RFP 19AQMM21R0260.pdf

19AQMM21R0260

SOLICITATION, OFFER, AND AWARD

1. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR

700)

RATING

2. CONTRACT NUMBER 3. SOLICITATION NUMBER

19AQMM21R0260 SEALED BID (IFB)

X NEGOTIATED (RFP)

4. TYPE OF SOLICITATION 5. DATE ISSUED

09/24/2021

6. REQUISITION/PURCHASE NUMBER

CODE: LMAQM

OFFICE OF ACQUISITION MANAGEMENT (A/LM/AQM)

PO BOX 9115, ROSSLYN STATION

US DEPARTMENT OF STATE

ARLINGTON, VA 22219

7. ISSUED BY 8. ADDRESS OFFER TO (If other than Item 7)

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

SOLICITATION

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

9. Sealed offers in original and ____ copies for furnishing the supplies or services in the Schedule will be received at the place specified in item 8, or if handcarried, in the depository located in ____ until

____ local time __11/17/2021__

10. FOR

INFORMATION

E-MAIL:

A. NAME

Stephanie Reid-Smith

B. TELEPHONE (NO

COLLECT CALLS)

C. E-MAIL ADDRESS

Reid-SmithSJ@state.gov

11. TABLE OF CONTENTS (See Table of Contents on page 2)

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. DESCRIPTION PAGE(S)

PART I - SCHEDULE PART II - CONTRACT CLAUSES

X A SOLICITATION/CONTRACT FORM X I CONTRACT CLAUSES Contract X B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

X C DESCRIPTION/SPECS./WORK STATEMENT X J LIST OF ATTACHMENTS

X D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE X K REPRESENTATIONS CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORSX F DELIVERIES OR PERFORMANCE

X L INSTRS., CONDS., AND NOTICES TO OFFERORSX G CONTRACT ADMINISTRATION DATA

X M EVALUATION FACTORS FOR AWARDX H SPECIAL CONTRACT REQUIREMENTS

OFFER (Must be fully completed by offeror)

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

In compliance with the above, the undersigned agrees, if this offer is accepted within __________ calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

12.

13. DISCOUNT FOR PROMPT PAYMENT (See Section I, Clause No.

52.232-8)

10 CALENDAR DAYS(%)

0.00 %

20 CALENDAR DAYS(%)

0.00 %

30 CALENDAR DAYS(%)

0.00 %

0 CALENDER DAYS(%)

0.00 %

14. ACKNOWLEDGEMENT OF AMENDMENTS (The offeror acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated):

AMENDMENT NO. DATE AMENDMENT NO. DATE

15A. NAME AND

ADDRESS OF

OFFEROR

CONTACT: DUNS: 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER (Type or Print)

15B. TELEPHONE NUMBER

15C. CHECK IF REMITTANCE ADDRESS IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS IN SCHEDULE.

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

10 U.S.C. 2304(c) ( ) 41 U.S.C. 253(c) ( )

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION: 23. SUBMIT INVOICES TO ADDRESS SHOWN IN (4 copies unless otherwise specified)

ITEM

CODE: OPEAQM

AQM Mexico City

OPE/AQM/IP/AQM MXC

Office of Acquisition (AQM) Mexico

24. ADMINISTERED BY (if other than Item 7) CODE:25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

Stephanie Reid-Smith (Signature of Contracting Officer)

27. UNITED STATES OF AMERICA 28. DATE

09/24/2021 IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (REV. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

CGFS : : CGFS

Line Item Summary

Solicitation Number:

19AQMM21R0260

Contract Number: Title: Health Care Insurance Services

- Santo Domingo

Date of Solicitation:

09/24/2021

Line Item No.

Description Quantity Unit Unit Price Total Cost

001 SEE ATTACHED STATEMENT OF WORK

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

0.00 LT

1001 OPTION YEAR ONE

SEE ATTACHED STATEMENT OF WORK

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

0.00 LT

2001 OPTION YEAR TWO

SEE ATTACHED STATEMENT OF WORK

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

0.00 LT

3001 OPTION YEAR THREE

SEE ATTACHED STATEMENT OF WORK

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

0.00 LT

4001 OPTION YEAR FOUR

SEE ATTACHED STATEMENT OF WORK

Type of Contract Pricing:

Doc Ref No:

Delivery Date FOB:

0.00 LT

Section A - Solicitation/Contract Form

52.252-2 - Clauses Incorporated by Reference (Feb 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/ these address(es):

https://acquisition.gov/browse/index/far https://www.acquisition.gov/dosar https://ecfr.io/ [Insert one or more Internet addresses] (End of clause)

