19GE5025R0095.pdf

June 27, 2025

Subject: Solicitation No. 19GE5025R0095 for Healthcare Services at the U.S. Embassy Skopje, North Macedonia

Dear Potential Offerors, The Regional Procurement Support Office (RPSO) Frankfurt invites your company to submit a proposal for Healthcare Services at the U.S. Embassy Skopje, North Macedonia, as per the attached solicitation documents.

IMPORTANT: You are encouraged to utilize the time from receipt of the solicitation to thoroughly examine all aspects of the documentation available to you, and if necessary, to submit questions to the undersigned no later than the date and time specified below in order for the government to supply an appropriate response without undue delay.

Please submit your proposal via email to Ms. Jenina Dosch, DoschJK@state.gov, with the subject line "Proposal 19GE5025R0095” no later than 12:00 PM Central European Time (CET) on July 28th, 2025.

No proposals will be accepted after the time indicated above. Delay due internet connection issues/failure, delay on electronic correspondence transmission or processing will not be an acceptable excuse for late delivery of a proposal.

Please note:

a. All communication and the award documents shall be in English.

b. Do NOT contact the U.S. Embassy North Macedonia directly regarding this project.

c. Attachment 1 Price Proposal Breakdown of the solicitation contains the Microsoft Excel spreadsheet for pricing you need to complete / submit. You may choose the currency of your offer but note that the chosen currency cannot be changed at a later date.

U.S. CONSULATE GENERAL

Regional Procurement Support Office

Giessener Strasse 30 60435 Frankfurt am Main

Germany mailto:DoschJK@state.gov

d. Submit your proposal in accordance with the instructions set forth in Section III Instructions to Offerors.

e. An active SAM registration is a condition of award (FAR 52.212-4 (t)).

f. Complete and submit Section V – Representations and Certifications of the solicitation.

g. Use the format provided in Attachment 2 (Contract Information Sheet / Experience Listing) to submit the requested information.

A virtual pre-proposal conference to discuss the terms and conditions of this solicitation and to explain the Instructions to Offerors for proposal submission will be held on July 8th, 2025 at 2:00 PM Central European Time (CET) via MS Teams.

Prior registration is required. Interested offerors shall register for the pre-proposal conference no later than 12:00 PM CET on July 7th, 2025 via email to Ms. Jenina Dosch, DoschJK@state.gov.

Any questions regarding the subject solicitation may be directed via email to Ms. Jenina Dosch at DoschJK@state.gov no later than 12:00 PM CET on July 14th, 2025. Questions will be collected and in the interest of fair contracting, replies will be provided anonymously in form of a solicitation amendment.

The Contracting Officer reserves the right to reject any proposals that deviate significantly from the instructions in Section III and to waive any information or minor irregularities in proposals received. In addition, the Contracting Officer reserves the right to award the contract based upon initial offers received without holding discussions.

Thank you for your interest and we look forward to receiving your proposal.

Sincerely, Travis Keon Contracting Officer

A/GA/AM/DMS/RPSO

Document Number: 19GE5025R0095 Page 1 of 97

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 97

5. SOLICITATION NUMBER

19GE5025R0095

2. CONTRACT NUMBER 3. AWARD/EFFECTIVE DATE

06/27/2025

4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

06/27/2025

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME Jenina K (Frankfurt) Dosch

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

TIME

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):

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

SKOPJ19007CODE18a. PAYMENT WILL BE MADE BY

AMERICAN EMBASSY SKOPJE

UL. SAMOILOVA # 21, 1000

ATTN: FMO

SKOPJE, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF

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)

X 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA ARE X ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

X 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 1 COPIES TO

ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH

OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE

TERMS AND CONDITIONS SPECIFIED.

