RFI Paraguay - Health Insurance.docx

1.0 INTRODUCTION

This Request for Information (RFI) is being issued to help the Department of State (DOS) better understand the capabilities, and availability of services offered by insurance providers as well as industry best practices related to procuring insurance coverage in Paraguay.

Historical medical claims for PLAN 1 for Embassy Locally Employed Staff are presented below. There is no historical claims information for LE staff under Plan 2 (+ Estimated Quantities)

Claims for December 2017 to December 2018

Claims for December 2018 to December 2019

Claims for December 2019 to December 2020

Claims for December 2020 to December 2021

Claims for December 2021 to December 2022

To gather the necessary information, specific questions have been listed in Section 3: RFI Topic Areas. DOS requests your responses to these questions, as the answers may indicate whether such an initiative is worth pursuing and, if so, how the initiative should be structured.

This is not a Request for Proposal (RFP), Request for Quotation (RFQ), or an invitation for bid, nor does its issuance obligate or restrict the Government to an eventual acquisition. All information received from this RFI will be used for market research purposes only. The Government does not intend to award a contract based on responses to this RFI nor otherwise reimburse vendors for the preparation of any information submitted or Government use of such information. Acknowledgement of receipt of responses will not be made, nor will respondents be notified regarding the outcome of the information received.

1.1 BACKGROUND

In today's budgetary environment, all government Departments must strive to spend taxpayer dollars as efficiently as possible. The DOS, like other Departments, faces the challenge of providing important services and products to the American people and represent American interests abroad, while simultaneously reducing costs.

An identified area of potential efficiency improvement is overseas health insurance for locally employed staff. Each of DOS’s over 300 posts abroad hires locally employed staff to support operations. Unlike Foreign Service Officers or other DOS staff based out of the United States, these staff require locally procured health insurance. DOS is looking to improve the procurement and administration of health insurance for locally employed staff, with emphasis on ensuring that each post has commercially provided health insurance coverage.

DOS is looking to industry to provide input around health insurance as it investigates solutions that will:

• Meet the required minimum benefits as defined in Appendix: Medical Coverage and Benefits

• Standardize provided benefits

• Ensure that all posts have health insurance coverage

• Reduce contract costs driven by customized policies

• Reduce administrative costs driven by direct reimbursements

• Lower premium costs through pooling

• Increase quality of service

• Adhere to government mandates and DOS policies

2.0 RFI INSTRUCTIONS

2.1 Responses should be submitted in Microsoft Word format and, excluding attachments, should not exceed fifteen (15) pages with Arial font equal to 12 pt.

2.2. Responses are to be submitted via e-mail to Mr. Grant Knutson at KnutsonGM@state.gov no later than 5:00 p.m. EST, December 4, 2023.

3.0 RFI TOPIC AREAS

Topic 1: Vendor Demographics

· The DOS is interested in understanding the profile of the companies responding to this RFI. Accordingly, responses to the following questions are requested.

· Organization Name.

· NAICS (North American Industry Classification System) Codes.

· Number of years of corporate experience.

· Describe your primary line of business (e.g., health insurance, life insurance, dental insurance, other non-insurance).

· Which countries in the region do you operate in currently?

Topic 2: Desired Abilities of an Insurance Provider Please answer the following questions to help provide more clarity regarding your capabilities / offerings. In countries where some benefits are provided by host governments, coverage will be supplemental to meet the minimum required benefits as defined in Appendix: Medical Coverage and Benefits.

A. Benefit Services

1. Which of your commercial, off-the-shelf products would meet the minimum benefits as described in the Appendix? If a particular benefit is not covered, which one(s)?

2. What is the prevailing practice for reimbursement of medical expenses (e.g., medical provider bills insurance, insurance company reimburses patient)?

3. Where patients must submit claims for reimbursement, what are common practices to allow patients to pay for large expenses (e.g., medical loans, etc.)?

