Jakarta_LES_Health_Insurance_2016_RFP-17OCT2016.pdf

X SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING PAGE OF PAGES

1 | 67

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

3. SOLICITATION NO.

SID320-16-R-0015

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[x] NEGOTIATED (RFP)

5. DATE ISSUED

October 17th, 2016

6. REQUISITION/PURCHASE NO.

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than item 7) Embassy of the United States of America Gedung Sarana Jaya, Jl. Budi Kemulyaan I/1, Jakarta 10110 Phone: +62 (21) 3435-9000 Fax: +62 (21) 3435-9910

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

SOLICITATION

9. Sealed offers in original and 2 copies for furnishing the supplies or services in the Schedule will be received at the place specificed, in the depository until

12 Noon local (Jakarta) time on Tuesday, 22 November, 2016.

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

10. FOR INFORMATION

CALL:

A. NAME

LAWRENCE P. LANE

B. TELEPHONE (NO COLLECT CALLS)

AREA CODE NUMBER EXT

(62-21) 3435-9000

C. E-MAIL ADDRESS

USEmbJak_Insurance@state.gov.

11. TABLE OF CONTENTS

(x) SEC. DESCRIPTION PAGE(S) (x) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM 1 I CONTRACT CLAUSES 32

B SUPPLIES OR SERVICE AND PRICES/COSTS 2 PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

C DESCRIPTION/SPECS/WORK STATEMENT 7 J LIST OF ATTACHMENTS 43

D PACKAGING AND MARKETING 22 PART IV - REPRESENTATIONS AND INSTRUCTIONS

E INSPECTION AND ACCEPTANCE 23 K REPRESENTATIONS, CERTIFICATIONS, AND 46

F DELIVERIES OR PERFORMANCE 25 OTHER STATEMENTS OF OFFERORS

G CONTRACT ADMINISTRATION 26 L INSTRS., COND., AND NOTICES TO OFFERORS 59

H SPECIAL CONTRACT REQUIREMENTS 28 M EVALUATION FACTORS FOR AWARD 66

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 inseted 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)

10 CALENDAR DAYS

20 CALENDAR DAYS

30 CALENDAR DAYS

CALENDAR DAYS

14. ACKNOWLEDGMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

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

15A. NAME CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED

AND ADDRESS

OF OFFEROR

TO SIGN OFFER (Type or print)

15B. TELEPHONE NO. (Include area code)

15C. CHECK IF REMITTANCE ADDRESS [ ]

IS DIFFERENT FROM ABOVE - ENTER SUCH

ADDRESS

17. SIGNATURE 18. OFFER DATE

AWARD (To be completed by Government)

19. ACCEPTED AS TO ITEM NUMBERED

20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

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

24. ADMINISTRATION BY (If other than Item 7) CODE 25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

LAWRENCE P. LANE

27. UNITED STATES OF AMERICA

28. AWARD DATE

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

NSN 7540-01-152-8064 STANDARD FORM 33 (REV 9-97)

SECTION B

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PART I: PRICE - HEALTH INSURANCE

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide Health Insurance services to employees of the Government of the United States of America in Indonesia, as described in Section C and the Exhibits in Section J. The groups of employees who shall be provided this insurance are listed in C.1.3 (Medical). This insurance shall be provided in accordance with Section C and the Exhibits in Section J.

B.1.1. Official Residence Expense (ORE) Staff and Peace Corps Personal Service Contractors (PSCs) are included under this contract only as a rider; the Contractor shall bill the Chief of Mission, Deputy Chief of Mission and/or Consul General Surabaya (for ORE Staff), at the rates specified below.

See Section G for billing procedures.

B.2. PRICES

B.2.1 VALUE ADDED TAX. The Government will not reimburse the Contractor for VAT under this contract.