29. AWARD OF CONTRACT: 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) Travis Keon

31c. DATE SIGNED 06/27/2025

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

Document Number: 19GE5025R0095 Page 2 of 97

Section A - Solicitation/Contract Form

Line Item Summary

Solicitation Number:

19GE5025R0095

Contract Number: Title:

Skopje - LES Health Insurance

Date of Solicitation:

06/27/2025

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

0.0 EA $0.00 $0.00

Description: BASE YEAR LES Health Insurance inclusive of Sub CLINs:

001A Self Only (one individual) 001B Self Plus One (two individuals) 001C Family (three or more individuals)

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

0.0 EA $0.00 $0.00

Description: OPTION YEAR 1 LES Health Insurance inclusive of Sub CLINs:

1001A Self Only (one individual) 1001B Self Plus One (two individuals) 1001C Family (three or more individuals)

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

0.0 EA $0.00 $0.00

Description: OPTION YEAR 2 LES Health Insurance inclusive of Sub CLINs:

2001A Self Only (one individual) 2001B Self Plus One (two individuals) 2001C Family (three or more individuals)

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

0.0 EA $0.00 $0.00

Description: OPTION YEAR 3 LES Health Insurance inclusive of Sub CLINs:

3001A Self Only (one individual) 3001B Self Plus One (two individuals) 3001C Family (three or more individuals)

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

0.0 EA $0.00 $0.00

Description: OPTION YEAR 4 LES Health Insurance inclusive of Sub CLINs:

4001A Self Only (one individual) 4001B Self Plus One (two individuals) 4001C Family (three or more individuals)

Document Number: 19GE5025R0095 Page 3 of 97

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

19GE5025R0095 U.S. Embassy Skopje, North Macedonia Health Insurance for Locally Employed Staff Page 4 of 97

Table of Contents

SECTION I – THE SCHEDULE

A. BACKGROUND / SCOPE OF SERVICES

A.1 General Scope of Services A.2 Type of Contract A.3 Minimum & Maximum

B. PRICING

B.1 General B.2 Economic Price Adjustment, Premium Adjustment Based on

Experience B.3 Premium Adjustment Based on Laws B.4 VAT – Value Added Tax B.5 Excise Tax – James Zadroga 9/11 Victims Health and Compensation

Act of 2010 Notice B.6 Pricing Table

C. SPECIFICATIONS / STATEMENT OF WORK

C.1 Health Insurance Services C.2 Overall Annual Maximum Limit C.3 Health Benefits Exclusions and Limitations C.4 Eligible Participants C.5 Eligible Dependents C.6 Individuals Not Eligible for Coverage C.7 Eligibility C.8 Brochure Requirement C.9 Acronyms and Abbreviations

D. CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

D.1 Quality Assurance and Surveillance Plan (QASP) D.2 Deliverables and Reports Requirements D.3 Contractor Responsibility in Claims and Reimbursement to Claims D.4 Key Personnel D.5 Miscellaneous Contractor Requirements D.6 Physical and Information Security Requirements D.7 Changes in Ownership

E. FUNDING / TASK ORDERS / PROCEDURES

E.1 Task Order E.2 Choice of Law E.3 Start / Period of Performance

F. LAWS AND REGULATIONS

G. CONTRACT ADMINISTRATION DATA

H. INVOICES, REVIEW AND PAYMENT

H.1 Invoices H.2 Erroneous Payment

Health Insurance for Locally Employed Staff Page 5 of 97

I. LIST OF ATTACHMENTS

SECTION II – CONTRACT CLAUSES

FAR 52.252-2 Clauses Incorporated by Reference (Feb 1998) FAR 52.204-21 Basic Safeguarding of Covered Contractor Information Systems

(Nov 2021) FAR 52.212-5 Contract Terms and Conditions Required To Implement Statutes or

Executive Orders—Commercial Products and Commercial Services. (Jan

2025) (DEVIATION FEB 2025)

FAR 52.216-18 Ordering (Aug 2020) FAR 52.216-19 Order Limitations (Oct 1995) FAR 52.216-21 Requirements (Oct 1995) FAR 52.216-22 Indefinite Quantity (Oct 1995) FAR 52.217-8 Option to Extend Services (Nov 1999) FAR 52.217-9 Option to Extend the Term of the Contract (Mar 2000)

