Exhibit E - Coverage Categories and Levels.pdf

Coverage Category Definition Current Benefit Levels GMC Solicitation Minimum Benefit Levels

Preffered Benefit Levels

Hospitalization Services and supplies provided during hospitalization, including services by a licensed healthcare provider, bed and board (semi-private accommodations), operating room, recovery room, intensive care, imaging, diagnostic testing, general hospital nursing care, physical therapy, as well as drugs and medicines administered while inpatient. 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 -

90% coverage of hospital medical expenses including nursing care, operating room expenses, intensive care, and physical therapy.

100% coverage of laboratory tests and x-rays. 100% coverage of room and board expenses for a semi-private room. 90% coverage of room and board expenses for a private room, not to exceed 100% of the cost of a semi-private room. Maximum amount of room and board expenses per day per individual up to 60,000 XOF

100% minimum coverage 100% Coverage

Emergency Services (trips to

ER)

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

Not covered 100% minimum coverage 100% coverage.

Ambulance Professional ground transport to move a patient from the place where injured or becomes ill to the nearest hospital able to provide treatment, or to move a patient from one medical facility to another

90% Coverage 80% minimum coverage 90% coverage

Preffered Benefit Levels

Outpatient Services Services provided by a licensed healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon fees, other medical services that may be 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 treatment - Immunizations recommended by local authorities and/or the World Health Organization - Diagnostic tests and diagnostic imaging -

Doctors, surgeons outpatient care 90% covered. Lab tests and X-rays: 100%.

80% minimum coverage -- Treatment: 90% coverage;

-- Consultation, diagnostic tests and diagnostic imaging: 100% -- Annual physical examinations: 100%.

Physical Therapy 90% Under Rehabilitative and Habilitative Services and Devices

90%

Psychiatric Therapy 50% coverage Under Mental Health and Substance Abuse Care

50%

Obstetric/Newborn Care and services that women receive during pregnancy (prenatal care), throughout labor and delivery, and post-delivery, and outpatient care for newborn babies.

Hospitalization during pregnancy and/or delivery will be covered as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services

90% coverage; Inpatient care; 100% Cesarean delivery; 90% miscarriages.

Inpatient: 100% minimum coverage;

Outpatient: 80% minimum coverage

Inpatient 100%; Outpatient 90%.

Pediatric Services Primary and preventive routine care services for covered dependent children, including, but not limited to: physical examination, developmental assessment, laboratory tests, and immunizations recommended by local authorities or the World Health Organization.

90% outpatient and inpatient care Inpatient: 100%; Outpatient: 80% Inpatient: 100%; Outpatient: 90%.

Preffered Benefit Levels

Prescription Drugs Medications prescribed by a certified health care provider that are medically necessary. 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; or contraceptive medication.

90% inpatient and outpatient care Inpatient: 100%; Outpatient: 80% Inpatient: 100%; Outpatient: 90%

Preventive and Wellness and Chronic Disease Management

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but not limited to: physicals, immunization, and cancer screenings.

90% coverage (Immunization) 80% minimum coverage 90% coverage

Hearing Aids 40% coverage; one apparatus; per year/ per patient in a three year period.

Examinations and Treatment: 80% Hearing Aid Apparatus: Limited to one apparatus per ear up to a max of USD 1,500 per covered individual per three-year period.

80% with annual cap

Examinations and Treatment: 80%.

Hearing Aid Apparatus: 80% covered. Limited to one apparatus per ear up to a maximum of USD 750 per covered individual per three-year period.

Optical 90% coverage; Eye treatment. 100% coverage; frame with CFA 70,000 annual cap. 80% coverage; two eye glasses with CFA 112,900.00 per 18 months

Examinations and Treatment: 80% Prescription lenses and frames, or contact lenses: Covered up to a maximum of USD 300 per covered individual every two years.

80% with annual cap

Optical: Examinations and Treatment: 90% Prescription lenses or contact lenses: 80% covered up to 112,900 CFA (2 lenses/covered individual/18 months); Frames: 100% up to 70,000 CFA.

Dental Examinations and Treatment:

Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges.

Orthodonia: Treatment is covered only if treatment begins before age 18, or if required as the result of an accident.

80% Dental care coverage;

Orthodontia started before age 15.

Examinations and Treatment:up to a maximum of USD 3,200 per covered individual per contract year. 80% with annual cap Orthodontia: Treatment 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% with contract lifetime cap

Examinations and Treatment: 90% covered up to a maximum of USD 3,200 per covered individual per contract year.

Orthodontia: A maximum of four years of orthodontia treatment will be covered 80% per covered individual up to a maximum of USD 1,200 for a maximum of 4 years.

Preffered Benefit Levels

Reproductive Health 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).

Not covered 80% minimum coverage 80% coverage

Mental Health and Substance Abuse Care

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 carried out at a facility licensed for detoxification and rehabilitation.

50% Psychiatric treatment covered 50% minimum coverage 50% coverage

Rehabilitative and Habilitative Services and Devices

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) 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.

80% Physical Therapy covered. 50% minimum coverage 80% coverage

Preffered Benefit Levels

HIV/AIDS 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

100% coverage; $10,000.00 annual limit. 100% up to $10,000 per coverage year 100% up to $10,000 per coverage year

Out-country Medical Treatment (optional under

GMC)

Medical expenses incurred out-of-country

Covered at the same percentage rate and subject to the annual limits as in country medical expenses. Attending physician must certify that service is unavailable locally.

Medical expenses incurred out-of-country will be covered at the same benefit levels and subject to the same total maximum annual limit as medical expenses incurred in-country.

Medical expenses incurred out-of-country will be covered, but coverage will be the same and subject to the same total maximum annual limit as for medical expenses incurred in-country.

Preffered Benefit Levels

Out-country Medical Travel (optional under GMC)

80% coverage of transportation cost.

Attending physician must certify that service is unavailable locally.

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.

Transportation for out-of-country medical treatment will be a covered expense for LE Staff 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. 90% 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. 90% 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.

Catastrophic Coverage (optional under GMC)

Covered at annual maximum limits of XOF 100,000.00 per covered individual, per year.

Additional coverage equal to 100% of the annual maximum. Catastrophic conditions are defined as major medical conditions occurring as a result of a single/illness/accident or closely related set of major illnesses (or conditions related to a single accident) that exceed the standard annual maximum coverage limit.

Additional coverage equal to 22,929,000 CFA 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.

Excess Coverage (optional under GMC)

Additional coverage equal to 100% of the annual maximum (FSN-9) to be applied to any covered individual to any covered benefit.

This can be used for any covered individual for any covered expense that exceed annual maximum.

Not Covered Additional coverage equal to 22,929,000 CFA/covered individual/conract year. This excess coverage will be offered as an optional benefit to LE Staff. LE Staff must pay 100% of the premium if they elect Excess Coverage.

Additional coverage equal to 22,929,000 CFA/covered individual/conract year. This excess coverage will be offered as an optional benefit to LE Staff. LE Staff must pay 100% of the premium if they elect Excess Coverage.

Preffered Benefit Levels

180 Day Extended Dependent Coverage After Employee’s Death (optional under GMC)

Not Covered At the time of a covered employee death, their eligible dependents covered under the medical plan as designated in the official personnel file are eligible to temporarily continue receiving the same level of medical coverage for up to 180 days.

The USG covers the full premium.

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.