B.2.2 This is a firm fixed price with economic price adjustment requirements type contract under which will be issued as firm, fixed-price task orders. The fixed prices/premium rates for the health insurance services as specified in Section C are as follows:

B.2.3. Basic Year

Bi-Weekly Rates per Employee

Category Estimated Number

Premium Rate per Bi-Weekly per category

Bi-Weekly Total

a. Male employee/spouse 1200

b. Female employee/spouse > 45 years old 227

c. Female employee/spouse < 45 years old 1000

d. Child 1812

e. Subtotal (a+b+c+d)

f. Total Price for Year Basic Year (e. x 26)

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B.2.4. Option Year 1

Estimated Number

Premium Rate per Bi-Weekly per category

Bi-Weekly Total

a. Male employee/spouse 1200

b. Female employee/spouse > 45 years old 227

f. Total Price for Option Year 1 (e. x 26)

B.2.5. Option Year 2

Estimated Number

Premium Rate per Bi-Weekly per category

Bi-Weekly Total

a. Male employee/spouse 1200

b. Female employee/spouse > 45 years old 227

f. Total Price for Option Year 2 (e. x 26)

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B.2.6. Option Year 3

Estimated Number

Premium Rate per Bi-Weekly per category

Bi-Weekly Total

a. Male employee/spouse 1200

b. Female employee/spouse > 45 years old 227

f. Total Price for Option Year 3 (e. x 26)

B.2.7. Option Year 4

Estimated Number

Premium Rate per Bi-Weekly per category

Bi-Weekly Total

a. Male employee/spouse 1200

b. Female employee/spouse > 45 years old 227

f. Total Price for Option Year 4 (e. x 26)

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B.2.8 Grand Total of Base Plus All Option Years

Grand Total of Base plus All Option Years

Base Year Total

First Option Year Total

Second Option Year Total

Third Option Year Total

Fourth Option Year Total

Grand Total of Base plus All Option Years

B.2.9. OFFERS AND PAYMENT IN LOCAL CURRENCY

All offers and payments shall be in local currency only, Indonesian Rupiah (IDR/ Rp) in accordance with the Bank Indonesia Regulation No. 17/3/PBI/2015. This applies to all firms and there are no exceptions.

B.3 ADMINISTRATIVE RETENTION AMOUNTS

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

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

NOTE TO OFFEROR: Fill in the fixed bi-weekly 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 (IDR). The fixed retention amount shall NOT be expressed in terms of a percentage of the premium.

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B.3.2.1 Bi-Weekly Retention Amounts per separate premium paid per covered employee.

Period of Performance

Male Employee/Spouse

Female Employee/Spouse

> 45 years old

Female Employee/Spouse

< 45 years old Child

Base Period

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

B.4. ECONOMIC PRICE ADJUSTMENT-HEALTH INSURANCE PREMIUMS

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

(1) receipts (premiums received) minus the retention amount; and

(2) distribution of insurance plans; and

(3) claims paid.

This information shall be provided per type of premium, i.e. per line item. The retention amount is not subject to adjustment. The Government reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract. Mutually agreed to adjustments shall be effective thirty days after complete information is received by the Government. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

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

B.4.2.1 Employee Pool – This clause is only in effect if the Contractor included details in its offer regarding a pooling arrangement, of which this contract is a part.

Before any adjustment is made under this price adjustment clause, the Contractor must include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

SECTION C

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DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America (“The Government”) requires Health Insurance coverage for its employees as further described in C.1.2 in Indonesia. The Government has determined that the prevailing practice by employers in Indonesia is to provide for their employees optional health insurance protection and that the cost of such insurance protection is usually borne by both the employee and the employer on a Premium cost sharing arrangement.

The U.S. Government will pay the Contractor the full premium amount on a quarterly basis. In the case of ORE and Peace Corps staff, the employer will pay the full premium amount on a quarterly basis.

For all employees, regardless of hours worked, the U.S. Government will pay 90% and the employee will pay 10% of the premium cost for health insurance coverage for the employee and any dependent/s coverage. Participation in this health insurance plan will be voluntary.

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.

C.1.1 Employee and Dependent Health Services Benefits

The health benefits under this contract are as follows. Reimbursement of covered expenses is limited to the stated maximums and percentages of reasonable and customary costs. Proposals that contain more benefits (even if there is no increase in cost) or fewer benefits than stated in the solicitation may be deemed technically unacceptable.

Reimbursements or payments shall be made for the following covered benefits, subject to reasonable and customary costs in the locality where treatment was provided. The medical treatment must be prescribed or provided by a physician or nurse licensed in Indonesia, the United States, or in the country in which the treatment or prescription is received. Coverage of expenses will be provided in Indonesian Rupiah.

