SS-Insurance Global Medical Coverage.pdf

EMBASSY OF THE

UNITED STATES OF AMERICA

UN AVENUE GIGIRI

NAIROBI, KENYA

April 07, 2025

Dear Prospective Offeror:

Subject: Request for Proposals Number 19KE5025R0001 LE Staff Health Insurance

The Embassy of the United States of America invites you to submit a proposal for locally employed staff health insurance coverage. The Embassy encourages prospective offerors to offer off-the-shelf plans that meet the minimum benefit levels required in this solicitation.

The U.S. Government intends to award a contract to the responsible company submitting an acceptable offer at the lowest price. We intend to award a contract based on initial proposals, without holding discussions, although we may hold discussions with companies in the competitive range if there is a need to do so.

The Embassy intends to conduct a pre-proposal conference at the site. The pre-proposal conference will be held on April 24, 2025 10:00 a.m. (East African time) at U.S. Embassy

Nairobi. Prospective offerors should contact nairobigso-contracts@state.gov by 10:00am East

African time, April 22, 2025 for additional information or to arrange entry to the building.

Proposals are due by May 06, 2025 4:00 p.m. East Africa Time. No proposals will be accepted after this time. Proposals must be in English and incomplete proposals will not be accepted.

Your proposal must be submitted electronically to nairobigso-contracts@state.gov. It is important to make sure the submission is made in specific size and format; as file attachments in

MS-Word 2007/2010 or MS-Excel 2007/2010 or Adobe Acrobat (pdf) file format. The file size must not exceed 30MB. If the file size should exceed the 30MB, the submission must be made in separate files and attached to separate emails with less than 30MB each.

In order for a quotation to be considered, you must also complete and submit the following:

1. SF-33

2. Section B, Pricing Schedule.

3. Section B, Retention Amounts in B.3 and B.7.

4. Section K, Representations and Certifications; and

5. Additional information as required in Section L.

6. Proof of SAM Registration

Offerors shall be registered in the SAM (System for Award Management) database at https://www.sam.gov prior to submittal of their offer/proposal as prescribed under FAR 4.1102.

Failure to be registered at time of proposal submission may deem the offeror’s proposal to be considered non-responsible and no further consideration will be given. Therefore, offerors are mailto:nairobigso-contracts@state.gov https://www.sam.gov/ highly encouraged to register immediately if they are interested in submitting a response to this requirement.

Sincerely, Leslie Marks

Contracting Officer

Enclosure:

SECTION A - MODEL CONTRACT

SOLICITATION, OFFER AND

AWARD

1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING PAGE OF PAGES

1 | 84

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

3. SOLICITATION NO.

19KE5025R0001

4. TYPE OF SOLICITATION

[ ] SEALED BID (IFB)

[x] NEGOTIATED (RFP)

5. DATE ISSUED

April 07, 2025

6. REQUISITION/PURCHASE NO.

7. ISSUED BY

CODE

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

U.S. Embassy

UN Avenue Gigiri Nairobi

Phone: +254203634579

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

SOLICITATION

9. Electronic offers for furnishing the supplies or services in the Schedule will be received by email nairobigso-contracts@state.gov addressed to contracting officer by May 06, 2025 E.A.local time 04:00pm .

(hour) (date)

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

10. FOR

INFORMATION

CONTACT:

A. NAME

Leslie Marks

B. TELEPHONE (NO COLLECT

CALLS)

+2543634579

C. E-MAIL ADDRESS

Marksle@state.gov

11. TABLE OF CONTENTS

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

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

X A SOLICITATION/CONTRACT FORM 3 X I CONTRACT CLAUSES 30

X B SUPPLIES OR SERVICE AND PRICES/COSTS 5 PART III - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACH.

X C DESCRIPTION/SPECS/WORK STATEMENT 11 X J LIST OF ATTACHMENTS 47

X D PACKAGING AND MARKETING 19 PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE 20 X K REPRESENTATIONS, CERTIFICATIONS, AND 53

X F DELIVERIES OR PERFORMANCE 22 OTHER STATEMENTS OF OFFERORS

X G CONTRACT ADMINISTRATION 23 X L INSTRS., COND., AND NOTICES TO OFFERORS 74

X H SPECIAL CONTRACT REQUIREMENTS 26 X M EVALUATION FACTORS FOR AWARD 82

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

(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

mailto:nairobigso-contracts@state.gov

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)

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

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)

PREVIOUS EDITION NOT USABLE Prescribed by GSA

SECTION B - PRICES

B.1. HEALTH INSURANCE SERVICES

The Contractor shall provide the Health Insurance services to employees of the Government of the United States of America in Kenya and their eligible dependents as described in Section C.

