Attachment 0001 PWS.pdf

Performance Work Statement to Provide Medical Insurance for Saudi Ministry of National Guard (MNG) Students/Dependents Attending Courses in the United States

03 March 2025

1. GENERAL:

1.1 Requirements to be a vendor of insurance products in the Kingdom of Saudi Arabia:

The contractor shall be Council of Cooperative Health Insurance (CCHI) and Saudi Arabian Monetary Agency (SAMA) certified in the Kingdom of Saudi Arabia to provide Life and Health Insurance Services. The contractor shall provide medical, vision and dental insurance as described within the Performance Work Statement (PWS) to MNG Students and their accompanied dependents who are attending training courses in the United States.

1.2 Contract employees shall be able to read, write and speak English effectively in order to communication with US Government personnel.

2 SPECIFIC REQUIREMENTS:

2.1 Eligibility: All MNG students, spouses, sons and daughters (18 and under) and (25 and under) unmarried daughters if they are fully dependent on the employee.

In addition, this policy includes the unmarried, divorced, widowed and unemployed daughters of the student whose livelihood depends on him. For estimation purposes, medical insurance premiums will be based on the following up to number of individuals per year:

• Single-100

• Married-100

• Number of MNG Students-200

• Family-100

• Total Number of Lives-300

Note: This is just an estimate. If adjustments are needed, the contractor will follow guidance under Section 2.4 of the PWS

2.2 Term of Eligibility: Each MNG student and their dependents must be enrolled prior to departing for the United States and must remain on the policy for the duration of the training. After the student completes their training and returns from the United States, the student and their dependents must be withdrawn from the policy immediately. Contractor needs to verify with the COR prior to processing/authorizing/paying a medical bill if a patient is not enrolled.

2.3 Price Adjustments for Health Insurance Premiums

2.3.1 Premium Adjustments: For health insurance, prices may be adjusted upward or downward based on the number of claims. 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. 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. 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.

3 STUDENT AND DEPENDENT HEALTH SERVICES BENEFITS:

3.1 In-Patient Mandatory Benefits:

3.1.1 Hospitalization Treatment for In-Patient Care (Paid in Full):

Accommodation in a private room, general hospital nursing care, operating theatre and recovery room, prescribed medicines, drugs and dressings administered while in-patient. The cost of accommodation of a person accompanying the in-patient member in the same room in cases of medical necessity to include parents accompanying children under the age of 18.

3.1.2 Surgical Procedures/Specialist (Paid in Full): This benefit includes surgeon and anesthetist’s fees, surgical procedures and regular visits by a specialist physician during stays in hospital to include intensive care for as long as required. Any artificial limb, prosthesis or device inserted during surgery, part of treatment after surgery or medically necessary is part of this benefit.

Radiotherapy, chemotherapy, oncology, radiology and pathology is also covered.

3.1.3 Organ Transplant (Paid in Full): Charges made for or in connection with approved organ transplant services, including immunosuppressive medications, organ procurement costs and donor’s medical costs. Transplants that are based on experimental procedures will not be covered and the policy member must seek approval with the insurance company before incurring costs related to this benefit.

3.1.4 Home Nursing (Paid in Full): This benefit will be paid in full if recommended by a specialist immediately after hospital treatment for as long as is required by medical necessity for treatment normally provided in hospital.

3.1.5 Physiotherapy and Rehabilitation (Paid in Full): This benefit covers treatment in the form of a combination of therapies such as physical, occupational and speech therapy aimed at restoring full function after an acute event such as a stroke.

3.1.6 Private Ambulance (Paid in Full): This benefit is payable for transport to or from a hospital when ordered for medical reasons.

3.1.7 International Emergency Services (Paid in Full): This benefit includes emergency medical evacuation, medical repatriation and repatriation of remains.

Pre-approval must be obtained prior to incurring costs.

3.2 Out-Patient Mandatory Benefits

3.2.1 Out-Patient Deductible: The policy must not have a co-pay or require co-insurance

3.2.2 Consultations with Medical Practitioners, Family Doctors and Specialists

(Paid in Full): This benefit includes any prescribed medicines, drugs and dressings as a result of medical necessity. In addition, prescribed vitamins as replacement therapy for known vitamin deficiency conditions.

3.2.3 Cancer Treatment (Paid in Full): This benefit includes radiology, radiography, chemotherapy, pathology, radiology, x-rays and laboratory tests.