52.252-1 - Solicitation Provisions Incorporated by Reference (Feb 1998)

This solicitation incorporates one or more solicitation provisions by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its quotation or offer. In lieu of submitting the full text of those provisions, the offeror may identify the provision by paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text of a solicitation provision may be accessed electronically at this/these address(es):

https://www.acquisition.gov/browse/index/far https://ecfr.io/ [Insert one or more Internet addresses] (End of provision) Clause Title Fill-ins

Clause Title Fill-ins

52.246-4 Inspection of Services-Fixed-Price (Aug 1996)

52.242-15 Stop-Work Order (Aug 1989)

52.242-17 Government Delay of Work (Apr 1984)

52.203-6 Restrictions on Subcontractor Sales to the Government (Jun 2020)

52.202-1 Definitions (Jun 2020)

52.203-3 Gratuities (Apr 1984)

52.203-5 Covenant Against Contingent Fees (May 2014)

52.204-25 Prohibition on Contracting for Certain Telecommunications and Video

Surveillance Services or Equipment (Aug 2020)

52.203-7 Anti-Kickback Procedures (Jun 2020)

52.203-8 Cancellation, Rescission, and Recovery of Funds for Illegal or Improper

Activity (May 2014)

52.203-10 Price or Fee Adjustment for Illegal or Improper Activity (May 2014)

52.203-12 Limitation On Payments to Influence Certain Federal Transactions (Jun 2020)

52.203-17 Contractor Employee Whistleblower Rights and Requirement To Inform

Employees of Whistleblower Rights (Jun 2020)

52.209-6 Protecting the Government's Interest When Subcontracting with Contractors

Debarred, Suspended, or Proposed for Debarment (Jun 2020)

52.215-13 Subcontractor Certified Cost or Pricing Data-Modifications (Jun 2020)

52.204-23 Prohibition on Contracting for Hardware, Software, and Services Developed or Provided by Kaspersky Lab and Other Covered Entities (Jul 2018)

52.222-50 Combating Trafficking in Persons (Oct 2020)

52.215-8 Order of Precedence - Uniform Contract Format (Oct 1997)

52.215-19 Notification of Ownership Changes (Oct 1997)

52.210-1 Market Research (Jun 2020)

52.222-1 Notice to the Government of Labor Disputes (Feb 1997)

52.204-19 Incorporation by Reference of Representations and Certifications (Dec 2014)

52.223-6 Drug-Free Workplace (May 2001)

52.224-1 Privacy Act Notification (Apr 1984)

Clause Title Fill-ins

52.215-11 Price Reduction for Defective Certified Cost or Pricing Data-Modifications

(Jun 2020)

52.224-2 Privacy Act (Apr 1984)

52.229-3 Federal, State and Local Taxes (Feb 2013)

52.204-18 Commercial and Government Entity Code Maintenance (Aug 2020)

52.209-9 Updates of Publicly Available Information Regarding Responsibility Matters

(Oct 2018)

52.222-19 Child Labor--Cooperation with Authorities and Remedies (Jan 2020)

52.232-25 Prompt Payment (Jan 2017)

52.233-1 Disputes (May 2014)

52.242-13 Bankruptcy (July 1995)

52.204-13 System for Award Management Maintenance (Oct 2018)

52.243-1 Changes-Fixed-Price (Aug 1987)

52.249-2 Termination for Convenience of the Government (Fixed-Price) (Apr 2012)

52.204-10 Reporting Executive Compensation and First-Tier Subcontract Awards (Jun

2020)

652.225-71 SECTION 8(a) OF THE EXPORT ADMINISTRATION ACT OF 1979, AS

AMENDED (AUG 1999)

52.204-9 Personal Identity Verification of Contractor Personnel (Jan 2011)

52.204-4 Printed or Copied Double-Sided on Postconsumer Fiber Content Paper (May

2011)

52.203-19 Prohibition on Requiring Certain Internal Confidentiality Agreements or

Statements (Jan 2017)

52.203-13 Contractor Code of Business Ethics and Conduct (Jun 2020)

52.215-21 Requirements for Certified Cost or Pricing Data and Data Other Than

Certified Cost or Pricing Data-Modifications (Jun 2020)

52.223-18 Encouraging Contractor Policies to Ban Text Messaging While Driving (Jun

2020)

52.224-3 Privacy Training (Jan 2017)

52.225-5 Trade Agreements (Oct 2019)

Clause Title Fill-ins

52.225-13 Restrictions on Certain Foreign Purchases (Feb 2021)