This insurance shall be provided in accordance with Section C.

B.1.1. Official Residence Expense (ORE) Staff and American Employees Association (AEA) are included under this contract only as a rider; the Contractor shall bill the Chief of Mission and

Deputy Chief of Mission (for ORE Staff), the Embassy Association (for AEAs) and U.S Peace

Corps Kenya PSC Contractors and Dependents at the rates specified below. See Section G for billing procedures. Note that USG is not responsible, nor liable, for any riders.

B.2. PRICES

B.2.1 Value Added Tax

The Government will not reimburse the Contractor for Value Added Tax (VAT) under this contract. All taxable supplies (goods and services) to the United States Embassy in Kenya are exempt from Value Added Tax. See the VAT Act, 2013, 2nd Schedule, Part B ‘Zero Rates

Supplies to Public Bodies, Privileged persons and Institutions’, para (3). Vendors are therefore required to present invoices without a tax element, i.e., indicate 0% VAT on all invoices. The

Purchase Orders or Contracts issued by the United States Embassy will serve as the basis for

Zero Rating when vendors are accounting for VAT with the Kenya Revenue Authority.

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

JAMES ZADROGA 9/11 VICTIMS HEALTH AND COMPENSATION ACT OF 2010

NOTICE: UNLESS A WAIVER OR EXCEPTION APPLIES, PAYMENTS

SUBSEQUENT TO THIS PROCUREMENT ARE SUBJECT TO AN EXCISE TAX OF

2% PERSUANT TO 26 U.S.C. 5000C.

B.2.3 Base Year of

Contract

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families per

Category*

Rate (Premium) per Category

Extended Bi-Weekly

Premium Total

a. Self 99

b. Self Plus One 154

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for Base

Year (e x 26)**

*estimated number of families does not include any Riders (B.1.1)

**does not include any premiums for Riders.

B.2.4 First Option

Year of Contract

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families per

Category*

Rate (Premium) per Category

Extended Bi-

Weekly

Premium Total

a. Self 99

b. Self Plus

One

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for First

Option Year (e x

26)**

B.2.5 Second Option

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families per Category s*

Rate (Premium) Per

Category

Extended Bi-Weekly

Premium Total

a. Self 99

b. Self Plus One 154

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for

Second Option Year

(e x 26)**

B.2.6 Third Option

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families Per

Category*

Rate (Premium) Per

Category

Extended Bi-Weekly

Premium Total

a. Self 99

b. Self Plus One 154

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for Third

B.2.7 Fourth Option

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families per

Category*

Rate (Premium) per

Category

Extended Bi-Weekly

Premium Total

a. Self 99

b. Self Plus One 154

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for Fourth

B.2.8 Optional

Extension up to 6 months of the

Contract

Bi-Weekly Rates Per Employee

Category Estimated Number of

Families per

Category*

Rate (Premium) per

Category

Extended Bi-Weekly

Premium Total

a. Self 99

b. Self Plus One 154

c. Family (3 to 6 individuals)

2,372

d. Family (7 or more individuals)

e. Subtotal

Total Price for 6 months extension period (e x 13)**

B.2.9 Grand Total of Base plus All Options

Base Year Total

First Option Year Total

Second Option Year Total

Third Option Year Total

Fourth Option Year Total

Optional Extension up to 6 months of the

Contract

Grand Total Of Base Plus All Option

Years

MINIMUM AND MAXIMUM AMOUNTS

During the Base Year of the contract, and during the option year that might be exercised, the

United States Government (USG) shall place orders totaling a minimum of Kes 646,750. This reflects the contract minimum guarantee for each period of performance. The amount of all orders, for base and all option years shall not exceed TBD until award for each 12-month period of performance. This reflects the contract maximum.”

B.3 ADMINISTRATIVE RETENTION AMOUNTS

B.3.1 If the Contractor requests a price adjustment under B.4 below, the Contractor shall 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 shall 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.

B.3.2 Bi-Weekly Retention Amounts per separate premium paid per single employee and per family plan.

