19GE5024R0086.pdf

SOLICITATION

DOCUMENT

Project Description:

Health Insurance Services

American Embassy Kyiv, Ukraine

Solicitation No. 19GE5024R0086

American Consulate General Regional Procurement Support Office

Giessener Strasse 30

60435 Frankfurt am Main, Germany

19GE5024R0086

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

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

1. REQUISITION NUMBER

5. SOLICITATION NUMBER

19GE5024R0086

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

DATE

06/24/2024

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

Hartmut Christe

b. TELEPHONE NUMBER (No collect calls)

c. EMAIL christeh@state.gov

8. OFFER DUE DATE / LOCAL

TIME

07/30/2024 03:00

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

X

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

KYIV_CODE15. DELIVER TO

AMERICAN EMBASSY KYIV

4 IHORYA SIKORSKOHO ST

ATTN: GSO

KYIV, UKRAINE

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 KYIV

4 Ihor Sikorsky St.

ATTN: FMC

KYIV, UKRAINE 04112

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

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN ____ 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 06/24/2024

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

x 1

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: _________________________________

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

PARTIAL FINAL

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED

CORRECT FOR

COMPLETE PARTIAL FINAL

36. PAYMENT 37. CHECK NUMBER

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 02/2012) BACK

Line Item Summary

Solicitation Number:

19GE5024R0086

Contract Number: Title: Kyiv, Ukraine - Group Health Insurance

Date of Solicitation:

06/24/2024

Line Item No.

Description Quantity Unit Unit Price Total Cost

001 BASE YEAR

Health Insurance Services CLINs 0001 - 0005 Type of Contract Pricing: FPE

Doc Ref No:

Delivery Date FOB:

1.00 SV $0.00 $0.00

002 FIRST OPTION YEAR

Health Insurance Services CLINs 1001 - 1005 Type of Contract Pricing: FPE

Doc Ref No:

Delivery Date FOB:

1.00 SV $0.00 $0.00

003 SECOND OPTION YEAR

Health Insurance Services CLINs 2001 - 2005 Type of Contract Pricing: FPE

Doc Ref No:

Delivery Date FOB:

1.00 SV $0.00 $0.00

004 THIRD OPTION YEAR

Health Insurance Services CLINs 3001 - 3005 Type of Contract Pricing: FPE

Doc Ref No:

Delivery Date FOB:

1.00 SV $0.00 $0.00

005 FOURTH OPTION YEAR

Health Insurance Services CLINs 4001 - 4005 Type of Contract Pricing: FPE

Doc Ref No:

Delivery Date FOB:

1.00 SV $0.00 $0.00

TABLE OF CONTENTS

Section I - The Schedule

• SF 1449 Cover Sheet

• Continuation to SF-1449, RFP Number 19GE5024R0086, Prices, Block 23

• Continuation to SF-1449, RFP Number 19GE5024R0086, Schedule of Supplies/Services, Block 20 Description/Specifications/Work Statement

• Attachment 1: W-14 Forms

• Attachment 2: W-14 Instructions

• Attachment 3: Price Proposal Breakdown

• Attachment 4: Information Regarding Contractor’s Recruitment of Third Country Nationals

(TCNs).

• Attachment 5: Employee Statistics

Section II - Contract Clauses

• Contract Clauses

• Addendum to Contract Clauses - FAR and DOSAR Clauses not Prescribed in Part 12

Section III - Solicitation Provisions

• Solicitation Provisions

• Addendum to Solicitation Provisions - FAR and DOSAR Provisions not Prescribed in Part 12

Section IV - Evaluation Factors

• Evaluation Factors

• Addendum to Evaluation Factors - FAR and DOSAR Provisions not Prescribed in Part 12

Section V - Representations and Certifications

• Offeror Representations and Certifications

• Addendum to Offeror Representations and Certifications - FAR and DOSAR Provisions not

Prescribed in Part 12

SECTION I - THE SCHEDULE

CONTINUATION TO SF-1449

RFP NUMBER 19GE5024R0086

PRICES, BLOCK 23

A. GENERAL

A.1 The U.S. Government requires Health Insurance for its Locally Employed Staff (LES) and their dependents at U.S. Embassy Kyiv, Ukraine. The Contractor shall provide the health insurance services in accordance with the Statement of Work (SOW).

