Solicitation for GMC Health insurance.pdf

U.S. Embassy Tbilisi

Date: December 23, 2024

Dear Prospective Offeror:

Subject: Request for Proposals number 19GG8025R0001

The Embassy of the United States of America in Tbilisi, Georgia invites eligible companies to submit a proposal for locally employed staff health insurance coverage. The Embassy encourages prospective offerors to offer off-the-shelf plans that meet at least the minimum benefit levels required in this solicitation.

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.

The Embassy intends to conduct a pre-proposal conference at the site, The pre-proposal conference will be held on January 13, 2025 at 10:30AM local time (GMT+4) at the US Embassy Tbilisi, 19Georgian American Friendship Ave. Tbilisi, Georgia. Please cpntact Tbilisi procurement section by email

TbilisiGSOProcurement@state.gov for additional information or to arrange entry to the building.

Proposals are due by 23:59 Local time (GMT+4) on January 31, 2025. No proposals will be accepted after this time. Proposals must be in English and incomplete proposals will not be accepted.

Your proposal must be submitted electronically to TbilisiGSOProcurement@state.gov . It is important to make sure the submission is made in specific size and format; in MS-Word 2007/2010 or MS-Excel

2007/2010 or Adobe Acrobat (pdf) file format. The file size must not exceed 30MB. If the file size should exceed the 30MB, the submission must be made in separate files and attached to separate emails with less than 30MB each.

In order for a quotation to be considered, you must also complete and submit the following:

1. SF-33

2. Section B, Pricing Schedule.

3. Section B, Retention Amounts in B.3 and B.7.

4. Section K, Representations and Certifications; and

5. Additional information as required in Section L.

6 Proof of SAM Registration

Offerors shall be registered in the SAM (System for Award Management) database at https://www.sam.gov prior to submittal of their offer/proposal as prescribed under FAR 4.1102. Failure to be registered at time of proposal submission may deem the offeror’s proposal to be considered non-responsible and no further consideration will be given. Therefore, offerors are highly encouraged to register immediately if they are interested in submitting a response to this requirement.

Sincerely, Anna Kosinska

Contracting Officer

Enclosure:

mailto:TbilisiGSOProcurement@state.gov mailto:TbilisiGSOProcurement@state.gov https://www.sam.gov/

SOLICITATION OFFER AND AWARD 1

1. ThisCon trac t isaRated Orderunder the Defense Prioriliesand A l lo cations ►

I

RATING

, , System (DPAS)- Code of Federal Regu lations - at 15 CFR 700. I PAGE or PAGES

2. CONTRACT NUMBER 3. SOLICITATION NUMBER 4. TYPE OF SOLICITATION 5. DATE ISSUED 6. REQUISITION/PURCHASE NUMBER

□ SEALED BID (IFB) INVITATION FOR BID

19GG8025R0001 � NEGOTIATED (RFP) REQUEST FOR

PROPOSAL 12/23/2024 PR14917752

7. ISSUED BY GODEi 8. ADDRESS OFFER TO (If other than item 7)

US Embassy Tbilisi TbilisiGSOProcurement@state.gov

29 Georgian American Friendship Ave, Tbilisi, Georgia

NOTE: In sealed bid solicitations "offer" and "offerer" mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and 1 copies for furnishings the supplies or services in the Schedule will be received at the place specified in item 8, or if hand carried, in the depository located in TbilisiGSOProcurement@state.gov until 23:59 local time 1/31/2025 (Hour) (Date)

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision Number 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation

10. FOR A. NAME B. TELEPHONE (NO COLLECT CALLS) C. EMAIL ADDRESS

INFORMATION AREA CODE

CALL: ► Tamar Jashi 32 I

NUMBER

2277000 I

EXTENSION

7172 TbilisiGSOProcurement@state.g

11. TABLE OF CONTENTS

(X) SECTION DESCRIPTION PAGE(S) (X) SECTION DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM 2 X I CONTRACT CLAUSES 125-39

B SUPPLIES OR SERVICES AND PRICES/COSTS 3-7 PART Ill - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

C DESCRIPTION/SPECIFICATIONS/WORK STATEMENT 8-14 X J

D PACKAGING AND MARKING 15

E INSPECTION AND ACCEPTANCE 16-17

18-19 X K

F DELIVERIES OR PERFORMANCE

G CONTRACT ADMINISTRATION DATA 20-21 X L

H SPECIAL CONTRACT REQUIREMENTS 22-24 X M

LIST OF ATTACHMENTS 140-44

PART IV - REPRESENT A T/ONS AND INSTRUCTIONS

REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS

OF OFFERORS 45-65

INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS 66-72

EVALUATION FACTORS FOR AWARD 73-75

OFFER (Must be fully completed by offeror)

