Questions_and_Answers_Insurance_Solicitation.docx

1. Premium history for health Insurance for the current year 2015 (till now); you have already provided the premium history from 2010 to 2014.

2. Claims history for health Insurance for the current year 2015 (till now) and for the last 5 years 2014, 2013, 2012, 2011 and 2010. It is standard practice in the insurance industry (and in other Department of State insurance solicitations) to provide this information to ensure equal/fair opportunity for all offerors in an open solicitation.

NOTE TO OFFERORS:

The claims paid by the incumbent contractor are provided for informational purposes only and under no circumstances shall it be construed to change any terms or conditions or requirements within the solicitation. Under no circumstances shall the U.S. Government be liable for this data or shall it become the basis for a request to adjust the premium rates after contract award. Offerors are advised any adjustments to contract premium rates shall be in accordance with the B.4.

3. Advise if 2014 benefit schedule for health insurance is the same as the benefit schedule currently being requested under SNG60016R0001; and if not advise us on the differences. Alternatively, you can simply provide the previous solicitation document.

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as further described in C.1.1 in Niger. The Government has determined that the prevailing practice by employers in Niger is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by both the employee and the employer – US Government pays 100% of the premium. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.1. The specific health benefit coverage under this contract is set forth in Section C and the Exhibit in Section J.

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

C.1.1 Employee and Dependent Health Services Benefits

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

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

C.1.1.3. Prescription drugs and medicines: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required. Expenses incurred for medicines, vitamins, cold remedies, etc., that are available over the counter without a prescription will not be reimbursed even if prescribed by a physician.

C.1.1.4 For employees only: 100% reimbursement for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS. For employee and employee's covered spouse/partner: 100% reimbursement for brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee’s child. This expanded coverage generally excludes medications for the long-term suppression of AIDS through the combination of anti-retroviral drugs at those posts with inadequate local healthcare infrastructures.

The Insurance Company will reimburse covered expenses up to a limit of 5,500,000 CFA per patient per contract year and a maximum overall limit is 15,000,000 CFA per family. A separate maximum limit applicable to the employee only will be included for the HIV/AIDS medications expanded coverage. The maximum limit for expenses reimbursed is the local currency equivalent of UDS 10,000 per patient per contract year.

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

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

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

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

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

C.1.1.10 Psychiatric treatment: 50% reimbursement.

C.1.1.11 Medical expenses incurred out of country

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

C.1.1.12 Transportation for Out of Country Treatment

Transportation for out of country treatment is a covered expense for employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally. 100% of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be reimbursed. 100% of the transportation expenses of an attendant will be reimbursed if the patient’s attending physician certifies that an attendant for the patient is necessary, e.g., a parent in the case of a patient who is a minor or a family member to make medical decisions in the case of a patient who is unconscious. All reimbursements for transportation expenses are subject to the annual maximum limit.

C.1.1.13 Annual Maximum Limit - The maximum annual reimbursement per patient per contract year, not including expenses covered under C.1.1.4, is 5,500,000 CFA per patient per contract year and a maximum overall limit of 15,000,000 CFA per family per contract year.

C.1.2 Health Benefits Conditions and Limitations

There is no reimbursement for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long term rehabilitative therapy; eyeglass frames; non-medical hospital charges such as telephones or television; home help, family help, or similar household assistance; fees of persons who are not licensed physicians or nurses; or services or supplies which have not been prescribed or approved by a physician or nurse.

There is no reimbursement for expenses that will be reimbursed or paid directly under a host country medical program or workers' compensation program; the U.S. workers’ compensation program; or post’s LES workers’ compensation program.

There is no reimbursement for expenses related to an illness or injury that is a result of an unlawful action on the part of the patient; the practice of a dangerous sport; excessive or illegal use of alcohol or drugs; a self-inflicted wound; or service in the armed forces of any country.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - The employees eligible for the health insurance services include the following:

C.1.3.1.1 All current active employees of the United States Government, employed within the geographic boundaries of Niger paid under the Local Compensation Plan, and certified by the Contracting Officer. Covered employees include:

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

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

C.1.3.2 Location of Employment

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

United States Department of State United States Agency for International Development

C.1.3.3 Participants Covered Under a Rider

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

C.1.4 Individuals Not Eligible for Coverage

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

C.1.5 Other Eligible Participants

Covered dependents include the participating employee’s spouse and children. A limit of one spouse per employee is covered. There is no limit on the number of children covered per employee. An eligible child is defined as the employee’s natural biological child, adopted child, or stepchild. The employee must present legal papers approved by Nigerien court proving adoption or guardianship. The “adoption simple” documentation will not be accepted. There is no limit on the number of children covered per employee as long as the aforementioned legally acceptable documentation is provided. The child must be unmarried, economically dependent upon the employee, and reside with the employee unless away at school. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 23 if a full time student. There is no age limit for a child who is physically or mentally handicapped so as to be unable to live independently.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date

Each current active eligible employee is enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee will be enrolled upon entering on duty with the United States Government. An employee is considered active ("on the rolls") whenever such employee is on approved leave, whether paid or unpaid.

During a period of Leave Without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor. The employee’s share of the premium will be collected through payroll deduction in that or the subsequent pay period.

C.1.6.2. Period of Ineligibility.

Employees and their dependents are not entitled to health benefits during any period of employment for which premiums are not paid.

Additionally, employee's dependents are not entitled to health benefits during any period of employment during which the employee was not eligible to participate.

During a period of extended (beyond one pay period) of Leave Without Pay or unpaid leave, the employee is responsible for the full cost of the insurance premiums for self and dependents. The Mission will pay the premiums directly to the contractor, and will collect the full cost from the employee on a quarterly basis. Alternatively, the employee may elect to have coverage cease if that employee prefers not to pay the premium.

4. We would like to know if you have been informed of Catastrophic cases presented last year, such as: Hemodynamics, Open Heart Surgery, Orthopedic Mayor Surgeries, Organ Transplant, Traumatic Accident, Cancer and Oncology Cases (Radio and Chemotherapy), and hospitalizations with more than 10 days. If Yes, please provide the number of instances for each major illness along with claims associated with the cases?

Information not available.

5. Are there any pregnant employees/spouses. If Yes, please provide number.

Information not available.

6. Are any persons not actively at work? If Yes, please provide number.

Information not available.

7. Price Table B.2.3 lists 489 (75+414) employees (singles and family plan) but the Exhibit A-Table-1 contains 494 employees; what is the correct number of employees?

The correct number of employees is 494.

8. What is the name if the insurance company that currently provides coverage?

La Nigerienne d’Assurances NIA