SECTION III – SOLICITATION PROVISIONS

FAR 52.252-1 Solicitation Provisions Incorporated by Reference (Feb 1998) FAR 52.212-1 Instructions to Offerors—Commercial Products and Commercial

Services (Sep 2023)

A. INSTRUCTIONS TO OFFERORS

A.1 QUALIFICATIONS OF OFFERORS

A.2 JOINT VENTURE AGREEMENTS

B. PRE-PROPOSAL CONFERENCE

C. SUBMISSION OF QUESTIONS

D. PROPOSAL DUE DATE

FAR 52.216-1 Type of Contract (APR 1984) DOSAR 652.206-70 Advocate for Competition/Ombudsman. (Feb 2015)

SECTION IV – EVALUATION FACTORS

A. EVALUATION PROCESS AND FACTORS

B. SEPARATE CHARGES

C. AWARD WITHOUT DISCUSSIONS

FAR 52.217-5 Evaluation of Options (Jul 1990) FAR 52.225-17 Evaluation of Foreign Currency Offers (Feb 2000)

SECTION V – REPRESENTATIONS AND CERTIFICATIONS

FAR 52.209-7 Information Regarding Responsibility Matters (Oct 2018) FAR 52.204-24 Representation Regarding Certain Telecommunications and Video

Surveillance Services or Equipment (Nov 2021)

Health Insurance for Locally Employed Staff Page 6 of 97

FAR 52.209-11 Representation by Corporations Regarding Delinquent Tax Liability or a Felony Conviction under any Federal Law (Feb 2016)

FAR 52.212-3 Offeror Representations and Certifications-Commercial Products and Commercial Services (May 2024) (Deviation Feb 2025)

FAR 52.222-56 Certification Regarding Trafficking in Persons Compliance Plan (Oct 2020)

FAR 52.229-11 Tax on Certain Foreign Procurements—Notice and Representation (Jun 2020)

DOSAR 652.225-70 Arab League Boycott of Israel (AUG 1999)

Health Insurance for Locally Employed Staff Page 7 of 97

SECTION I – THE SCHEDULE

CONTINUATION TO SF-1449

PRICES – BLOCK 23

A. BACKGROUND / SCOPE OF SERVICES

A.1 General Scope of Services The Government of the United States of America (USG) in North Macedonia requires Health Insurance for its Locally Employed Staff (LES) and their eligible dependents. The Contractor shall provide the Health Insurance services, as described in Section I. C. Specifications / Statement of Work. The groups of employees who shall be provided with this insurance are listed in Section I.C.4 Eligible Participants and Section I.C.5 Eligible Dependents.

A.2 Type of Contract

A.2.1 This is a firm fixed-price Indefinite Delivery, Indefinite Quantity (IDIQ) type contract with economic price adjustment requirements type contract under which annual firm, fixed-price task orders will be issued. The required minimum purchase shall be obligated on a task order at the time the contract is executed. The fixed prices / premium rates for the health insurance services as specified in Section I.C. Specifications / Statement of Work are listed in Section I.B. Pricing.

A.2.2 The contract will be for a one base year period starting from October 30, 2025, and four (4) one-year options periods, which may be exercised by modification to the contract.

Including option years in the contract does not obligate the Government to exercise one or all option years.

A.2.3 Payments will be made only to the extent specifically authorized in the task order.

A.3 Minimum & Maximum

As per FAR 52.216-22, "INDEFINITE QUANTITY," the minimum and maximum amounts for this indefinite quantity contract shall be any quantity or combination of supplies and services equal to the amount (s) set forth below. The US Government (USG) makes no guarantee as to the number of orders or actual amount of services that may be requested above the guaranteed minimum value for the life of the contract.

