Tender Description

Provision of Medical Services for CARE Somalia/Somaliland Staff

1. Background

CARE International is an international humanitarian and development organization operating in Somalia and Somaliland, with staff based across multiple locations in Somalia, Somaliland, and Kenya. In delivering its programmes, CARE has a duty of care to ensure that staff and eligible dependents have access to reliable, quality, and timely medical services.

Given the varied availability of healthcare services across the region, CARE Somalia/Somaliland seeks to engage a qualified and licensed medical insurance provider with the capacity to offer comprehensive medical cover, efficient claims administration, access to accredited healthcare providers, and emergency referral and evacuation support where required.

This Terms of Reference outlines the requirements for the tender for provision of medical insurance services for the period 1 July 2026 to 30 June 2027.

1. Purpose

The purpose of this Request for Proposal (RFP) is to identify and contract a qualified, licensed, and financially sound medical insurance provider to deliver comprehensive medical coverage for CARE Somalia/Somaliland staff and their eligible dependents for the period 1 July 2026 to 30 June 2027.

The scheme is intended to ensure reliable and timely access to quality healthcare services across Somalia, Somaliland, and Kenya, supported by an established provider network, efficient claims administration, and effective referral and emergency evacuation arrangements where required.

The selected provider must demonstrate the operational capacity to deliver these services consistently across a geographically dispersed and complex operating environment.

1. Scope of Work

The selected service provider shall deliver and administer a comprehensive medical insurance scheme for CARE Somalia/Somaliland staff and their eligible dependents for the contract period. The scheme shall provide access to quality healthcare services across Somalia, Somaliland, Ethiopia and Kenya, and shall include the following minimum service requirements:

1. Medical Coverage

The medical insurance scheme shall, at a minimum, provide coverage for the following:

• Inpatient services, including hospitalization, surgeries, specialist treatment, nursing care, and related medical costs 
• Outpatient services, including general consultations, specialist consultations, diagnostic services, and prescribed medication 
• Maternity services, including prenatal care, delivery, and postnatal care 
• Optical services, including eye consultations, prescribed lenses, and related optical care 
• Dental services, including routine and emergency dental treatment
  1. Emergency and Referral Services
• Emergency medical treatment and stabilization 
• Medical referrals within and across service locations, where clinically necessary 
• Local and international medical evacuation, including air evacuation where applicable 
• Coordination of emergency evacuation from somalia, somaliland, or kenya, subject to operational feasibility and applicable aviation or landing requirements 
• Evacuation coverage up to the applicable benefit limit under the policy
  1. Insurance Administration and Claims Management
• End-to-end claims management, including claims submission, review, processing, reconciliation, and reporting 
• Pre-authorization for treatment, procedures, and hospital admissions 
• Care coordination for beneficiaries requiring hospitalization, specialist care, referral, or follow-up treatment 
• Beneficiary support services for medical inquiries, claims follow-up, and case management 
• Regular reporting to care on utilization, claims trends, and service performance
  1. Provider Network and Service Access
• Provide access to hospitals, clinics, specialists, pharmacies, and diagnostic facilities within the required coverage areas 
• Demonstrate the availability of panel providers across somalia, somaliland, and kenya, and where relevant, in other referral locations 
• Manage relationships with healthcare providers to support service quality, billing arrangements, and continuity of care 
• Ensure beneficiaries are informed of available providers, referral pathways, and access procedure
  1. Coverage Information and Policy Clarity
• Benefit limits and applicable ceilings 
• Eligibility criteria for staff and eligible dependents 
• Policy inclusions and exclusions 
• Applicable waiting periods, co-payments, or cost-sharing arrangements, if any 
• Conditions governing referrals, admissions, and evacuation services

The provider shall ensure access to emergency medical support and referral services, including:

The provider shall be responsible for the effective administration of the medical scheme, including:

The provider shall maintain an established and accessible network of accredited healthcare providers and shall:

The provider shall clearly define the terms of coverage for all benefit categories and specify:

Skills Required

Attachment

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