TERMS OF REFERENCE HEALTH INSURANCE PROVIDER

Transcription

1 TERMS OF REFERENCE HEALTH INSURANCE PROVIDER The World Agroforestry Centre (ICRAF) is one of a network of the Consultative Group on International Agricultural Research (CGIAR). As a global leader in agroforestry research and development, ICRAF s ultimate purpose is to improve human welfare by reducing poverty, increasing cash income, improving food and nutritional security, and increasing environmental resilience through improved agroforestry systems. ICRAF has its headquarters in Nairobi, Kenya and works in 21 countries throughout Africa, Asia and Latin America. In 1993, the World Agroforestry Centre opened a program for Southeast Asia with Bogor, in Indonesia, as its regional headquarters. We currently work in 3 Southeast Asian countries including Indonesia, Philippines, and Vietnam. In line with the mandate from Government of Indonesia, ICRAF provides benefits to the staff as health insurance coverage for employees and their dependants. SCOPE OF WORK The company which is selected to perform the work will have to carry out the following functions: 1. In-Patient Treatment In-patient treatment will be provided to employees and their dependants with maximum room rate of IDR 1,000,000/day (details benefit on attachment 1). The coverage has to be a cashless system; therefore the selected company ought to have a wide network with hospitals in national and international regions. 2. Out-Patient Treatment The out-patient treatment provided to employees and their dependants will be a cashless system with maximum RP. 11,000,000/year. 3. Medical Evacuation coverage The Medical Evacuation coverage for staff only such as Tele-Medical Consultation, Evaluation and Referral 24 hours, Medical Evacuation and Repatriation, Hospital Admission, Monitoring of Medical Condition, Dispatch of Medicine in the event of Emergency, Emergency Message Transmission, transportation to Join Patient, Care/Transportation of Minor Children, Return of Mortal Remains, Interpreter and Legal Referrals, Pre-Trip Information and General Assistance Services, and Loss of Luggage or Document. 4. Providing service agreement to cover ICRAF for 36 months (3 years) The selected company should be willing to provide service agreement of covering ICRAF for 3 years, based on annual renewal with possibility of terms and conditions changes. CRITERIA FOR PROPOSAL EVALUATION 1. Technical Proposal. Each bidder shall submit a technical proposal addressing the services required how they will meet the Centre s requirements. The technical proposal will account for 70% of the total combined score. The proposal will be evaluated according to the following criteria: a) Company & personnel qualifications b) Benefit coverage c) Provider network (Medical providers, Coverage Area) d) Quality of service (Reservation, billing and reporting systems) 2. Financial Proposal The financial proposal shall be evaluated according to the price structure proposed and will account for 30% of the total combined scoring.

2 QUALIFICATIONS OF THE COMPANY AND PERSONNEL QUALIFICATION Extensive experience and a proven track record in the health insurance business Wide networks for national and international coverage Reliable health coverage services Sound experience in servicing international organizations Ability to provide 24-hours service Ability to provide reimbursement system by sending the claim to employee s bank account Real time administrative support systems Ability to respond immediately to emergency situations, whilst maintaining high quality standards of service delivery GENERAL PROVISIONS This tender is open for both Health Insurance Company and Health Insurance Broker. The Health Insurance Broker should provide letter of attorney from the insurance company. Detail data is attached, consisted of: 1. Health insurance benefit requested 2. Total number of employee and dependants, including the birth dates 3. Claim ratio from the current service provider Please submit the health insurance proposal according to the health insurance benefit as requested which contains below information: - Inpatient benefit - Outpatient benefit - Provider coverage - Premium price - General condition - General Exclusion Committee will provide a standard template that should be followed. Any modification should only be made at the remark column. Each bidder may have their own proposal version, but the technical proposal must be submitted as a separate document from the financial proposal. Only proposals that fully address the mandatory services listed in the bidding requirement will be evaluated. Technical meeting : Tuesday, March 14, 2017 at WIB Due date of submission: Tuesday, March 21, 2017 at WIB. The proposal comes after the time will not be accepted. Short-listed bidders may be invited to make presentations to the evaluation team.

