RFP_Health_Insurance-Final.docx

Solicitation: S-FR630-17-R-0013 Page | 2 of 72 Health Insurance Benefits

UNDER DPAS (15 CFR 350)

2. CONTRACT (Proc. Inst. Ident.) NO.

3. SOLICITATION NO.

S-FR630-17-R-0013

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[x] NEGOTIATED (RFP)

5. DATE ISSUED

August 16, 2017

6. REQUISITION/PURCHASE NO.

7. ISSUED BY CODE

8. ADDRESS OFFER TO (If other than item 7)

Contracts Office, A M-8 American Embassy 2 Avenue Gabriel 75008 Paris, France Phone: (33) 1 43122409 Fax: (33) 1 42661194

NOTE: In sealed bid solicitation "offer" and "offeror mean "bid" and "Bidder".

SOLICITATION

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

A. NAME

Mr. Farhaad MOHAMED (or) Ms. Una O’DWYER

B. TELEPHONE (NO COLLECT CALLS) AREA CODE NUMBER EXT

(33) 143122409

(33) 143122435

C. E-MAIL ADDRESS

MohamedFA@state.gov O’DwyerUM@state.gov

11. TABLE OF CONTENTS

PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

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.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (120 calendar days unless a different period is inserted by the offer) 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.

13. DISCOUNT FOR PROMPT PAYMENT SEE 14

(See section I, Clause No 52.232-8)

(The offeror acknowledges receipt of amendments to the solicitation for offerors and related documents numbered and dated:

FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED

AND

ADDRESS

OF

OFFEROR

TO SIGN OFFER (Type or print)

15B. TELEPHONE NO. (Include area code)

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

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

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

G.2.1

24. ADMINISTRATION BY (If other than Item 7) CODE

25. PAYMENT WILL BE MADE BY CODE

American Embassy Attn: FMO Voucher/DBO 2, Avenue Gabriel 75382 Paris Cedex 08

26. NAME OF CONTRACTING OFFICER (Type of print)

IMPORTANT - Award will be made on this form, or on the Standard Form 26, or by other authorized official written notice.

SECTION B – SERVICES AND PRICES

PRICES - HEALTH INSURANCE

B.1 HEALTH INSURANCE SERVICES:

The Contractor shall provide health insurance services, including medical, maternity, disability and death benefits, for locally employed staff of the U. S. Mission in France and their eligible dependents as described in Section C and the Attachments in Section J. Locally Employed Staff (LES) shall be French, American or third country nationals as well as Personal Service Contractors (PSCs, or PSAs if hired under a Personal Services Agreement) employed by the U. S. Government. Individuals entitled to coverage under this contract are described in the following categories:

B.1.2. Official Residence Employees (ORE) and categories C and D are included under this contract as riders; the contractor shall bill the Chief of Mission separately for ORE employee insurance at the rates specified below and in the attachments. Individuals covered under categories C and D will be billed directly for the rates cited in the attachments. See Section G for billing procedures.

Category A consists of:

Employees and their eligible dependents, i.e. spouses, PACS as well as children up to 18 years of age, or up to 25 years of age if still enrolled full-time in an educational institution, affiliated with the French Social Security system. A dependent is an adult person who is acknowledged as a legal dependent on the employee’s income tax report or recognized by the French Social Security as a dependent by inclusion in the insured employee’s social security card.

Category B consists of:

Employees and their eligible dependents not affiliated with the French Social Security system, (i.e. CSR system or U.S. Social Security system) for whom this insurance is the only health benefits coverage.

Category C consists of:

Retirees, former employees who left employment due to a reduction in force and their eligible dependents, and eligible dependents of deceased employees affiliated with the French Social Security system.

Category D consists of:

Retirees under the Civil Service Retirement (or U.S. Social Security) system, former employees who left employment due to a reduction in force and their eligible dependents and eligible dependents of deceased employees not affiliated with the French Social Security system.

The above categories characterize the main groups in this contract but Attachment A and A-1 contains the separate contract line items (CLINS) and their prices fill-ins. Each CLIN shall be filled in to represent a total premium price.

B.2 PRICES

B.2.1 PREMIUMS AND COST SHARING:

The premiums to be paid for the above categories shall be provided for each CLIN in Attachments A and A-1. The percentage levels of coverage for the specifications are described in Section C for two levels of coverage, a basic option offering minimum percentage levels of coverage and a high option offering greater percentage levels of coverage. Premium costs are attributable as follows:

Category A. Premium costs for the basic option are shared between the employer and the employee, the employer contribution being 2/3 of the premium and the employee contribution being 1/3. This cost sharing by the employer is applicable only to the employees of this category. Eligible dependents are responsible for their own premium payments. The difference in cost between the high option and low option premiums are payable entirely by the insured.