All Benefits are Per Person

C.1.1.1. Hospitalization:

A. Room and Board:

1. Room and board for a ward room or semi-private room;

Room and board expenses: 100% coverage, not to exceed Rp.800,000/day

B. Hospital Medical Expenses

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1. Hospital medical expenses including laboratory tests and x-rays, nursing care, operating room expenses, surgery cost, anesthetics, intensive care (ICU/ICCU), prescription medicines, and physical therapy; doctor’s and surgeon’s fees including attending physician visits and specialist doctor consultations;

2. Ambulance service.

Hospital Medical expenses: 100% coverage

C.1.1.2. Outpatient:

1. Professional services and treatment: doctors’ and surgeons' fees incurred at a hospital on an out-patient basis, at a clinic or doctor's office, or at home;.

2. Specialist’s and physiotherapist’s fee;

3. Medical services & expenses when not hospitalized such as laboratory test and x-rays

4. Prescription medicines and drugs for which prescription is legally required; Expenses incurred for medicines, vitamins, cold remedies, etc, that are available over the counter without prescription will not be reimbursed even if prescribed by a physician;

5. Pre-natal and post-natal care treatment which include obstetrical medical care, including treatment of complications of pregnancy;

6. Family planning: prescribed contraceptive devices and drugs.

Outpatient care expenses: 100% coverage, not to exceed Rp.25,000,000/year

C.1.1.3. Obstetrical Care.

There is no limitation of obstetrical care based on age or total number of prior deliveries per employees and/or spouse.

1. Normal Delivery

Obstetrical medical care including delivery with or without forceps or vacuum. Any childbirth, not involving hospital confinement; the maternity benefit shall be equal to the actual charges by a Registered Medical Practitioner or Qualified Nurse relating to the maternity, but not to exceed the Normal Delivery benefit.

Normal birth max benefit: 100% coverage, not to exceed Rp.10,000,000/occurance

2. Caesarean

Surgical incision through the abdominal wall to extract a fetus when normal delivery can not be accomplished due complication such as toxemia, eclampsia and pre-eclampsia or other abnormality conditions raised due to pregnancy

C-Section max benefit: 100% coverage, not to exceed Rp.15,000,000/ occurance

3. Miscarriage

Premature birth of a fetus due to a medical conditions or therapeutic abortion

Miscarriage max benefit: 100% coverage, not to exceed Rp.7,500,000/ occurance

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C.1.1.4. Preventative Care

1. Annual Medical Checkup

One examination per person per year, including any medically necessary laboratory or ancillary test incident there to specifically include pap-smears and mammograms for female employees or dependents, 100% coverage of expenses

2. Immunization

Immunization charges, 80% coverage of expenses.

Preventive Care maximum: Rp.2,200,000/year

C.1.1.5. Optical Care:

1. Reimbursement of eye examination and treatment and prescription eyeglass lenses, 100% coverage of expenses

2. Reimbursement of contact lenses, 80% coverage of expenses

3. Limited to two lenses per patient per two years

4. No coverage of expenses for eyeglass frames, nonprescription lenses, or tinting

Optical care maximum: Rp.4,000,000/bi-annual

C.1.1.6. Dental Service, reimbursement of:

1. General Dental Services

Professional dental treatments and services from a dentist for amalgam and anterior fillings, extractions, x-rays, examination and treatments of abscesses, root canal fillings, pins for cusp restorations, cleaning, filling, extractions, false teeth, crowns, and bridges;

Expenses for treatments rendered by a dentist in respect of scaling, polishing and prophylaxis;

Expenses for dentures required as a result of loss of teeth, dental treatment and services which shall include periodontal surgery, gold inlays, crowns, and bridge work, surgical extraction of wisdom teeth.

Maximum coverage: 80% coverage of expenses

2. Orthodontia treatment

Orthodontia treatment is covered only if treatment begins before age 16, unless required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per patient.

Maximum coverage: 80% coverage of expenses

C.1.1.7 Medical Expenses Incured Out of Country

Medical expenses incurred out of country, will be covered for employees and dependents when:

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(a) life threatening conditions 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 in Indonesia certifies in advance that such treatment is medically necessary and unavailable in Indonesia.

The reimbursement will be made at the same rate and subject to the same annual maximum limit as for expenses incurred in Indonesia.

C.1.1.8. Transportation for Out of Country Medical Treatment:

Transportation for out of country treatment will be covered expenses for eligible employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally.

Eighty percent (80%) of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facility will be reimbursed.

