Quality Management Program

MetroPlusHealths’ mission is to provide every New Yorker equitable access to quality health care. Our purpose goes beyond offering insurance. We take on the City’s most complex health challenges. Our work connects us to what every New Yorker needs. Our vision is to be the number one plan of choice for the communities we serve.

MetroPlusHealths’ Values:

• Real: Transparency and trust go hand in hand. MetroPlus focuses on the needs of our members first. Clear, comprehensive care is our top priority.
• Welcoming: MetroPlus treats every person with dignity. Race, religion, and cultural backgrounds should not impact someone’s health outcomes. Neither should gender expression, sexuality, citizenship, or economic standing.
• Diverse: MetroPlus embraces the differences and common values of all New Yorkers. Our doctors, health plans, community partnerships, and staff all reflect the City we serve.
• Focused: MetroPlus anticipates what tomorrow will bring. MetroPlus uses the latest research to design our plans and programs.
• Loyal: Good health is a journey, not a destination. MetroPlusHealth sticks with our members through it all. Our practical, research-based tools and programs bring out the best in everyone.

The goals and objectives of the Quality Management Program Description (QMP) are to support MetroPlusHealth in realizing its mission.  The QMP provides a framework and processes that will facilitate the continuous improvement in medical (including pharmacy and dental) and behavioral health care and service provided to MetroPlus Health Plan’s complex, culturally and linguistically diverse membership.

The scope and content of the QMP is designed to continuously monitor, evaluate, and improve the clinical care and service provided to members and their service delivery systems.  MetroPlus Health Plan’s QMP involves all levels of staff as well as provider and member representatives.   Specifically, the QMP includes, but is not limited to the following responsibilities and monitoring of key performance measures:

• Health Promotion Activities
• Continuity and Coordination of Care
• Chronic Care Improvement Program (CCIP) for Medicare, MAP and SNP Members
• Quality Improvement Projects and Studies for Medicaid/CHP, HIV SNP, MLTC, MAP Essential Plan, QHP, and HARP members
• Care Management
• Pharmacy Management
• Behavioral Health
• Partnership in Care
• Quality of Care
• Quality of Service
• Patient Safety
• Utilization Management
• Member and Provider Satisfaction
• Provider Availability and Accessibility
• Delegation
• Member Complaints, Grievances, and Appeals
• Human Resources

Member Resource Support Tools:

The Plan’s website, Metroplus.org contains an array of support tools to assist members with understanding and managing their benefits and health care needs. The website is available in several languages, including, but not limited to, English, Spanish, Chinese, Hmong, Japanese, Korean, Punjabi, Russian, Tagalog, and Vietnamese. Tools include but are not limited to the following:

• On-line comprehensive Provider Search Directory. Includes search capabilities to find a PCP, Specialist, Pharmacy, Dentist, Hospital, and a robust list of other Health Care Providers.  Searchable criteria include gender, location, zip code, languages, etc.
• Link to MetroPlusHealth Member Rewards program where members in designated lines of business can earn incentives for making healthy choices.
• Link to the New York State Smokers Quitline and free downloadable material to support smoking cessation.
• Links to Health-Related Events hosted by our business and community partners. Events include wellness and chronic disease seminars, health fairs, holiday, and community events.
• Link to important COVID-19 updates, information, and testing sites
• Resources for members living with HIV/AIDS including general information, HIV counseling and testing and HIV Clinical Trials.
• Information about the Health Home Program.
• LGBTQ Resource Guide that compiles resources that are specifically committed to assisting the LGBTQ community. Included is information on assistance with primary care services, health, and legal support as well as information on marriage, family planning and where to find substance abuse help and more.
• Links to social services programs addressing the social determinants of health for seniors, people with disabilities and/or low income. Links to Medicare Savings Programs, Elderly Pharmaceutical Insurance Coverage (EPIC), SSI, Food Stamps, Reduced MTA fares, Senior Centers, America the Beautiful are some examples of resources provided.
• A comprehensive health library, featuring health information on extensive topics, healthy recipes, educational videos, and much more.
  • Ordering a new ID card
  • Changing a PCP
  • Reviewing claim history
  • Viewing benefit summaries

Cultural Diversity:

• The Plan endeavors to provide clinical and non-clinical services in a culturally competent manner to accommodate members who have limited English proficiency in speaking and/or understanding languages other than or in addition to English, diverse cultural and ethnic background, race, gender, or health literacy.
• Bronx Community Office: MetroPlus held a series of Holiday and Community Events, such as Easter, Mother’s Day and Father’s Day, Summer Jam Ticket Raid, Community Blitzes, Thanksgiving Holiday Celebrations, etc. in the Bronx Community Office on Southern Blvd. We also joined organizations such as the Bronx Borough President’s Office to launch the “MetroPlusHealth Back to School” events to distribute backpacks and essential school supplies. In 2022, we enhanced our direct relationships within the Muslim/ African Communities nearby the office. We partnered with Muslim organizations who are dedicated to serving the newly arriving immigrants approaching the mosques, and other African establishments such as, Union Fouta, Aljaned & Futa Islamic Centers, GadInterprises, Ramatoulaye Sow Immigration Services and Ivore Car Services.
• Brooklyn Community Office: The Church Ave. Community Office in Brooklyn hosted a series of “Books For Tots” events with Councilwoman Rita Joseph. In addition, we partnered with “Public Health Solutions” (Navigator CBO) in the Brooklyn, Queens, and Staten Island Community Offices to provide SNAP (Food Stamps) benefits. We partnered with the “Pakistani American Youth Organization (PAYO) & Councilwomen Rita Joseph” to provide food to undeserved communities (Pop Up Food Pantries) at the Brooklyn Community Office. We held several “Back to School” events distributing bookbags, notebooks and pencil kits to kids in need. On September 7th, we held a “Child/Adolescent Dental Screening” event with HealthPlex at the Brooklyn Community Office. We held a number of “Caribbean Flag Celebrations” for Haiti, Guyana, Trinidad, and Jamaica.
• We also participated in “Life is Sweet Friday’s,” Child Health Plus Initiative providing ice treats to communities on Summer Fridays and Pop-up Food Pantry in partnership with Community Conversation Collaboration. We worked directly with FQHC Morris Heights Health Center with on-site marketing days at BCO to assist with clinic outreach to communities.
• Manhattan Community Office: In 2022 we opened a brand-new Manhattan Community Office located on Adam Clayton Powell Jr. Blvd. at 125th Street in the heart of Harlem. We partnered with Borinquen Health Clinic every other Friday to offer screenings for Diabetes, High Blood Pressure, and COVID testing. We hosted two Thanksgiving events providing MetroPlusHealth grocery bags in partnership with Borinquen Health & Harlem Hospital. Additionally, we partnered with Harlem Hospital Public Affairs & our Partnership in Care Department to offer screenings for genetic testing & HIV testing.
• Queens Community Office: MetroPlus conducted a series of events at both the Flushing and Jackson Heights Community Office to raise awareness of the services offered. We partnered with ACS, WIC, CommonPoint to coordinate joint quarterly Baby Showers. These baby showers offered mothers pertinent information regarding their journey before delivery and post-delivery. The goal of these events was to improve the overall infant mortality rate in Queens. We conducted holiday events such as Lunar New Year Celebrations, Easter, Mother’s Day, Father’s Day, and Thanksgiving Grocery giveaways. We conducted back to school events in partnership with the local BIDS (Flushing, Corona/82nd Street). We partnered with HungerFree NYC each week at both Community Offices to provide food snap services to consumers and with the Mayor’s Public Engagement Unit, GetCovered  to help with health insurance.
• Staten Island Community Office: At the Port Richmond Ave. Community Office we are partnering with Public Health Solutions to provide SNAP benefits enrollment and renewals in our office every Tuesday and Wednesday. We did two pop-up IDNYC events with MOIA in the summer, and another event in December to provide on the spot ID cards. We hosted a number of “Back to School” events distributing school supplies. With Health and Hospitals support we were able to have a year-long distribution of PPE to our community. Book distribution for Kids (Spanish and English) partnering with Literacy Inc. In collaboration with Staten Island Community Partnerships (SICP), we are providing 130 jackets, from toddler to adult sizes to the community.
• The Plan provides training for clinical and non-clinical staff in cultural competency, disparities in healthcare, health literacy and other relevant topics.
• MetroPlus Health Plan is in full compliance with the requirements under 45 CFR 92 that implements Section 1557 of the Affordable Care Act. Appropriate Plan publications and communications include a non-discrimination statement and taglines that are published in 15 languages other than English.