Period of

Performance

Employee

Employee’s Spouse Employee’s Dependent

Child

Base Period

First Option Year

Second Option Year

Third Option Year

Fourth Option Year

Extension Period up to 6 months

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, (2) number 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 shall include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

SECTION C

DESCRIPTION/SPECIFICATION/WORK STATEMENT

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as described herein.

Annual Maximum Limit - The maximum annual reimbursement per contract year will be:

i. Annual maximum limit for Self: = KES 4,500,000

ii. Annual maximum limit for Self +1: = KES 9,000,000

iii. Annual maximum limit for Family: = KES 15,000,000

Within the annual maximum limit, each covered individual will have outpatient services coverage up to KES 800,000 per year.

C.1.1 Employee and Dependent Health Service Benefits

C.1.1.1 Hospitalization (Treatment in the Hospital for Inpatient Care):

Minimum Coverage - 100%

Services and supplies provided during hospitalization including services provided by a licensed healthcare provider, bed, and board (semi-private accommodations), operating room, recovery room, intensive care, imaging and diagnostic testing, chemotherapy and radiation treatments, and general hospital nursing care, physical therapy, as well as drugs, medicines, and supplements administered while in-patient. When private accommodations are required, coverage will be limited to the cost of a semi-private room.

Chemotherapy and radiation treatments- chemotherapy is considered an inpatient day case procedure.

See Mental Health and Substance Abuse care (C.1.1.13) for details concerning inpatient psychiatric care.

See Outpatient Services (below) for details concerning professional services.

C.1.1.2 Emergency Services (Trips to Emergency Room): Coverage - 100%

Services provided for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness.

C1.1.3 Ambulance: Coverage - 100%

Professional ground transport to move a patient from the place where s/he is injured or becomes ill to the nearest hospital able to provide treatment or to move a patient from one medical facility to another.

C.1.1.4 Outpatient Services: Coverage - 100% with the maximum annual limit of

KES 800,000 per covered individual per contract year.

Services provided by a licensed healthcare provider on an ambulatory or outpatient basis

(without being admitted to a hospital), including surgeon’s fees and other medical services provided at a hospital, clinic, doctor’s office, medical facility, etc. Examples include, but are not limited to:

- Annual physical examinations

- Specialist consultations and treatment, including second surgical opinion

- Minor surgical interventions

- Immunizations recommended by local authorities and/or the World Health Organization including baby friendly vaccines

- Diagnostic tests and diagnostic imaging.

See Rehabilitative and Habilitative Services and Devices (below) for details concerning physical therapy.

See Mental Health and Substance Abuse Care (below) for details concerning psychiatric therapy.

C.1.1.5 Obstetric and Newborn Care: Coverage - Inpatient/Emergency: 100%;

Outpatient: 100%

Care and services that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and outpatient care for newborn babies. Hospitalization during pregnancy, delivery and/or prematurity will be reimbursed as inpatient care. All other treatments will be considered outpatient services. Hospitalization for prematurity falls under the overall annual limit.

C.1.1.6 Pediatric Services: Coverage - Inpatient/Emergency: 100%, Outpatient: 100%

Primary and preventive routine care services for covered dependent children, including, but not limited to: physical examinations, developmental assessments, laboratory tests, and immunizations recommended by local authorities and/or the World Health Organization, including baby friendly vaccines.

C.1.1.7 Prescription Drugs: Coverage -Inpatient/Emergency: 100%, Outpatient: 100%

Medications prescribed by a licensed health care provider that are medically required. Examples include, but are not limited to prescription antibiotics to treat an infection, medication used to treat an ongoing condition, such as high cholesterol, prophylaxis, contraceptive medication, prescribed supplements.

C.1.1.8 Preventive and Wellness Services and Chronic Disease Management:

Coverage - 100%

Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but are not limited to:

physicals, immunizations, and cancer screenings. This could include a chronic disease management program.

C.1.1.9 Hearing Aids: Minimum Coverage – 100%

Examinations and Treatment: 100% Minimum Coverage

Hearing Aid Apparatus: Limited to one apparatus per ear up to a maximum of USD 1,500 (KES

193,875) per covered individual per three-year period. 100% Coverage: with annual cap.

C.1.1.10 Optical Care: Coverage – 100%

Examinations and Treatment: 100% Coverage

Prescription lenses and frames, or contact lenses: Covered up to a maximum of USD 300 (KES

38,775) per covered individual every two years. 100% Minimum Coverage; with annual cap.

Non-accidental ophthalmology surgeries within overall inpatient limit.

