Combined Synopsis/Solicitation 19GE5026R0041 LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

COMBINED SYNOPSIS/SOLICITATION 19GE5026R0041

ATTACHMENT 1 – SCHEDULE AND CLAUSES

The Schedule – page 1 – 26 Contract Clauses – page 27 - 40

THE SCHEDULE

A. GENERAL

The U.S. Government requires Health and Life Insurance for its Locally Employed Staff (LES) of the United States Embassy Kingston, Jamaica and their eligible dependents as described in Section C. This insurance shall be provided in accordance with Section C.

Official Residence Expense (ORE) Staff 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) at the rates specified in Section B. ORE staff are covered for single coverage health services only.

Marine Security Guard (MSG) employees are included under this contract only as a rider; the contractor shall bill the Marine Security Guard separately for employee insurance at the rate specified in Section B. MSG staff are covered for single coverage health insurance services only.

Retirees are included under this contract only as a rider and are responsible for 100% of premium (Self-Only). Employees who retire from the service of the US mission who were covered under the medical insurance plan at the time of retirement remain eligible for coverage for themselves only.

A.1 TYPE OF CONTRACT

A.1.1 This is a fixed-price indefinite delivery/indefinite quantity (IDIQ) with economic price adjustment requirement under which annual firm-fixed price task orders will be issued. The fixed premium rates for the health insurance services as specified in Section C – Statement of Work are listed in Attachment 3 – Prices, which will be incorporated into Section B – Pricing upon award. The quantities set forth in the pricing section are estimates; the Government does not guarantee that such quantities will be ordered.

A.1.2 The contract will be for a one base year period and four (4) one-year periods. Services shall commence no later than June 01, 2026. The complete performance period is June 01, 2026 through to May 31, 2031. The Government is obligated only to the extent of authorized task orders actually made under this IDIQ.

A.1.3 Payments will be made only to the extent specifically authorized in the task order. Each task order will fund a specific period of time and number of covered individuals.

A.2 ACQUISITION METHOD

This is a commercial acquisition as defined in the Federal Acquisition Regulation (FAR) 2.101, Definitions, and as described in FAR part 12, Acquisition of Commercial Products and Commercial Services. The government intends to use phased acquisition methods in accordance with FAR 12.201- 1(d) and comparative evaluation procedures as per FAR 12.203.

B. PRICING

B.1 GENERAL

The contractor shall complete all work, including furnishing all labor, material, equipment, and services, unless otherwise specified herein, required under individual calls issued against this contract.

The fixed unit prices established in the Price Schedule shall include all materials, equipment, labor, overhead, and profit necessary to provide the required services at the order level.

No additional sums will be payable due to any escalation in the cost of labor, materials, equipment, overhead, profit, or due to the contractor’s failure to properly estimate or accurately predict the cost or difficulty of performing the required services.

Established unit prices will not be adjusted based on fluctuations in currency exchange rates. Price adjustments to individual calls will be made only for changes directed by the Government or delays caused by the Government. Any cost element not separately priced will be considered included within overhead or other indirect costs.

The currency of the established unit prices shall be fixed and cannot be changed during the lifetime of the contract.

B.1.1 VALUE ADDED TAX

Value Added Tax (VAT) is not applicable to this contract and shall not be included in the prices or invoices. The U.S. Embassy will provide a tax exemption letter for the tax authority of the host government.

B.1.2 EXCISE TAX

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% pursuant to 26 U.S.C. 5000C.

B.1.3 ECONOMIC PRICE ADJUSTMENT, PREMIUM ADJUSTMENT BASED ON

EXPERIENCE

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

B.1.3.1 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.

No adjustment will be allowed during the Base Year.

B.1.3.2 The contractor or the Government may request an adjustment 60 days prior to the end of the base year or current year, to take effect at the start of the following year. Adjustments are not retroactive to previous periods of performance, and the contractor may not seek to recover costs incurred during a prior period of performance through an Economic Price Adjustment. Economic Price Adjustments only apply as an adjustment to the rates to be charged by the contractor for the services identified as in the contract and cannot be recovered as a lump sum adjustment paid to the contractor.

