Questions_and_Answers.docx

Date: March 22, 2019 RE: Solicitation Number : 19MP101—R-0001 Health Insurance Services

Questions:

1. Claims Activity in Prior Periods – See below chart

OF MEMBERS PER

PERIOD

2. Catastrophic cases presented last year?

Is not covered under current contract

3. Does this solicitation number 119MP1019-R-0001 contain the same requirements as the current contract? If no what are the differences

No. DESCRIPTION/SPECIFICATION/WORK STATEMENT for differences (last 4 pages)

4. Have there been any claims more than $10,000 within the last year? If yes, please indicate the number and amounts of such claims? See below chart

Claims more than $ 10,000 within the last year

5. Are there dependent children to be covered who are studying outside the country? If yes, please provide the country and number of dependent children studying there.

Yes

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

CONTRACT NO. SMP10014-D-0001 (Period 2014-2019)

The Government of the United States of America requires Health Insurance coverage for its employees as further described below in Port Louis, Mauritius. The Government has determined that the prevailing practice by employers in Port Louis, Mauritius is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by both the employee and the employer. For eligible employees who are regularly scheduled to work 30 or more hours per week: The USG will pay 75% and the employee pay 25% of the premium cost for both employee and dependent coverage. For eligible employees who are regularly scheduled to work less than 30 hours per week: The USG will pay a prorated share of the premium cost for employee, based on the number of hours the employee is regularly scheduled to work. Health insurance protection will be representative of locally prevailing compensation practice. The specific health benefit coverage under this contract is set forth in Section C.

The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care.

C.1.1 Employee and Dependent Health Services Benefits

C.1.1.1. Hospitalization: 100% reimbursement of room and board for a ward room or semi-private room. 80% reimbursement of room and board for a private room, not to exceed 100% of the cost of a semi-private room. 100% reimbursement of hospital medical expenses including laboratory tests and x-rays, nursing care, operating room costs, intensive care, prescription medicines, and physical therapy. 100% reimbursement of ambulance service.

C.1.1.2 Professional services and treatment: 80% reimbursement of doctors’ and surgeons’ fees incurred while hospitalized, at a hospital on an out-patient basis, at a clinic or doctor’s office, or at home. 80% reimbursement for medical services and expenses when not hospitalized such as laboratory tests and x-rays, prescription medicines, physical therapy, routine annual physical examination, and inoculations.

C.1.1.3. Prescription drugs and medicines: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required. Expenses incurred for medicines, vitamins, cold remedies, etc., that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician.

C.1.1.4 For employees only: 100% reimbursement for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS. For employee and spouse: 100% reimbursement for brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee’s child. This expanded coverage generally excludes medications for the long-term suppression of aids through the combination of anti-retroviral drugs at those posts with inadequate local healthcare infrastructures.

The maximum limit for expense reimbursed under Section C.1.1.4 is Rs. 300,000 per patient per contract year.

C.1.1.5 Obstetrical care: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of obstetrical medical care including prenatal and postnatal care.

C.1.1.6 Family planning: 80% reimbursement of prescribed contraceptive devices and drugs, voluntary sterilization, and diagnosis and treatment of infertility. Not covered is reversal of voluntary sterilization, infertility treatment after voluntary sterilization, genetic counseling, fertility drugs, and assisted reproductive technology.

C.1.1.7 Hearing aids: 80% reimbursement of the cost of a hearing aid apparatus and related examination. Limited to one apparatus per year per patient in a three-year period.

C.1.1.8 Optical care: 50% reimbursement for eye examination and treatment and prescription eyeglass or contact lenses. Limited to two lenses per patient every two years. No reimbursement for eyeglass frames, nonprescription lenses, or tinting.

C.1.1.9 Dental care: 50% of expenses for dental services including dentists’ fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, and bridges. Orthodontia treatment is covered only if treatment begins before age 15, unless required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per patient.

C.1.1.10 Psychiatric treatment: 50% reimbursement.

C.1.1.11 Medical expenses incurred out of country

Medical expenses incurred out of country will be covered for employees and dependents when (a) a life threatening condition occurs when the individual is out of the country and treatment is medically necessary before the individual returns home or (b) the individual’s attending physician certifies in advance that such treatment is medically necessary and unavailable locally. Reimbursement will be made at the same percentage rate and subject to the same annual maximum limit as for expenses incurred in country.

C.1.1.12 Transportation for Out of Country Treatment

Transportation for out of country treatment is a covered expense for employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally.

80% of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be reimbursed.

80% of the transportation expenses of an attendant will be reimbursed if the patient’s attending physician 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 unconscious.

All reimbursements for transportation expenses are subject to the annual maximum limit.

C.1.1.13 Annual Maximum Limit - The maximum annual reimbursement per patient per contract year, not including expenses covered under C.1.1.4, is Rs. 600,000 per patient per contract year.

C.1.2 Health Benefits Conditions and Limitations.

No reimbursement will be made for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long term rehabilitative therapy; eyeglass frames; non-medical hospital charges such as telephones or television; home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

No reimbursement will be made for expenses that will be reimbursed or paid directly under a host country medical program, the U.S. workers’ compensation program; or any host government workers’ compensation program.

No reimbursement will be made for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self-inflicted wound; or service in the armed forces of any country.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - The employees eligible for the health insurance services include the following:

C.1.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of MAURITIUS paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include

C.1.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts (PSCs);

C.1.3.2 Location of Employment

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Mauritius by:

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1 All costs for retirees of US Embassy Port Louis are the responsibility of the retiree, not the U.S. Government.

C.1.4 Individuals Not Eligible for Coverage

Individuals not eligible for coverage under this contract are non-personal services contract personnel; employees working on a temporary basis; employees with an intermittent, seasonal, or WAE (when actually employed) schedule; and any other individual not falling within one of the categories of employees described in this clause.

C.1.5. Other Eligible Participants

Covered dependents include the participating employee’s spouse and children. A limit of one spouse per employee is covered. An eligible child is defined as the employee’s natural child, adopted child, stepchild, or foster child. The child must be unmarried, economically dependent upon the employee, and reside with the employee unless away at school. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 23 if a full time student. There is no age limit for a child who is physically or mentally handicapped so as to be unable to live independently. There is no limit on the number of children covered per employee.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee 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.

During a period of Leave Without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.