QUESTIONS AND ANSWERS_19RP3826Q0042.pdf

QUESTIONS AND ANSWERS

RFQ NO. 19RP3826Q0042

GROUP LESHEALTH INSURANCE UNDER GMC

The answers provided in response to the questions submitted, are provided for informational purposes and under no circumstances shall it be construed to change any terms or conditions or requirements within the solicitation. Only a formal solicitation amendment, issued by the Contracting Officer, can change the solicitation's terms or conditions or requirements.

In addition, for any answer provided regarding claims data incurred under the existing contract, please be advised that this data may not be indicative of future claims. Therefore, it is each offeror’s decision on whether to use or not to use this information.

However, under no circumstances shall the U.S. Government be liable for this data or shall it become the basis for a request to adjust the premium rates once the contract is awarded. Rather, offerors are advised that any adjustments to contract premium rates shall be in accordance with 4.0 ECONOMIC PRICE

ADJUSTMENT-HEALTH INSURANCE PREMIUMS.

Q1: We are performing independent research on the Presolicitation

(19RP3826Q0042). We would like to know if this is a brand new contract OR if there is (was) an incumbent performing these services. If not brand new, could you please provide the current / previous contract number?

A1: Philhealthcare, Inc. – 19RP3821D0014

Q2: May a U.S. corporation that is not itself a licensed insurer/HMO submit as prime if a duly licensed Philippine insurer/HMO will perform and administer all coverage?

A2: Refer to Section 2, DOSAR 652.242-73 AUTHORIZATION AND PERFORMANCE (AUG 1999) on page 54 and Section 3, Part 4 Licensing Information on page 59 and Section 4 - EVALUATION FACTORS on pages 64-65 of the solicitation.

Q3: Must the Section 3 Part 4 licensing/accreditation proof be in the offeror’s own name, or may it be provided in the name of the performing subcontractor/underwriter?

A3: See A2

Q4: When Section 4 refers to the “offeror” being an authorized insurance company permitted to write and administer health insurance policies in the Philippines, is that a strict eligibility requirement for the prime contractor?

A4: See A2

Q5: I would like to request whether an employee census report is available, including a breakdown of employees and dependents.

A5: Refer to EXHIBIT A – EMPLOYEE STATISTICS on pages 28 -29, EXHIBIT

B ORE EMPLOYEES RIDER on page 30 and EXHIBIT C PEACE CORPS PSC EMPLOYEES RIDER on page 31 of the solicitation.

Q6: (1) Upon review of the solicitation packages, we would like to request the following information to proceed with the preparation of your proposal:

(a) Dates of birth of all enrolees, Age, including dependents

(b) Preferred maximum benefit limit

(c) Preferred room and board accommodation

(2) In addition, kindly provide the following documents from your current health provider:

(a) Detailed utilization report

(b) Schedule of benefits

A6: (1) (a) Refer to EXHIBIT A – EMPLOYEE STATISTICS on pages 28-29

(b) Refer to 1.2 ANNUAL MAXIMUM LIMIT on page 12 of the solicitation.

(c) Refer to 1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care): Minimum Coverage - 100% on page 9 of the solicitation.

(2) (a) A detailed utilization report is not available.

(b) Refer to 1.0 HEALTH INSURANCE SERVICES pages 9-14 of the solicitation for the schedule of benefits.

Q7: I reviewed the solicitation package in detail; however, I was unable to locate a complete employee census with the level of detail typically required for underwriting (e.g., age, gender, salary breakdown, or dependent structure, country of origin).

If there is a specific section or attachment within the solicitation that contains this information, please kindly point me to it.

Otherwise, we are prepared to proceed with a preliminary quote based on the available employee count and general assumptions, with the understanding that rates may be adjusted upon receipt of a full census.

I have attached a census from one of the solicitations on Sam.gov

A7: See A5

Q8: I would like to inquire about your current HMO provider and the end date of your existing coverage, as this will help us better align our proposal with your requirements.

