Insurance FAQs

At MetroPlusHealth, we focus on primary and preventive care. Our plans offer access to doctors and specialists, 24/7 telehealth, prescription drug coverage, and prepackaged medications.

MetroPlusHealth Highlights

• Over 34,000 doctors and specialists, 40 hospitals and 110 urgent care centers
• Network includes NYC Health + Hospitals, NYU Langone, Mt. Sinai, CityMD, Montefiore, Labcorp, Lenox Hill Radiology, and many more
• Offices and local family care sites throughout the City
• The plan of choice for more than 690,000 New Yorkers
• 24/7 telehealth right from your smartphone, tablet, or computer
• Earn rewards for taking healthy steps like visiting your doctor or getting a flu shot

Additionally, with all our plans, and at no cost to you, you get:

• 4 free non-emergency transportation
• Trips to the emergency room
• Immunization and vaccines
• Prescription drugs and lab tests

Yes, MetroPlusHealth representatives are available around the clock to help find a plan that’s right for you.

There are three ways you can speak to someone and get help:

1. Call us

Call us at 855.809.4073 (TTY: 711),
MPH Gold Plan: 877.475.3795
Medicaid (including PIC, CHP, HARP, MLTC): 844.284.8819
Medicare (including UltraCare):  844.831.9099
HIX/Essential (QHP and EP):  844.831.9097
TTY: 800.466.7566
Hours: Monday through Saturday, 8am to 8pm. After hours and during holidays, call 800.442.2560.

2. Speak to someone in your language or in your community

Want to speak to someone in your community or in your language? Visit our Virtual Phone Book to find MetroPlusHealth representatives in each borough who speak over 40 languages.

3. Visit us in person

MetroPlusHealth has several locations throughout the five boroughs. Find a MetroPlusHealth location.

Signing up for health insurance with MetroPlusHealth is easy. We offer dozens of quality health plans that are low-cost and designed to meet the needs of individuals and families, NYC workers, those 65+, and those with Special Needs and Long Term Care. With over 34,000 doctors and specialists, 40 hospitals and 110 urgent care centers within the MetroPlusHealth care system, you will be in good hands no matter what plan you choose.

Ready to join?

Call us at 855.809.4073(TTY 711), Monday through Saturday, 8am to 8pm. After hours and during holidays, call 800.442.2560.

Want to speak to someone in your community or in your language? Visit our Virtual Phone Book to find MetroPlusHealth representatives in each borough who speak over 40 languages.

Wondering if you’re eligible?

Use our eligibility checker to see which MetroPlusHealth plans are available.

No. You do not need to be a green card holder or citizen to qualify for MetroPlusHealth’s Medicaid Managed Care plan.

Immigrants in New York have more health insurance options than in many other states. Applying for health insurance won’t affect your immigration status or application status. Your immigration status won’t be shared with federal immigration authorities.

MetroPlusHealth offers a variety of insurance plans that meet the needs of immigrants who are both documented and undocumented:

ChildHealth Plus: All New York children can get Child Health Plus, regardless of immigration status or income.

Medicaid: Free or very low cost insurance for New Yorkers with low income.

• If you are pregnant, you can get Medicaid regardless of immigration status, as long as you meet other requirements.
• If you are undocumented and not pregnant, you can still get Medicaid for emergency services, as long as you meet other requirements.
• DACAmented New Yorkers with Deferred Action for Childhood Arrivals status can qualify for Medicaid.

EssentialPlan: Free or very low cost insurance for adults with low income who don’t qualify for Medicaid. Immigrants can qualify for Essential Plan right after moving to New York, as long as they have a valid visa or deferred action status. DACA individuals don’t qualify.

Private/Qualified Health Plans: Insurance plans on the NY State of Health Marketplace (financial help is available) and directly from insurance companies. Most immigrants can purchase private plans on the NY State of Health Marketplace. Financial help is available. Anyone can purchase private health insurance directly from an insurance company by calling the insurance company or visiting their website.

To learn more about immigration status requirements in applying for health insurance, check out the Guide to Health Insurance and Health Care Services for Immigrants in New York City.

Yes, we offer dozens of quality health plans that are low-cost and designed to meet the needs of individuals and families. We want you to find the best plan for you and your family.

Call us at 855.809.4073 (TTY 711), Monday through Saturday, 8am to 8pm. After hours and during holidays, call 800.442.2560.

Want to speak to someone in your community or in your language? Visit our Virtual Phone Book to find MetroPlusHealth representatives in each borough who speak over 40 languages.

Wondering if you’re eligible?