52.225-14 Inconsistency Between English Version and Translation of Contract (Feb

2000)

52.228-4 Workers' Compensation and War-Hazard Insurance Overseas (Apr 1984)

52.228-5 Insurance-Work on a Government Installation (Jan 1997)

52.229-6 Taxes-Foreign Fixed-Price Contracts (Feb 2013)

52.232-1 Payments (Apr 1984)

52.232-8 Discounts For Prompt Payment (Feb 2002)

52.232-11 Extras (Apr 1984)

52.232-17 Interest (May 2014)

52.232-18 Availability of Funds (Apr 1984)

52.232-24 Prohibition of Assignment of Claims (May 2014)

52.232-33 Payment by Electronic Funds Transfer-System for Award Management (Oct

2018)

52.232-40 Providing Accelerated Payments to Small Business Subcontractors (Dec

2013)

52.233-3 Protest after Award (Aug 1996)

52.233-4 Applicable Law for Breach of Contract Claim (Oct 2004)

52.237-2 Protection of Government Buildings, Equipment, and Vegetation (Apr 1984)

52.244-6 Subcontracts for Commercial Items (Jul 2021)

52.246-25 Limitation of Liability-Services (Feb 1997)

52.246-26 Reporting Nonconforming Items (Jun 2020)

52.249-8 Default (Fixed-Price Supply and Service) (Apr 1984)

52.232-34 Payment by Electronic Funds Transfer-Other than System for Award

Management (Jul 2013)

52.248-1 Value Engineering (Jun 2020)

52.237-3 Continuity of Services (Jan 1991)

52.204-15 Service Contract Reporting Requirements for Indefinite-Delivery Contracts

(Oct 2016)

52.215-2 Audit and Records-Negotiation (Jun 2020)

Clause Title Fill-ins

52.229-12 Tax on Certain Foreign Procurements (Feb 2021)

52.225-25 Prohibition on Contracting with Entities Engaging in Certain Activities or

Transactions Relating to Iran--Representation and Certifications (Jun 2020)

52.203-11 Certification And Disclosure Regarding Payments To Influence Certain

Federal Transactions (Sept 2007)

52.209-2 Prohibition on Contracting with Inverted Domestic Corporations--

Representation (Nov 2015)

52.229-11 Tax on Certain Foreign Procurements--Notice and Representation (Jun 2020)

52.203-18 Prohibition on Contracting with Entities that Require Certain Internal

Confidentiality Agreements or Statements--Representation (Jan 2017)

652.206-70 ADVOCATE FOR COMPETITION/OMBUDSMAN (FEB 2015)

52.204-7 System for Award Management (Oct 2018)

52.204-16 Commercial and Government Entity Code Reporting (Aug 2020)

52.214-34 Submission of Offers in the English Language (Apr 1991)

52.215-1 Instructions to Offerors-Competitive Acquisition (Jan 2017)

52.222-56 Certification Regarding Trafficking in Persons Compliance Plan (Oct 2020)

52.214-35 Submission of Offers in U.S. Currency (Apr 1991)

A-001 - NOTICE OF CHANGE

NOTE: This RFP replaces Draft notice sent under 19AQMM21R0026, in its entirety.

The North American Industry Classification System (NAICS) code for this acquisition: 524114 - Direct Health and Medical Insurance Carriers.

If applicable, the small business size standard is 38,5000,000.

B-004 - MINIMUM AND MAXIMUM CONTRACT AMOUNTS (Indefinite Quantity Contract)

Per FAR 52.216-22 "INDEFINITE QUANTITY," the minimum for this indefinite quantity contract shall be any quantity or combination of supplies and services equal to the amount(s) set forth below.

During the Base Year of the contract, the United States Government (USG) shall place orders totaling a minimum of DOP$ 100,000.00. This reflects the contract's minimum guaranteed.

The maximum for this indefinite quantity contract (including all options): The amount of all orders, for the base and all option years shall not exceed DOP$ 150,000,000.00. This reflects the contract's maximum (including all options).”

(end of clause)

B-010 - TYPE OF CONTRACT

The Government contemplates award of an Indefinite-Delivery, Indefinite-Quantity (IDIQ) type contract that contains FIXED PRICES, WITH ECONOMIC PRICE ADJUSTMENTS, resulting from this solicitation. The quantities shown in SECTION B are estimates only and the Government is not obligated to order the estimated quantities shown in this section.

(end of clause)

B.1 - HEALTH INSURANCE SERVICES

The Contractor shall provide the Health Insurance services to employees of the Government of the United States of America Embassy in Santo Domingo, Dominican Republic and their eligible dependents as described in Section C. This insurance shall be provided in accordance with Section C.

