new york state medicaid administrative services n.
Skip this Video
Loading SlideShow in 5 Seconds..
New York State Medicaid Administrative Services PowerPoint Presentation
Download Presentation
New York State Medicaid Administrative Services

Loading in 2 Seconds...

play fullscreen
1 / 26

New York State Medicaid Administrative Services - PowerPoint PPT Presentation

  • Uploaded on

New York State Medicaid Administrative Services. Vendors’ Conference July 8th, 2013 10:00 AM ET. Introduction 10 minutes Department of Health Introductions Key MAS Procurement Dates Designated Contacts New York Medicaid Program Background

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'New York State Medicaid Administrative Services' - teagan-obrien

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
new york state medicaid administrative services

New York StateMedicaid Administrative Services

Vendors’ Conference

July 8th, 2013

10:00 AM ET


Introduction 10 minutes

Department of Health Introductions

Key MAS Procurement Dates

Designated Contacts

New York Medicaid Program Background

Procurement Overview 15 minutes

Goals and Objectives of the MAS Procurement

Scope of the MAS Procurement

Current and Future MMIS Components

Comparing the MAS Procurement to a Traditional MMIS Procurement

Software Ownership Scenarios in the MAS Procurement

Vendor Preclusions/Restrictions

Contract Overview 10 minutes

Phases and Timeline

Release of Medicaid System and Operational Components

RFP Review 20 minutes

RFP Structure/Components

MITA Overview

High-level Response Instructions

Elaboration on Key Technical Requirements

Attachment H: Pricing Schedule Key Focus Areas

Evaluation Criteria 5 minutes

Q&A 30 minutes

Today’s Agenda

speaker introductions
Speaker Introductions


Subject Matter Experts

Jonathan Halvorson

Deputy Director

Division of Systems

Office of Health Insurance Programs

Janet Elkind

Cynthia H. Beaudoin

Jonathan Bick

Deputy Director

Division of Program Development and Management

Office of Health Insurance Programs

Senior Attorney

New York State Department of Health

Division of Legal Affairs


Division of OHIP Operations

Office of Health Insurance Programs

Joseph Zeccolo

Christine Hall-Finney

Dennis Wright

Fiscal Management Group,

Bureau of Contracts

Division of Administration


Division of Systems

Office of Health Insurance Programs

Administration and Contracts Director

Division of Systems

Office of Health Insurance Programs


Designated Contacts

Please note that all communication in relation to this procurement, MUST go through the below contacts only

Contact for all communications attempting to influence this procurement or related to subject matter pertinent to this solicitation

  • Contacts for communications related to the following subjects:
  • Debriefings
  • Negotiation of Contract Terms after Award

Contact for communications related to the following subjects:

  • Submission of Written Questions
  • Submission of Written Proposals
  • Procurement Library Requests

Mr. Joseph Zeccolo

NYS Department of Health

Fiscal Management Group,

Bureau of Contracts

Phone: (518) 474-7896


Mr. Dennis Wright

NYS Department of Health

Office of Health Insurance Programs

Division of Systems

Phone: (518) 649-4274 (work)E-mail:

Mr. Patrick Allen

NYS Department of Health

Office of Health Insurance Programs

Division of Systems

Phone: (518) 649-4267



New York Medicaid Program Background

  • Largest Medicaid program in the US
  • Along with affiliated programs, it provides health care coverage to over five (5) million New Yorkers
  • Medicaid Managed Care: 3.3 million, Family Health Plus: 430,000, Child Health Plus: 340,000


  • Encompasses a variety of components allowing it to process over 2 million transactions per day in 2012, 1.3 million of which are claims
  • Provides application access for the Department, other State agencies, LDSS, and providers
  • Provides a variety of capabilities such as transaction processing, web-based application for the State, internet application for provider access, external file transfer, etc.



  • Governor Cuomo established the Medicaid Redesign Team (MRT) in January 2011, to reform the Medicaid system and reduce costs.

Goals and Objectives of the MAS Procurement


  • Solicit proposals for an MAS contractor to provide fiscal agent services and other services for the NYS Medicaid Program in a manner that complies with Centers for Medicare & Medicaid Services (CMS) guidelines and certification requirements for an MMIS
  • Replace existing eMedNY functions, except encounter processing
  • Ensure that the new system will meet CMS certification requirements and comply with all federal regulations and policy
  • Take over clinical review and administration functions, including claims processing, for NYS pharmaceutical programs including the Elderly Pharmaceutical Insurance Coverage (EPIC) Program, the New York Prescription Saver Program (NYPS), and the Preferred Diabetic Supply Program (PDSP)
  • Take over administration of MEIPASS incentive program for electronic health record adoption
  • Take over prior approval functions from DOH staff