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within 60 calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT ► 10 CALENDAR DAYS (%)

20 CALENDAR DAYS(%) 30 CALENDAR DAYS(%)

I

CALENDAR DAYS(%)

(See Section I, Clause Number 52.232-8)

14. ACKNOWLEDGMENT OF AMENDMENTS AMENDMENT NUMBER DATE AMENDMENT NUMBER DATE

(The offeror acknowledges receipt of amendments to the SOL/CITATION for offerors and related documents numbered and dated):

CODE I I FACILITY I 16. NAME AND THE TITLE OF PERSON AUTHORIZED TO SIGN OFFER

15A. NAME AND (Type or print)

ADDRESS

OF OFFEROR

15B. TELEPHONE NUMBER

□ 15C. CHECK IF REMITTANCE ADDRESS IS 17. SIGNATURE

AREA CODE

I

NUMBER

I

EXTENSION DIFFERENT FROM ABOVE - ENTER

SUCH ADDRESS IN SCHEDULE.

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEMS NUMBERED

20. AMOUNT

22. AUTHORITY FOR USING OTHER THAN FULL OPEN COMPETITION UNDER THE

UNITED STATES CODE AT:

D 10 U.S.C. 3204(a) D 41 U.S.C. 3304(a) (

24. ADMINISTERED BY (If other than Item 7)

26. NAME OF CONTRACTING OFFICER (Type or print)

21. ACCOUNTING AND APPROPRIATION

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

25. PAYMENT WILL BE MADE BY

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

IMPORTANT -Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

18. OFFER DATE

I

ITEM

GODEi

28. AWARD DATE

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (REV.12/2022)

Prescribed by GSA- FAR (48 CFR) 53.214 (c)

2 75

SECTION B - PRICES

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide the Health Insurance services to employees of the Government of the United States of America in Georgia and their eligible dependents as described in Section C.

This insurance shall be provided in accordance with Section C.

B.1.1. Official Residence Expense (ORE) Staff and Tbilisi Employee Association (TEA) employees are included under this contract only as a rider; the Contractor shall bill the Chief of

Mission and Deputy Chief of Mission (for ORE Staff), and the Embassy Association (for TEA) at the rates specified below. See Section G for billing procedures. Note that USG is not responsible, nor liable, for any riders.

B.2. PRICES

B.2.1 Value Added Tax

The Government will not reimburse the Contractor for VAT under this contract. The Contractor shall not include a line for VAT on Invoices as the U.S. Embassy has a tax exemption certificate with the host government.

B.2.2 This is a fixed price with economic price adjustment requirements type contract under which will be issued firm, fixed-price task orders. The fixed prices/premium rates for the health insurance services as specified in Section C are as follows:

B.2.3 Base Year of Contract -June 1, 2025 – May 31, 2026

Monthly Rates Per

Premium

Category Estimated Number of

Premiums*

Rate per

Premium

Extended Monthly Total

a. Self 94

b. Self Plus One 112

c. Family (3 or more individual)

d. Subtotal

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% PERSUANT TO 26 U.S.C. 5000C.

Total Price for Base

Year (d x 12)**

*estimated number of premiums does not include any Riders (B.1.1)

**does not include any premiums for Riders.

B.2.4 First Option Year of Contract - June 1, 2026 – May 31, 2027

Monthly Rates

Per Premium

Category Estimated

Number of

Premiums*

Rate per

Premium

Extended Monthly Total

a. Self 94

b. Self Plus

One

c. Family (3 or more individual)

d. Subtotal

Total Price for First

Option Year (d x

12)**

B.2.5 Second Option Year of Contract - June 1, 2027 – May 31, 2028

Bi-Weekly Rates Per

Premium

Category Estimated Number of

Premiums*

Rate per Premium Extended Bi-Weekly

Total

a. Self 94

b. Self Plus One 112

c. Family (3 or more individuals)

Total Price for Second

B.2.6 Third Option Year of Contract - June 1, 2028 – May 31, 2029

Premiums*

Rate per Premium Extended Bi-Weekly

Total

a. Self 94

b. Self Plus One 112

c. Family (3 or more

Total Price for Third

B.2.7 Fourth Option Year of Contract - June 1, 2029 – May 31, 2030

Premiums*

Rate per Premium Extended Bi-Weekly

Total

a. Self 94

b. Self Plus One 112

c. Family (3 or more

Total Price for Fourth

MINIMUM AND MAXIMUM AMOUNTS

During the Base Year of the contract, and during the option year that might be exercised, the

United States Government (USG) shall place orders totaling a minimum of 50(fifty) employees.

