SSS - Dominican Republic Health Care.docx

1.0 INTRODUCTION

This Request for Information (RFI) is being issued to help the Department of State (DOS) better understand the capabilities, and availability of services offered by insurance providers as well as industry best practices related to procuring insurance coverage in the Dominican Republic.

Historical medical claims for Embassy Locally Employed Staff are presented below.

Claims for 01 March-2017 to 28 Feb 2018

Claims for 01-March-2018 to 28 Feb 2019

Claims for 01-March-2019 to 29 Feb 2020

To gather the necessary information, specific questions have been listed in Section 3: RFI Topic Areas. DOS requests your responses to these questions, as the answers may indicate whether such an initiative is worth pursuing and, if so, how the initiative should be structured.

This is not a Request for Proposal (RFP), Request for Quotation (RFQ), or an invitation for bid, nor does its issuance obligate or restrict the Government to an eventual acquisition. All information received from this RFI will be used for market research purposes only. The Government does not intend to award a contract based on responses to this RFI nor otherwise reimburse vendors for the preparation of any information submitted or Government use of such information. Acknowledgement of receipt of responses will not be made, nor will respondents be notified regarding the outcome of the information received.

1.1 BACKGROUND

In today's budgetary environment, all government Departments must strive to spend taxpayer dollars as efficiently as possible. The DOS, like other Departments, faces the challenge of providing important services and products to the American people and represent American interests abroad, while simultaneously reducing costs.

An identified area of potential efficiency improvement is overseas health insurance for locally employed staff. Each of DOS’s over 300 posts abroad hires locally employed staff to support operations. Unlike Foreign Service Officers or other DOS staff based out of the United States, these staff require locally procured health insurance. DOS is looking to improve the procurement and administration of health insurance for locally employed staff, with emphasis on ensuring that each post has commercially provided health insurance coverage.

DOS is looking to industry to provide input around health insurance as it investigates solutions that will:

• Meet the required minimum benefits as defined in Appendix: Medical Coverage and Benefits

• Standardize provided benefits

• Ensure that all posts have health insurance coverage

• Reduce contract costs driven by customized policies

• Reduce administrative costs driven by direct reimbursements

• Lower premium costs through pooling

• Increase quality of service

• Adhere to government mandates and DOS policies

2.0 RFI INSTRUCTIONS

2.1 Responses should be submitted in Microsoft Word format and, excluding attachments, should not exceed fifteen (15) pages with Arial font equal to 12 pt.

2.2. Responses are to be submitted via e-mail to Mr. Patrick Murphy at murphypj@state.gov no later than 1:00 p.m. EST, August 20, 2020.

3.0 RFI TOPIC AREAS

Topic 1: Vendor Demographics

· The DOS is interested in understanding the profile of the companies responding to this RFI. Accordingly, responses to the following questions are requested.

· Organization Name.

· NAICS (North American Industry Classification System) Codes.

· Number of years of corporate experience.

· Describe your primary line of business (e.g., health insurance, life insurance, dental insurance, other non-insurance).

· Which countries in the region do you operate in currently?

Topic 2: Desired Abilities of an Insurance Provider Please answer the following questions to help provide more clarity regarding your capabilities / offerings. In countries where some benefits are provided by host governments, coverage will be supplemental to meet the minimum required benefits as defined in Appendix: Medical Coverage and Benefits.

A. Benefit Services

1. Which of your commercial, off-the-shelf products would meet the minimum benefits as described in the Appendix? If a particular benefit is not covered, which one(s)?

2. What is the prevailing practice for reimbursement of medical expenses (e.g., medical provider bills insurance, insurance company reimburses patient)?

3. Where patients must submit claims for reimbursement, what are common practices to allow patients to pay for large expenses (e.g., medical loans, etc.)?

4. How will reimbursements claims be calculated for both in and out of network coverage? If market comparisons will be used, how will they be established?

5. When will coverage for newborns begin? How will the enrollment process for newborns work to ensure coverage is guarantee from their date of birth?