Eighty percent (80%) of the transportation expenses of an attendant will 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 reimbursement for transportation expenses are subject to the annual maximum limit.

C.1.1.9. HIV/AIDS Expanded Coverage

100% coverage of expenses for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for covered individuals who have HIV AIDS. Brief courses of anti retroviral drugs during childbirth to prevent the transmission of HIV to the child

This expanded coverage generally excluded medications for the long-term suppression of AIDS through the combination of anti-retroviral drugs at those posts with inadequate local healthcare infrastructure.

Maximum coverage under section C.1.1.9. Rp.70,000,000/year

C.1.1.10 Annual Maximum Limit – The maximum annual reimbursement per patient per contract year,

1. For section C.1.1.1 through C.1.1.8. is Rp. 232,000,000 per covered individual per contract year

2. For section C.1.1.9. HIV/AIDS expanded coverage is Rp.70,000,000 per covered individual per contract year

Below is a summary (repetition) of benefit listed above in the form of a table format:

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Paragraph Description Maximum Coverage per person

C.1.1.1.

Hospitalization:

A. Room and Board:

1. Room and board for a ward room or semi-private room.

B. Hospital Medical Expenses

1. Hospital medical expenses including laboratory tests and x-rays, nursing care, operating room expenses, surgery cost, anesthetics, intensive care (ICU/ICCU), prescription medicines, and physical therapy; doctor’s and surgeon’s fees including attending physician visits, and specialist doctor consultations;

2. Ambulance service

100% coverage not to exceed Rp.800,000/day

100% coverage

C.1.1.2 Outpatient:

1. Professional services and treatment: doctors' and surgeons' fees incurred at a hospital on an outpatient basis, at a clinic or doctor's office, or at home;

2. Specialist’s and physiotherapist’s fee;

3. Medical services & expenses when not hospitalized such as laboratory test and x-rays;

4. Prescription medicines and drug for which prescription is legally required;

Expenses incurred for medicines, vitamins, cold remedies, etc, that are available over the counter without prescription will not be reimbursed;

5. Pre-natal and post-natal care treatment which include obstetrical medical care, including treatment of complications of pregnancy;

6. Family planning: prescribed contraceptive devices and drugs.

Not to exceed Rp.25,000,000/year

100% coverage

C.1.1.3 Obstetrical Care.

There is no limitation of obstetrical care based on age or total number of prior deliveries per employees and/or spouse.

1. Normal Delivery:

Obstetrical medical care including delivery with or

100% coverage, not to exceed:

Page 12 of 67 RFQ: SID32016R0015: U.S Embassy Jakarta LES Health Insurance without forceps or vacuum. Any childbirth, not involving hospital confinement; the maternity benefit shall be equal to the actual charges by a Registered Medical Practitioner or Qualified Nurse relating to the maternity, but not to exceed the Normal Delivery benefit.

2. Caesarean:

Surgical incision through the abdominal wall to extract a fetus when normal delivery can not be accomplished due complication such as toxemia, eclampsia and pre-eclampsia or other abnormality conditions raised due to pregnancy

3. Miscarriage:

Premature birth of a fetus due to a medical conditions or therapeutic abortion

Rp.10,000,000/occurance

Rp.15,000000/occurance

Rp.7,500,000/occurance

C.1.1.4. Preventative Care:

1. Annual Medical Checkup:

One examination per person per year, including any medically necessary laboratory or ancillary test incident there to specifically include pap-smears and mammograms for female employees or dependent, 100% of claim

2. Immunization:

Maximum Rp.2,200,000/year

100% coverage of experence

80% coverage of expenses

C.1.1.5. Optical Care:

1. Reimbursement of eye examination and treatment and prescription eyeglass lenses

2. Reimbursement of contact lenses

3. Limited two lenses per patient per two years.

4. No coverage of expenses for eyeglass frames, nonprescription lenses, or tinting.

Rp.4,000,000/bi-annual

100% coverage of expenses

C.1.1.6. Dental Service,

1. General Dental Services

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Professional dental treatments and services from a dentist for amalgam and anterior fillings, extractions, x-rays, examination and treatments of abscesses, root canal fillings, pins for cusp restorations, cleaning, filling, extractions, false teeth, crowns, and bridges;

Expenses for treatments rendered by a dentist in respect of scaling, polishing and prophylaxis;

Expenses for dentures required as a result of loss of teeth, dental treatment and services which shall include periodontal surgery, gold inlays, crowns, and bridge work, apocalyptic surgical extraction of wisdom teeth.