Use our eligibility checker to see which MetroPlusHealth plans are available.

Yes, MetroPlusHealth takes pride in providing health plan coverage to a variety of New York City residents, including freelancers.

Ready to join?

Call us at 855.809.4073 (TTY 711), Monday through Saturday, 8am to 8pm. After hours and during holidays, call 800.442.2560.

Want to speak to someone in your community or in your language? Visit our Virtual Phone Book to find MetroPlusHealth representatives in each borough who speak over 40 languages.

Wondering if you’re eligible?

Use our eligibility checker to see which MetroPlusHealth plans are available.

Yes, Medicaid Managed Care is our plan for people eligible for Medicaid, a government assistance program. You may qualify for Medicaid if you have high medical bills, receive Supplemental Security Income (SSI), or meet certain income, resource, age or disability requirements.

MetroPlusHealth Medicaid Managed Care offers low- or no-cost health coverage to New Yorkers who live anywhere in New York City. You can choose your own primary care physician (PCP). When it comes to other doctors, you can pick from a comprehensive list of doctors and specialists in all five boroughs.

Covered services range from emergency visits to prenatal care. Best of all, MetroPlusHealth Medicaid Managed Care comes with no monthly premiums or copays.

Enroll Anytime

Medicaid Managed Care has a year-round open enrollment period. Learn more about Medicaid and how to enroll with MetroPlusHealth below:

• NY State of Health, The Official Health Plan Marketplace, online at https://nystateofhealth.ny.gov/ or by phone at 1.855.355.5777
• Navigators and Certified Application Counselors
• Medicaid Helpline: 1.800.541.2831
• Local Departments of Social Services

Call us at 1-866-986-0356 (TTY users: 711), 24 hours a day, 7 days a week to speak with a representative for help.  You can also call Medicare directly at 1-800-MEDICARE or 1-800-633-4227. TTY users: 1-877-486-2048. Explain your circumstances to a representative. It may be possible to switch plans at other times, depending on your situation.

MetroPlus Health Plan
50 Water Street, 7th Floor
New York, NY 10004
Phone: 1-866-986-0356, TTY users: 711
24 hours a day, 7 days a week
Fax: 1-212-908-8601

• We recommend carrying your physical ID card however you can still obtain services with your MetroPlusHealth ID number.
• You can also get a virtual ID card through your member portal at (members.metroplus.org).

If you are a Medicaid, SNP or HARP member:

• You will receive your MetroPlusHealth ID card within the first 15 days of membership.

If you are a Qualified Health Plan, Essential Plan or Child Health Plus member:

• If you pay a premium
  • If you make your payment before the start of your membership you will receive your card within the first 15 days of membership.
  • If you make your payment during the first 10 calendar days of the month after your eligibility start date, you will receive your card 15 days after your payment is received.
• If you don’t pay a premium (only applicable to Essential Plan and Child Health Plus)
  •  You will receive your card within the first 15 days of membership

You may also receive a new card when you initiate a PCP change by contacting our Member Services Department or request one from your member portal (members.metroplus.org)

• Your Member ID will be available to you via a physical card that will be mailed and virtually through your member portal (members.metroplus.org).
• If you are a new member and don’t have your member ID yet, please contact MetroPlusHealth Customer Service at 1-800-303-9626.
• You can also email us at [email protected]. If you email to receive your member ID, we will need to schedule a call back to verify your identity for security purposes.

Absolutely! Both dental and vision care are covered by the Essential Plan and Child Health Plus.

Yep! Both the Essential Plan and Child Plus Health cover prescription medication.

If you sign up for the Essential Plan through MetroPlusHealth, you can use it at CityMD.

Yes! Both the Essential Plan and Child Health Plus cover emergency room visits.

There are just a few eligibility requirements that have to be met in order to qualify for the Essential Plan.

To qualify for the Essential Plan, you must:

• Be a resident of New York State
• Be a legal resident of the United States
• Be between 19–64 years old
• Not be eligible for Medicaid or Child Health Plus plans
• Not be eligible for employer-based or other health insurance options

There are also income eligibility requirements for the Essential Plan, which expanded significantly this year to include many more New Yorkers.

Previously, in order to qualify New Yorkers could earn no more than 200% of the federal poverty line. As of April 1, 2024, New Yorkers can now qualify for the Essential Plan if they earn up to 250% of the federal poverty line.

The federal poverty line changes each year and depends on the size of your household. For 2024, New Yorkers are eligible for the Essential Plan based on these annual household income limits:

• $30,120 for a single person
• $40,880 for a family of two
• $51,640 for a family of three
• $62,400 for a family of four

Have more family members than that? Calculate your household’s income limit by adding $10,760 for each additional person.