The MetroPlus Health Plan Sales Department focused on maintaining a diverse network and resource environment through the community offices.

• Bronx Community Office

• Fordham Community Office : In 2024, MetroPlus Health Plan opened the new Fordham Community Office to increase the services offered to the community. The Grand Opening on July 31, 2024, was attended by several business partners and community leaders. MetroPlus Health Plan organized and promoted the Back to School at Fordham event to the senator’s office, local pediatric center, urgent care and most importantly, to school parents and students. 300 bookbags with school supplies were given away. Senator Gustavo Rivera was present during the event, which was broadcasted in media.

Health Conversations with BBP series events, centered on women’s health, were held at the community office in collaboration with Bronx Borough Vanessa L. Gibson, H+H Jacobi and H+H North Central Bronx. A Halloween event, “Fright Fest on Fordham” where over 200 Halloween bags and giveaways were distributed, was held on October 30, 2024 to create awareness of the new location and to increase engagement with the community. To ensure that every household was able to celebrate Thanksgiving, MetroPlus Health Plan partnered with LivON, Mekong and the Mayor’s Office of Immigrant Affairs (MOIA) for the Turkey Giveaway with LivOn event hosted at the community office, where turkeys and cooked rotisserie chickens were given away to the community and people in need. An annual toy drive was held on December 20, 2024 to celebrate the holiday season, complete with an encounter with Santa, and distribution of toys, hats, scarves, and gloves.

In addition to the events, the Fordham Community Office accommodates various agencies and organizations to meet the needs within the area. Workforce 1 sets up a table weekly to address employment-related queries and a representative from the Mayor’s Office assists with ID NYC program on Mondays. The Kid’s Day Fridays was implemented in September where popcorn and giveaways were provided to children and their parents. A representative from the Moshulu Montefiore Community Center (MMCC) visits the Fordham Community Office twice a month to educate and assist the community with food stamp applications.

• Southern Boulevard Community Office: The Sales Department created a series of events to continue nurturing relationships with the Southern Boulevard Community Office area by supporting community partners through Health and Wellness events, residential and educational presentations and Immigration and Community Resource Fairs. Some of the events include Community Outreach Blitzes to small businesses, Mother’s Day and Father’s Day events, Blood Pressure and Wellness Day in June in cooperation with Alegria Health and Wellness, and Southern Boulevard Blitzes with radio activation in October 2024. The Sales Department joined the community festivities during the Halloween on the Boulevard Parade. Annual Turkey Giveaway and Annual Toy Drive events were held at the Southern Boulevard Community Office to celebrate the holiday season.

MetroPlus Health Plan established relationships with community partners to broaden the services to clients and members. MetroPlus Health Plan attended the Annual Membership Meeting of the Southern Boulevard Business Improvement District (SoBo BID) and participated in its first annual LGBTQ – Bronx BID Pop-up event. External partners such as Verizon, Housing Works and MOIA had on-site presence to provide assist clients and members who walk into the community office. The Sales Department connected with community-based organizations (CBOs), faith-based organization and local businesses who were committed to serving low-income families and immigrants and nearby shelters, recreational centers, churches/mosques, and cultural establishments such as:

• Aljaned Islamic Center
• Ivore Limo Car Services
• Longwood Farmers Market
• Petel Yengue African
• Senegalese Association
• Union Fouta Organization
• Workforce 1
• Way to Lead

Brooklyn Community Office: The Brooklyn Community Office celebrated its tenth year of service to the community on November 11, 2024. The event was attended by Assembly Member, Monique Chandler-Waterman, City Council Member Rita Joseph, and City Council Member Farah N. Louis. Key community partners were recognized during the event, as the community office continued to be a hub for services needed by the constituents. Events organized at the Brooklyn Community Office include the Coat Giveaway and Pop-up Pantry in cooperation with the Council Member Rita Joseph, Back to School Backpack Giveaway on August 30, 2024, the Apostle Chloe Turkey Giveaway on November 11, 2024 and the Toy Giveaway event on December 20, 2024.

The Brooklyn Community Office worked closely with community-based organizations and agencies for on-site assistance such as Grow Brooklyn for free tax preparation, SNAP for food stamp application assistance, the Haitian-American Community Coalition (HCC) and the Mayor’s Office for Immigrant Affairs (MOIA) for various community services.  The Manhattan School of Technology held ESL classes and offered opportunities for qualified individuals to get into the medical field career path while True Care offer school and job opportunities to clients who come into the community office.

• Manhattan Community Office: Metroplus Health Plan’s business partners in Manhattan hold on-site outreaches at the Manhattan Community Office. The presence of Assurance Cell Phone and Heart to Heart Home Care Agency drew the public into the community office and those in need of health insurance coverage were assisted by MetroPlus Health Plan Sales Representatives. ID NYC and SNAP representatives set up tables and addressed inquiries of those in need of help with processing of their ID and food stamp requests. Boriken Medical Center has set up a tent to increase awareness and membership in collaboration with the Sales Team. The Harlem Hospital Public Affairs in collaboration with All of Us conducts DNA and genetic screenings at the Manhattan Community Office. The Harlem BID sets up at the community office to promote local businesses in Harlem.