B.1.1. Official Residence Expense (ORE) Staff and American Embassy Recreation Association (AERA) Embassy Association Employees (EAE) are included under this contract only as a rider; the Contractor shall bill the Chief of Mission and Deputy Chief of Mission (for ORE Staff), and the Embassy Association (for EAEs) at the rates specified below. See Section G for billing procedures.

Note that USG is not responsible, nor liable, for any riders.

Retirees and their spouses are included under this contract only as riders, the Contractor shall bill the USG at the rates specified below.

JAMES ZADROGA 9/11 VICTIMS HEALTH AND COMPENSATION ACT OF 2010 NOTICE: UNLESS A WAIVER OR EXCEPTION APPLIES, PAYMENTS SUBSEQUENT TO THIS PROCUREMENT ARE SUBJECT TO AN EXCISE TAX OF 2%

PURSUANT TO 26 U.S.C. 5000C

B.2 - PRICES

All prices shall be in DOMINICAN PESOS.

B.2.1 VALUE ADDED TAX.

The Government will not reimburse the Contractor for VAT under this contract. The Contractor shall not include a line for VAT on Invoices as the U.S. Embassy has a tax exemption certificate with the host government.

B.2.2 This is a FIXED PRICE, WITH ECONOMIC PRICE ADJUSTMENTS requirement type contract under which will be issued firm fixed-price task orders. The fixed prices/premium rates for the health insurance services as specified in Section C are as follows:

B.2.3 Base Year of Contract

Monthly Rates Per Premium Category Category Estimated Number of

Premiums* Rate per Premium Extended Monthly Total

a. Self 150

b. Self Plus One 75

c. Family (3 or more individual) 235

d. Subtotal Total Price for Base Year (d x 12 months)**

* estimated number of premiums does not include any Riders (B.1.1)

** does not include any premiums for Riders.

Rider Category*** Estimated Number of Premiums* Monthly Rate per Premium

Retirees 28 Retirees Plus One 8

*** not included in the Total Price for Base Year Calculation

B.2.4 Option Year One of Contract

Monthly Rates Per Premium Category Category Estimated Number of

Premiums* Rate per Premium Extended Monthly Total

a. Self 150

b. Self Plus One 75

c. Family (3 or more individual) 235

d. Subtotal Total Price for First Option Year (d x 12 months)**

*estimated number of premiums does not include any Riders (B.1.1)

** does not include any premiums for Riders.

Rider Category*** Estimated Number of Premiums* Monthly Rate per Premium Retirees 28 Retirees Plus One 8

*** not included in the Total Price for First Option Year Calculation

B.2.5 Option Year Two of Contract

Monthly Rates Per Premium Category Category Estimated Number of

Premiums* Rate per Premium Extended Monthly Total

a. Self 155

b. Self Plus One 80

c. Family (3 or more individual) 240

d. Subtotal Total Price for Second Option Year (d x 12 months)**

* estimated number of premiums does not include any Riders (B.1.1)

** does not include any premiums for Riders.

Rider Category*** Estimated Number of Premiums* Monthly Rate per Premium Retirees 26 Retirees Plus One 6

*** not included in the Total Price for Second Option Year Calculation

B.2.6 Option Year Three of Contract

Monthly Rates Per Premium Category Category Estimated Number of

Premiums* Rate per Premium Extended Monthly Total

a. Self 155

b. Self Plus One 80

c. Family (3 or more individual) 240

d. Subtotal Total Price for Third Option Year (d x 12 months)**

*estimated number of premiums does not include any Riders (B.1.1)

** does not include any premiums for Riders.

Rider Category*** Estimated Number of Premiums* Monthly Rate per Premium Retirees 25 Retirees Plus One 5

*** not included in the Total Price for Third Option Year Calculation

B.2.7 Option Year Four of Contract

Monthly Rates Per Premium Category Category Estimated Number of

Premiums* Rate per Premium Extended Monthly Total

a. Self 160

b. Self Plus One 85

c. Family (3 or more individual) 245

d. Subtotal Total Price for Fourth Option Year (d x 12 months)**

* estimated number of premiums does not include any Riders (B.1.1)

** does not include any premiums for Riders.

Rider Category*** Estimated Number of Premiums* Monthly Rate per Premium Retirees 25 Retirees Plus One 5

*** not included in the Total Price for Fourth Option Year Calculation

B.2.8 Grand Total of Base plus All Option Years

Base Year Total Option Year One Total Option Year Two Total Option Year Three Total Option Year Four Total Grand Total = Base and All Option Years

B.3 - ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the Contractor requests a price adjustment under B.4 below, the Contractor shall present cost experience data that includes the retention amount. For purposes of any economic price adjustment, this retention amount is a fixed amount that is a part of the premium amounts in B.2. This retention amount will not be adjusted for any reason.