4. How will reimbursements claims be calculated for both in and out of network coverage? If market comparisons will be used, how will they be established?

5. When will coverage for newborns begin? How will the enrollment process for newborns work to ensure coverage is guarantee from their date of birth?

6. What communications channels will be available to employees to handle coverage requests such as pre-authorizations, reimbursements claims, benefits levels, dependent status information etc.?

7. How frequent is the provider network is updated? How are changes communicated to the affiliates?

B. Geographic Coverage

1. Are there any local laws requiring additional benefits that are not listed in the Appendix?

2. Is there anything unique about insurance in Paraguay that DOS should be aware of as it considers this initiative?

C. Contracts & Contract Structure

1. If you serve other multinational clients in the region, what structures (e.g., pooling, teaming with local providers, etc.) do you use to provide services to these clients across regions / countries?

2. Do you serve other government clients with operations abroad (e.g., DOD)? If so, which agencies? What structures do you use to cover their locally employed staff (e.g., type of contract, whether subcontracting, teaming is involved)?

D. Contract Administration / Tracking / Fraud

1. What essential functions do you offer for the administration of health insurance coverage (e.g., tracking claims and reimbursements, answering questions about eligibility, etc.)?

2. What factors within DOS control, outside of benefit levels, drive increases in premiums? What practices do you employ to control premium increases?

3. What mechanisms do you employ for dispute resolution (e.g., disputes regarding claims)?

4. How can the Government build visibility into this contract to ensure important financial information is readily available (e.g., the cost of premiums, the amount reimbursed, number of dependents covered, etc.)?

5. What infrastructure do you employ to track compliance with these contracts and make this information readily available to government (e.g., online system where government can track claims submitted by post)?

6. What are common risk areas or types of fraud (e.g., submitting false receipts for medical expenses) in this region?

7. What tactics do you employ to discover and mitigate cases of fraud?

8. In what ways can the enrollment process be streamlined?

E. Alternative Health Insurance Solutions

1. Are there other innovative health insurance solutions that can be provided to locally employed staff such as managed Flexible Spending Accounts, Health Saving Accounts, Health-Sharing Plans, or direct claim management services?

F. Information Required to Develop a Competitive Offer

1. Based on your experience with requirements of this type, what information and data are essential for you to develop a competitive offer (i.e., estimates of total contract value, # of insured, dependents, etc.)?

4.0 Appendix: Medical Coverage and Benefits - Core Health Insurance Benefits Requested:

DESCRIPTION/SPECIFICATION/WORK STATEMENT

(PLAN 1, Section C.1 - Current Employees Only)

C.1. HEALTH INSURANCE SERVICES – PLAN 1 (Current Employees Only) The Government of the United States of America requires Health Insurance coverage for its employees as described herein. The Government has determined that the prevailing practice by employers in Paraguay is to provide for their employees’ health insurance protection and that the cost of such insurance protection is usually borne by both the employee (15%) and the employer (85%).

The specific health benefit coverage under this contract is set forth in Plan 1, Section C.1. This is a standard package that must be provided to all current employees at U.S. Mission Paraguay who do not elect to participate in Plan 2, Section C.2 set forth below. New employees hired after the health insurance contract’s effective date do not qualify for the benefit levels in this Plan 1, Section C.1 (see Plan 2, Section C.2 below).

The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care, unless exclusion has been authorized by GTM/OE/CM.

C.1.1. Employee and Dependent Health Service Benefits The insurance company will cover 100% of reasonable and customary costs of benefits and services received and referenced below subject to any stated limits or applicable maximums as noted below. The medical treatment must be prescribed or provided by a physician or nurse licensed in Paraguay, the United States, or in the country in which the treatment or prescription is received. Payment will be made in local currency.

C.1.1.1. Deductible: None

C.1.1.2. Hospitalization: 100% coverage of room and board for a standard ward room, semi-private room, or private room; disposable/expendable medical supplies, medicines and utilitarian materials. 100% coverage of hospital medical expenses including laboratory tests, x-rays, nursing care, operating room costs, intensive care, and prescription medicines.

