19GE5025R0064.pdf

CGFS // CGFS Document Number: 19GE5025R0064 PROCESSED Page 1 of 69

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

NOTE: OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30 1. REQUISITION NUMBER PAGE 1 OF 69

5. SOLICITATION NUMBER

19GE5025R0064

2. CONTRACT NUMBER 3. AWARD/EFFECTIVE DATE

See Block 31c

4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

05/06/2025

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME Katy Fischer

b. TELEPHONE NUMBER (No collect calls) 8. OFFER DUE DATE / LOCAL

TIME

06/02/2025 15:00

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

(SDVOSB)

WOMEN-OWNED SMALL

BUSINESS (WOSB)

ECONOMICALLY DISADVANTAGED WOMEN-

OWNED SMALL BUSINESS (EDWOSB)

8(A)

NORTH AMERICAN INDUSTRY

CLASSIFICATION STANDARD

(NAICS): 541330

SIZE STANDARD:

10. THE ACQUISITION IS

SEE

SCHEDULE

11. DELIVERY FOR FREE ON BOARD

(FOB) DESTINATION UNLESS BLOCK IS

MARKED

0 Days: 0.00 %

0 Days: 0.00 % 0 Days: 0.00 % 0 Days: 0.00 %

12. DISCOUNT TERMS

13a. THIS CONTRACT IS

RATED ORDER UNDER THE

DEFENSE PRIORITIES AND

ALLOCATIONS SYSTEM -

DPAS (15 CFR 700)

13b. RATING

REQUEST

FOR

QUOTE

(RFQ)

INVITATION

FOR BID

(IFB)

X REQUEST

FOR

PROPOSAL

(RFP)

14. METHOD OF SOLICITATION

CODE15. DELIVER TO 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

BRUSS19310CODE18a. PAYMENT WILL BE MADE BY

AMERICAN EMBASSY BRUSSELS

REGENTLAAN 27, BOULEVARD DU REGENT

ATTN: FMC

BRUSSELS, BELGIUM 1000

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 NUMBER 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 Information

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Government Use Only)

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA 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: REFERENCE _____________________________

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) Daniel J Jackson

31c. DATE SIGNED 05/06/2025

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 11/2021)

Prescribed by GSA - FAR (48 CFR) 53.212

CGFS // CGFS

X

X

X

CGFS // CGFS Document Number: 19GE5025R0064 PROCESSED Page 2 of 69

Section A - Solicitation/Contract Form

Line Item Summary

Solicitation Number:

19GE5025R0064

Contract Number: Title:

Brussels Belgium Health Insurance

Date of Solicitation:

05/06/2025

Number Supplies or Services Qty Unit Unit Price Total (Inc. disc., tax, and fees)

PSC: G007

PSC Description: SOCIAL- GOVERNMENT HEALTH

INSURANCE PROGRAMS

Type of Contract Pricing: Firm Fixed Price

1.0 EA $0.00 $0.00

Period of Performance: 07/01/2025 - 06/30/2026

Description: Base Year

CLIN 0001- 0008

Health Insurance services for the base year period as detailed in Section B - Pricing

Number Supplies or Services Qty Unit Unit Price Total (Inc. disc., tax, and fees)

PSC: G007

PSC Description: SOCIAL- GOVERNMENT HEALTH

INSURANCE PROGRAMS

Type of Contract Pricing: Firm Fixed Price

1.0 EA $0.00 $0.00

Period of Performance: 07/01/2026 - 06/30/2027

Description: First Option Year

CLIN 1001- 1008

Health Insurance services for the first year period as detailed in Section B - Pricing

Number Supplies or Services Qty Unit Unit Price Total (Inc. disc., tax, and fees)

PSC: G007

PSC Description: SOCIAL- GOVERNMENT HEALTH

INSURANCE PROGRAMS

Type of Contract Pricing: Firm Fixed Price

1.0 EA $0.00 $0.00

Period of Performance: 07/01/2027 - 06/30/2028

Description: Second Option Year

CLIN 2001- 2008

Health Insurance services for the second year period as detailed in Section B - Pricing

Number Supplies or Services Qty Unit Unit Price Total (Inc. disc., tax, and fees)

PSC: G007

PSC Description: SOCIAL- GOVERNMENT HEALTH

INSURANCE PROGRAMS

Type of Contract Pricing: Firm Fixed Price

1.0 EA $0.00 $0.00

Period of Performance: 07/01/2028 - 06/30/2029

Description: Third Option Year

CLIN 3001- 3008

Health Insurance services for the third year period as detailed in Section B - Pricing

Number Supplies or Services Qty Unit Unit Price Total (Inc. disc., tax, and fees)

