QA Solicitation 19GG8025R0001.pdf

SENSITIVE BUT UNCLASSIFIED

# Question Answer

1 Please provide five years of loss data (Table 1) by year of account, including the annual net premium for the same period and incurred claims.

Claims information is critical for accurate pricing, as analyzing the relationship between claims and employee growth or reduction is essential.

Providing this information is a standard practice in the insurance industry and in other Department of State insurance solicitations to ensure equal and fair opportunities for all offerors during open solicitations

Contractual Year

Total Claims Paid (Local Currency)

Retention Amount (Local Currency)

Total Premium Paid to Insurer (Local Currency)

Net Gain (Local Currency)

Net Gain (USD or EUR)

01/04/2020 – 31/03/2021

1,981,467.26₾ 159,777.62 ₾ 1,572,859.60

-568,385.27

$(172,237.96)

01/04/2021 – 31/03/2022

2,421,836.40

166,931.89 ₾ 1,634,087.82

-954,680.47

$(298,337.65)

01/04/2022 – 31/03/2023

2,322,278.97

166,243.60 ₾ 2,431,925.43

-56,597.14 ₾ $ (20,961.90)

01/04/2023 – 31/03/2024

2,477,245.00

171,099.96 ₾ 2,741,761.31

93,416.35 ₾ $ 34,598.65

01/04/2024 – 12/31/2024

2,036,970.71

127,117.42 ₾ 1,882,891.10

26,962.19 ₾ $9,629.35

2 Please provide membership history detailing the number of employees, spouses, and children over the past five years at the end of each year. No confidential information is

Employee statistics is provided in the EXHIBIT A – EMPLOYEE STATISTICS of the solicitation package (page 41).

The numbers are average, and changes are not substantial over the years depending on employees added/removed or status change.

required, only general group statistics.

3. B.4.1. Premium Adjustment

Based on Experience

3.a. If the financial results, such as those after e.g. the second optional year, are significantly unfavorable, but adjustments are not applied retroactively, can the offeror request a price adjustment for only the third and fourth optional years, while excluding adjustments for the second year that caused the losses? Please confirm.

3.b. Given that financial results e.g. for the second optional year become apparent only after the third year that has already commenced, when would be the appropriate time to submit a price adjustment request for the third and fourth option years, considering that adjustments cannot be applied retroactively to previous contract terms.

3.a. Yes, you can request price adjustment for the next option year. Price cannot be adjusted retroactively.

3.b. The company can request price adjustment any time, it’s up to the contractor to determine when request for price adjustment can be executed, provided 12month wait period is passed.

New prices will become in effect after agreement between government and the contractor is achieved and formal modification is signed by both parties.

4 Catastrophic Cases: Has the

Embassy been informed of catastrophic cases such as hemodynamics, open-heart surgery, major orthopedic surgeries, organ transplants, traumatic accidents, cancer treatments (radio and chemotherapy), or hospitalizations exceeding 10 days?

No record. Not required by contract terms.

5 Current Provider: What is the name of the current health insurance provider?

TBC Insurance JSC

6 Direct Billing: Does the current provider offer direct billing for outpatient treatments at medical facilities?

Yes, the current provider offers direct billing to the medical facilities they have agreements with.

7 Out-of-Country Claims:

Could you provide information on claims incurred outside the country during the current coverage period?

Have no record. Not required by contract.

8 Table of Benefits Changes:

Have there been any changes to the Table of Benefits over the past five years?

No, no changes were made to the benefit levels, as this is the standard package offered by Global Talent Management/Overseas Employment (GTM/OE) in Washington DC and is not subject to any changes during entire contract performance.

9 Table of Benefits Comparison:

Are there differences between the current Table of Benefits and the new solicitation?

Yes, there are several. See attached documents with the current and new benefits.

10 Proposal Submission: Can the final proposal be submitted electronically, or does the

Embassy require hard copies?

Proposals shall be submitted electronically. See cover page and Section L.3. of the solicitation package

11 Voluntary or Mandatory Plan:

Is the health insurance plan for LES and their dependents mandatory or voluntary?