The retention amount is part of the premium and may include, but not be limited to, such costs as overhead and general and administrative costs. It will also include any profit. Essentially, it includes all costs except the actual portion of the premium intended to fund claims paid to the health care provider / claimant. B.3.2 sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

NOTE TO OFFEROR: Fill in the fixed monthly retention amounts for each period of performance and for each category of premium. This fixed amount shall be expressed in the currency in which the premium amount is proposed: DOMINICAN PESOS. The fixed retention amount shall NOT be expressed in terms of a percentage of the premium.

B.3.2 Monthly Retention Amounts per separate premium paid per single employee and per family plan.

Period of Performance Self Self plus One Family (3 or more individual) Base Period First Option Year Second Option Year Third Option Year Fourth Option Year

B.4 - ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

B.4.1. Premium Adjustment Based on Experience - For health insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract, and it specifically excludes all riders in B.1.1. No adjustment will be allowed during the first twelve months. After such time, the Contractor or the Government may request an adjustment in premiums on an annual basis. Adjustments are not retroactive to previous contract terms.

Before any such adjustment is made, the Contractor agrees to provide the Government a balance sheet showing three main components for the time period:

(1) Receipts (premiums received) minus the retention amount

(2) Number of insurance plans and

(3) Claims paid

This information shall be provided per type of premium, i.e., per line item. The retention amount is not subject to adjustment.

The Government reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract. Mutually agreed to adjustments shall be effective 30 days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.4.2. Premium Adjustment Based on Laws - The rates may also be adjusted during the performance period of the contract as a result of laws enacted by the host Government, if such change in the laws has a direct impact on the cost to the Contractor to perform this contract at the contracted rate. In that event, the Contracting Officer may enter into negotiations with the Contractor to modify the contract to adjust the premium rate. The Contractor agrees to provide all documentation necessary to support any requested adjustment.

B.4.2.1 Employee Pool – This clause is only in effect if the Contractor included details in its offer regarding a pooling arrangement, of which this contract is a part. Before any adjustment is made under this price adjustment clause, the Contractor shall include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

C.1 - DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

This section defines the required minimum benefits and corresponding coverages. These are the minimally acceptable levels of coverage. If offerors choose to include additional benefits or higher coverages than the required minimums this is acceptable;

however, evaluations will be based on meeting the stated minimums only. For each benefit listed, proposals must clearly state its coverage. Any proposal that reduces a benefit definition or offers lower than the minimum required coverage may be determined technically unacceptable. The resultant contract will contain the actual proposed coverages or increased benefit offerings if they exceed the solicitation’s minimum requirements.

Multiple proposals - If an offeror has multiple plans available that meet or exceed the minimum benefit levels and wants to propose them, a separate proposal with its respective prices must be submitted individually for each.

The Government of the United States of America requires Health Insurance coverage for its employees as described herein.

Unless otherwise specified the annual maximum for any benefit will be tie to the Annual Maximum limit for the policy found in C.1.2.

C.1.1 Employee and Dependent Health Service Benefits

C.1.1.1 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, and board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, and 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 (below C.1.1.4) for details concerning professional services.

C.1.1.2 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.

C1.1.3 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.

C.1.1.4 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 below) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (C.1.1.13 below) for details concerning psychiatric therapy.

C.1.1.5 Obstetric and Newborn Care: Minimum Coverage - 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 Coverage - 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 Coverage -Inpatient/Emergency: 100%, Outpatient: 80%

Medications prescribed by a licensed 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.

C.1.1.8 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.

Outpatient services generally refers to a patient making appointments to address a pain or health problem. Preventative and Wellness -- a patient makes these appointments as part a routine visit to get the annual physical, get the annual screenings -- the goal is to identify problems early. So, every January many people schedule "annual" physicals. (Having a separate category for Preventative and Wellness ensures that employees are aware and become more accustomed to schedule these visits and that insurance companies understand that these patient visits and annual screenings are covered.)

C.1.1.9 Hearing Aids: Minimum Coverage – 80%

Examinations and Treatment: 80% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per year up to a maximum of DOP$ 90,000.00 per covered individual per three-year period. 80% Minimum Coverage: with annual cap.

