About MetroPlusHealth

Since 1985, MetroPlus Health Plan (MetroPlusHealth) has served New Yorkers through offering affordable, quality health care. MetroPlusHealth is certified under Section 4403-a of New York Public Health Law. We are part of NYC Health + Hospitals (H+H), the largest municipal health system in the United States. MetroPlusHealth is the plan of choice for nearly 700,000 New Yorkers across the five boroughs of New York City.

MetroPlusHealth invests in care designed to keep our members healthy. We have a robust network of doctors and specialists including local providers and offices. This network includes telehealth for both physical and behavioral health. Together, we work to educate members about healthy living.

At the heart of the network is NYC H+H, with eleven acute care hospitals, five long-term care facilities, six diagnostic and care centers, and over fifty satellite clinics. The NYC H+H network serves all the communities of New York, particularly those who may face challenges in getting care due to language.

What is a Dual Special Needs Plan (D-SNP) Model of Care (MOC)?

The Model of Care (MOC) outlines how health care providers work together to support people who have both Medicare and Medicaid. Plans that ensure these individuals are called Dual Eligible Special Needs Plans. MetroPlus has two such plans: the Medicare Advantage Plan (HMO D-SNP) and MetroPlus UltraCare (HMO D-SNP).

The MOC explains:

• How our plan meets the complex health needs of D-SNP plan members
• How to make sure plan members get the right care when, how and where they need it
• How to make sure that the MOC will be followed

How does MetroPlusHealth meet our care goals?

We regularly review how well we meet our care goals by tracking key performance measures. This helps us identify improvements that make a difference for our members. We use dashboards to track goals and outcomes that can be measured. Internal teams review them every quarter. Areas needing more attention are discussed more often. We track all improvement efforts to make sure that we stay on target. This ongoing review helps ensure the MOC is effective, especially in areas that need the most improvement.

How did we do in 2024?

Overall plan performance measures
We use operation and process metrics to measure how well and how efficiently our organization is doing. We set high goals for three key areas to reach excellence and improve on last year’s performance. In 2023, MetroPlusHealth set a goal to achieve a 4 Star rating and set a goal of 97% of appeals where the Independent Review Entity upheld the plan’s decision.  For unplanned adult readmissions, and avoiding unplanned ER visits,  MetroPlusHealth set a goal to reduce the amount from the previous year and attain a 4 Star plan rating for the measure.

Goal: Raise the percent of appeals where the Independent Review Entity upheld the plan’s decision to 97%.
Result: 91% by the end of 2024, nearly reaching our goal.

Goal: Reduce unplanned adult hospital readmissions to 9%.
Result: 12% at the end of 2024, nearly reaching our goal.

Goal: 95% of MAP members avoided ER visits in the past 90 days.
Result: 91% at the end of 2024, nearly reaching our goal.

We believe the fact that we fell short of our goal reflects a variety of factors, including complex workflows and insufficient training; in 2025, we plan to address as many of them as possible. Through collaboration and using new data sources, we will improve the timeliness of receipt of admission and discharge notifications which will help us reach these members more quickly. We will also retrain our staff in best practices for assessing and addressing member needs after hospitalizations and start case conferences to improve oversight and focus on all opportunities for improvement.

Access to care
People with lower incomes have less access to medical care. This can lead to more illness, earlier death, and lower quality of life. We want to make sure all MetroPlus Advantage Plan (HMO D-SNP) and MetroPlus UltraCare (HMO D-SNP) members get the care they need to stay healthy. That may mean helping them set up regular primary care visits so they can get preventive services. It may also mean helping them with transportation to medical visits. We set high goals for these measures to reach excellence and improve on last year’s performance. In an effort to achieve at least a 4 Star Rating, MetroPlus set a goal of 77% of women ages 50-74 to get a mammogram, which exceeds the previous year’s rate of 78% and provides a 4 Star Rating for our plan.  For members ages 45-75 years old, the Plan set a goal to improve from the previous year’s rate of 69% percent to obtain a rate of screening in the 4 Star range.

Goal: 77% of women ages 50 to 74 get a mammogram (breast cancer screening).
Result: 79% at the end of 2024, surpassing our goal.

Goal: 79% of members ages 45 to 75 years get a colon cancer screening.
Result: 74% at the end of 2024, nearly reaching our goal.

Our Care Management and Quality Management teams worked together to address access to care, members’ Gaps in Care and made proactive outreaches to members who were due for a mammogram and/or colorectal cancer screening. Strategies include direct case management through telephonic outreach, reminders via IVR calls, education through web-based modalities and 2-way texting.  These efforts helped us surpass the mammogram goal and come close to the colorectal cancer screening goal. Members refusing these screenings and not wanting to go through the process contributed to the results.  In 2025, we will continue supporting members get preventive screenings so they can stay healthy and catch problems early. We will continue assisting members with scheduling necessary screenings and provide education regarding importance of getting the screenings and early detection.

Coordination of Care
D-SNP members have multiple complex medical problems. This can make helping them get the right care a challenge. We have created a unique scoring system to identify members who need the most help. We use this score to guide our outreach approach. Each D-SNP member gets a full Health Risk Assessment (HRA). The HRA looks at their medical, mental health, long-term care and social needs.  Then we assign a care manager who is qualified to review the results and the risk score. They may be a Registered Nurse or Licensed Master Social Worker. For MAP members, the care manager is always a Registered Nurse, and they use the New York Uniform Assessment System as the HRA.

Next, the Interdisciplinary Care Team (ICT) reviews each member’s Care Plan. They may add recommendations to the Care Plan.