LES enrollment is mandatory. Dependents are voluntary

12 Minimum Enrollment Guarantee: If the plan is voluntary, is there a guaranteed minimum number of insured LES?

Refer to Minimum and Maximum Amounts of Section B (page 6) and Section I 52.216-19

ORDER LIMITATIONS (OCT 1995) (page 29) of the solicitation package

13 Enrollment Impact: How will premium rates be impacted if less than 75% of the staff and dependents enroll in the plan?

100% of employees will be enrolled.

14 Premium Share: Will the

Embassy collect the 10% employee premium contribution?

The Government shall make payments directly to the Contractor for all Government employees, whether or not the employee is contributing to the basic premium amount. Section G.4.3. (page 21)

15 EU Insurance Company:

Would the Embassy accept proposals from EU insurance companies passported across all member states?

The company shall meet requirements of the paragraph H.6 (page 24) and L.2 (page 66) to be registered and operate business in Georgia, obtaining all required licenses mandated by the Georgian law.

16 James Zadroga Act Tax: Is a

2% tax under the James

Zadroga Act applicable to this solicitation?

Yes, Section B (page 3), Section I, TAX ON CERTAIN FOREIGN PROCUREMENTS— NOTICE AND REPRESENTATIONS (FEB 2021) (page 31), Section K.13 TAX ON CERTAIN FOREIGN PROCUREMENTS—NOTICE AND REPRESENTATION (JUN 2020) (page 62)

17 DBA Insurance: Is DBA

(Defense Base Act) insurance applicable?

No, DBA waiver was granted by DOL on April 3, 2024

18 Dependent Residency: Must eligible dependents reside in the same country as the employee, or are they covered even if studying abroad?

See section C.1.4 ELIGIBLE PARTICIPANTS (page 12) and C.1.5 ELIGIBILITY (page 13)

Since we have authorized by Out-of-County’ Medical Treatment, dependents studying abroad, shall be covered with the same total max annual limits.

19 HIV/AIDS Benefit: What is the annual maximum limit for HIV/AIDS coverage?

See section C.1.1.15 (page 10)

20 Plan Start Date: When is the plan expected to commence?

See Section F.2 PERIOD OF PERFORMANCE (page 18), and B2.3 through B 2.7. (pages 3- 5)

21 Pricing Validity: Are prices for the additional four years binding or indicative?

Prices for base and all option years are mandatory and fixed see paragraph M .4. FIXED PRICES (page 73-74)

22 Coverage for Dependents: Are coverage limits different for employees and their dependents?

The whole coverage is the same for employees and dependents. See Section C.1.1.

Employee and Dependent Health Service Benefits (pages 8 – 14).

Policy Premium Limits: What are the minimum and maximum policy premium amounts?

Not a public information

24 Out-of-Residence Coverage:

Are medical services covered only for LES and family members residing in Georgia, or also for dependents living abroad?

Since we have ‘Out-of-County’ Medical Treatment, it shall be part of reimbursable expenses with the same total max annual limits.

25 Proposal Evaluation: How will proposals be evaluated if different companies offer varying levels of benefits?

What holds more importance—price or benefit levels?

See the cover page 1 and the Section M - EVALUATION FACTORS FOR AWARD of the solicitation package (pages 73 -75)

26 Optical Care Limits: Can prices be proposed with annual caps instead of two-year caps for optical care and four-year caps for orthodontia?

Price shall be provided in accordance with the minimum requirements set forth in Section C (pages 8-14)

27 Dental Treatment Definition:

Please clarify the scope of

"dental care."

ALL treatment/manipulation that is medically necessary to improve dental health condition.

28 Orthodontia: Is orthodontia considered an additional treatment? Are there age limits?

See C.1.1.11 Dental Care (page 10)

29 Premium Payment: Are all policy premiums paid by the Embassy, or is there a shared payment arrangement?

See paragraph G4 SUBMISSION OF INVOICES AND PAYMENT (page 20-21)

30 Proposal Adjustments: If information is missing from the submitted proposal, will the Embassy provide an opportunity for correction or additional submission?

See the cover page 1 and the Section M - EVALUATION FACTORS FOR AWARD of the solicitation package (pages 73 -75) The U.S. Government intends to award a contract/purchase order to the responsible company submitting an acceptable offer at the lowest price. We intend to award a contract/purchase order based on initial proposals, without holding discussions, although we may hold discussions with companies in the competitive range if there is a need to do so.