A.2 The quantities set forth in the pricing section (attachment #3) are estimates; the Government does not guarantee that such quantities will be ordered. The contract will be for a one-year period from the date of the contract award, with four (4) one-year options. The performance period is set to commence on November 17, 2024.

A.3 This is a fixed-price Indefinite-Delivery Indefinite-Quantity (IDIQ) contract with economic price adjustment requirements 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 the SOW are listed in Section B, Pricing.

A.4 The general liability policy required of the Contractor shall name “the United States of

America” as additional insured. The general liability insurance shall be as required by law or as ordinarily obtained in the location of the work. The limit of such insurance shall be as provided by law or sufficient to meet normal and customary claims. The Contractor agrees that the Government shall not be responsible for personal injuries or for damages to Government’s property in Contractor’s custody, any property of the Contractor, its officers, agents, servants, and employees, or any other person, arising from, and incident to, the Contractor's performance of the work detailed herein. The

Contractor shall hold harmless and indemnify the Government from any and all claims arising therefrom, except in the instance of gross negligence on the part of the Government. The Contractor shall submit evidence of general liability insurance within 10 calendar days after award.

A.5 Minimum and Maximum Amounts: During life of this contract, the Government shall place orders totaling a minimum of $5,000.00 or local currency equivalent. This reflects the contract minimum for this period of performance. The amount of all orders shall not exceed $18,000,000.00 or local currency equivalent, which reflects the contract maximum.

A.6 Acquisition Method: This is a commercial acquisition as defined in Federal Acquisition

Regulation (FAR) 2.101, Definitions, and as describe in FAR part 12, Acquisition of Commercial

Products and Commercial Services. Pursuant to FAR 12.102(b), the policies in FAR part 12 are used in conjunction with the policies and procedures for solicitation, evaluation and award prescribed in FAR part 13, Simplified Acquisition Procedures.

B. PRICING

B.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 materials, equipment, labor, overhead, profit, general liability insurance, and transportation necessary to deliver the required services. 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.

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

Pricing shall be provided with Attachment 3, Price Proposal Breakdown.

B.2 VALUE ADDED TAX (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. 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 repay the refund amount to the U.S.

Government.

B.3 JAMES ZADROGA 9/11 VICTIMS HEALTH AND COMPENSATION ACT OF 2010

NOTICE

Unless a waiver or exception applies, payments subsequent to this procurement are subject to an excise tax of 2% pursuant to 26 U.S.C. 5000C.

B.4 ADMINISTRATIVE RETENTION AMOUNTS

B.4.1 If the Contractor requests a price adjustment under B.5 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

3, Price Proposal Breakdown. This retention amount will not be adjusted for any reason.

B.4.2 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.4.3 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

B.4.3 Monthly Retention Amounts per separate premium paid per self only, per self plus one and per family plan.

The offeror shall complete the fixed monthly retention amounts for each performance period and premium category. Ensure these amounts are expressed in the currency proposed for the premium.

Note that the fixed retention amount should not be indicated as a percentage of the premium.

Period of Performance Employee Only Employee Plus One Family

Base Year

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.5 ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.5.1 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 U.S. Government 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 U.S. Government 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. 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 U.S. 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 effective for the following option year. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.5.2 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(s). The contractor agrees to provide all documentation necessary to support any requested adjustment.

B.5.3 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.

CONTINUATION TO SF-1449,

RFP NUMBER 19GE5024R0086

SCHEDULE OF SUPPLIES/SERVICES, BLOCK 20

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C. STATEMENT OF WORK

C. INTRODUCTION – HEALTH INSURANCE SERVICES

The Contractor shall provide the Health Insurance services to employees of the Government of the

United States of America in Ukraine as described in Section C and the Exhibits A, B, C. The groups of employees who shall be provided this insurance are listed in C.1.3. This insurance shall be provided in accordance with Section C and the Exhibits A, B, C.

