C.DOCX

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as further described in C.1.2 in Azerbaijan. The Government has determined that the prevailing practice by employers in Azerbaijan is to provide for their employees health insurance protection and that the cost of such insurance protection is borne by the employer. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.2. The specific health benefit coverage under this contract is set forth in Section C and based on your current database.

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

C.1.1 Employee and Dependent Health Services Benefits

C.1.1.1. Hospitalization: 100% reimbursement of room and board for a ward room or semi-private room. 80% reimbursement of room and board for a private room, not to exceed 100% of the cost of a semi-private room. 100% reimbursement of hospital medical expenses including laboratory tests and x-rays, nursing care, operating room costs, intensive care, prescription medicines, and physical therapy. 100% reimbursement of ambulance service.

C.1.1.2. Professional services and treatment: 100% for doctors and surgeons’ fees while hospitalized. 80% reimbursement of doctors' and surgeons' fees incurred while at a hospital on an out-patient basis, at a clinic or doctor's office, or at home. 80% reimbursement for medical services and expenses when not hospitalized such as laboratory tests and x-rays, prescription medicines, physical therapy, routine annual physical examinations, an inoculations.

C.1.1.3. Prescription drugs and medicines: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of the cost of medicines and drugs prescribed by a doctor. Expenses incurred for shampoos and cosmetic remedies will not be reimbursed even if prescribed by a physician.

C.1.1.4. For employees only: 100% reimbursement for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS. For employee and employee's covered spouse/partner: 100% reimbursement for brief courses of anti-retroviral 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 anti-retroviral drugs at those posts with inadequate local healthcare infrastructures.

C.1.1.5. Obstetrical care: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of obstetrical medical care including prenatal and postnatal care.

Not covered are medical procedures, services, drugs, and supplies related to abortion, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of rape or incest.

C.1.1.6. Family planning: 80% reimbursement of prescribed contraceptive devices and drugs, voluntary sterilization, and diagnosis and treatment of infertility. Not covered is reversal of voluntary sterilization, infertility treatment after voluntary sterilization, genetic counseling, fertility drugs, and assisted reproductive technology.

C.1.1.7. Hearing aids: 80% reimbursement of the cost of a hearing aid apparatus and related examination. Limited to one apparatus per year per patient in a three-year period.

C.1.1.8. Optical care: 50% reimbursement for eye examination and treatment and prescription eyeglass or contact lenses. Limited to two lenses per patient every two years. No reimbursement for eyeglass frames, nonprescription lenses, or tinting.

C.1.1.9. Dental care: 50% of expenses for dental services including dentists’ fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, and bridges. Orthodontia treatment is covered only if treatment begins before age 15, unless required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per patient.

C.1.1.10. Psychiatric treatment: 50% reimbursement.

C.1.1.11. Medical expenses incurred out of country

Medical expenses incurred out of country will be covered for employees and dependents when (a) an illness or injury occurs when the individual is out of the country and treatment is medically necessary before the individual returns home or (b) the individual’s attending physician certifies in advance that such treatment is medically necessary and unavailable locally. Reimbursement will be made at the same percentage rate and subject to the same annual maximum limit as for expenses incurred in country.

C.1.1.12. Transportation for Out of Country Treatment

Transportation for out of country treatment is a covered expense for employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally. 80% of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be reimbursed. 80% of the transportation expenses of an attendant will be reimbursed if the patient’s attending physician certifies that an attendant for the patient is necessary, e.g., a parent in the case of a patient who is a minor or a family member to make medical decisions in the case of a patient who is unconscious. All reimbursements for transportation expenses are subject to the annual maximum limit.

C.1.1.13. Annual Maximum Limit

The maximum annual reimbursement per patient per contract year, not including expenses covered under c.1.1.4, is USD 37,000 per patient per contract year. The maximum limit for employees regularly scheduled to work on a part-time basis work for fewer than 30 hours per week will be prorated based on hours in the work week. For example, the maximum limit for an employee regularly scheduled to work 20 hours per week is USD 37,000 x 20/40, or USD 18,500 per patient per contract year.

Expenses incurred under section C.1.1.4. of the plan are subject to a separate annual maximum limit of USD 37,000 per patient. This limit also will be prorated for employees regularly scheduled to work on a part-time basis for fewer than 30 hours per week.

C.1.2. Health Benefits Conditions and Limitations

Conditions and limitations on the entitlement to health care under this contract are as follows:

A. Expenses incurred by an employee's eligible dependents are covered under this plan if the eligible employee is regularly scheduled to work 30 hours or more per week.

B. Expenses incurred by an employee's dependents are not covered under this plan if the employee is regularly scheduled to work less than 30 hours per week.

C. Medical expenses incurred prior to the effective date of this plan are not covered by this' plan.

D. No exclusions or reduced benefits shall be made because of pre-existing conditions.

E. There is no reimbursement 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 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.

F. 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 les workers’ compensation program.

G. There is no reimbursement 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.

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 Azerbaijan paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include

C.1.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts (PSCs);

C.1.3.1.3. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

C.1.3.2. Location of Employment

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

U.S. Department of Justice Department of Energy

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1. All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account. All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.1.3.3.2. All current active employees of the Employee Association at Embassy Baku. All costs for EAEs are the responsibility of the Employee Association, not the U.S. Government.

C.1.3.4. In the event of an employee’s death while in active service and subject to availability of funds to pay premium, the contactor shall provide up to 180 days of medical coverage to dependents.

C.1.4. Individuals Not Eligible for Coverage

Individuals not eligible for coverage under this contract are nonpersonal services contract personnel; employees working on a temporary basis; employees with an intermittent, seasonal, or WAE (when actually employed) schedule; and any other individual not falling within one of the categories of employees described in this clause.

C.1.5. Other Eligible Participants

Covered dependents include the participating employee’s spouse and children. A limit of one spouse per employee is covered. An eligible child is defined as the employee’s natural child, adopted child, stepchild, or foster child. The child must be unmarried, economically dependent upon the employee, and reside with the employee unless away at school. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 25 if a full time student. There is no age limit for a 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. Parents, grandparents, siblings, and other relatives are not eligible dependents.

Retirees can be included in insurance coverage provided they pay 100% of the premium.

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. Each new eligible employee 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.

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, if any, will be collected through payroll deduction in that or the subsequent pay period.

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 extended (beyond one pay period) of Leave Without Pay or unpaid leave, 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 that employee prefers not to pay the premium.