PWS BG Healthcare Insurance - RFI.pdf

10 September 2024

SECTION C

PERFORMANCE WORK STATEMENT (PWS)

LOCAL NATIONAL HEALTHCARE INSURANCE (LNHCI)

C.1. Health Insurance Services

The U.S. Government requires Health Insurance coverage for its Bahraini Grade (BG) employees in the designated country of the Kingdom of Bahrain to provide for these employees’ health insurance protection.

In some cases, the cost of such insurance protection is usually borne by both the employees and the employer on a co-insurance basis. Health insurance protection shall be representative of host country prevailing compensation practice. The contractor shall provide the required health insurance coverage in accordance with (IAW) the section C and section H set forth under this PWS.

C.1.1 Employee Health Services Benefits

The health benefits under this contract are as follows and coverage shall not exceed the annual limit stated in C.1.1.13.

C.1.1.1 Hospitalization:

100% coverage of room and board expenses for a ward room or semi-private room.

100% coverage of hospital medical expenses including laboratory tests and x-rays, nursing care, operating room costs, intensive care, prescription medicines, and physiotherapy on an in-patient or day case basis.

100% coverage for major surgery including but not limited to, cost of surgery for body organ system transplant for only the insured employee, internal prosthesis, hip, knee replacement, heart surgery, appendix surgery, brain surgery, kidney stone removal surgery and other related types of major surgery.

100% coverage of ambulance service.

C.1.1.2 Medical Services and Treatment:

100% coverage of doctors’ and surgeons’ fees incurred while hospitalized, at a hospital on an out-patient basis, at a clinic or doctor’s office, or at home.

100% coverage for medical services and expenses on an out-patient basis such as laboratory tests and x-rays, prescription medicines, physiotherapy, routine annual physical examination, and vaccinations.

C.1.1.3 Prescription Drugs and Medicines: 100% coverage when hospitalized and when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required as prescribed by a physician.

C.1.1.4 Maternity Care: 100% coverage of prenatal, postnatal care, delivery and complications, when hospitalized or not hospitalized.

C.1.1.5 Optical Care: Coverage includes eye examination and prescription eyeglass lenses. 80% coverage of optical care expenses with a limit of $300.00 per employee every two years. Prescription eyeglass lenses are limited to one set of lenses per employee every two years. Optical care benefit shall remain open and be available for employee use throughout the policy periods with the limit fully restored every two years only. Optical care benefit shall begin at the start of the first year of policy coverage. For new employees, lenses benefit shall begin on the day of enrollment regardless of remainder of years for policy coverage.

C.1.1.6 Dental Care: 100% coverage of expenses for dental services including dentists’ fees, x-rays, examination and treatment, gum treatment, cleaning, fillings, extractions, dentures, crowns, and bridges. Dental care is subject an annual maximum of $1,000.00 per policy year per employee. Orthodontist treatment is covered only if required as the result of an accident. A maximum of four years of orthodontist treatment shall be covered per employee.

C.1.1.7 Minor Surgery: Including but not limited to coverage of minimally invasive procedures such as for treatment of skin disorders, removal of foreign objects, incision and drainage of abscess, nail removal, POP cast application, cataract surgery and other related types of minor surgery.

C.1.1.8 Pre-existing and Chronic Illness: Including but not limited to 100% coverage upon diagnosis of the following ailments such as cancer, leukemia, stroke, heart attack, lung disease, liver disease, kidney failure, hypertension, diabetes, coma and other related types of pre-existing and chronic illness. All types of cancer treatment shall have 100% coverage without exclusion.

C.1.1.9 Medical Expenses Incurred Out of Country:

Medical expenses incurred outside the boundaries of the Kingdom of Bahrain shall be covered for employees when (a) a life threatening condition occurs when the employee is out of the country and treatment is medically necessary before the employee returns to the Kingdom of Bahrain or (b) the employees’ attending physician certifies in advance that such treatment is medically necessary and unavailable in the Kingdom of Bahrain. Coverage shall be on cost reimbursement basis and shall be made at the same percentage rate and subject to the same annual maximum limit as for expenses incurred in country.

C.1.1.10 Transportation for Out of Country Treatment: Transportation expenses for out of country treatment is the responsibility of the employee and not covered by this contract.

