plus One (two individuals) -- Family (three or more individuals)

B. EMPLOYEE & DEPENDENT HEALTH SERVICE BENEFITS

B.1. MANDATORY/REQUIRED BENEFITS

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

100% Coverage

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 (B.1.13) for details concerning inpatient psychiatric care.

See Outpatient Services (B.1.4) for details concerning professional services.

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.

B.1.3 Ambulance:

80% Minimum Coverage

Professional ground transport to move a patient from the place where s/he is injured or becomes ill to the nearest hospital able to provide treatment or to move a patient from one medical facility to another.

Amendment 0001 - Updated Benefit Levels

Locally Employed Staff Health Insurance Page 11 of 77

B.1.4 Outpatient Services:

80% Minimum Coverage

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

See Rehabilitative and Habilitative Services and Devices (B.1.14) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (B.1.13) for details concerning psychiatric therapy.

B.1.5 Obstetric and Newborn Care:

Inpatient: 100% Coverage Outpatient: 80% Minimum Coverage

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.

B.1.6 Pediatric Services:

Inpatient: 100% Coverage Outpatient: 80% Minimum Coverage

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.

B.1.7 Prescription Drugs:

Inpatient: 100% Coverage Outpatient: 80% Minimum Coverage

Medications prescribed by a certified health care provider that are medically necessary. Examples include, but are not limited to: prescription antibiotics to treat an infection; medication used to treat an ongoing condition, such as high cholesterol; prophylaxis; or contraceptive medication.

Locally Employed Staff Health Insurance Page 12 of 77

B.1.8 Preventive and Wellness and Chronic Disease Management:

80% Minimum Coverage

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, and cancer screenings.

B.1.9 Hearing Aids:

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear up to a maximum of USD 1,500 per covered individual per three-year period.

80% Minimum Coverage; with annual cap

B.1.10 Optical Care:

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames or contact lenses: Covered up to a maximum of USD 300 per covered individual every two years.

80% Minimum Coverage; with annual cap

B.1.11 Dental Care:

Examinations and Treatment:

Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges up to a maximum of USD 3,200 per covered individual per contract year.

80% Minimum Coverage; with annual cap

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 up to a maximum of USD 2,400 lifetime limit.

80% Minimum Coverage; with contract lifetime cap

B.1.12 Reproductive Health:

80% Minimum Coverage

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 B.2 Exclusions to Coverage).

Locally Employed Staff Health Insurance Page 13 of 77

B.1.13 Mental Health and Substance Abuse Care:

50% Minimum Coverage

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.

B.1.14 Rehabilitative and Habilitative Services and Devices:

50% Minimum Coverage

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke or physical therapy after an accident) and habilitative services (e.g., developing skills, such as speech therapy for children) that help develop skills needed for everyday life. Devices to help gain or recover mental or physical skills lost due to injury, disability or a chronic condition, and devices needed for habilitative reasons.

B.1.15 HIV/AIDS:

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

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.

B.1.16 Out-of-Country Medical Treatment:

Medical expenses incurred out-of-country will be covered, but coverage will be the same and subject to the same total maximum annual limit as for medical expenses incurred in-country.

B.1.17 Out-of-Country Medical Travel:

Transportation for out-of-country medical treatment will be a covered expense for LE Staff and eligible family members. To be considered a covered expense, the attending certified health care provider must certify in advance that the treatment is medically necessary and unavailable locally. 80% of covered individual’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be covered. 80% of the transportation expenses of an attendant will also be covered, but only if the covered individual's attending certified health care provider certifies that an attendant for the patient is necessary, (e.g., a parent in the case of a patient who is a minor, or a family member to make medical decisions in the case of a patient who is unwell or unconscious). All coverage for transportation for out-of-country medical treatment is subject to the total maximum annual limit. Transportation to a neighboring country without the attending certified health care provider certifying that the treatment is medically necessary and unavailable locally will not be covered.

Locally Employed Staff Health Insurance Page 14 of 77

B.1.18 180 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.

B.1.19 Employee Assistance Program (EAP):

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. This optional benefit is subject to availability of funds at post.

B.1.20 Excess Coverage:

Additional coverage equal to $68,000 per covered individual per contract year. This excess coverage will be offered as an optional benefit to LE Staff. LE Staff must pay 100% of the premium if they elect Excess Coverage. The employee will enroll directly with the contractor and pay 100% of the premium costs. Excess Coverage will apply to a covered employee and to eligible dependents depending on the level of coverage the employee elects: Self only, Self Plus One, or Family health insurance coverage.

