A0001 updated Benefit Levels.pdf

19GE5023R0039 Juba, South Sudan

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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:

100% 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 71

B.1.4 Outpatient Services:

100% 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: 100% 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:

Outpatient: 100% 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:

Outpatient: 100% 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.

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B.1.8 Preventive and Wellness and Chronic Disease Management:

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

B.1.9 Hearing Aids:

Examinations and Treatment: 100% 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.

100% Minimum Coverage; with annual cap

B.1.10 Optical Care:

Examinations and Treatment: 100% Minimum Coverage

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

100% 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.

100% 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.

100% Minimum Coverage; with contract lifetime cap

B.1.12 Reproductive Health:

Prescribed contraceptive devices, preventive care and routine examinations, voluntary sterilization, and diagnosis and treatment of conditions which may cause infertility. Assisted reproductive technology (ART), fertility treatments, and reversal of sterilization are not covered (see B.2 Exclusions to Coverage).

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B.1.13 Mental Health and Substance Abuse Care:

100% 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:

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.

OPTIONAL BENEFITS:

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.

The contractor must provide the same medical coverage for employees and family members regardless of location, within the annual maximum. The U.S. Embassy estimates that approximately 60% of covered individuals reside outside of South Sudan, although most of these are in neighboring countries of Uganda, Kenya, Sudan, and Egypt.

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

Locally Employed Staff Health Insurance Page 14 of 71 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.

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.

This optional benefit is subject to availability of funds at post and no extensions are permitted.

B.1.19 Catastrophic Coverage:

Additional coverage equal to $15,400 per covered individual per contract year. Catastrophic conditions shall be defined as major medical conditions occurring as a result of a single/illness/accident or closely related set of major illnesses (or conditions relating to a single accident) that exceed the standard maximum coverage limit.

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.

Requirement for List of pre-approved facilities:

Contractor must provide a pre-approved list of facilities/medical service providers that it has an established agreement to provide medical services its clients.

B.3. Annual Maximum Limit

The maximum annual coverage per covered individual per contract year, not including expenses covered under HIV/AIDS benefits if selected by post, is $15,400.

C.1. Eligible Participants

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.