Exhibit E Health Insurance Benefits.xlsx
XLSX spreadsheet 22 KB Posted
- Solicitation number
- 19LG7524R0001-Riga
- Issued by
-
Department of State US Embassy Riga
About this file
This document contains an exhibit outlining health insurance benefits and a related federal contract opportunity solicitation for health insurance services. The exhibit specifies minimum coverage levels for medical, hospitalization, emergency services, ambulance, outpatient services, obstetric and newborn care, pediatric services, prescription drugs, preventive services, hearing aids, optical care, dental care, reproductive health, mental health, and rehabilitative services. The related solicitation is for health insurance services for an estimated 150 local employees and 220 family members of the U.S. Embassy in Riga, Latvia. Offerors are encouraged to propose off-the-shelf plans that meet the minimum benefit levels. The contractor must have all required permits and licenses to perform the work.
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Other files
| File | Type | Posted |
|---|---|---|
| Questions and Answers continued.docx | DOCX document | |
| Questions and Answers.docx | DOCX document | |
| 19LG7524R0001.pdf | ||
| Solicitation Invitation letter.pdf |
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Sheet1
| Medical Benefits | Medical benefit levels for LE Staff and their eligible dependents. | Describe eligibility and medical benefits offered by vendor. NOTE: references to other documents are not acceptable. | Minimum coverage (if different) | COMMENTS |
| Annual Max Limit | The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations, is 6,000 EUR. |
The maximum annual coverage per covered individual (employee, dependents) per contract year, not including expenses defined under Exclusions and Limitations (C.1.3), or those covered under C.1.1.15, HIV/AIDS is 6,000 EUR. Breakdown as follows:
--Self Only (Employee): 6,000 EUR
--Self Plus One: 12,000 EUR
--Self Plus Two: 18,000 EUR
--Self Plus Three: 24,000 EUR
--Self Plus Four: 30,000 EUR
--Self Plus Five: 36,000 EUR
Extended Family Legal spouse or domestic partner, to include same-sex domestic partners, as certified by COM: one legal spouse as defined by local law or one domestic partner may be covered. LE Staff with more than one legal spouse or domestic partner must select only one individual for coverage.
In cases where LE Staff and their legal spouse or domestic partner 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 or domestic partner.
| Child Age Limit | Dependent children: Unless local law provides a more expansive definition, 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. |
| 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 & board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, 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 (C.1.1.4.) for details concerning professional services.
| 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. |
| 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. |
| 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 (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.
| Obstetric and Newborn Care: Minimum Coverage - Inpatient: 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 covered as Hospitalization (treatment in the hospital for inpatient care). All other treatments will be considered Outpatient Services. |
| Pediatric Services: Minimum Coverage - Inpatient: 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. |
| Prescription Drugs: Minimum Coverage -Inpatient: 100%, Outpatient: 80% | Medications prescribed by a certified 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. |
| 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. | |
| Hearing Aids: Minimum Coverage – 80% | Examinations and Treatment: 80% Minimum Coverage |
Hearing Aid Apparatus: Limited to one apparatus per ear. The maximum coverage is EUR 1,374.00 per covered individual per three-year period. 80% Minimum Coverage: with applicable cap.
Optical Care: Minimum Coverage – 80% Examinations and Treatment: 80% Minimum Coverage
Prescription lenses and frames, or contact lenses: The maximum coverage is EUR 274.80 per covered individual every two years. 80% Minimum Coverage; with applicable cap.
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 EUR 2,931.20 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 EUR 2,198.40 lifetime limit. 80% Minimum Coverage; with contract lifetime cap.
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).
See also Exclusion to Coverage (b)(C.1.3.)
| 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. |
| 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. | |
| 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. |
See also Exclusion to Coverage (b)(C.1.3.)
| Other benefits | Other benefits, if provided by the vendor |
| Cost of the insurance |
policy per individual
File details come from the government source that posted it. Updated .