C.1.1.11 Dental Care: Coverage – 100%

Examinations and Treatment: Dentist’s fees, x-rays, examinations and treatment, cleanings, fillings, extractions, false teeth, crowns, and bridges up to a maximum of USD 1,000 (KES

129,000) per covered individual per contract year. 100% Coverage: with annual cap.

Non-accidental dental surgery within overall inpatient limit.

Orthodontia: Treatment is covered only if treatment begins before age 18, or if required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per covered individual up to a maximum of USD 1200 (KES 155,100) lifetime limit. 100%

Coverage; with contract lifetime cap.

C.1.1.12 Reproductive Health: Coverage - 100%

Prescribed contraceptive devices, preventive care and routine examinations, voluntary sterilization, and diagnosis and treatment of conditions which may cause infertility. Assisted reproductive technology (ART), fertility treatments, and reversal of sterilization are not covered

(see Exclusions to Coverage).

C.1.1.13 Mental Health and Substance Abuse Care: Coverage - 100%

Inpatient and outpatient care provided to evaluate, diagnose, and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Services must be provided by a licensed psychiatrist, psychoanalyst, psychologist, or psychiatric social worker. Inpatient care for alcohol and substance abuse must be provided at a facility licensed for detoxification and rehabilitation.

C.1.1.14 Rehabilitative and Habilitative Services and Devices:

Coverage - 100%

Rehabilitative services (e.g., recovering skills, such as speech therapy after a stroke or physical therapy after an accident) and habilitative services (e.g., developing skills, such as speech therapy for children, etc.) that help develop skills needed for everyday life. Devices to help gain or recover mental or physical skills lost due to injury, disability or a chronic condition, and devices needed for habilitative reasons.

C.1.1.15 HIV/AIDS: 100% - part of annual maximum limit cover

Medications to suppress opportunistic infections (such as tuberculosis or toxoplasmosis for covered individuals who have HIV/AIDS). Brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV/AIDS to the child.

*C.1.1.16 Group Excess of Loss (XOL)

In the event that individual family member(s) exceed the designated family maximum coverage limit for inpatient medical services, the eligible family member(s) can access coverage from claims arising from all hospitalization costs subject to a maximum limit of KES

3,500,000 per individual per contract year. The aggregate liability of the insurer for all claims arising under XOL policy shall not exceed KES 50,000,000 for the group per contract year.

*C.1.1.17 Out-of-Country Medical Treatment:

Medical expenses incurred out-of-country will be covered at the same benefit levels and subject to the same total maximum annual limit as for medical expenses incurred in-country.

*C.1.1.18 Out-of-Country Medical Travel: Reserved

C.1.1.19 90-Day Coverage for Dependents After Employee’s Death

At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 90 days. This optional benefit is subject to availability of funds at post and no extensions are permitted.

C.1.1.20 Employee Assistance Program (EAP): Reserved

C.1.2 Annual Maximum Limit - The maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) and

Group Excess of Loss (C.1.1.16), is equivalent to the annual maximum limit per family category in C.1, including outpatient services coverage up to KES 800,000 per year per individual.

C.1.3 Exclusions and Limitations

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

exercise therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider. Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusions require prior authorization.

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

C.1.4 ELIGIBILITY

To be eligible to participate in the medical plan, LE Staff must be:

Paid under the terms of the Local Compensation Plan (LCP); and –

Under a non-temporary direct hire appointment, personal services agreement (PSA), or personal services contract (PSC); or

Under a temporary direct hire appointment or PSA Fixed Term of one year or more.

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 Kenya who provides services to other local organizations as well as to the U.S. Mission; employees working on an intermittent or When Actually Employed (WAE) schedule; employees of USAID institutional contractors; Peace Corps personal services contractors as indicated in MS 743; and

Recreation Association employees.

Official Residence Expense (ORE), U.S. Peace Corps Kenya Contractors and American

Employee Association (AEA) employees may be covered under a rider to the contract. The employing officer/EA, not the USG, is responsible for the employer's share of the premium costs for an ORE/EA employee. 1998 Embassy Bombing Victims and Victim’s Family Members.

C.1.4.1 Periods 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 Leave Without Pay (LWOP) or unpaid leave beyond one pay period, 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 they prefer not to pay the premium.

C.1.4.1.1 Definition of Dependents

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

C1.4.1.1.1 Legal spouse: one legal spouse as defined by local law may be covered. LE Staff with more than one legal spouse must select only one spouse for coverage. Tandem employees may be enrolled separately as individuals.