3 Attachment. Requested health Insurance benefit scheme (current): INPATIENT BENEFIT Maximum Limit Benefit Room & Board Intermediary room Intensive Care Unit (ICU/ICCU) 1,000,000 1,500,000 Per day, max. 30 days 1,500,000 Surgical Fee Per 85,000,000 In hospital physician s visit In hospital specialist consultation 300, ,000 Private Nurse Per day, max 30 days 300,000 Miscellaneous hospital expenses Per hospitalization 30,000,000 Rental medical expenses Per 1,500,000 Ambulance Per 600,000 Pre and post hospitalization Emergency and outpatient treatment Emergency dental treatment 30 days prior to and after hospitalization 2,500,000 Due to emergency condition 6,000,000 Due to accident 3,000,000 Chemotherapy & Dialysis Per Year 30,000,000 Complication of pregnancy until miscarriage Pen, stent, ring, k wire, IOL Circumcision due to Medical Indication for children max. 5 years old Per 20,000,000 30,000,000 Per Under surgical benefit Minor/One day surgery Per Under surgical benefit Hernia Per Under surgical benefit, no limitation Endometriosis Per Under surgical benefit, cover acne infection Congenital Per Covered under benefit scheme Odontectomy Per under surgical fee Tolerance room & board at provider hospitals due to unavailability or fullybooked room entitled Reinstatement benefit for same illness Annual Limit Room and board tolerance due to unavailability or fully booked, may upgrade IDR 100,000 until discharged. If member use higher room than IDR 1,100,000 insurer will cover up to IDR 1,200,000 until discharged and/or until available. 14 days after discharged hospital Unlimited Death Benefit 10,000,000 Outpatient BENEFIT Maximum Limit Benefit General Practitioner (GP) visit Per visit Specialist consultation per visit No limit Doctor and medicines Per visit Prescribed medicines

4 BENEFIT Maximum Limit Benefit Lab, test diagnostic Physiotherapy Administration Fee Per visit Basic Immunization for Child max 5 Years old All kind of immunization Vaccination for Adult HPV and Typhoid for adult Family Planning IUD, pill, injection and implant Acupuncture Vitamin and Food supplement To be covered if acupuncture treated by certified doctor and not for aesthetic treatment. To be covered if prescribed by doctor in reasonable amount and following by prescribed medicines related to medical condition for recovery and not for preventive treatment and not MLM product Both vitamin and food supplement Eye refraction Covering arm sling, Dekker, cervical collar, Corset Spine under outpatient Hormonal Treatment such as Menstruation and acne infection Both menstruation and acne infection Psychiatric consultation, include the medical treatment and medicines (Inpatient and outpatient) Remark 11,000,000 General Condition BENEFIT Pre-existing condition to be waived for all members No waiting period for all members Critical illnesses to be covered under inpatient and outpatient Buffer fund Rp. 25,000,000 to cover any excess claim occurred under inpatient and outpatient due to excess limit or exclusion. Insurer shall provide membership handbook Hormonal Treatment to be covered under inpatient and outpatient Cover any treatment or surgery to congenital defects (congenitally physical invalidities or illnesses), hereditary illnesses and its complication, such as: Atresia Ani, VSD, ASD, harelip, bone defects, debile, imbecile, mongoloid, cretinism, thalassemia, haemophilia hydrocephalus. Insurer provide reimbursement claim report sent to employee s address and or text message (sms) facility; Provide free Influenza Vaccine for Employee. Provide two health talk every year. Insurer shall provide Cash Plan Benefit to member as eligible room and board amount subject to the member follow BPJS s procedure without submit any excess charges from BPJS to Insurer, without limitation of hospitalization number of days Membership: 1. Eligible age for child: 0 days (in any conditions) 25 years old with children premium; 2. Eligible age for adult: up to 65 years old; 3. Automatic addition and deletion 30 days; 4. Premium for members deletion Inpatient cashless facility at provider networks, excess to be settled by Insurer first, than to be charged later to ICRAF; Outpatient cashless facility at provider networks, excess shall be settled by patients at discharge from hospitals or clinics; Reimbursement claim submission 90 days after treatment within Jabodetabek and outside Jabodetabek area;

5 BENEFIT Reimbursement claim process: max. 10 working days; Reimbursement claim payment: direct to employee s bank account without additional charges for payment transfer; To cover Midwife and Nurse ( mantri ) charges and prescribed drugs/medicine at remote area for emergency cases;