31 Service Inclusions: How can prescribed and non-prescribed services be identified?

Services and medication prescribed by a licensed physician

32 Maximum Benefit Proposal:

Can proposals offer maximum benefit amounts that exceed the minimum requested?

Yes, you can, please refer to Paragraph L.4.3 Technical Proposal of Section L (page 67)

33 The total number of employees according to the price tables in Sections B.2.3 to B.2.7 is 437, broken down as follows: 94 Self, 112 Self- Plus-One, and 231 Family.

However, Section J, Exhibit A lists the total employee count as 469 (165 Female and 304 Male). Please confirm the actual counts to be used in the price tables under Section B.

The numbers are estimates only. In the section B.2.3 to B.3.7. are current numbers whereas the exhibit A provides employee statistics which are average numbers for the ongoing contract.

The numbers change depending on employees added /removed and family status changes happening every two weeks (pay period).

34 The price tables in Sections B.2.3 and B.2.4, as well as the retention table in Section B.3.2 specify monthly rates per premium. However, the price tables in Sections B.2.5, B.2.5 – B.2.7 shall be monthly rates, typo mistake.

B.2.6, and B.2.7 specify biweekly rates per premium.

Please confirm whether the offer should include monthly rates per premium and monthly retention amounts, or biweekly rates per premium and monthly retention amounts.

35 Please confirm if the claims data provided under Section J, Exhibit C includes claims from ORE employees and EAE employees.

Claims data does not include ORE or EAE data

36 Please provide average insured member counts for Health Insurance for the last 5 years – 2024, 2023, 2022, 2021 & 2020. It is standard practice in the insurance industry (and in other Department of State insurance solicitations) to provide this information to ensure equal/fair opportunity for all offerors in an open solicitation.

See Exhibit A for Employee Statistics

37 Can offerors provide several different offers for your consideration

Yes - Multiple proposals - If an offeror has multiple plans available that meet or exceed the minimum benefit levels and wants to propose them, a separate proposal with its respective prices must be submitted individually for each. However, evaluation will be based on meeting the stated minimums only.

See Paragraph L.4.3. Technical Proposal of Section L - INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS (page 67)

38 Which medicines are reimbursable

Any medicine that is prescribed by a licensed physician both local and international. Drugs that are registered by FDA and are medically necessary to treat specified diagnosis.

39 Can you please clarify further:

C.1.1.19 Employee Assistance Program (EAP):

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. This optional benefit is subject to availability of funds at post.

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.

40 Can you please clarify further:

Describe the pool(s) of coverage the offeror uses to administer its insurance, which pool of coverage the employees under this requirement will be contained, and what percentage of that pool they would represent.

B.4.2.1 Employee Pool – This clause is only in effect if the Contractor included details in its offer regarding a pooling arrangement, of which this contract is a part.

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.

An "employee pool" in a health insurance policy refers to the collective group of employees from a company that are covered under a single health insurance plan, essentially combining their risk profiles to calculate premiums, where healthier employees subsidize the costs of those with higher healthcare needs; this practice is known as "risk pooling" and allows for potentially lower overall costs for the employer and employees.

By pooling employees together, the insurance company can spread out the risk of high medical costs among a larger group, potentially leading to lower premiums for everyone.

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

41 Can you please suggest your recommendation about the length of one-time paid/prescribed supplies for drugs and medicines (1 month, 2 months etc.)

Prospective offerors shall provide this information with their proposal.

42 would be acceptable to submit an offer from a local insurance provider in Georgia, accompanied by a teaming agreement between their company and the local provider.

Please refer to Section L. 2. Summary of Offers (page 66) and Part 4 Licensing Information of L.4. Contents of Proposals (page 68 – 69)

Benefit levels for the contact 19GG8020D0002

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as described herein.

C.1.1 Employee and Dependent Health Service Benefits

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

Minimum Reimbursement Rate - 100%

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

Health and Substance Abuse care (C.1.1.13) for details concerning inpatient psychiatric care.

C.1.1.2 Emergency Services (Trips to Emergency Room): Minimum

Reimbursement Rate - 100%

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

C1.1.3 Ambulance: Minimum Reimbursement Rate - 80%

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

C.1.1.4 Outpatient Services: Minimum Reimbursement Rate - 80%

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 C.1.1.14 for details concerning physical therapy.