C.1.1.3. Surgery - 100% coverage of all types of major or minor surgical operations, anesthesia, blood transfusions, medicines, disposable/expendable medical supplies, utilitarian materials.

C.1.1.4. Doctor Visits – 100% coverage of hospital and office calls and medical appointments; and professional services of general clinic specialists; excluding home visits. Use of physicians and professionals not included on the Contractor’s list of preferred providers would result in coverage in the amount the physicians of the Contractor's staff would receive.

C.1.1.5. Hospital Outpatient Services – 100% coverage of ambulatory services, studies, treatments, simple and specialized laboratory analysis, and diagnostic studies.

C.1.1.6. Prescription Drugs and medicines: – 100% coverage of the cost of medicines and drugs while hospitalized for which a prescription is legally required. Expenses incurred for medicines in ambulatory prescriptions, vitamins, cold remedies, etc., that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician.

C.1.1.7. Obstetrical Care - 100% coverage when hospitalized for obstetrical medical care to include post-natal care and newborn care.

C.1.1.8. Family Planning: Not covered.

C.1.1.9. Ambulance Service - 100% coverage (extended to the entire territory of Paraguay).

C.1.1.10. Expenses Incurred Out-of-Country – Not covered.

C.1.1.11. HIV/AIDS Treatment Coverage: 100% coverage for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS; as well as brief courses of antiretroviral drugs during childbirth to prevent the transmission of HIV to the employee's child. This expanded coverage generally excludes medications for the long-term suppression of AIDS through the combination of antiretroviral drugs at those posts with inadequate local healthcare infrastructures. A separate maximum limit per year of USD $10,000 per employee applies to this coverage.

C.1.1.12. Emergencies: 100% coverage of treatment, procedures and medicines received as the result of urgencies and emergencies.

C.1.1.13 Intensive Care: 100% coverage of intensive therapy and/or poly-trauma services, therapies, medicines, supplies and materials. Adults and children covered.

C.1.1.14 Specialized Cases: 100% coverage for treatment in specialized medical centers for burn cases or contagious diseases.

C.1.1.15. Laboratory, analysis and diagnosis: 100% coverage of analyses and test ordered by an approved physician, radiology and scans, x-rays, etc. Medicines not covered.

C.1.1.16. Preventative Care: 100% coverage for annual preventative service to include: physical examination, general analysis, x-ray and electrocardiogram. For females this includes a pap smear, bone densitometry and mammography, etc.

C.1.1.17. Physical Therapy - 100% coverage for services prescribed by a physician.

C.1.1.18. Psychiatric Treatment – Reserved (special fee).

C.1.1.19. Dental Service - 100% coverage of basic dental treatments.

C.1.1.20. Optical Service – 100% coverage of examinations and eye surgery.

Prescriptions, frames and lenses are not covered.

C.1.1.21. Hearing Aids - Not covered.

C.1.1.22. NOTE: Procedures and disposable/expendable and materials/supplies for blood transfusions are covered at 100%, however, the provision of blood is not covered.

C.1.1.23. CONTRACTOR AND CONTRACTOR’S PERSONNEL KNOWLEDGE

AND EXPERIENCE IN THE WORK.

C.1.1.23.1. The Contractor shall have a minimum of two (2) years progressively responsible prior work experience in this business.

C.1.1.23.2. The Contractor shall have an office settled in the City of Asuncion properly registered under the laws of the republic of Paraguay.

C.1.1.23.3. The Contractor shall provide sufficient personnel possessing the skill, knowledge, education, training, etc. to perform the task described herein. Moreover, the Contractor shall assure that any required local licenses, permits, medical board certification etc. are obtained prior the Contractor personnel performing these services. The Contractor shall not hire off duty Government employees who serve as inspector or Contracting Officer’s Representative (COR) in their Government position, or any other persons whose employment would result in conflict of interest.