Category B. Premium costs for the basic option for employees under the CSR system, are completely payable by the employer for employees and their eligible dependents. For employees under the U.S. Social Security system, the premium is fully paid by the employee. The difference in cost between the high option and low option premiums are payable entirely by the insured.

Category C. Premium costs for both the basic option and the high option are fully payable by the insured.

Category D. Premium costs for both the basic option and the high option are fully payable by the insured.

NOTE 1: Premiums will vary for employees and their eligible dependents who are affiliated with the French Social Security in the Alsace-Lorraine region, due to different French Social Security rates in effect in this region of France. Additional CLINS have been created to allow for this divergence and are included in Attachment A.

NOTE 2: Premiums shall be priced for each category and CLIN as described in this solicitation and in accordance with Attachment A. A temporary change of status for an employee e.g. an employee on maternity leave or on leave without pay, shall not permit any change to the agreed upon premium except as outlined in this contract.

B.2.2 PRICES/PREMIUMS FOR MEDICAL COVERAGE OF CATEGORIES A & B

Medical benefits for the Basic Option are described in Section C.2. Employee and Dependent Maximum Health Services Benefits. These benefits are summarized in French and English in Attachment B. If a conflict results between the French attachment and the English-written specifications in Section C, the English version will control in compliance with FAR 52.225-14. Additional benefits for the High Option premiums are specifically outlined in bold italics, and involve increased percentage levels of coverage as follows and as shown in Attachment B, but may also involve additional specifications as described in Section C.2. The additional cost for the High Option premiums shall be fully payable by the employee regardless of category. The premium amounts submitted in Attachment A shall reflect total costs for premiums, including the aggregate of the employee and employer premiums. The estimated total of the premium rates in local currency are as follows:

The offeror shall submit a breakdown of prices provided under Attachment A of Section J to complete the following.

Note: Offeror submitting prices in US Dollars shall change the Euro currency indicator to US Dollars.

B.2.2.1 Base Year Prices for Medical Coverage:

Total Estimated Base Year Price: € _______________________________

B.2.2.2 First Option Year Prices for Medical Coverage :

Prices for the first option year shall remain the same as for the base year unless adjusted in accordance with the clause B.4.

Total Estimated First Option Year Price: € _______________________________

B.2.2.3. Second Option Year Prices for Medical Coverage:

Prices for the second option year shall remain the same as for the first option year unless adjusted in accordance with the clause B.4.

Total Estimated Second Option Year Price: € ________________________________

B.2.2.4. Third Option Year Prices for Medical Coverage:

Prices for the third option year shall remain the same as for the second option year unless adjusted in accordance with the clause B.4.

Total Estimated Third Option Year Price: € ________________________________

B.2.2.5. Fourth Option Year for Medical Coverage:

Prices for the fourth option year shall remain the same as for the third option year unless adjusted in accordance with the clause B.4.

Total Estimated Fourth Option Year Price: € ________________________________

B.2.2.6. Total Estimated Contract Price for Medical Coverage:

Note: Please refer to Attachment A-1 to provide Prices/Premiums for Medical coverage of Categories C & D.

B.3 PRICES/CONTRIBUTIONS FOR DISABILITY AND DEATH BENEFITS FOR CATEGORIES A AND B (PREVOYANCE)

In addition to medical insurance the contractor is also tasked with providing Disability and Death Benefits (Prevoyance) for employees in categories A and B regardless of what medical benefits option they have chosen. As with the medical insurance, the employees may choose between a Basic or a High Option for minimum or increased benefits in the event of disability and death. The contributions for Category A will be calculated in percentage of gross salary and for Category B a flat rate shall be applied as well as a percentage of gross salary. The rates of contributions are shown in Attachments C, Prices for Prevoyance, and the benefits are described in Section C.4. The benefits are summarized in French in Attachment D. If a conflict results between the French attachment and the English-written specifications in Section C, the English version will control in compliance with FAR 52.225-14.

The offeror shall submit a breakdown of prices provided under Attachment C of Section J to complete the following:

B.3.1 BaseYear Prices for Prevoyance:

Total Estimated Base Year Price: € _________________________________

B.3.2. First Option Year Prices for Prevoyance :

Total Estimated First Option Year Price: € _________________________________

B.3.3. Second Option Year Prices for Prevoyance:

Total Estimated Second Option Year Price: € _________________________________

B.3.4. Third Option Year Prices for Prevoyance:

Total Estimated Third Option Year Price: € _________________________________

B.3.5. Fourth Option Year for Prevoyance:

Total Estimated Fourth Option Year Price: € _________________________________

B.3.6. Total Estimated Contract Price for Prevoyance Insurance:

B.3. 7 GRAND ESTIMATED TOTAL FOR MEDICAL (B.2.2.6) AND PREVOYANCE (B.3.6) FOR A 5 YEAR CONTRACT PERIOD:

B.4 ADMINISTRATIVE RETENTION AMOUNTS AND ECONOMIC PRICE ADJUSTMENT

B.4.1 If the Contractor requests a price adjustment, the Contractor must present cost experience data for each Category by CLIN that includes the retention amount. For purposes of any economic price adjustment, the retention amount is a fixed amount that is a part of the premium amounts in Attachment A and C. The 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.

Attachment A 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 retention amounts for each period of performance and for each category of premium. This fixed amount must be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall NOT be expressed in terms of a percentage of the premium. The retention amounts shall not be subject to Economic Price Adjustments. Final Option Year retention amounts shall be applied for any extension period of the contract.

B.4.2 Premium Adjustment based on Experience - prices may be adjusted upward or downward based on the experience rating of the Mission(s) by Category by CLIN covered by this contract. 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. Before any such adjustment is made, the contractor agrees to provide the Government a balance sheet per Category by CLIN showing two main components for the time period: (1) receipts (premiums received) minus the retention amount and (2) claims paid. The retention amount is not subject to adjustment. The Government reserves the right to have an independent third party review the balance sheet 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. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

B.4.3 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.4.3.1 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 must include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

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 the Locally Employed Staff (LE Staff) employees in France employed by the U.S. Mission to France. The Government has determined that the prevailing practice by employers in France is to provide health insurance protection for their employees to supplement the benefits provided by the French Social Security system (Categories A and C herein) or to provide full health insurance coverage (Categories B and D); that the cost of such insurance protection is usually borne by both the employee and the employer, except in the case herein of Categories C and D (retirees and their eligible dependents or survivors), and that such health insurance protection is representative of locally prevailing compensation practice; therefore, the Government will adopt such locally prevailing practice as part of its compensation plan for locally employed staff. The specific health benefit coverage under this contract is set forth in Section C and in the Attachments of Section J.

C.1.2. Definitions:

· Auxiliary Medical Professional – Accredited medical personnel, other than a physician or doctor of medicine, registered with the FSS, e.g. registered nurses etc.

· Beneficiary - For death benefits under the terms of this contract, the beneficiary shall be the designated recipient of any benefits to which the deceased is entitled. Normally, the beneficiary shall be the surviving spouse and/or family members of the deceased. A Designation of Beneficiary form shall be completed by each employee and submitted to the Contractor within a period of two weeks from the effective date of the contract or from the entry on duty date of a new employee.

· FMO – Financial Management Office or the paying office for the U.S. Government.

· CADRE – Executive or management level employee

· Contracting Officer's Representative (COR) - Contracting Officer’s Representative. For this contract, the COR shall be the Human Resources Officer of the U.S. Embassy.

· Consommation Medicale Totale (CMT) - Total Medical Consumption (CMT) - This index, published at the end of each calendar year by the National Institute for Statistics and Economic Studies (INSEE), is used as a reference by insurance companies to determine the percentage of increase for insurance premiums that is justifiable based on a national actuarial study.

· Couverture Medicale Universelle (CMU) – A mandatory social security contribution which is included in the premiums. Premiums for employees earning less than SMIC (minimum wage) shall be fully covered by the employer.

· Contributory Insurance - Insurance for which the employee pays a part of the premium.

· Conventioned - When applied to a medical doctor, paramedical practitioner or dentist, or to a hospital, clinic or other establishment for medical services, this adjective indicates that the individual or institution abides by the tariff conventions, specific fee-for-service rates established by the National Health Service and used as a basis for reimbursement for medical services by the French Social Security system. This term has been superceded by OPTAM for physicians but still applicable to hospitals and clinics.

· Daily rate -A daily charge (Forfait Journalier) claimed by hospitals and clinics, set by national decree, to cover expenses for food, linens, building maintenance, use of equipment and supplies, in-patient pharmaceuticals and dressings/bandages. This daily rate is charged by the hospital in addition to other specific charges.

· Dependent - Any minor child who depends on an insured employee for subsistence up to the age of 18 years if not a student and up to the age of 25 years when enrolled full-time in an educational institution. The spouse of an insured employee who depends on the employee for (partial) subsistence. An adult person who is acknowledged as a legal dependent on the employee’s income tax report or recognized by the French Social Security as a dependent by inclusion in the insured employee’s social security card.

· Disability - A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions. If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

· Employee - A locally employed staff of the U.S. Government, whether French, locally-resident American, or third country national, hired as a Personal Services Contractor (PSC,or PSA (under a Personal Services Agreement)) or as a Foreign Service National (FSN), or as an employee of an Official Residence (ORE).

· Employer

– 1. The United States Government for all categories of employees cited above other than the ORE.

– 2. Chief of Mission for the ORE.

· Forfait journalier - A daily charge (daily rate) claimed by hospitals and clinics, set by national decree, to cover expenses for food, linens, building maintenance, use of equipment and supplies, in-patient pharmaceuticals and dressings/bandages. This daily rate is charged by the hospital in addition to other specific charges.

· French Social Security Monthly Ceiling (PMSS) - The monthly ceiling of the French Social Security system is set annually by decree by the Ministry of Finance. This monthly ceiling represents a median monthly income index established to determine the percentage of benefits of all types (health, disability, retirement, death, family allowances) to which a citizen or affiliate with the French Social Security is entitled, based on a comparison of the individual’s monthly income and the median monthly index, a hypothetical monthly income.

· 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 injury.

· Illness - A deterioration of an individual’s health resulting from a viral, bacteriological, genetic predisposition, or other external or internal cause, so certified by a medical authority. Illness in this contract excludes occupational diseases resulting from exposure to elements in the work place.

· In-patient treatment - Treatment administered to a hospital patient.

· Liability rate: Another term for the Tariff Convention used in labor law.

· Maximum Benefit - The total amount that will be paid to any one employee for injury or disease, or alternately the total reimbursement amount for medical services separately defined in section C.2. of this contract. The maximum benefit payable under the terms of this contract shall never exceed actual costs paid for medical/dental services

· Minimum Benefit - The minimum amount of reimbursement that will be paid to any one employee for injury or disease, or alternately, the minimum reimbursement for medical services separately defined in section C.2 of this contract.

· Maison de Repos – Convalescence Home

· Non-conventioned - When applied to a medical doctor, paramedical practitioner or dentist, or to a hospital, clinic or other establishment for medical services, this adjective indicates that the individual or institution does not abide by the tariff convention, specific fee-for-service rates established by the national health service and used as a basis for reimbursement for medical services by the French Social Security system. These individuals or institutions constitute the private sector of the medical services industry in France and generally charge rates or fees-for-service that are higher than the tariff convention. This term has been superceded by OPTAM for physicians but still applicable to hospital and clinics.

· Ordinary and Necessary Treatment - A diagnostic test or medical treatment which is usually performed in the community where the individual is being treated.

· Out-patient - An out-patient receives treatment at a hospital, clinic, or doctor’s office but does not remain overnight.

· OPTAM: Mastered Tariffed Practical Option, a new convention for medical professionals which allows them to invoice freely within an annualized overrun envelope. OPTAM agree to cap their average overrun of their fees to 100 % of the Tariff Convention. Signatories to OPTAM are not further subject to a reimbursement ceiling under the law. Non-OPTAM practitioners are capped by law at maximum reimbursement rate of the Ticket Moderator plus 100% of the Tariff Convention and reimbursement must be at least 20% less that the reimbursement for OPTAM practitioner for the same service.

· Paramedical - A medical service provider who is accredited and specially trained in specific functions but who does not have generalist medical training such as a physician. Examples are accredited midwives, laboratory technicians, ambulance or firefighter emergency personnel, physical therapists, nurses, speech therapists.

· 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.

· PMSS - Plafond Mensuel de la Securite Sociale The monthly ceiling of the French Social Security system is set annually by decree by the Ministry of Finance. This monthly ceiling represents a median index established to determine the percentage of benefits of all types (health, disability, retirement, death, family allowances) to which a citizen or affiliate with the French Social Security is entitled, based on a comparison of the individual's monthly income and the median monthly index, a hypothetical monthly income.

· Prevoyance: Insurance coverage for disability and death benefits.

· Prise en charge - A written document guarantee that services provided to an individual will be covered or reimbursed by a third party. The third party in this contract will be the Contractor who will provide a 'prise en charge' document prior to hospitalization of an insured.

· Self-pay - As used in this contract, self-pay indicates that the premium for medical insurance will be paid fully by the insured without employer or former employer contributions.

· Surgical procedure - Any invasive medical procedure by manual or instrument operation, whether scalpel or laser technology, undertaken for diagnosis or treatment of a diseased or injured patient.

· Tariff convention - Charges established by the national health service for specific medical or paramedical or dental treatment. Each medical or paramedical branch may sign, through its union, a national convention or agreement with the French Social Security system. Fees paid to medical, paramedical or dental practitioners or establishments will be partially reimbursed to those affiliated with the French Social Security on the basis of the tariff convention for each service. Signatories to such conventions are conventioned medical service providers, i.e., adhere to the national health system’s fees for service.

· Ticket modérateur - The difference between the Social Security reimbursement rate and the tariff convention is called the ticket moderateur. The fees-for-service established for the national health system and identified as tariff conventions are generally not reimbursed 100% by the French Social Security system. The difference is herein described.

· Total Medical Consumption (CMT) - This index, published at the end of each calendar year by the National Institute for Statistics and Economic Studies (INSEE), is used as a reference by insurance companies to determine the percentage of increase for insurance premiums that is justifiable based on a national actuarial study.

C.2. EMPLOYEE AND DEPENDENT MAXIMUM HEALTH SERVICES BENEFITS:

The benefits described in each subsection of C.2 describe the benefits package under the BASIC OPTION and the HIGH OPTION. The differences between the Basic Option and the High Option pertain mainly to percentage levels in coverage and are summarized in Attachment B. Any other additional benefits covered under increased percentage levels for the High Option are described in bold italic font and are available to employees already enrolled in the Basic Option for a supplementary premium payment. All itemized descriptions for CATEGORIES A and C pertain to complementary insurance since the members of these categories are under the French Social Security system. For CATEGORY A and C members, the Contractor shall provide Basic Option benefits to supplement French Social Security reimbursements as long as the treatment is reimbursable by French Social Security and has been prescribed by duly accredited physicians, hospitals or clinics. All itemized descriptions for CATEGORY B and D pertain to full Basic Option insurance coverage up to the maximum amount described for each itemized description, as long as the medical treatment has been prescribed by duly accredited physicians, hospitals or clinics and such medical treatment would normally be reimbursable by the French Social Security system. Members of CATEGORY B and D are NOT affiliated with the French Social Security system.

C.2.1. INPATIENT AND OUT-PATIENT HOSPITALIZATION, EMERGENCY ROOM TREATMENT, SURGERY AND ANESTHESIOLOGY

Upon the written request by the insured, the Contractor shall provide a guarantee of insurance coverage (prise en charge) to the hospital or clinic prior to actual hospitalization except in emergency cases. Hospitalization, whether inpatient or outpatient services, in-patient or out-patient surgery and anesthesiology, emergency room, including paramedical care and related expenses during hospitalization and surgery, shall be reimbursed as follows:

Category A & C:

Low Option:

· In the conventioned sector at 100% of the tariff convention, for surgery;

· In the non-conventioned sector, at 200% of the tariff convention, for surgery;

· Consultation fees in cases of surgery

· OPTAM: TM+120% of the tariff convention

· Non-OPTAM physician: TM+100% of the tariff convention

· Daily Rate (forfait journalier): shall be fully covered.

Not covered: single room accommodation and any elective or cosmetic surgery.

High Option:

· In the conventioned sector, at 100% of the tariff convention for surgery;

· In the non-conventioned sector, at 300% of the tariff convention for surgery;

· Physician consultation fees, in case of surgery:

· OPTAM- TM+120% of the tariff convention Non-OPTAM: TM+280%

(Single accommodation shall be covered up to an amount not to exceed 2.20% of the PMSS per day).

Not covered: any elective or cosmetic surgery.

Category B & D:

Low Option:

Whether in the conventioned or non-conventioned sector, at 200% of the tariff convention for surgery:

Daily Rate (forfait journalier): shall be fully covered Not covered: single room accommodation and any elective or cosmetic surgery.

High Option:

· Whether in the conventioned OR non-conventioned sector, at 300% of the tariff convention for surgery:

· Single room accommodation shall be covered up to an amount not to exceed 2.20% of PMSS per day.

Not covered: any elective or cosmetic surgery.

C.2.2. DOCTOR VISITS, LABORATORY TESTS, MEDICAL PROSTHESES, X-RAYS

Category A&C:

Low Option:

Office visits for treatment by a physician, house calls (i.e. a physician’s visit to the patient’s home), and X-Rays shall be covered as follows:

· OPTAM: Ticket modérateur + 90% of the tariff convention;

Non-OPTAM: Ticket modérateur + 70% of the tariff Registered nurse and laboratory tests shall be covered at 100% of the tariff convention.

High Option:

Office visits for treatment by a physician, house calls (i.e. a physician’s visit to the patient’s home), and X-Rays shall be covered as follows:

· OPTAM: Ticket modérateur + 170% of the tariff convention;

Non-OPTAM: Ticket modérateur + 170% of the tariff convention Registered nurse and laboratory tests shall be covered at 200% of the tariff convention.

Category B&D:

Low Option:

150% of the tariff convention.

High Option:

300% of the tariff convention for doctor visits, medical prostheses, and X-Rays, and ;

200% of the tariff convention for laboratory tests.

C.2.3. PHARMACEUTICALS/PRESCRIPTION DRUGS

Category A&C:

Whether Basic or High option: Reimbursement shall not exceed 100% of the ticket moderateur.

Category B&D:

Whether Basic or High option: Reimbursement shall not exceed 100% of the tariff convention.

C.2.4. MATERNITY/OBSTETRICS

Employees are eligible for the following maternity benefits after one full year of continued employment with the U.S. Government.

Category A&C:

Low Option:

· Normal or Caesarian delivery - The Contractor shall pay a fixed amount birth premium equivalent to 10% of the Monthly Ceiling of Social Security (PMSS) to cover expenses related to childbirth and obstetric care provided by a physician or accredited midwife. This payment is either payable to the mother or to her legal spouse. It will be paid concurrently to both parents, if both are employed by the U.S. Government.

