SF30_-_Amendment_1.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE

524114

PAGE OF PAGES

2. AMENDMENT/MODIFICATION NO.

A001

3. EFFECTIVE DATE

September 26, 2014

4. REQUISITION/PURCHASE REQ. NO.

PR3069505

5. PROJECT NO. (If applicable)

6. ISSUED BY CODE

7. ADMINISTERED BY (If other than Item 6) CODE

Department of State

American Embassy

Abu Dhabi, United Arab Emirates

8. NAME AND ADDRESS OF CONTRACTOR (NO., street,city,county,State,and ZIP Code)

9a. AMENDMENT OF SOLICITATION NO.

STC10014R0001

9b. DATED (SEE ITEM 11)

September 5, 2014

10a. MODIFICATION OF CONTRACT/ORDER NO.

10b. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

[X] The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

[X] is extended, [ ] is not extended

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning ___2____ copies of the amendment;(b) By acknowledging receipt of this amendment on each copy of the offer submitted; or(c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers.

FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF

OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b)

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

X

D. OTHER (Specify type of modification and authority)

Amended to revise pricing table, annual maximum limit, to change Exhibit A in Section J, and to extend the RFP submission deadline

E. IMPORTANT: Contractor [] is not, [X] is required to sign this document and return _2__ copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

1. Section B.2.3. and B.3.2.1. to change the pricing table from Family Plan to Family members (see continuation sheet).

2. Section C.1.1.15. to change the maximum annual limit from family to individual member (see continuation sheet).

3. Section J. To change the annual maximum limit in Exhibit A – List of Health Insurance Coverage (see continuation sheet).

4. To extend the RFP submission deadline from October 7, 2014 to October 16, 2014. (see continuation sheet).

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

16A. NAME OF CONTRACTING OFFICER

Wendy M. Wahington

15B. NAME OF CONTRACTOR/OFFEROR

BY

(Signature of person authorized to sign)

15C.DATE

SIGNED

16B. UNITED STATES OF AMERICA

BY

(Signature of Contracting Officer)

16C.DATE SIGNED

NSN 7540-01-152-8070 Standard Form 30 (revised 10/83)

Previous edition unusable Prescribed by GSA FAR (48 CFR) 53.243 http://ilmsariba.irm.state.gov/Buyer/Main/aw?awh=r

B.2.3. BASE YEAR OF CONTRACT: (Annual maximum AED 400,000 per individual per year)

Bi-Weekly Rates Per Insured Members:

Category Estimated

Number of insured members

Rate Total

Single Employees

(Self only)

Family Members 619

SUBTOTAL

Total Price for Base Year (Subtotal x 26): _______

B.2.4. FIRST OPTION YEAR OF THE CONTRACT:

Number of insured members

Rate Total

Single Employees

(Self only)

Total Price for First Option Year (Subtotal x 26): _______

B.2.5. SECOND OPTION YEAR OF THE CONTRACT:

number of

Insured

Members

Rate Total

Single Employees

(Self only)

Total Price for Second Option Year (Subtotal x 26): _______

B.2.6. THIRD OPTION YEAR OF THE CONTRACT:

Insured

Members

Rate Total

Single Employees

(Self only)

Total Price for Third Option Year (Subtotal x 26): _______

B.2.7. FOURTH OPTION YEAR OF THE CONTRACT:

Insured

Members

Rate Total

Single Employees

(Self only)

Total Price for Fourth Option Year (Subtotal x 26): _______

GRAND TOTAL (BASE PERIOD PLUS OPTION YEARS): _________________

B.3 ADMINISTRATIVE RETENTION AMOUNTS

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

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

NOTE TO OFFEROR - Fill in the fixed bi-weekly retention amounts for each period of performance and for each category of premium. This fixed amount must be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall NOT be expressed in terms of a percentage of the premium.

B.3.2.1 Bi-Weekly Retention Amounts per separate premium paid per single employee and per family members.

Period of

Performance

Single Employees (Self

Only)

Family Members

Base Period

Option Year 1

Option Year 2

Option Year 3

Option Year 4

C.1.1.15. Maximum Annual Limit:

With the exception of expenses incurred under paragraph C.1.1.5. above, the Insurance Company will reimburse covered expenses up to a limit of AED 400,000 per individual per contract year.

RFP Submission Date:

October 16, 2014 at 5:00 PM (local time).

Section J, Exhibit A:

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.