19GE5024R0025 0002.pdf

19GE5024R0025

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE RATING

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

04/29/2024

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

FRANKCODE

AMERICAN CONSULATE GENERAL FRANKFURT

GIESSENER STRASSE 30

ATTN: RPSO

60435, FRANKFURT

GERMANY

Andra Balta

NAME

TEL.

BaltaA@state.gov

EMAIL

6. ISSUED BY OPEAQMCODE

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

7. ADMINISTERED BY (If other than Item 6)

9A. AMENDMENT OF SOLICITATION NO.

19GE5024R0025

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)

03/12/2024

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 purpose of amendment 0002 is to provide:

1) Answers to the 37 questions received;

2) Attachment V - "Employees & dependents data April 25, 2024" and Attachment VI - "Loss data for vendors 04-25-2024";

3) Additional changes to the RFP. Changes are provided in red. See the following paragraphs for details:

a) Section B. Services and prices:

o B.4. Pricing And Value Added Tax, Paragraph B.4.2 o B.5. Minimum and maximum amounts o B.7. Economic Price Adjustment-Health Insurance Premiums, Paragraph B.7.1

b) Provision 52.212-1 Addendum Instructions to offerors, Volume 2: Technical Proposal, 3. Past Performance Information

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

04/29/2024

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

Table of Contents

Section Description Page Number

B Supplies or Services and Prices/Costs

B SERVICES AND PRICES

C Descriptions/Specifications/Statement of Work

C PERFORMANCE WORK STATEMENT

F Deliveries or Performance 52.242-15 Stop-Work Order (Aug 1989) 52.242-17 Government Delay of Work (Apr 1984)

652.237-72 OBSERVANCE OF LEGAL HOLIDAYS AND ADMINISTRATIVE LEAVE (FEB

2015)

G Contract Administration Data 652.237-802 Contractor identification

652.242-70 CONTRACTING OFFICER'S REPRESENTATIVE (COR) (AUG 1999)

I Contract Clauses 52.203-12 Limitation On Payments to Influence Certain Federal Transactions (Jun 2020) 52.204-9 Personal Identity Verification of Contractor Personnel (Jan 2011) 52.204-13 System for Award Management Maintenance (Oct 2018) 52.204-18 Commercial and Government Entity Code Maintenance (Aug 2020) 52.204-19 Incorporation by Reference of Representations and Certifications (Dec 2014) 52.222-50 Combating Trafficking in Persons (Nov 2021) 52.224-3 Privacy Training (Jan 2017) 52.225-14 Inconsistency Between English Version and Translation of Contract (Feb 2000) 52.229-6 Taxes-Foreign Fixed-Price Contracts (Feb 2013) 52.232-1 Payments (Apr 1984) 52.232-18 Availability of Funds (Apr 1984) 52.232-39 Unenforceability of Unauthorized Obligations (Jun 2013) 52.233-1 Disputes (May 2014) 52.233-4 Applicable Law for Breach of Contract Claim (Oct 2004) 52.242-13 Bankruptcy (July 1995) 52.244-6 Subcontracts for Commercial Products and Commercial Services (Feb 2024) 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (Nov 2023) 52.212-5 Contract Terms and Conditions Required To Implement Statutes or Executive Orders- Commercial Products and Commercial Services (Feb 2024) 52.216-18 Ordering (Aug 2020) 52.216-19 Order Limitations (Oct 1995) 52.216-21 Requirements (Oct 1995) 52.217-8 Option to Extend Services (Nov 1999) 52.217-9 Option to Extend the Term of the Contract (Mar 2000) 52.229-12 Tax on Certain Foreign Procurements (Feb 2021) 52.232-19 Availability of Funds for the Next Fiscal Year (Apr 1984) 52.237-3 Continuity of Services (Jan 1991)

652.216-70 ORDERING INDEFINITE-DELIVERY CONTRACTS (APR 2004)

652.225-71 SECTION 8(a) OF THE EXPORT ADMINISTRATION ACT OF 1979, AS AMENDED

(AUG 1999)

652.232-70 Payment Schedule and Invoice Submission (Fixed-Price)(Aug 1999)

652.242-73 AUTHORIZATION AND PERFORMANCE (AUG 1999)

K Representations, Certifications, and Other Statements of Offerors or Respondents 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (Nov 2021) 52.204-29 Federal Acquisition Supply Chain Security Act Orders-Representation and Disclosures (Dec 2023) 52.209-7 Information Regarding Responsibility Matters (Oct 2018) 52.212-3 Offeror Representations and Certifications-Commercial Products and Commercial Services (Feb 2024) 52.225-25 Prohibition on Contracting with Entities Engaging in Certain Activities or Transactions Relating to Iran--Representation and Certifications (Jun 2020)