2. Orthodontia treatment Orthodontia treatment is covered only if treatment begins before age 16, unless required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per patient.

C.1.1.7. Medical Expenses Incurred Out of Country:

will be covered for employees and dependents when:

(a) life threatening conditions 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 in Indonesia certifies in advance that such treatment is medically necessary and unavailable in Indonesia.

The reimbursement will be made at the same rate and subject to the same annual maximum limit as for expenses incurred in Indonesia.

C.1.1.8. Transportation for Out of Country Medical Treatment:

Transportation for out of country treatment will be covered expenses for eligible employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally.

Eighty percent (80%) of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facility will be reimbursed.

All reimbursement for transportation expenses are subject to the annual maximum limit

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Eighty percent (80%) of the transportation expenses of an attendant will 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.

C.1.1.9. HIV/AIDS Expanded Coverage):

100 % coverage of expenses for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV AIDS.

Brief courses of anti retroviral drugs during childbirth to prevent the transmission of HIV to the child.

This expanded coverage generally excluded medications for the long-term suppression of AIDS through the combination of anti-retroviral drugs at those posts with inadequate local healthcare infrastructure.

Maximum coverage under section C.1.1.9:

Rp.70,000,000/year

C.1.1.10 Annual Maximum Limit – The maximum annual reimbursement per patient per contract year,

1. For section C.1.1.1 through C.1.1.8.:

2. For section C.1.1.9. HIV/AIDS treatment:

Rp. 232,000,000 per covered individual per contract year

Rp.70,000,000 per covered indivicual per contract year

C.1.2 Health Benefits Conditions and Limitations.

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

There is no coverage of elective cosmetic surgery; spa cures; rejuvenation cures; massage;

exercise therapy; long term rehabilitative therapy; 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 coverage for expenses that will be reimbursed or paid directly under a host country medical program, the U.S. workers' compensation program, or any Indonesian workers' compensation type program.

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There is no coverage 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.

There is no coverage for psychiatric treatment, hearing aid, expenses for eyeglass frames, nonprescription lenses, or tinting.

There is no coverage of reversal of voluntary sterilization, infertility treatment after voluntary sterilization, genetic counseling, and assisted reproductive technology.

There is no coverage for expenses incurred after an employee leaves the service of the U.S.

Mission.

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 Indonesia 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. The participation will be voluntary. Open session program will be conducted annually.

C.1.3.2 Location of Employment

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

U.S. Department of State –Jakarta

U.S. Consulate – Medan

U.S. Consulate General – Surabaya

U.S. Consular Agency –Bali

US Agency for International Development (USAID)

Foreign Agriculture Service (FAS)

Foreign Commercial Service (FCS)

Defense Attaché Office (DAO)

Department of Justice (DOJ)

Library of Congress (LOC)

Office of Defense Cooperation (ODC)

Open Source Enterprise (OSE) – formerly OSC or FBIS

Diplomatic Security Anti-Terrorism Assistance (DS/ATA)

Center for Disease Control (CDC)

International Broadcasting Bureau/Voice of America (IBB/VOA)

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President’s Emergency Plan for HIV/AIDS relief (PEPFAR)

Naval Facilities Engineer Command (NAVFAC)

Department of Homeland Security (DHS)

Drugs Enforcement Administration (DEA)

International Narcotics and Law Enforcement Affairs (INL)

Peace Corps LES/direct hire appointments

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1. All current active employees of the Chief of Mission (The U.S. Ambassador to Indonesia), Deputy Chief of Mission, the Consul General in Surabaya and the Consul in Medan 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.1.3.3.2. All current active employees of the U.S. Peace Corps employed under Personal Service Contract. All costs for Peace Corps employees are the responsibility of the Peace Corps, not the U.S. Embassy in Jakarta or Consulate Surabaya.

C.1.4 Individuals Not Eligible for Coverage

Not eligible are those working under temporary appointments; those working under a PSC or PSA that is time limited to less than one year; non-personal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Indonesia who provides services to other local organizations as well as to the U.S. Mission; employees of USAID institutional contractors; Recreation Association employees; 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:

Expenses incurred by a participating employee's enrolled eligible dependents are covered under this plan.