3.2.4 Non-Surgical and Minor Surgical Procedures and Treatment (Paid in Full)

3.2.5 Alternative Therapies (Paid in Full): This benefit includes acupuncture, chiropody, chiropractor, osteopathy, homeopathy and physiotherapy.

3.2.6 Adult Wellness Tests: Routine adult physical exams for

members/dependents over the age of 18 years old up to SR 1,687 per year.

3.2.6.1 Pap Smear (Paid in Full)

3.2.6.2 Adult Vaccinations (Paid in Full)

3.2.6.3 Prostate Cancer Screening (Paid in Full): This benefit covers prostate cancer screening for eligible males over 50 years old

3.2.6.4 Mammograms for Breast Cancer Screening (Paid in Full): This benefit covers one (1) baseline mammogram for asymptomatic women aged 35-39; a mammogram for asymptomatic women aged 40-49 every two (2) years; and a mammogram every year for women aged 50 and over

3.2.7 Child Wellness Tests (Paid in Full): This benefit will be payable for dependent children under the age of 6 and will cover immunizations for children 18 and under. In addition, children under the age of 15 are eligible for one (1) hearing and one (1) eye test.

3.2.7.1 Circumcision for Newborn (Up to SAR 500/ USD $133)

3.2.7.2 Ear Piercing for Newborn (Up to SAR 300/USD $80)

3.2.7.3 Newborn Early Examination (Up to SAR 100,000/USD $26,666)

3.2.7.4 Early Hearing Screening Program and Critical Heart Disease

Detection (Paid in Full)

3.2.7.5 Immunizations (Paid in Full)

3.2.7.6 Baby Formula (Paid in Full): This benefit will cover baby formula up to the age of 24 months and must be prescribed by the treating doctor associated with metabolic disorders, diseases identified during early examination or allergy from milk or sugar.

3.2.7.7 Autism (Up to SAR 50,000/ USD $13,314): The services available under this benefit are diagnosis, analyses or genes, psychological evaluation, medical rehabilitation, speech therapy, functional therapy, behavior modification therapy, early intervention program and medical/physical counseling.

3.2.8 AIDS/HIV Treatment (Paid in Full): Treatment in connection with

AIDS/HIV or related illnesses.

3.2.9 Congenital and Hereditary Disorders (Paid in Full): This benefit will cover any disorder or illness acquired during conception or the fetal stage of development as a result of the genetic makeup of the parents or environmental factors, whether or not it is manifested or diagnosed before birth, at birth after birth or years late. The individual policy holder must seek approval prior to incurring costs associated with this benefit.

3.2.10 Cosmetic Operations: This benefit will cover any necessary cosmetic operations which are related to an injury, sickness or congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body to include breast reconstruction following a mastectomy.

3.2.11 Costs of Acquired Heart Valves (Up to SAR 150,000/USD $39,943)

3.2.12 Costs of Hearing Aids (Up to SAR 6,000/USD $15,977)

3.2.13 Cost of Renal Dialysis (Up to SAR 100,000/ USD $26,629)

3.2.14 Obesity (Up to SR 15,000/USD $4,000): This benefit will cover the sleeve gastrectomy surgery when the patient’s Body Mass Index (BMI) is greater than 45.

3.2.15 Obstructive Sleep Apnea (OSA) Diagnosis (Paid in Full): This benefit will cover a sleep study as medically necessary for the diagnosis of suspected OSA in an adult 18 years of age or older.

3.2.16 Dietician Services/Nutritional Counseling (Paid in Full): This benefit covers nutritional evaluation and counseling as part of the medical management of a documented disease.

3.2.17 Emergency out of Area Coverage (Reimbursable): This benefit will refund reasonable costs for a policy holder’s treatment and for services related to treatment which are included in the policy in respect of emergency conditions when treatment occurred during a period of 30 days of absence from the selected area of coverage, whether the absence is for business or pleasure.

Emergency treatment is defined as a medical condition which manifests itself by acute symptoms of sufficient pain that a patient could reasonably expect the absence of immediate medical attention will result in serious impairment to body functions or dysfunction of any body part.

3.2.18 Emergency Psychiatric Conditions (Paid in Full): This benefit will cover in-patient and out-patient emergency psychiatric conditions. Under this benefit, an emergency is defined as a situation which calls for immediate medical intervention by a health services provider in order to prevent injury to the policy holder or another person.