See Mental Health and Substance Abuse Care (C.1.1.13) for details concerning psychiatric therapy

C.1.1.5 Obstetric and Newborn Care: Minimum Reimbursement Rate -

Inpatient/Emergency: 100%; Outpatient: 80%

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

C.1.1.6 Pediatric Services: Minimum Reimbursement Rate -

Inpatient/Emergency: 100%, Outpatient: 80%

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.1.1.7 Prescription Drugs: Minimum Reimbursement Rate -

Inpatient/Emergency: 100%, Outpatient: 80%

Medications prescribed by a licensed health care provider that are medically necessary to treat a specified diagnosis. Examples include, but are not limited to prescription antibiotics to treat an infection, medication used to treat an ongoing condition, such as high cholesterol, or birth control medication.

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

Minimum Reimbursement Rate - 80%

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but are not limited to: physicals, immunizations, and cancer screenings.

C.1.1.9 Hearing Aids: Minimum Reimbursement Rate – 80%

Hearing aid apparatus and related examination. Limited to one apparatus per ear up to a maximum of 4,400.00GEL per covered individual per three-year period.

C.1.1.10 Optical Care: Minimum Reimbursement Rate – 80%

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames, or contact lenses: Covered up to a maximum of 880.00

GEL per covered individual every two years. 80% Minimum Coverage;

C.1.1.11 Dental Care: Minimum Reimbursement Rate – 80%

Dentist fees, x-rays, examination and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges per covered individual up to a maximum of 9,400.00GEL per contract year. 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 shall be covered per patient up to a maximum of 7,000 GEL lifetime limit.

C.1.1.12 Family Planning: Minimum Reimbursement Rate - 80%

Prescribed contraceptive devices, 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.1.3.).

C.1.1.13 Mental Health and Substance Abuse Care: Minimum

Reimbursement Rate - 50%

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

C.1.1.14 Rehabilitative and Habilitative Services and Devices:

Minimum Reimbursement Rate - 50%

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

C.1.1.15 HIV/AIDS: 100% Reimbursement at a minimum of $10,000.00 per covered year

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. Reimbursement under this benefit is excluded from the annual maximum limit (C.1.2).

C.1.1.16 Catastrophic Coverage

RESERVED

C.1.1.17 Out-of-Country Medical Treatment:

Medical expenses incurred out-of-country will be covered at the same benefit levels and subject to the same total maximum annual limit as for medical expenses incurred in-country.

C.1.1.18 Transportation for Out-of-Country Treatment: 80% Reimbursement

RESERVED

C.1.1.19 Excess Coverage

NOTE: Employee responsible for paying 100% of premium for Excess Coverage

Additional coverage equal to 150,000.00GEL to be applied to any covered individual to any covered benefit. LE Staff must pay 100% of the premium if they elect Excess

Coverage. This can be used for any coverage individual for any covered expense that exceed annual maximum.

C.1.2 Annual Maximum Limit - The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) and

C.1.1.16, Catastrophic Coverage, or those covered under C.1.1.15, HIV/AIDS, and C.1.1.19, Excess Coverage is equivalent to 150,000.00GEL

C.1.3 Exclusions and Limitations

There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures; massage;

exercise therapy; long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, intracellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider. Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable.

Removal of any exclusions require prior authorization.

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

C.1.4 Eligible Participants

C.1.4.1 Identification of Eligible Employees and Dependents: U.S. Embassy

Tbilisi 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 monthly basis.

C.1.4.1.1 Eligible Employees: Eligible employees are Locally Employed

Staff who are:

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

b. Under a non-temporary direct hire appointment, personal services agreement

(PSA), or personal services contract (PSC); or

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

C.1.4.1.2 Definition of Dependents

C1.4.1.2.1 Spouse: a limit of one legal spouse as defined by local law per employee will 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.

C.1.4.1.2.2 Children: a child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE Staff. A child will be covered until the end of the contract year in which s/he reaches age 26. An unmarried child determined to be incapable of self-support due to a physical or mental condition will continue to be eligible to participate in the medical plan as long as the condition persists, the child remains unmarried, and the LE

Staff maintains coverage.