MetroPlusHealth Medicaid Managed Care is our plan for people eligible for Medicaid, a government assistance program. You may qualify for Medicaid if you have high medical bills, receive Supplemental Security Income (SSI), or meet certain income, resource, age or disability requirements.

The Child Health Plus plan provides protection for the little ones—everything from check-ups to dental care, from the MetroPlusHealth citywide list of providers. It’s available for all children under age 19, who live in New York City and don’t qualify for Medicaid.

Yes, MetroPlusHealth offers a variety of plans for individuals and families that include dental and vision:

1. Marketplace Plans
   Marketplace plans include a wide variety of comprehensive health plans for individuals and families with great benefits and services, including vision care, and at very competitive prices.

2. Essential Plan
   The Essential Plan covers emergency, preventive, and routine vision care, including a vision examination, and prescribed lenses and frames.

Accessing Vision Services

If you need to find or change a participating ophthalmologist please call the number on your ID card or visit our website.

3. Medicaid Managed Care
   Medicaid Managed Care vision care includes:

• Services of an ophthalmologist, ophthalmic dispenser and optometrist, and coverage for contact lenses, polycarbonate lenses, artificial eyes, and or replacement of lost or destroyed glasses, including repairs, when medically necessary. Artificial eyes are covered as ordered by a plan doctor or specialist.
• Eye exams, generally every two years, unless medically needed more often
• Glasses (new pair of Medicaid approved frames every two years, or more often if medically needed)
• Low vision exam and vision aids ordered by your doctor
• Specialist referrals for eye diseases or defects

4. Medicare Products

MetroPlus Advantage Plan (HMO D-SNP) – Medicare-covered eye exams, including diagnosis and treatment of diseases and conditions of the eye. This benefit can be combined with your Medicaid benefits to provide coverage for additional eyewear, or to purchase eyewear beyond the Medicaid spending limit. MetroPlus Advantage Plan (HMO D-SNP) also covers additional vision care services not covered by Original Medicare. Additional covered benefits include:

Eyewear is covered up to a total of $350 per year for:

• Contact lenses
• Eyeglasses (lenses and frames)
• Eyeglass lenses
• Eyeglass frames
• Upgrades

MetroPlus Platinum Plan (HMO) – Medicare-covered eye exams, including diagnosis and treatment of diseases and conditions of the eye.

MetroPlus UltraCare (HMO D-SNP) – Medicare-covered eye exams, including diagnosis and treatment of diseases and conditions of the eye. Additional covered benefits include:

• We will cover services provided by optometrists, ophthalmologists and ophthalmic dispensers including eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes (stock or custom made), low-vision aids and low-vision services.
• Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease.
• Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary.
• Eyewear is covered up to a total of $350 per year for:
• Contact lenses
• Eyeglasses (lenses and frames)
• Eyeglass lenses
• Eyeglass frames
• Upgrades

Yes, MetroPlusHealth offers a variety of plans for individuals and families that include dental and vision:

1. Marketplace Plans

Marketplace plans include a wide variety of comprehensive health plans for individuals and families with great benefits and services, including dental care, and at very competitive prices.

To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

2. Essential Plan

The Essential Plan covers emergency, preventative, and routine dental care, including:

• • Dental examinations, visits and consultations once within a six (6) month consecutive period (when primary teeth erupt)
  • X-rays, full mouth x-rays or panoramic x-rays at 36-month intervals, bitewing x-rays at six (6) to 12-month intervals, and other x-rays if medically necessary (once primary teeth erupt)
  • Procedures for simple extractions and other routine dental surgery not requiring hospitalization, including preoperative care and postoperative care
  • In-office conscious sedation
  • Amalgam, composite restorations and stainless steel crowns

3. Medicaid members can access dental care using their MetroPlusHealth ID card. Medicaid benefits include dental check-ups, cleanings, X-rays, fillings, and follow-up care. Medicaid members do not need a referral from a PCP to see a dentist.
4. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.  Child Health Plus cover routine, preventive and emergency dental services through DentaQuest. You do not need a referral from your PCP to see a dentist. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

5. Medicare Products
   To be eligible for our MetroPlus Advantage Plan (HMO D-SNP), you must have Medicare Part A, be enrolled in Medicare Part B, be eligible for Medicaid or Medicare cost-sharing assistance under Medicaid, and live in New York City.

6. Please be aware that emergency dental services are not restricted. In the event of a dental emergency, members may obtain care from any emergency provider.