Scope of the MAS Procurement

The prime contractor must provide fiscal agent services and will be responsible for replacement of the current NYS MMIS with a new mechanized claims processing and information retrieval system. Services include, but are not limited to, the following (a full set of required services is provided in Attachment E):

Claims adjudication, payment, and post-payment adjustment

Provider servicing, communication, and education

Provider screening, enrollment, and recertification

Pharmacy Benefit Management

Prior approval of certain services

Specific benefit carve-outs

Member and provider call center

Managed Care capitation payments

Program integrity

Grievance and appeals processes

Facilitation of Electronic Health Records (EHR) incentive program

Coordination of benefits (private third-party liability, Medicare dual-eligibles)


Current and Future Components of MMIS

  • The scope of this procurement does not represent the entire MMIS enterprise
  • Current NYS MMIS is comprised of eMedNY and the Medicaid Data Warehouse (MDW). The MMIS interfaces with the Welfare Management System (WMS), managed care organizations (MCOs), the managed care enrollment broker, and the state's third-party liability (TPL) contractor to provide MMIS functions
  • The diagram below provides an overview of the future MMIS environment and interactions with other major NYS systems, delineating the division of high-level responsibilities among the various entities.

High-Level Differences

High-Level Similarities

Emphasis on Existing Infrastructure

Diverse Vendors

Fiscal Agent Responsibility and State Oversight

  • Vendors expected to focus on configuring existing infrastructure and platforms for claims processing, customer service, care managerment and other services where possible
  • The COTS product(s) delivered by the contractor will be licensed to the Department in accordance with contractor’s or other independent software vendor’s (ISV) standard license agreement, amended if necessary to satisfy Section VI: Contract Requirements
  • Procurement open for vendors including but not limited to traditional MMIS vendors, System Integrators, Medicare Administrative Contractors (MACs), Admnistrative Services Organization (ASOs), and commercial and Medicaid managed care organizations (MCOs)
  • The primary contractor is expected to provide fiscal agent services and other services for the NYS Medicaid Program in a manner that complies with CMS guidelines and MMIScertification requirements as identified in the CMS Medicaid Enterprise Certification Toolkit (MECT)
  • The contractor will configure and supplement its existing infrastructure to provide selected health program administration services to NYS, but will not bear health insurance risk for member coverage. Health insurance risk and fiduciary responsibility for member coverage still reside with NYS
  • Regardless of whether the Department owns or licenses particular components of the system, it must have access to and oversight of all systems and records procured as part of the MAS procurement to ensure its ability to determine and enforce compliance with requirements of the MAS RFP

Comparing MAS Procurement to Traditional MMIS Procurement


Vendor Preclusions/Restrictions

Primary Contractor


  • An MCO that provides risk-based capitated Medicaid services in NYS is not eligible to function as the fiscal agent and therefore it cannot submit a proposal as a prime vendor to the RFP, but can serve as a subcontractor
  • NYS has elected to carve drug rebate responsibilities out in a separate procurement because of the openness of the MAS contract to commercial and Medicaid health plans
  • Medicaid MCOs currently providing or intending to provide Medicaid services in NYS can be included as a subcontractor but must be insulated from providing the following services or having exposure to/interaction with the following information:
    • FFS Payments
    • Maternity kick payment processing
    • Stop-loss
    • Capitation payments

Summary of Scenarios

Software Ownership Scenarios in the MAS Procurement

The ownership rights of the contractor in relation to existing commercially distributed software product(s) as well as conditions on license grant are provided in detail in Section VI: Contract Requirements. The scenarios below help to provide further guidance on ownership:


Phases and Timeline

The contract will be awarded for five (5) years with the option to renew for three (3) additional one (1) year periods at the sole option of the State. The initial five (5) year period would begin in January 2014 and include all project planning, DDI, operations, certification, and operational enhancement tasks.


RFP Structure/ Components

RFP Section I

  • Provides Procurement Overview including vision, goals and objectives, term of the contract and scope of work summary

RFP Section 2

  • Provides description of the NYS Medicaid Program and current MMIS environment
  • Describes ancillary and related MMIS systems and components

RFP Section 3

  • Includes SOW and guiding principles of the procurement
  • Describes project personnel requirements, performance and monitoring expectations, including the service level agreements

RFP Section 4

  • Provides an overview of the proposal requirements
  • Includes proposal submission instructions, technical and price proposal contents, certifications and the evaluation process

RFP Section 5

  • Provides an overview of the NYS Administrative requirements
  • Includes designated contacts for submission of the proposal
  • Describes department and contractor responsibilities and elaborates on the appendices

