19GE5024R0003.pdf

19GE5024R0003

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

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

1. REQUISITION NUMBER

5. SOLICITATION NUMBER

19GE5024R0003

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

DATE

12/05/2023

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

01/19/2024 10:00

CODE FRANK

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

60435, FRANKFURT, 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

(15 CFR 700)

13b. RATING

RFQ IFB X RFP

14. METHOD OF SOLICITATION

OUAGACODE15. DELIVER TO

AMERICAN EMBASSY OUAGADOUGOU

SECTUER 15 OUAGA 2000, AVE SEMBENE OUSMANE

ATTN: HEALTH UNIT

OUAGADOUGOU, BURKINA FASO 011

CODE OPEAQM16. ADMINISTERED BY

RPSO Frankfurt OPE/AQM/IP/RPSO Frankfurt Office of Acquisition (AQM) Frankfurt

FACILITY

CODE

CODE

Contact UEI:

Telephone No.

17a. CONTRACTOR/

OFFEROR

OPEAQMCODE18a. PAYMENT WILL BE MADE BY

AMERICAN EMBASSY OUAGADOUGOU

SECTUER 15 OUAGA 2000, AVE SEMBENE OUSMANE

ATTN: FMC

OUAGADOUGOU, BURKINA FASO 011

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

X 27a. SOLICITATION INCORPORATES BY REFERENCE 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. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

X 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 1 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) Nicolas Wilhelm

31c. DATE SIGNED 12/05/2023

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 02/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

CGFS // CGFS

19GE5024R0003

Line Item Summary

Solicitation Number:

19GE5024R0003

Contract Number: Title: BF-Ouagadougou Health insurance

Date of Solicitation:

12/05/2023

Line Item No.

Description Quantity Unit Unit Price Total Cost

001 BASE YEAR

LES Health Insurance inclusive of Sub CLINs 0001A, 0001B, 0001C Type of Contract Pricing: OTH

Doc Ref No:

Delivery Date FOB:

0.00 EA $0.00 $0.00

1001 OPTION YEAR 1

LES Health Insurance inclusive of Sub CLINs 1001A, 1001B, 1001C Type of Contract Pricing: OTH

Doc Ref No:

Delivery Date FOB:

0.00 EA $0.00 $0.00

2001 OPTION YEAR 2

LES Health Insurance inclusive of Sub CLINs 2001A, 2001B, 2001C Type of Contract Pricing: OTH

Doc Ref No:

Delivery Date FOB:

0.00 EA $0.00 $0.00

3001 OPTION YEAR 3

LES Health Insurance as per attached Pricing Schedule inclusive of Sub CLINs 3001A, 3001B, 3001C Type of Contract Pricing: OTH

Doc Ref No:

Delivery Date FOB:

0.00 EA $0.00 $0.00

4001 OPTION YEAR 4

LES Health Insurance inclusive of Sub CLINs 4001A, 4001B, 4001C Type of Contract Pricing: OTH

Doc Ref No:

Delivery Date FOB:

0.00 EA $0.00 $0.00

19GE5024R0003 Ouagadougou, Burkina Faso

Health Insurance for LES Page 3 of 110

Table of Contents

SECTION I – THE SCHEDULE

A. BACKGROUND / SCOPE OF SERVICES

B. PRICES

C. SPECIFICATIONS / STATEMENT OF WORK

C.1 HEALTH INSURANCE SERVICES

C.1.1 MANDATORY/REQUIRED BENEFITS

C.1.1.1 Hospitalization (treatment in the hospital for inpatient care):

C.1.1.2 Emergency Services (trips to emergency room): ... 10 C.1.1.3 Ambulance:

C.1.1.4 Outpatient Services:

C.1.1.5 Obstetric and Newborn Care:

C.1.1.6 Pediatric Services:

C.1.1.7 Prescription Drugs:

C.1.1.8 Preventive and Wellness and Chronic Disease

Management:

C.1.1.9 Hearing Aids:

C.1.1.10 Optical:

C.1.1.11 Dental:

C.1.1.12 Reproductive Health:

C.1.1.13 Mental Health and Substance Abuse Care:

C.1.1.14 Rehabilitative and Habilitative Services and

Devices:

C.1.1.15 HIV/AIDS:

C.1.1.16 Out-of-Country Medical Treatment:

C.1.1.17 Out-of-Country Medical Travel:

C.1.2 Annual Maximum Limit:

C.1.3 Exclusion to Coverage C.1.4 Eligible Participants:

C.1.4.1 Definition of Dependents C.1.5 Eligibility C.1.5 Periods of Ineligibility:

C.2 BROCHURE REQUIREMENT

C.3 ACCRONYMS AND ABBREVIATIONS

D. CONTRACT ADMINISTATIVE REQUIREMENTS AND

PROCEDURES

D.1 Quality Assurance and Surveillance Plan (QASP)

D.2 DELIVERABLES

D.3 Contractor Responsibility in Claims and

Reimbursement to Claims D.4 Report Requirements D.5 Miscellaneous Contractor Requirements

Health Insurance for LES Page 4 of 110

D.6 Erroneous Payment D.7 Key personnel D.8 Physical and Information Security Requirements D.9 Laws And Regulations D.10 Contract Administration Data D.11 Invoices, Review and Payment D.12 Changes In Ownership D.13 Funding / Task Orders / Procedures D. 14 Choice of Law D.15 Start / Period of Performance D.16 Risk Assessment and Risk Mitigation Plan D.17 List Of Attachments

SECTION II – CONTRACT CLAUSES

52.212-4 Contract Terms and Conditions—Commercial

Products and Commercial Services (Nov 2023) ... 27 52.212-5 – Contract Terms and Conditions Required

To Implement Statutes or Executive Orders—

Commercial Products and Commercial Services

(Nov 2023)

52.252-2 – CLAUSES INCORPORATED BY REFERENCE (FEB

1998) 52.204-25 Prohibition on Contracting for Certain

Telecommunications and Video Surveillance

Services or Equipment (Nov 2021)

52.216-4 – ECONOMIC PRICE ADJUSTMENT – LABOR AND

MATERIAL (JAN 2017)

52.216-18 – ORDERING (AUG 2020)

52.216-19 – ORDER LIMITATIONS (OCT 1995)

52.216-21 – REQUIREMENTS (OCT 1995)

52.216-22 – INDEFINITE QUANTITY (OCT 1995)

52.217-5 –EVALUATION OF OPTIONS (JULY 1990)

52.217-8 – OPTION TO EXTEND SERVICES (NOV 1999)

52.217-9 – OPTION TO EXTEND THE TERM OF THE

CONTRACT (MAR 2000)

52.222-50 Combating Trafficking in Persons (Nov

2021) 52.225-19 Contractor Personnel in a Designated

Operational Area or Supporting a Diplomatic or Consular Mission Outside the United

States (May 2020) 52.229-12 Tax on Certain Foreign Procurements

(FEB 2021)

652.232-70 Payment Schedule and Invoice

Submission (Fixed-Price) (AUG 1999)

652.242-70 – CONTRACTING OFFICER'S REPRESENTATIVE

(COR) AUG 1999)

Health Insurance for LES Page 5 of 110

652.242-73 – AUTHORIZATION AND PERFORMANCE (AUG

1999)

652.243-70 – NOTICES (AUG 1999)

SECTION III– SOLICITATION PROVISIONS

52.212-1 Instructions to Offerors—Commercial

Products and Commercial Services (Sep 2023) ... 68

INSTRUCTIONS TO OFFERORS

Pre-proposal conference Submission of questions Proposal Due Date

52.216-1 – TYPE OF CONTRACT (APR 1984)

52.252-1 – SOLICITATION PROVISIONS INCORPORATED

BY REFERENCE (FEB 1998)

652.206-70 – ADVOCATE FOR COMPETITION / OMBUDSMAN

(FEB 2015)

SECTION IV – EVALUATION FACTORS

52.212-2 Evaluation—Commercial Products and

Commercial Services (Nov 2021)

52.217-5 – EVALUATION OF OPTIONS (JUL 1990)

52.225-17 – EVALUATION OF FOREIGN CURRENCY OFFERS

(FEB 2000)

SECTION V – REPRESENTATIONS AND CERTIFICATIONS

52.212-3 Offeror Representations and

Certifications—Commercial Products and

Commercial Services (Nov 2023)

52.204-19- INCORPORATION BY REFERENCE OF

REPRESENTATIONS AND CERTIFICATIONS (DEC

2014)