Some of the events and initiatives conducted at the Manhattan Community Office include Back-to-School Bookbag Drive, Easter Event, Halloween Event, 4 radio activations with WBLS and iHeart Radio, ticket raids and 4 Boriken Resource Events. The Sales Team participated in the Harlem BID Parade and holds bi-weekly telethons to assist members who need to recertify. Pop-up events were held to distribute marketing materials and giveaways.

• Queens Community Offices: MetroPlus Health Plan conducted a series of activities at both the Jackson Heights and Flushing locations. There were Dental Clinic Series Workshops wherein MetroPlus Health Plan partnered with DentaQuest to conduct. A dentist/hygienist attended the events and provided dental screening with note cards for those needing a follow-up. There workshops were promoted to schools, businesses, and elected officials.

A calendar was created for the Vax Pop-up Event Series in cooperation with Plaza Del Sol (Urban Health) at the Jackson Heights Community Office, wherein flu and COVID vaccines were administered. The initiative was promoted through local businesses, partners, social media, and flyers. During these pop-up events, MetroPlus Health Plan invited community partners such as CommonPoint, Make the Road, Voces Latinas, Latina’s Share and Hunger Free, NYC where consumers can avail of different services.

Quarterly Baby Showers in collaboration with Hunger Free NYC, Get Covered NYC, ACS, WIC and CommonPoint, offered mothers pertinent information regarding their journey before and post-delivery to improve the overall mortality rate in Queens.

Back-to-School events were conducted with local BIDs, local elected officials, and partners at the Department of Education. Job Fairs were held at the two community offices, joined by various vendors such as Urban Compound, Charles B. Wang Health Center, Tribeca Pediatrics, T-Mobile Main Street, New York Life Insurance, AAFE, Cricket Wireless, CommonPoint. The job fairs brought in an average of 50 candidates throughout the day.

Holiday Events hosted at the Queens Community Offices include Ramadan/Eid Celebration, Lunar New Year Celebrations, Easter, Mother’s Day, Father’s Day, Diwali Thanksgiving Turkey giveaways and Toy Drives.

MetroPlusHealth aims to have a holistic approach when offering services to the community by providing the community a ‘One-Stop Shop Experience’ at the Queens community offices. Both of offer the following services to the community:

• GetCovered NYC, directs individuals to apply for health insurance and those not eligible for health insurance to NYC Cares. They conduct phone bound outreach to their resource listings.
• Urban Upbound: Free Tax services available to the community
• HungerFreeNYC: Provides WIC and SNAP services to individuals who qualify
• Gotham Health- Appointment Scheduling support
• ACQC Wellbeing Workshops: ACQC is a vital partner in supporting the LGBTQ+ community and advancing health initiatives and has been instrumental in providing workshops at the Queens community office and collaborating with events to deliver vaccines and HIV/STD testing. This partnership aligns with our shared mission of supporting community health and expanding access to health insurance. The workshops conducted weekly at the community office are as follows:
  • Sexual Health & the Elderly Part 1
  • LGBTQ+ Pronouns
  • Stigma Part 1 & Part 2
  • Cultural Competency Part 1 & Part 2

• Staten Island Community Office: The St. George Public Library conducted ESL classes in August 2024 and deploys a portable minivan every Friday in front of the Staten Island Community Office.

ID NYC and MOIA performed electronic application and appointment booking every Thursday, however, these were suspended due to staffing changes. SNAP benefits enrollments are offered every Tuesday and Thursday from 9:30AM to 4:30PM.

Two in-service sessions on MetroPlus Health Plan’s products and services were offered to Community Health Center of Richmond and La Colmena.

MetroPlus Health Plan partnered with Staten Island community partners and local businesses during the Block Party on Richmond Avenue held outside the community office.

• The Plan provides training for clinical and non-clinical staff in cultural competency, disparities in healthcare, health literacy and other relevant topics.

• MetroPlus Health Plan is in full compliance with the requirements under 45 CFR 92 that implements Section 1557 of the Affordable Care Act. Appropriate Plan publications and communications include a non-discrimination statement and taglines that are published in 15 languages other than English.

MetroPlusHealth’s Quality Management Department strives to offer important information and support to our members. We are extremely proud to continue to be a Plan that receives high “quality measure” scores from the Center for Medicare and Medicaid Services (CMS) and New York State Department of Health for our work in helping our members get the preventive and chronic care needed to stay healthy.

The Plan’s consistently high quality results reflect the investment MetroPlusHealth makes in keeping its members healthy. The MetroPlusHealth staff works closely with members and providers throughout the year to ensure that members get the care they need.  This includes reminder notices and arranging for doctors’ appointments and helping members adhere to their medication schedules to improve their health.

Listed below are some of the initiatives that were conducted in 2024 and that will continue in 2025:

• MetroPlusHealth Member Website: MetroPlusHealth continuously updates the member website where you can find important information and resources. Go to https://www.metroplus.org/Member

• Flu Vaccination: Ever since the COVID-19 pandemic, getting the influenza vaccination is even more important to protect oneself and loved ones. Preventing influenza helps decrease the number of people who may get sick and need to be hospitalized which will lower the burden on healthcare providers and the public health system.  MetroPlusHealth continues to communicate to both members and providers through texting, mailings, website postings, and newsletters to get the message out about how important the flu shot is, especially in the cooler months of the year and how safe it is to get a flu vaccine and a COVID-19 vaccine at the same visit. MetroPlusHealth members can get the flu shot for free at CVS stores, any in-network pharmacy, CityMD Urgent Care, or doctor’s office. Members are also informed that they can receive Member Rewards for receiving a flu shot.

• Coronavirus (COVID 19): We know that our members have questions about this virus, and we continuously update our website to reflect updates and changes in knowledge. Information is provided at https://www.metroplus.org/member/health-information/coronavirus

• MetroPlusHealth Virtual Visit: MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. This service is provided by NYC Health + Hospitals / ExpressCare and is available as part of your MetroPlusHealth coverage, at no cost to you! MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 – and in your language.  You can connect with a board-certified or licensed provider, including Emergency medicine trained medical doctors and psychiatrists, social workers, and addiction counselors. MetroPlusHealth Virtual Visit provides interpretation in oner 200 languages. No appointments needed.

Our providers can access your health history, order lab testing, write prescriptions, and coordinate your follow-up with primary and specialty care and other services that you may need.  And care does not end with your visit.  MetroPlusHealth Virtual Visit, powered by ExpressCare, will work with your doctor for any follow-up care you may need. If you do not have a doctor, we will help you find one who is right for you.

