New_Table_of_Benefits.pdf

LES Health Insurance Services

STC10014R0001

Exhibit A

Health Insurance Coverage

Deductible: None

Reimbursement of Covered Medical Expenses

Hospitalization:

Room Charges: 100% (coverage of room and board expenses for ward room, semi-private room, or private room).

Medical Expense: 100% (coverage of hospital medical expenses including laboratory tests and x-rays, nursing care, operating room expenses, intensive care, prescription medicines, and physical therapy.

Ambulance: 100% (coverage of land ambulance service).

Professional Services and Treatment:

Doctor/Surgeon Fees: 100% (coverage of doctors’ and surgeon’s fees incurred while hospitalized, at a hospital on an out-patient basis, at a clinic or doctor’s office, or at home

– Co-Payment: Employee is responsible for 50 AED per doctor’s visit for out-patient for employees and dependents).

Out Patient Medical Services: 100% (coverage for medical services and expenses when not hospitalized such as laboratory tests, x-rays, prescription medicines, physical therapy, routine annual physical examination (general consultation, ECG, Chest x rays, CBC, fasting blood sugar, blood urea, creatinine, peripheral smear/pap smear, ESR, cholesterol, triglycerides, HDL/LDL, urine routine, stool routines), and inoculations (as per HAAD & DHA inoculation schedule).

Prescription Drugs & Medicines:

In-patient & Out-patient: 100% (coverage of expenses when hospitalized, and 100% coverage of expenses when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required. Prior approval is required for any medication that exceeds 500AED.

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.

HIV/AIDS Coverage: 100% (coverage of expenses for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS;

as well as 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. This expanded coverage does not apply to dependents or to retired employees.

NOTE: WHEN THE INSURANCE COMPANY WILL NOT PROVIDFE

HIV/AIDS COVERAGE, THE U.S. EMBASSY WILL PROVIDE 100%

REIMBURSEMENT TO A MAXIMUM OF USD 10,000 PER PERSON

FOR MEDICATIONS TO SUPPRESS OPPORTUNISTIC INFECTIONS,

SUCH AS TUBERCULOSIS AND TOXOPLASMOSIS FOR

EMPLOYEES ONLY WHO HAVE HIV/AIDS; AS WELL AS 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. THIS EXPANDED COVERAGE DOES NOT

APPLY TO DEPENDENTS OR TO RETIRED EMPLOYEES.

Obstetrical Care (including pre-and post-post-natal): 100% (coverage of expenses when hospitalized and 100% coverage of expenses when not hospitalized, of obstetrical medical care including pre-natal care and post-natal care.

Family Planning: Not Covered.

Hearing Aids: 70% (coverage of the cost of a hearing aid apparatus and related examination).

Optical Care: 50% (coverage of expenses for eye examination and treatment and prescription eyeglass or contact lenses.

Prescription eyeglass or contact lenses up to a maximum of 832 AED a year per patient).

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

Dental Care: 100% (coverage of expenses for dental services including dentists' fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, and bridges).

100% (coverage for minor restorative, major restorative and orthodontia treatments up to a maximum of 7,190 AED per patient per year).

Psychiatric Treatment: 100% (coverage of expenses for psychiatric treatment).

Medical Expenses Incurred Out of Country: Medical expenses incurred out of country will be covered for employees and dependents when (a) a life threatening condition 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.

Transportation for Out of Country Treatment: Transportation for out of country treatment is not a covered expense.

Expenses Not Covered: Expenses will not be covered 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.

No coverage will be made for expenses that will be reimbursed or paid directly under a host country medical program, the U.S. workers' compensation program, or any U.A.E. LES workers compensation program workers' compensation type program.

No coverage will be made 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.

No coverage will be made for expenses incurred after an employee leaves the service of the U.S. Mission.

Maximum Annual Coverage: With the exception of expenses incurred for HIV/AIDS treatment above, the maximum coverage limit is AED

400,000.00 per individual per contract year.

The maximum limit for employees regularly scheduled to work on a part-time basis work for fewer than 30 hours per week will be prorated based on hours in the workweek.

Eligible Employee: Eligible employees are Locally Employed (LE) Staff who are:

Working on a full time or part time basis under non-temporary Direct Hire (DH) appointments, Personal

Services Agreements (PSAs), or Personal Services

Contracts (PSCs) and paid under the terms of the Local

Compensation Plan (LCP).

Not Eligible Employees: Not eligible employees are those LE Staff who are:

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

United Arab Emirates who provides services to other local organizations as well as to the U.S. Mission;

employees of USAID institutional contractors; Peace

Corps personal services contractors as indicated in MS

743; and Recreation Association employees.

Dependent Coverage: For the purposes of this plan, an employee's dependents are defined as the employee's legal spouse (limit one) and each unmarried, economically dependent child who primarily resides with the employee unless away at school.

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 contract year in which the child turns age 19, or in the case of a child who is a full-time student, until the end of the contract year in which the child turns age 22. There is no age limit for an eligible child who is physically or mentally handicapped so as to be unable to live independently. There is no limit on the number of children covered per employee.

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