B.1.3.3 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, i.e. per line item for the preceding 12 months.

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.

B.1.3.4 Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government, and after the corresponding modification has been signed by the Contracting Officer. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.1.4 PREMIUM ADJUSTMENT BASED ON LAWS

The rates may also be adjusted 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 contract. In that event, the Contracting Officer may enter into negotiations with the contractor to modify the contract pricing schedule. The contractor agrees to provide all documentation necessary to support any requested adjustment.

B.1.4.1 Employee Pool – This clause is only in effect if the contractor included details in its offer regarding a pooling arrangement.

Before any adjustment is made under this price adjustment clause, the contractor shall include in its quotation for adjustment details setting forth how the pool impacts the requested price adjustment.

B.1.5 Official Residence Expense (ORE) employees, Employee Association employees (EA), and Peace Corps (PSC)

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

Official Residence Expense (ORE), Employee Association employees (EA), and Peace Corps (PSC) Employees are included in this CONTRACT only as a rider. The contractor shall bill the individual covered at the rates specified in B.2.

Note that the USG is not responsible, nor liable for any riders.

B.2 PRICING TABLE

The offeror shall provide fixed prices in Attachment 3 – Prices.

PRICES OF ATTACHMENT 3 – PRICES WILL BE INSERTED HERE

B.3 ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the contractor requests a price adjustment under B.3 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 Attachment 3-Price.

This retention amount will not be adjusted for any reason.

B.3.2 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.3.3 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

B.3.3 Bi-weekly Retention Amounts per separate premium paid per self only, per self plus one and per family plan.

The contractor shall complete the fixed bi-weekly retention amounts for each performance period and premium category. This fixed amount must be expressed in the currency in which the premium amount is proposed. Ensure these amounts are expressed in the currency proposed for the premium. Note that the fixed retention amount shall not be indicated as a percentage of the premium.

The contractor shall provide the administrative retention amounts on Attachment 3 – Prices.

The remainder of this page is left blank intentionally

C. STATEMENT OF WORK

C.0 INTRODUCTION

The Contractor shall provide health insurance services to Locally Employed Staff of the U.S. Mission Jamaica, and their eligible dependents, as further described in this Section. The below are the minimum benefits levels which are accepted. Offers including additional benefits or higher benefit levels may be accepted.

C.1 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)

C.1.1 EMPLOYEE AND DEPENDENT HEALTH SERVICE BENEFITS

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

Minimum Coverage - 100%

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 accommodation is 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 (C.1.1.4) for details concerning professional services.

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

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

C1.1.3 Ambulance: Minimum Coverage - 80%

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.

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

C.1.1.4 Outpatient Services: Minimum Coverage - 80%

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 (below) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (below) for details concerning psychiatric therapy.

C.1.1.5 Obstetric and Newborn Care: Minimum Coverage - Inpatient/Emergency:

100%; Outpatient: 80%

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: Minimum Coverage - Inpatient/Emergency: 100%, Outpatient: 80%

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: Minimum Coverage -Inpatient/Emergency: 100%, Outpatient: 80%

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:

Minimum Coverage - 80%

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: Minimum Coverage – 80%

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear up to a maximum of $238,500 Jamaican Dollars (JMD) per covered individual per three-year period. 80% Minimum Coverage: with annual cap.

C.1.1.10 Optical Care: Minimum Coverage – 80%

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames or contact lenses: Covered up to a maximum of USD 300 per covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11 Dental Care: Minimum Coverage – 80%

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges up to a maximum of $508 USD 3,200 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 lifetime limit. 80% Minimum Coverage; with contract lifetime cap.

C.1.1.12 Reproductive Health: Minimum Coverage - 80%

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 in Sub-Section C.1.3).

C.1.1.13 Mental Health and Substance Abuse Care: Minimum Coverage - 50%

Inpatient and outpatient care provided to evaluate, diagnose, and treat a 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: Minimum Coverage - 50%

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 a chronic condition, and devices needed for habilitative reasons.