652.225-70 ARAB LEAGUE BOYCOTT OF ISRAEL (AUG 1999)

K.1 CONTRACTOR RECRUITMENT OF THIRD COUNTRY NATIONALS (TCNs)

L Instructions, Conditions, and Notices to Offerors and Respondents 52.204-16 Commercial and Government Entity Code Reporting (Aug 2020) 52.204-7 System for Award Management (Oct 2018) 52.212-1 Instructions to Offerors-Commercial Products and Commercial Services (Sep 2023) 52.212-1 Addendum INSTRUCTIONS TO OFFERORS 52.214-34 Submission of Offers in the English Language (Apr 1991) 52.222-56 Certification Regarding Trafficking in Persons Compliance Plan (Oct 2020)

652.206-70 ADVOCATE FOR COMPETITION/OMBUDSMAN (FEB 2015)

M Evaluation Factors for Award 52.212-2 Evaluation-Commercial Products and Commercial Services (Nov 2021) 52.217-5 Evaluation of Options (July 1990) 52.225-17 Evaluation of Foreign Currency Offers (Feb 2000)

Line Item Summary

Solicitation Number:

19GE5024R0025

Contract Number: Title: Health Insurance Plan - US Embassy Baku

Date of Solicitation:

04/29/2024

Line Item No.

Description Quantity Unit Unit Price Total Cost

001 Health Insurance services for the base year period as detailed in Attachment I - Price schedule Type of Contract Pricing: FFP

Doc Ref No:

Delivery Date (Start to End) Date FOB:

08/03/2024 to 08/02/2025

1.00 0.00 1.00

EA

BASE PERIOD

002 Health Insurance services for the first option year period as detailed in Attachment I - Price schedule Type of Contract Pricing: FFP

Doc Ref No:

Delivery Date (Start to End) Date FOB:

08/03/2025 to 08/02/2026

1.00 0.00 1.00

EA

003 Health Insurance services for the second option year period as detailed in Attachment I - Price schedule Type of Contract Pricing: FFP

Doc Ref No:

Delivery Date (Start to End) Date FOB:

08/03/2026 to 08/02/2027

1.00 0.00 1.00

EA

004 Health Insurance services for the third option year period as detailed in Attachment I - Price schedule Type of Contract Pricing: FFP

Doc Ref No:

Delivery Date (Start to End) Date FOB:

08/03/2027 to 08/02/2028

1.00 0.00 1.00

EA

005 Health Insurance services for the fourth option year period as detailed in Attachment I - Price schedule Type of Contract Pricing: FFP

Doc Ref No:

Delivery Date (Start to End) Date FOB:

08/03/2028 to 08/02/2029

1.00 0.00 1.00

EA

B - SERVICES AND PRICES

B.1. GENERAL INFORMATION

B.1.1. The Contractor shall provide health insurance services to locally employed staff of the Government of the United States of America in Azerbaijan and their eligible dependents as described in Section C- Performance work statement.

B1.2. Acronyms and definitions

CLIN: Contract Line Item Number

Contractor: Insurance Company

CO: Contracting Officer

COR: Contracting Officer Representative (Human Resources Supervisor of the US Embassy Baku)

Dependent:

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.

Employer: The United States Government (USG)

Employee: Staff member of the US Embassy Baku

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

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

B.1.3. 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).

B.1.4. 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 results required by this contract. Nor will the contract price be adjusted on account of fluctuations in the currency exchange rates.

B.1.5. Retirees are not eligible for coverage.

B.2. PERIOD OF PERFORMANCE

B.2.1. Period of Performance. The performance period of this contract is one year beginning on the effective date of the contract with four (4) one-year options to renew.

B.3. OPTIONS

(a) The Government may extend this contract in accordance with the option clause at Section I, clause I.2, FAR Clauses Incorporated by Full Text (FAR 52.217-9, Option to Extend the Term of the Contract), which also specifies the total potential duration of the contract.

(b) The Government may exercise the option set forth at Section I, "FAR 52.217-8, Option to Extend Services".

B.4. PRICING AND VALUE ADDED TAX

B.4.1. VAT does not apply to this contract. Embassy Baku is holding a VAT Exemption Certificate from the host government .

B.4.2. This is a requirements type contract with fixed priced units with economic price adjustment under which will be issued fixed-price orders. The fixed prices/premium rates for the health insurance services as specified in Section C are detailed in Attachment I – Price schedule.