Click here to talk to a doctor now NYC Health + Hospitals (expresscare.video) or, you can call us 24/7 ar1-855-287-3508 to access Virtual Visit

• MetroPlusHealth Member Rewards Program: The new MetroPlus Member Rewards program launched in March 2024. MetroPlusHealth Member Rewards is designed to reward our members for taking steps to stay healthy and rewards them how they like, with the flexibility of a Rewards Card.

To get your card, members need to register for the program by calling 800-510-3944 or going to metroplusrewards.org.

Since the program inception over 65,000 members have registered for the Member Rewards Program. Members can earn rewards for preventive screenings such as annual flu shot, mammography, cervical and colon cancer screening, medication refills, child and adolescent check-ups, diabetes eye exam, postpartum visits and much more.

• MetroPlusHealth Member Texting Program. Campaigns include but are not limited to encouraging Future Appointment Reminders, Post-Emergency Department/Inpatient Stay, Medication Adherence, Children &Adolescent Well Visits,  Childhood Immunization reminders, Annual Dental Visit, Asthma Care, Breast Cancer Screening, Cervical Cancer Screening, Colorectal Cancer Screening, Flu Vaccine Reminders, Access to Virtual Visits, Medication Refill Reminders, Prenatal and Postpartum Care, and Diabetes Care. Many texting programs are interactive allowing MetroPlusHealth another way to communicate with our members! The following actions took place in 2024:
• Over 3,406,863 outbound text messages were delivered
• Over 276,935 IVR calls were made
• 25 new campaigns were launched
• Health Education: MetroPlusHealth works closely with our members and providers to ensure appropriate, high-quality care is provided. We educate providers and members on different aspects of health and wellness (clinical guidelines, prevention and screenings, chronic care management, quality measures, etc.) through a wide array of media (direct mailings, website, provider & member portals, social media, texting, public health advertisements, posters, webinars, community events, site visits, telephonic and face-to-face encounters, etc.).
• Health Navigator Program: The primary function of the Quality Management (QM) Health Navigator is to outreach members missing important health screenings, to assist in coordinating needed appointments for a variety of clinical and social services and ensuring maintenance medications are filled regularly. The QM Health Navigator serves as a source of empowerment for MetroPlusHealth members, educating members on the importance of, and motivating them to complete, needed services and providing support as the member navigates the health care system. In 2024, the Health Navigators have completed over 38,000 outreach calls and have assisted with scheduling over 400 appointments.
• Pharmacy:
• MetroPlus members can go to any network pharmacy to fill prescriptions, which includes many large pharmacy chains such as CVS Pharmacy and Rite Aid. MetroPlusHealth partners with various pharmacies that offer programs such as pre-packaged multiple medications that are sent directly to our member’s home for no additional cost.
• MetroPlus members can also fill a 90-day supply of most maintenance medications at any in-network pharmacy, including mail-order pharmacies. These are medications members take regularly for an extended period to stay healthy. There are many benefits to filling a medication prescription for 90-days at a time. Members who have a 90-day supply of medication tend to not run out of medication or experience delays in trying to refill.  That means members take their medication more and maintain their health!  Members can also get medications mailed right to their home if their pharmacy offers delivery service or through our mail-order pharmacy partner, CVS Caremark. Setting up home delivery service is easy.  For assistance members can contact MetroPlus Health Plan Customer Service.
• We have partnered with CVS Pharmacies to offer same-day or next-day delivery for medications. Members can contact their local CVS retail pharmacy to find out more information on how to access this benefit.
• For more information about pharmacy benefits visit https://www.metroplus.org/member/pharmacy
• Virtual Visit: Access to a doctor—whenever and wherever you need it!

MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. This service is provided by NYC Health + Hospitals / ExpressCare and is available as part of your MetroPlusHealth coverage, at no cost to you!

MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 – and in your language.  You can connect with a board-certified or licensed provider, including Emergency medicine trained medical doctors and psychiatrists, social workers, and addiction counselors. MetroPlusHealth Virtual Visit provides interpretation in over 200 languages. No appointments needed!

Our providers can access your health history, order lab testing, write prescriptions, and coordinate your follow-up with primary and specialty care and other services that you may need.  And care does not end with your visit.  MetroPlusHealth Virtual Visit, powered by ExpressCare, will work with your doctor for any follow-up care you may need. If you do not have a doctor, we will help you find one who is right for you.

It is easy to get started with the MetroPlusHealth Virtual Visit app. Visit https://metroplusvirtualvisit.com/landing.htm or, you can call us 24/7 at 1-855-287-3508 to access Virtual Visit.

• New York State Smokers Quitline (NYSSQL): The NYSSQL is a service of the New York State Department of Health Tobacco Control Program which is a free and confidential program providing services to New York State residents who want to stop vaping, smoking or using other forms of tobacco.  The NYSSQL provides the following services:
• Talk to a Quit Coach. Chat, text, or call a coach.
• Free patches and more. Enroll online or by phone.
• Texting program. Build the skills needed to quit any tobacco product.
• Savings calculator. Help you find out how much money you can save by quitting.
• Addiction quiz. Teach about levels of nicotine addiction and steps to take.
• Information to quit. Extensive information to quit at any stage of the journey
• Social media. Get the latest and talk with a Coach.
• Local programs. Online, local, and in-person group support in your area.
• Printed materials. Brochures, cards, posters, handouts, reports, and more.
• Family and Friends. How to support someone looking to quit.
• To learn more about the NYS Quitline visit https://www.nysmokefree.com/
• To find local resources visit https://www.nysmokefree.com/ToolsAndResources/LocalResources
• NYC Health + Hospitals Smoking Cessation Program: This program provides comprehensive and affordable treatment choices for New Yorkers who use tobacco or vaping products and works with smokers who are willing to quit to find effective, individualized treatment, including nicotine replacement therapy (NRT), counseling services, and other available resources. To find a smoking cessation program visit: https://www1.nyc.gov/assets/doh/downloads/pdf/csi/cessation-guide.pdf or Smoking Cessation Resources – MetroPlusHealth
• The Integrated Care Management (ICM) Program: The Integrated Care Management (ICM) program, is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the services and options available to meet the health and human service needs of members with complex care needs and are at increased risk for hospital admissions and emergency room visits. The ICM program serves eligible members in the 5 boroughs of New York City. Care Managers complete a comprehensive assessment, identify/prioritize goals, coordinate based on member need and available resources and work with the primary care provider, specialist, and other members of the health care team to develop and implement a plan of care.
• ICM Program Goal: The goal of ICM is to provide high quality, integrated, culturally competent care management services to members assessed as having complex medical and social determinants of health care management needs. Care Managers will provide services that meet the unique racial, ethnic and language needs of our members. Care Managers will assist members in provider selection or will match members with specific health professionals who can best meet their linguistic and cultural needs thus enhance the quality of care and improve member outcomes.