This reflects the contract minimum guarantee for each period of performance. The amount of all orders, for base and all option years shall not exceed 2500 employees. This reflects the contract maximum.”

B.3 ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the Contractor requests a price adjustment under B.4 below, the Contractor shall present cost experience data that includes the retention amount. For purposes of any economic price adjustment, this retention amount is a fixed amount that is a part of the premium amounts in B.2. This retention amount will not be adjusted for any reason.

The retention amount is part of the premium and may include, but not be limited to, such costs as overhead and general and administrative costs. It will also include any profit. Essentially, it includes all costs except the actual portion of the premium intended to fund claims paid to the health care provider/claimant. B.3.2 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

NOTE TO OFFEROR: Fill in the fixed monthly retention amounts for each period of performance and for each category of premium. This fixed amount shall be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall not be expressed in terms of a percentage of the premium.

B.3.2 Monthly Retention Amounts per separate premium paid per single employee and per family plan.

Period of

Performance Employee

Self plus one (2 covered individuals)

Family (three or more covered individuals)

Base Period

B.2.8. Grand Total of Base plus All Option Years

Base Year Total

First Option Year Total

Second Option Year Total

Third Option Year Total

Fourth Option Year Total

Grand Total of Base plus All Option Years

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.4. ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.4.1. Premium Adjustment Based on Experience - 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 in B.1.1. No adjustment will be allowed during the first twelve months. After such time, the Contractor or the Government may request an adjustment in premiums on an annual basis. Adjustments are not retroactive to previous contract terms.

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, ie per line item. The retention amount is not subject to adjustment. The Government reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract. 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.4.2. Premium Adjustment Based on Laws - The rates may also be adjusted during the performance period of the contract as a result of laws enacted by the host Government, if such change in the laws has a direct impact on the cost to the Contractor to perform this contract at the contracted rate. In that event, the Contracting Officer may enter into negotiations with the

Contractor to modify the contract to adjust the premium rate. The Contractor agrees to provide all documentation necessary to support any requested adjustment.

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.

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.

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%

Examinations and Treatment: 80% Minimum Coverage

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%

Examinations and Treatment: 80% Minimum Coverage

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.

SECTION D

PACKAGING AND MARKING

(RESERVED)

SECTION E

INSPECTION AND ACCEPTANCE

E.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. In addition, the full text of a clause may be accessed electronically at: Acquisition.gov this address is subject to change.

If the Federal Acquisition Regulation (FAR) is not available at the location indicated above, use the Department of State Acquisition website at e-CFR to see the links to the FAR. You may also use an Internet “search engine” (for example, Google, Yahoo or Excite) to obtain the latest location of the most current FAR.

THE FOLLOWING FEDERAL ACQUISITION REGULATION CLAUSE(S) IS/ARE

INCORPORATED BY REFERENCE:

CLAUSE TITLE AND DATE

52.246-4 INSPECTION OF SERVICES - FIXED PRICE (AUG 1996)

E.2. 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

Government, is responsible for management and quality control to meet the terms of the contract.

The role of the Government is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective

PWS

Paragraph Performance Threshold

Services

Performs all the insurance services set forth in the Performance Work Statement (PWS)

C.1.0 thru

C.1.6

All required services are performed and no more than one

(1) customer complaint is received per month

Ensures comprehensive data base to safeguard PII information.

https://acquisition.gov/browse/index/far https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

E.2.1 Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided. If appropriate, the COR will send the complaints to the Contractor for corrective action.

E.2.2 Standard. The performance standard is that the Government receives no more than one

(1) 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.

E.2.3 Procedures

(a) If any Government personnel observe unacceptable services, either incomplete work or required services not being performed, they should immediately contact the COR.

(b) The COR will complete appropriate documentation to record the complaint.

(c) If the COR determines the complaint is invalid, the COR will advise the complainant. The COR will retain the annotated copy of the written complaint for his/her files.

(d) If the COR determines the complaint is valid, the COR will inform the Contractor and give the Contractor additional time to correct the defect, if additional time is available. The

COR shall determine how much time is reasonable.

