Last Updated: June 29, 2010

Important Information for MetroPlus Providers about MetroPlus Special Needs Plans

As a MetroPlus Health Plan provider, you are responsible for the overall supervision and coordination of care for MetroPlus Health Plan members. Primary Care Providers (PCPs) are responsible for managing and coordinating specialty care, ancillary services and maintaining continuity of care.

Through our Model of Care, we seek to coordinate services on behalf of all members to improve their access to medical, mental health and social services and in so doing optimize the medical and psychosocial care they receive. As our partner, we work with you to provide the highest quality of care for our SNP members. Please refer to the MetroPlus Provider Manual for your responsibilities as a MetroPlus Health Plan provider.

Claims Process for SNP members

Members enrolled in the MetroPlus Select Plan dual eligible SNP plan are full benefit dual eligible Medicare beneficiaries. This means that these members receive full Medicaid benefits from New York State. These members are not responsible for cost sharing for services MetroPlus is required to provide. Please see the MetroPlus Select Plan Summary of Benefits on our website http://www.metroplus.org/mcr_select.php for a summary of services. Please submit your claims to MetroPlus and we will coordinate the adjudication of your claims for all Medicare and Medicaid covered services. Payment from MetroPlus should be considered payment in full as you are not permitted to charge these members for cost-sharing or balance- bill them.

Members enrolled in the MetroPlus Advantage Plan may not all be full benefit dual eligibles or Qualified Medicare Beneficiaries (QMBs). QMBs are eligible for Medicaid payment of Medicare premiums, deductibles, co-insurance and co-pays. When we receive your claim, we will adjudicate the claim and will send you and Explanation of Payment to advise you on the billed services and payment information. We will also let you know whether you will need to bill New York State Medicaid for the cost sharing allowed by New York State Medicaid. Please note that you may not balance-bill members for copayments that are the responsibility of New York State Medicaid.

Additionally, the Social Security Act provides that a State is not required to provide any payment for any expenses incurred relating to payment for deductibles, coinsurance, or co-payment for Medicare cost-sharing to the extent that payment under Medicare for the service would exceed the payment amount that otherwise would be made under the State Medicaid plan.

If you have require additional information or have questions about MetroPlus Health Plan Special Needs Plans and the cost-sharing, please visit our website or call 1-866-986-0356.