ICM Program Overview: Our ICM program has two components: Comprehensive Care Management for members who have high complex care needs and Transitions of Care (TOC) for members who move from one setting of care to another.

• Comprehensive Care Management: Comprehensive Care Management is provided to members having ongoing complex needs. Members will be screened in order to determine the type of services needed.

• Transition of Care (TOC) Program: This program provides coordination and continuity of care for members transitioning from an inpatient facility setting to home. A Care Manager will support the member through the transition process by providing coordination of care including teaching self-management skills, medication reconciliation and medication adherence, and facilitating follow up appointments. The TOC process is focused on improving quality of care and preventing avoidable admissions, readmissions, and Emergency Department (ED) visits. Members receive transitional care management for up to 30 days post hospitalization. Members who continue to have needs after the transitional period receive comprehensive care management.
• Medicaid High Risk Care Coordination: The High-Risk Medicaid Team provides care management to members enrolled into MetroPlusHealth Medicaid Managed plan who have complex care needs. These members are holistically care managed by a team that includes Care Managers and Health and Wellness Advisors. This team collaborates with members’ providers, internal providers, and other departments to meet the needs of the member. The team works to address member’s gaps in care and connects members to community resources and healthcare providers. Care Managers address the needs of members and develop individualized goals and interventions to improve quality outcomes. Care managers outreach members to prevent potential readmissions, reduce avoidable hospitalizations, and ensure members remain safe in the community.  Members are typically engaged in Care Management for up to four months based on the member’s individual needs and progress.

• Medicare Care Coordination: Every Medicare member is assigned a care manager who is either an RN or licensed social worker and receives a comprehensive Health Risk Assessment (HRA) of their medical, behavioral health, long-term services and supports (LTSS), and social needs. In addition to the annual HRA, the care managers outreach and engage members throughout the year.  Members are encouraged to actively participate in the development of the plan of care. The HRA includes such items as:
• Language Preference
• Clinical History
• Health Status
• Pain Assessment
• Functional Status
• Depression Screening
• Fall Risk Medication Listing
• Social Determinants of Health (i.e., housing, food insecurity)
• Support Services (i.e., food stamps, meals on wheels, public assistance, etc.)

• Long Term Services and Supports (LTSS) Care Management: MetroPlusHealth identifies members receiving LTSS and enrolls them in care Members are assigned a care manager who is either an RN or Licensed Social Worker who completes a comprehensive assessment of their medical, behavioral health, and social needs. LTSS members are managed by a team of Care Managers, LTSS Coordinators and a Care Management Associate (CMA) who assists the team with DME (Durable Medical Equipment) supplies, arranging appointments, transportation, and completes calls to provider offices for required prescriptions. LTSS team ensures services are in place and that there is a back-up plan so that the members can remain safely in the community.

The Person-Centered Service Plan (PCSP) is a plan of care used to assist the member to achieve optimal health through monitoring specific evidence-based clinical indicators

such as gaps in care, coordinating outpatient and inpatient services, supporting the member’s self-management skills, directing the member to the most appropriate care setting, minimizing barriers to accessing care and assessing outcomes on a regular basis.

• High-Risk OB Care Management: MetroPlus Health’ High Risk OB Program focuses on attaining positive health outcomes for both mother and newborn. The Care Management Program partners with Obstetrical providers to promote early entry into prenatal care for members identified with a High-Risk diagnosis. An RN Care Manager (CM) ensures that the pregnant member’s needs are met through a complete initial assessment, planning, implementation, and evaluation once they have been stratified a High-Risk pregnancy.  Education is provided to the member to increase understanding about pregnancy risks and necessary interventions allowing the member to develop a realistic pregnancy and delivery plan.
• Social Determinants of Health: MetroPlus addresses the importance of identifying ways to create social and physical environments that promote good health for our members. The Plan has taken steps to address food insecurity, transportation needs, and housing insecurity in conjunction with the medical management services offered through the Plan. As Case Management staff encounter members with social needs, they make referrals to community- based organizations (CBOs) and social service agencies to assist members. In addition, MetroPlus has partnered with CBOs to provide individualized assistance, including home delivered medically tailored meals, and supportive housing opportunities. Metro-Plus implemented FindHelp, an electronic community-based resource platform which provides up to date information regarding community resources at a zip code level.
• Medically Tailored Meals (MTM): MetroPlus Health will continue to provide home-delivered meals to members with chronic illnesses and food insecurity. This meal service is made available to members who could use temporary supplemental nutrition, particularly those who have been recently discharged from acute care settings (Discharge Meals benefit) and for whom nutrition is paramount to achieving optimal health care, including wound healing, malnutrition, and the need for improved diabetes control.  While the members are receiving home delivered meals, Case Managers facilitate member referrals to CBOs to determine eligibility and potential enrollment into Women, Infants, Children (WIC) and/or Supplemental Nutrition Assistance Program (SNAP) benefits.
• In Lieu of Services Medically Tailored Meals (ILS- MTM): MetroPlusHealth will continue to participate in the NYS Department of Health ILS MTM program which offers two meals a day for a six-month period renewable every six months. Members must have high Emergency Department or In-patient utilization with a diagnosis of cancer, diabetes, heart failure or HIV/AIDS. Also, members who receive personal care hours can exchange their meal prep/shopping time for meals.

• Value Based Payment (VBP) –Level 2: Under the VBP program, MetroPlusHealth offers 30 days of two MTM per day to eligible members with chronic diseases and food insecurity. Members can renew enrollment for an additional 60 days, for a total of 90 days of MTM home delivery.

• Discharge Meals for Medicare Members: Medicare members who are recently discharged from an acute care setting are eligible to receive two meals a day for 10 days.

• Patient Safety: MetroPlusHealth addresses patient safety through a variety of mechanisms and participates in improving safety by working within the local and regional health care community. Safety is promoted by the following activities, including but not limited to:

• Educating members and physicians about medical safety issues.
• Making performance data available publicly for members, providers, and consumers.
• Working with community agencies to develop and promote safety initiatives.
• Promoting reporting of issues affecting member safety.
• Analyzing events within organizations to evaluate the need for process improvement.

• MetroPlusHealth has over 137 Urgent Care Centers in our service area to further assist members with access to urgent care.  MetroPlusHealth has employed multiple strategies to ensure that our provider directory is as accurate as possible.  The Plan is consistently auditing and educating providers to notify the plan of any change in address, telephone number or demographics important to our members.