C.1.1.11 Repatriation of Mortal Remains:

For death that occurs when the insured employee is in the country of the Kingdom of Bahrain or out of country, the coverage shall include all reasonable and necessary expenses for transporting the employees’ mortal remains to the employees’ home country or country of residence. Benefit shall cover local burial at the place of death, but such expenses are not to exceed the cost to repatriate the insured employees’ mortal remains from the place of death to employees’ home country or country of residence. Benefit shall be on a cost reimbursement basis and subject to maximum coverage of $10,000.00.

Cost shall be reimbursed for coordination with local authorities on the post-mortem exam, removal and transportation of the body to medical facilities, coroner and airport, a coffin or appropriate container for the transport of remains, coordination with government agents to arrange for services, authorizations, and approvals for transport and air and ground shipping expenses.

C.1.1.12 Deductible: The deductible for this insurance coverage shall not exceed $13.25 per employee per consultation visit.

C.1.1.13 Annual Maximum Coverage Limit: The maximum annual coverage is $37,100.00 per employee per contract year.

C.1.2. Health Benefits Limitations

There is no coverage for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long term rehabilitative therapy; eyeglass frames; non-medical hospital charges such as telephones or television; home nursing care; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a registered physician.

There is no coverage for expenses related to an illness or injury that is a result of an unlawful action on the part of the employee; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self-inflicted wound; or service in the armed forces of any country.

C.1.3. Eligible Participants

C.1.3.1 Eligible Employees: The employees’ eligible for the health insurance services are appropriated funded and non-appropriated funded employees and sponsored by Naval Support Activity

Bahrain.

C.1.3.2 Location of Employment: Eligible employees must be located and hired within the geographic boundaries of the Kingdom of Bahrain.

C.1.4. Eligibility

C.1.4.1 Term of Eligibility and Effective Date:

Each current active eligible employee is enrolled for health benefits under this contract upon task order award and thereafter during the performance period of this contract. Each new eligible employee shall be enrolled upon entry. An employee is considered active whenever such employee is on approved leave, whether paid or unpaid.

C.1.4.2 Period of Ineligibility

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

C.1.5. Online System Requirement

C.1.5.1 The Contractor shall provide an online system (such as a website or mobile application) for access to complete listing of accurate healthcare benefits, including but not limited to, policy card viewing, list of network providers, cashless transactions, notification alerts, customer service, pre-approval requests and approvals. The online system shall have the ability to process, submit and track medical claims and reimbursement claims. All services shall be processed in a timely manner.

C.1.5.2 The Contractor assumes full responsibility for ensuring that the online system accurately reflects the requirements of the contract, as implemented by the Contractor’s technical proposal. In all cases, this contract shall take precedence. Should the Government discover that the online system contains inaccuracies, the Contractor shall 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.1.5.3 The Contractor shall provide all employees proof of identification of insurance within five working days.

C.1.5.4 The Contractor shall have a functioning process in place for Claims Processing and Claims

Settlement. Processes should be able to handle requests 24 hours 7 days a week. Any change to process should be notified to the employees within two working days.

SECTION H

SPECIAL CONTRACT REQUIREMENTS

H.1. Security: On occasion, a Contractor employee may require entry into U.S. Government-owned or -operated facilities. If so, the Contractor should be prepared to provide the necessary identification to permit escorted access within that facility.

H.2. Standards of Conduct: The Contractor shall maintain satisfactory standards of employee competency, conduct, cleanliness, appearance, and integrity and shall be responsible for taking such disciplinary action with respect to employees as may be necessary. Each Contractor employee is to adhere to standards that reflect credit on themselves, their employer, and the United States Government.

H.3. Ordering Procedures:

The Government shall issue a task order as soon as possible after contract award to list all employees to be covered by the insurance described in this contract. The COR shall monitor subsequent additions or deletions to this list in writing and provide the revised list to the KO. The KO shall issue a bilateral modification to the task order to include all changes made since the task order was issued and shall include any increase or decrease in necessary funding. The Government anticipates issuance of a modification of the task order on a monthly basis. The changes to the list of the employees shall supersede the previous list when the task order was issued and without prejudice to the ineligibility clause. Task order shall indicate the effective date of employment for purposes of calculating the premium due.

H.4. Response to Request for Information: The Government shall request information from the

Contractor such as data calls, log requests, enquiries, reports and other relevant information throughout the period of performance. Responses shall be provided within five working days of request receipt.