52.209-11 – REPRESENTATION BY CORPORATONS

REGARDING AN UNPAID TAX LIABILITY OR A

FELONY CRIMINAL CONVITION UNDER ANY FEDERAL

LAW (FEB

2016)

52.222-56 – CERTIFICATION REGARDING TRAFFICKING

IN PERSONS COMPLIANCE PLAN (OCT

2020)

52.204-24 REPRESENTATION REGARDING CERTAIN

TELECOMMUNICATIONS AND VIDEO SURVEILLANCE

SERVICES OR EQUIPMENT (NOV

2021)

52.229-11 Tax on Certain Foreign Procurements—

Notice and Representation (JUN

Health Insurance for LES Page 6 of 110

2020)

652.225-70 – ARAB LEAGUE BOYCOTT OF ISRAEL (AUG

1999)

CERTIFICATION ON CONTRACTOR

EMPLOYEES

Health Insurance for LES Page 7 of 110

SECTION I – THE SCHEDULE

CONTINUATION TO SF-1449

PRICES – BLOCK 23

A. BACKGROUND / SCOPE OF SERVICES

1. The Government of the United States of America (USG) requires Health Insurance for its

Locally Employed Staff (LES) and their dependents at US Embassy Ougadougou, Burkina Faso. The Contractor shall provide the Health Insurance services, as described in

Section I.C. Specifications / Satememt of Work. The groups of employees who shall be provided this insurance are listed in Section I.C.1.4.

2. This is a fixed price with economic price adjustment requirements type contract under which annual firm, fixed-price task orders will be issued. The contract shall remain unfunded. The fixed prices / premium rates for the health insurance services as specified in Section I.C. Specifications / Satememt of Work are listed in Section I.B. Prices.

3. MINIMUM (Reference Section I, Clause 52.216-22(b))

During the term of this contract, the Government shall order, as a minimum, services in an amount of $5,000.00 or equivalent in local currency.

The Government makes no guarantee as to the number of orders or actual amount of services that will be requested above the guaranteed minimum of $5,000.00 or equivalent in local currency.

The maximum value during the entire life of this contract is $4,500,000.00.

B. PRICES

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).

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

Health Insurance for LES Page 8 of 110 results required by this contract. Nor will the contract price be adjusted on account of fluctuations in the currency exchange rates.

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

2. Economic Price Adjustment, Premium Adjustment Based on Experience – For health insurance, prices may be adjusted upward or downward based on the experience rating of the Mission covered by this contract, and it specifically excludes all riders.

No adjustment will be allowed during the first twelve months.

After such time, the contractor or the USG may request an adjustment in premiums on an annual basis to be effective per contract year. Adjustments are not retroactive to previous contract terms. Before any such adjustment is made, the contractor agrees to provide the

USG a balance sheet showing three main components for the previous time period:

(1) receipts (premiums received),

(2) number of insurance policies and

(3) claims paid.

This information shall be provided per type of premium, i.e. per line item.

The USG reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract effective for the following option year. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

3. Premium Adjustment Based on Laws – The rates may also 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.

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.

Health Insurance for LES Page 9 of 110

4. VAT – if applicable, the contractor shall be responsible for paying to the appropriate authority the applicable rate of Value Added Tax (VAT). Offerors shall identify the

VAT as a separate line item. The VAT 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 only up to the amount listed in each task order and upon presentation of proof that VAT has been paid to the host country government. If the contractor receives a VAT refund from the host government, he shall re-pay the refund amount to the US Government

5. Offeror, insert the currency of prices offered __________________

The fixed prices / premium rates for the health insurance services as specified in Sub

Section C below are as follows:

Attachment 1 Pricing Table will be inserted here with contract award

Health Insurance for LES Page 10 of 110

CONTINUATION TO SF-1449

SCHEDULE OF SUPPLIES / SERVICES, BLOCK 20

DESCRIPTION / SPECIFICATIONS / WORK STATEMENT

C. SPECIFICATIONS / STATEMENT OF WORK

C.1 HEALTH INSURANCE SERVICES

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

C.1.1 MANDATORY/REQUIRED 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

See Mental Health and Substance Abuse care (below) for details concerning inpatient psychiatric care.

See Outpatient Services (below) for details concerning professional services.

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:

Health Insurance for LES Page 11 of 110

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 (below) for details concerning physical therapy.

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

C.1.1.5 Obstetric and Newborn Care:

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.