C.1.4.2 Location of Employment: The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Georgia by:

US Department of State

Defense Security Cooperation Agency (ODC)

Defense Wide Program (PFP)

U.S. Agency for International Development (USAID)

Center for Disease Control (CDC)

Office of Bilateral Agreement (BAO)

Export Control and Related Border Security (EXBS)

US Department of Justice (DOJ)

US Department of Defense (DAO)

US Department of Treasury

US Army Corp of Engineers (USACE)

US Department of Agriculture (USDA)

International Narcotics Liaison (INL)

Defense Threat Reduction Agency (DTRA)

Force Protection Detachment (FPD)

EUCOM

NAVY-GDP –ICAF

Population, Refugee and Migration (PRM)

Army Medical Research Center (WRAIR)

C.1.4.3 Participants Covered Under a Rider

a. All current active ORE Staff personally employed by the Chief of Mission and the Deputy Chief of Mission and assigned to their respective official

Government residences and paid under an ORE account. All costs for coverage of ORE Staff are the responsibility of the Chief of Mission and the Deputy Chief of Mission, not the U.S. Government.

b. All current active employees of the Employee Association at Embassy

Tbilisi. All costs for coverage of TEAYs are the responsibility of the Employee

Association, not the U.S. Government.

C.1.5 Eligibility

C.1.5.1 Term of Eligibility and Effective Date

Each current active eligible employee and their eligible dependents are enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee and eligible dependents will be enrolled upon entering on duty with the United States Government. An employee is considered active

("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

C.1.6 Brochure Requirement

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in Georgian that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The Contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made.

C.1.6.2 The Contractor shall provide the document described in C.1.6.1 to the COR not later than 45 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) business days of the COR’s request.

C.1.6.3 The Contractor assumes full responsibility for ensuring that the document described in

C.1.6.1 accurately reflects the requirements, coverage, and contract terms of the contract, as implemented by the Contractor’s technical proposal. In all cases, the contract shall take precedence. Should the COR discover that the document contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the U.S. Government to notice any inaccuracies shall in no way limit, revise or otherwise affect the requirement under this contract for the Contractor to fully comply with all contract terms.

Benefit levels new solicitation 19GG8025R0001

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as described herein.

C.1.1 Employee and Dependent Health Service Benefits

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

Minimum Coverage - 100%

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

(C.1.1.13) for details concerning inpatient psychiatric care.

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

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

C.1.1.2 Emergency Services (Trips to Emergency Room): Minimum Coverage - 100%

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

C1.1.3 Ambulance: Minimum Coverage - 80%

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

C.1.1.4 Outpatient Services: Minimum Coverage - 80%

Services provided by a 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.1.1.5 Obstetric and Newborn Care: Minimum Coverage - Inpatient/Emergency: 100%;

Outpatient: 80%

Care and services that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and outpatient care for newborn babies. Hospitalization during pregnancy and/or delivery will be reimbursed as inpatient care All other treatments will be considered outpatient services and will be reimbursed at that rate.

C.1.1.6 Pediatric Services: Minimum Coverage - Inpatient/Emergency: 100%, 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.1.1.7 Prescription Drugs: Minimum Coverage -Inpatient/Emergency: 100%, Medications prescribed by a licensed health care provider that are medically required. 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, contraceptive medication.

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

Minimum Coverage - 80%

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but are not limited to:

physicals, immunizations, and cancer screenings.

C.1.1.9 Hearing Aids: Minimum Coverage – 80%

Hearing Aid Apparatus: Limited to one apparatus per ear up to a maximum of 3,000.00GEL per covered individual per three-year period. 80% Minimum Coverage: with annual cap.

C.1.1.10 Optical Care: Minimum Coverage – 80%

Prescription lenses and frames, or contact lenses: Covered up to a maximum of 1,000.00GEL per covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11 Dental Care: Minimum Coverage – 80%

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges up to a maximum of 12,000.00GEL 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 up to a maximum of 10,000.00GEL lifetime limit. 80% Minimum Coverage;

with contract lifetime cap.

C.1.1.12 Reproductive Health: Minimum Coverage - 80%

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

(see Exclusions to Coverage).