A.3.1 The minimum guaranteed order amount: The Government shall order, as a minimum, services in an amount of 5,000 USD during the term of this contract. The Government

Health Insurance for Locally Employed Staff Page 8 of 97 makes no guarantee as to the number of orders or actual amount of services that will be requested above the guaranteed minimum of 5,000 USD.

The required minimum purchase shall be obligated on a task order at the time the contract is executed.

A.3.2 The maximum ordered amount during the entire life of this contract is 3,850,000 USD.

B. PRICING

B.1 General The contractor shall complete all work, including furnishing all labor, material, equipment and services, unless otherwise specified herein, required under this contract for the firm fixed unit prices indicated below and within the time specified herein. These individual prices shall include all labor, materials, profit, and, if applicable, value-added tax (VAT).

Any costs not separately priced will be considered to be included in the individual prices as overhead or other indirect cost. No additional sums will be payable on account of any escalation in the cost of materials, equipment or labor, or because of the contractor's failure to properly estimate or accurately predict the cost or difficulty of achieving the 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.

B.2 Economic Price Adjustment, Premium Adjustment Based on Experience

B.2.1. For health insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract, and it specifically excludes all riders. No adjustment will be allowed during the base year.

B.2.2 The Contractor or the Government may request an adjustment 60 days prior to the end of the base year or current option year, to take effect at the start of the following option year. Adjustments are not retroactive to previous periods of performance, and Contractors may not seek to recover costs incurred during a prior period of performance through an Economic Price Adjustment. Economic Price Adjustments only apply as an adjustment to the rates to be charged by the Contractor for the services identified as in the contract, and cannot be recovered as a lump sum adjustment paid to the Contractor.

Health Insurance for Locally Employed Staff Page 9 of 97

B.2.3 Before any such adjustment is made, the Contractor agrees to provide the Government a balance sheet showing three main components for the time period:

(1) receipts (premiums received) minus the retention amount;

(2) number of insurance plans and

(3) claims paid.

This information shall be provided per type of premium, i.e. per line item for the preceding 12 months. The retention amount is not subject to adjustment.

B.2.4 Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.2.5 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 the mutual agreement of the parties and shall result in a written modification to the contract. Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.3 Premium Adjustment Based on Laws

The rates may also be adjusted during the performance period of the contract as a result of laws enacted by the host government, if such change in the laws has a direct impact on the cost to the contractor to perform this contract at the contracted rate. In that event, the Contracting Officer may enter into negotiations with the contractor to modify the contract to adjust the premium rate(s). The contractor agrees to provide all documentation necessary to support any requested adjustment.

Employee Pool – This clause is only in effect if the contractor included details in its offer regarding a pooling arrangement, of which this contract is a part.

Before any adjustment is made under this price adjustment clause, the contractor must include in its proposal for adjustment details setting forth how the pool impacts the request for equitable adjustment.

B.4 VAT – Value Added Tax

Health Insurance for Locally Employed Staff Page 10 of 97

VAT is not applicable to Health Insurance services in North Macedonia.

B.5 Excise Tax – 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. The Contractor shall complete attached form W-14 in order to apply for an exemption of the Excise Tax, if applicable.

B.6 Pricing Table

B.6.1 Contract Pricing (to be inserted at the time of award by the contracting office)

B.6.2 Rider and Optional Benefits (to be inserted at the time of award by the contracting office)

C. SPECIFICATIONS / STATEMENT OF WORK

C.1 Health Insurance Services The Government of the United States of America (USG) in North Macedonia requires Health Insurance for its Locally Employed Staff (LES) and their eligible dependents as further described in in this section.

Medical insurance premiums will be based on the number of individuals covered:

• Self-Only (1 covered individual)

• Self Plus One (two individuals)

• Family (three or more individuals)

The Contractor shall ensure that health care under this contract includes HIV/AIDS care.

C.1.1 Employee and Dependent Health Services Benefit – Mandatory Benefits

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care) Reimbursement Rate for Inpatient and/or Emergency: 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

Health Insurance for Locally Employed Staff Page 11 of 97 private accommodations are provided, coverage will be limited to the cost of a semi-private room unless otherwise covered in an off the shelf plan.

