5 - 2026-SOLICITATION_LOME_GMC HEALTH INSURANCE -ALL DOCS - UNLOCKED.pdf

Embassy of the United States of America

RFP 19T04026R00001 Page 1 of 3

Lome

January 26, 2025

Dear Prospective Offeror:

Subject: Request for Proposals number 19T04026R00001

GMC-LE Staff Health Insurance Service Provision

The Embassy of the United States of America invites you to submit a proposal for locally employed staff health and/or life 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 Thursday February 12th, 2026 at 3.00 pm (local time) at the US Embassy Lome. Prospective offerors should contact the Embassy via the email address LOME-GSO-PROC-DL@STATE.GOV or via phone number +

228 22 61 54 70 ext 4509 by Monday February 9th, 2025 by 3.00 pm for additional information or to arrange entry to the building.

Proposals are due by Thursday March 12, 2026 by 4.00 pm local time. No proposals will be accepted after this time. Proposals must be in English and incomplete proposals will not be accepted.

mailto:LOME-GSO-PROC-DL@STATE.GOV

RFP 19T04026R00001 Page 2 of 3

Your proposal may be submitted in a sealed envelope marked:

"Proposal Enclosed for 19T04026R00001 - General Services Office” to

LOME CONTRACTING OFFICER

EMBASSY OF THE UNITED STATES

4332 BLVD EYADEMA – CITE OUA

LOME TOGO

Your proposal must be submitted electronically to LOME-GSO-PROC-

DL@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. The Offeror should submit a completed IRS Form W-14, found at www.irs.gov/w14, to ensure compliance with FAR 52.229-11;”]

7. 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 http://www.irs.gov/w14 https://www.sam.gov/

RFP 19T04026R00001 Page 3 of 3 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, Hilary C. Dewhurst

Acting Contracting Officer

Enclosure:

Solicitation for the LE Staff Health Insurance Services Provision

SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING PAGE OF PAGES

1 | 147

2. CONTRACT (Proc. Inst. Ident.) NO.

3. SOLICITATION NO.

19T04026R0001

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[X] NEGOTIATED (RFP)

5. DATE ISSUED

January 26th, 2025

6. REQUISITION/PURCHASE NO.

PR15128714

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

General Services Office – US Embassy Lome

4332, Blvd Eyadema, BP 852 Lome Togo

Phone: 228 22 61 54 70 –

Fax: 228 22 61 5503/228 22 61 5504

Attn: Contracting Officer

General Services Office

US Embassy Lome

4332, Blvd Eyadema, BP 852 Lome Togo

NOTE: In sealed bid solicitation "offer" and "offeror” mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and 3 copies for furnishing the supplies or services in the Schedule will be received at the place specified, in the depository located in see block 7 until

Thursday March 12, 2025, Universal Time 3.00 pm (date) (hour) CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L. Provision No. 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR

INFORMATION

CALL-→

A. NAME

Hilary C. Dewhurst, A/Contracting Officer

B. TELEPHONE (NO COLLECT CALLS)

AREA CODE NUMBER EXT

228 22 61 5470 - 4558

C. E-MAIL ADDRESS

lome-gso-proc-dl@state.gov

11. TABLE OF CONTENTS

(x) SEC. DESCRIPTION PAGE(S) (x) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

X A SOLICITATION/CONTRACT FORM 1 X I CONTRACT CLAUSES 32

X B SUPPLIES OR SERVICE AND PRICES/COSTS 2 X PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

X C DESCRIPTION/SPECS/WORK STATEMENT 10 X J LIST OF ATTACHMENTS 77

X D PACKAGING AND MARKETING 19 X PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE 20 X K REPRESENTATIONS, CERTIFICATIONS, AND 84

X F DELIVERIES OR PERFORMANCE 23 X OTHER STATEMENTS OF OFFERORS

X G CONTRACT ADMINISTRATION 25 X L INSTRS., COND., AND NOTICES TO OFFERORS 135

X H SPECIAL CONTRACT REQUIREMENTS 28 X M EVALUATION FACTORS FOR AWARD 144

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 calendar days (120 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 price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT SEE 14