(e) The COR shall, as a minimum, orally notify the Contractor of any valid complaints.

(f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR. The COR will review the matter to determine the validity of the complaint.

(g) The COR will consider complaints as resolved unless notified otherwise by the complaint.

(h) Repeat customer complaints are not permitted for any services. If a repeat customer complaint is received for the same deficiency during the service period, the COR will contact the Contracting Officer for appropriate action under the Inspection clause.

SECTION F

DELIVERIES OR PERFORMANCE

F.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

THE FOLLOWING FEDERAL ACQUISITION REGULATION CLAUSES ARE

52.242-15 STOP WORK ORDER (AUG 1989)

52.242-17 GOVERNMENT DELAY OF WORK (APR 1984)

F.2 PERIOD OF PERFORMANCE. The base year period of performance for this contract begins on June 1, 2025 with four (4) one-year renewal options to be exercised at the discretion of the U.S. government.

F.3 OPTIONS

(a) The Government may extend this contract in accordance with the option clause at

Section I, clause I.2, FAR Clauses Incorporated by Full Text (FAR 52.217-9, Option to Extend the Term of the Contract), which also specifies the total potential duration of the contract.

(b) The Government may exercise the option set forth at Section I, "FAR 52.217-8, Option to Extend Services".

F.4 REPORTS AND OTHER DELIVERABLES

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

US Embassy Tbilisi

29 Georgian American Friendship Ave.

Tbilisi, Georgia https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

By email: TbilisiGSOProcurement@state.gov , hrotbilisi@state.gov mailto:TbilisiGSOProcurement@state.gov mailto:hrotbilisi@state.gov

SECTION G

CONTRACT ADMINISTRATION DATA

G.1. 652.242-70 CONTRACTING OFFICER’S REPRESENTATIVE (COR) (AUG 1999)

(a) The Contracting Officer may designate in writing one Government employee, by name or position title, to take action for the Contracting Officer under this contract. This designee shall be identified as a Contracting Officer’s Representative (COR). Such designation shall specify the scope and limitations of the authority so delegated; provided, that the designee shall not change the terms or conditions of the contract, unless the COR is a warranted Contracting Officer and this authority is delegated in the designation.

(b) The COR for this contract is the Human Resources Specialist.

G.2 COR DUTIES

G.2.1 The COR is responsible for inspection and acceptance of services. These duties include review of Contractor invoices, including the supporting documentation required by the contract.

The COR may provide technical advice, substantive guidance, inspections, invoice approval, and other purposes as deemed necessary under the contract.

G.2.2 In addition, the COR shall maintain updated list of employees and dependents insured, which will supersede the initial list provided under this contract and as reported to the insurer without prejudice to the ineligibility clause.

G.2.3. The COR has the additional responsibility of maintaining the eligible listing of employees and dependents for insurance coverage.

G.2.4 The COR may not change the terms and conditions of the contract. While the COR is authorized to provide the Contractor with updated listings of eligible employees and dependents, only the Contracting Officer may modify existing task orders or issue new task orders, reflecting these changes, since only the Contracting Officer can obligate funding and commit the

Government.

G.3. Payment shall be made in Georgian Lari (GEL).

G.4 SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted electronically to

TbilisiFMOVouchering@state.gov

Payments at Beginning of Covered Period

G.4.2. Frequency of Payments. All funds under this contract will be obligated by issuance of task orders, as described in H.3 for all non-rider coverage. Each task order will fund a specific period of time and number of employees, and the task orders will be issued at the frequency mailto:TbilisiFMOVouchering@state.gov described in H.3. Contractor may submit invoices quarterly for payment to be made at the beginning of the month for which insurance coverage is provided in accordance with FAR

32.404.

G.4.3. U.S. Government Employees. 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.

G.4.4 Riders:

a. ORE. The Chief of Mission and/or Deputy Chief of Mission will make payment directly to the Contractor for the entire premium amount of the ORE staff, whether or not the ORE employee is contributing to the premium amount.

b. TEA Staff. The Employee Association will make payment directly to the Contractor for the entire premium amount of the EA employee, whether or not the EA employee is contributing to the premium amount.

G.5 REFUNDS TO THE GOVERNMENT

If at any time during performance of the contract the Government finds that the Contractor has been overpaid because the number of employees and/or dependents covered has decreased, the

Contracting Officer may either allow that overpayment to be credited to the Government’s account or require that the Contractor refund the overpayment. If the Contracting Officer requests a refund, the Contractor shall make that refund to the Government within ten calendar days of receipt of the request.