C.1.1.10 Optical Care: Minimum Coverage – 80%

Examinations and Treatment: 80% Minimum Coverage

Prescription lenses and frames, or contact lenses: Covered up to a maximum of DOP$ 18,000.00 per covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11 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 DOP$100,000.00 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 DOP$ 140,000.00 lifetime limit. 80% Minimum Coverage; with contract lifetime cap.

C.1.1.12 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 C.1.3 Exclusions to Coverage).

C.1.1.13 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.

C.1.1.14 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.

C.1.1.15 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.

*C.1.1.16 Catastrophic Coverage

Additional coverage equal to DOP$1,000,000.00 per covered individual per contract year. Catastrophic conditions shall be defined as major medical conditions occurring because 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.

C.1.1.17 Reserved

C.1.1.18 Reserved

C.1.1.19 180 Day Coverage for Dependents After Employee’s Death

At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 180 days. This optional benefit is subject to availability of funds at post and no extensions are permitted.

The USG will cover 100% of the premium for covered dependents of a deceased employee for up to 180 days with no extensions. This benefit is subject to funding availability and can only be requested and authorized by the U.S. Government.

C.1.1.20 Employee Assistance Program (EAP)

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. This optional benefit is subject to availability of funds at post.

The Employee Assistance Program benefit will be available for U.S. Government employees only and does not include dependents, retirees, or retiree’s dependents. This is an optional benefit for the policy, and if offered and becomes part of the benefit packages for the entire policy.

The use of these services is at the request of the U.S. Government only and it is intended to address employees’ issues affecting their work performance. The basic purpose of an EAP is to promote the well-being of the individual in a confidential and professional manner.

C.1.1.21 Reserved.

C.1.2 Annual Maximum Limit

The maximum annual reimbursement per individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) and C.1.1.16, Catastrophic Coverage, or those covered under C.1.1.15, HIV/AIDS, is equivalent to DOP$ 1,000,000.00

C.1.2.1 Retirees Coverage Limit - The maximum coverage per calendar year will be reduced 50% for the retirees and retiree dependents, grandfathered under the previous plan.

C.1.3 Exclusions and Limitations

There is no coverage 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 coverage 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.

C.1.4 Eligible Participants

C.1.4.1 Identification of Eligible Employees and Dependents: U.S. Mission Santo Domingo will provide a list of all eligible employees and dependents with relationship to employee (self/spouse/child) and Date of Birth (DOB) for each. Updates will be provided to add or remove individuals monthly.

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 if 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 the Dominican Republic by:

DEPARTMENT OF STATE

DEPARTMENT OF TREASURY

DEPARTMENT OF DEFENSE

DEPARTMENT OF JUSTICE

DEPARTMENT OF INTERIOR

DEPARTMENT OF AGRICULTURE

DEPARTMENT OF COMMERCE

DEPARTMENT OF LABOR

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

DEPARTMENT OF TRANSPORTATION

DEPARTMENT OF ENERGY

DEPARTMENT OF EDUCATION

DEPARTMENT OF VETERAN AFFAIRS

DEPARTMENT OF HOMELAND SECURITY

UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID)

SOCIAL SECURITY ADMINISTRATION (SSA)

C.1.4.3 Participants Covered Under a Rider

a. 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. 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.

b. All current active employees of the Employee Association at Embassy/ Consulate Santo Domingo. All costs for coverage of American Embassy Recreation Association (AERA) EAEs are the responsibility of the Employee Association, not the U.S.

Government.

c. Retirees and Retirees Dependents. This plan will allow for continued coverage of current retired employees and their dependents as provided under the previous plan. All costs for coverage are the responsibility of the U.S. Government.

C.1.5 Eligibility

C.1.5.1 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.1.5.2 Newborn Coverage Effective Date.

All newborns under this contract shall be covered under their mother’s insurance card for the first 30 days from their date of birth.

During that period the COR shall request the child’s inclusion into the plan.

C.1.6 Brochure Requirement

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in Spanish 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.1.6.2 The Contractor shall provide the document described in C.1.6.1 to the COR not later than thirty (30) 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.1.6.3 The Contractor assumes full responsibility for ensuring that the document described in C.1.6.1 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.

SECTION D - PACKING AND MARKING - RESERVED

RESERVED

E.2 - QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

E.2. QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

This plan is designed to provide an effective surveillance method to promote effective Contractor performance. The QASP provides a method for the Contracting Officer's Representative (COR) to monitor Contractor performance, advise the Contractor of unsatisfactory performance, and notify the Contracting Officer of continued unsatisfactory performance. The Contractor, not the Government, is responsible for management and quality control to meet the terms of the contract. The role of the Government is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective PWS Paragraph Performance Threshold Services

Performs all the insurance services set forth in the Performance Work Statement (PWS)

C.1.0 thru C.1.6

All required services are performed and no more than one (1) customer complaint is received per month.