A8: See A1. The Fourth Option Year end date is December 31, 2026

Q9: Will you be providing a master list of employees and dependents, including birthdates and ages?

A9: Yes, a list of employees and dependents with birth dates and ages will be provided once the contract is awarded.

Q10: Will you be able to share a detailed utilization report from your current

HMO?

A10: Refer to A6 (2)(a)

Q11: Will you be providing us with the Schedule of Benefits from your current

HMO provider?

A11: Refer to A6 (2)(b)

Q12: What will be the inception date of the coverage?

A12: The performance period is anticipated to start on January 1, 2027.

Q13: Will dependents have the same Annual Benefit Limit (ABL 1,268,000 PHP) as employees?

A13: See A6 (1)(b) and refer to 1.4 ELIGIBLE PARTICIPANTS on page 13 of the solicitation.

Q14: Will dependents also be entitled to dental benefits or same benefits as

Principal?

A14: Refer to 1.1.11 DENTAL CARE on page 11 and 1.4 ELIGIBLE

PARTICIPANTS on page 13 of the solicitation.

Q15: Part of the Requirements for Embassies:

A15: Only the VAT exemption certificate was provided in previous contracts.

Q16: Under Section 1.1.4:

(1) Specifics on APE coverage?

(2) Can we request for existing benefits TOR?

A16: (1) APE coverage will be based on offeror’s proposal.

(2) No. The Terms of Reference (TOR) for existing benefits are not available as part of this solicitation. Each offeror must carefully review the benefits and requirements specified in this solicitation document and develop their proposed firm fixed-price premiums accordingly, independent of any current contract arrangements.

Q17: Under Section 1.1.13, Since we don't have accredited Psychologist, is client willing to do reimbursement for this. And as part of due diligence one of the requirements for claim is detailed statement of the cost?

A17: Requirements for reimbursement claims, if outright coverage is not possible or available, will be based on the offeror’s proposal.

Q18: Under Section 1.1.21 Excess Coverage ABL:

(1) Is Excess ABL Coverage applicable to Principal Member (LE Staff) only or for dependents as well as long as its paid by (LE Staff)?

(2) To prevent anti-selection of members opting for this when they are in urgent need of extra coverage. It should be enrolled outright with initial coverage is this doable?

(3) Can you share your current process in implementing this coverage?

A18: (1) The Excess Coverage option is available for any covered individual in accordance with 1.4 ELIGIBLE PARTICIPANTS on page 13 of the solicitation.

(2) Beginning of the coverage period will be based on the vendor’s proposal.

(3) Principal member notifies the COR and vendor regarding their intent to election of Excess Coverage. Payment is made by the member in accordance with the vendor’s requirements prior to the beginning of the coverage period.

Q19: Under Exhibit D Historical Claims and Premiums, yearly claims from

PY2021 to PY2025, Coverage is from Jan 1 to Dec 31; IBNR not included for PY2025, Annual premiums from PY2021 to PY2025, Amount provided both in PHP and USD:

(1) Run date for PY2025?

(2) Based on the total claims paid and retention amounts, these are total expenses vs the premiums. Does it mean that the account’s loss ratio is more than 100% YoY? Does the Insurance Premium Illustration include the retention amount?

A19: (1) March 9, 2026. Also, refer to Amendment 001

(2) Refer to EXHIBIT D CLAIMS, RETENTION AMOUNTS AND

PREMIUMS FOR THE PAST 5 YEARS on page 32 of the solicitation and Amendment 001.

Q20: Under FAR 52.217- 9, Extension of services and contract may extend for maximum of 5 years. Is this after 5 years and 6 month you can extend another 4.5 or 5 years after that? Kindly confirm

A20: No, it refers to the option years and 6 months option to extend, if exercised by the Government. Refer to Section 1, Subsections 2.3-2.9 on pages 3-6 and Section 2, FAR 52.217-8 and FAR 52.217-9 on page 46 of the solicitation.

