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 Introduction
Section II Procurement Protocol and Process
Section III Administrative Proposal Requirements
Section IV Technical Proposal Requirements / Word Version (Amended 4-17-14)
Section V Cost Proposal Requirements / Word Version
Section VI Evaluation and Selection Criteria
Section VII Contract Provisions
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: This Exhibit was Intentionally Left Blank
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.1: Key Subcontractors / Word Version
Exhibit I.U.2: NYS Supplier & Subcontractor / 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: Comparison 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: 2014 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: Utilization (Amended 4-17-14)
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
Exhibit II.L: Non‐Quantitative Treatment Limitations
Exhibit II.M: Mixed Services Protocol (Amended 4-17-14)

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.1: Instructions for Completing Exhibits V.A.2 and V.A.3
Exhibit V.A.2: Guaranteed Average Unit Cost Quote - Network Outpatient Services / Excel Version
Exhibit V.A.3: Guaranteed Average Unit Cost Quote - Network Inpatient and Alternative Level of Care (ALOC) Services / Excel Version
Exhibit V.B: Administrative Fee Quote


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