19GE5023R0043_00002.pdf

19GE5023R0043

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE RATING

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

09/29/2023

4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicable)

FRANKCODE

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

60435, FRANKFURT

GERMANY

Wencke Jacobsen

NAME

TEL.

jacobsenw@state.gov

EMAIL

6. ISSUED BY CODE

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

60435, FRANKFURT

GERMANY

7. ADMINISTERED BY (If other than Item 6)

9A. AMENDMENT OF SOLICITATION NO.

19GE5023R0043

CONTACT: UEI:

CODE FACILITY CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, country, state and ZIP Code) (X)

X 9B. DATED (SEE ITEM 11)

03/21/2023

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X XThe above numbered solicitation is amended as set forth in item 14. The hour and date specified for receipt of Offers is extended, is not extended, Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing items 8 and 15, and returning __1__copies of the amendment;(b)By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

The solicitation has been amended to incorporate the following changes:

1) Provide update Section I - Sub Section C - Specifications / Statement of Work.

2) The proposal due date has been extended until 12:00 noon Central European Summer Time on October 6, 2023.

3) All offerors shall submit as signed copy of this amendment with their proposal.

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

Nicolas Wilhelm

(Signature of person authorized to sign)

15B. CONTRACTOR/OFFEROR 15C. DATE SIGNED

By (Signature of Contracting Officer)

16B. UNITED STATES OF AMERICA 16C. DATE SIGNED

09/29/2023

NSN 7540-01-152-8070

Previous edition unusable

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA FAR (48 CFR) 53.243

CGFS // CGFS

x

19GE5023R0043_00002 Suva, Fiji

Health Insurance for LES Page 1 of 6

C.1. HEALTH INSURANCE SERVICES

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

C.1.1 Employee and Dependent Health Service Benefits

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care)

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.

100% Coverage

C.1.1.2 Emergency Services (Trips to Emergency Room)

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

100% Coverage

C.1.1.3 Ambulance

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.

80% Minimum Coverage

C.1.1.4 Outpatient Services

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:

• 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

80% Minimum Coverage

C.1.1.5 “Reserved”

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C.1.1.6 Pediatric Services

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.

Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

C.1.1.7 Prescription Drugs

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;

Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

C.1.1.8 “Reserved”.

C.1.1.9 “Reserved”

C.1.1.10 Optical Care

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames, or contact lenses: Covered up to a maximum of FJD 633.00 per covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11 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 FJD 6,752.00 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 FJD 5,064.00 lifetime limit. 80% Minimum Coverage;

with contract lifetime cap.

C.1.1.12 “Reserved”

C.1.1.13 “Reserved”

C.1.1.14 “Reserved”

C.1.1.15 “Reserved”

C.1.1.16 Catastrophic Coverage

Additional coverage equal to F$70,000 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.

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C.1.1.17 Out-of-Country Medical Treatment

Medical expenses incurred out-of-country will be covered at the same benefit levels and subject to a combined annual maximum limit of F$300,000 for out-of-country medical treatment.

C.1.1.18 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. 100% 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. 100% 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.

Out of Country Medical Travel 100%.

C.1.1.19 “Reserved”

C.1.1.20 “Reserved”

C.1.1.21 “Reserved"

C.1.2 Annual Maximum Limit

The maximum annual reimbursement per covered individual per contract year, not including expenses covered under HIV/AIDS benefits, if selected by post, is F$120,000 for local medical treatment and combined annual maximum limit of F$300,000 for out-of-country medical treatment.

C.1.3 Exclusions and Limitations

There is no coverage 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 coverage 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.

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C.1.4 Eligible Participants – Definition of Dependents

C.1.4.1 Identification of Eligible Employees and Dependents:

U.S. Mission Fiji 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.1.4.1.1 Definition of Dependents

C.1.4.1.1.1 Spouse:

a limit of one legal spouse as defined by local law per employee will be covered.

C.1.4.1.1.2 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 24. 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.1.4.2 Location of Employment

The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Fiji by: Department of State, U.S. Agency for International Development and, Department of

Defense.

C.1.4.3 “Reserved”

C.1.5 Eligibility

Eligible employees are Locally Employed Staff who are:

• 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 Fiji 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. The employing officer/EA, not the

USG, is responsible for the employer's share of the premium costs for an ORE employee.

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C.1.6 Brochure Requirement

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in English 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.1.6.2 The Contractor shall provide the document described in C.1.6.1 to the COR not later than five (5) after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) business days of the COR’s request.

C.1.6.3 The Contractor assumes full responsibility for ensuring that the document described in C.1.6.1 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.1.6.4 During the contract period, any changes regarding the information in the submitted documents/brochures will be updated and re-submitted as revised documents/brochures (i.e.

changes to the list of approved institutes, etc.).

C.2 ACCRONYMS AND ABBREVIATIONS

Acronym Definition

CLIN Contract Line-Item Number

Contractor Insurance Company

CO

Contracting Officer

COR

Contracting Officer Representative

Customary and

Reasonable Treatment

A diagnostic test or medical treatment which is usually performed in the community where the individual is being treated

Dependent See C.1.4.11

Disability- Total and

Permanent

A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment. If the impairment is the result of a

Health Insurance for LES Page 6 of 6 previous impairment, it shall be considered a continuation of the prior impairment.

Employer

The United States Government = USG

Employee See C.1.4

FMO Financial Management Officer

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

Maximum Benefit The total amount that will be paid to any one covered individual for covered medical expenses

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

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