Q21: Under 1.1.2, Emergency Services - If done in non-accredited provider which is subject for reimbursement. Reimbursement claim processing disbursement should be based on HMO rates or Actual cost?

A21: Actual cost for non-affiliated providers.

Q22: Customer Care Officer Onsite - Do we need to include putting a JCCO Staff in US Embassy site? 1 per each site. We believe you have 2 sites in Roxas Blvd.

A22: Not required for this solicitation.

Q23: Effective date - Please confirm if the Start Date for this is January 1, 2027.

A23: See A12

Q24: Under Section 2.11, Payment in Local Currency - Is the rate application for the date receipt of payment. Fix rate / variable rate conversion?

A24: Refer to 4.3 Payment on page 21 and FAR 52.232-1 PAYMENTS (APR

1984) on page 43 of the solicitation.

Q25: Under Section 4.4.2, Submission of Invoice Payment –

(1) What current acceptable process with your current HMO provider?

(2) Question billing department will be done for one annual billing initially then for additions, billing will be bi-weekly?

A25: (1) Refer to 4.4.1 on page 21 of the solicitation.

(2) Refer to 4.4.2 Frequency of Payments on page 21 of the solicitation.

Q26: Under Section 6.3, Ordering Procedures - What current acceptable process with your current HMO provider?

A26: Refer to 6.3 ORDERING PROCEDURES on pages 22-23 of the solicitation.

Q27: Under Section 1.1.11, Dental Care

(1) Orthodontia: Clarification on the lifetime limit. When is the onset of utilization?

(2) Question from Claims: Will the bidder be provided of the utilization history of those who availed the benefit?

A27: (1) The treatment start date indicated on the dental treatment records.

(2) Yes, Orthodontia utilization history shall be provided to the winning bidder after contract award for the continuity of ongoing treatments.

Q28: Under Section 5.0, Refunds to the Government - Refunds to the company follow a certain protocol to determine if such members availed or not with the HMO services. If there is availment we don't allow any refund to the premium. What is current process being used by your HMO provider to accommodate this?

A28: The overpayment is credited to the Government on the next billing period.

Q29: Under Part 3, Experience and Past Performance, Items 1-5:

(1) For numbers 1,2,4,5, Is there any way to waive this requirement? We are bound by confidentiality clause in our contracts, and we cannot disclose company names without their explicit consent. [Company Name Redacted] has been in the HMO business for almost 40 years, with more than 1 million ++ customers and growing, and with xx% of total market share based on 2025 Insurance Commission data.

(2) For no 3. We refer to them to this Performance of the HMO Industry as of 31 December 2025 | Insurance Commission

A29: Refer to Section 3, Subsection 1.0 SUBMISSION OF OFFERS on page 56 of the solicitation. Any deviation, exceptions, or conditional assumptions taken with respect to any of the instructions or requirements of this solicitation shall be identified and explained/justified in the appropriate volume of the offer.

Q30: Under Section 1.1.1, Room and board - Semi Private:

(1) If the client opts for a higher room client should shoulder all excess and incremental cost?

(2) Applies to all In-patient availment?

(3) Embassy has access to all Major hospitals inclusive SLMC - BGC?

A30: (1) Refer to 1.1.1 Hospitalization (Treatment in the Hospital for Inpatient

Care): Minimum Coverage - 100%.

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.

(2) Yes

(3) Yes

Q31: Under Section 2.2, What does fixed price with economic price adjustment?

A31: The contract has a fixed price at award in accordance with the prices provided under Section 1, Subsections 2.3-2.9 on pages 3-6, but includes clauses that allow the price to be adjusted in accordance with Subsection 4.0

ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

on pages 7-8 of the solicitation.

Q32: Under Section 4.0 Economic Price Adjustment, we got your notes in the

MOM. Can you explain details further?