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

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

C.1.1.2 Emergency Services (Trips to Emergency Room)

Reimbursement Rate - 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.1.1.3 Ambulance

Reimbursement Rate – 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.1.1.4 Outpatient Services

Reimbursement Rate - 80% minimum coverage

Services provided by a certified healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon’s fees and other medical services that may be provided in a hospital, clinic, doctor’s office, medical facility, etc. Examples include, but are not limited to:

- Annual physical examinations

- Specialist consultations and treatment, including second surgical opinion

- Minor surgical interventions

- Chemotherapy and radiation treatments

- Immunizations recommended by local authorities and/or the World Health Organization

- Diagnostic tests and diagnostic imaging

• See Rehabilitative and Habilitative Services and Devices (below) for details concerning physical therapy.

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

Health Insurance for Locally Employed Staff Page 12 of 97

C.1.1.5 Obstetric and Newborn Care

Reimbursement Rate Inpatient: 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 covered as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services.

C.1.1.6 Pediatric Services

Reimbursement Rate for Inpatient: 100% Coverage; Outpatient: 80% Minimum Coverage

Primary and preventive routine care services for covered dependent children, including, but not limited to: physical examination, developmental assessment, laboratory tests, and immunizations recommended by local authorities or the World Health Organization.

C.1.1.7 Prescription Drugs

Reimbursement Rate for Inpatient: 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.

C.1.1.8 Preventive and Wellness Services and Chronic Disease Management

Reimbursement Rate: 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 not limited to:

physicals, immunization, and cancer screenings.

C.1.1.9 Hearing Aids

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear. The maximum coverage is USD 1,500 per covered individual per three-year period. 80% Minimum Coverage; with applicable cap

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C.1.1.10 Optical Examinations and Treatment: 80% Minimum Coverage

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

C.1.1.11 Dental

Reimbursement Rate – 80% Minimum Coverage

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges. The maximum coverage is USD 3,200 per covered individual per contract year. 80% Minimum Coverage; with annual cap

Orthodontia: Treatment is covered only if treatment begins before age 18, or if required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per covered individual. The maximum coverage is USD 2,400 lifetime limit. 80% Minimum Coverage; with contract lifetime cap

C.1.1.12 Reproductive Health

Reimbursement Rate: 80% Minimum Coverage

Prescribed contraceptive devices, preventive care and routine examinations, voluntary sterilization, and diagnosis and treatment of conditions which may cause infertility. Assisted reproductive technology (ART), fertility treatments, and reversal of sterilization are not covered (see Exclusions to Coverage).

C.1.1.13 Mental Health and Substance Abuse Care

Reimbursement Rate: 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 carried out at a facility licensed for detoxification and rehabilitation.

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

Health Insurance for Locally Employed Staff Page 14 of 97

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke or physical therapy after an accident) and habilitative services (e.g., developing skills, such as speech therapy for children) that help develop skills needed for everyday life. Devices to help gain or recover mental or physical skills lost due to injury, disability or a chronic condition, and devices needed for habilitative reasons.

C.1.1.15 HIV/AIDS

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

Medications to suppress opportunistic infections (such as tuberculosis or toxoplasmosis for covered individuals who have HIV/AIDS). Brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV/AIDS to the child. Generally, excludes medication for the long-term suppression of HIV/AIDS through the combination of anti-retroviral drugs in locations with inadequate local healthcare infrastructures.

OPTIONAL BENEFITS:

C.1.1.16 Out-of-Country Medical Treatment Medical expenses incurred out-of-country will be covered, but coverage will be the same and subject to the same total maximum annual limit as for medical expenses incurred in-country.

C.1.1.17 180 Day Coverage for Dependents After Employee’s Death

At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 180 days. This benefit is subject to availability of funds at post and no extensions are permitted.