B.4.3. Pricing Summary

BASE YEAR TOTAL (0001-0006)

FIRST OPTION YEAR TOTAL (1001-1006)

SECOND OPTION YEAR TOTAL (2001-2006)

THIRD OPTION YEAR TOTAL (3001-3006)

FOURTH OPTION YEAR TOTAL (4001-4006)

ESTIMATED GRAND TOTAL (BASE + ALL OPTIONS)

CURRENCY OF OFFER:_______________________________________________

*Insert currency of offer

B.5. MINIMUM AMOUNTS

During the Base Year of the contract, and during the option year that might be exercised, the United States Government (USG) shall place orders totaling a minimum of $5,000.00. This reflects the contract minimum guarantee for each period of performance.

B.6. ADMINISTRATIVE RETENTION AMOUNTS

B.6.1 If the Contractor requests a price adjustment under B.7 below, the Contractor shall present cost experience data that includes the retention amount. For purposes of any economic price adjustment, this retention amount is a fixed amount that is a part of the premium amounts Attachment I – Price schedule. This retention amount will not be adjusted for any reason.

B.6.2. The retention amount is part of the premium and may include, but not be limited to, such costs as overhead and general and administrative costs. It will also include any profit. Essentially, it includes all costs except the actual portion of the premium intended to fund claims paid to the health care provider/claimant. B.6.3 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

NOTE TO OFFEROR: Fill in the fixed monthly retention amounts for each period of performance and for each category of premium. This fixed amount shall be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall NOT be expressed in terms of a percentage of the premium.

B.6.3. Monthly Retention Amounts per separate premium paid per self only, per self plus one and per family plan.

Period of Performance Single Employees (Self only) Self Plus One

(two individuals) Family (three or more individuals)

Base Period First Option Year Second Option Year Third Option Year Fourth Option Year

B.7. ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.7.1. Premium Adjustment Based on Experience - For health insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract, and it specifically excludes all riders in B.1.1. No adjustment will be allowed during the first twelve months. After such time, the Contractor or the Government may request an adjustment in premiums on an annual basis. Adjustments are not retroactive to previous contract terms. Before any such adjustment is made, the Contractor agrees to provide the Government a balance sheet showing three main components for the time period: (1) receipts (premiums received) minus the retention amount, (2) number of insurance plans and (3) claims paid. This information shall be provided per type of premium, ie per line item.

EPA adjustments will only be made to the contract line item rate amount for each type of premium, and cannot be collected as a lump sum adjustment based on the annual projected price.

The retention amount is not subject to adjustment. The Government 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. Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.7.2. 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. The Contractor agrees to provide all documentation necessary to support any requested adjustment.

B.7.2.1 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 shall include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

Section C - Descriptions/Specifications/Statement of Work

C - PERFORMANCE WORK STATEMENT

C.1.0. HEALTH INSURANCE SERVICES

The Contractor shall provide health insurance services to locally employed staff of the Government of the United States of America in Azerbaijan and their eligible, as further described in this section.

C.1.1. EMPLOYEE AND DEPENDENT HEALTH SERVICE BENEFITS

C.1.1.1. Hospitalization (Treatment in the Hospital for Inpatient Care): Minimum Coverage - 100%

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 (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): Minimum Coverage - 100%

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

C1.1.3. Ambulance: Minimum Coverage - 80%

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.

C.1.1.4. Outpatient Services: Minimum Coverage - 80%

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: Minimum Coverage - Inpatient/Emergency: 100%; 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.

C.1.1.6. Pediatric Services: Minimum Coverage - Inpatient/Emergency: 100%, 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.

C.1.1.7. Prescription Drugs: Minimum Coverage -Inpatient/Emergency: 100%, 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.

C.1.1.8. Preventive and Wellness Services and Chronic Disease Management:

Minimum Coverage - 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 are not limited to: physicals, immunizations, and cancer screenings.

C.1.1.9. Hearing Aids: Minimum Coverage – 80%

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 Care: Minimum Coverage – 80%

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.

C.1.1.11. Dental Care: Minimum Coverage – 80% Minimum Coverage

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: Minimum Coverage - 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 Exclusions to Coverage).

C.1.1.13. Mental Health and Substance Abuse Care: Minimum Coverage - 50%

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.

C.1.1.14. Rehabilitative and Habilitative Services and Devices: Minimum Coverage - 50%

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.

C.1.1.15. HIV/AIDS: 100% up to USD 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.

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

C.1.1.16. Catastrophic Coverage

Additional coverage equal to USD $60,000 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.

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 the same total maximum annual limit as for medical expenses incurred in-country.

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. 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.

C.1.1.19. 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.

C.1.1.20. Excess Coverage

Additional coverage equal to USD $60,000 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. This can be used for any covered individual, for any covered expense that exceeds the annual maximum limit.