To be eligible for our MetroPlus Platinum Plan (HMO), you must have Medicare Part A, be enrolled in Medicare Part B, and live in New York City.

Our MetroPlus UltraCare (HMO D-SNP) is a Medicaid Advantage Plus plan designed for people who are dual eligible for Medicare and full Medicaid and need long-term care services such as home care and personal care.

To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

You can also call 800.303.9626 (TTY: 711), Monday through Friday, from 8am to 8 pm and Saturday, 9am to 5pm. Member Services representatives are here to help you. Many speak your language or have services that will translate in any language you need.

Child Health Plus covers routine, preventive, and emergency dental services through DentaQuest. You do not need a referral from your PCP to see a dentist. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

Medicaid members can access dental care using their MetroPlusHealth ID card. Your benefits include dental check-ups, cleanings, X-rays, fillings, and follow-up care. You do not need a referral from your PCP to see a dentist. To choose a Primary Care Dentist (PCD) or if you need help finding a dentist in your area, contact DentaQuest.

Yes, MetroPlusHealth Virtual Visit is a fast and easy way for our members to see a doctor for common physical, mental, emotional, and behavioral health issues that are not emergencies. This 24/7 service is provided by NYC Health + Hospitals / ExpressCare and is available as part of MetroPlusHealth coverage, at no cost to our members.

Learn more about MetroPlusHealth Virtual Visit, our telemedicine program, and how to use it.

MetroPlusHealth wants you to know your rights and protections against surprise medical bills. 

When you get emergency care or are treated by an out-of-network doctor or specialist at an in-network hospital or ambulatory surgical center, you are protected from “balance billing” (sometimes called “surprise billing”). In these cases, you shouldn’t be charged more than your plan’s in-network copayments, coinsurance, and/or deductible.

You’re protected from balance billing for:

• Emergency services
• Certain services at an in-network hospital or ambulatory surgical center
• Services referred by your in-network doctor

Visit surprise bills for a comprehensive overview of your rights and protections.

Yes, at MetroPlusHealth, we believe good health is not just about taking care of your body. Being healthy includes protecting your mental and emotional wellbeing, too. How you feel matters. We offer many services to our members, from toddlers to seniors, that support mental and emotional health. Learn more about and access our behavioral health resources.

To see what is covered, check the benefits in your health plan via the Member Portal.

Finding a specialist within the MetroPlusHealth network is easy. Using our doctor or specialist search, you can access over 34,000 doctors and specialists located across the five boroughs who accept MetroPlusHealth insurance.

Finding a primary care provider (PCP) is an important step in establishing your health care and should be the first thing you do upon signing up for an insurance plan. 

To find your PCP:

• Call the number on your ID card, or
• Visit our directory of doctors and specialists where you will find our comprehensive list, that includes their
  • Name, address, and telephone number
  • Specialty
  • Board certification (if applicable)
  • Languages spoken
  • Whether that participating doctor or specialist is accepting new patients

Finding a doctor or specialist within the MetroPlusHealth network is easy. Using our doctor or specialist search, you can access over 34,000 doctors and specialists located across the five boroughs who accept MetroPlusHealth insurance.

Yes, Marketplace Plans, the Essential Plan, and Medicaid Managed Care each include contact lenses within their vision care packages. However, it is important to read the benefits of each plan closely as the terms vary from plan to plan. Some Marketplace Plans only offer contact lenses under their Pediatric Vision Care section. There are seven Marketplace Plans that you can compare to find the right plan for you:

1. BronzePlus
2. SilverPlus
3. GoldPlus
4. PlatinumPlus
5. BronzePlusHSA
6. SilverPrime
7. Gold Prime

MetroPlusHealth Medicare Plans

• MetroPlus Advantage Plan (HMO D-SNP)
• MetroPlus UltraCare (HMO D-SNP)

MetroPlusHealth Commercial Plans

• MetroPlus Gold
  • MetroPlusHealth GoldCare I
  • MetroPlusHealth GoldCare II

All MetroPlusHealth members can choose from more than 34,000 top doctors and specialists, 40 hospitals and 110 urgent care centers, including:

• NYC Health + Hospitals
• NYU Langone
• Mt. Sinai
• CityMD
• Montefiore
• Labcorp
• Lenox Hill Radiology

To search for doctors by location, coverage, or specialty, visit Find a Doctor.

Our members can go to any CVS Caremark in-network pharmacy to fill prescriptions. The MetroPlus PillPack program allows members to get multiple medications pre-packaged and sent to your home for no additional cost. To sign up, you can contact PillPack directly at 855-745-5725.