6. What communications channels will be available to employees to handle coverage requests such as pre-authorizations, reimbursements claims, benefits levels, dependent status information etc.?

7. How frequent is the provider network is updated? How are changes communicated to the affiliates?

B. Geographic Coverage

1. Are there any local laws requiring additional benefits that are not listed in the Appendix?

2. Is there anything unique about insurance in the Dominican Republic that DOS should be aware of as it considers this initiative?

C. Contracts & Contract Structure

1. If you serve other multinational clients in the region, what structures (e.g., pooling, teaming with local providers, etc.) do you use to provide services to these clients across regions / countries?

2. Do you serve other government clients with operations abroad (e.g., DOD)? If so, which agencies? What structures do you use to cover their locally employed staff (e.g., type of contract, whether subcontracting, teaming is involved)?

D. Contract Administration / Tracking / Fraud

1. What essential functions do you offer for the administration of health insurance coverage (e.g., tracking claims and reimbursements, answering questions about eligibility, etc.)?

2. What factors within DOS control, outside of benefit levels, drive increases in premiums? What practices do you employ to control premium increases?

3. What mechanisms do you employ for dispute resolution (e.g., disputes regarding claims)?

4. How can the Government build visibility into this contract to ensure important financial information is readily available (e.g., the cost of premiums, the amount reimbursed, number of dependents covered, etc.)?

5. What infrastructure do you employ to track compliance with these contracts and make this information readily available to government (e.g., online system where government can track claims submitted by post)?

6. What are common risk areas or types of fraud (e.g., submitting false receipts for medical expenses) in this region?

7. What tactics do you employ to discover and mitigate cases of fraud?

8. In what ways can the enrollment process be streamlined?

E. Alternative Health Insurance Solutions

1. Are there other innovative health insurance solutions that can be provided to locally employed staff such as managed Flexible Spending Accounts, Health Saving Accounts, Health-Sharing Plans, or direct claim management services?

F. Information Required to Develop a Competitive Offer

1. Based on your experience with requirements of this type, what information and data are essential for you to develop a competitive offer (i.e., estimates of total contract value, # of insured, dependents, etc.)?

4.0 Appendix: Medical Coverage and Benefits - Core Health Insurance Benefits Requested:

C.1. HEALTH INSURANCE SERVICES

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

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, and general hospital nursing care, physical therapy, as well as drugs and medicines administered while in-patient. When private accommodations are provided, coverage will be limited to the cost of a semi-private room unless otherwise covered in an off the shelf plan. See Mental Health and Substance Abuse care (C.1.1.13) for details concerning inpatient psychiatric care.

See Mental Health and Substance Abuse Care (below) 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): Minimum 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: Minimum Coverage - 80% 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: Minimum Coverage - 80% 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

· Chemotherapy and radiation treatments

· Immunizations recommended by local authorities and/or the World Health Organization

· 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: Minimum Coverage - Inpatient/Emergency: 100%; Outpatient: 80% 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 and/or delivery will be reimbursed as inpatient care All other treatments will be considered outpatient services and will be reimbursed at that rate.

C.1.1.6 Pediatric Services: Minimum Coverage - Inpatient/Emergency: 100%, Outpatient: 80% 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.

C.1.1.7 Prescription Drugs: Minimum Coverage -Inpatient/Emergency: 100%, Outpatient: 80% 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.

C.1.1.8 Preventive and Wellness Services and Chronic Disease Management: Minimum Coverage - 80% Counseling or preventive care designed to prevent or detect medical conditions and care for chronic conditions such as asthma and diabetes. Examples include, but are not limited to: physicals, immunizations, and cancer screenings.

C.1.1.9 Hearing Aids: Minimum Coverage – 80% Examinations and Treatment: 80% Minimum Coverage Hearing Aid Apparatus: Limited to one apparatus per ear up to a maximum of USD 1,500 per covered individual per three-year period. 80% Minimum Coverage: with annual cap.