Clinical and Service Initiatives

Measures

The 2024 Quality Program targeted many clinical and service measures for improvement. Below are short descriptions of the work we did in 2024 along with MetroPlusHealth’ most recent quality results. Results are compared to national and state-wide benchmarks.

Interpreting the Tables Below:

To gauge performance MetroPlusHealth compares the Plan’s HEDIS®/QARR score to a relevant industry benchmark, such as NYS QARR benchmarks or the CMS Star rating thresholds. Plan scores higher than the benchmark indicate that the Plan is successfully capturing health care information and using it to encourage its members to seek services that help them regain, maintain, or improve their health care better than other plans. Improving quality is challenging work; MetroPlusHealth has a team of dedicated health care professionals who work every day toward improving health services for MetroPlusHealth members.

Clinical Initiatives

MetroPlusHealth sends personalized health communications to make members aware of gaps in preventive or chronic maintenance care. Members are provided with preventive health guidelines, member newsletters and personalized communications throughout the year to help them maintain their health. Some of the services members are encouraged to receive are as follows:

Well-Child Visits

MetroPlusHealth encourages children and adolescents to have an annual well-child visit to promote good health and monitor appropriate development.  MetroPlusHealth sends educational mailings and text messages to inform parents/guardians about the importance of visiting the pediatrician yearly and reminds them to take their child for a complete well visit for needed immunizations, screenings, and counseling. Health Navigators outreach caregivers telephonically to assist with scheduling appointments. Incentives are offered for children who complete their well visits through the MetroPlusHealth Member Rewards Program (metroplusrewards.org).  Providers are notified of their members that are missing an annual well-visit and are given guidance on how to best close gaps-in-care. Incentives are offered to providers for demonstrating high completion rates.

During well-visits, providers also assess body mass index (BMI) and educate parents about the importance of physical activity and nutrition.  Health education about the importance of regular exercise and diet is provided by MetroPlusHealth through text and posted to the online newsletter and website/social media to reach our busy members.  MetroPlusHealth also sends providers gap in care reports detailing children who need preventive care.  The tables below show rates of members attending a well-child visit.

Immunizations for Adolescents

Vaccinations for older children are also very important to prevent diseases such as meningococcal, tetanus, diphtheria toxoids, acellular pertussis, and human papillomavirus.  MetroPlusHealth provides member education by sending out letters and texts to inform caregivers about vaccinations and remind them that their child is due for a vaccination.  MetroPlusHealth also provides tips to providers through in-person and virtual provider meetings such as taking the opportunity to vaccinate during sports physicals so that busy parents do not have to make another appointment and reminding providers to input vaccination information into the Citywide Immunization Registration so that both members and public health officials can keep track of vaccinations for infectious diseases.

Breast Cancer Screening

Breast cancer is one of the most common cancers in women in the United States. Regular checkups and screenings can find breast cancer at an earlier stage when treatment is most effective. MetroPlusHealth sends educational materials and reminders, through phone, mail and text messaging to women who are due for a mammogram. Health Navigators outreach members to assist with scheduling mammograms. Educational materials and newsletters on the importance of early detection are posted on the member portal.  Gap-in-care reports are sent to providers so that they can follow up with members who are due for mammograms during routine visits. The MetroPlusHealth Member Rewards Program (metroplusrewards.org) offers Member Rewards for members who complete their breast cancer screening.  The table below captures the percentage of women screened for breast cancer.

Cervical Cancer Screening

Regular checkups and screenings can help find cervical cancer at an earlier stage when treatment is most effective. .  Women ages 21 to 64 should have a cervical cancer screening (Pap test) every 3 years.  Alternatively, women ages 30 to 64 can rely on human papillomavirus (HPV) testing instead of, or in addition to, a Pap test. Women in this age group should get HPV testing every five years, a Pap test every three years, or a combination of the two tests every five years.  MetroPlusHealth endeavors to notify members who are missing a cervical cancer screening that one is due through phone, mail, and text messaging.  Health Navigators outreach members to assist with scheduling a cervical cancer screening. Providers are rewarded for closing cervical cancer screening gaps through the Provider P4P program.  The MetroPlusHealth Rewards Program offers Member incentives once a cervical cancer screening is completed.  List of members who are due for a cervical cancer screening are shared with primary care providers so they can assist their patients to get cervical cancer screening.

Chlamydia Screening in Women

Chlamydia is a common sexually transmitted disease (STD), especially among young people. As chlamydia is usually has no symptoms, screening is necessary to identify most infections. The Centers for Disease Control and Prevention (CDC) recommends chlamydia screening every year for all sexually active women younger than 25. If not treated, chlamydia can cause severe pain and infertility (inability to have children).  Educational materials and newsletters on the importance of chlamydia screening are posted on the member portal. The goal is to educate members about the importance of screening and early detection. Health Navigators outreach members to assist with scheduling chlamydia screenings. Additionally, MetroPlusHealth shares information with providers on members who may need screening and are rewarded for closing the gap. The table below captures the percentage of women screened for chlamydia.

Prenatal and Postpartum Care

MetroPlusHealth supports the health of new mothers and their babies by offering resources and education through mailings, texting, telephonic outreach, and posting of materials on the MetroPlusHealth website.  These communications include contact information for MetroPlusHealth High-Risk OB/GYN Case Management, community-based organizations that provide services for expecting and new mothers, and reminders to stop smoking and get the flu and Tdap immunizations.  The MetroPlus Healthy Rewards Program offers incentives for completing a postpartum visit and well-baby check-ups.  To assist expecting and new mothers to monitor their emotional health, MetroPlusHealth provides a Patient Health Questionnaire that members can fill out and take with them to their next doctor’s appointment as a prompt to start a discussion about how members are coping with motherhood.  Calls are conducted to new mothers as a reminder to attend their postpartum visit for important follow-up care after delivery.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Colorectal Cancer Screening

Regular screening, beginning at age 45, is the key to preventing colorectal cancer and finding it early. The U.S. Preventive Services Task Force recommends that adults aged 45 to 75 be screened for colorectal cancer. The Task Force recommends that adults aged 76 to 85 talk to their doctor about screening. MetroPlusHealth calls, texts, and sends mailings to members to educate them about the importance of colorectal cancer screening and the different options available such as easy and fast stool-based screening tests.  Health Navigators outreach members who have been distributed a stool-based test kit to help them in completing and returning it to their providers.  During Colon Cancer Awareness Month, MetroPlusHealth conducts a social media campaign to encourage members to get their colorectal cancer screening. Members can also earn Member Rewards for completing their colorectal cancer screening. Providers are informed of members who need screening and are provided with educational resources and payments for high performance.

