MetroPlus Customer Care: An Expert, Practical Guide

MetroPlusHealth (often shortened to MetroPlus) is New York City’s health plan affiliated with NYC Health + Hospitals. Whether you’re enrolled in Medicaid Managed Care, the Essential Plan, Child Health Plus, a Marketplace plan, or Medicare Advantage, the fastest way to resolve issues is to contact customer care with the right information and a clear objective. This guide explains how to reach support, what to have ready, how to escalate concerns, and what timelines you can expect under New York State rules.

Below you’ll find exact phone numbers, hours, complaint options, and timeframes for grievances, appeals, and authorizations—plus practical tips used by seasoned patient advocates to shorten resolution time. Keep your MetroPlus ID card on hand; the plan-specific Member Services number printed on the card is always the most authoritative contact.

How to Reach MetroPlus Customer Care

The general Member Services line is the best first contact for benefits questions, PCP changes, eligibility, authorizations, claims status, and replacement ID cards. If you don’t have your card, call Member Services at 1-800-303-9626 (TTY: 711). Typical hours are 8:00 a.m.–8:00 p.m., 7 days a week (hours can vary by product and season; listen to the recording for current hours). For enrollment or renewals through the NY State of Health Marketplace, call 1-855-355-5777 (TTY: 1-800-662-1220), Monday–Friday 8:00 a.m.–8:00 p.m., Saturday 9:00 a.m.–1:00 p.m.

MetroPlus maintains online self-service at https://www.metroplus.org where members can register for the portal to view benefits, find in-network providers, download digital ID cards, check claims, and send secure messages. For in-person help, use the location finder at https://www.metroplus.org/locations to see walk-in community offices across the five boroughs; hours and services vary by site, so verify before you go.

Key Contacts and Links

• MetroPlus Member Services: 1-800-303-9626 (TTY: 711), 8:00 a.m.–8:00 p.m., 7 days
• NY State of Health (enrollment/renewals): 1-855-355-5777 (TTY: 1-800-662-1220), nystateofhealth.ny.gov
• NY Medicaid Managed Care help/complaints: NYS DOH 1-800-206-8125
• NYS Dept. of Financial Services (commercial/Marketplace complaints): 1-800-342-3736, dfs.ny.gov/consumers
• Medicare help (for Medicare Advantage members): 1-800-MEDICARE (1-800-633-4227), medicare.gov
• Mental health crisis (any plan): 988 Suicide & Crisis Lifeline (24/7), 911 for emergencies
• Member portal and locations: https://www.metroplus.org and https://www.metroplus.org/locations

What to Have Ready Before You Call

Arrive prepared and your issue will typically be resolved in a single call. Have your MetroPlus ID number, full name as printed on the card, date of birth, address, and a good callback number. If your question concerns a specific visit, gather the provider’s name and NPI, date of service, and any claim, bill, or prior authorization numbers shown on correspondence.

For coverage or authorization questions, ask the provider for the exact CPT/HCPCS procedure codes and ICD-10 diagnosis codes—they determine coverage and medical necessity. If you’re disputing a bill, request an itemized bill and the Explanation of Benefits (EOB). For pharmacy issues, have the prescription number (Rx#), the drug name, dose, and the pharmacy’s phone number. Take notes: record the date, time, representative’s name or ID, and a reference number for your call.

Common Requests and Typical Timeframes

Eligibility, PCP changes, ID cards, and benefit clarifications are usually handled during the call. Replacement ID cards typically ship within 5–10 business days; many members can download a digital card immediately via the portal. Provider referrals, if required by your plan, are usually generated same-day once eligibility and network status are confirmed.

Standard prior authorization decisions generally follow New York State timelines. For Medicaid Managed Care, plans must make standard service authorization decisions as quickly as the member’s condition requires and no later than 14 calendar days; expedited/urgent requests are decided as fast as the member’s condition requires and typically within 72 hours. For grievances (service quality or dissatisfaction), the plan must resolve standard cases within 45 calendar days, and expedited grievances within 48–72 hours. Appeals of adverse determinations are usually resolved within 30 calendar days for standard appeals and 72 hours for expedited appeals.

Escalations, Grievances, Appeals, and External Help

If a representative cannot resolve your issue, ask for a supervisor. To file a grievance (service concern) or appeal (denial/authorization issue), tell Member Services you want to file formally and ask for a tracking/reference number. You can submit by phone, in writing, or via the portal; keep copies of everything you send. When medical urgency exists, explicitly request an expedited grievance or expedited appeal and explain why a delay could jeopardize health, life, or function.