C.1.1.15 HIV/AIDS: 100% up to USD 10,000 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 Catastrophic Coverage

Additional coverage equal to $5,317,000.00JMD per covered individual per contract year.

Catastrophic conditions shall be defined as major medical conditions occurring as a result of a single illness/accident or closely related set of major illnesses (or conditions relating to a single accident) that exceed the standard maximum coverage limit.

C.1.1.17 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.1.1.18 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 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.1.1.19 180 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.1.1.20 RESERVED

C.1.1.21 Excess Coverage

NOTE: Employee is responsible for paying 100% of premium for Excess Coverage

Additional coverage equal to $5,317,000.00JMD per covered individual per contract year. This excess coverage will be offered as an optional benefit to locally employed (LE) Staff. This can be used for any covered individual for any covered expense that exceeds annual maximum. LE Staff must pay

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

100% of the premium if they elect Excess Coverage. The premium for this additional coverage is a rider to be paid by the employee to the vendor directly and US Government will not be responsible for collecting of these premium payments.

C.1.2 ANNUAL MAXIMUM LIMIT - The maximum annual reimbursement per covered individual per contract year, not including expenses defined under HIV/AIDS benefits if selected by post, is JMD 5,317,000 (100% of the annual base salary of an FSN-9 highest step/maximum base annual salary rate rounded up to the nearest thousand).

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.

There is no reimbursement 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: To be eligible to participate in the medical plan, LE Staff (both full time and part time) must be:

- -paid under the terms of the Local Compensation Plan (LCP); and --Under a non-temporary direct hire appointment, personal services agreement (PSA), or personal services contract (PSC); or --Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

C.1.4.1.1 Definition of Dependents

C1.4.1.1.1 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.

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

C.1.4.1.1.2 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.1.4.2 Location of Employment: The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Kingston, Jamaica, by: Department of State, USAID, Peace Corps., FAS, APHIS, DHS/CBP, MLO, DEA, USMS, CDC, USPIS, and ORA.

C.1.4.3 Participants Covered Under a Rider

a. 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.

b. All current active employees of the Employee Association at US Embassy EAEs are the responsibility of the Employee Association, not the U.S. Government.

c. Retired Employees: Employees who retire from the service of the US mission who were covered under the medical insurance plan at the time of retirement remain eligible for coverage for themselves only.

Employees who separate from employment due to total disability are considered to be medically retired and are eligible for medical benefits regardless of an age at the time of separation. An employee is considered disabled when an illness or physical or mental impairment results in the employee’s inability to perform work. In the event that the medically retired employee recovers and starts employment with another entity, his/her eligibility for coverage under this plan ceases as soon as he/she becomes eligible for medical benefits form his/her new employer and/or the LSSS.

The maximum benefit levels outlined apply to retirees unless post opts to use less than the maximum benefit levels or retired employees.

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.

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

During a period of Leave Without Pay (LWP) 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.

C.1.5.2. Period of Ineligibility

Employees and their dependents are not entitled to health benefits during any period of employment for which premiums are not paid.

Additionally, employees’ dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate.

During a period of extended (beyond one pay period) of Leave Without Pay (LWP) or unpaid leave, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the Contractor and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if that employee prefers not to pay the premium.

C.1.6 BROCHURE REQUIREMENT

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in 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 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 ten (10) days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) 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 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 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.

C.1.7 MEDICAL AID CARDS

The Contractor shall provide individual medical aid identification cards to all eligible employees and their registered beneficiaries within thirty (30) calendar days after Award and upon request by the COR. These cards shall serve as the primary means of eligibility verification at the point of service.