C.1.4.1.1.2 Dependent Children.

A dependent child is defined as the LE Staff’s natural, adopted, stepchild, or foster child. The child must be unmarried and financially dependent upon the LE Staff. A child will be covered until the end of the contract year in which s/he reaches age 26. An unmarried child determined to be incapable of self-support due to a physical or mental condition will continue to be eligible to participate in the medical plan as long as the condition persists, the child remains unmarried, and the LE Staff maintains coverage.

C.1.4.2 Term of Eligibility and Effective Date

Each current active eligible employee and their eligible dependents are enrolled for health benefits under this contract upon award and thereafter during the performance period of this contract. Each new eligible employee and eligible dependents 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.

C.1.5 ELIGIBLE PARTICIPANTS

C.1.5.1 Identification of Eligible Employees and Dependents: U.S. Mission Kenya will provide a list of all eligible employees and dependents with relationship to employee

(self/spouse/child) and DOB for each. Updates will be provided to add or remove individuals on a bi-weekly/monthly basis.

C.1.5.2 Location of Employment: The eligible employees covered by C.1.4. must be employed within the geographic boundaries of Kenya by Department of State and all Agencies under the terms of the Local Compensation Plan (LCP)

C.1.5.3 Participants Covered Under a Rider

a. All current active ORE Staff personally employed by the Chief of Mission and the

Deputy Chief of Mission and assigned to their respective official Government residences and paid under an ORE account. All costs for coverage of ORE Staff are the responsibility of the

Chief of Mission and the Deputy Chief of Mission, not the U.S. Government.

b. All current active employees of the Employee Association at Embassy Nairobi. All costs for coverage of American Employees Association (AEA). AEAs are the responsibility of the

Employee Association, not the U.S. Government.

c. 1998 Embassy Bombing Victims and Victim’s Family Members. The Embassy will make payment directly to the Contractor for the entire premium amount.

d. U.S. Peace Corps Kenya PSC Contractors and Dependents. All costs for coverage of U.S.

Peace Corps Kenya are the responsibility of U.S. Peace Corps, not the U.S. Government.

C.1.6 Brochure Requirement

C.1.6.1 The Contractor shall provide a document (brochure/pamphlet/other written document) in English that sets forth a complete listing of the health insurance benefits to be provided under this contract. This brochure shall be provided in sufficient quantities so that each covered employee receives a copy. The Contractor shall furnish all copies of the brochures to the COR, who will ensure that appropriate distribution is made. The Contractor shall include their Service Level Agreement (SLA), including information on case management and the preauthorization process, the reimbursement process, process of seeking a second opinion, policy on daycare surgeries.

C.1.6.2 The Contractor shall provide the document described in C.1.6.1 to the COR not later than 10 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) business days of the COR’s request.

C.1.6.3 The Contractor assumes full responsibility for ensuring that the document described in C.1.6.1 accurately reflects the requirements, coverage, and contract terms 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 document contains inaccuracies, the

Contractor will be notified in writing; however, failure on the part of the U.S. 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.

SECTION D

PACKAGING AND MARKING

(RESERVED)

SECTION E

INSPECTION AND ACCEPTANCE

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

This contract incorporates one or more 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. In addition, the full text of a clause may be accessed electronically at: Acquisition.gov this address is subject to change.

If the Federal Acquisition Regulation (FAR) is not available at the location indicated above, use the Department of State Acquisition website at e-CFR to see the links to the FAR. You may also use an Internet “search engine” (for example, Google, Yahoo or 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.1.6

All required services are performed and no more than one

(1) customer complaint is received per month https://acquisition.gov/browse/index/far https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

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.

E.2.2 Standard. The performance standard is that the Government receives no more than one

(1) customer complaint 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 should 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

DELIVERIES OR PERFORMANCE

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

THE FOLLOWING FEDERAL ACQUISITION REGULATION CLAUSES ARE

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 on effective date of the contract with four one-year options to renew and an option for a 6 month extension period

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 contract.

(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 and other deliverables required under this contract shall be delivered to the following email address: TBD https://gov.ecfr.io/cgi-bin/text-idx?SID=d9a7851186785ba2b1896db79b1b6b29&mc=true&tpl=/ecfrbrowse/Title48/48tab_02.tpl

SECTION G

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 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 Kenya Shillings.