A32: See A31 and the Minutes from the Pre-Quotation Conference.

Q33: Request for company health profile with the following details:

(1) Complete name of the company (DTI/SEC-Registered Name/Overseas)

(2) Business TIN

(3) Affiliates (Included in the Request)

(4) Nature of the business

(5) Complete company address

(6) Head Office Address

(7) Business Type (Private/Government)

(8) Contact Person / Designation / Email address / Contact number

(9) Proposal Addressee and Designation / Contact number

(10) Existing HMO

(11) Expiry Date (if with Existing HMO)

(12) Total number of employees

a. Principal

b. Dependents

(13) For Individual/Family account, please provide the following:

a. Complete Name

b. Birthdate

c. Address

d. Contact number

A33: (1) Embassy of the United States of America

(2) TIN to be provided after contract award

(3) Refer to 1.4.2 Location of Employment on page 14 and 1.4.3 Participants

Covered Under a Rider on page 15 of the solicitation.

(4) Diplomatic Mission

(5) 1201 Roxas Boulevard, Manila, Philippines 1000

(6) Refer to (5) above.

(7) Private

(8) Refer to SF-1449 cover sheet. Also, see Section 4.1, 652.242-70

Contracting Officer's Representative (COR), on pages 20-21 of the solicitation. The COR's contact information will be provided after contract award. During the solicitation and award phase, all correspondence must be sent to: ManilaContracting@state.gov.

(9) Refer to SF-1449 cover sheet and Section 3 of the solicitation.

(10) See A1

(11) See A8

(12) See A5

(13) See A9

Q34: Can the Government provide complete historical claims data including

IBNR (incurred but not reported), as current data excludes IBNR?

A34: Refer to A19 (2)

Q35: Can the Government provide details of large claims (“shock claims”), specifically claims exceeding ₱500,000 and ₱1,000,000, for the past five (5) years?

A35: No. All claims, including large claims are included in EXHIBIT D CLAIMS, RETENTION AMOUNTS AND PREMIUMS FOR THE PAST 5 YEARS on page 32 of the solicitation.

Q36: Can the Government provide a diagnosis/procedure breakdown identifying the top 20 cost drivers over the past five (5) years?

A36: See A35

Q37: What target loss ratio, if any, does the Government expect under this contract?

A37: Not specified on this solicitation. It is the offeror's responsibility to determine an appropriate loss ratio based on the solicitation requirements and actuarial principles.

mailto:ManilaContracting@state.gov

Q38: Are there any known ongoing high-cost treatments or chronic conditions (e.g., dialysis, oncology, HIV/AIDS, specialty pharmaceuticals) within the covered population?

A38: See A35

Q39: Please confirm that the retention amount is required to be a fixed currency value, rather than a percentage of premium.

A39: Refer to Section 1, Subsection 3.0 ADMINISTRATIVE RETENTION

AMOUNTS on pages 6-7 of the solicitation.

Q40: What cost components must be included within the retention amount (e.g., administration, TPA services, broker fees, reserves, profit margin)?

A40: See A39

Q41: Is the retention amount subject to reconciliation based on actual utilization, or is it fixed regardless of claims experience?

A41: See A39

Q42: Does the Government allow tiered retention structures based on population segments or claims experience?

A42: See A39

Q43: Is there a minimum guaranteed retention floor required?

A44: See A39

Q45: Is stop-loss/reinsurance coverage required or optional under this contract?

A45: Not required for this solicitation.

Q46: If required, what is the attachment point (per member and/or aggregate)?

A46: Not required for this solicitation.

Q47: Is the cost of pooling/reinsurance included within the premium or priced separately?

A47: All costs associated with providing the health insurance services must be incorporated into the bi-weekly premium rates proposed in Section 1, Paragraph 2.0 PRICING. Also, refer to Section 4 – Evaluation Factors on page 64 of the solicitation. Separate charges in any form are not solicited. The Government shall not be obligated to pay any charges other than the contract price, including any exercised options.