Official Residence Expense (ORE) Staff, Embassy Association Employees (AEEA) and Peace Corp

Personal Service Contracts (PSC) are included under this contract only as a rider; the Contractor shall bill the Chief of Mission and Deputy Chief of Mission (for ORE Staff), Peace Corp Ukraine and the

Embassy Association (for AEEA s) at the rates specified below. See Section G for billing procedures.

C.1 HEALTH INSURANCE SERVICES

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as further described in C.1.2 in Ukraine. The Government has determined that the prevailing practice by employers in Ukraine is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by both the employee and the employer. Under this contract the premium cost will be shared as follows:

- Employee coverage: the USG will pay 95% and the employee will pay 5%

- Dependent coverage: the USG will pay 60% and the employee will pay 40%

Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.2. The specific health benefit coverage under this contract is set forth in

Section C and the Exhibits in A, B, C.

The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care, unless exclusion has been authorized by HR/OE/CM.

C.1.1 Employee and Dependent Health Services Benefits

The health benefits under this contract are as follows. Reimbursement of covered expenses is limited to the stated percentages of reasonable and customary costs. Proposals that contain more benefits

(even if there is no increase in cost) or fewer benefits than stated in the solicitation may be deemed technically unacceptable.

The Insurance company will reimburse covered expenses up to following limits:

1) USD 13,400 per covered individual per contract year (USD 13,000.00 for medical services plus

USD 400.00 for dental care) for covered expenses with the exception of expenses incurred under paragraph C.1.1.14.

2) USD 10,000 per covered individual per contract year for expenses described under the paragraph C.1.1.14 (HIV/AIDS care).

The insurance company will reimburse covered medical expenses incurred, subject to the stated limits.

Payment will be made for reasonable and customary expenses of covered benefits. The medical treatment must be prescribed or provided by a physician or nurse licensed in Ukraine, the United

States, or in the country in which the treatment or prescription is received.

According to the local business practice, receiving of medical services under health insurance contracts must be preauthorized by the insurance company. Therefore the Contractor must provide 24-our 7 days/week assistance to the persons insured under this contract in receiving all medical services provided by this contract. The contractor must have “round the clock” functioning office/call center with a dedicated special phone lines and duty physician(s) who must:

- Promptly assess the situation, determine the appropriate medical treatment, make all necessary arrangements for care and organize medical care in Ukraine;

- Monitor of service from the moment of the initial reference up to the moment of recovery;

- Control the quality of treatment during the entire period of treatment;

- Provide information and consultations on medical services by phone;

Clinics that are listed below are acceptable and are currently being used by the persons insured under the current health insurance contract. The Offeror must provide medical service at the below listed clinics as well as at the other clinics on the territory of Ukraine of the same level of standard (existing or newly opened during the course of the contract): Oberih, Medikom, Dobrobut, Isida, Adonis, Leleka, Ohmatdyt, etc.

When the treatment cannot be provided by the private clinic it should be organized in specialized clinic

(e.g. Oncology Center, Proctology Center, SRI of Orthopedic & Trauma, SRI of Urology &

Nephrology etc.)

Description:

Paragraph Covered Benefit Employee Dependent

C.1.1.1.

Hospitalization (inpatient):

- 100 % coverage of room and board expenses for a semi-private room.

- 100% coverage of inpatient hospital medical expenses including laboratory tests and x-rays, nursing care, operating room expenses, intensive care, prescription medicines, and physical therapy.

- 100% coverage for land ambulance service. 100% 100%

C.1.1.2.

Surgery (inpatient):

- 100% coverage of doctor, surgeon and nursing fees incurred while hospitalized, on an in-patient basis, at a hospital, clinic, doctor's office, or at home.

- 100% coverage for medical services and expenses when not hospitalized such as laboratory tests, x-rays and inoculations. 100% 100%

C.1.1.3.

Doctor Visits:

- 100% coverage for annual examinations with a general practitioner.

- 100% coverage for examinations provided by a medical specialist on an outpatient basis.

and inoculations. 100% 100%

C.1.1.4.

