Single Source Procurement: Ombudsman Services Expansion

Pursuant to New York State Finance Law § 163.10(b), The New York State Department of Health is presenting the following summary of relevant circumstances, and material and substantial reasons why a competitive procurement was not feasible.

The Ombudsman program was launched on October 1, 2014 to serve the following Medicaid populations: enrollees in managed long-term care programs (Partial, MAP, PACE, & FIDA) and individuals who are enrolled in mainstream Medicaid managed care plans but receive one or more long-term care services.

These programs serve vulnerable, mostly elderly individuals, with various complex medical, social, cognitive, and behavioral conditions. All of these individuals require long-term care services.

The program provides a full range of services, which are to help enrollees navigate program rules related to their health coverage, and understand and exercise their rights. The program provides one-on-one consumer assistance: 1) answers questions related to enrollee rights; Medicare, Medicaid, and long term care benefits; differences between various types of managed care plans; any issues relating to health insurance or services; 2) helps resolve issues relating to health insurance or services through mediation and informal negotiation with plans and/or providers; 3) provides advice and representation all the way through formal hearings and appeals; 4) offers informational training about various aspects of managed care programs and outreach to consumers, providers, and advocates.

As stated above, the program primarily benefits individuals in managed long term care plans. However, DOH will also benefit from utilizing data from the Ombudsman program to make improvements to managed care programs in addressing the needs of its participants. This is a standard practice: NYSDOH has historically used data from grant-recipient organizations to improve its services. Therefore, the purpose of the program is to assist NYSDOH in achieving its State and Federal goals relative to improving benefit coordination, quality of care, and patient outcomes over the full range of health care services for each of the populations served. The program is also required under the Special Terms and Conditions of the State's 1115 Waiver.

NYSDOH is adding two more enrollee populations to the program:

  • Individuals enrolled in the Fully Integrated Duals Advantage program for people with intellectual and developmental disabilities (FIDA IDD);
  • Individuals enrolled in the Health and Recovery Plan program (HARP).

NYSDOH will use the single source process because it best serves the interests of the State for the following reasons:

  • The current contractor, Community Service Society of New York, was competitively selected for provision of ombudsman services;
  • Another procurement would be not be a good use of state funds due to duplicative deliverables and infrastructure;
  • The existence of a separate contractor for provision of the services to the two populations would be inconsistent with the hub-and-spokes model used under the ombudsman contract;
  • The current contractor, Community Service Society of New York, and its subcontractors, 13 major community-based advocacy organizations already have the required infrastructure in place;
  • If the two populations had been included in the original procurement, it likely would have had the same result.
Procurement / Program Name Ombudsman Services Expansion
Contractor Name(s) Community Services Society of New York
Contract Period 4/1/2016 – 7/31/2019 (additional funds only)
Contract Number(s) C029863