GMC Medical Coverage.pdf

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

PART I - MEDICAL INSURANCE

C.1. MEDICAL INSURANCE SERVICES

The Government of the United States of America requires Medical Insurance coverage for its employees as described in Section C and the Exhibits in Section J.

C.1.1 Employee and Dependent Medical Services Benefits

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

Minimum Reimbursement Rate - 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, 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.

C.1.1.2 Emergency Services (Trips to Emergency Room): Minimum Reimbursement Rate - 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 Reimbursement Rate - 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.

C.1.1.4 Outpatient Services: Minimum Reimbursement Rate - 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

C.1.1.5 Obstetric and Newborn Care: Minimum Reimbursement Rate - 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 Reimbursement Rate - 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 Reimbursement Rate - Inpatient/Emergency: 100%, Outpatient: 80% Medications prescribed by a licensed health care provider that are medically necessary to treat a specified diagnosis. Examples include, but are not limited to prescription antibiotics to treat an infection, medication used to treat an ongoing condition, such as high cholesterol, and prophylaxis and contraceptive medication.

C.1.1.8 Preventive and Wellness Services and Chronic Disease Management:

Minimum Reimbursement Rate - 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 Reimbursement Rate – 80% Hearing aid apparatus and related examination. Limited to one apparatus per ear up to a maximum of USD 1500 per covered individual per three-year period.

C.1.1.10 Optical Care: Minimum Reimbursement Rate – 80%

Eye examination, treatment, and prescription lenses and frames or contact lenses up to a maximum of USD150 per covered individual per contract year.

C.1.1.11 Dental Care: Minimum Reimbursement Rate – 80% Dentist fees, x-rays, examination and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges per covered individual up to a maximum of USD 3200 per contract year. 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 patient up to a maximum of USD 2400 lifetime limit.

C.1.1.12 Family Planning: Minimum Reimbursement Rate - 80%

Prescribed contraceptive devices, voluntary sterilization, and diagnosis and treatment of conditions which may cause infertility.

C.1.1.13 Mental Health and Substance Abuse Care: Minimum

Reimbursement Rate - 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 Reimbursement Rate - 50% Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke, etc.)

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.

OPTIONAL BENEFITS

C.1.1.15 HIV/AIDS: 100% Reimbursement up to $10,000 per year Medications to suppress opportunistic infections (such as tuberculosis or toxoplasmosis for employees and dependents 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. Reimbursement under this benefit is excluded from the annual maximum limit (C.1.2). (Note: If local medical benefit plans do not provide HIV/AIDS treatment coverage at the minimum level define, or is prohibitively expensive, this category of benefits will be mandatory)

C.1.1.16 Medical Expenses Incurred Out-of-Country:

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 Transportation for Out-of-Country Treatment: 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.1.1.18 Excess Coverage

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

Additional coverage equal to [Note to Contracting Officer: Insert authorized amount equal to the FSN-9 highest step/maximum base annual salary rate and round up to the nearest thousand (i.e. $17,001 would be rounded up to $18,000) . This amount will be denominated in local currency, unless HR/OE has authorized the LCP in an alternative currency.] to be applied to any covered individual to any covered benefit. LE Staff must pay 100% of the premium if they elect Excess Coverage. Not applicable to direct reimbursement posts. This can be used for any coverage individual for any covered expense that exceed annual maximum.

C.1.1.19 Catastrophic Coverage

NOTE: Employee responsible for paying 100% of premium for Catastrophic Coverage

Additional coverage equal to [Note to Contracting Officer: Insert authorized amount equal to the FSN-9 highest step/maximum base annual salary rate and round up to the nearest thousand (i.e. $17,001 would be rounded up to $18,000) . This amount will be denominated in local currency, unless HR/OE has authorized the LCP in an alternative currency.] per covered individual. 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. LE Staff must pay 100% of the premium if they elect Excess Coverage. Not applicable to direct reimbursement posts.

C.1.2 Annual Maximum Limit - The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) or those covered under an Optional Benefits (C.1.1.15, C.1.1.18, C.1.1.19) is equivalent to [Note to Contracting Officer: Insert authorized amount equal to the FSN-9 highest step/maximum base annual salary rate and round up to the nearest thousand (i.e. $17,001 would be rounded up to $18,000) . This amount will be denominated in local currency, unless HR/OE has authorized the LCP in an alternative currency.]

C.1.3 Exclusions and Limitations

There is no reimbursement 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, artificial insemination, 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 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.

[Note to Contracting Officer: Include following statement(s) if post opted not to cover out-of-country expenses (option 1 in C.1.1.16) or not to cover transportation expenses for out-of-country coverage (option 1 in C.1.1.17).]

There is no reimbursement for medical expenses incurred out-of-country. There is no reimbursement for transportation for out-of-country treatment.

C.1.4 Eligible Participants

C.1.4.1 Identification of Eligible Employees and Dependents: U.S. Mission [Note to Contracting Officer: Insert Mission name] 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.1.4.1.1 Definition of Dependents

C1.4.1.1.1 Spouse: a limit of one legal spouse as defined by local law per employee will be covered.

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 [Note to Contracting Officer:

List host country] by: [Note to Contracting Officer: List U.S. Government agencies, e.g., Department of State, U.S. Agency for International Development, etc.]

[Note to Contracting Officer: Add one or both of the following paragraphs, if appropriate, if Official Residence Expense (ORE) Staff and/or Employee Association Employees (EAEs) are included under a rider. If only EAEs are included, mark C.1.4.3. “RESERVED” so the numbering remains consistent.]

C.1.4.3 Participants Covered Under a Rider

C.1.4.3.1 All current active ORE Staff 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 (see separate rider, Exhibit B). 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.1.4.3.2 All current active employees of the Employee Association at Embassy/Consulate [Note to Contracting Officer: Fill in name of post] (see separate rider, Exhibit C). All costs for coverage of [Note to Contracting Officer: Enter name of Embassy Employee Association and revise reference as appropriate] EAEs are the responsibility of the Employee Association, not the U.S. Government.

C.1.6 Eligibility

C.1.6.1 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.1.7 Brochure Requirement

C.1.7.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in [Note to Contracting Officer: State the required language this document will be prepared] 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.1.7.2 The Contractor shall provide the document described in C.1.7.1 to the COR not later than [Note to Contracting Officer: insert number of 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.1.7.3 The Contractor assumes full responsibility for ensuring that the document described in C.7.5.1 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.