3.3 Maternity Benefits

3.3.1 Routine In/Out-Patient (Paid in Full): This benefit is payable to eligible women covered under this policy.

3.3.2 Complicated In/Out-Patient (Paid in Full): This benefit is payable to eligible women covered under this policy and includes non-elective Caesarean sections.

3.3.3 Newborn Care (Paid in Full): This benefit provides coverage for newborns for up to 30 days from birth and includes BCG, Hepatitis B, neo-natal screening test, Phenylketonuria (PKU), Congenital Hypothyroidism, sickle cell screening and congenital adrenal hyperplasia.

3.4 Dental Care Benefits

3.4.1 Annual Maximum: Maximum per member or dependent is SAR

11,812.50/USD $3,150 per year.

3.4.2 Class One (Paid in Full): Includes investigative and preventative treatment such as x-rays, scale and polish. Examinations, scales and polish services will be limited to 2 visits per year of insurance. X-rays will be limited to four bitewings, six Intra Oral and OPG every 3 years.

3.4.3 Class Two (Paid in Full): Basic Restorative Treatment, Periodontal Treatment and Treatment of Dental Injury to include root canals, extractions, surgical procedures, occasional treatment, anesthetics and periodontal treatment.

Prolonged periodontal treatment is limited to one course per year of insurance.

3.4.4 Class Three (Paid in Full): Major restorative treatment to include dentures

(acrylic, synthetic and metal) and crowns, inlays, mouth guard or occlusal splint.

3.4.5 Orthodontic Treatment (Paid in Full up to the Dental Maximum):

Maximum benefit for members under the age of 18.

3.4.6 Dental Supplement: Cover additional dental treatments that are not covered under routine dental care via reimbursement or pre-approval.

3.5 Vision Benefits

3.5.1 Out-Patient Deductible: The policy must not have a co-pay or require co-insurance.

3.5.2 Eye Examination (Paid in Full): This benefit covers one (1) eye examination per year of insurance by an Optometrist or Ophthalmologist up to the annual vision maximum.

3.5.3 Expenses (Up to SAR 750/USD 200): This benefit covers lenses to correct vision, eyeglass frames and prescription sunglasses.

4 EXCLUSIONS:

4.1 General Medical Exclusions

4.1.1 Treatment in nature-cure clinics, health spas and nursing homes.

4.1.2 Male or female birth control

4.1.3 Treatment related to infertility or any type of fertility treatment with the exception of the investigation of the infertility to the point of diagnosis

4.1.4 Supportive treatment for chronic kidney failure or failure which cannot be cured

4.1.5 Sex change operations or any treatment needed to prepare for or recover from these operations including complications arising out of such treatment

4.1.6 Any form of experimental treatment that does not amount to orthodox treatment or does not adhere to commonly accepted, customary or traditional practice of medicine

4.1.7 Assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other custodial services or self-care activities, homemaker services and services primarily for rest or convalescent care

4.1.8 Reports, evaluations, physical examination or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses and court-ordered evaluations.

4.1.9 Routine foot care

4.1.10 Genetic screening or pre-implantations genetic screening

4.1.11 Any form of sterilization or contraception to include vasectomy

4.1.12 Pregnancy and delivery treatment of a woman identified in the policy as unmarried

4.1.13 Medically recognized venereal or sexually transmitted diseases

4.2 General Dental Exclusions

4.2.1 Purely cosmetic, not necessary for oral health

4.2.2 Replacement of any dental appliance, bridge, crown or denture which can be usable according to standard.

4.2.3 Replacement of a bridge, crown or denture within five (5) years of original fitting

4.2.4 Porcelain or acrylic veneers on the upper and lower first, second or third molars

4.2.5 Surgical implants of any type to include attaching prosthetic device

4.2.6 Orthodontic treatment for employees and dependents who are over the age of 18

4.3 General Vision Exclusions

4.3.1 Medical or surgical treatment of the eye

4.3.2 Lenses which are not a medical necessity and are not prescribed by an optometrist

5 BROCHURE REQUIREMENT

5.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in Arabic and English 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 policy holder receives a copy.

5.2 The Contractor assumes full responsibility for ensuring that the document accurately reflects the requirements of the contract, as implemented by the Contractor’s technical quote. In all cases, the contract shall take precedence. Should the Government discover that the brochure contains inaccuracies, the Contractor will be notified in writing; however, failure on the part of the 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.