For the purpose of this plan, an employee’s dependents are defined as the legal spouse (limit one) and each unmarried, economically dependent child who primarily resides with the employee unless away at school, up to a maximum of three children.

Parents, grandparents, siblings, and other relatives are not eligible dependents.

Employees with one dependent are defined as employee and one spouse OR one child.

Family plans are defined as employee and dependents (including up to three children per family and one spouse)

A child is defined as the employee's natural child, adopted child, stepchild, or foster child. An eligible child will be covered until the end of the calendar year in which the child turns age 21, or in the case of a child who is a fulltime student, until the end of the calendar year in which the

Page 17 of 67 RFQ: SID32016R0015: U.S Embassy Jakarta LES Health Insurance child turns age 23. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently.

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 or, for ORE staff, with their employer. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

For each employee who elects to enroll in the program the USG will pay 90% of the premium cost for employee and dependent coverage.

There is no coverage for retired employees.

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. Premiums will be paid via payroll deductions.

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 an extended period (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 and Information Requirement

C.1.7.1. The Contractor shall provide a document (brochure/pamphlet/other written document) in Indonesian language 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 21 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR’s request.

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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

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C.3. Definitions

Name Definition

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 (limit one) and each unmarried, economically dependent child who primarily resides with the employee unless away at school, up to maximum three (3) children.

A child is defined as the employee's natural child, adopted child, stepchild, or foster child. An eligible child will be covered until the end of the calendar year in which the child turns age 21, or in the case of a child who is a fulltime student, until the end of the calendar year in which the child turns age 23. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently.

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. This may also include ORE Staff and Peace Corps PSCs if this category of individual is listed as participating under a rider in C.1.3.3 for health insurance.

Employer The United States Government or in the case of ORE and the Chief of Mission/Deputy Chief of Mission/Consul General Surabaya

GSO General Services Officer in charge of the General Services Office at post. This officer is usually the Contracting Officer (CO) for this contract.

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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.

Surgical Fee The amount charged by the Physician and the Anesthesiologist for performing operation, including pre and post-operative care. The total amount shall not exceed the annual maximum benefit ceiling.

Intensive Care Benefits Benefit in addition to those provided for Room and Board and Special Hospital Services but in no event shall the benefit exceed the maximum limit as shown in the Schedule of Benefits.

IMPORTANT:

Expenses incurred for the treatment of diseases and/or injuries not specifically mentioned in the above-listed exclusions will be included as “inclusions” and therefore covered by this healthcare contract, subject to the maximum benefit limit of Rp.232,000,000 per injury or per illness (regardless of illness category) per contract year.

SECTION D

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(RESERVED)

PACKAGING AND MARKING

SECTION E

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INSPECTION AND ACCEPTANCE

E.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

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

http://www.acquisition.gov/far/ or http://farsite.hill.af.mil/vffara.htm

These addresses are subject to change. If the Federal Acquisition Regulation (FAR) is not available at the locations indicated above, use the Department of State Acquisition website at http://www.statebuy.state.gov/ to see the links to the FAR. You may also use an internet “search engine” (for example, Google, Yahoo, Excite) to obtain the latest location of the most current FAR.

The following Federal Acquisition Regulation clause(s) is/are incorporated by reference:

CLAUSE TITLE AND DATE

52.246-4 INSPECTION OF SERVICES - FIXED PRICE (AUG 1996)

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

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

Performance Objective PWS Paragraph Performance Threshold

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

C.1.0 thru C.3.0

All required services are performed and no more than three formal (3) customer complaints are received per month

E.2.1 Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided. If appropriate, the COR will send the complaints to the Contractor for corrective action.

http://www.acquisition.gov/far/ http://farsite.hill.af.mil/vffara.htm http://www.statebuy.state.gov/

SECTION E

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E.2.2 Standard. The performance standard is that the Government receives no more than three (3) customer complaints per month. The COR shall notify the Contracting Officer of the complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR 52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of Services clause), if any of the services exceed the standard.

E.2.3 Procedures

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

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

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

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

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

(f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR. The COR will review the matter to determine the validity of the complaint.

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

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

SECTION F

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DELIVERIES OR PERFORMANCE

F.1. 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

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

http://www.acquisition.gov/far/ or http://farsite.hill.af.mil/vffara.htm

These addresses are subject to change. If the Federal Acquisition Regulation (FAR) is not available at the locations indicated above, use the Department of State Acquisition website at http://www.statebuy.state.gov/ to see the links to the FAR. You may also use an internet “search engine” (for example, Google, Yahoo, Excite) to obtain the latest location of the most current FAR.