H.5. Contractor Responsibility in Claims and Reimbursement to Claimants

The Contractor shall be responsible for all planning, estimating, programming, project management, scheduling, dispatching, supervision, and inspection of work. The Contractor shall be responsible to acknowledge and respond to employee queries 24 hours 7 days a week. The nature of these queries may range from pre-approval or pre-authorization requests, clarifications and benefits enquiries. Responses shall be provided within 48 hours from time of enquiry directly to the requesting employee. The Contractor shall treat the information concerning employee' personal data and medical information, as highly sensitive and not divulge any employee information to unauthorized persons. The Contractor shall maintain their own reference library of technical reference works and local laws and regulations, including current tariffs and registries.

The Contractor shall establish procedures for the following:

(a) Administrative Records

(1) The Contractor shall maintain medical insurance files (hard copies or digital) for each covered 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 person limits.

(3) The Contractor shall use the English spelling of the employees' names in all transactions.

(b) Medical Insurance Claims for Investigation and Reimbursement: Settlement of medical insurance claims shall be completed as follows:

(1) Claims submission period shall be within 30 days from the treatment date.

(2) The Contractor shall acknowledge and notify employees within 48 hours upon receipt of a claims request.

(3) All medical claims and documents requested as necessary, shall be submitted directly to the Contractor by employees, through the online system/mobile application.

(4) The Contractor shall date/time 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 days.

(5) For claim investigation, the Contractor shall provide a response for approval or denial to the requesting employee, no later than 30 days from the date the claim is submitted to the

Contractor.

(6) For claim reimbursement, the employee shall select the reimbursement payment method and settlements shall be filed in the name of the employee for each claim submitted. Each addressed claim shall be accompanied by a settlement sheet providing details of the amount reimbursed with an explanation of deductions, if any. The Contractor shall settle the reimbursement claim to the requesting employee, no later than 30 days from the date the claim is submitted to the Contractor.

(7) The Contractor shall accept the employee's choice to go for surgery to hospitals designated by the Contractor in order that the Contractor shall pay the expenses directly to the hospitals.

H.6. Report Requirements: The Contractor shall provide the following reports monthly. All reports must be received by the COR no later than the 10th day of each month. These reports shall report on the previous month's activities.

(a) Employee Enrollment Report: The report shall list current employees. Any additions, deletions or changes shall be updated by the Contractor.

(b) Declined Claims Report: The report shall list the claims that were declined by the

Contractor as they were out of scope and not covered by the health benefits listed in Section

C.1.1.

(c) Reimbursement 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.

H.7. Miscellaneous Contractor Requirements

H.7.1 General:

The Contractor shall take all such steps as are necessary, and obtain and pay for all permits, taxes and fees as are required by the Bahrain government to establish and/or operate a commercial venture locally. A contract with the U.S. Government conveys no special privileges or immunities to the Contractor. The

Contractor is an independent commercial concern and not a part of the U.S. Government. The Contractor's employees are not U.S. Government employees. Registration of this contract with the Bahrain government, if required by law, shall be the sole responsibility of the Contractor, and any fees, taxes, or other duties shall be payable by the Contractor without recourse to the Government of the amounts thereof.

H.7.2 Licenses and Local Laws:

The Contractor shall possess all permits, licenses, and any other appointments required for the prosecution of work under this contract, all at no additional cost to the Government. The Contractor shall perform this contract in accordance with local laws.

H.8. Erroneous Payments: If the Government becomes eligible for a refund of payment because of erroneous overpayment or other cause, the Contractor shall refund the amounts or use them to offset future payments owed by the Government, whichever the Government prefers. The Contractor shall refund any refunds not complete or discovered after the completion date of this contract.

H.9. Requiring Activity: The requiring activity under this contract is Naval Support Activity Bahrain located in the Kingdom of Bahrain.

H.10. Definition

KO Contracting Officer

COR Contracting Officer Representative

Employee An individual employed by the U.S. Government under a direct hire appointment and further defined under

Section C.1.3

Employer/ Government The United States Government or any other USG agency under Department of Defense.

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.

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 a Board Certified in that specialty.

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

In-patient In-patient care requires overnight hospitalization, for at least one night.

Day case Day case patient is admitted for a selected procedure but returns home the same day, and does not remain overnight.

Out-patient Out-patient receives diagnostic care and treatment at a hospital but is not admitted for overnight care.

Provider A list of medical facilities available for health services.

There are designated Network Providers for which payment will be on direct billing to the hospital on your behalf.

Co-insurance Co-insurance is the percentage of amount, in addition to a deductible and premium, that you need to pay for certain services. This percentage amount shall be paid to the Provider of the health service at the time of service or when billed by the Provider.

Deductible Deductible is a specific amount you must contribute and pay for each hospital visit.