C.2 Overall Annual Maximum Limit

The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.3) or those covered under C.1.1.15 HIV/AIDS is equivalent to USD 10,000.

C.3 Health Benefits Exclusions and Limitations There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures;

massage; exercise therapy; long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of

Health Insurance for Locally Employed Staff Page 15 of 97 persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider. Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusions require prior authorization.

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

C.4 Eligible Participants

C.4.1 Eligible Employees

To be eligible to participate in the medical plan, LE Staff (both full time and part time) must be:

- Paid under the terms of the Local Compensation Plan (LCP); and –

- Under a non-temporary direct hire appointment, personal services agreement (PSA), or personal services contract (PSC); or

- Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

C.4.2 Location of Employment

The individuals covered by C.4.1 must be employed within the geographic boundaries of North Macedonia by: U.S. Department of State, U.S. Department of Justice, U.S.

Department of Defense and Peace Corps.

C.4.3 Participants and Benefits Covered Under a Rider:

a. 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.

b. Peace Corps (PSC) active employees may be covered under a rider to the contract. Peace Corps is responsible for the employer’s share of the premium costs for Peace Corps (PSC) employees.

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See Section I. H for billing procedures. Note that USG is not responsible, nor liable, for any riders.

C.4.4. Identification of Eligible Employees and Dependents U.S. Mission North Macedonia will provide a list of all eligible employees and their dependents with relationship to employee (self/spouse/family) and date of birth upon award. Any changes in the number of covered employees and their applicable categories will be issued through task order modifications.

C.5 Eligible Dependents

LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

C.5.1 Legal Spouse Legal spouse or domestic partner, to include same-sex domestic partners, as certified by COM: one legal spouse as defined by local law or one domestic partner, to include the same sex domestic partners, as certified by COM, may be covered. LE Staff with more than one legal spouse or domestic partner must select only one individual for coverage.

In cases where LE Staff and their legal spouse or domestic partner 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 or domestic partner.

C.5.2 Dependent Children A child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. Any child of a recognized domestic partner shall be deemed a stepchild of the employee. Children 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.

There is no limit on the number of children covered per employee. Parents, grandparents, siblings, and other relatives are not eligible dependents.

C.6 Individuals Not Eligible for Coverage

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C.6.1 Not eligible are those working under temporary appointments; those working under a PSC or PSA that is time limited to less than one year; non-personal services contract personnel and their employees, supplied by an independent contractor licensed to do business in North Macedonia, who provides services to other local organizations as well as to the U.S. Mission; employees working on an intermittent or When Actually Employed (WAE) schedule; employees of USAID institutional contractors; Peace Corps contractors;

and Recreation Association employees.

C.6.2 Opposite-sex partners who are not legally married and are currently enrolled in the program will be grandfathered. Enrollment of new opposite-sex partners will only be permitted if they are legally married.

C.7 Eligibility

C.7.1 Term of Eligibility and Effective Date

C.7.1.1 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.7.1.3 During a period of Leave Without Pay (LWOP) or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The employee will pay the total cost of the coverage for the duration of LWOP exceeding one pay period. The USG will pay the total premium cost to the Contractor.

C.7.1.4 In the event of death of an insured employee, he/she shall be removed from the insurance as of the date of death. At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 180 days. This optional benefit is subject to availability of funds at post and no extensions are permitted. Premiums will be paid by the USG in its entirety.

C.7.2 Period of Ineligibility Employees and their dependents are not entitled to health benefits during any period of employment for which premiums are not paid.

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Additionally, employee's dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate.

During a period of extended Leave Without Pay (LWOP) or unpaid leave beyond one pay period, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the contractor and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

C.7.3 Withdrawal from Insurance Coverage

C.7.3.1 An employee may withdraw from the ongoing insurance coverage within 30 days before the beginning of the contract year (base and option years). Payment of premiums will cease with the beginning of the next contract year.