· Miscarriage - The Contractor shall reimburse up to 100% of the tariff convention.

· Stillborn birth - The Contractor shall pay a fixed amount birth premium equivalent to 10% of the Monthly Ceiling of Social Security (PMSS) to cover expenses related to childbirth and obstetric care provided by a physician or accredited midwife, as long as the deceased infant has been registered with the official authorities.

· Abortion - No payment or reimbursement shall be paid for the interruption of a pregnancy at any stage of the pregnancy for any reason.

High Option:

The Contractor shall pay a fixed amount birth premium equivalent to 15% of the Monthly Ceiling of Social Security (PMSS) to cover expenses related to childbirth and obstetric care provided by a physician or accredited midwife for a normal delivery or for a stillborn birth, as long as in the latter case the deceased infant has been registered with the official authorities.

Category B&D:

Whether Basic or High option, reimbursement shall be:

· Normal or Caesarian delivery - The Contractor shall pay an amount of a minimum of 915€, for all expenses related to childbirth and obstetric care provided by a physician or accredited midwife in a normal delivery. Reimbursement shall not exceed a maximum of 2,287€, payable by the Contractor upon presentation of actual costs incurred and paid by the insured.

· Miscarriage - The Contractor shall reimburse 150% of the tariff convention.

· Stillborn birth - The Contractor shall pay a fixed amount not to exceed 1,524€ to cover expenses related to childbirth and obstetric care provided by a physician or accredited midwife as long as the deceased infant has been registered with the official authorities.

· Abortion - No payment or reimbursement shall be paid for the interruption of a pregnancy at any stage of the pregnancy for any reason.

C.2.5. OPTOMETRIC OR OPTICIAN SERVICES

The Contractor will reimburse expenses related to optometric or optician services as follows:

(However treatment, diagnosis, eye examinations and other ocular care provided by an M.D. ophthalmologist shall be covered under the terms of C.2.2. Doctor Visits, as described above.)

Category A, B, C, D:

Low Option:

Reimbursement of expenses is limited over a two-year contract period to one pair of glasses, except in case of change in eyesight, and for children.

· Single vision and progressive/multifocal lenses: A maximum of 250€ and a maximum of 100€ for the frame;

· Contact lenses: whether or not guarantee-reimbursed by the French Social Security system, reimbursement is limited to 5% of the Monthly Social Security Ceiling (PMSS) per year.

High Option:

Reimbursement of expenses is limited over a two-year contract period to one pair of glasses, except in case of change in eyesight, and for children.

· Single vision lenses: A maximum of 550€ (including a maximum of 150€ for the frame);

Progressive/multifocal lenses: A maximum of 800€ (including a maximum of 150€ for the frame).

· Contact lenses: whether or not guarantee-reimbursed by the French Social Security system, reimbursement is limited to10% for the Monthly Social Security Ceiling (PMSS) per year.

C.2.6. PHYSICAL THERAPY

Only post-surgical and/or physician-prescribed physical therapy normally reimbursable by the French Social Security system shall be reimbursed as follows:

Low Option

Category A&C:

· 100% of the tariff convention.

Category B&D:

· 150% of the tariff convention.

High Option

Category A, B, C, D:

· 200 % of the tariff convention.

C.2.7. PSYCHIATRIC TREATMENT

Psychiatrist-prescribed hospitalization in a psychiatric ward of a general hospital or in a psychiatric hospital or clinic shall be reimbursed based on the terms for C. 2.1. (Hospitalization).

Subsequent to hospitalization in a psychiatric ward or psychiatric hospital, treatment/residence in a “maison de repos” shall not be covered under the terms of this contract.

Category A&C:

Whether Basic or High option, costs for treatment by a conventioned M.D. (Medical Doctor) psychiatrist, shall be reimbursed at 100% of the tariff convention.

Category B&D:

Whether Basic or High option, costs for treatment by a conventioned M.D. psychiatrist shall be reimbursed at 150% of the tariff convention.

C.2.8. AMBULANCE SERVICE

The Contractor shall reimburse costs for ambulance service (Secteur convention) when it is prescribed by a physician or in cases of emergency and when such service is normally reimbursable by the French Social Security system.

No coverage for the non-conventioned sector.

Category A, B, C, D:

Whether Basic or High Option, at 100% of the tariff convention.

C.2.9. HEARING AIDS

The terms of Hearing Aids pertain only to appliances used to correct a hearing deficiency.

Costs for treatment by a physician for ear infections, hearing problems and other ear-related medical treatments based on the terms of C.2.2.

Category A&C:

Whether Basic or High option, at 100% of the tariff convention.

Category B&D:

Whether Basic or High option, at 150% of the tariff convention.