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

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.

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; medication used to treat an ongoing condition, such as high cholesterol; prophylaxis; or contraceptive medication.

Health Insurance for LES Page 12 of 110

C.1.1.8 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.

C.1.1.9 Hearing Aids:

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear. The maximum coverage is USD

1,500 per covered individual per three-year period. 80% Minimum Coverage; with applicable cap

C.1.1.10 Optical:

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames, or contact lenses: The maximum coverage is USD 300 per covered individual every two years. 80% Minimum Coverage; with applicable cap

C.1.1.11 Dental:

Examinations and Treatment: Dentist's fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges. The maximum coverage is 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. The maximum coverage is USD 2,400 lifetime limit. 80% Minimum

Coverage; with contract lifetime cap

C.1.1.12 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 Exclusions to Coverage).

C.1.1.13 Mental Health and Substance Abuse Care:

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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.

50% Minimum Coverage

C.1.1.14 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.

50% Minimum Coverage

C.1.1.15 HIV/AIDS:

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.

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

C.1.1.16 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.

C.1.1.17 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.

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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.

C.1.2 Annual Maximum Limit:

The maximum annual coverage per covered individual per contract year, not including expenses covered under HIV/AIDS benefits is CFA 6,800,000.

C.1.3 Exclusion 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, intracellular 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.1.4 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.

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 Burkina Faso, 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 U.S. Government, is responsible for the employer's share of the premium costs for an ORE employee.

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C.1.4.1 Definition of 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.

C.1.5 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 is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

C.1.5 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 quarterly basis. Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

C.2 BROCHURE REQUIREMENT

C.2.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in

French 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

Health Insurance for LES Page 16 of 110 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.2.2. The Contractor shall provide the document described in C.7.1 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.

C.2.3. The Contractor assumes full responsibility for ensuring that the document described in C.2.1 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.2.4 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.3 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 An eligible spouse and/or child of the employee as further defined in C.1.6

Employer

The United States Government = USG

Employee An individual employed by the US Government, under a direct-hire appointment, personal service contract (PSC), or personal services agreement (PSA), as further defined in Section C.1.4. This may also include ORE staff, EAE and Peace Corps PSCs, if this category of individuals is listed as participating under a rider in C.1.4

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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

Health Insurance for LES Page 18 of 110

D. CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

D.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

Services

Performs all the insurance services set forth in the Performance Work Statement (PWS)

All required services are performed and no more than one (1) customer complaint is received per month

Timely payment of benefits (within 14 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.

• 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.

• 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.

• 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.

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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.

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.

D.2 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 OUAGADOUGOU

Attn: HR

(Contact details to be provided in contract document)

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.

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Description QTY Submission Date Deliver to and how:

Reference

C.2 Brochures

As instructed by COR

Additional copies

10 days after contract award

Within 10 calendar days of the COR’s request

COR

hard copy

D.4 Employee Claims Report 1 monthly COR

D.9 Invoice 1 monthly COR /

Designated

Billing

Office

D.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

Health Insurance for LES Page 21 of 110 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 send employee claim reimbursement checks to employees not later than two weeks after a claim is submitted.

b. Medical Insurance Claims – Settlement of medical insurance shall be completed as follows:

(1) All medical claims shall be submitted directly to the Contractor by employees.

(2) The Contractor shall date stamp and screen all claims submitted on the day of receipt. If there are any missing documents or information thereby disallowing said claim to be payable, the Contractor shall notify the employee within two days, with a copy to the COR (if notification is written).

(3) The Contractor shall settle the claims no later than two weeks from the date the claim is submitted to the Contractor.

(4) Settlement shall be by issuance of checks in the name of the employee for each claim submitted or via EFT. Each payment shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any.

(5) The Contractor shall accept the employee's or dependent's choice to go for surgery to hospitals designated by the Contractor in order that the Contractor will pay the expenses directly to the hospitals.

D.4 Report Requirements

The Contractor shall provide the following monthly report. The report shall be received by the

COR no later than the 10th day of each month. The report shall report on the previous month's activities.

(a) Employee Claims Report. 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. The report shall not include any claims information for riders.