RFP Section 6


  • Presents the legal provisions that govern the resulting contract.
  • Standard RFP attachments for NYS and DOH
  • Attachment E: Vendor Requirements Traceability Matrix (provides technical requirements)
  • Attachment H: Pricing Schedule (provides a cost template to be filled by the vendor)

Note: The RFP and its attachments become part of the final contract


MAS MITA 3.0 Business Architecture to Support Functional Requirements

MITA Overview

  • Importance of Attachment E: Vendor Requirements
  • Developed based on the business needs of NYS, MITA 3.0 and CMS MMIS Certification Requirements
  • Organized by overarching technical architecture and the MITA 3.0 Business Architecture framework
  • New Framework MITA 3.0:
  • Addresses the new legislative requirements outlined in the Health Information Technology for Economic and Clinical Health Act, the Children’s Health Insurance Program Reauthorization Act, and the Patient Protection and Affordable Care Act
  • Reflects the use of newer technologies such as Service-oriented architecture (SOA)

Response Instructions (High Level)

  • Detailed response instructions are provided in Section IV of the RFP.
  • Responses must be received by the Department in Albany, New York no later than the time and date specified in the RFP.
  • Separate electronic files should be produced for each proposal section as outlined in this RFP and clearly identified through the file name for the section the file represents.
  • The Department discourages overly lengthy proposals.
  • Hard and electronic copies should contain identical information. The hard copy is the copy of record.

Elaboration on Key Technical Requirements

Vendors are advised to submit proposals that are comprehensive and clearly reflect the technical proposal requirements. This includes, among other proposal requirements, contractor and staff background, understanding of the scope of the project, responsiveness to specifications, a robust SDLC that includes adequate project and schedule controls, adequacy of staffing levels, etc.


Pricing Schedule

Attachment H: Pricing Schedule Key Focus Areas

Project Planning/ DDI/ Certification (Schedule B)

  • Provides a summary total of all information entered on the sheets that follow
  • Reimbursable Postage and Potential Annual Satisfaction Incentive are provided as estimates for budgetary purposes and should not be altered by the bidder

Operations Base Fee (Schedule C)

  • Total Project Planning, DDI, and Certification price MUST be no more than 25% of the proposed Total Price on Tab A: Pricing Schedule.
  • Milestone based payment during this phase.

Operations Adjustment (Schedule D)

  • Operations price must specify a fixed monthly price to operate the solution for the first contract year and annual price for contract years 2, 3, 4 and 5
  • Transaction pricing is used to determine the payment due for allowed types of transactions on a per transaction fee basis if the number of transactions goes over the baseline range specified in the RFP
  • The baseline range is based on historical data and future projections

Systems and Operational Enhancement Payment Staff (Schedule E)

  • This phase commences with the start of the contract and includes both maintenance and enhancement tasks that must be performed throughout the life of the contract
  • Any and all system and operational enhancements that are applicable to multiple customers of the contractor will be executed at no additional cost to the State, but unique enhancements will be paid for on a monthly estimate based on a rate card

Transition (Schedule F)

  • Vendors should submit the fixed price for all activities required to support the transition tasks required by this RFP and as detailed in the Transition Plan approved by the Department

Evaluation Approach

Compliance Assessment

  • The Compliance Assessment will have a pass/fail screening that includes the following requirements:
  • All vendor proposal materials were submitted to the Procurement Officer on or before 4:00 PM ET 09/25/2013
  • Attachment E: Vendor Requirement Traceability Matrix and Attachment H: Pricing Schedules have been completed in the correct format using the spreadsheets provided in the MAS RFP

Vendor Technical Proposal (70%)

Vendor Price Proposal (30%)

The price proposal score will be normalized as follows:

C = (A ÷ B) * 30% where:

A is the total price of the lowest price proposal;

B is the total price of the price proposal being evaluated; and

C is the Price Score

The technical raw scores will be normalized as follows:

N = (A÷B) * 70% where:

A is the raw score of the proposal being evaluated;

B is the highest technical score; and

N is the Technical Score

The State will select a contractor using the Best Value award methodology. Best Value is defined in Article XI, Section 163 (1)(j) of the NYS Finance Law as the basis for awarding contracts for services to the vendor which optimizes quality, cost and efficiency, among responsive and responsible vendors.


Evaluation Approach

Minority and Women Owned Businesses

  • For purposes of this solicitation, the Department hereby establishes an overall goal of at least 10% for M/WBE participation.
    • 5% Minority-owned business
    • 5% Women-owned business
  • A contractor that does not propose at least 10% of total contract value expensed to NYS-certified M/WBE firms must document good faith efforts to provide meaningful participation by MWBEs in the performance of the contract.
  • Directory of certified businesses: