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Tenders are invited for Medical Insurance 3. PURPOSE AND OBJECTIVES The purpose of this RFP is to procure a reliable Health Insurance Service Provider capable of providing comprehensive, accessible, timely, and responsive healthcare coverage. The objectives are to: 1. Provide comprehensive Inpatient and Outpatient coverage. 2. Cover eligible dependents under M+6. 3. Ensure access to healthcare in Juba and SP operational locations. 4. Cover chronic and pre-existing medical conditions. 5. Provide maternity, pediatric, neonatal, mental health, dental and optical services. 6. Provide emergency ambulance and medical evacuation. 7. Facilitate national and international medical referrals. 8. Provide cashless treatment wherever possible. 9. Provide reimbursement for eligible out-of-network treatment. 10. Provide 24/7 emergency support and efficient claims management. 11. Provide value for money. 4. MEMBERSHIP AND ELIGIBILITY Principal Members 100 National Staff Dependents M+6 Principal Staff Member + up to Six (6) eligible dependents. Eligible dependents may include: Legal spouse Children Father Mother Siblings Legally adopted children, subject to documentation. Age Eligibility Joining age: birth to 75 years. Parents: coverage to 80 years. Children: coverage to 25 years, or earlier upon marriage or employment. Bidders shall clearly identify any deviation. 5. MINIMUM BENEFIT SCHEDULE All limits shall apply per insured member, unless expressly stated otherwise and accepted by Samaritans Purse. Benefit Minimum Requirement Inpatient USD 12,000/member/year Outpatient USD 3,000/member/year Emergency treatment Included Ambulance Included Emergency medical evacuation Mandatory International medical referral Included Chronic conditions Included Pre-existing conditions Included HIV/AIDS Included Maternity Included Normal delivery Included Caesarean Section Included Pediatric/neonatal care Included Cancer/major illness Included Mental health Included Optical Included Dental Included Preventive healthcare Included Vaccinations Included as specified Annual medical check-up Included Cancer screening Included Annual Staff Wellness Day Included Funeral benefit Included Life Cover Excluded 6. MEDICAL COVERAGE 6.1 Inpatient The minimum annual Inpatient limit shall be USD 12,000 per member. Coverage shall include medically necessary: Hospital accommodation GP and specialist consultations Emergency treatment Trauma and accident treatment Ambulance ICU Surgery Laboratory and diagnostic investigations Prescribed medicines Physiotherapy Orthopedic, ENT, urology and neurosurgery Chronic and pre-existing conditions HIV/AIDS Maternity Normal delivery Caesarean Section Pediatric and neonatal care Cancer treatment Major illness and specialized treatment. 6.2 Outpatient The minimum annual Outpatient limit shall be USD 3,000 per member. Coverage shall include: GP and specialist consultations Emergency outpatient treatment Prescribed medicines Laboratory tests Diagnostic investigations Radiology Ultrasound X-rays ECG CT scans Barium studies IVP Physiotherapy Follow-up treatment Chronic disease management. 6.3 Maternity and Neonatal Coverage shall include: Antenatal and postnatal care Normal delivery Caesarean Section Medically necessary elective C-section Pregnancy complications Maternal complications Pediatric care Term and pre-term babies Neonatal care Congenital conditions. Bidders shall state maternity limits and any waiting periods. 6.4 Chronic, Pre-existing and Major Conditions Coverage shall include medically necessary treatment of chronic and pre-existing conditions, including asthma, sickle cell disease, hypertension, diabetes, hyperlipidemia, cancer, HIV/AIDS, arthritis, thyroid conditions, blood disorders, cardiac conditions, eczema, psoriasis, pemphigus, scleroderma, dermatomyositis, and other recognized chronic conditions. Major treatment shall include, where medically necessary, cancer treatment, cardiac treatment, stents, valve procedures, hip replacement, spinal procedures, major orthopedic procedures and specialized surgery. No disease-specific exclusion or sub-limit shall apply unless expressly disclosed and accepted. 7. MENTAL HEALTH, DENTAL, OPTICAL AND WELLNESS Mental Health Coverage shall include psychiatric and psychological consultations, counselling, treatment, prescribed medication, stress management and trauma counselling. The provider shall support quarterly staff wellbeing talks. Optical Coverage shall include eye examinations, visual acuity tests, medically necessary eye treatment, simple external eye procedures, prescription lenses and frames. The bidder shall state the annual Optical limit and replacement frequency. Dental Coverage shall include extraction, scaling and polishing, amalgam/composite fillings, root canal treatment, dentures and other medically necessary dental treatment. The bidder shall state the annual Dental limit. Preventive Health Coverage shall include: Annual medical check-up General health screening Cervical cancer screening Prostate cancer screening Health education Preventive health awareness. One Annual Staff Wellness Day shall be conducted in coordination with Samaritans Purse and included in the premium. Tender Link : https://comms.southsudanngoforum.org/c/tenders
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