MetroPlus is a Medicaid health plan, not Medicaid itself

MetroPlus Health is a private insurance company that contracts with New York State to deliver Medicaid coverage. When you enroll in MetroPlus, you are receiving Medicaid benefits through their plan rather than through the state directly. MetroPlus manages your doctor visits, prescriptions, and hospital care on behalf of Medicaid.

The distinction matters because MetroPlus is the organization you contact for claims, referrals, and customer service — not the state. Your Medicaid coverage itself comes from New York, but MetroPlus is the intermediary that processes it. This arrangement is called a managed care plan, and New York uses several of them to administer Medicaid for different regions and populations.

MetroPlus operates primarily in New York City and surrounding counties. If you live outside their service area, you would be enrolled in a different Medicaid plan or receive Medicaid through fee-for-service, where the state pays providers directly without a middleman plan.

Key Takeaways

  • MetroPlus is a private company contracted by New York State to deliver Medicaid benefits, not a separate program you apply for.
  • You receive your Medicaid coverage through MetroPlus if you live in their service area and are assigned to them during enrollment.
  • MetroPlus handles your medical claims, provider network, and customer service calls, while New York State funds the actual benefits.
  • You do not pay MetroPlus directly; your Medicaid coverage is free, and MetroPlus is paid by the state to manage your care.
  • If you move out of MetroPlus's service area or want to switch plans, you can request a change during open enrollment or if you have a may have access to life event.

How you get enrolled in MetroPlus

You do not apply directly to MetroPlus. Instead, you apply for Medicaid through New York State's Department of Social Services or the state's online portal. Once you are approved for Medicaid, the state assigns you to a managed care plan based on where you live and what type of Medicaid you may have access to for.

If you live in MetroPlus's service area, you may be automatically assigned to them. You will receive a welcome packet in the mail with your member ID card, plan documents, and information about how to choose a primary care doctor. If you prefer a different plan, you have a window of time (usually 30 to 60 days after enrollment) to request a change.

Some people are exempt from managed care enrollment and receive Medicaid through fee-for-service instead. This includes people over 65, those on certain disability programs, and people in long-term care facilities. If you fall into one of these categories, you would not be enrolled in MetroPlus even if you live in their service area.

What MetroPlus covers and what you pay

MetroPlus covers the same benefits that all New York Medicaid plans cover: doctor visits, hospital stays, prescription drugs, mental health services, dental care, and vision care. The specific copays and coverage details are set by New York State, not by MetroPlus, so your out-of-pocket costs are the same whether you are in MetroPlus or another plan.

Most MetroPlus members pay nothing for preventive care, such as annual checkups and screenings. You may have small copays for other services — for example, $1 to $3 for a doctor visit or prescription — but these are capped by state law and do not apply if your income is very low. You will never receive a bill from MetroPlus for covered services; if a provider tries to bill you, contact MetroPlus customer service to dispute it.

MetroPlus also offers some benefits beyond the state minimum, such as fitness programs or transportation to medical appointments. These vary by plan and change year to year, so check your plan documents or call their member services line to see what is available to you.

How to contact MetroPlus and use your coverage

Your MetroPlus member ID card has a customer service phone number on the back. Call that number to ask questions about your coverage, find an in-network doctor, request a referral, or report a billing problem. MetroPlus customer service is available during business hours and often has language interpretation services.

You can also visit MetroPlus's website to search for doctors and hospitals in their network, view your claims history, and download plan documents. When you see a doctor, bring your member ID card and tell them you have MetroPlus Medicaid. If a provider is not in MetroPlus's network, you may still be covered for emergency care, but non-emergency out-of-network care may require a referral or may not be covered at all.

If you need to change your primary care doctor or request a specialist referral, contact MetroPlus directly. They process these requests and can usually complete them within a few business days. For urgent medical questions, MetroPlus also operates a nurse hotline that you can call 24/7.

What happens if you move or want to switch plans

If you move out of MetroPlus's service area, you will be automatically disenrolled and assigned to a different plan that serves your new location. MetroPlus will send you a notice before this happens, and your new plan will contact you with a welcome packet and member ID card.

If you want to switch to a different plan while still living in MetroPlus's service area, you can request a change during the annual open enrollment period, which typically runs from November through January. You can also request a plan change if you have a may have access to life event, such as losing other health insurance, moving, or having a baby. Contact the New York State Department of Social Services or call 211 to request a change outside of open enrollment.

Some people have the right to disenroll from managed care altogether and receive Medicaid through fee-for-service. This is usually only available to people with serious medical conditions who need access to out-of-network providers. Ask MetroPlus or the state whether you may have access to for this option.

Common confusion: MetroPlus versus Medicaid

MetroPlus is not a separate program from Medicaid. It is one way that New York delivers Medicaid. When people say "I have MetroPlus," they mean "I have Medicaid through the MetroPlus plan." The benefits, income limits, and rules are all set by New York State's Medicaid program; MetroPlus simply administers them.

This can be confusing because you will hear both names used interchangeably. Your Medicaid case worker at the Department of Social Services handles your may be able to access and income verification. MetroPlus handles your medical claims and provider network. Both organizations need to communicate with each other, but they have different jobs.

If you have questions about whether you may have access to for Medicaid, contact the Department of Social Services. If you have questions about your coverage, copays, or which doctors are in-network, contact MetroPlus. Knowing which organization to call saves you time.

Frequently Asked Questions

Do I have to pay MetroPlus a monthly premium?

No. Medicaid is free, and MetroPlus is paid by New York State to manage your coverage. You will never receive a bill from MetroPlus for a monthly premium. You may have small copays when you use services, but these are capped and do not apply to preventive care or if your income is very low.

Can I see any doctor I want with MetroPlus?

You can see any doctor in MetroPlus's network without a referral for most services. For specialist care, you usually need a referral from your primary care doctor. If you want to see an out-of-network doctor, contact MetroPlus first to ask whether they will cover it; emergency care is usually covered even out-of-network.

What if MetroPlus denies a claim or refuses to cover something?

You have the right to appeal any denial. MetroPlus must give you a written explanation of why they denied the claim and tell you how to file an appeal. You can also file a complaint with New York State's Department of Financial Services if you believe MetroPlus made an error or treated you unfairly.

Does MetroPlus cover prescription drugs?

Yes. MetroPlus covers all medications that New York Medicaid covers, which includes most prescription drugs. Some drugs may require prior approval from MetroPlus before the pharmacy will fill them. Ask your doctor or pharmacist, or call MetroPlus customer service, if you are unsure whether a specific drug is covered.

Can I switch from MetroPlus to a different Medicaid plan?

Yes, during the annual open enrollment period (usually November through January) or if you have a may have access to life event such as moving or losing other insurance. Contact the New York State Department of Social Services or call 211 to request a change. You can also ask MetroPlus directly, and they can help you understand your options.