C.7.3.2 Withdrawal may only be done in full and for the entire contract year. Employees who have withdrawn from insurance coverage may reenroll for insurance coverage within 30 days before the next option year.

C.7.3.3 Enrolled employees who will not withdraw, will be enrolled for the next contract year automatically.

C.7.3.4 At the time of employment termination and/or death, subsequent claims should be disregarded. The insured will be responsible for payment of his/her share of the cost of insurance coverage up to the date of separation from duty.

C.8 Brochure Requirement

C.8.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in Macedonian and Albanian 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.8.2 The Contractor shall provide the document described in C.8.1 to the COR not later than 15 (fifteen) days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR’s request.

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C.8.3 The Contractor assumes full responsibility for ensuring that the document described in C.8.1 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.8.4 During the contract period, any changes regarding the information in the submitted documents/brochures will be updated and re-submitted as revised documents/brochures (i.e. changes to the list of approved institutes, etc.).

C.9 Acronyms and Abbreviations

Acronym Definition

CLIN CONTRACT LINE-ITEM NUMBER

CONTRACTOR INSURANCE COMPANY

CO CONTRACTING OFFICER

COR CONTRACTING OFFICER REPRESENTATIVE

Customary and Reasonable Treatment

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

Dependent An eligible spouse and/or child of the employee as further defined in C.5.

Disability- Total and Permanent

A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment. If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

Employer The United States Government = USG Employee An individual employed by the US Government, under a direct-hire appointment, personal service contract (PSC), or personal services agreement (PSA), as further defined in Section C.4. This may also include ORE staff, EAE and Peace Corps PSCs, if this category of individuals is listed as participating under a rider in C.4.4

Employee plus one Any eligible spouse or child of the Employee

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FMO Financial Management Officer GSO General Services Officer in charge of the General Services Office at post Hospital An institution established and operated for the care and treatment of sick and injured persons. It provides 24-hour nursing care and has diagnostic, laboratory, treatment, and surgical facilities. Any institution which does not meet this definition is not considered a hospital.

Hospital Patient An individual who has been admitted to a hospital, is assigned a bed, and is given diagnostic tests or receives treatment for a disease or an injury.

LS Lump Sum Maximum Benefit The total amount that will be paid to any one covered individual for covered medical expenses PII Personally Identifiable Information

Physician An individual who has graduated from an accredited medical school and is licensed to practice medicine in the jurisdiction in which the contract is to be performed. If the individual is a medical specialist, then he or she is Board Certified in that specialty

Pre-existing condition Refers to any disease or health condition arising from injury, illness, congenital or genetic factors, disease caused by sexual transmission, and/or autoimmune conditions.

QA Quality Assurance QC Quality Control QCP Quality Control Plan QTY Quantity SOW Statement of Work Surgical Procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.

TBD To be determined USG U.S. Government

D. CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

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D.1 Quality Assurance and Surveillance Plan (QASP)

This plan is designed to provide an effective surveillance method to promote effective contractor performance. The QASP provides a method for the Contracting Officer's Representative (COR) to monitor contractor performance, advise the contractor of unsatisfactory performance, and notify the Contracting Officer of continued unsatisfactory performance. The contractor, not the USG, is responsible for management and quality control to meet the terms of the contract. The role of the USG is to conduct quality assurance to ensure that contract standards are achieved.

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

Claims processing time The Contractor will reimburse claims to the claimant within two weeks from the moment the Contractor receives a complete request for reimbursement in 90% of the cases.

Processing incomplete claim submissions The Contractor will inform within two days the claimant if they have submitted an incomplete claim that will not be considered until made complete.

Reporting The Contractor will provide monthly claims reports to the COR which will comprise clear and accurate information comprising the name of the claimant, claim reference number, date of claim submission, date of claim

C.1 – C.8 All required services are performed and no more than one

(1) customer complaint is received per month.

This standard must be met in 80% of cases.

This standard must be met in 90% of cases.

