Table of Contents

(files on this site are in PDF, Excel and Word format)
(PDF files are controlling)

Empire Plan Mental Health and
Substance Abuse Program

Section I


Section II Procurement Protocol and Process (amended 2-26-13)
Section III Administrative Proposal Requirements (amended 3-11-13)
Section IV Technical Proposal Requirements / Word Version (amended 3-29-13)
Section V Cost Proposal Requirements / Word Version
Section VI Evaluation and Selection Criteria (amended 3-11-13)
Section VII Draft Contract (amended 3-29-13)
Section VIII Glossary of Terms
Appendix A Standard Clauses for New York State Contracts
Appendix B Standard Clauses for all DCS Contracts
Appendix C Third Part Connection and Data Exchange Agreement / Word Version
Appendix D Participation by Minority Group Members and Woman With Respect to State Contracts: Requirements and Procedures

Exhibit I

Exhibit I.A: Proposal Submission Requirement Checklist / Word Version
Exhibit I.B: Biographical Sketch Form / Word Version
Exhibit I.C: Freedom of Information Law - Request for Redactions Chart / Word Version
Exhibit I.D: MacBride and Non-Collusive Bidding Certification / Word Version
Exhibit I.E: ST-220-CA / Word Version
Exhibit I.F: ST-220-TD
Exhibit I.G: EEO Staffing Plan (Form EEO-100) / Word Version
Exhibit I.H: Debriefing Guidelines
Exhibit I.I: New York State Standard Vendor Resposibility Questionnaire 6-2010 / Word Version
Exhibit I.J: Notice of Bidding Intention / Word Version
Exhibit I.K: Offeror Affirmation of Understanding and Agreement / Word Version
Exhibit I.L: Procurement Lobbying Policy
Exhibit I.M: Compliance with Public Officers Law Requirements / Word Version
Exhibit I.N: Compliance with American’s with Disabilities Act / Word Version
Exhibit I.O: MWBE Utilization Plan (form MWBE-100) / Word Version
Exhibit I.P: Offeror’s Certification of Compliance Pursuant to State Finance Law 139-k / Word Version
Exhibit I.Q:

Certification of Good Faith Efforts (form MWBE-104) / Word Version

Exhibit I.R: Questions Template / Word Version
Exhibit I.S: Formal Offer Letter / Word Version
Exhibit I.T: Offeror Attestations Form / Word Version
Exhibit I.U: Key Subcontractors / Word Version
Exhibit I.V: Program References / Word Version
Exhibit I.W: Compliance with NYS Workers' Compensation Law
Exhibit I.X: Extraneous Terms Template / Word Version
Exhibit I.Y.1: Offeror's MHSA Network Record layout / Excel Version
Exhibit I.Y.2: Offeror's Proposed MHSA Provider Network File
Exhibit I.Y.3: Offeror's Proposed MHSA Network Access Prerequisite Worksheet / Excel Version
Exhibit I.Y.4: Comparision of Current MHSA Network and Proposed MHSA Network
Exhibit I.Z: Confidential Agreement and Certificate of Non-Disclosure / Word Version

Exhibit II

Exhibit II.A:

Enrollment by Contract Type

Exhibit II.A2:

Covered Lives by Bargaining Unit

Exhibit II.A3:

Enrollment by Age

Exhibit II.A4:

Enrollment by Month

Exhibit II.B:

Non-Network Deductibles & Co-Insurance

Exhibit II.B2:

Network Copays and Bargaining Groups

Exhibit II.C:

2012 NYSHIP Benefit Plan Comparison

Exhibit II.C2:

Empire Plan Certificate

Exhibit II.D:

SEHP Benefit Summary

Exhibit II.E:

Empire Plan Benefit Card

Exhibit II.E2:

SEHP Benefit Card

Exhibit II.E3:

Excelsior Benefit Card

Exhibit II.F:

Reports Due Dates and Specifications

Exhibit II.F2:


Exhibit II.F3:

Quarterly Performance Guarantee Report

Exhibit II.F4:

This Exhibit was Intentionally Left Blank

Exhibit II.F5:

File Layout of the Shared Accumulator Claims Files

Exhibit II.G:

Paid Claims by Benefit

Exhibit II.G2:

Selected Financial Data

Exhibit II.G3:

2011 and 2012 Incurred Claims by Type of Service

Exhibit II.G4:

Paid Claims Triangles

Exhibit II.H:

NYBEAS Enrollment Record Layout

Exhibit II.I:

Live and Work Well Website Usage

Exhibit II.J:

Health Benefits Fairs

Exhibit II.K:

Statement of Disability

Exhibits III

Exhibit III.A: CD of Claim Utilization by Provider and Geo Information

Exhibits IV

Exhibit IV: There are No Exhibits

Exhibits V

Exhibit V.A:

Quoted Average Cost Per Each CPT/Revenue Code / Excel Version (amended 3-11-13)

Exhibit V.A1:

Exhibit V.A Instructions

Exhibit V.B:

Applied Behavioral Analysis Fee Quote / Word Version

Exhibit V.C:

Administrative Fee Evaluation / Excel Version (amended 3-11-13)

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