C.2.10. DENTAL TREATMENT

For category A, C: Costs for dental treatment and dental prostheses per person, per annum, shall not exceed the Monthly French Social Security Ceiling (PMSS) in any given year.

For category B, D: Only costs for dental prostheses per person, per annum, shall not exceed the Monthly French Social Security Ceiling (PMSS) in any given year.

Category A, B, C, D

· Dentist visits: Treatment by a Doctor of Dental Surgery or a periodontist (Secteur Conventioné), to remedy dental cavities or other dental or periodontal disease as well as for prophylactic treatment is reimbursed at

Low Option:

100% of the tariff convention.

High Option:

200% of the tariff convention.

· Dental Prostheses: Employees are eligible for dental prostheses benefits after one full year of employment with the U.S. Government.

Reimbursement is at

Low Option:

100% of the tariff convention per prosthesis.

High Option:

300% of the tariff convention per prosthesis.

· Orthodontics: Costs for orthodontic appliances and orthodontic treatment for a child - if the treatment has started before the age of 16 are reimbursed as follows:

Low Option:

Category A & C:

100% of the tariff convention.

Category B & D:

150% of the tariff convention.

High Option:

Category A,B,C,D:

200% of the tariff convention.

· Emergency Dental Surgery

Emergency, accident-related dental surgery shall be reimbursed as follows:

Category A, B, C, D:

Low Option:

100% of the tariff convention.

High Option:

300% of the tariff convention.

C.2.11. EXPENSES INCURRED OUT-OF-COUNTRY

Expenses incurred out-of-country for medical expenses - emergency medical and/or surgical expenses, including anesthesiology, ambulance service, surgeon’s fees, and hospitalization in a semi-private room – shall be reimbursed in accordance with European Union or other bilateral or multilateral medical services totalization agreements to which France is signatory. Reimbursement shall not exceed the actual total of expenses incurred. In the event of medical expenses incurred out-of-country in a state that has no such totalization or exchange agreement to which France is signatory, or in a country that is not reimbursable by the French Social Security system, there shall be no reimbursement under this contract.

Category A & C:

100% of the tariff convention

Category B & D:

150% of the tariff convention

C.2.12.

Reserved

C.2. 13. DIRECT PAYMENT CARD (CARTE TIERS PAYANT).

The Contractor shall provide all members of categories A and C, a “Carte Tiers Payant” for usage in conjunction with the French Social Security reimbursement system.

C. 2.14. HEALTH SERVICES AND TREATMENTS EXCLUDED FROM THIS CONTRACT:

The following medical/health services or treatments are excluded from the benefits allowable under the terms and conditions of this contract.

1. Cosmetic or plastic surgery or hair transplants for esthetic effect unless such surgery qualifies as plastic reconstructive surgery subsequent to an accident or required due to a congenital malformation and is recommended by a surgeon. To be included as a benefit under C.2.1. Hospitalization and C.2.2. Surgery above, the plastic surgery (reconstructive surgery only) must be approved for reimbursement by the French Social Security system for Category A insured. For Category B insured, the surgery must be approved by the Contractor’s medical consultant.

2. Physical therapy or massages are excluded unless the treatment meets the criteria in C.2.6. Physical Therapy above.

3. Thermal water cures, thalassotherapy, rest cures and maison de repos -except following a surgical procedure - are excluded from the terms of this contract.

4. Pedicures and other treatments of the foot, unless by prescription from an accredited M.D. podiatrist, are excluded from this contract.

5. Weight control clinics, special diets and weight-loss clubs or camps are excluded from the terms of this contract.

6. Detoxification clinics for drug or alcohol addiction are excluded from this contract unless (a) treatment at such a clinic as an in-patient is prescribed by an M.D. and (b) in-patient clinical treatment at the facility is approvable for reimbursement by the French Social Security. If these two conditions are met, reimbursement under the terms of this contract shall conform to C.2.1. Hospitalization, as described above. However, no daily indemnity shall be paid to Category B insured for detoxification treatment.

7. Acupuncture treatments shall not be covered under the terms of this contract.

8. Abortion shall not be covered under the terms of this contract.

PART II – DISABILITY AND DEATH BENEFITS INSURANCE

C. 3. EMPLOYEE DISABILITY AND DEATH BENEFITS INSURANCE (PREVOYANCE)

These benefits are available only to employees currently on the U.S. Government payroll. Disability insurance benefits under this contract shall not be payable when the disability results from an occupation-related illness or injury. This benefit does not apply to dependent family members, to survivors of the employee or to retired employees. Employees who were separated and were receiving disability benefits from the contractor will continue to receive such benefits. See Attachments C and D for a table of benefits and prices for all CLINS covered under this contract.

C.3.1 DISABILITY

Low Option:

Category A:

Subsequent to an illness or non-occupational accident resulting in permanent total or partial disability, the Contractor shall pay a fixed amount which shall be prorated depending on the degree of permanent disability: such sum shall not exceed the annual Social Security ceiling, nor shall such sum be less than 10% of the official disability rate.