Deliverables

All reports shall be delivered on a timely matter to the address set forth in Section

F.4. and H.5

All required reports are received by the COR no later than the 10th day of each month and no more than one (1) customer complaint is received per month.

F.4, in accordance with requirements described in Section H.5 – Report Requirements.

(a) Employee Claims Report.

(b) Overall Claims Rate Report (Indice de Siniestralidad).

(c) Employee Out of Network Reimbursement Claims Report

Deliverables

All reports shall be delivered on a timely matter to the address set forth in Section F.4, in accordance with requirements described in Section H.5 – Report Requirements.

Report on rates at which out of network reimbursement claims will be processed.

F.4. and H.5

The initial required Report will be provided no later than 15 days after award and no later than five (5) business days when the report is updated either annually, each time changes in rates occur, or when requested by the COR.

E.2.1 Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided.

If appropriate, the COR will send the complaints to the Contractor for corrective action.

E.2.2 Standard. The performance standard is that the Government receives no more than one (1) customer complaint per month. The COR shall notify the Contracting Officer of the complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR 52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of Services clause), if any of the services exceed the standard.

E.2.3 Procedures

(a) If any Government personnel observe unacceptable services, either incomplete work or required services not being performed, they should immediately contact the COR.

(b) The COR will complete appropriate documentation to record the complaint.

(c) If the COR determines the complaint is invalid, the COR will advise the complainant. The COR will retain the annotated copy of the written complaint for his/her files.

(d) If the COR determines the complaint is valid, the COR will inform the Contractor and give the Contractor additional time to correct the defect, if additional time is available. The COR shall determine how much time is reasonable.

(e) The COR shall, as a minimum, orally notify the Contractor of any valid complaints.

(f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR.

The COR will review the matter to determine the validity of the complaint.

(g) The COR will consider complaints as resolved unless notified otherwise by the complaint.

(h) Repeat customer complaints are not permitted for any services. If a repeat customer complaint is received for the same deficiency during the service period, the COR will contact the Contracting Officer for appropriate action under the Inspection clause.

F-007 - PLACE OF PERFORMANCE

The principal place of performance for this contract shall be: DOMINICAN REPUBLIC

NOTE: The specific location will be determined at the individual task order level.

F.2 - PERIOD OF PERFORMANCE

This contract shall be effective on the actual date of contract award. It is the Government’s intention to award a BASE YEAR (12 – months) and FOUR OPTION YEARS (12-months each) contract. However, there is no obligation for the Government to extend the contract beyond the Base Year.

The contract may be extended by the exercise of an option pursuant to FAR 52.217-9, Option to Extend the term of the Contract and FAR 52.217-8, Option to Extend Services.

(end of clause)

F.4 - REPORTS AND OTHER DELIVERABLES

All reports and other deliverables required under this contract shall be delivered to the following address:

SantoDomingoInsurance@state.gov

652.242-70 - CONTRACTING OFFICER'S REPRESENTATIVE (COR) (AUG 1999)

(a) The Contracting Officer may designate in writing one or more Government employees, by name and position title, to take action for the Contracting Officer under this contract. Each designee shall be identified as a Contracting Officer's Representative (COR).

Such designation(s) shall specify the scope and limitations of the authority so delegated; provided, that the designee shall not change the terms or conditions of the contract, unless the COR is a warranted Contracting Officer and this authority is delegated in the designation.

(b) The COR is SUPERVISORY HUMAN RESOURCES SPECIALIST.

(End of clause)

G-001 - ORDERING PROCEDURES

(a) In accordance with FAR 52.216-18 "ORDERING," the following individuals and activities are authorized to issue delivery orders or task orders hereunder:

The Office of Acquisitions Management and US Embassy Santo Domingo Contracting Officers

(b) Orders placed under this contract shall contain the following information:

(1) Date of order;

(2) Contract number and order number;

(3) Item number and description, quantity, and unit price;

(4) Delivery or performance date;

(5) Place of delivery or performance (including consignee);

(6) Packaging, packing, and shipping instructions, if any;

(7) Accounting and appropriation data;

(8) Security clearance level(s), applicable to the order, if any; and

(9) Any other pertinent information.

(c) Issuance of orders by facsimile is authorized in accordance with FAR 52.216-18 "ORDERING."