G.4 SUBMISSION OF INVOICES AND PAYMENT

G.4.1. Invoices for U.S. Government employees shall be submitted in an original to the following address (designated billing office only for the purpose of submitting invoices):

Invoices should be sent electronically to the COR and Attn: FMO

Kindly submit the invoice in my ILMS.

See below instructions.

The Embassy is pleased to inform you that we recently rolled out an online based Invoicing platform that amongst other things enables you to;

• Submit your Invoice online.

• Track Realtime the status & progress of your Invoice.

• Get updates upon final approval.

• View all orders currently awarded to your company.

To access the system:

1. Create a user account using the following link, https://mygrants.servicenowservices.com/ and click on create an account.

2. Download the Okta Authenticator app to your smartphone. You will need this app to access my ILMS portal. The app is free to download.

The Contractor shall create an online account to submit invoices as described above.

G.4.2. Frequency of Payments. All funds under this contract for non-rider coverage 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 basic premium amount.

G.4.4 Riders:

a. ORE. The Chief of Mission and/or Deputy Chief of Mission 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.

b. AEA Staff. The Employee Association will make payment directly to the Contractor for the entire premium amount of the AEA employee, whether or not the AEA employee is contributing to the premium amount.

c. 1998 Embassy Bombing Victims and Victim’s Family Members. The Embassy will make payment directly to the Contractor for the entire premium amount.

d. U.S. Peace Corps Kenya PSC Contractors and Dependents. The U.S. Peace Corps will make payment directly to the Contractor for the entire 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 https://mygrants.servicenowservices.com/

Contracting Officer may either allow that overpayment to be credited to the Government’s account or require that the Contractor refund the overpayment. If the Contracting Officer requests a refund, the Contractor shall make that refund to the Government within ten calendar days of receipt of the request.

SECTION H

SPECIAL CONTRACT REQUIREMENTS

H.1 SECURITY. On occasion, a Contractor employee may require entry into U.S.

Government-owned or -operated facilities. If so, the Contractor should be prepared to provide the necessary identification to permit escorted access within that facility.

H.2 STANDARDS OF CONDUCT. The Contractor shall maintain satisfactory standards of employee competency, conduct, cleanliness, appearance, and integrity and shall be responsible for taking such disciplinary action with respect to employees as may be necessary. Each

Contractor employee is to adhere to standards that reflect credit on themselves, their employer, and the United States Government.

H.3 ORDERING PROCEDURES. The Government will issue a task order as soon as possible after contract award to identify all employees to be covered by the insurance described in this contract and the coverage selected by each employee, including dependents to be covered.

The COR will make subsequent additions or deletions to this list in writing and provide the revised list to the Contractor by email. All such revisions shall be consolidated, and a new or modified task order will be issued by the Contracting Officer. If any changes have been made to the coverage listing, the Government anticipates issuance of a new task order on a quarterly basis. This new task order will include all changes made since the previous task order was issued and will include any increase or decrease in necessary funding. The changes to the list of eligible individuals will supersede the initial list provided under prior task orders without prejudice to the ineligibility clause. Task orders will indicate the effective date of employment, for purposes of calculating the premium due.

H.3.1 Riders are not included under the task orders issued by the Contracting Officer. Because their coverage is under a rider, either their employer or themselves are responsible for directly interacting with the Contractor to order any coverage. When contacted, the Contractor shall advise the person of the paperwork and payment that will be necessary to order coverage for the identified individuals. The Contractor may be contacted by more than one individual.

H.4. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS

General.

The Contractor shall be responsible for all planning, estimating, programming, project management, scheduling, dispatching, supervision, and inspection of work. The Contractor shall maintain his own reference library of technical reference works and local laws and regulations, including current tariffs and registries. The Contractor shall treat the information provided by the Embassy concerning employee' personal data, medical information, and salaries as highly sensitive and not divulge any employee information to unauthorized persons.

The Contractor shall limit visibility of coverage levels to respective service providers to specific approval, to avoid blanket approvals without pre-authorization at the service level.

The Contractor shall establish procedures for handling medical insurance claims as follows:

(a) Administrative Records

(1) The Contractor shall maintain medical insurance files for each covered employee and each covered dependent including receipts and proof of paid claims, requests for claim reimbursements, and accounting of paid benefits with balances of amounts remaining in the annual per person reimbursement ceiling.

(2) The Contractor shall provide the COR with the necessary claim forms for each type of benefit that can be claimed under the contract. These forms shall specify a list of documents required to be appended to each claim and otherwise provide instructions for claim filing.

