19GE5026Q0004_Attachment 3-Volume 2.docx

COMBINED SYNOPSIS/SOLICITATION 19GE5026Q0004

Health Insurance for Locally Employed Staff (LES) U.S. Embassy Bandar Seri Begawan

VOLUME 2 – TECHNICAL CAPABILITY

The technical offer shall demonstrate a clear understanding of the requirements in the statement of work (SOW), and provide accurate, complete responses to the items below. Evaluation will be conducted on a comparative basis among offers in accordance with FAR Part 13, Simplified Procedures for Commercial Products and Commercial Services, and Section (ix) of this solicitation. The technical capability shall specifically address the following aspects in detail:

Table of Contents

PART I: MANAGEMENT AND TECHNICAL APPROACH

(a) Work Plan: Briefly describe how enrollment, claims management, communication with subscribers, and reporting will be performed.

Confirm that proposed benefits meet or exceed the SOW requirements.:

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

100% Coverage

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

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

Emergency Services (trips to emergency room): Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.

100% Coverage

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

80% Minimum Coverage

Outpatient Services: 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

80% Minimum Coverage

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.

Obstetric and Newborn Care: Care and services that women receive during pregnancy (prenatal care), throughout labor and delivery, and post-delivery, and outpatient care for newborn babies. Hospitalization during pregnancy and/or delivery will be covered as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services.

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

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

Prescription Drugs: Medications prescribed by a certified health care provider that are medically necessary. Examples include but are not limited to: prescription antibiotics to treat an infection; medication used to treat an ongoing condition, such as high cholesterol; prophylaxis; or contraceptive medication.

Preventive and Wellness and Chronic Disease Management: Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but not limited to: physicals, immunization, and cancer screenings.

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

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

Dental:

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

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

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

Mental Health and Substance Abuse Care:

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

50% Minimum Coverage

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

50% Minimum Coverage

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

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

Catastrophic Coverage: Additional coverage equal to B$75,556.00 per covered individual per contract year. Catastrophic conditions shall be defined as major medical conditions occurring as a result of a single/illness/accident or closely related set of major illnesses (or conditions relating to a single accident) that exceed the standard maximum coverage limit.

Excess Coverage: Additional coverage equal to B$75,556.00 per covered individual per contract year. This excess coverage will be offered as an optional benefit to LE Staff. LE Staff must pay 100% of the premium if they elect Excess Coverage.

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.

Out-of-Country Medical Travel: Transportation for out-of-country medical treatment will be a covered expense for LE Staff and eligible family members. To be considered a covered expense, the attending certified health care provider must certify in advance that the treatment is medically necessary and unavailable locally. 80% of covered individual’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be covered. 80% of the transportation expenses of an attendant will also be covered, but only if the covered individual's attending certified health care provider certifies that an attendant for the patient is necessary, (e.g., a parent in the case of a patient who is a minor, or a family member to make medical decisions in the case of a patient who is unwell or unconscious). All coverage for transportation for out-of-country medical treatment is subject to the total maximum annual limit. Transportation to a neighboring country without the attending certified health care provider certifying that the treatment is medically necessary and unavailable locally will not be covered.

Exclusions to Coverage:

There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, 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.

PART II: COMPANY CAPABILITY

(a) Corporate Overview: Provide a concise summary of the company’s organization, staffing, and ability to perform this requirement. Include a brief statement of financial soundness (e.g., solvency ratio or other accepted metric).

(b) Data Protection: Describe how personally identifiable information (PII) will be safeguarded in compliance with local law and accepted commercial insurance practices.

(c) Provider Network: Provide a list (or sample) of participating medical providers (hospitals, clinics, and pharmacies). The list should be current as of proposal submission.

(d) Tax and Licensing Documentation: Submit a copy of the company’s current insurance license and tax identification certificate.

Note: The Government may request additional supporting documentation from the apparent successful Offeror only.

PART III: PAST PERFORMANCE AND EXPERIENCE

(a) Relevant Experience Demonstrate successful performance of comparable health insurance or benefits administration contracts within the last three (3) years.

Each example should include:

· Client name and contact information

· Period of performance

· Number of covered employees or dependents

· Description of services provided

(b) References The Government may contact listed clients or other sources to verify quality, timeliness, and customer satisfaction.

(c) Lack of Past Performance If no organizational past performance is available, provide references for key personnel with relevant experience. Lack of past performance will be considered neutral in evaluation, consistent with FAR 12.602(b).

Failure to furnish and deliver all requested information in accordance with these instructions may result in exclusion from further consideration pursuant to FAR 52.212-1(b)(11). The penalty for making false statements is prescribed in 18 U.S. Code § 1001.

END OF VOLUME 2