Preproposal Conference - Answers to Posted Questions.docx

19KE5025R0001 LE Staff Health Insurance Questions submitted before the pre-proposal meeting.

The following answers are provided to the respective questions with reference to the solicitation amendment number A00001 dated May 19, 2025.

Estimated population Question 1.

A. We note that the population provided in section B (B.2.3, B.2.4, B.2.5, B.2.6, B.2.7, B.2.8 ) is not specific in terms of the estimated number of dependents to be covered. Kindly advise on the estimated number of dependents as the benefits are per covered individual.

Answer.

Section B of the solicitation 19KE5025R0001 shows the number of families (Employees) per the respective benefit categories. It is per benefit category/family size, not lives. For example: There are approximately 74 families that have a self/principal + 1 (spouse or child). There are approximately 500 families that have 3-6 individuals in them. This solicitation groups together different family sizes to pool risk.

Section J of the solicitation 19KE5025R0001 shows the projected demographics indicating the U.S. Government Employees and dependents by sex and age ranges.

Bidders may refer to Section J to understand the demographic data and then use that to price employee premiums, per respective benefit category/family size, in Section B.

Section C C.1. , specifies the respective annual maximum limits for each benefit category and the outpatient benefit limit per covered individual.

B. Please advise if we have a family of more than 9 individuals.

Answer.

Yes, the families included in the demographic data provided under section J with more than 9 individuals are listed as follows.

i. Embassy & Other Agencies:

- Three families with 10 individuals

- Two families with 9 individuals

ii. ORE (Riders): None

iii. Peace Corps (Riders) None

iv. 1998 Group: None

v. AEA : None

C. We note that the population in section B (pg 6-8) differs from the population in section J (Pg 47). Kindly clarify on the population data to use.

Answer.

Section B number of employees per benefit category does not include the riders stated under B.1.1. Also see section C.1.4 on eligibility for riders and participants covered as Riders per section C.1.5.3.

Question 2.

Exhibit F- Claims Estimate Paid Out for The past 5 years

Question 3.

Section K.4 (d)-Tax Payer Identification Number

Question 4.

C.1.1.10 & C.1.1.11 (Optical Care and Dental Care)

Question 5.

C.1.1.18 & C.1.1.20

Question 6.

Section K.5 52.204-8

(1) The NAICS Code for this acquisition is 524114 - Direct Health and Medical Insurance Carriers

(2) The Small business standard size is not applicable for this solicitation.

Question 7.

Is it possible to have the claims estimates - in Exhibit J - separated between the USG staff and the USAID staff?

Answer.

The data available is not itemized, and therefore it is not possible to split the claims estimates between the USG and USAID Staff.

Question 8.

Meaning of the term Reserved under the blank section D.

Answer.

The term ‘Reserved” in this case means Not Applicable.

Question 9.

Is the dental limit and the Orthodontia limit mutually exclusive?

Answer The dental and orthodontia limits are independent of each other.

Question 10.

Is wellness benefit to the full OP limit and what is the limiting measure to ensure abuse is not rampant?

Answer The Wellness benefits just like other medical benefits will be administered by the insurance company. The medical service provider should seek authorization from Insurance company subject to exclusions indicated under section C.1.3.

Question 11.

The Annual Maximum Limit mentioned under Section C of the solicitation is not very clear.

Section C.1 states:

Annual Maximum Limit - The maximum annual reimbursement per contract year will be:

i. Annual maximum limit for Self: = KES 4,500,000

ii. Annual maximum limit for Self +1: = KES 9,000,000

iii. Annual maximum limit for Family: = KES 15,000,000 Within the annual maximum limit, each covered individual will have outpatient services coverage up to KES 800,000 per year.

Section C.1.2 states:

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 Group Excess of Loss (C.1.1.16), is equivalent to the annual maximum limit per family category in C.1, including outpatient services coverage up to KES 800,000 per year per individual.

Based on the above statements, the Annual Maximum Limit is not clear with incorrect references to individual/member, categories in Section C.1 (Self, Self Plus One, Family), categories in Section B.2.2 (Self, Self Plus One, Family of 3 to 6 members, Family of 7 plus members). Please assign either the Annual Maximum Limit per member (preferred in this case in order to be consistent with the Excess of Loss Coverage) OR Annual Maximum Limit per category, but not both.

Answer The USG requirement as stated under section C is a follows;

Annual maximum limit for Self: = KES 4,500,000: Outpatient benefit is included in this annual maximum limit but capped at KES 800,000 per individual.

Annual maximum limit for Self +1: = KES 9,000,000: Outpatient benefit is included in this annual maximum limit but capped at KES 800,000 per individual.

Annual maximum limit for Family: = KES 15,000,000: Outpatient benefit is included in this annual maximum limit but capped at KES 800,000 per individual.

Question 12.

Please clarify inconsistencies in Section C.1.1.16 (Group Excess of Loss (XOL)), which references both individual limit and family limit. Typically, Excess of Loss Coverage based on an individual limit should be consistent with an Annual Maximum Limit per individual/member.

Answer UPDATED per amendment: Per clause C.1.1.16 Group Excess of Loss maximum coverage is based on individual limit of KES 3,500,000. Claims from the entire membership shall not exceed KES 40,000,000 per year.

Question 13.

Please clarify in section C.1.1.16 Group Excess of Loss (XOL), if the limit applies to all conditions or only specific cases.

Answer The XOL limit applies to coverage from claims arising from all hospitalization costs subject to a maximum limit of KES 3,500,000 per individual per contract year and exclusions and limitations under C.1.3.

Question 14.

Please clarify inconsistencies in Section C.1.1.16 (Group Excess of Loss (XOL)), whether utilization of this benefit requires the discretion of an authorized party, especially after the Primary cover is depleted, in light of the Group Limit and the Non-Exceeding clause.

Answer The normal pre-authorization procedures will apply. Insurance to monitor the bills before tapping into the XOL limit. Notify the U.S. Government and employee before all medical benefits limits would be exhausted.

Question 15 Under section L.4.3. Part 3, Experience and Past Performance: item number 7, which states regarding IRA complaints, please Clarify whether these should be reported at the company level or under the health division.

All complaints shall be reported per industry practice and guidance provided by the Industry Regulatory Authority.

Question 16 Kindly confirm if the insurer will be responsible for paying Net SHA (i.e. the claim amount less the benefits provided by Kenyan health Insurance).

Answer All Embassy Employees are registered in SHA and will be subject to compliance with SHA regulations.

Question 17 Please confirm HIV/AIDS benefits under C.1.1.15 is included within the annual maximum limit per member in section C.1.2 Answer Section C.1.1.15 of the solicitation states, “HIV/AIDS: 100% -part of annual maximum cover limit.”

Question 18 We also write to seek for further clarification on the number employee's spouses, Employee's dependent child per the below categories (B: Self Plus One, C: Family (3 to 6 individuals, D: Family (7 or more individuals) from page 6 of the tender document which will enable us complete the Bi-weekly premium per single employee and per family plan form on page 10 of the tender document as extracted below.

TOTAL

See solicitation 19KE5025R002 amendment.

Question 19 Will the pricing include the staff categories below from page 48 - 52 of the tender document?

1. Exhibit B: ORE Employees

2. Exhibit C: American Employee Association (AEA)

3. Exhibit D: Embassy Bombing Victims and Victims Family Members

4. Exhibit E: U.S Peace Corps Contractors and Dependents.

Per section B of the solicitation, the pricing table will not include calculations for any riders as stated under B.1.1. However, the said riders will be billed premiums as stated under section B.2. Billing procedures for the riders are as stated under C.1.5.3.