(3) The Contractor shall use the English spelling of the employees' names in all transactions, including reimbursement checks.

(4) The Contractor shall send employee claim reimbursement checks to employees not later than two weeks after a claim is submitted.

(b) Medical Insurance Claims.

Settlement of medical insurance shall be completed as follows:

(1) All medical claims shall be submitted directly to the Contractor by employees, through a drop box in the COR's office. The claims shall be picked up from the COR each

Tuesday.

(2) The Contractor shall date stamp and screen all claims submitted on the day of receipt. If there are any missing documents or information thereby disallowing said claim to be payable, the Contractor shall notify the employee within two days, with a copy to the COR (if notification is written).

(3) The Contractor shall settle the claims no later than two weeks from the date the claim is submitted to the Contractor.

(4) Settlement shall be by issuance of checks in the name of the employee for each claim submitted. Each check shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any.

(5) The Contractor shall accept the employee's or dependent's choice to go for surgery to hospitals designated by the Contractor in order that the Contractor will pay the expenses directly to the hospitals.

H.5. REPORT REQUIREMENTS. The Contractor shall provide the following monthly report. The report shall be received by the COR no later than the 10th day of each month. The report shall report on the previous month's activities.

(a) Employee Claims Report. The report shall list all claims paid by the Contractor to a claimant, including the name of the claimant, date claim is received by the

Contractor, and the amount claimed. This report shall also include all outstanding claims and a brief description of why claim has not been paid. The report shall not include any claims information for riders.

(b) Employee Utilization Reports Data. The report shall show;

(i) Dashboard with a detailed overview of the Group Health Insurance scheme performance.

(ii) Utilization levels reports addressing the following questions.

Spending/Claims Based on Individuals:

1. What is the total amount claimed or spent by each individual across all sub-benefits over the three years?

2. For each sub-benefit, what is the range of amounts claimed or spent by unique individuals, considering that one individual may have multiple claims or visits? (i.e., minimum, maximum, and average per individual)

3. How many unique individuals have made claims for each sub-benefit, and what is the total amount claimed by these individuals?

4. What is the average amount claimed or spent by individuals for each sub-benefit, excluding multiple claims by the same individual?

5. What is the distribution of amounts spent or claimed by individuals across each sub-benefit?

Spending/Claims Based on Families:

6. What is the total amount claimed or spent by each family for each sub-benefit over the three years?

7. For each sub-benefit, what is the range of total amounts claimed by families (i.e., the minimum, maximum, and average amounts per family)?

8. How many families have made claims for each sub-benefit, and what is the total amount claimed by these families?

9. What is the average amount claimed or spent by families for each sub-benefit?

10. What is the distribution of amounts spent or claimed by families across each sub-benefit?

Sub-benefit Utilization:

11. How do the amounts claimed or spent vary by sub-benefit when viewed at the individual level versus the family level?

Patterns by Sub-benefit Type:

12. For each sub-benefit, how does the number of claims or visits compare with the total amount spent, and are there any outliers or anomalies?

Key Insights:

13. Which sub-benefits are most frequently claimed by individuals, and how does this correlate with the total amounts claimed?

14. For sub-benefits with high spending, is there a pattern of repeat claims by individuals or families?

15. What proportion of the total amount claimed or spent on each sub-benefit is concentrated among the top 10% (highest claims) of individuals and families?

H.6. MISCELLANEOUS CONTRACTOR REQUIREMENTS

H.6.1. General. The Contractor shall take all such steps as are necessary, and obtain and pay for all permits, taxes and fees as are required by the Kenya government to establish and/or operate a commercial venture locally. A contract with the U.S. Government conveys no special privileges or immunities to the Contractor. The Contractor is an independent commercial concern and not a part of the U.S. mission. The Contractor's employees are not U.S. Government employees.

Registration of this contract with the Kenya government, if required by law, will be the sole responsibility of the Contractor, and any fees, taxes, or other duties shall be payable by the

Contractor without recourse to the Government of the amounts thereof.

H.6.2. Licenses and Local Laws. The Contractor shall possess all permits, licenses, and any other appointments required for the prosecution of work under this contract, all at no additional cost to the Government. The Contractor shall perform this contract in accordance with local laws.

H.7 ERRONEOUS PAYMENTS. If the Government becomes eligible for a refund of payment because of erroneous…