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

USD $60,000.

C.1.3 EXCLUSIONS AND LIMITATIONS

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.1.4 ELIGIBLE PARTICIPANTS

C.1.4.1 Eligibility:

C.1.4.1.1. 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.

C.1.4.1.2. 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 Azerbaijan 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.

C.1.4.1.3. 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 and EA employee.

C.1.4.1.4. Retiree Coverage: Retirees are not eligible for coverage.

C.1.4.2. Periods of Ineligibility:

C.1.4.2.1. Employees and their dependents are not entitled to health benefits during any period of employment for which premiums are not paid.

C.1.4.2.2. 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.1.4.2.3. 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.1.4.3. Dependents:

C.1.4.3.1. 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.1.4.4. Premium: Premiums will be based on the number of individuals covered:

• Self-Only: 1 covered individual

• Self Plus One (two individuals)

• Family (three or more individuals)

C.1.5 Eligibility

C.1.5.1 Term of Eligibility and Effective Date

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. 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 Government, is responsible for management and quality control to meet the terms of the contract. The role of the Government is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective PWS Paragraph Performance Threshold Services Performs all the insurance services set forth in the Performance Work Statement (PWS)

C.1.0 thru C.1.4

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

Timely payment of benefits (within 21 calendar days)

C.1.7 No more than one (1) customer complaint is received per month

No incorrectly denied claims.

C.1.0 thru C.1.4 and C.1.7 No more than one (1) customer complaint is received per month.

C.1.5.1. Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided. If appropriate, the COR will send the complaints to the Contractor for corrective action.

C.1.5.2. Standard. The performance standard is that the Government receives no more than one (1customer 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.

C.1.5.3. Procedures

(a) If any Government personnel observe unacceptable services, either incomplete work or required services not being performed, they should immediately contact the COR.

(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, orally notify the Contractor of any valid complaints.

(f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR.

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 complaint.

(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.

C.1.6. DELIVERABLES

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in English, Azerbaijani and Russian 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 thirty (30) 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. Insurance Card (Optional – this requirement shall be discussed with the COR after contract award) An ID card shall be provided for each insured person (preferably with photo).

If the ID card is lost or stolen the contractor shall provide a replacement at no cost.

C.1.6.5. Summary reports

The Contractor shall provide the following summary reports monthly. All reports must be received by the COR no later than the 10th day of each month. These reports shall report on the previous month's activities. No PII information will be included in the report.

a. Employee Claims Report. The report will 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.

b. Demographic Information Report to include employee age distribution, dependent distribution, member movement, and distribution of benefits.

c. Benefits utilization information to include hospital benefit statistics, chronic illness statistics, claims expenditure distribution, and health promotion utilization.

C.1.6.6. 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 Baku ATTN: Human Resources Officer 111 Azadlig Ave

AZ 1007

Baku, Azerbaijan

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.

Description Quantity Submission Date Delivery:

Brochures

Additional copies

For review 30 days after contract award

After review by the COR

Within 10 calendar days of the COR’s request

COR

hard copy

Employee claims report 1 each No later than the 30th calendar day of each month e-mail, pdf document

Claim forms for each type of benefit that can be claimed under the contract

Basic supply

Additional copies

30 days after contract award

Within 10 calendar days of the COR’s request e-mail, hard copy

Employee claim reimbursement via EFT each Within 21 calendar days of the submission of the claim e-mail, hard copy

Draft version of Management Plan 1 each As part of the offer CO

Final version of Management Plan 1 eaach 15 calendar days after receipt of contract award

C.1.7. 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 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

4. The contractor shall provide claim reimbursement via EFT to the employees no later than two weeks after the claim has been 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, through a drop box in the COR's office.

The claims shall be picked up from the COR each Tuesday.

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 reimbursement via EFT. For each reimbursement the contractor shall send 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.

C.1.8. 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.

C.1.9. KEY PERSONNEL / QUALIFICATIONS AND CAPABILITIES

C.1.9.1. Key personnel under this contract is:

Project Manager – the contractor shall provide a project manager who shall be responsible for the administration, supervision, and coordination of the contractor’s Government operations. The project manager shall be the focal point for all activities related to the performance of this contract. He/she is to be considered the Contractor's POC for the Government.

The project manager shall have good working skills in English.

C.1.9.2. During the first 90 days of performance, the Contractor shall make no substitutions of key personnel unless the substitution is required due to illness, death, or termination of employment. The Contractor shall notify the Contracting Officer within 15 calendar days after the occurrence of any of these events and provide the information required below to the Contracting Officer at least 15 days before making any permanent substitutions.