PSC: G007

PSC Description: SOCIAL- GOVERNMENT HEALTH

INSURANCE PROGRAMS

Type of Contract Pricing: Firm Fixed Price

1.0 EA $0.00 $0.00

Period of Performance: 07/01/2029 - 06/30/2030

CGFS // CGFS Document Number: 19GE5025R0064 PROCESSED Page 3 of 69

Description: Fourth Option Year

CLIN 4001- 4008

Health Insurance services for the fourth year period as detailed in Section B - pricing

CLIN Funding: Cost:

Base Totals: $0.00 $0.00

Exercised Options Totals: $0.00 $0.00

Unexercised Options Totals: $0.00 $0.00

Base and Options Totals: $0.00 $0.00

Section A - Solicitation/Contract Form

SECTION I - THE SCHEDULE

CONTINUATION TO SF-1449

RFP NUMBER 19GE5025R0064

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 Brussels, Belgium. 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 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 June 1, 2025.

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.

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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 $4,000,000.00 or local currency equivalent, which reflects the contract maximum.

A.6 Official Residence Expense (ORE) Staff ) and Employee Association (EA) employees are included under this contract only as a rider; the Contractor shall bill the Chief of Mission and Deputy Chief of Mission employing officer/EA for ORE Staff at the rates specified below.

A.7 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.8 Acquisition Method. This is a commercial acquisition as defined in Federal Acquisition Regulation (FAR) 2.101, Definitions, and as described 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 15, Contracting by Negotiation.

A.9 Value Added Tax (VAT). Value Added Tax (VAT) is not applicable to this contract and shall not be included in the contract line item numbers (CLINs) rates or invoices because the U.S. Embassy has a tax exemption certificate from the host government.

A.9.1 Additional mandatory tax on insurances in Belgium is applicable to this contract and shall be included in the contract line item numbers (CLINs) rates or invoices specified in CLIN 0007, CLIN 1007, CLIN 2007, CLIN 3007, and CLIN 4007. This annual tax is payable on all insurance transactions in Belgium. The Federal Public Service (FPS) Finance manages this tax of the standard rate of 9.25%.

A.9.2 Additional mandatory taxation of 10% applies to hospitalization insurances. This is implemented by law of 1994 on the obligatory insurance for medical care and allowances and is applicable to this contract and shall be included in the contract line item numbers (CLINs) rates or invoices specified in CLIN 0008, CLIN 1008, CLIN 2008, CLIN 3008, and CLIN 4008.

A.10 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. 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

CGFS // CGFS Document Number: 19GE5025R0064 PROCESSED Page 5 of 69 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.

BASE YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

0001 Employee Only Coverage under age 66

EA 295 12

0002 Employee Only Coverage over age 66

EA 1 12

0003 Employee Plus One Coverage (Dependent Spouse/Legal Partner under age 66)

EA 120 12

0004 Employee Plus One Coverage (Dependent Spouse/Legal Partner over age 66)

EA 2 12

0005 Family Coverage Dependent Child under age 21

EA 177 12

0006 Family Coverage Dependent Child over age

EA 23 12

0007 MANDATORY

YEARLY

TAXES 9.25%

for CLIN

0001 - CLIN

0006 **: (on hospitalization

EA 1 12

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BASE YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F] and outpatient premiums)

0008 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

0001 - CLIN

0006 **: (on hospitalization premium only)

EA 1 12

Total Cost (CLINs 0001-0008)

FIRST OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

1001 Employee Only Coverage under age 66

EA 295 12

1002 Employee Only Coverage over age 66

EA 1 12

1003 Employee Plus One Coverage (Dependent Spouse/Legal Partner under age 66)

EA 120 12

1004 Employee Plus One Coverage (Dependent Spouse/Legal Partner over age 66)

EA 2 12

1005 Family Coverage Dependent Child under age 21

EA 177 12

1006 Family Coverage Dependent

EA 23 12

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FIRST OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

Child over age

1007 MANDATORY

YEARLY

TAXES 9.25%

for CLIN

1001 - CLIN

1006 **: (on hospitalization and outpatient premiums)

EA 1 12

1008 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

1001 - CLIN

1006 **: (on hospitalization premium only)

EA 1 12

Total Cost (CLINs 1001-1008)

SECOND OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

2001 Employee Only Coverage under age 66

EA 295 12

2002 Employee Only Coverage over age 66

EA 1 12

2003 Employee Plus One Coverage (Dependent Spouse/Legal Partner under age 66)

EA 120 12

2004 Employee Plus One Coverage (Dependent Spouse/Legal Partner over age 66)

EA 2 12

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SECOND OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