Controlling High Blood Pressure 

High blood pressure, also called hypertension, is a risk factor for cardiovascular disease. Many times, people live with hypertension without knowing due to being a largely asymptomatic condition. The World Health Organization estimates that annually, high blood pressure directly and indirectly causes the deaths of at least nine million people globally. Between 2017 to March 2020, around half of the adult U.S population was diagnosed as hypertensive (48.1%).  In New York City, it is estimated that 1 in 4 residents suffer from high blood pressure with cases disproportionately affecting Black and Latino adults compared to White and Asian adults.

MetroPlusHealth is dedicated to supporting its members with hypertension by providing guidance and care to keep their blood pressure under control. Members are reminded to attend their annual wellness visits to proactively check in on their health and take preventative steps from either becoming hypertensive or controlling their symptoms if they are diagnosed with hypertension. Healthy lifestyle tips are disseminated through educational materials that are posted on the MetroPlusHealth website. For members’ convenience, 90-day prescriptions of anti-hypertensive medications are also encouraged.  The following table indicates rates of hypertensive members who have their blood pressure under control.

Asthma Medication Ratio

About 1 in 12 people in the United States are diagnosed with asthma, approximating 28 million of the total population. In New York City, asthma is a leading cause of emergency room visits and disproportionately affects low-income Black and Latino communities. There is no cure for asthma, but there are ways to control it.

Broadly speaking, there are two types of asthma medications: 1) controllers and 2) relievers. Clinical guidelines as outlined by the Global Initiative for Asthma advise patients to take controllers on a consistent basis to prevent acute asthma symptoms while reliever medications are used as “rescuers” and are to be taken only when a person experiences an exacerbated asthma attack. Using more controller than reliever medications is an indication that the patient has their asthma symptoms under control.

MetroPlusHealth supports members in maintaining a greater-than 50% asthma medication ratio of long-acting controller medications to total asthma medications to effectively manage their symptoms. Asthma management tips are shared through educational materials in text messages and newsletters on the MetroPlus website. Asthma controller medication refill reminders are also administered through text messaging and phone calls conducted by our Health Navigators. Members can also earn rewards by refilling long-term controller asthma medication prescriptions. For members’ convenience, 90-day prescriptions of asthma controller medications are also encouraged for members who are stable with asthma medication management. Providers are educated on proper prescribing practices and rewarded for maintaining members at the recommended ratio. The following table below indicates rates of members with asthma medication management in control.

Comprehensive Diabetes Care

According to the Centers for Disease Control & Prevention (CDC) more than 30 million people in the United States have diabetes, and 1 in 4 of them do not know they have it. Diabetes is the 7^th leading cause of death in the United States. In the last 20 years, the number of adults diagnosed with diabetes has more than doubled as the American population has aged and become more overweight or obese. Much of the burden of illness and cost of diabetes is related to potentially preventable long-term complications that includes heart disease, blindness, kidney disease and stroke. Timely screenings and careful treatment can significantly reduce and delay the onset of complications diabetes can cause.

MetroPlusHealth has effective mechanisms to ensure members are getting the care and support they need to manage their diabetes. This includes texts campaigns to provide tips on how to manage diabetes and reminders to complete the following checkups: retinal eye screening, HbA1c testing, kidney health evaluation, and frequent blood pressure readings. Educational materials and community resources are also posted on the member portal. Care Managers also provide education and help members address barriers to care. Providers are notified of members who are overdue for diabetic screenings. An incentive is offered to members who complete their diabetic eye exam and kidney health evaluation through the MetroPlusHealth Member Rewards Program (metroplusrewards.org). The table below captures the percentage of diabetic adults who completed components of diabetes care.

Statin Adherence for Patients with Cardiovascular Disease

Cardiovascular disease remains the number one cause of death in the United States. According to the CDC, over 700,000 people have died from heart disease in 2020 in the United States. People with unhealthy cholesterol levels have a greater risk of developing Atherosclerotic Cardiovascular Disease (ASCVD). Additionally, for adults diagnosed with diabetes, 69% had high blood pressure and 44% had high cholesterol. Medications that help control cholesterol levels belong to a class called statins. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines state that statins of moderate or high intensity are recommended for adults with established clinical ASCVD. Additionally, moderate, or high intensity statin therapy reduces the risk of developing ASCVD for adults with diabetes. MetroPlusHealth conducts telephonic outreach with members to discuss the importance of adhering to their statin medication and relay information about pharmacy benefits such as 90-day refills, mail order and home delivery programs such as Capsule and CVS Home Delivery. The table below captures the percentage of members who are dispensed at least one statin medication of any intensity and members who were 80% adherent to their statin therapy during the measurement year.

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

MetroPlusHealth encourages and supports all members who have recently been diagnosed with Alcohol or Drug Abuse Dependence to engage in ongoing substance use treatment. Multiple treatment options are available including Inpatient Rehabilitation, Inpatient Detox, Outpatient Detox, Residential Treatment, Outpatient Clinic Care and Medication Assisted Treatment. MetroPlusHealth makes use of various data sources to outreach members who have been diagnosed with substance use disorders for intervention. The Plan contacts members via telephonic outreach to assist them in securing treatment. The Plan meets regularly with Inpatient Substance Abuse Rehab facilities to address adequate aftercare planning for all members discharged from their facilities. Additionally, MetroPlusHealth offers case management supports to members who struggle with substance misuse to help them address barriers to care.

The Plan also surveys providers to assess their practices related to the diagnosis and treatment of substance use disorders and makes available screening tools and treatment resources for their patients with substance use disorders. The Plan website also has information available regarding the diagnosis and treatment available to members with substance use disorders.

Antidepressant Medication Management (AMM)

Depression is one of the most common mental health disorders in the United States and symptoms vary from person to person and go from mild to severe. A person that experiences depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration, or self-worth for a period of at least two weeks, might be experiencing depression.

MetroPlusHealth utilizes claims and other data to identify members prescribed antidepressant medication and encourages members to participate in psychotherapy and psychotropic treatment. The Plan utilizes text messages, mail, phone calls and other communication methods to remind members to remain adherent to their medication regiment and inform them of services available to them.  Also, MetroPlusHealth works in collaboration with members to schedule needed follow up appointments to connect them with network providers. Additionally, we monitor and work with the member’s pharmacies and providers to ensure timely medication refill processing. Members can find information regarding the diagnosis and treatment available to members struggling with depression on the MetroPlusHealth website. The table below captures the percentage of adults filling antidepressants who were adherent to their medication regiment during the acute (remained on treatment for 3 months) and continuation phases (remained on treatment for 6 months) of their treatment.

Medication Therapy Management (MTM)

The Medication Therapy Management (MTM) program helps Medicare members, and their doctors monitor the efficacy/side-effects of being on multiple medications by:

• Preventing or reducing drug-related risks
• Increasing you and your doctor’s awareness on changes in medication.