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D.5 Miscellaneous Contractor Requirements

D.5.1 A contract with the U.S. Government conveys no special privileges or immunities to the contractor. The contractor is an independent commercial concern and not a part of the U.S.

mission. The contractor's employees are not U.S. Government employees. Registration of this contract with the local government, if required by law, will be the sole responsibility of the contractor, and any fees, taxes, or other duties shall be payable by the contractor without recourse to the Government of the amounts thereof.

D.5.2 Licenses and Local Laws. The Contractor shall possess all permits, licenses, and any other appointments required for the prosecution of work under this contract, all at no additional cost to the Government. The Contractor shall perform this contract in accordance with local laws.

D.6 Erroneous Payment

If the USG becomes eligible for a refund of payment because of erroneous overpayment or other cause, the contractor shall refund the amounts or use them to offset future payments owed by the

USG, whichever the USG prefers. The contractor shall refund any refunds not complete or discovered after the completion date of this contract.

D.7 Key personnel

The US Government considers the contractors Project Manager as Key Personnel for this contract.

During the entire performance period of this contract, the contractor shall make no substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment.

The contractor shall notify the Contracting Officer Representative within 15 calendar days after the occurrence of any of these events. The proposed substitute shall possess qualifications comparable to the original key person, as well as satisfying any minimum standards set forth elsewhere in the solicitation / contract. The Contracting Officer Representative will notify the contractor within 15 calendar days after receipt of all required information of the decision on the substitution.

D.8 Physical and Information Security Requirements

The contractor shall be responsible for safeguarding all government information provided for contractor use. All material / documentation produced for the USG will be the sole property of the USG. The contractor shall not release any documents to anyone unless authorized by the

USG. The following considerations shall be followed by the contractor.

• All documents received or generated under the contract are the property of the USG.

Health Insurance for LES Page 23 of 110

• All documents shall be controlled and disseminated on a need-to-know basis.

Reproductionand distribution are prohibited without express approval of the USG. All design documents generated shall be annotated as follows:

• All documents shall be marked and handled in strict accordance with all applicable requirements and regulations. Proposed and actual contract documents shall only be disseminated on a strict need-to-know basis and shall not be further disseminated without prior authorization from the USG.

• Those receiving any type of proposed and / or actual contract documents shall be responsible for these materials while in their possession, or that of any of their subcontractors. They shall return all documents, including all copies, promptly upon demand by the USG.

D.9 Laws And Regulations

• Compliance Required - If the contractor has or will establish a local office, he shall without tadditional expense to theUSG, be responsible for complying with all laws, codes, ordinances, and regulations applicable to the performance of the work, including those of the host country, and with the lawful orders of any governmental authority having jurisdiction.

• Labor, Health and Safety Laws and Customs – If the contractor has or will establish a local office, he shall comply with all local labor laws, regulations, customs and practices pertaining to labor, safety, and similar matters, to the extent that such compliance is not inconsistent with the requirements of this contract.

A contract with the USG conveys no special privileges or immunities to the contractor. The contractor is an independent commercial concern and not a part of the

U.S. mission. The contractor's employees are not USG employees. Registration of this contract with the host country government, if required by law, will be the sole responsibility of the contractor, and any fees, taxes, or other duties shall be payable by the contractor without recourse to the USG of the amounts thereof.

The only items that the USG will consider for price adjustments are those that are mandated e.g., changes in the VAT rate (if applicable) or minimum hourly wage rate.

D.10 Contract Administration Data

Authority of the Contracting Officer – All work shall be performed under the general direction of the Contracting Officer, who alone shall have the power to bind the Government and to exercise the rights, responsibilities, authorities and functions vested by the contract, except that the Contracting Officer and the Procurement Executive shall have the right to

Health Insurance for LES Page 24 of 110 designate authorized representatives to act for the Contracting Officer, as specifically provided in the designation of that individual, such as the COR

Government Personnel

Contracting Officer: Nicolas A. Wilhelm

Contract Administrator: Wencke Jacobsen

E-mail address: JacobsenW@state.gov

Contracting Officer's Representative (COR): named at time of award

D.11 Invoices, Review and Payment

The Contractor shall submit monthly invoices to the Contracting Officer Representative.

• A proper invoice must include the following information:

• Contractor’s name and bank account information for payments by wire transfers

• Invoice Date

• Contract Number

• A summary showing a listing of each member with total monthly price the currency the contract has been issued in. A detailed invoice for each Agency has to be attached to each summary invoice and should include the cost breakdown by each membership fee line according to the pricing schedule

• Value Added Tax (VAT), if applicable, shall be a separate line item on each invoice.

