Health Insurance services for US Embassy Tbilisi LES

C.1. HEALTH INSURANCE SERVICES

The Government of the United States of America requires Health Insurance coverage for its employees as further described in C.1.2 in Georgia. The Government has determined that the prevailing practice by employers in Georgia is to provide for their employees health insurance protection and that the cost of such insurance protection is usually borne by the employer. Health insurance protection will be representative of locally prevailing compensation practice as further described in C.1.2. The specific health benefit coverage under this contract is set forth in Section C and the Exhibits in Section J.

The Contractor shall insure that health care under this contract does not exclude HIV/AIDS care, unless exclusion has been authorized by HR/OE/CM.

C.1.1 Employee and Dependent Health Services Benefits

The insurance company will reimburse covered medical expenses incurred subject to the stated limits. Payment will be made for reasonable and customary costs of covered benefits. The medical treatment must be prescribed or provided by a physician or nurse licensed in Georgia, the United States, or the country where treatment is received.

Deductible: NONE

C.1.1.1. Hospitalization: 100% reimbursement of room and board for a ward room or semi-private room. 80% reimbursement of room and board for a private room, not to exceed 100% of the cost of a semi-private room. 100% reimbursement of hospital medical expenses including laboratory tests and diagnostic imaging tests, doctors' and surgeons' fees, nursing care, operating room costs, intensive care, prescription medicines and medical supplies, and physical therapy. 100% reimbursement of land ambulance service.

C.1.1.2 Professional services and treatment: 100% reimbursement of doctors' and surgeons' fees incurred while hospitalized. 80% reimbursement of doctors' and surgeons' fees incurred at a hospital on an out-patient basis, at a clinic or doctor's office, or at home. 80% reimbursement for medical services and expenses when not hospitalized such as laboratory tests and diagnostic imaging tests, prescription medicines, and physical therapy. 90% reimbursement of routine annual physical examination and inoculations.

C.1.1.3. Prescription drugs and medicines: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of the cost of medicines and drugs for which a prescription is legally required in most countries. Expenses incurred for medicines, vitamins, cold remedies, etc., that are available over the counter without a prescription in most countries will not be reimbursed even if prescribed by a physician.

C.1.1.4 For employees only: 100% reimbursement for medications to suppress opportunistic infections, such as tuberculosis and toxoplasmosis for employees who have HIV/AIDS. For employee and employee's covered spouse/partner: 100% reimbursement for 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

The maximum limit for expenses reimbursed under section C.1.1.4 is USD 10,000 per contract year per patient.

C.1.1.5 Obstetrical care: 100% reimbursement when hospitalized, and 80% reimbursement when not hospitalized, of obstetrical medical care including prenatal and postnatal care.

C.1.1.6 Family planning: 80% 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.

C.1.1.7 Hearing aids: 80% reimbursement of the cost of a hearing aid apparatus and related examination. Limited to one apparatus per ear per patient in a three-year period.

C.1.1.8 Optical care: 80% reimbursement for eye examination and treatment and prescription eyeglass or contact lenses. Limited to two lenses per patient every two years. No reimbursement for eyeglass frames, nonprescription lenses, or tinting.

C.1.1.9 Dental care: 80% of expenses for dental services including dentists' fees, x-rays, examination and treatment, cleaning, fillings, extractions, false teeth, crowns, implants, and bridges. Orthodontia treatment is covered only if treatment begins before age 15, unless required as the result of an accident. A maximum of four years of orthodontia treatment will be covered per patient. Dental care is subject to an annual maximum of USD 2,500 per contract year per insured individual.

C.1.1.10 Psychiatric treatment: 80% reimbursement.

C.1.1.11 Medical expenses incurred out of country

Medical expenses incurred out of country will be covered for employees and/or 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.

C.1.1.12 Transportation for Out of Country Treatment

Transportation for out of country treatment is not a covered expense

C.1.1.13 Annual Maximum Limit - The maximum annual reimbursement per patient per contract year, not including expenses covered under c.1.1.4, is USD 150,000.00 per patient per contract year.

C.1.2 Health Benefits Conditions and Limitations

There is no reimbursement for elective cosmetic surgery unless resulting from accident, illness or injury; 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.

There is no reimbursement for medical expenses related to an illness or injury that is a result of an unlawful action on the part of the employee; 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; and expenses incurred after an employee leaves the service of the mission.

There is no reimbursement 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.

There is no reimbursement for round trip transportation expenses to travel out of country for medical treatment.

C.1.3 Eligible Participants

C.1.3.1 Eligible Employees - Eligible employees are Locally Employed Staff who are (1) working on a full time or part time basis under non-temporary direct hire appointments, personal services agreements, or personal services contracts and (2) paid under the terms of the Local Compensation Plan.

C.1.3.2 Location of Employment

The individuals covered by C.1.3.1 must be employed within the geographic boundaries of Georgia by the agencies under the Chief of Mission authority:

US Department of State
Open Source Center (OSC)
Defense Security Cooperation Agency (ODC)
Defense Wide Program (PFP)
U.S. Agency for International Development (USAID)
Center for Disease Control (CDC)
Office of Bilateral Agreement (BAO)
Export Control and Related Border Security (EXBS)
US Department of Justice (DOJ)
US Department of Defense (DAO)
US Department of Treasury
US Army Corp of Engineers (USACE)
US Department of Agriculture (USDA)
International Narcotics Liaison (INL)
Defense Threat Reduction Agency (DTRA)
Force Protection Detachment (FPD)
EUCOM
NAVY-GDP -ICAF
Population, Refugee and Migration (PRM)
Army Medical Research Center (WRAIR)
Millennium Challenge Corporation (MCC)
US Peace Corps - employees eligible in accordance with C.1.3.1 and Personal Services Contractors (PSC) under separate rider (see C.1.3.3.3)

C.1.3.3 Participants Covered Under a Rider

C.1.3.3.1 All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account (see separate rider, Exhibit B). All costs for ORE employees are the responsibility of the employing officer, not the U.S. Government.