(See section I, Clause No 52.232-8)

10 CALENDAR DAYS

20 CALENDAR DAYS

30 CALENDAR DAYS

CALENDAR DAYS

14. ACKNOWLEDGMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

(The offeror acknowledges receipt of amendments to the solicitation and related documents) numbered and dated:

15A. NAME CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED

AND

ADDRESS

OF

OFFEROR

TO SIGN OFFER (Type or print)

15B. TELEPHONE NO. (Include area code)

15C. CHECK IF REMITTANCE ADDRESS IS

DIFFERENT FROM ABOVE - ENTER SUCH ADDRESS

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

10 U.S.C. 2304(c)( ) 41 U.S.C. 253(c)( )

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTRATION BY (If other than Item 7) CODE 25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

Hilary C. Dewhurst

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

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

NSN 7540-01-152-8064 STANDARD FORM 33 (REV 9-97)

PREVIOUS EDITION NOT USABLE Prescribed by GSA https://ilmsariba.state.sbu/Buyer/Main/aw?awh=r&awssk=uzfy&dard=1

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 Lomé, Togo and their eligible dependents as described in Section C. This insurance shall be provided in accordance with Section C.

B.1.1. Riders: Official Residence Expense (ORE) Staff and Peace Corps 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 Peace Corps

Director for Peace Corps employees at the rates specified below.

See Section G for billing procedures. Note that USG is not responsible, nor liable, for any riders.

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

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. Premium:

Premiums will be based on the number of individuals covered:

-- Self-Only: 1 covered individual

-- Self Plus One (two individuals)

-- Family (three or more individuals)

B.2.3. Type of Contract

This is a fixed price with economic price adjustment requirements type contract under which firm, fixed-price task orders will be issued.

The prices are stated in currency (offerors to fill in currency).

The fixed prices/premium rates for the health insurance services as specified in Section

C are as follows:

B.2.4. Base Year of Contract

Category

Monthly Rates Per Premium

Estimated

Number of

Premiums*

Rate per

Premium

Extended

Monthly

Total

a. Self (Employee only) 14

b. Self Plus One (Employee + One dependent)

c. Family: (3 or more individual) 114

d. Subtotal

Total Price for the Base Year (d x 12)**

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

**does not include any premiums for Riders.

Rider Category*** Monthly Rate per

Premium

-ORE Staff

Peace Corps Employees

***not included in the Total Price for Base Year Calculation

B.2.5. First Option Year of Contract

Monthly Rates Per Premium

Category

Estimated

Number of

Premiums*

Rate per

Premium

Extended

Monthly

Total

a. Self (Employee) 14

b. Self Plus One (Employee + One dependent)

c. Family: (3 or more individual) 114

d. Subtotal

Total Price for the First Option Year (d x 12)**

Rider Category*** Monthly Rate per

Premium

ORE Staff

***not included in the Total Price for the First Option Year Calculation

B.2.6. Second Option Year of Contract

Estimated

Number of

Premiums*

Rate per

Premium

Extended

Monthly

Total

a. Self (Employee) 14

b. Self Plus One (Employee + One dependent)

c. Family: (3 or more individual) 114

d. Subtotal

Total Price for the Second Option Year (d x 12)**

Rider Category*** Monthly Rate per Premium

ORE Staff

***not included in the Total Price for the Second Option Year Calculation

B.2.7. Third Option Year of Contract

Estimated

Number of

Premiums*

Rate per

Premium

Extended

Monthly

Total

a. Self (Employee) 14

b. Self Plus One (Employee + One dependent)

c. Family: (3 or more individual) 114

d. Subtotal

Total Price for the Third Option Year (d x 12)**

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

Rider Category*** Monthly Rate per

Premium

ORE Staff

***not included in the Total Price for Third Option Year Calculation

B.2.8. Fourth Option Year of Contract

Estimated

Number of

Premiums*

Rate per

Premium

Extended

Monthly

Total

a. Self (Employee) 14

b. Self Plus One (Employee + One dependent)

c. Family: (3 or more individual) 114

d. Subtotal

Total Price for the Fourth Option Year (d x 12)**

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

Rider Category*** Monthly Rate per Premium

ORE Staff

***not included in the Total Price for the Fourth Option Year Calculation

B.2.9. 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

B.2.10. 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 Seventy-five (75) annual premiums. 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 one thousand (1,000) annual premiums. 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.