Category B:

Permanent Partial or Total Disability:

Subsequent to an accident or illness, the Contractor will pay a maximum of 15,245€. The exact amount of the fixed payment will depend on (a) evaluation of the degree of disability by the Contractor’s medical consultant and (b) the fixed amount payment rate established by the French Social Security system for that degree of disability.

Temporary Disability:

The contractor will make a monthly payment of 365€ in the following cases:

· Accident or injury: from the date of the occurrence for a period not to exceed 24 months.

· Illness requiring hospitalization for more than two days, from the first day of disability from work for a period not to exceed 12 months.

· Illness without hospitalization, beginning after 60 calendar days of disability from work for a period not to exceed 12 consecutive months. Payment will resume if the employee returns to work and is disabled again without incurring a new 60 days waiting period.

High Option :

In addition to the basic option, a supplementary benefit may be granted to the employees, if a minimum number of them voluntarily enroll. The premium for this option shall be fully paid by the employee. Once enrolled, employees will not be authorized to cancel, except in case of resignation or retirement.

Temporary Disability with Medical Discharge:

Subsequent to an illness or an accident, the Contractor shall pay a daily indemnity. This benefit is only payable to active employees under the age of 70, and does not apply to family members or retirees.

Category A:

Once all the employee’s sick leave has been used, the Contractor shall pay a daily indemnity equal to 75% of the employee’s daily net salary including reimbursement from the French Social Security. These payments are made as long as the French Social Security benefits are paid, up to the 1095th day (or max 3 years) of the medical discharge, but without exceeding the retirement date at the 70th birthday, or up to the date at which the permanent partial or total disability is recognized by the French Social Security as stated below

Category B:

Once all the employee’s sick leave and annual leave has been used, the Contractor shall pay an indemnity equal to 75% of the employee’s daily net salary less the daily indemnity as established in the basic option in C.3.1. for Category B, above.

Permanent (Partial or Total) Disability:

An employee not eligible for immediate retirement benefits will receive compensation at the end of each quarter once the status of permanent (partial or total) disability is recognized. This compensation shall be calculated as follows:

· First Level of Disability- Permanent Partial Disability

Category A: The contractor shall pay compensation equal to 45% of the employee’s daily net salary less the amount for disability paid by the French Social Security System. This payment shall be made for as long as the disability status lasts, even in case of an eventual return to work.

Category B: The Contractor shall pay compensation equal to 45% of the employee’s daily net salary less the amount paid by the contractor in C. 3 above, Category B until the employee resumes duties.

· Second and Third Levels of Disability - Permanent Total Disability

Category A: For an employee whose disability prevents him or her from working, the Contractor shall pay a compensation equal to 75% of the employee’s daily net salary less the amount for disability paid by the French Social Security

Category B: The Contractor shall pay compensation equal to 75% of the employee’s daily net salary less the daily indemnity as established in C.3.1. for Category B, above, until the US Civil Commission establishes the disability retirement date.

C.3.2 DEATH BENEFITS:

Death benefits are payable only to dependents or other designated beneficiaries, if the employee was on the payroll at the time of death by accident or illness. This benefit does not apply to former employees of the US Government, dependent family members or retirees.

Category A & B:

The death benefit subsequent to illness or accident payable to the deceased’s spouse, legal heirs, and/or other designated beneficiary shall be equal to the official annual applicable ceiling of the French Social Security system as published on January 1st of the year of death. The death benefit payment shall be payable by the Contractor within 30 days of the death, once all documentation has been provided.

Low Option:

The Contractor shall pay to the entitled survivors or beneficiaries, death benefits equal to 100% of the Social Security Annual Ceiling.

High Option:

a. When the deceased employee is single, the Contractor shall pay to the entitled survivors or beneficiaries, death benefits equal to 100% of the employee’s annual net salary.

b. When the deceased employee is married, the Contractor shall pay to the entitled survivors or beneficiaries, death benefits equal to 150% of the employee’s annual net salary.

C.4 ELIGIBLE PARTICIPANTS:

The employees, former employees and eligible dependents under the terms and conditions of this contract are the following:

- All current active locally employed staff of the United States Government, including third country nationals and American employees locally-employed under the terms of the Rockefeller Amendment, employed by the United States Government for the United States Embassy to France including USOECD, USUNESCO, and the United States Consulates and Agricultural Research Center in France, and paid under the local compensation plan, the Official Residence Employees (ORE) whose names shall be provided as a separate attachment upon award of contract. It shall be understood by the Contractor that in addition to the insured employees, whether under Category A (for employees affiliated with the French Social Security system) or under Category B (for employees under the U.S. Civil Service Retirement system, or the U.S. Social Security System), employed by the U.S.