2005 Family Coverage Dependent Child under age 21

EA 177 12

2006 Family Coverage Dependent Child over age

EA 23 12

2007 MANDATORY

YEARLY

TAXES 9.25%

for CLIN

2001 - CLIN

2006 **: (on hospitalization and outpatient premiums)

EA 1 12

2008 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

2001 - CLIN

2006 **: (on hospitalization premium only)

EA 1 12

Total Cost (CLINs 2001-2008)

THIRD OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

3001 Employee Only Coverage under age 66

EA 295 12

3002 Employee Only Coverage over age 66

EA 1 12

3003 Employee Plus One Coverage (Dependent Spouse/Legal

EA 120 12

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THIRD OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

Partner under age 66)

3004 Employee Plus One Coverage (Dependent Spouse/Legal Partner over age 66)

EA 2 12

3005 Family Coverage Dependent Child under age 21

EA 177 12

3006 Family Coverage Dependent Child over age

EA 23 12

3007 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

3001 - CLIN

3006 **: (on hospitalization premium only)

EA 1 12

3008 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

3001 - CLIN

3006 **: (on hospitalization premium only)

Total Cost (CLINs 3001-3008)

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FOURTH OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

4001 Employee Only Coverage under age 66

EA 295 12

4002 Employee Only Coverage over age 66

EA 1 12

4003 Employee Plus One Coverage (Dependent Spouse/Legal Partner under age 66)

EA 120 12

4004 Employee Plus One Coverage (Dependent Spouse/Legal Partner over age 66)

EA 2 12

4005 Family Coverage Dependent Child under age 21

EA 177 12

4006 Family Coverage Dependent Child over age

EA 23 12

4007 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

4001 - CLIN

4006 **: (on hospitalization premium only)

EA 1 12

4008 MANDATORY

YEARLY

SOCIAL

SECURITY

CHARGES

10% for CLIN

4001 - CLIN

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FOURTH OPTION YEAR

A B C D E F

CLIN Description Unit Quantity Month Rate per Premium

Amount [D x E x F]

4006 **: (on hospitalization premium only) Total Cost (CLINs 4001-4008)

*Estimated quantity for evaluation purposes only. Actual number may be lower or higher than the estimates in the solicitation/contract.

** Note to contractor: Indicate which specific taxes and social charges are being added and give their respective amounts and percentages.

STATE CURRENCY: __________________________________

TOTAL CONTRACT PRICE

Total Base Year Total First Option Year Total Second Option Year Total Second Option Year Total Second Option Year Grand Total

B.2 ADMINISTRATIVE RETENTION AMOUNTS

B.2.1 If the Contractor requests a price adjustment under B.3 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 1, Price Proposal Breakdown. This retention amount will not be adjusted for any reason.

B.2.2 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.2.3 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

B.2.3 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.

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Period of Performance

Employee Only

Coverage under age 66

Employee Only

Coverage over age 66

Employee Plus One Coverage

(Dependent Spouse/Legal

Partner under age 66)

Employee Plus One Coverage (Dependent Spouse/Legal

Partner over age 66)

Family Coverage Dependent Child under age 21

Family Coverage Dependent Child over age

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

B.3 ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.3.1 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.3.2 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.

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B.3.3 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 19GE5025R0064

SCHEDULE OF SUPPLIES/SERVICES, BLOCK 20

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C. STATEMENT OF WORK

C.1 INTRODUCTION

The Contractor shall provide health insurance services to locally employed staff of the U.S. Embassy Brussels, Belgium, and their eligible, as further described in this Section. The below are the minimum benefits levels and offers which include additional benefits or higher benefit levels may be accepted.

C.2 EMPLOYEE AND DEPENDENT HEALTH SERVICE BENEFITS

C.2.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

100% Coverage.

Services and supplies provided during hospitalization, including services provided by a licensed healthcare provider, bed & board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, general hospital nursing care, physical therapy, as well as drugs and medicines administered while in-patient. When private accommodations are provided, coverage will be limited to the cost of a semi-private room unless otherwise covered in an off the shelf plan.

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

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

C.2.2 Emergency Services (Trips to Emergency Room):

100% Coverage.

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

C.2.3 Ambulance:

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80% Minimum Coverage.

Professional ground transport to move a patient from the place where s/he is injured or becomes ill to the nearest hospital able to provide treatment or to move a patient from one medical facility to another.

C.2.4 Outpatient Services:

80% Minimum Coverage.

Services provided by a licensed healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon’s fees and other medical services provided at 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.2.5 Obstetric and Newborn Care:

Inpatient/Emergency: 100% Coverage; 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 reimbursed as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services and will be reimbursed at that rate.

C.2.6 Pediatric Services:

Inpatient/Emergency: 100% Coverage; Outpatient: 80% Minimum Coverage.