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

NOTE TO OFFEROR: Fill in the fixed monthly retention amounts for each period of performance and for each category of premium. This fixed amount must 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.

Period of

Performance

Employee

XOF (FCFA)

Employee + One

XOF (FCFA

Employee + 3 and more XOF (FCFA

Base Period

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.4.3. 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): 100%

Minimum Coverage

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 Outpatient Services (below) for details concerning professional services.

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

Coverage

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

C.1.1.3. Ambulance: 80% Minimum Coverage

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: 80% Minimum Coverage

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: 100% Minimum Coverage for Inpatient/

Emergency: 100%; 80% Minimum Coverage for Outpatient:

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: 100 % Minimum Coverage for Inpatient/Emergency;

80% minimum coverage for Outpatient

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: 100% Minimum Coverage for-Inpatient/

Emergency; 80% minimum coverage for Outpatient

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:

80 % Minimum Coverage

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: 80% Minimum Coverage

Examinations and Treatment: 80% Minimum Coverage. Hearing Aid Apparatus:

Limited to one apparatus per ear up to a maximum of USD 1,500.00 equal to FCFA

853,500.00 (RoE: $1=FCFA 569.00) per covered individual per three-year period. 80%

Minimum Coverage: with annual cap.

C.1.1.10. Optical Care: 80% Minimum Coverage

Examinations and Treatment: 80% Minimum Coverage

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

559.85 per equal to FCFA 318,554.65 (RoE: $1=FCFA 569.00) covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11. Dental Care: 80% Minimum Coverage

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges up to a maximum of

USD 3,200.00 equal to FCFA 1,820,800.00 (RoE: $1=FCFA 569.00) 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 USD 2,400.00 equal to FCFA 1,365,600.00 (RoE: $1=FCFA 569.00) lifetime limit. 80% Minimum

Coverage; with contract lifetime cap.

C.1.1.12. Reproductive Health: 80% Minimum Coverage

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: 50% Minimum Coverage

Inpatient and outpatient care is provided to evaluate, diagnose, and treat 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: 50% Minimum

Coverage

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 chronic condition, and devices needed for habilitative reasons.

C.1.1.15. HIV/AIDS: 100% up to USD 10,000 equal to FCFA 5,690,000.00 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 covered 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.1.2. Annual Maximum Limit

The maximum annual reimbursement per covered individual per contract year, not including expenses defined under C.1.1.15, HIV/AIDS benefits, is FCFA

11,875,000.00

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

C.1.4.1. Identification of Eligible Employees and Dependents:

U.S. Embassy Lome 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 bi-weekly/monthly basis.

C.1.4.2. Eligible Employees

Employees eligible for the health insurance services include the following:

C.1.4.2.1. All current active employees of the United States

Government, employed within the geographic boundaries of Togo paid under the Local

Compensation Plan, and certified by the Contracting Officer. Covered employees include:

C.1.4.2.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts

(PSCs);

C.1.4.2.3. -- Under a non-temporary direct hire appointment, personal services agreement (PSA), or personal services contract (PSC); or

C.1.4.2.4. Under a temporary direct hire appointment or PSA Fixed

Term of one year or more.

C.1.4.2.5. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

C.1.4.3. Definition of Dependents

LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

C.1.4.3.1. Legal 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.1.4.3.2. 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.1.4.4. Location of Employment

The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Togo by the US Department of State and agencies of the US

Government under the US Diplomatic Mission of Lome and represented in Togo

C.1.4.5. Participants Covered Under a Rider

C.1.4.5.1. All current active ORE Staff are 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.