PART II: GROUP LIFE INSURANCE

C.2. GROUP LIFE INSURANCE

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

The Government of the United States of America requires group life insurance coverage for its employees, as further described in C.2.2, in Kingston, Jamaica. The Government has determined that the prevailing practice by employers in Kingston, Jamaica is that group life insurance coverage is representative of locally prevailing compensation practice and that the cost of such insurance protection is usually borne by the employer (100%). Therefore, the Government desires to adopt such locally prevailing practice as part of its compensation plan for its employees as further described in

C.2.2. Eligible Employees: Eligible employees are Locally Employed (LE) Staff who are (1) working on a full-time or part-time basis under non-temporary direct-hire appointments and under personal services agreements/contracts that are not time limited to less than one year and (2) paid under the terms of the Local Compensation Plan. Not eligible are LE Staff working under temporary appointments; those working under a PSA or PSC that is time limited to less than one year; those with a When Actually Employed (WAE) workweek schedule; nonpersonal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Jamaica who provide services to other local organizations as well as to the U.S. Mission; employees of USAID institutional contractors; and Peace Corps personal services contractors as indicated in MS 743. Official Residence Expense (ORE) employees may be covered under a rider to the contract. The employing officer, not the USG, is responsible for the employer’s share of the premium costs for an ORE employee.

Premium Costs: The USG will pay 100% of the premium costs.

C.2.1. Group Life Insurance Coverage

The amount of group life insurance coverage is as follows:

C.2.1.1 Death Benefit: The following benefit will be paid to the participant’s named beneficiaries or estate upon the death of the participant:

Natural Death: 26 months’ basic salary volume which is $1,623,016,000.00JMD

C.2.1.2 Accidental or work-related death/disability: 34 months’ basic salary volume which is

$2,122,380,000.00JMD

C.2.2 Life Insurance Benefits Conditions and Limitations

Conditions and limitations on the entitlement to life insurance benefits under this contract are as follows:

No benefits shall be payable if an employee's death or other insurance event was caused directly or indirectly by war. War shall be defined as declared or non-declared war or any martial operations or invasion, hostile acts of foreign powers, rebellion, riot, civil war, uprising, mutiny, operations by military or usurpatory authorities, martial law or state of siege or any other similar event or reason for declaring martial law or war. A terrorist attack shall not be considered war.

No benefit shall be payable under this contract if the employee's bodily injuries have been caused directly or indirectly and totally or partially by:

1. violating the law or in resisting detention or arrest,

2. participation in competitions involving the use of wheeled vehicles, horses, boats or water skis, LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

3. an accident resulting from the employee being under the influence of alcohol, drugs or other toxic substance unless administered by a physician. Death as a result of a disease or physical or mental infirmities and medical or surgical treatment thereof (except pyogenic infection due to an accidental cut or wound) shall be considered a natural and not an accidental death. Suicide will not be covered.

C.2.3. Eligible Participants

C.2.3.1 Eligible Employees. The employees eligible for the group life insurance coverage include the following:

C.2.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Kingston, Jamaica paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include:

C.2.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts (PSCs);

C.2.3.1.3. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

C.2.3.1.4. Participants Covered Under a Rider All current active employees of the Chief of Mission and the Deputy Chief of Mission are assigned to their respective official Government residences and paid under an ORE account. All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.2.3.2 Location of Employment

The individuals covered by C.2.3.1 must be employed within the geographic boundaries of Kingston, Jamaica by: Department of State, USAID, Peace Corps, DEA, DAO, FAS, APHIS, DHS/ICE, DHS/CBP, MLO, USMS, CDC, USPIS, US Treasury and ORA.

C.2.4 Individuals not Eligible for Coverage

Dependents and retirees are not covered.

C.2.4.1. New employees who have reached the age of 60 and 65 prior to entering on duty with the U.S. Government will not be eligible for life insurance coverage.

C.2.4.2 Individuals not eligible for coverage under this contract are nonpersonal 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.

Employees of USAID institutional contractors; and Peace Corps personal services contractors are not eligible.

C.2.5. Other Eligible Participants

The following additional categories of persons are covered by this insurance:

C.2.6 Eligibility and Effective Date

C.2.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for life insurance, accidental or word related death/disability 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 (LWP) 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.

C.2.6.2. Period of Ineligibility

Employees are not entitled to life insurance hereunder during any period of employment for which premiums are not paid.