Prescription Drugs:

- 100% coverage of expenses for the cost of medicines and drugs for which a prescription is legally required.

Expenses incurred for medicines, vitamins, cold remedies, etc. that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician.

100% 100%

C.1.1.5.

Maternity:

- 100% coverage for incurred delivery expenses when hospitalized.

- 100% coverage for incurred obstetrical medical care expenses for prenatal and postnatal care.

Family Planning:

- The Mission does not cover expenses of prescribed contraceptive devices and drugs, voluntary sterilization, diagnosis and treatment of infertility, fertility drugs, reversal of voluntary sterilization, infertility treatment after voluntary sterilization, generic counseling and assisted reproductive technology. 100% 100%

C.1.1.6.

Hospital Outpatient Services:

- 100% coverage of doctor, surgeon and nursing fees incurred while hospitalized, on an out-patient basis, at a hospital, clinic, doctor's office, or at home.

and inoculations.

100% 100%

C.1.1.7.

Optical Services:

- 100% coverage of expenses for eye examination and treatment and prescriptions. No coverage of expenses for eyeglass frames, lenses, or tinting.

100% 100%

C.1.1.8.

Dental Services:

- 100% coverage of for dental services including dentists' fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, and bridges.

Coverage of expenses for dental services is capped at

USD 400 per year.

- No coverage of expenses for orthodontic treatment.

100% 100%

C.1.1.9. Physical Therapy 100% 100%

C.1.1.10.

Psychiatric Treatment:

- 100% coverage of expenses for psychiatric treatment, diagnostic only.

100% 100%

C.1.1.11.

Ambulance Service:

- Coverage for land ambulance service.

100% 100%

C.1.1.12.

Hearing Aids:

- no coverage for the cost of a hearing aid apparatus and related examinations.

N/A N/A

C.1.1.13.

Expenses Incurred Out-of-Country:

- The Mission does not cover medical expenses incurred out of the country. N/A N/A

C.1.1.14.

Other Benefits:

100% coverage of expenses for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS; as well as brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee's child. This expanded coverage generally excludes medications for the long-term suppression of AIDS through the combination of anti-retroviral drugs at those posts with inadequate local healthcare infrastructures. 100% 100%

C.1.1.15.

Maximum Limits:

With the exception of expenses incurred under paragraph

C.1.1.14. , the Insurance company will reimburse covered expenses up to a limit of USD 13,400.00 (including USD

400.00 for dental services) per covered individual per contract year.

The insurance company will pay covered expenses described under paragraph C.1.1.14. (HIV/AIDS) of the plan up to a separate limit of USD 10,000 per covered individual per contract year.

C.1.2 Health Benefits Conditions and Limitations.

Conditions and limitations on the entitlement to health care under this contract are as follows:

Expenses will not be covered for elective cosmetic surgery; spa cures; rejuvenation cures; massage;

exercise therapy; long term rehabilitative therapy; eyeglass frames; non-medical hospital charges such as telephones or television; home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

No coverage of expenses for eyeglass frames, lenses, or tinting.

No coverage of expenses for orthodontic treatment.

No coverage for the cost of a hearing aid apparatus and related examinations.

No coverage of expenses of prescribed contraceptive devices and drugs, voluntary sterilization, diagnosis and treatment of infertility, fertility drugs, reversal of voluntary sterilization, infertility treatment after voluntary sterilization, generic counseling and assisted reproductive technology.

No coverage will be made for expenses that will be reimbursed or paid directly under a host country medical program, the U.S. workers' compensation program, or any Ukrainian workers' compensation type program.

No coverage will be made for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self- inflicted wound; or service in the armed forces of any country.

No coverage will be made for expenses incurred after an employee leaves the service of the U.S.

Mission, except in the case of retired employees who elect to continue coverage.

No coverage of transportation for out of country treatment.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - The employees eligible for the health insurance services include the following:

C.1.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Ukraine paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include

C.1.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts (PSCs);

C.1.3.1.3. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

Participation in the supplemental medical insurance plan is voluntary.

