SECTION C only.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 Kingston, Jamaica. The Government has determined that the prevailing practice by employers in Kingston, Jamaica 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 90% and the employee pays 10%. 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.

Premium: All LE Staff covered under post’s medical benefit plan will pay a 10% share of the premium. Premiums will be based on the number of individuals covered:

-- Self-Only: 1 covered individual

-- Self Plus One (two individuals)

-- Family (three or more individuals)

-- Retirees are responsible for 100% of the premium (Self-Only: 1 covered individual)

Annual Maximum Limit: The maximum annual reimbursement per covered individual per contract year, not including expenses covered under HIV/AIDS benefits if selected by post, is

JMD 5,317,000 (100% of the annual base salary of an FSN-9 highest step/maximum base annual salary rate rounded up to the nearest thousand).

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

ALTERNATE B

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: 80% 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. 80% 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 80% 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 USD10,000 per patient per contract year.

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.

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: 80% 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: 50% reimbursement. 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. Inpatient: 100% Coverage; Outpatient: 80%

Minimum Coverage.

C.1.1.11 Emergency Services (trips to emergency room): Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. 100% Coverage

C.1.1.12 Ambulance: 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. 80% Minimum Coverage

C.1.1.13 Outpatient Services: 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

80% Minimum Coverage

C.1.1.14 Preventive and Wellness Services and Chronic Disease Management:

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.

C.1.1.15 Mental Health and Substance Abuse Care: 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 carried out at a facility licensed for detoxification and rehabilitation.

C.1.1.16 Rehabilitative and Habilitative Services and Devices: 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) 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. 50% Minimum Coverage.

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 JMD 5,317,000

(100% of the annual base salary of an FSN-9 highest step/maximum base annual salary rate rounded up to the nearest thousand) per patient per contract year.

C.1.1.14 Optional Benefit - Catastrophic Coverage:

Additional coverage equal to JMD 5,317,000 per covered individual per contract year.

Catastrophic conditions shall be defined as major medical conditions occurring as a result 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.1.1.15 180 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.

ALTERNATE B

C.1.2 Health Benefits Conditions and Limitations.

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.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - 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 Kingston, Jamaica 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.1.3.1.4. Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

C.1.3.2 Location of Employment

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Kingston, Jamaica by: Department of State, U.S.A.I.D, Peace Corps, FAS, APHIS, DHS/ICE, DHS/CBP, MLO, DAO, DEA, USMS, CDC, USPIS, US Treasury, and ORA

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 paid under an

ORE account and Marine Security Guard staff (see separate rider, Exhibit B). All costs for ORE employees and Marine Security Guard staff 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

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

LE Staff who are eligible to participate in the medical plan automatically confer coverage to eligible family members who meet the following criteria:

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.

-- Dependent 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 as long as the condition persists, the child remains unmarried, and the LE Staff maintains coverage.

Retired Employees:

Employees who retire from the service of the US mission who were covered under the medical insurance plan at the time of retirement remain eligible for coverage for themselves only.

Employees who separate from employment due to total disability are considered to be medically retired and are eligible for medical benefits regardless of age at the time of separation. An employee is considered disabled when an illness or physical or mental impairment results in the employee's inability to perform work. In the event that the medically retired employee recovers and starts employment with another entity, his/her eligibility for coverage under this plan ceases as soon as he/she becomes eligible for medical benefits from his/her new employer and/or the

LSSS.

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 (LWP) 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 (LWP) 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 ten (10) 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.

PART II: GROUP LIFE INSURANCE

C.2. GROUP LIFE INSURANCE

The Government of the United States of America requires group life insurance coverage for its employees, as further described in C.2.2, in Kingston, Jamaica. The Government has determined that the prevailing practice by employers in Kingston, Jamaica is that group life insurance coverage is representative of locally prevailing compensation practice and that the cost of such insurance protection is usually borne by the employer (100%). Therefore, the Government desires to adopt such locally prevailing practice as part of its compensation plan for its employees as further described in C.2.2. The specific group insurance coverage under this contract is set forth in this part of Section C and the Attachments in Section J.

C.2.1. Group Life Insurance Coverage

The amount of group life insurance coverage is as follows:

C.2.1.1 Amount of Employee Life Insurance.

The amount of life insurance coverage for each employee is based upon:

26 months’ basic salary.

C.2.1.2 Amount of Accidental Death and Dismemberment Coverage.

