Responses_to_Questions_2015_set_3.pdf

Embassy of the United States of America

Port of Spain, Trinidad

Pre-Proposal Conference and Formal

Questions and Answers - Set 3

Request For Proposal (RFP) Number: STD550-15-R-0001

1. Please clarify the membership as data received differs from data provided in the RFP – please use the following table to provide details of each of the employees to be covered.

Member No. Sex Coverage Type

(Single/Family) Date of Birth or Age

Classification

(ORE/EAE/USG Employee/ Retired)

Please use the data which includes the age range provided in question 8 of the “Responses to questions-

Set 2”. No. of employees change from time to time due to new positions, resignations and retirement thus change in data. The Embassy will not be providing specific information on each member at this time but rather ranges which would be adequate. The contract awardee will receive the specifics.

2. With reference to Question/Answer 13, contracted parties cannot be the employees themselves, please confirm that the contract is between the Embassy of the United States of America Port of

Spain Trinidad and the Insurer.

Yes.

3. Confirm the total health benefit (inclusive of dental and vision) to be covered is TT 922,333 =

General Cover $400,000 + Catastrophic Cover $458,333 + HIV Cover $64,000 (US 10,000)

Reference is made to the coverage required for each contract year:

SEPARATE MAXIMUM BENEFIT LIMIT:

There must be a maximum limit for this benefit for HIV/AIDS coverage for employees, a limit of U.S.

Dollars (USD) $10,000.

C.I.I.15: MAXIMUM LIMITS:

Maximum Annual Coverage:

a) The insurance company will reimburse covered expenses described under paragraph C.1.1.14

(Separate Maximum Benefit Limit for HIV/AIDS) of the plan up to a separate limit of 400,000TT per employee per contract year.

b) FOR CATASTROPHIC CONDITIONS:

The annual aggregate maximum shall be 458,333TT per covered individual for medical expenses. 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

4. Does catastrophic pertain to the amount of the claim or the nature of the claim? If it pertains to the amount, what triggers the catastrophic cover?

It pertains to the amount and the nature as stated in the solicitation.

5. If the catastrophic limit of $458,333 is exceeded, is it expected that the excess will be covered from the general cover maximum of $400,000? Also confirm the same for the HIV/Aids cover limit excess.

The annual aggregate maximum shall be 458,333TT per covered individual for medical expenses. 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.

6. B4.1, B8.1 indicates premiums for EAE & ORE Employees (riders) cannot be increased / decreased.

What is the expectation if claims for these groups of employees result in an undesirable claims experience? Will the increase that should be borne by these “riders” to the policy be absorbed by the main group (USG Employees)?

Yes, the riders are excluded from price adjustments. There will be six (6) persons in this group.

7. Please provide the schedule of benefits which matches the claims experience information provided for 2012-2014.

Please see below the schedule of benefits that matches the claim experience information

Hospitalization:

Room & Board: ward, semi-private, private: Not defined Amount per day: 300 TT$ per day, per person Maximum days per confinement: 31 days per disability Hospital medical expenses: 100% reimbursement (Includes Lab tests, X-rays, nursing care, Operating room costs, intensive care, Prescription medicines, physical therapy)

Hospital Outpatient Services

As described above

Surgery:

Doctors’ and Surgeons’ fees incurred while hospitalized, at a hospital.

An out-patient basis, at a clinic or Doctor’s office or at home 85% reimbursement

Doctor Visits

An out-patient basis, at a Clinic or Doctor’s office or at Home 85% reimbursement

Prescription Drugs When hospitalized or not hospitalized: 90% reimbursement with a Maximum of TT$500

(Including those that suppress opportunistic infections, such as tuberculosis and toxoplasmosis)

Maternity

Obstetrical Care:

Reimbursement when hospitalized of obstetrical medical care including prenatal and postnatal care as follows:

Routine Delivery: 100% reimbursement; TT$2,500 Maximum

Caesarean: 100% reimbursement; TT$6,000 Maximum

Miscarriage: 100% reimbursement; TT$600 Maximum

Family Planning: 90% reimbursement of prescribed contraceptive devices and drugs, voluntary sterilization, and diagnosis and treatment of infertility.

Not covered is reversal of voluntary sterilization, infertility treatment after voluntary sterilization, genetic counseling, fertility drugs and assisted reproductive technology including provisions for brief courses of anti-retroviral drugs during childbirth to prevent the transmission of HIV to the employee’s child. Duration of treatment is to be determined by the employee’s personal physician, following WHO and CDC guidelines.

Optical Service

Optical Care: 90% reimbursement of TT$1,000 (Employee may choose one or the other, for eligible participants.

contact or regular lenses, one pair, per year) Examinations: Limited to one per year

Contact Lenses: 1 pair per 12 months Lenses: 1 pair per 12 months Frames: 1 set per eligible participant During any consecutive 24 months.

Dental Service:

Dental Care: 100% of reimbursement of TT$2,000 for eligible participants for preventative and minor and major restorative work.

80% for reimbursement for orthodontic a maximum of lifetime benefit of TT$2,000.

Physical Therapy:

TT$80 per visit per disability for 10 days

Psychiatric Treatment:

TT$125 per visit per disability for 10 days

Ambulance Service:

Ambulance service: 100% reimbursement

Hearing Aids: Not covered

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.

Transportation for Out of Country Medical Treatment:

Transportation for out of country treatment is a covered expense for employees and dependents. The patient’s attending physician must certify in advance that the treatment is medically necessary and unavailable locally. 80% of the patient’s transportation expenses by the least expensive, appropriate means of transportation to the nearest city with adequate medical facilities will be reimbursed. 80% of the transportation expenses of an attendant will be reimbursed if the patient’s attending physician certifies that an attendant for the patient is necessary, e.g. a parent in the case of a patient who is a minor or a family member to make medical decisions in the case of a patient who is unconscious. All reimbursements for transportation expenses are subject to the annual maximum limit.

Other Benefits:

Preventative Care

Specialist Consultations

Maximum Limits:

The Insurance Company will reimburse covered expenses up to a limit of TT$400,000 per covered individual over the lifetime of the insurance contract. The insurance company will reimburse covered expenses for HIV/AIDS care to a separate limit of USD 10,000 per employee per contract year.