C.1.1.10 Optical Care: Minimum Coverage – 80% Examinations and Treatment: 80% Minimum Coverage Prescription lenses and frames or contact lenses: Covered up to a maximum of USD 300 per covered individual every two years. 80% Minimum Coverage; with annual cap.

C.1.1.11 Dental Care: Minimum Coverage – 80% 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 3,200 per covered individual per contract year. 80% Minimum Coverage: with annual cap.

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 2,400 lifetime limit. 80% Minimum Coverage; with contract lifetime cap.

C.1.1.12 Reproductive Health: Minimum Coverage - 80% 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: Minimum Coverage - 50% 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: Minimum Coverage - 50% 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% Reimbursement at a minimum of $10,000 per year per covered individual 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. Generally, excludes medication for the long-term suppression of HIV/AIDS through the combination of anti-retroviral drugs in locations with inadequate local healthcare infrastructures. Reimbursement under this benefit is excluded from the annual maximum limit (C.1.2).

OPTIONAL BENEFITS -- POSTS MAY ELECT TO INCLUDE AS PART OF THE MEDICAL PLAN

C.1.1.16 Catastrophic Coverage Additional coverage equal to the annual maximum reimbursement level. per covered individual per contract year. Catastrophic conditions shall be defined as major medical conditions occurring as a result of a single/illness/accident or closely related set of major illnesses (or conditions relating to a single accident) that exceed the standard maximum coverage limit.

C.1.1.17 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: 80% Reimbursement Transportation for out-of-country medical treatment will be a covered expense for covered employees and eligible family members. To be considered a covered expense, the attending certified health care provider must certify in advance that the treatment is medically necessary and unavailable locally. 80% of covered individual’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be covered. 80% of the transportation expenses of an attendant will also be covered, but only if the covered individual's attending certified health care provider 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 unwell or unconscious). All coverage for transportation for out-of-country medical treatment is subject to the total maximum annual limit. Transportation to a neighboring country without the attending certified health care provider certifying that the treatment is medically necessary and unavailable locally will not be covered.

C.1.1.19 180 Day Coverage for Dependents After Employee’s Death At the time of a covered employee’s death, his/her eligible dependents covered under post’s medical plan are eligible to continue receiving the same level of medical coverage for up to 180 days. This optional benefit is subject to availability of funds at post and no extensions are permitted.

C.1.1.20 Employee Assistance Program (EAP) An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. This optional benefit is subject to availability of funds at post.

C.1.1.21 Excess Coverage (Employee responsible for paying 100% of premium for Excess Coverage) Additional coverage equal to equal to the annual maximum reimbursement level per covered individual per contract year. This excess coverage will be offered as an optional benefit to LE Staff. This can be used for any covered individual for any covered expense that exceeds annual maximum. LE Staff must pay 100% of the premium if they elect Excess Coverage. The premium for this additional coverage is a rider to be paid by the employee to the vender directly and USG will not be responsible for collecting of these premium payments.

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 C.1.1.16, Catastrophic Coverage, or those covered under C.1.1.15, HIV/AIDS, and C.1.1.21 Excess Coverage is equivalent to the annual maximum reimbursement level.

C.1.3 Exclusions and Limitations There is no coverage for elective cosmetic surgery; spa cures; rejuvenation cures; massage; exercise therapy; long-term rehabilitative therapy; non-medical hospital charges (e.g., telephone, television, etc.); home help, family help, or similar household assistance; fees of persons who are not certified health care providers; advanced reproductive technology (e.g., in-vitro fertilization, intra-cellular sperm injection, artificial insemination, microsurgical epididymal sperm aspiration, testicular sperm extraction, cryopreservation, etc.); or services or supplies which have not been prescribed or approved by a certified health care provider. Exclusions to coverage may be amended if provided in an off the shelf plan and is the lowest-cost and technically acceptable. Removal of any exclusions require prior authorization.

There is no 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.

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.

SBU - CONTRACTING AND ACQUISITIONS