If you disagree with a final decision or timelines are missed, you have external options. For Medicaid Managed Care or Child Health Plus, contact the New York State Department of Health Managed Care Complaint Line at 1-800-206-8125. Marketplace/commercial plan issues (e.g., Essential Plan or Qualified Health Plans) can also be escalated to the NYS Department of Financial Services at 1-800-342-3736 or dfs.ny.gov/consumers. Medicare Advantage members can call 1-800-MEDICARE (1-800-633-4227) for appeal rights and plan complaints. For Medicaid fair hearings in New York, you can request one online at https://otda.ny.gov/hearings/ or by phone at 1-800-342-3334 after exhausting plan-level appeal steps when required.

Enrollment, Renewals, and Costs You Can Expect

Most MetroPlus products enroll through NY State of Health. Open Enrollment for Marketplace plans typically runs November through January; qualifying life events (e.g., loss of coverage, moving, birth) trigger Special Enrollment Periods within 60 days. Medicaid and Child Health Plus allow year-round enrollment. As of 2024, New York’s Essential Plan generally has a $0 monthly premium for eligible adults up to 250% of the Federal Poverty Level (FPL), with no deductible; some services may have low copays.

Child Health Plus premiums range from $0 to about $60 per child per month depending on household income, with no copays for preventive care. Medicaid Managed Care premiums are $0 for eligible members. For precise rates and cost-sharing, confirm your household size and income with NY State of Health (1-855-355-5777) or review the plan-specific Summary of Benefits and Coverage in your MetroPlus portal. After enrollment or recertification, ID cards generally arrive within 10 business days; coverage typically starts the 1st of the month following your plan selection or eligibility confirmation.

Provider Networks, Referrals, and Pharmacy Help

Use the online directory at https://www.metroplus.org to find in-network primary care, specialists, hospitals, labs, and behavioral health providers. Always verify network status and whether a referral or prior authorization is required before scheduling. For out-of-network questions, ask Member Services about exceptions, continuity of care, or transition-of-care coverage when switching plans or providers.

For prescription issues, have your Rx# ready. If a drug is denied due to formulary rules, ask about alternatives, prior authorization, quantity limits, or step therapy. Your prescriber can submit medical necessity documentation to support an exception. If you’re at the pharmacy with an urgent need, ask Member Services whether a temporary transition fill is available while an authorization is pending.

Pro Tips for Faster Resolutions

• State your goal at the start (e.g., “I need an expedited appeal because delaying this MRI could harm my health”). Representatives can route calls correctly when your objective is clear.
• Request reference numbers for every call and document promised callbacks or deadlines; this helps supervisors track your case and holds timelines accountable.
• For disputed bills, ask providers to bill MetroPlus with the correct member ID, group, and coordination-of-benefits info, then wait for the Explanation of Benefits before paying.
• Use the NY State of Health line (1-855-355-5777) for enrollment/renewal and eligibility questions; use MetroPlus Member Services (1-800-303-9626) for benefits, claims, and authorizations.
• If health could be at risk, explicitly request “expedited” handling for authorizations, grievances, or appeals; document the clinical reason.

Finally, remember that plan details and contact numbers can vary by product and may change. The number on the back of your MetroPlus ID card and the portal at https://www.metroplus.org are your most reliable, up-to-date sources for customer care.

What type of insurance is MetroPlus health NYC?

MetroPlus Health Plan is a prepaid health services plan and a wholly owned subsidiary of NYC Health + Hospitals (H+H).

How do I speak to Medicaid customer service?

★ Department of Health Care Services

1. California State Contacts.
2. Eligibility.
3. Enrollment.
4. ☎ Call the Medi-Cal Helpline: 800-541-5555, or 916-636-1980.

What is the 800 number for Metro Plus?

METROPLUS HEALTH PLAN SPECIFIC BENEFITS:
Our dedicated team is here to assist you Monday – Saturday, 8am-8pm, and Sunday, 9am-5pm, Call us at 866.496. 6636. At MetroPlusHealth, we are more than just a health plan; we are your partners in achieving a healthier, happier life.

What is Metroplus NY customer service number?

Our Member Services team is always here to help.
Just call 1.800. 303.9626 (TTY:711). Our 24/7 Customer Service Hotline will answer your call at other times and on holidays.