Finally, we mail the Care Plan to the member and their provider.  The ICT and care managers watch for any future transitions of care. These are the critical times we work extra hard to make sure members get the right care.

We set high goals to align with our CMS-approved model of care.

Goal for MetroPlusHealth UltraCare (HMO D-SNP) members: 100% receive an HRA. Timeframe for new members: first 90 days of joining the plan. For existing members: within a year of the last HRA.
Result: 74% at the end of 2024; there is room for improvement.

Goal for MetroPlusHealth UltraCare (HMO D-SNP) members: 100% receive a UAS. Timeframe for new members: the first 90 days of joining the plan. Timeframe for existing members: within a year of the last UAS.
Result: 87% at end of 2024; there is room for improvement.

Goal for our MetroPlusHealth Medicare Advantage (HMO D-SNP) members: 100% receive a care plan within 30 days of an HRA (or review of claims/utilization data).
Result: 8% at the end of 2024, effectively achieving our goal.

Goal for new MetroPlusHealth UltraCare (HMO D-SNP) members: 100% receive an ICP within 15 days of joining the plan.
Result: 91% at the end of 2024, nearly reaching our goal.

Goal for existing MetroPlusHealth UltraCare (HMO D-SNP) members: 100% receive a care plan within 15 days of completing a UAS (or review of claims/utilization data).
Result: 92% at the end of 2024, nearly reaching our goal.

Goal for our MetroPlusHealth Medicare Advantage (HMO D-SNP) members: 100% of members and/or their caregivers receive a care plan.
Result: 100% at the end of 2024, meeting our goal.

Goal for our MetroPlusHealth Medicare Advantage (HMO D-SNP) members: 95% of high-risk members have a Care Manager within 6 months of joining plan.
Result: 100% of these members engaged, surpassing our goal.

Goal for our MetroPlusHealth UltraCare (HMO D-SNP) members: 95% of all members have a monthly call with their Care Manager.
Result: 89% at the end of 2024, nearly reaching our goal.

For 2024, being unable to reach members upon enrollment contributes to issues completing the HRA and/or the UAS. For 2025, our goal is to continue to increase the number of members who receive appropriate screening, assessment, care plan development and care coordination. We will expand text messaging by care managers or related staff to improve our ability to connect with members for HRA completion.  We will also continue with staff trainings, compliance monitoring and improved reporting and tracking to achieve the MOC compliance requirements with monthly calls and timely post UAS care plan development.

Care Transition
MetroPlusHealth has a focus on helping members move smoothly from one care setting to another (for example, from hospital to home). These are called transitions of care. Each member is assigned a Care Manager during their transition. When the Care Manager is notified that the member has been admitted to the hospital, they:

• Work with the hospital discharge staff, the member’s doctor, the member and/or their caregiver to plan next steps. (If needed, they will work with any in-home medical caregivers.)
• Work with the member to help them understand how to care for themself at home. (For example, members may need help determining how and when to take their medicines and when to call their doctor.)
• Help set up follow-up visits with primary care and specialists (if needed).
• Update the member’s care plan, when needed.

Goal for MetroPlusHealth 2024 care transition plan: 28% of adult patients get a medication review within 30 days of leaving the hospital to achieve a rating in the 4 Star range for the plan.

Result: 43% at the end of 2024, surpassing our goal.

For 2024, our success was related to our improved follow up process, scheduling timely follow up appointments for members post discharge. For 2025, our goal is to continue improving teamwork across departments and building stronger partnerships with our providers. We will also add case conferencing to improve results.

Appropriate Utilization of Services

Our Utilization Management (UM) department works with Care Management (CM) to help members get the care they need, where, when and how they need it. This includes helping members get covered services outside the network, if needed.UM reviews and approves care for the member. It may help guide members to more appropriate or cost-effective care, when possible. For example, instead of hospital care, skilled nursing facility care, at-home care or outpatient care can be safe and cost-effective choices.

UM reviews are done by UM RN Care Managers at MetroPlusHealth. Clinical guidelines determine when the UM Care Manager can approve a service. If needed, a Medical Director (a licensed physician) can make a final decision.  Any denial of care decision is made by a Medical Director. If a member makes an appeal, a different Medical Director will review it.

MetroPlusHealth 2024 Utilization Goals:

Goal: 93% of adult members take their diabetes medicines according to their doctors’ orders to achieve a 5-Star Rating.

Result: 89% at year’s end, nearly reaching our goal.

Goal: 79% of members reporting that they received their annual flu shot (member survey) to achieve a 5-Star Rating.

Result: 66% (early result); there is room for improvement.

In 2024, our results can be attributed to staff training and member education on importance of medication adherence and vaccinations. We used a variety of techniques such as text messaging, automated calls and direct member calls to educate and assist members to obtain vaccinations.  Barriers to achieving the goals include missing data   for members who received the flu shot that do not come through traditional claims. In 2025, we plan to help teams work better together across departments to get stronger results. We’ll also start holding regular case conferences to help improve how we work and support our goals.

Summary: In 2024, MetroPlusHealth successfully launched our D-SNP Model of Care (MOC), making progress toward our goals. While we came close to meeting most goals, we remain committed to tracking performance closely and driving continued improvement throughout 2025.

Note: This report fulfills CMS requirements for annual evaluation of our Model of Care performance.

Data sources, methods: Data sources used for this analysis include pharmacy and medical claims, data from assessments, and survey data. Encounter data and medical record reviews are also incorporated. Analysis is conducted by MetroPlusHealth staff and also by a contracted vendor that supports quality measurement against standard national metrics. Findings are shared with internal Quality Management Committee and the external Quality Assurance and Performance Improvement Committee.