C.1.3.3.2 All current active employees of the Tbilisi Employee Association (TEA) at Embassy Tbilisi (see separate rider, Exhibit C). All costs for TEA employees are the responsibility of the Employee Association, not the U.S. Government.

C.1.3.3.3 All current active Peace Corp PSCs (see separate rider, Exhibit D). All costs for PC PSC employees are the responsibility of the Peace Corps.

C.1.3.3.4 Employees separated due to retirement are eligible. Premium costs are entirely borne by the retiree.

C.1.4 Individuals Not Eligible for Coverage

Not eligible are those working under temporary appointments; those working under a PSC or PSA that is time limited to less than one year; those with an intermittent, seasonal, or WAE (when actually employed) schedule; non-personal services contract personnel and their employees, supplied by an independent contractor licensed to do business in Georgia who provides services to other local organizations as well as to the U.S. Mission; employees of USAID institutional contractors..

C.1.5 Other Eligible Participants

Covered dependents include the participating employee's spouse and children. A limit of one spouse per employee is covered. An eligible child is defined as the employee's natural child, adopted child, stepchild, or foster child. The child must be unmarried, economically dependent upon the employee, and reside with the employee unless away at school. An eligible child will be covered until the end of the contract year in which he/she reaches age 18, or age 25 if a full time student. There is no age limit for a 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.

C.1.6. Eligibility

C.1.6.1. Term of Eligibility and Effective Date

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

During a period of Leave Without Pay or unpaid leave that is one pay period or less, coverage under the insurance contract will continue. The USG will pay the total premium cost to the contractor.

C.1.6.2. Period 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 (beyond one pay period) of Leave Without Pay or unpaid leave, 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 that employee prefers not to pay the premium.

C.1.6.3. Premium Costs

For active employees who are regularly scheduled to work 30 or more hours per week, the USG will pay 100% of the premium cost for both employee and eligible dependent coverage.

For active employees who are regularly scheduled to work less than 30 hours per week, the USG will pay a prorated share of the premium cost for employee coverage based on the number of hours the employee is regularly scheduled to work, and the employee will pay the remaining premium cost.

For active employees who are regularly scheduled to work less than 30 hours per week, there is no USG contribution for dependent coverage, and the employee will pay 100% of the premium cost for dependent coverage.

For retirees, there is no USG contribution for retiree or dependent coverage, and the retiree will pay 100% of the premium cost for both his/her own and dependent coverage.

C.1.7. BROCHURE REQUIREMENT.

C.1.7.1. The contractor shall provide a document (brochure/pamphlet/other written document) in Georgian and 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.

C.1.7.2. The contractor shall provide the document described in C.1.7.1 to the COR not later than 20 days after date of contract award. The Contractor shall provide additional brochures for new employees within ten (10) days of the COR's request.

C.1.7.3. The contractor assumes full responsibility for ensuring that the document described in C.1.7.1 accurately reflects the requirements 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 brochure contains inaccuracies, the contractor will be notified in writing; however, failure on the part of the 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.




C.2.0 GROUP LIFE INSURANCE - RESERVED


C.3.0 DEFINITIONS

FMO The Financial Management Officer or the paying office for all U.S. Government Agencies except AID.

COR Contracting Officer's Representative.

Dependent The legal spouse and children of eligible employees

Disability, Total and Permanent A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment. If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

Employee An individual employed by the U.S. Government, under a direct-hire appointment, personal services contract, or personal services agreement, as further defined in Section C.1.3 for health insurance. This may also include ORE Staff, EAE and Peace Corp PSCs, if this category of individual is listed as participating under a rider in C.1.3.3 for health insurance.

Employer The United States Government or in the case of ORE and Tbilisi Employee Assosiation employees, the Chief of Mission/Deputy Chief of Mission, Employee Association and Peace Corps respectively.

GSO General Services Officer in charge of the General Services Office at post. This officer is usually the Contracting Officer for this contract.

Hospital An institution established and operated for the care and treatment of sick and injured persons. It provides 24-hour nursing care and has diagnostic, laboratory, treatment, and surgical facilities. Any institution which does not meet this definition is not considered a hospital.

Hospital Patient An individual who has been admitted to a hospital, is assigned a bed, and is given diagnostic tests or receives treatment for a disease or an injury.

Maximum Benefit The total amount that will be paid to any one covered individual for covered medical expenses or life insurance/disability benefit.

Customary and Reasonable Treatment A diagnostic test or medical treatment which is usually performed in the community where the individual is being treated.

Physician An individual who has graduated from an accredited medical school and is licensed to practice medicine in the jurisdiction in which the contract is to be performed. If the individual is a medical specialist, then he or she is Board Certified in that specialty.

Surgical procedure Any invasive medical procedure by manual or instrument operation undertaken for diagnosis or treatment of a diseased patient.