The following Federal Acquisition Regulation clauses are incorporated by reference:

CLAUSE TITLE AND DATE

52.242-15 STOP WORK ORDER (AUG 1989)

52.242-17 GOVERNMENT DELAY OF WORK (APR 1984)

F.2 PERIOD OF PERFORMANCE. The performance period of this contract is one year beginning from the date set forth in the Notice to Proceed (NTP)following contract award with four one-year options to renew.

The performance period of this contract is one year beginning on date established in the Notice to Proceed and continuing for twelve (12) months with four (4) one-year options to renew. This contract also includes an additional option under FAR 52.217-8.

F.3 OPTIONS

(a) The Government may extend this contract in accordance with the option clause at Section I, clause I.2, FAR Clauses Incorporated by Full Text (FAR 52.217-9, Option to Extend the Term of the Contract), which also specifies the total potential duration of the

(b) The Government may exercise the option set forth at Section I, "FAR 52.217-8, Option to

Extend Services".

F.4 REPORTS AND OTHER DELIVERABLES

All reports must be provided in electronic format to the COR in either PDF or XLSX (MS Excel) format, depending on the type of report. Any report including claims information must be submitted in XLSX format.

SECTION F

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

Human Resources Office US Embassy Jakarta

Gedung Sarana Jaya Lantai 11, Jl. Budi Kemulyaan I/1 Jakarta 10110

Remarks: LES Health Benefit Contract

F.5. NOTICE TO PROCEED

Following receipt from the Contractor of acceptable evidence that the Contractor has obtained all required licenses, permits and insurance and is otherwise prepared to commence providing the services, the Government Contracting Officer shall issue a Notice to Proceed.

On the date established in the Notice to Proceed (this notice will allow a minimum of seven (7) calendar days from the date set forth in the Notice to Proceed, unless the Contractor agrees to an earlier date), the Contractor shall start work.

SECTION G

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CONTRACT ADMINISTRATION DATA

G.1. 652.242-70 CONTRACTING OFFICER’S REPRESENTATIVE (COR) (AUG 1999)

(a) The Contracting Officer may designate in writing one Government employee, by name or position title, to take action for the Contracting Officer under this contract. This designee shall be identified as a Contracting Officer’s Representative (COR). Such designation shall specify the scope and limitations of the authority so delegated; provided, that the designee shall not change the terms or conditions of the contract, unless the COR is a warranted Contracting Officer and this authority is delegated in the designation..

(b) The COR for this contract is the U.S. Embassy in Jakarta Deputy Human Resources Officer.

G.2 COR DUTIES

G.2.1 The COR is responsible for inspection and acceptance of services. These duties include review of Contractor invoices, including the supporting documentation required by the contract.

The COR may provide technical advice, substantive guidance, inspections, invoice approval, and other purposes as deemed necessary under the contract..

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

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

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

G.3. Payment shall be made in Indonesian Rupiah (IDR), per the Bank Indonesia Regulation No.

17/3/PBI/2015.

G.4 SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted as one set of electronic copies (either in PDF or XLS format) to the Financial Management Office. The email address for the submission is JakartaFMCAccountants@state.gov.

Payments at End of Covered Period

SECTION G

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G.4.2. Frequency of Payments. All funds under this contract will be obligated by issuance of task orders, as described in H.3. Each task order will fund a specific period of time and number of employees, and the task orders will be issued at the frequency described in H.3. All payments under this contract will be made at the conclusion of the period covered. Invoices may be submitted monthly with payments being made monthly by the Government.

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

G.4.4 ORE Staff. The Chief of Mission, Deputy Chief of Mission and the Consul General Surbaya will make payment directly to the Contractor for the entire premium amount of the ORE staff, whether or not the ORE employee is contributing to the premium amount.

G.4.5. Peace Corp Employees. The Peace Corp will make payment directly to the Contractor for the entire premium amount of the Peace Corp PSC employee, whether or not the Peace Corp PSC employee is contributing to the premium amount.

G.5 REFUNDS TO THE GOVERNMENT

If at any time during performance of the contract the Government finds that the Contractor has been overpaid because the number of employees and/or dependents covered has decreased, the Contracting Officer…