C.1.4.5.2. All current and active employees of the Peace Corps at Peace

Corps Lome. All costs for coverage of Peace Corps employees and their dependents are the responsibility of Peace Corps, 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 English and French 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 30 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.

C.1.7. Photo Identification Requirement.

C.1.7.1. Provision of Identification Card

The insurer shall provide a photo identification card to each insured and authorized dependents. The individuals covered under this contract shall present the card to official health care providers and pharmacies. The issued card is for identification of the patient who is admitted or treated. The issuance of the card is at the cost of insurer.

C.1.7.2. Loss of Photo Identification Card

The insured will be responsible for the cost of a replacement identification card in the event that the original card is lost.

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.

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

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 the required services are performed and no more than Two

(2) customer complaints are received per month.

Contract Special requirements H.4 thru H.5

All required services are performed and no more than Two

(2) customer complaints are received per month

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 standard of performance is that the Government receives no more than two (2) customer complaints 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)

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 CLAUSES

ARE INCORPORATED BY REFERENCE:

CLAUSE TITLE AND DATE

52.242-15 STOP WORK ORDER (AUG 1989)

52.242-17 GOVERNMENT DELAY OF WORK (APR 1984)

F.2. PERIOD OF PERFORMANCE

The performance period of this contract is one year beginning on July 28, 2026 with four (4) one-year options to renew.

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".

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

F.4. REPORTS AND OTHER DELIVERABLES

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

Attn: Contracting Officer Representative, Human Resources Specialist

Embassy of the United States

4332 Blvd Eyadema – Cite OUA

BP 852 Lome Togo

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 Officer.

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 or/and “through the broker” 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

Payment shall be made in the currency identified in B.2.2

G.4. SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted in an original and One (1) copy to the following address (designated billing office only for the purpose of submitting invoices):

Designated Billing Office

Attn : Financial Management Officer

(FMO)

US Embassy Lome Togo

4332 Boulevard Eyadema – Cite OUA

BP 852 Lome Togo

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 described in H.3. Contractor may submit invoices for payment to be made for each specific period and individuals 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) Peace Corps Staff. The Peace Corps director will make payment directly to the Contractor for the entire premium amount of the Peace Corps employees, whether or not the Peace Corps employees are contributing to the premium amount.

G.5. REFUNDS TO THE GOVERNMENT

If at any time during the 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

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. This initial task order will be issued on yearly basis. 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 quarterly basis if necessary.

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 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

H.4.1. 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:

H.4.2. Administrative Records

H.4.2.1. 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.

H.4.2.2. 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.

H.4.2.3. The Contractor shall use the English spelling of the employees' names in all transactions, including reimbursement checks.

H.4.2.4. The Contractor shall provide employee claim reimbursement checks or Electronic Funds Transfers to the employees no later than two (2) weeks after the claim has been submitted.

H.4.2.5.

H.4.3. Medical Insurance Claims.

Settlement of medical insurance shall be completed as follows:

H.4.3.1. All medical claims shall be submitted directly to the Contractor by employees, through a drop box in the COR's office. The claims shall be picked up from the COR each Tuesday.

H.4.3.2. 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).

H.4.3.3. The Contractor shall settle the claims no later than two weeks from the date the claim is submitted to the Contractor.

H.4.3.4. Settlement shall be by issuance of checks in the name of the employee or Electronic Funds Transfers to the employee bank account for each claim submitted. All employees will have bank accounts at either Ecobank or Orabank. A statement of each transaction shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any and sent to the employee.

H.4.3.5. 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 10th day of each month. The report shall report on the previous month's activities.

H.5.1. 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 Togolese 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

Togolese 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)

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 FAR CLAUSES ARE INCORPORATED BY

REFERENCE:

CLAUSES TITLE AND DATE DATE

52.202-1 DEFINITIONS JUNE 2020

52.203-3 GRATUITIES APR 1984

52.203-5 COVENANT AGAINST CONTINGENT FEES MAY 2014

52.203-6

RESTRICTIONS ON SUBCONTRACTOR SALES

TO THE GOVERNMENT

JUNE 2020

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…