Q48: Will the Government accept multi-employer or pooled risk arrangements?

A48: Refer to 4.2.1 Employee Pool on page 8, Section 3 2.3.1 Part 2

Understanding of the Requirement on page 58 and 2.3.3 Employee Pool on page 59 of the solicitation.

Q49: Are catastrophic claims reimbursable outside of the stated annual maximum benefit, or must all claims remain within the cap?

A49: Refer to 1.2 ANNUAL MAXIMUM LIMIT on page 12 of the solicitation.

Q50: The solicitation estimates approximately 3,300 covered lives. Can the

Government provide the expected monthly fluctuation rate in enrollment?

A50: No. Hiring of personnel is based on the needs of the Mission and the U.S.

Government.

Q51: Are there any anticipated seasonal hiring patterns (e.g., Peace Corps or program cycles)?

A51: Hiring of personnel is based on the needs of Peace Corps, the Mission and the U.S. Government.

Q52: Are there any minimum enrollment guarantees?

A52: Refer to MINIMUM AND MAXIMUM AMOUNTS on page 6 of the

Q53: Are retroactive enrollments or terminations permitted?

A53: No, unless there are extenuating circumstances, i.e. justifiable delays in the enrollment of newborns or notification of death of member.

Q54: How are late enrollees and mid-period dependent additions handled for premium and coverage purposes?

A54: Premiums and coverage period starts on the date of enrollment, the hire date for newly hired employees or in the case of newborns, on the date of birth.

Q55: Please confirm the relationship between bi-weekly premium payments and claims reimbursement timing.

A55: Refer to 4.4.2 Frequency of Payments on page 21 and 6.4 (b) Medical

Insurance Claims (3) on page 24 of the solicitation and Amendment 001.

Q56: What is the average payment cycle/lag from invoice submission to payment?

A56: 2 to 3 weeks, depending on when the billing statement was received.

Q57: Are payments structured as advance (capitated) payments or arrears

(reimbursement-based)?

A57: It is not clear which payments are being referred to.

If it refers to payments for coverable medical services, local practice is for affiliated or in-network facilities to accept letters of authorization (LOA) from the insurer. For non-affiliated or out of network providers, reimbursement based.

Q58: For optional riders (e.g., excess coverage), please confirm who is responsible for premium collection and remittance.

A58: Refer to Section 1, Subsection 1.2 on page 3, 1.1.21 Excess Coverage on page 12, 1.4.3 Participants Covered Under a Rider on page 15 and 4.4.4 Riders: on pages 20-21 of the solicitation.

Q59: Are there any mandatory hospitals, clinics, or providers that must be included in the network?

A59: No

Q60: Is there a required geographic coverage scope (e.g., nationwide vs. Manila-centric)?

A60: No

Q61: Are out-of-network reimbursements required, and if so, at what levels?

A61: Refer to Section 1, Subsection 1.0 PERFORMANCE WORK STATEMENT on page 2 and 1.0 HEALTH INSURANCE SERVICES on pages 9-14 of the

Q62: Please confirm whether direct billing arrangements are required across all facilities.

A62: See A61

Q63: Please confirm the required claims processing turnaround time (currently stated as within two (2) weeks).

A63: Refer to 6.4 CONTRACTOR RESPONSIBILITY IN CLAIMS AND

REIMBURSEMENT TO CLAIMANTS on pages 23-34 of the solicitation and Amendment 001.

Q64: Is there a required ratio or expectation for direct billing vs. reimbursement claims?

A64: No.

Q65: Are fully digital claims submission and processing workflows acceptable, or are paper-based processes required?

A65: Fully digital claims submission and processing workflows are acceptable.

Q66: Please confirm the required reporting granularity and frequency, including any standardized reporting templates.

A66: Refer to 6.5 REPORT REQUIREMENTS on page 24 of the solicitation.