C.1.3.2 Location of Employment

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Ukraine by:

Department of State

U.S. Agency for International Development

Department of Defense

Department of Commerce

Department of Agriculture

Department of Energy

Department of Health and Human Services

Department of Justice and other Departments assigned to post during the course of the contract.

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1 All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account (see separate riders, attachment 3 pricing and attachment 6 – Employee Statistics, Exhibit B). All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.1.3.3.2 All current active employees of the Employee Association at Embassy

Kyiv, Ukraine (see separate riders, attachment 3 pricing and attachment 6 – Employee

Statistics, Exhibit C). All costs for AEEA employees are the responsibility of the Employee

Association, not the U.S. Government.

C.1.3.3.3 All current active employees of the Peace Corps Ukraine paid under the

Peace Corps account (see separate riders, attachment 3 pricing and attachment 6 – Employee

Statistics, Exhibit D). All costs for Peace Corps Ukraine employees are the responsibility of their employer, Peace Corps Ukraine, not the U.S. Government.

C.1.4 Individuals Not Eligible for Coverage

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, employees with an intermittent, seasonal, or WAE (When Actually Employed) schedule; supplied by an independent contractor licensed to do business in Ukraine who provides services to other local organizations as well as to the U.S. Mission; employees of USAID institutional contractors; Peace

Corps personal services contractors as indicated in MS 743; and Recreation Association employees and other individual not falling within one of the categories of employees described in this clause.

C.1.5. Other Eligible Participants

The following additional categories of persons are covered by this insurance:

Dependent Coverage:

For the purposes of this plan, an employee's dependents are defined as the employee's legal spouse and each unmarried, economically dependent child who primarily resides with the employee unless away at school. A maximum of one spouse and six children will be covered per employee at one time. If both spouses are employed by the U.S. Mission, a maximum of six children will be covered per family.

Child is defined as the employee’s natural child, adopted child, stepchild, or foster child. An eligible child will be covered until the end of the calendar year in which the child turns age 18, or in the case of a child who is a full-time student, until the end of the calendar year in which the child turns age

22. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently.

Parents, grandparents, siblings, and other relatives are not eligible dependents.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee 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.

During a period of Leave Without Pay (LWP) or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the

Contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.

C.1.6.2. Period 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 (beyond one pay period) of Leave Without Pay (LWP) or unpaid leave, 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 that employee prefers not to pay the premium.

C.1.7. BROCHURE REQUIREMENT

C.1.7.1. The Contractor shall provide a document (brochure/pamphlet/other written document) in

Ukrainian that sets forth a complete listing of the health insurance benefits to be provided under this contract. The Contractor shall send the brochures to the COR, who will ensure that appropriate distribution is made.

C.1.7.2. The Contractor shall provide the document described in C.1.7.1 to the COR not later than 10 days after date of contract award.

C.1.7.3. The Contractor assumes full responsibility for ensuring that the document described in C.1.7.1 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.2.0 DEFINITIONS

Contributory Insurance Insurance for which the employee contributes toward the premium.

Customary and Reasonable

Treatment

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

Dependent For the purposes of this plan, an employee's dependents are defined as the employee's legal spouse and each unmarried, economically dependent child who primarily resides with the employee unless away at school. A maximum of one spouse and six children will be covered per employee at one time. If both spouses are employed by the U.S. Mission, a maximum of six children will be covered per family.

Child is defined as the employee’s natural child, adopted child, stepchild, or foster child. An eligible child will be covered until the end of the calendar year in which the child turns age 18, or in the case of a child who is a full-time student, until the end of the calendar year in which the child turns age 22. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently.

Parents, grandparents, siblings, and other relatives are not eligible dependents.

Employee An individual employed by the U.S. Government, under a direct-hire appointment, personal services contract (PSC), or personal services agreement (PSA), as further defined in Section C.1.3 for health insurance. This may also include ORE Staff, EAE, and

Peace Corp PSCs, if this category of individual is listed as participating under a rider in C.1.3.3 for health insurance and

C.2.3.3 for life insurance.