ADDITIONAL ORDERING PROCEDURES FOR OTHER GOVERNMENT AGENCIES:

Contracting Officers for the other Government agencies, identified in the clause entitled "ORDERING PROCEDURES,' are authorized to issue delivery orders or task orders under this contract only after obtaining prior written authorization from the designated Contracting Officer's Representative (COR). A copy of each delivery order or task order shall be provided to the U. S.

Department of State, Office of Acquisitions Management's Contracting Officer and COR at the time the order is issued. Method of payment is via task/delivery order.

(End of clause)

G-002 - CONTRACT ADMINISTRATION DATA

Contracting Officer: Stephanie Reid-Smith E-mail: Reid-SmithSJ@state.gov

First Class Mailing:

U.S. Department of State ATTN: Office of Acquisition Management P.O. Box 9115, Rosslyn Station Arlington, Virginia 22219

PREFERRED METHOD via E-mail: Reid-SmithSJ@state.gov

Contracting Officer's Representative (COR): TBD Telephone Number: TBD U.S. Department of State: TBD (End of clause)

G.1.1 - 642.271 Government Technical Monitor (GTM) Duties and Responsibilities

(a) Policy. The Contracting Officer may appoint a Government Technical Monitor (GTM) to assist the Contracting Officer's Representative (COR) in monitoring a contractor's performance. The Contracting Officer may appoint a GTM because of physical proximity to the contractor's work site, or because of special skills or knowledge necessary for monitoring the contractor's work.

The Contracting Officer may also appoint a GTM to represent the interests of another requirements office or post concerned with the contractor's work.

The GTM may not add or modify the terms and conditions of the contract. Only the Contracting Officer may modify the contract, existing task orders or issue new task orders, reflecting these changes, since only the Contracting Officer can obligate funding and commit the Government.

NOTE: A GTM shall be a direct-hire U. S. Government employee.

G.2 - CONTRACTING OFFICER REPRESENTATIVE (COR) DUTIES AND RESPONSIBILITIES

G.2.1 The Contracting Officer's Representative (COR) is responsible for inspection and acceptance of services. These duties include review of Contractor invoices, including the supporting documentation required by the contract. The COR may provide technical advice, substantive guidance, inspections, invoice approval, and other technical purposes as deemed necessary under the contract.

G.2.2 In addition, the COR shall maintain updated list of employees and dependents insured, which will supersede the initial list provided under this contract and as reported to the insurer, without prejudice to the ineligibility clause.

G.2.3. The COR has the additional responsibility of maintaining the eligible listing of employees and dependents for insurance coverage.

G.2.4 The COR may not add or modify the terms and conditions of the contract. While the COR is authorized to provide the Contractor with updated listings of eligible employees and dependents, only the Contracting Officer may modify the contract, existing task orders or issue new task orders, reflecting these changes, since only the Contracting Officer can obligate funding and commit the Government.

NOTE: A COR shall be a direct-hire U. S. Government employee.

G.3 - PAYMENT IN LOCAL CURRENCY

Payment shall be made in DOMINICAN PESOS.

G.4 - SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted in a non-editable format to the following address (designated billing office only for the purpose of submitting invoices:

Financial Management Office U.S. Embassy Santo Domingo SantoDomingoPayments@state.gov

G.4.2. Frequency of Payments. All funds under this contract will be obligated by issuance of task orders, as described in H.3 for all non-rider coverage. Each task order will fund a specific period of time and number of employees and the task orders will be issued at the frequency described in H.3. Contractor may submit invoices monthly for payment to be made at the beginning of the month for which insurance coverage is provided in accordance with FAR 32.404.

G.4.3. U.S. Government Employees. The Government shall make payments directly to the Contractor for all Government employees, whether or not the employee is contributing to the basic premium amount.

G.4.4 Riders:

a. ORE. The Chief of Mission and/or Deputy Chief of Mission will make payment directly to the Contractor for the entire premium amount of the ORE staff, whether or not the ORE employee is contributing to the premium amount.

b. EAE Staff. The Employee Association will make payment directly to the Contractor for the entire premium amount of the EA employee, whether or not the EA employee is contributing to the premium amount.

c. Retirees and Retirees Dependents. The USG will make payments directly to the Contractor for the entire premium amount.

G.5 - REFUNDS TO THE GOVERNMENT

If at any time during performance of the contract the Government finds that the Contractor has been overpaid because the number of employees and/or dependents covered has decreased, the Contracting Officer may either allow that overpayment to be credited to the Government’s account or require that the Contractor refund the overpayment.