C.1.9.3. After the first 90 days of performance, the Contractor may substitute a key person if the contractor determines that it is necessary. The Contractor shall notify the Contracting Officer of the proposed action immediately. Prior to making the substitution, the Contractor will provide the information required below to the Contracting Officer.

C.1.9.4. The Contractor shall provide a detailed explanation of the circumstances requiring the proposed substitution, a complete resume for the proposed substitute. The proposed substitute shall possess qualifications comparable to the original key person. The

Contracting Officer will notify the Contractor of its approval or disapproval of the substitution within 15 calendar days after receiving the required information. The Government will modify the contract to reflect any changes in key personnel.

C.1.10. PERMITS

Without additional cost to the Government, the Contractor shall obtain all permits, licenses, and appointments required for the prosecution of work under this contract. The Contractor shall obtain these permits, licenses, and appointments in compliance with applicable host country laws. The Contractor shall provide evidence of possession or status of application for such permits, licenses, and appointments to the Contracting Officer with its proposal. Application, justification, fees, and certifications for any licenses required by the host government are entirely the responsibility of the Contractor.

C.1.11 - RESERVED

C.1.12 - RECRUITMENT OF THIRD COUNTRY NATIONALS FOR PERFORMANCE ON DEPARTMENT OF STATE

CONTRACTS (MAY 2023)

C1.12.1. Where contracts exceeding the Simplified Acquisition Threshold will require the recruitment of Third Country Nationals (TCNs), the offeror is required to submit a Recruitment Plan as part of its proposal. Offerors providing employer furnished housing are required to submit a Housing Plan. All plans are assessed on a pass/fail basis.

C1.12.2. Recruitment Plans must:

a. State the anticipated number of workers to be recruited, the skills they are expected to have, and the country or countries from which the contractor intends to recruit them.

b. Explain how the contractor intends to attract candidates and the recruitment strategy including the recruiter.

c. State in the offer that the recruited employee will not be charged recruitment fees as defined in FAR 22.1702 and FAR 52.22-50.

The contractor or employer pays the recruitment fees for the worker if recruited by the contractor or subcontractor to work specifically on Department of State contracts.

d. Recruitment fees included by the prime contractor in the contract price must be allowable by country law, allocable to the contract based on benefit to the program, and reasonable based on what a prudent businessperson would pay for similar expenses and charges.

The reasonableness of recruitment fees should be assessed based on the reasonableness of the individual components.

e. State in the offer that the contractor’s recruitment practices comply with recruiting nation and host country labor laws.

f. State in the offer that the contractor has read and understands the requirements of FAR 52.222-50 Combating Trafficking in Persons.

g. Contractor will advise the Contracting Officer of any changes to the Recruitment Plan during performance.

30.3. The offeror will submit a Housing Plan if it intends to provide employer furnished housing for TCNs. The Housing Plan must describe the location and description of the proposed housing. Contractors must state in their offer that housing meets host country housing and safety standards and local codes. Contractor shall comply with any Temporary Labor Camp standards contained in their contract. In contracts without a Temporary Labor Camp standard, a minimum of 70 square feet per employee must be allocated if an employee is housed individually; if housed together, a minimum of 50 square feet per employee must be allocated unless waived by the Contracting Officer. Contractor shall submit proposed changes to their Housing Plan to the Contracting Officer for approval.

30.4. Department of State contractor and subcontractors will prevent human trafficking and treat employees with respect and dignity by taking the following actions:

a. Contractor may not destroy, conceal, confiscate, or otherwise deny access to an employee’s identity documents, passports, or immigration documents. Contractors and subcontractors are reminded of the prohibition contained in Title 18, United States Code, Section 1592, against knowingly destroying, concealing, removing, confiscating, or possessing any actual or purported passport or other immigration document to prevent or restrict the person’s liberty to move or travel in order to maintain the services of that person, when the person is or has been a victim of a severe form of trafficking in persons. Contractor must be familiar with any local labor law restrictions on withholding employee identification documentation.

b. Contractor shall provide employees with signed copies of the/their employment contracts that are in a language the worker understands and define the terms of employment, compensation including salary, overtime rates, allowances, salary increases, job description, description of any employer provided housing, benefits including leave accrual, and information on whether hazardous working conditions are anticipated. Contracts must be provided prior to employee departure from their countries of origin. Fraudulent recruiting practices, including deliberately misleading information, will be considered a material breach of this contract.

c. Contractor shall provide all employees with the Department’s “Know Your Rights” poster and document that employees have been briefed on the contents of the poster. The English language version is available at posters and accompanying directions or from the Contracting Officer.

d. Contractor shall display posters in worker housing advising employees…