Visit our Find a Pharmacy page to learn more.

You can fill a 90-day supply of your approved maintenance medications at any in-network pharmacy of your choice. You can also get them mailed right to your home if your pharmacy offers delivery service or through one of our mail-order pharmacy partners such as CVS Caremark. For more information or assistance in setting up home delivery service, please contact the MetroPlus Health Plan Customer Service number on your member ID card or your local pharmacy.

During this public health crisis, MetroPlusHealth will allow for a short-term supply for most essential medications even if you are not due for a refill at any in-network pharmacy.

We have partnered with CVS Retail Pharmacies to offer same-day delivery for your medications. During this state of emergency, all delivery fees will be waived. Please contact your local CVS retail pharmacy to find out more information on how to access this benefit.

MetroPlusHealth has participating pharmacies all across New York City.

Visit our Find a Pharmacy page for more information about your pharmacy benefits.

• People who are 65 or older
• People under 65 with certain disabilities
• People with End-Stage Renal Disease (permanent kidney failure)

Some people are automatically enrolled in Original Medicare (Part A and Part B) and other people have to sign up for it. In most cases, if you’re turning 65 and will be getting benefits from Social Security or the Railroad Retirement Board (RBB) at least 4 months before you turn 65, you will automatically get Medicare Part A and Part B starting the first day of the month you turn 65. If you’re under 65 and have a disability, you’ll automatically get Medicare Part A and Part B after you get disability benefits from Social Security or certain disability benefits from the RRB for 24 months. You don’t need to sign up if you automatically get Medicare Part A and Part B. You will get your Medicare card in the mail three months before your 65th birthday or 25th month of disability.

You can join or switch plans during certain times of the year. Since your health and finances may change from year to year, it’s smart to review your health care needs every year to see if you need to change to a plan that works better for your current needs. You can join or switch plans during the following times:

• Initial Enrollment Period: You can enroll three months before you turn 65 (or 25th month of disability), during your birthday month (or 25th month of disability) and up to three months after your birthday (or 25th of disability).
• Medicare Annual Enrollment Period (October 15-December 7): During this period, you can enroll in or switch plans, including adding or dropping prescription drug coverage or switch from a Medicare Advantage Plan back to Original Medicare. Your new coverage will start on January 1 of the following year.
• Special Election Period: If you qualify for Medicaid, “Extra Help” or meet other special circumstances, you may be eligible for this period. If you are eligible, you can add new coverage or make changes to your current coverage depending on your situation.
• Medicare Advantage Open Enrollment Period (January 1-March 31): During this time, you have a one-time opportunity to switch from one Medicare Advantage plan to a different one. You can also drop your current plan and return to Original Medicare with the option to purchase a stand-alone Medicare Part D Prescription Drug Plan.

Absolutely! Both dental and vision care are covered by the Essential Plan and Child Health Plus.

Yep! Both the Essential Plan and Child Plus Health cover prescription medication.

If you sign up for the Essential Plan through MetroPlusHealth, you can use it at CityMD.

Yes! Both the Essential Plan and Child Health Plus cover emergency room visits.

Yes, MetroPlusHealth is offering a new and exciting rewards program in 2023. Members will now earn reward dollars directly when they see their doctors and take part in certain healthy activities.

Members can earn rewards for making healthy choices! For more information visit our Members’ Rewards site, Memberwell.

Yes, the Essential Plan, Gold Plan, and Marketplace Plans all offer some variation on a fitness reimbursement. 

Essential Plan Fitness Reimbursement: 

• $200 every 6 months for members

Gold Plan Fitness Reimbursement: 

• $250 every 6 months for members and $250 every 6 months for spouses

Marketplace Plans Fitness Reimbursement: 

• $200 every 6 months for members and $100 every 6 months for spouses

MetroPlus Advantage Plan (HMO D-SNP) and MetroPlus UltraCare (HMO D-SNP)

• $250 every 6 months for members

No, someone who resides in New Jersey isn’t eligible for MetroPlusHealth, with the exception of emergency services. Other benefits are covered and reimbursed when provided by In-Network providers.

Exception for Commercial Plans – NYC Employees part of our NYC Employee Health Insurance – MetroPlusHealth plans can reside outside of the service area. However, all medical services must be received within the MetroPlus Health participating network.0

MetroPlusHealth serves eligible New Yorkers with health care at little to no cost. We are over 700,000 members strong across New York City. Our network includes primary care doctors, specialists, and behavioral health and OB/GYN doctors at over 34,000 sites across the five boroughs of New York City.