B.2 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. Eligible Participants

C.1. Eligibility

Each current active eligible employee and their eligible dependents are enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee and eligible dependents will be enrolled upon entering on duty with the United States Government. An employee’s coverage for all services listed above, is effective immediately upon enrolment. There shall be no waiting period for any service for all employees. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

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

Paid under the terms of the Local Compensation Plan (LCP); and –

Locally Employed Staff Health Insurance Page 15 of 77

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 Zimbabwe 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.

Official Residence Expense (ORE) and Employee Association (EA) employees may be covered under a rider to the contract. 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.

C.2. Identification of Eligible Employees and Dependents:

U.S. Mission Harare, Zimbabwe 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/monthly basis.

C.2.1.1. 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.

Locally Employed Staff Health Insurance Page 16 of 77

C.2.2. Premium:

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 Section B.1.15 HIV/AIDS benefits if selected by post, is $68,000.

C.2.3. Location of Employment:

The eligible employees covered by C.2.1. must be employed within the geographic boundaries of Zimbabwe by: U.S. Government agencies, e.g., Department of State, U.S. Agency for International Development (USAID), U.S. Department of Defense & U.S. Centers for Disease Control & Prevention

(CDC).

C.3. Participants Covered Under a Rider:

a. All current active ORE Staff personally employed by the Chief of Mission and the Deputy Chief of Mission and assigned to their respective official Government residences and paid under an ORE account. All costs for coverage of ORE Staff are the responsibility of the Chief of Mission and the Deputy Chief of Mission, not the U.S. Government.

b. All current active employees of the Employee Association at Embassy Harare. All costs for coverage of AEWRA are the responsibility of the Employee Association, not the U.S.

Government.

Note that USG is not responsible, nor liable, for any riders.

C.4. Brochure Requirement

C.4.1. The Contractor shall provide a digital and print document (brochure/pamphlet/other written document) in English that outlines:

A complete listing of the health insurance benefits to be provided under this contract.

Detailed instructions, including documents required, timeline for submission of claims, how and whom to submit claims for reimbursement of services paid out of pocket.

Details of how to access the Employee Assistance Program, contact numbers / location for employee counselling.

Instructions on how to access out of country medical travel and out of country medical benefits.

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 described above 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) business days of the COR’s request.

Locally Employed Staff Health Insurance Page 17 of 77

The Contractor assumes full responsibility for ensuring that the document described above accurately reflects the requirements, coverage, and contract terms 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 document contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the U.S. 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.5. Service Requirements

C.5.1. Contract Management / Key Personnel The contractor must provide a point of contact for the Embassy who can communicate effectively regarding all contractual matters in English. This individual must have at least 2 years’ experience in the Zimbabwe or international insurance industry and working with contracts of similar size. The contractor must obtain COR approval before replacing this individual.

C.5.2. Claims And Appeals The contractor must maintain a user-friendly system for employees to access their claims, submit and track claims, and a clear appeal process for any rejected claims. Customer satisfaction with this process must be included as an indicator in the quality assurance plan. Claims appeal shall not take more than 7 business days to resolve / provide feedback to the employee and Contracting Officer’s representative.

C.5.3.

Service providers shall be paid in United States Dollars for the duration of this contract.

C.5.4.

Service providers shall be paid in not more than 30 days.

C.5.5.

Contractor shall make reimbursements for services paid for out of pocket within 30 business days from submission of reimbursement claim in United States dollars.

C.5.6.

Contractor shall provide a dedicated 24-hour customer service facility to handle and customer enquiries and after-hours authorizations.

C.5.7.

Contractor shall provide a Preferred Provider Network (PPN) of service providers for the benefits listed in B.1.- B.2. in Zimbabwe Areas of coverage to include but not limited to Victoria Falls, Bulawayo, Gwanda, Gweru, Kwekwe, Kadoma, Chegutu, Norton, Marondera, Rusape, Mutare, Nyanga, Chipinge, Masvingo, Chiredzi, Bindura, Harare (CBD, Westgate, Avondale, Borrowdale, Ruwa, Waterfalls, Chitungwiza, Waterfalls, Avondale, Eastlea, Highlands/Chisipite and Greendale. The PPN shall be reviewed and updated bi-annually and shared with all employees.

C.5.8.

Contractor shall respond to medical aid enquiries within 24 hours of notification.

C.5.9.

Contractor will provide the Embassy regular monthly reports on claims submission, and other matters important to good overall management of the contract.