C.1.1.24. Exclusions or limitations: No coverage will be made for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long term rehabilitative therapy; non-medical hospital charges such as telephones or television, home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

No coverage will be made for expenses that will be reimbursed or paid directly under a host country medical program, the U.S. workers' compensation program, or any Paraguayan workers' compensation program.

No coverage will be made for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; drug addiction; a self-inflicted wound; or service in the armed forces of any country.

Any exclusion, exception or limitation to the services provided by the Contractor under the Contractor shall be clearly spelled out by the Contractor and provided to the Government and the Beneficiaries. Services not properly listed as called under this clause shall be considered as covered under the Contractor and must be covered by Contractor.

C.1.2. Health Benefits Conditions and Limitations

With the exception of expenses incurred under paragraph C.1.11 above, the Insurance company shall cover expenses up to a limit of (USD) [120,000] per individual, per event, per contract year.

The insurance company shall cover expenses described under paragraph C.1.1.11 of the plan up to a separate limit of (USD) [10,000] per employee per contract year.

No coverage for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long term rehabilitative therapy; non-medical hospital charges such as telephones or television; home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

No coverage for expenses that will be covered or paid directly under a host country medical program, the U.S. workers’ compensation program, or a post's LE Staff workers' compensation program.

No coverage for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; 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. There is no reimbursement for medical expenses incurred outside of Paraguay. There is no reimbursement for round trip transportation expenses to travel out of country for medical treatment.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees.

The employees eligible for the health insurance services include the following:

C.1.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Paraguay paid under the Local Compensation Plan, and certified by the Contracting Officer. Eligible employees are Locally Employed Staff who are (1) working on a full time or part time basis under non-temporary direct hire appointments or under personal services agreements/contracts that are not time limited to less than one year and (2) paid under the terms of the Local Compensation Plan. Participation is mandatory.

C.1.3.2. Location of Employment.

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Paraguay by:

U.S. Department of State, U.S. Agency for International Development (USAID), Drug Enforcement Administration (DEA), Defense Attaché Office (DAO), Office of Defense Cooperation (ODC), Open Source Center (OSC) former Foreign Broadcast Information Service

(FBIS),

Peace Corps (PC), Department of Justice, Department of Treasury, Federal Bureau of Investigation, or Any other USG Agency as certified by the CO.

C.1.3.3 RESERVED

C.1.4 Individuals Not Eligible for Coverage Not eligible are those working under temporary appointments; those working under a PSA or PSC that is time limited to less than one year; non-personal services Contractor personnel and their employees, supplied by an independent Contractor licensed to do business in Paraguay who provides services to other local organizations as well as to the U.S. Mission; employees of USAID institutional Contractors; and Peace Corps personal services Contractors as indicated in

MS 743.

C.1.5. Other Eligible Participants.

The following additional categories of persons are covered by this insurance:

C.1.5.1. Dependent Coverage: Expenses incurred by an enrolled employee's eligible dependents are covered under this plan. For the purposes of this plan, an employee's dependents are defined as the employee's legal spouse (limit one), economically dependent parents, and each unmarried, economically dependent child who primarily resides with the employee unless away at school. Child is defined as the employee's natural child, adopted child, foster child, or stepchild. An eligible child will be covered until the end of the calendar year in which the child turns age 21. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently. There is no limit on the number of children covered per employee.

C.1.5.2. Special agreements between the Contractor and covered employee may be established to cover the following dependents based on an additional premium which will be paid in each case by the employee without charge to the U.S. Government.

a. Parents of the covered employee, who are not economically dependent.

b. Dependent children of the covered employee over twenty-one (21) years old, single or married; no coverage for spouses.

c. Parents-in-law of the covered employee.

d. Brothers and sisters of the covered employee only, single and/or married.

e. Grandchildren of the beneficiary employee only, single and/or married.