The employee's estate or employee will receive an amount equal to 34 months basic salary times the amount of monthly basic salary, in addition to the life insurance benefit in

C.2.1.1, in the event the employee is killed in an accident.

C.2.1.3 Partial and Total Disability Coverage

C.2.2 Life Insurance Benefits Conditions and Limitations

Conditions and limitations on the entitlement to life insurance benefits under this contract are as follows:

No benefits shall be payable if an employee's death or other insurance event was caused directly or indirectly by war. War shall be defined as declared or non-declared war or any martial operations or invasion, hostile acts of foreign powers, rebellion, riot, civil war, uprising, mutiny, operations by military or usurpatory authorities, martial law or state of siege or any other similar event or reason for declaring martial law or war. A terrorist attack shall not be considered war.

No benefit shall be payable under this contract if the employee's bodily injuries have been caused directly or indirectly and totally or partially by:

1. violating the law or in resisting detention or arrest,

2. participation in competitions involving the use of wheeled vehicles, horses, boats or water skis,

3. an accident resulting from the employee being under the influence of alcohol, drugs or other toxic substance unless administered by a physician. Death as a result of a disease or physical or mental infirmities and medical or surgical treatment thereof (except pyogenic infection due to an accidental cut or wound) shall be considered a natural and not an accidental death. Suicide will not be covered.

C.2.3. Eligible Participants

C.2.3.1 Eligible Employees. The employees eligible for the group life insurance coverage include the following:

C.2.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Kingston, Jamaica, paid under the Local

Compensation Plan, and certified by the Contracting Officer. Covered employees include:

C.2.3.1.2. Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal Services Agreements (PSAs) and Personal Services Contracts

(PSCs);

C.2.3.1.3. Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

C.2.3.2 Location of Employment

C.2.3.2 The individuals covered by C.2.3.1 must be employed within the geographic boundaries of Kingston, Jamaica by: Department of State, USAID, Peace Corps, DEA, DAO, FAS, APHIS, DHS/ICE, DHS/CBP, MLO, USMS, CDC, USPIS, US Treasury and

ORA.

C.2.4 Individuals not Eligible for Coverage

C.2.4.1. New employees who have reached the age of 60 and 65 prior to entering on duty with the U.S. Government will not be eligible for life insurance coverage.

C.2.4.2 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.

Employees of USAID institutional contractors; and Peace Corps personal services contractors as indicated in MS 743.

C.2.5. Other Eligible Participants

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

C.2.6 Eligibility and Effective Date

C.2.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for life insurance, accidental or word related death/disability 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 (LWP) 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.

C.2.6.2. Period of Ineligibility

Employees are not entitled to life insurance hereunder during any period of employment for which premiums are not paid.

During a period of extended (beyond one pay period) of Leave Without Pay

(LWP) or unpaid leave, the employee is responsible for the full cost of the insurance premiums. 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.2.7. BROCHURE REQUIREMENT

C.2.7.1. The Contractor shall provide a document (brochure/pamphlet/other written document) in English that sets forth a complete listing of the life 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.2.7.2. The document described in C.2.7.1 shall be provided to the COR not later than ten (10) days after date of contract award. The Contractor shall provide additional brochures for new employees within ten days of the COR’s request.

C.2.7.3. The Contractor assumes full responsibility for ensuring that the document described in C.2.7.1 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.3.0. DEFINITIONS

The Contractor shall provide Health and Life Insurance services to employees of the

Government of the United States of America in Kingston, Jamaica

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

Government Agencies, except U.S. AID.

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.

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

Dependent 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. Dependent 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 as long as the condition persists, the child remains unmarried, and the

LE Staff maintains coverage. - For Life Insurance - Dependents and retirees are not covered.

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 and C.2.3 for life insurance. [Note to Contracting Officer: Only include reference to ORE Staff and Peace Corp PSCs and enter name of Embassy Employee Association if covered under the contract.] This may also include ORE Staff, EAE, and Peace Corp PSCs, if this category of individual is listed as participating under a rider in C.1.3.3 for health insurance and C.2.3.3 for life insurance.

Employer The United States Government or in the case of ORE and [Note to

Contracting Officer: Enter name of Embassy Employee Association and revise reference as appropriate] EAE employees, the Chief of

Mission/Deputy Chief of Mission and the Employee Association, respectively.

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

This officer is usually the Contracting Officer (CO) 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.

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.

C.3.0 DEFINITIONS