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

06 August 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 assigned to this contract shall be able to read, write and speak

English effectively in order to communicate 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, up to 300 medical insurance premiums may be required annually. This includes premiums for Single, Married and Family.

Note: This is just an estimate. If adjustments are needed, the contractor will follow guidance under Section 2.3 of the PWS

2.2 Term of Eligibility: Each MNG student and his 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 After the student completes his training and returns from the United States, the student and his dependents must be withdrawn from the policy immediately.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 Coordination Between the MNG Medical, Dental, and Vision Insurance contractor and the CONUS Schools Support Contractor

• The MNG Medical, Dental, and Vision Insurance contractor POC shall coordinate with the CONUS Schools Support Contractor POC to request a list of all participants scheduled to travel to CONUS.

• The CONUS Schools Support Contractor will enroll participants in the MNG

Medical, Dental, and Vision Insurance program with coverage to begin twenty-four (24) hours prior to departure from KSA and perform disenrollment of personnel not later than twenty-four (24) hours after returning to KSA.

• The MNG Medical, Dental, and Vision Insurance contractor will provide the CONUS Schools Support Contractor POC with a list of enrollments for each participant in the medical program, along with an insurance policy card, within 48 hours of the participants' and their family members' departure to CONUS.

• The CONUS Schools Support Contractor POC information will be provided at time of award.

• The PCO, Contract Specialist, and COR shall be copied on all correspondence during coordination.

2.4 Enrollment Process: This contract is an Indefinite Delivery Indefinite Quantity (IDIQ) agreement with a five-year ordering period, issued in one-year increments. The

Government’s intent is to issue two task orders during each one-year ordering period, approximately one every six months. However, additional task orders may be issued within an ordering period if deemed necessary. The requirements in this section apply to each individual task order issued under this contract. For each task order, the contractor shall submit monthly Contract Data Requirement List (CDRL) deliverables, beginning in the first full month of performance and continuing through the end of the task order’s period of performance.

• The enrollment process includes tracking, reporting, and verifying all students and eligible dependents covered under this contract. The contractor is responsible for documenting all initial enrollments, additions, and terminations and ensuring all actions are submitted and approved.

1. Monthly Reporting: The contractor shall submit a monthly CDRL deliverable in the form of a single Microsoft Excel spreadsheet (Technical Exhibit A). This spreadsheet must include three distinct worksheet tabs to capture:

• Tab 1 – Initial Enrollment: Students and eligible dependents enrolled at the time of Task Order issuance.

• Tab 2 – Additions: Students and eligible dependents added after Task Order issuance. Note: Any changes to insurance coverage classification resulting from qualifying life events (e.g., marriage, childbirth) must be annotated in the “Additions” tab. These changes include but are not limited to:

▪ Single to Couple policy (e.g., upon marriage)

▪ Couple to Family policy (e.g., upon birth or legal addition of dependent)

▪ Each entry must include the type of life event, the effective date of change and justification for the policy update. All changes must be clearly identified in the CDRL and tracked against the appropriate task order.

• Tab 3 – Terminations: Students and dependents removed from coverage after Task Order issuance.

The format and required data elements for each tab are defined in Exhibit A. All additions must receive prior written approval from COR/PCO before enrollment.

Retroactive enrollments are not authorized. All monthly CDRL submissions must be provided to the PCO, COR, and ACOR, if assigned.

2. Tracking Requirement: To maintain consistency and alignment between government and contractor records, all students and dependents data shall be tracked using both Working Control Number (WCN) and Policy Number. These identifiers must be included in all monthly submissions and used consistently across all enrollment actions.

2.5 Historical Data: The contractor will be required to provide details of the Historical

Claims and Historical Number of Lives annually at the end of each Period of

Performance in the form of a single Microsoft Excel Spreadsheet (Technical Exhibit B).

This spreadsheet includes two distinct worksheet tabs to capture:

• Tab 1 – Historical Claims: Number of Lives insured, number of claims paid, and the dollar amount of paid claims detailed by month for the Period of Performance.

• Tab 2 – Historical Number of Lives: Age Range, Family Tier (Single, Couple, or Family), Number of Employees, and Total Number of Lives.

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, as determined by medical professionals, is part of this benefit. Radiotherapy, chemotherapy, oncology, radiology and pathology is also covered.

3.1.3 Organ Transplant (Paid in Full): 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. Charges made for or in connection with approved organ transplant services, including immunosuppressive medications, organ procurement costs and donor’s medical costs. Transplants must be medically necessary as determined by medical professionals.

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 from medical professionals 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 SAR 1,687/USD 449 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 13,313): 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 (Paid in Full): 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 as determined by medical professionals and approved by the insurance company. This does not cover any of the following:

– treatment carried out by a plastic surgeon, whether or not for medical/psychological purposes and any cosmetic or aesthetic treatment to enhance the individual’s appearance;

– any cosmetic healthcare services and services associated with replacement of an existing breast implant;

– abdominoplasty or treatment related to or arising from the removal or addition of non-diseased or surplus or fat tissue;

– nose surgeries for cosmetic purposes

3.2.11 Costs of Acquired Heart Valves (Up to SAR 150,000/USD 40,000)

3.2.12 Costs of Hearing Aids (Up to SAR 6,000/USD 1,600)

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 that are determined medically necessary by medical professionals up to the annual maximum benefit amount authorized.

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

4.1.5 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 as determined by medical professionals

4.1.6 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

4.1.7 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.

4.1.8 Routine foot care

4.1.9 Genetic screening or pre-implantations genetic screening

4.1.10 Any form of sterilization or contraception to include vasectomy

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

4.1.12 Medically recognized venereal or sexually transmitted diseases, excluding HIV (see

3.2.8)

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 medical professional’s 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.