C.1.5.3 Retired U.S. Government Employees: USG retirees shall have the option, upon a written request addressed to Contractor and cleared by the COR to be covered by the Contractor, at any time, by virtue of a private agreement signed between the Contractor and the retiree. All Retired employees covered by this clause must pay the total amount of the premium to the Contractor; the Government shall not contribute to these premium payments. Retirees covered under this clause shall have all rights and benefits conceded to USG employees including coverage for spouses and the options stipulated above at same prices set for employees/beneficiary coverage.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

C.1.6.2. Period of Ineligibility.

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

Additionally, employee's dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate.

During a period of Leave Without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.

During a period of extended (beyond one pay period) of Leave Without Pay or unpaid leave, the employee is responsible for the full cost of the insurance premiums (employee’s and the Government’s share) for self and dependents. The Mission will pay the premiums directly to the contractor, and will collect the full cost from the employee.

C.1.7. Brochure Requirement.

C.1.7.1. The contractor shall provide a document (brochure/pamphlet/other written document) in Spanish language 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 30 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR’s request.

C.1.7.3. The contractor assumes full responsibility for ensuring that the document described in C.1.7.1 accurately reflects the requirements 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 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.

PLAN 2, SECTION C.2 - CURRENT EMPLOYEES AND NEW EMPLOYEES – ADDITIONAL PLAN

C.2 HEALTH INSURANCE SERVICES – PLAN 2 (Current Employees and New Employees) The Government of the United States of America requires Health Insurance coverage for its employees as described herein. The benefit levels listed in Plan 2, Section C.2 are a standard package that must be provided to all new employees hired at U.S. Embassy Paraguay after the new health insurance contract’s effective date and current employees who enroll in Plan 2, Section C.2, during an initial enrollment period or during Annual Open Season. Current employees may select Plan 2, Section C.2, during an initial enrollment period or during Annual Open Season. Once Plan 2. Section C.2 is selected, current employees cannot opt back into Plan 1, Section C.1.

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 Outpatient Services (below) for details concerning professional services.

C.2.1.2 Emergency Services (trips to emergency room): 100% Coverage Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.

C.2.1.3 Ambulance: 100% Coverage 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.2.1.4 Outpatient Services: 100% Coverage Services provided by a certified healthcare provider on an ambulatory or outpatient basis (without being admitted to a hospital), including surgeon’s fees and other medical services that may be provided in 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.2.1.5 Obstetric and Newborn Care: Inpatient: 100% Coverage; Outpatient: 100% Coverage 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.

C.2.1.6 Pediatric Services: Inpatient: 100% Coverage; Outpatient: 100% Coverage 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.

C.2.1.7 Prescription Drugs: Inpatient: 100% Coverage; Outpatient: No Coverage 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.

C.2.1.8 Preventive and Wellness and Chronic Disease Management: 100% Coverage 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, hearing tests for diagnostic and preventative purposes, and cancer screenings.

C.2.1.9 Hearing Aids: No Coverage

C.2.1.10 Optical:

Examinations and Treatment: 100% Coverage Prescription lenses and frames, or contact lenses: No Coverage C.2.1.11 Dental:

Basic dental treatments: 100% Coverage

Orthodontia: No Coverage

Physical Therapy: For services prescribed by a physician. 100% Coverage C.2.1.15 HIV/AIDS: 100% up to USD 10,000 per contract year per covered individual 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.

Note to Contracting Officer: Post should consider electing this option if HIV/AIDS treatment is not covered as prevailing practice by local medical insurance providers, or is prohibitively expensive.

*C.2.1.16 RESERVED

*C.2.1.17 RESERVED

*C.2.1.18 RESERVED

*C.2.1.19 RESERVED

*C.2.1.20 RESERVED

*C.2.1.21 RESERVED

C.2.2 Annual Maximum Limit:

The maximum annual coverage per covered individual per contract year, not including expenses covered under HIV/AIDS benefits if selected by post, is USD 120,000.