Employer The United States Government or in the case of ORE and AEEA employees, the Chief of Mission/Deputy Chief of Mission and the

Employee Association, respectively.

GSO General Services Officer in charge of the General Services Office at post. This officer is usually the Contracting Officer (CO) for this contract.

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.

Maximum Benefit The total amount that will be paid to any one covered individual for covered medical expenses or life insurance/disability benefit.

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

Surgical Procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.

CLIN Contract Line Item Number

CO Contracting Officer

COR Contracting Officer's Representative (COR) is the Human

Resources Officer (HRO) at post.

FMO The Financial Management Officer (FMO) or the paying office for all U.S. Government Agencies, except U.S. AID.

PII Personal Identifiable Information

QA Quality Assurance

QC Quality Control

QCP Quality Control Plan

USG United States Government

C.3 KEY PERSONNEL

The U.S. Government considers the contractor’s 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’s Representative (COR) 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 contract. The COR will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the substitution.

D. CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

D.1 QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

This plan provides an effective method to promote satisfactory 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 monitor quality to ensure that contract standards are achieved.

Performance Objective Performance Threshold

Services:

Performs all services set forth in the scope of work.

All required services are performed and no more than three (3) customer complaint are 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.

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.

2. STANDARD:

The performance standard is that the Government receives no more than five (5) 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 52.212.4, Contract Terms and Conditions-Commercial Items), if any of the services fail to meet the standard.

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 after investigation of the site 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 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: *To be determined on award.

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.

No. Description Quantity Submission Date Deliver to:

1 Management Plan 1 15 calendar days after contract award.

COR

2 Brochures As instructed by the COR

Additional copies

15 calendar days after contract award.

Within 10 calendar days if the COR’s request.

COR

3 Employee Claims Report 1 No later than the

10th of the following month.

COR

4 Management Plan 1 15 calendar days after contract award.

COR

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:

D.3.1 Administrative Records

• 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.

• 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.

• The Contractor shall use the English spelling of the employees' names in all transactions, including reimbursement checks.

• The Contractor shall send employee claim reimbursement checks to employees not later than two weeks after a claim is submitted.

D.3.2 Medical Insurance Claims - Settlement of medical insurance shall be completed as follows:

• All medical claims shall be submitted directly to the Contractor by employees.

• 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 (2) days, with a copy to the COR (if notification is written).

• The Contractor shall settle the claims no later than two (2) weeks from the date the claim is submitted to the Contractor.

• 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.

• 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.

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.

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 U.S. Government 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 U.S. Government, whichever the U.S. Government prefers. The Contractor shall refund any refunds not complete or discovered after the completion date of this contract.

D.7 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 U.S. Government will be the sole property of the U.S. Government. The Contractor shall not release any documents to anyone unless authorized by the U.S. Government. The following considerations shall be followed by the Contractor:

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

• All documents shall be controlled and disseminated on a need-to-know basis. Reproduction and distribution are prohibited without express approval of the U.S. Government.

• 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 U.S. Government.

• 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 U.S. Government.

D.8 LAWS AND REGULATIONS

Compliance Required: If the Contractor has or will establish a local office, he shall without additional expense to the U.S. Government, 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 U.S. Government 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.9 INVOICES, REVIEW AND PAYMENT

The Contractor shall submit monthly invoices to the Contracting Officer Representative and the designated billing office at:

American Embassy Kyiv

Attn: Financial Management Office

4 Igor Sikorsky Str.

Kyiv, 04112

Ukraine

A proper invoice must include the following information:

• Contractor’s name and bank account information for payments by Electric Funds Transfer

(EFT).

• Invoice date and number.

• Contract number and line-item 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.

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

Advance Payment shall not be authorized under this contract.

D.10 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.

D.11 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 a Contracting Officer (CO) 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 Personal Identifiable

Information (PII). The COR informs the CO if any additions or deletions are required throughout the year and the CO will issue funded modifications as required.

Riders: As stated in C.1.1.3, 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 employee.

Therefore, any ORE and EA staff are not included under the task orders issued by the CO. 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. Since 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.12 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…