• Each invoice shall include the items listed in Section 2, FAR 52.212-4 g.1.

• Payment shall be made in the currency the contractor specified in Section I.B Prices.

• Advance Payment shall not be authorized under this contract.

• Payment will be made via EFT.

D.12 Changes In Ownership

The contractor shall furnish the COR advance notification (90 calendar days prior to the effective date) of any disposition or the change in ownership or terms of lease of any facilities utilized by him for performance of any service under this contract.

mailto:JacobsenW@state.gov

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D.13 Funding / Task Orders / Procedures

The contract remains unfunded; funding will be provided by issuing annual task orders with possible modification for staffing changes. Each task order will contain the following information:

• Name of contractor

• Contract number

• Date of purchase

• Task order number

• Name of person placing the order

• Quantity, unit price, and total price of each service / insurance premium

• VAT or other taxes as a separate item, if applicable

• COR and post points of contact, including e-mail addresses

• applicable contract clauses, either in reference or in full text if necessary

Only an RPSO Contracting Officer may place a written order.

Ordering Procedures – The Government shall issue annual funded task orders to cover all eligible employees and their dependents. No task order shall include any names or PII

(personally identifiable information). The COR informs the contracting officer if any additions or deletions are required throughout the year and the Contracting Officer will issue funded modifications as required.

Riders - As stated in C.1.4 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.

Therefore, any ORE amd EA staff are are not included under the task orders issued by the

Contracting Officer. As their coverage is under a rider, their employer is responsible for directly interacting with the Contractor to order any coverage for their employees. When contacted by the employer, the Contractor shall advise the employer of the paperwork and payment that will be necessary to order coverage for the identified individuals. Because more than one employer may have ORE staff, the Contractor may be contacted by more than one employer (typically the Chief of Mission and Deputy Chief of Mission).

D. 14 Choice of Law

This contract shall be construed and interpreted in accordance with the substantive laws of the

United States of America. By the execution of this contract, the contractor expressly agrees to waive any rights to invoke the jurisdiction of local national courts where this contract is performed and agrees to accept the exclusive jurisdiction of the United States Civilian Board of

Contract Appeals and the United States Court of Federal Claims for hearing and determination of any and all disputes that may arise under the Disputes clause of this contract.

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D.15 Start / Period of Performance

Contract performance is estimated to start March / April 2024.

The period of performance is one year, with four possible annual option years. Option years, if exercised, shall be for twelve (12) months each, commencing at the expiration of the previous period of performance.

The Government may extend this contract in accordance with the option clause in Section 2, FAR 52.217-9, Option to Extend the Term of the Contract - Deviation, which also specifies the total duration of this contract.

The Government may exercise the option set forth at Section 2, "FAR 52.217-8, Option to

Extend Services", within the currently ongoing period of performance.

Notwithstanding the expressed contract expiration date, this contract shall remain in full force and effect until the last items or services ordered hereunder have been delivered and accepted by the Government.

D.16 Risk Assessment and Risk Mitigation Plan

Burkina Faso is listed on the Department of State’s Designated Critical Environments List.

The Government will have to perform a comprehensive risk assessment and develop a risk mitigation plan for contractor personnel who are non-local resident American Citizens or Third

Country Nationals in country for more than 45 cumulative days in a calendar year.

(It does not apply to local country nationals)

When requested the contractor shall provided the required information to the Government within one week.

D.17 List Of Attachments

• Attachment 1 Pricing

• Attachment 2 Experience / Past Performance

• Attachment 3 Form W-14

• Exhibit A Employee Statistic

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SECTION II – CONTRACT CLAUSES

52.212-4 Contract Terms and Conditions—Commercial Products and Commercial

Services (Nov 2023)

(a) Inspection/Acceptance. The Contractor shall only tender for acceptance those items that conform to the requirements of this contract. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The

Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or reperformance will not correct the defects or is not possible, the

Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights-

(1) Within a reasonable time after the defect was discovered or should have been discovered; and

(2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item.

(b) Assignment. The Contractor or its assignee may assign its rights to receive payment due as a result of performance of this contract to a bank, trust company, or other financing institution, including any Federal lending agency in accordance with the

Assignment of Claims Act ( 31 U.S.C. 3727). However, when a third party makes payment…