G.6 VALUE ADDED TAX

VALUE ADDED TAX (VAT). The Government will not reimburse the Contractor for VAT under this contract. The Contractor shall not include a line for VAT on Invoices as the U.S.

Embassy has a tax exemption certificate with the host government.

SECTION H

SPECIAL CONTRACT REQUIREMENTS

H.1 SECURITY. On occasion, a Contractor employee may require entry into U.S.

Government-owned or -operated facilities. If so, the Contractor should be prepared to provide the necessary identification to permit escorted access within that facility.

H.2 STANDARDS OF CONDUCT. The Contractor shall maintain satisfactory standards of employee competency, conduct, cleanliness, appearance, and integrity and shall be responsible for taking such disciplinary action with respect to employees as may be necessary. Each

Contractor employee is to adhere to standards that reflect credit on themselves, their employer, and the United States Government.

H.3 ORDERING PROCEDURES. The Government will issue a task order as soon as possible after contract award to identify all employees to be covered by the insurance described in this contract and the coverage selected by each employee, including dependents to be covered.

The COR will make subsequent additions or deletions to this list in writing and provide the revised list to the Contractor. All such revisions shall be consolidated, and a new or modified task order will be issued by the Contracting Officer. If any changes have been made to the coverage listing, the Government anticipates issuance of a new task order on a [ ] monthly, (X ) quarterly basis. This new task order will include all changes made since the previous task order was issued and will include any increase or decrease in necessary funding. The changes to the list of eligible individuals will supersede the initial list provided under prior task orders without prejudice to the ineligibility clause. Task orders will indicate the effective date of employment, for purposes of calculating the premium due.

H.3.1. Riders are not included under the task orders issued by the Contracting Officer. Because their coverage is under a rider, either their employer are themselves are responsible for directly interacting with the Contractor to order any coverage. When contacted, the Contractor shall advise the person of the paperwork and payment that will be necessary to order coverage for the identified individuals. The Contractor may be contacted by more than one individual.

H.4. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS

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 employee' 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

(1) The Contractor shall maintain medical insurance files for each covered employee and each covered dependent 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 person reimbursement ceiling.

(2) 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.

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

(4) The Contractor shall deposit to employee’s bank account the amount claimed within 5 business days or provide written justification in case of denial within 3 days after the claim is submitted..

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

(1) All medical claims shall be submitted directly to the Contractor by employees, through a drop box in the Embassy main entrance CAC2. The claims shall be picked up each Tuesday.

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

(3) The contractor shall develop a comprehensive online reimbursement portal for online submission and claim settlement with detailed information of the required documents to be uploaded for each type of claim. The settlement shall be made within 5 business days the contractor accepts the form. In case when submittal is missing information or does not qualify for reimbursement the contractor shall give written notification to an insured within 2 business days

(4) The Contractor shall settle the claims no later than 5 business days from the date the claim is submitted to the Contractor.

(5) Settlement shall be deposit to employee’s bank account.

(6) 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.

H.5. REPORT REQUIREMENTS. The Contractor shall provide the following monthly report. The report shall be received by the COR no later than the 15th day of each month. The report shall report on the previous month's activities.

(a) Employee Claims Report. The report shall list all claims paid by the Contractor to a claimant, including the name of the claimant, date claim is received by the Contractor, and the amount claimed. This report shall also include all outstanding claims and a brief description of why claim has not been paid. The report shall not include any claims information for riders.

H.6. MISCELLANEOUS CONTRACTOR REQUIREMENTS

H.6.1. General. The Contractor shall take all such steps as are necessary, and obtain and pay for all permits, taxes and fees as are required by the Georgian government to establish and/or operate a commercial venture locally. A contract with the U.S. Government conveys no special privileges or immunities to the Contractor. The Contractor is an independent commercial concern and not a part of the U.S. mission. The Contractor's employees are not U.S.

Government employees. Registration of this contract with the Georgian government, if required by law, will be the sole responsibility of the Contractor, and any fees, taxes, or other duties shall be payable by the Contractor without recourse to the Government of the amounts thereof.

H.6.2. Licenses and Local Laws. The Contractor shall possess all permits, licenses, and any other appointments required for the prosecution of work under this contract, all at no additional cost to the Government. The Contractor shall perform this contract in accordance with local laws.

H.7 ERRONEOUS PAYMENTS. If the Government becomes eligible for a refund of payment because of erroneous overpayment or other cause, the Contractor shall refund the amounts or use them to offset future payments owed by the Government, whichever the

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

H.8 REQUIRING ACTIVITY. The requiring activity under this contract is the U.S.