C.2.3 Exclusions to Coverage:

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, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, 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.

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

To be eligible to participate in the medical plan, LE Staff must be 1) Paid under the terms of the Local Compensation Plan (LCP); and 2) Under a non-temporary direct hire appointment, personal services agreement (PSA), or Personal services contract (PSC); or 3) Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

Not eligible are those working under temporary appointments; those working under a PSC or PSA that is time limited to less than one year; non-personal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Paraguay who provides services to other local organizations as well as to the U.S. Mission; employees working on an intermittent or When Actually Employed (WAE) schedule; employees of USAID institutional contractors; Peace Corps personal services contractors as indicated in MS 743; and Recreation Association employees.

C.2.4.1.1. Definition of Dependents LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

C.2.4.1.1.1 Legal spouse: one legal spouse as defined by local law may be covered. LE Staff with more than one legal spouse must select only one spouse for coverage.

In cases where LE Staff and their legal spouse 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.

a. Parents of the covered employee, who are not economically dependent.

b. Dependent children of the covered employee over twenty one (21) years old, single or married; no coverage for spouses.

c. Parents-in-law of the covered employee.

d. Brothers and sisters of the covered employee only, single and/or married.

e. Grandchildren of the beneficiary employee only, single and/or married.

C.2.4.2 Location of Employment: The eligible employees covered by C.1.4.1 must be employed within the geographic boundaries of Paraguay by:

U.S. Department of State, U.S. Agency for International Development (USAID), Drug Enforcement Administration (DEA), Defense Attaché Office (DAO), Office of Defense Cooperation (ODC), Open Source Center (OSC) former Foreign Broadcast Information Service (FBIS), Peace Corps (PC), Department of Justice, Department of Treasury, Federal Bureau of Investigation, or Any other USG Agency as certified by the CO.

C.2.4.3 Participants Covered Under a Rider Official Residence Expense (ORE) and Employee Association (EA) employees may be covered under a rider to the contract. The employing officer/EA, not the USG, is responsible for the employer's share of the premium costs for an ORE employee.

Retiree Coverage: Retirees have the option to participate in this plan under a rider for continued coverage for themselves and eligible covered dependents. All health benefits and limitations outlined apply to the retired employee and covered dependents. The retired employee will be responsible for paying 100% of the premium costs for the coverage of themselves and their dependents.

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.2.5.2 Periods of Ineligibility:

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

Additionally, employee's dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate.

During a period of extended Leave Without Pay (LWOP) or unpaid leave beyond one pay period, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the Contractor, and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if they prefer not to pay the premium.

FMO The Financial Management Officer or the paying office for all U.S.

Government Agencies except AID and Peace Corps.

COR Contracting Officer's Representative (COR) is the Human Resources Officer (HRO) at post

Contributory Insurance: Insurance for which the employee contributes toward the premium.

Dependent The spouse, children under the age of twenty one (21) years old, if they are not married and are economically dependent (child is defined as the employee’s natural child, adopted child, stepchild, or foster child), as well as the parents of the employee, if economically dependent and/or living at the employee’s house.

Disability-Total and Permanent: A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment. If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

Employee An individual employed by the U.S. Government, under a direct-hire appointment, personal services contract (PSC), or personal services agreement (PSA), as further defined in Section C.1.3 for health insurance.

Employer The United States Government.

GSO General Services Officer in charge of the General Services Office at post.

This officer is usually the Contracting Officer for this contract.

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.

Hospital Patient: An individual who has been admitted to a hospital, is assigned a bed, and is given diagnostic tests or receives treatment for a disease or an injury.

Maximum Benefit: The total amount that will be covered/paid to any one covered individual for covered medical expenses.

Customary and Reasonable Treatment: A diagnostic test or medical treatment which is usually performed in the community where the individual is being treated.

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 Board Certified in that specialty.

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

Annual Open Season: Time of the year to enroll, update, or cancel health insurance coverage.

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