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

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

C.1.1.14 Rehabilitative and Habilitative Services and Devices:

Minimum Coverage - 50%

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

C.1.1.15 HIV/AIDS: 100% up to USD 10,000 per contract year per covered individual

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

C.1.1.16 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.1.1.17 Out-of-Country Medical Travel: 80% Reimbursement

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

C.1.1.18 180 Day Coverage for Dependents After Employee’s Death

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

C.1.1.19 Employee Assistance Program (EAP):

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. This optional benefit is subject to availability of funds at post.

C.1.2 Annual Maximum Limit - The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) and, or those covered under C.1.1.15, HIV/AIDS, is equivalent to 150,000.00 GEL.

C.1.3 Exclusions and Limitations

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.1.4 ELIGIBLE PARTICIPANTS

LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members.

C.1.4.1 Identification of Eligible Employees and Dependents: U.S. Mission in Tbilisi

Georgia will provide a list of all eligible employees and dependents with relationship to employee (self/spouse/child/same sex partner) and DOB for each. Updates will be provided to add or remove individuals on a monthly basis.

C.1.4.1.1 Definition of Dependents

C1.4.1.1.1 Legal spouse: one legal spouse or same-sex partner 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 or same-sex 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.

C.1.4.1.1.2 Dependent children: a child is defined as the LE Staff's natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE

Staff. A child will be covered until the end of the contract year in which s/he reaches age 26. An unmarried child determined to be incapable of self-support due to a physical or mental condition will continue to be eligible to participate in the medical plan as long as the condition persists, the child remains unmarried, and the LE Staff maintains coverage..

C.1.4.2 Location of Employment: The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Georgia under US Embassy Tbilisi Chief of

Mission authority including but not limited to

US Department of State

Defense Security Cooperation Agency (ODC)

U.S. Agency for International Development (USAID)

Center for Disease Control and Prevention (CDC)

Office of Bilateral Agreement (BAO)

Export Control and Related Border Security (EXBS)

US Department of Justice (DOJ)

US Department of Defense (DAO)

US Department of Treasury

US Army Corp of Engineers (USACE)

US Department of Agriculture (USDA)

International Narcotics Liaison (INL)

Defense Threat Reduction Agency (DTRA)

Force Protection Detachment (FPD)

EUCOM

NAVY-GDP –ICAF

Army Medical Research Center (WRAIR)

C.1.4.3 Participants Covered Under a Rider

a. All current active ORE Staff personally employed by the Chief of Mission and the

Deputy Chief of Mission and assigned to their respective official Government residences and paid under an ORE account. All costs for coverage of ORE Staff are the responsibility of the

Chief of Mission and the Deputy Chief of Mission, not the U.S. Government.

b. All current active employees of the Employee Association at Embassy Tbilisi. All costs for coverage of Tbilisi Employee Association (TEA) are the responsibility of the Employee

Association, not the U.S. Government.

C.1.5 ELIGIBILITY

C.1.5.1 Term of Eligibility and Effective Date

To be eligible to participate in the medical plan, LE Staff must be:

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

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

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

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 Georgia who provides services to other local organizations as well as to the U.S. Mission; employees working on an intermittent or When Actually Employed (WAE) schedule; employees of USAID institutional contractors; Peace Corps personal services contractors as indicated in MS 743; and

Recreation Association employees.

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.

Periods of Ineligibility:

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

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

During a period of extended Leave Without Pay (L WOP) or unpaid leave beyond one pay period, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the Contractor, and will collect the full cost from the employee on a quarterly basis.

Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

C.1.6 Brochure Requirement

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in Georgian that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The Contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made.

C.1.6.2 The Contractor shall provide the document described in C.1.6.1 to the COR not later than fourteen (14) days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) business days of the COR’s request.

C.1.6.3 The Contractor assumes full responsibility for ensuring that the document described in C.1.6.1 accurately reflects the requirements, coverage, and contract terms of the contract, as implemented by the Contractor’s technical proposal. In all cases, the contract shall take precedence. Should the COR discover that the document contains inaccuracies, the

Contractor will be notified in writing; however, failure on the part of the U.S. Government to notice any inaccuracies shall in no way limit, revise or otherwise affect the requirement under this contract for the Contractor to fully comply with all contract terms.