Embassy/Consulate.

SECTION I

CONTRACT CLAUSES

I.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

THE FOLLOWING FEDERAL ACQUISITION REGULATION CLAUSES ARE

52.202-1 DEFINITIONS (JUN 2020)

52.203-3 GRATUITIES (APR 1984)

52.203-5 COVENANT AGAINST CONTINGENT FEES (MAY 2014)

52.203-7 ANTI-KICKBACK PROCEDURES (JUN 2020)

52.203-8 CANCELLATION, RESCISSION, AND RECOVERY OF FUNDS FOR

ILLEGAL OR IMPROPER ACTIVITY (MAY 2014)

52.203-10 PRICE OR FEE ADJUSTMENT FOR ILLEGAL OR IMPROPER ACTIVITY

(MAY 2014)

52.203-12 LIMITATION ON PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS (JUN 2020)

52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS (JUN 2020)

52.203-17 CONTRACTOR EMPLOYEE WHISTLEBLOWER RIGHTS AND

REQUIREMENT TO INFORM EMPLOYEES OF WHISTLEBLOWER

RIGHTS (JUN 2020)

52.203-19 PROHIBITION ON REQUIRING CERTAIN INTERNAL CONFIDENTIALITY

AGREEMENTS OR STATEMENTS (JAN 2017)

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52.204-4 PRINTED OR COPIED DOUBLE-SIDED ON POSTCONSUMER FIBER

CONTENT PAPER (MAY 2011)

52.204-7 SYSTEM FOR AWARD MANAGEMENT (NOV 2024)

52.204-10 REPORTING EXECUTIVE COMPENSATION AND FIRST-TIER

SUBCONTRACT AWARDS (JUN 2020)

52.204-13 SYSTEM FOR AWARD MANAGEMENT MAINTENANCE (OCT 2018)

52.204-18 COMMERCIAL LAND GOVERNMENT ENTITY CODE MAINTENANCE

(AUG 2020)

52.204-19 INCORPORATION BY REFERENCE OF REPRESENTATIONS AND

CERTIFICATIONS (DEC 2014)

52.204-23 PROHIBITION ON CONTRACTING FOR HARDWARE, SOFTWARE, AND

SERVICES DEVELOPED OR PROVIDED BY KASPERSKY LAB AND

OTHER COVERED ENTITIES (JUL 2018)

52.204-25 PROHIBITION ON CONTRACTING FOR CERTAIN

TELECOMMUNICATION AND VIDEO SURVEILLANCE SERVICES OR

EQUIPMENT (NOV 2021)

52.204-27 PROHIBITION ON A BYTEDANCE COVERED APPLICATION (JUN 2023)

52.209-6 PROTECTING THE GOVERNMENT’S INTEREST WHEN

SUBCONTRACTING WITH CONTRACTORS DEBARRED, SUSPENDED,

OR PROPOSED FOR DEBARMENT (JUN 2020)

52.209-9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING

RESPONSIBILITY MATTERS (OCT 2018)

52.215-2 AUDIT AND RECORDS - NEGOTIATION (JUN 2020)

52.215-8 ORDER OF PRECEDENCE--UNIFORM CONTRACT FORMAT (OCT 1997)

52.215-11 PRICE REDUCTION FOR DEFECTIVE CERTIFIED COST OR PRICING

DATA – MODIFICATIONS (JUN 2020)

52.215-13 SUBCONTRACTOR CERTIFIED COST OR PRICING DATA -

MODIFICATIONS (JUN 2020)

52.215-21 REQUIREMENTS FOR COST OR PRICING DATA OR INFORMATION

OTHER THAN COST OR PRICING DATA--MODIFICATIONS (JUN 2020)

52.222-19 CHILD LABOR – COOPERATION WITH AUTHORITIES AND REMEDIES

(JAN 2020)

52.222-50 COMBATTING TRAFFICKING IN PERSONS (OCT 2020)

52.223-18 ENCOURAGING CONTRACTOR POLICIES TO BAN TEXT MESSAGING

WHILE DRIVING (JUN 2020)

52.224-1 PRIVACY ACT NOTIFICATION (APR 1984)

52.224-2 PRIVACY ACT (APR 1984)

52.224-3 PRIVACY TRAINING (JAN 2017)

52.225-5 TRADE AGREEMENTS (OCT 2019)

52.225-13 RESTRICTIONS ON…