During a period of extended (beyond one pay period) of Leave Without Pay (LWP) or unpaid leave, the employee is responsible for the full cost of the insurance premiums. The Mission will pay the premiums directly to the Contractor and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if that employee prefers not to pay the premium.

C.2.7. BROCHURE REQUIREMENT

C.2.7.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in English that sets forth a complete listing of the life 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.2.7.2. The document described in C.2.7.1 shall be provided to the COR not later than ten (10) days after the date of the contract award. The Contractor shall provide additional brochures for new employees within ten days of the COR’s request.

C.2.7.3. The Contractor assumes full responsibility for ensuring that the document described in C.2.7.1 accurately reflects the requirements of the contract, as implemented by the Contractor’s quotation. In all cases, the contract shall take precedence. Should the COR 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.

C.3 KEY PERSONNEL

The U.S. Government considers the contractor’s project manager as key personnel for this contract meeting the following minimum requirements:

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

The Project Manager must be able to speak and write English and shall possess at least 5 years of experience in working with contracts of similar size and work. The offeror shall provide a resume in the English language demonstrating these experiences.

During the entire performance period of this contract, the Contractor shall make no substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment.

The Contractor shall notify the Contracting Officer’s Representative (COR) within 15 calendar days after the occurrence of any of these events. The proposed substitute shall possess qualifications comparable to the original key person, as well as satisfying any minimum standards set forth elsewhere in the contract. The COR will notify the Contractor within 15 calendar days after receipt of all required information of the decision on the substitution.

C.4 SERVICE REQUIREMENTS

C.4.1 Claims and Appeals The contractor must maintain a user-friendly system for employees to access their claims, submit and track claims, and a clear appeal process for any rejected claims. Customer satisfaction with this process must be included as an indicator in the quality assurance plan. Claims appeal shall not take more than 7 business days to resolve / provide feedback to the employee and Contracting Officer’s representative.

C.4.2 Payment Service providers shall be paid in not more than 30 days.

C.4.3 Reimbursement Contractor shall make reimbursements for services paid for out of pocket within 30 business days from submission of reimbursement claim.

C.4.4 Customer Service Contractor shall provide a dedicated 24-hour customer service facility to handle any customer enquiries and after-hours authorizations.

C.4.5 Preferred Provider Network (PPN)

Contractor shall provide a Preferred Provider Network (PPN) of service providers for the benefits listed in Section B in Jamaica. The PPN shall be reviewed and updated bi-annually and shared with all employees.

C.4.6 Response Time Contractor shall respond to medical aid enquiries within 48 to 72 hours of notification.

C.4.7 Monthly reports Contractor will provide the Embassy regular quarterly reports on claims submission, and other matters important to good overall management of the contract.

C.5. DEFINITIONS

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

CONTRACT Contract

CO Contracting Officer

COR The Contracting Officer's Representative (COR) is the Human Resources Officer (HRO) at post.

Contributory Insurance Insurance for which the employee contributes toward the premium.

Customary and Reasonable Treatment

A diagnostic test or medical treatment which is usually performed in the community where the individual is being treated.

Dependent

Legal spouse: one legal spouse as defined by local law may 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. Dependent 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.

For Life Insurance - Dependents and retirees are not covered.

Disability - Total and Permanent

A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment. If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

Employee

An individual employed by the U.S. Government, under a direct-hire appointment, personal services contract (PSC), or personal services agreement (PSA), as further defined in Section C.1 for health insurance and C.2 for life insurance.

This may also include ORE Staff, and Peace Corp PSCs, if this category of individual is listed as participating under a rider for health insurance, Employer The United States Government or in the case of ORE the Chief of Mission/Deputy Chief of Mission.

FMO The Financial Management Officer (FMO) or the paying office for all U.S. Government Agencies, except U.S. AID.

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

GSO

General Services Officer in charge of the General Services Office at the Embassy. This officer is usually the Contracting Officer at the Embassy providing support to the Contracting Officer’s Representative at Post and the Contracting Officer for this contract.