MetroPlus automatically enrolls members who qualify for the plan for the program year if:

• They are part of a Medicare drug plan,
• Have several chronic health conditions (such as asthma, diabetes, and hypertension),
• Take eight or more different medications for these conditions,
• Total medication costs are likely to be exceed the defined threshold in the program year.

MetroPlusHealth partners with CVS Caremark, our Pharmacy Benefit Manager, to make sure that a pharmacist or other health professionals can offer members a comprehensive review of all their medications. Health providers/pharmacists talk to members about:

• How well their medications are working.
• Whether their medications have side effects.
• If there might be interactions between the medications, they are taking.
• Whether their current medication costs can be lower.
• Other problems they may be having with their medications.
• Use of over the counter (OTC) medications, vitamins, and supplements and how they can interact with their prescribed medications.

The health provider/pharmacist will provide a Medication Action Plan and a Personal Medication list upon completing the discussion with the member. Additionally, texting and IVR messaging are used to educate members on the value of participating in the MTM program.

For more information about Medication Therapy Management (MTM), please visit:  https://metroplus.org/plans/medicare/medication-therapy/

The table below captures medication review completion rates for the Medicare Stars program:

Care of Older Adults (COA)

Healthcare needs change with age.  It is therefore important that older adults get health checkups that will help their providers track health concerns and provide guidance for conditions related to aging. Members should have a review of their medications and get a functional status and pain assessment conducted by a provider at least annually.  For a medication review a provider reviews a list of all medications (prescriptions, OTC, vitamins, herbal remedies, etc.) a member is taking to help them understand how and when to take the medication, find potential drug-drug and drug-disease interactions, and discuss possible side effects.

For functional status assessment, a provider assesses a member’s activities of daily living (ADL) such as ability to eat, dress and bathe oneself.  Providers also check members’ cognitive status, sensory abilities, and other areas such as ability to shop for groceries and drive.  Providers also ask members about any pain they may be experiencing.  Additionally, providers discuss advance care planning which is a continuous process of conversation and documentation to align a patient’s care and interventions with their beliefs, values, and preferences if they become unable to make care decisions.

MetroPlusHealth has built these assessments/screenings into the Health Risk Assessment (HRA), thus members outreached for HRA completion will also have their COA needs addressed. Results are integrated into the member’s Plan of Care (POC), which is shared with both the member and their PCP. MetroPlusHealth also utilizes in-home providers to conduct home visits to complete these assessments and screenings.  In addition, targeted outbound calls are conducted by MetroPlusHealth staff to provide these services.  The overarching goals of these activities are to educate members on how to proactively address these issues with their providers and simultaneously help providers track and monitor members who present concerns in these areas.  The table below captures rates for Care for the Older Adult measure that are applicable to the CMS Medicare Stars Program.

Service Initiatives

Member & Provider Satisfaction

At MetroPlusHealth, we believe that gathering continuous member and provider feedback and insight is critical to the plan’s ability to deliver exceptional care to those who need it the most. Member satisfaction is monitored by multiple mechanisms including, but not limited to the annual CAHPS® Survey for Medicare, UltraCare (MAP) and Essential Plans, QHP Enrollee Survey and analysis of complaints and appeals. Plan Medicaid, HIVSNP, HARP and MLTC members are surveyed by the NYS DOH using the NYS DOH Adult or Child CAHPS® survey using a certified CAHPS® vendor to conduct surveys. Members also receive plan off-cycle drill down surveys, administered by the plan, to identify and resolve key drivers to poor satisfaction scores. Additionally, after-call surveys are administered to members daily to ensure that the plan understands member satisfaction continuously and is able to positively impact any service issues.

To conduct the annual CAHPS® surveys for Medicare, UltraCare (MAP), Essential Plan, and the QHP Enrollee Survey, the Plan uses the services of a certified CAHPS® vendor.  Results are reviewed, analyzed for barriers and opportunities for improvement and presented to the appropriate QI Committees and workgroups for recommendations and implementation of interventions.

The Plan also measures the following leading indicators of member satisfaction:

• Enrollment Processing
  • Enrollment mean processing time
• Customer Service
  • Abandonment rate
  • Average Speed of Answer
  • Average Wait Time
  • Satisfaction with the Representative
  • Staff Demonstrating Courtesy and Respect
  • Staff Demonstrating Helpfulness and Professionalism
  • Routine after call text surveys measuring customer experience and Net Promoter Scores
• Getting Needed Care/Access to Care
  • Appointment availability
  • Easiness of getting care, tests, or treatments needed
  • Provider network availability
• Care Coordination
  • Timeliness in receiving test results or reports
  • Easiness in understanding their test results or reports
  • Doctor having up-to-date medical records or other information relating to member’s care
  • Discussion about prescription medications
  • Discussion about healthy diet and eating habits
  • Discussion about things that worry or causes stress
  • Discussion about things to do to prevent illness
  • Getting help needed to manage care
  • Doctor is informed and up-to-date about the care member got from specialists
• Personal Doctor and Specialists
  • Satisfaction with personal doctor/specialist
  • Easiness of getting an appointment
  • Easiness of getting the care, tests, or treatments needed

Customer Experience had three Member Advisory Board meetings in 2024. Member representation spanned across multiple lines of business.   The Member Advisory Board meeting has representation from the Executive and Senior Leadership teams at MetroPlusHealth and focuses on specific areas related to the member experience to gather member feedback. Members are encouraged to share their stories and feedback on specific issues and these needs are captured and help to shape the strategy for the future.

For Customer Service hours please see below. After hours, Sundays and Holidays, members are connected to our 24/7 Customer Service Hotline. TTY users have access through 711.

Medicaid, Child Health Plus, Partnership in Care (SNP), MetroPlusHealth Enhanced

Monday-Saturday, 8am-6pm                                     1-800-303-9626 (TTY 711)
Sunday, 9am-5pm

Saturday, 9am-5pm                                                1-800-442-2560

After hours, please call 1-800-422-2560

MetroPlusHealth Gold & GoldCare

Monday-Friday, 8am-6pm                                     1-877-475-3795 (TTY 711)

Saturday, 9am-5pm                                                1-800-442-2560

After hours, please call 1-800-422-2560

Marketplace & Essential Plans

Monday-Friday, 8am-6pm                                     1-855-809-4073 (TTY 711)

Saturday, 9am-5pm                                                1-800-442-2560

After hours, please call 1-800-422-2560

Medicare Plans

Monday-Friday, 8am-8pm                                     1-866-986-0356 (TTY 711)

Saturday, 9am-5pm                                               

Managed Long-Term Care (MLTC)

Monday-Friday, 8am-8pm                                     1-855-355-6582 (TTY 711)

Saturday, 9am-5pm

After hours, please call 1-800-422-2560