Section_C_of_ongoing_Contract.pdf

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

PART I - HEALTH INSURANCE

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 Brazzaville, Republic of Congo. The Government has determined that the prevailing practice by employers in Brazzaville, Republic of Congo is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by both the employee and the employer. The USG pays 100 % and the employee pays 0 % 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 the Exhibits in Section J.

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

C.1.1.3. Prescription drugs and medicines: (100 %) reimbursement when hospitalized, and (100 %) reimbursement when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required. Expenses incurred for medicines, vitamins, cold remedies, etc., that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician.

C.1.1.4 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.

The maximum limit for expenses reimbursed under section C.1.1.4 is CFA 800.000 per patient per contract year.

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

C.1.1.6 Family planning N/A

C.1.1.7 Hearing aids: N/A

C.1.1.8 Optical care: (100 %) 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: (80 %) 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: (80 %) reimbursement.

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 CFA 800.000 per patient per contract year.

C.1.2 Health Benefits Conditions and Limitations

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.

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.

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 the Republic of Congo 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 the Republic of Congo by Department of State

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 (see separate rider, Exhibit B). All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.1.4 Individuals Not Eligible for Coverage

Individuals not eligible for coverage under this contract are non-personal 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 22 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.

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 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.

C.1.7. BROCHURE REQUIREMENT.

C.1.7.1. The contractor shall provide a document (brochure/pamphlet/other written document in English that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered 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 15 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.

C.2 RESERVED

C.3.0 DEFINITIONS

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

Agencies except AID.

COR Contracting Officer's Representative (Human Resources Officer at post).

Contributory Insurance for which the employee contributes toward the premium.

Dependent One Legal spouse/husband and five children

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, or personal services agreement, as further defined in Section C.1.3. This may also include ORE Staff, if this category of individual is listed as participating under a rider in C.1.3.3

Employer The United States Government or in the case of ORE the Chief of

Mission/Deputy Chief of Mission.

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 paid to any one covered individual for covered medical expenses or life insurance/disability benefit.

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.