Hospital

An institution established and operated for the care and treatment of sick and injured persons. It provides 24-hour nursing care and has diagnostic, laboratory, treatment, and surgical facilities. Any institution which does not meet this definition is not considered a hospital.

Hospital Patient An individual who has been admitted to a hospital, is assigned a bed, and is given diagnostic tests or receives treatment for a disease or an injury.

Maximum Benefit The total amount that will be paid to any one covered individual for covered medical expenses or life insurance/disability benefit.

Physician

An individual who has graduated from an accredited medical school and is licensed to practice medicine in the jurisdiction in which the contract is to be performed. If the individual is a medical specialist, then he or she is Board Certified in that specialty.

Surgical Procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.

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D. CONTRACT ADMINISTATIVE REQUIREMENTS AND PROCEDURES

D.1 QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

This plan provides an effective method to promote satisfactory 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 monitor quality to ensure that contract standards are achieved.

Performance Objective Performance Threshold Services:

Performs all services set forth in the scope of work.

All required services are performed and no more than three (3) customer complaint are received per month.

Timely payment of benefits (within 30 calendar days).

No more than one (1) customer complaint is received per month.

No incorrectly denied claims. No more than one (1) customer complaint is received per month.

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.

2. STANDARD:

The performance standard is that the Government receives no more than three (3) 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), if any of the services fail to meet the standard.

3. COMPLAINT 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.

LES Health and Life Insurance, U.S. Embassy Kingston, Jamaica

(f) If the Contractor disagrees with the complaint after investigation of the site 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 complainant.

(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.

D.2 DELIVERABLES

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

U.S. Embassy Jamaica ATTN: Human Resources Office (Contact details to be provided in the contract)

NOTE: Any and all costs for the preparation, handling, mailing and submission of progress reports or any other required reports and documentation shall be included in the total price of each delivery order.

Reference Description Quantity Submission Date Deliver to:

C.1.6 + C.2.7

Brochures As instructed by the COR

Additional copies

10 calendar days after Award

Within 10 calendar days upon COR’s request.

COR

C.1.7 Medical Aid Cards for employee and beneficiaries

As instructed by the COR

Additional copies for new hires or new dependents

30 days after Award

Within 30 calendar days of COR’s request

COR & HR

POC*

D.3 Employee Claims Report 1 No later than the 10th of the following month.

COR

D.9 Invoice 1 Monthly COR & HR

POC* &

Designated Billing Office

*POC stands for “Point of Contact”

D.3 CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMS

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 employees' 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:

D.3.1 Administrative Records

• The Contractor shall maintain medical insurance files for each eligible employee 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 employee per year reimbursement ceiling.

• 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.

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

• The Contractor shall send employee claim reimbursement checks to employees not later than two weeks after a claim is submitted.

D.3.2 Medical Insurance Claims - Settlement of medical insurance shall be completed as follows:

• All medical claims shall be submitted directly to the Contractor by employees.

• 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 (2) days, with a copy to the COR (if notification is written).

• The Contractor shall settle the claims no later than two (2) weeks from the date the claim is submitted to the Contractor.

• Settlement shall be by issuance of checks in the name of the employee for each claim submitted or via EFT. Each reimbursement shall be in the same currency as the receipt. Each reimbursement shall be accompanied by a form or email providing details of the amount reimbursed with an explanation of deductions, if any.

D.3.3 Report Requirements

The contractor shall provide the following quarterly report. The report shall be received by the COR no later than the 10th day of the required month. The report shall report on the previous month's activities.

(a) 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.

D.4 Key Personnel

The US Government considers the contractor’s Project Manager as Key Personnel for this contract.

Project Manager Name: To be inserted by the Contracting Office at the time of award

During the entire performance period of this contract, the contractor shall make no substitutions of key personnel unless the substitution is necessitated by illness, death, or termination of employment.

The contractor shall notify the Contracting Officer Representative within 15 calendar days after the occurrence of any of these events. The proposed substitute shall possess qualifications comparable to the original key person, as well as satisfying any minimum standards set forth…