Monthly report sent to the COR by the 15th of the next month for the previous month.

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Customer Service Response Time The Contractor will provide customer service 24 hours a day, 7 days a week, allowing employees and dependents to obtain information by phone in case of emergencies.

Accuracy of information The Contractor should provide precise information regarding the documents required for claim submission, listing specific cases or claims types, to include rationale for requesting certain documents.

Employees and dependents should not have more than one (1) customer complaint on this topic per month and annual surveys should report a satisfactory level of customer service.

There should be no instances where the contractor will request a document that is not listed in the brochure as a requirement.

• Surveillance – The COR will receive and document all complaints from USG personnel regarding the services provided. If found valid, the COR will send the complaints to the contractor for corrective action.

• Standard – The performance standard is that the USG receives no more than one (1) customer complaint per month. The COR shall notify the Contracting Officer of the complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR 52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of Services clause), if any of the services exceed the standard.

• Complaint Procedures

i. If USG personnel observe unacceptable services such as but not limited to lack of coordination during medical evacuation, extended referral periods, delays in receipt of payment, etc., they will immediately contact the COR.

ii. The COR will complete appropriate documentation to record the complaint.

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iii. 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.

iv. 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.

v. The COR shall, as a minimum, provide e-mail notification informing the contractor of any valid complaints.

vi. If the contractor disagrees with the complaint and challenges the validity of the complaint, the contractor shall notify the COR by e-mail. The COR will review the matter to determine the validity of the complaint.

vii. The COR will consider complaints as resolved unless notified otherwise by the complainant.

viii. 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 and Reports Requirements

All reports and other deliverables required under this contract shall be delivered by email to the COR and mailed to the following address:

American Embassy Skopje Attn: HR

TBD

NOTE: Any and all costs for the preparation, handling, mailing and submission of progress reports or any other required reports and documentation shall be included in the total price of each delivery order.

Description QTY Submission Date Deliver to/via:

Reference C.8 Brochures

As instructed by COR

Additional copies

15 days after contract award

Within 10 calendar days upon COR’s request

COR

hard copy

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D.1 Claims Reports

1 Monthly (by the 15th of the next month for the previous month)

COR

H.1 Invoice 1 monthly COR / Designated Billing Office

D.3 Contractor Responsibility in Claims and Reimbursement to Claims

General – The contractor shall be responsible for all planning, estimating, programming, project management, scheduling, dispatching, supervision, and inspection of work. The contractor shall maintain his own reference library of technical reference works and local laws and regulations, including current tariffs and registries. The contractor shall treat the information provided by the Embassy concerning employees' personal data, medical information, and salaries as highly sensitive and not divulge any employee information to unauthorized persons.

The contractor shall establish procedures for handling medical insurance claims as follows:

a) Administrative Records

I. 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.

II. 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.

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

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

I. All medical claims shall be submitted directly to the Contractor by employees electronically via e-mail or an electronic system provided by the Contractor. The Contractor reserves the right to request from employees to submit original documents.

Medical claims may also be submitted through a drop box in the COR's office, which the Contractor shall pick up from the COR every week.

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II. The Contractor shall date stamp and screen all claims submitted on the day of receipt. If there are any missing documents or information thereby disallowing said claim to be payable, the Contractor shall notify the employee within two days in writing.

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

IV. Claims shall be settled via an Electronic Funds Transfer (EFT). Each EFT shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any.

V. 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.

VI. The Contractor may also provide a direct billing system whereby healthcare providers directly bill the contractor for services rendered to the claimants, thereby eliminating the need for claimants to pay out-of-pocket and seek reimbursement. The contractor may establish a network of healthcare providers who agree to participate in the direct billing system, to include hospitals, clinics, and individual practitioners. Policyholders retain the option to seek medical care from providers outside the insurance company's network.

D.4 Key Personnel

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

Project Manager: To be inserted by the Contracting Office at the time of award

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

The contractor shall notify the Contracting Officer Representative within 15…