Primary and preventive routine care services for covered dependent children, including, but not limited to:

physical examinations, developmental assessments, laboratory tests, and immunizations recommended by local authorities and/or the World Health Organization.

C.2.7 Prescription Drugs:

Inpatient/Emergency: 100% Coverage; 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.

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C.2.8 Preventive and Wellness Services and Chronic Disease Management:

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.2.9 Hearing Aids:

Examinations and Treatment: 80% Minimum Coverage.

Hearing Aid Apparatus: Limited to one apparatus per ear. The maximum coverage is USD 1,500.00 per covered individual per three-year period. 80% Minimum Coverage; with Applicable Cap.

C.2.10 Optical Care:

Examinations and Treatment: 80% Minimum Coverage.

Prescription lenses and frames or contact lenses: The maximum coverage is USD 300.00 per covered individual every two years. 80% Minimum Coverage; with Applicable Cap.

C.2.11 Dental Care:

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 3,200.00 per covered individual per contract year. 80% Minimum Coverage; with Annual Cap.

Orthodontia: Treatment is covered only if treatment begins before age 18, or if required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per covered individual. The maximum coverage is USD 2,400.00 lifetime limit. 80% Minimum Coverage; with Contract Lifetime Cap.

C.2.12 Reproductive Health:

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.2.13 Mental Health and Substance Abuse Care:

50% Minimum Coverage.

Inpatient and outpatient care provided to evaluate, diagnose, and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Services must be provided by a licensed psychiatrist, psychoanalyst, psychologist, or psychiatric social worker. Inpatient care for alcohol and substance abuse must be provided at a facility licensed for detoxification and rehabilitation.

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C.2.14 Rehabilitative and Habilitative Services and Devices:

50% Minimum Coverage.

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.2.15 HIV/AIDS:

100% Coverage up to USD 10,000.00 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.

C.2.16 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.2.17 Out-of-Country Medical Travel:

80% Reimbursement.

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.3 ANNUAL MAXIMUM LIMIT

The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.4), or those covered under C.2.15, HIV/AIDS is unlimited in accordance with customary health insurance market practices in Belgium.

C.4 EXCLUSIONS AND LIMITATIONS

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There is no coverage for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy;

long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers;

advanced reproductive technology (e.g., in-vitro fertilization, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider.

Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusions require prior authorization.

There is no coverage for expenses that will be reimbursed or paid directly under a host country medical program or workers' compensation program, the U.S. workers’ compensation program, or post’s LE Staff workers’ compensation program.

C.5 ELIGIBLE PARTICIPANTS

C.5.1 Identification of Eligible Employees and Dependents:

U.S. Tri-Mission Brussels will provide a list of all eligible employees and dependents with relationship to employee (self/spouse/child) and DOB for each. Updates will be provided to add or remove individuals on a bi-weekly/monthly basis.

C.5.1.1 Definition of Dependents

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.5.2 Location of Employment:

The eligible employees covered by C.5.1 must be employed within the geographic boundaries of Belgium by:

the U.S. Department of State, the Department of Agriculture, the Department of Commerce, the Department of Defense, the Department of Health and Human Services, the Department of Justice, the Department of the Treasury, the Department of Transportation, and the Department of Homeland Security.

C.5.3 Participants Covered Under a Rider:

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Official Residence Expense (ORE) and Employee Association (EA) employees may be covered under a rider to the contract. The employing officer/EA, not the U.S. Government, is responsible for the employer's share of the premium costs for an ORE/EA employee.

C.6 ELIGIBILITY

C.6.1 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.7 BROCHURE REQUIREMENT

C.7.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in English that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The Contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made.

C.7.2 The Contractor shall provide the document described in C.7.1 to the COR not later than 15 days after date of contract award. The Contractor shall provide additional brochures for new employees within 10 days of the COR’s request.

C.7.3 The Contractor assumes full responsibility for ensuring that the document described in C.7.1 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.8 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.

C.9 DEFINITIONS

CLIN Contract Line Item Number CO Contracting Officer

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COR Contracting Officer’s Representative FMO Financial Management Office PII Personal Identifiable Information QA Quality Assurance QC Quality Control QCP Quality Control Plan USG The United State Government

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.

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(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 Provide a Trafficking in Persons compliance plan (FAR 52.222-50 and

FAR 52.222-56)

1 30 calendar days after contract award.

CO and 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:

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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.

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D.5 MISCELLANEOUS CONTRACTOR REQUIREMENTS

D.5.1 A contract with the U.S. Government conveys no special privileges or immunities to the Contractor.

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

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

D.6 ERRONEOUS PAYMENT

If the 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. Government.

• 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.

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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.

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: *To be determined on award.

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.

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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.5.3, 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.