September 2022

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Overview

MetroPlus Health Plan is a prepaid health services plan and a wholly owned subsidiary of NYC Health + Hospitals (H+H). MetroPlus contracts with H+H and other providers to offer managed care health care services such as Medicaid, Essential Plan, Child Health Plus (CHP) and Medicare Advantage plans, plans for eligible New York City employees and day care workers of City agencies, and private plans through NY State of Health (NYSOH, the State’s online marketplace) for over 670,000 members. Changes in MetroPlus enrollment have a direct impact on H+H's financial stability. As more of its members choose H+H as a provider, the hospital system generates more revenue, an explicit goal of its strategic plan. This brief provides an update to MetroPlus enrollment trends as discussed in our report: NYC Health + Hospitals Check-Up: The Impact of COVID-19.

Pandemic Impact on MetroPlus Health Plan Enrollment

MetroPlus enrollment reached a record high of 670,915, an increase of 159,284 members (31 percent) between February 2020 and June 2022, the period impacted by the COVID-19 pandemic (see Figure 1).

FIGURE 1 – MetroPlus Enrollment

Sources: MetroPlus Health Plan; OSC analysis

Nearly 70 percent of MetroPlus membership is enrolled in the mainstream Medicaid managed care plan which experienced the largest actual membership growth of all plans offered. Enrollment in the Essential Plan, a subsidized basic health plan offered through NYSOH, experienced the largest growth rate of all plans at 44 percent (see Figure 2). In late January 2020, the Secretary of the U.S. Department of Health and Human Services (HHS) declared a public health emergency (PHE) for COVID-19 which permits the Centers for Medicare & Medicaid Services (a federal agency in the HHS) to grant states emergency flexibilities to respond to the crisis. The federal Families First Coronavirus Response Act, enacted in March 2020, authorized fiscal relief to states that created a requirement to keep most beneficiaries continuously enrolled in Medicaid during the PHE. The New York State Department of Health (DOH) is allowed to keep people enrolled in Medicaid, CHP and the Essential Plan without them going through their annual renewal while continuing to enroll newly eligible individuals. This provision means enrollment in these plans will likely continue to rise through the PHE which is currently authorized through mid-October 2022. 

FIGURE 2 – MetroPlus Enrollment By Plan Type

Notes: NY State of Health includes health plans for individuals and small businesses. Specialized Medicaid managed care plans include long-term care plans. MetroPlus Gold plans are available for all city employees and NYC day care workers of the Day Care Council of NY Local 205, DC 37 Welfare Fund. The Essential Plan is a subsidized basic health plan offered with the NY State of Health.

Sources: MetroPlus Health Plan; OSC analysis

Additionally, MetroPlus experienced an increased market share in mainstream Medicaid Managed Care and Essential Plan enrollment in the City. The MetroPlus share of citywide enrollment in mainstream Medicaid managed care plans, that covers the largest share of its members, increased from 14.8 percent in February 2020 to 15.8 percent in June 2022, the highest since 2014 (based on year over year February data) and the third largest plan in the City. Enrollment in these plans grew by 34 percent while enrollment in all other Medicaid Managed Care plans offered in the City grew by 24 percent. MetroPlus share of citywide enrollment in the Essential Plan increased from about 17 percent to 19 percent during the same time period. 

MetroPlus Financial and Operational Impact on NYC Health + Hospitals

The financial stability of H+H is impacted by MetroPlus' ability to continue to attract new members and maintain its current membership, while focusing on better care management. To maximize revenues from MetroPlus, H+H is working with it to attract more of its members to utilize H+H’s health services and engage its members in routine chronic care management to avoid unnecessary high-cost utilization. Moreover, to address the needs of MetroPlus members with frequent hospital utilization at H+H, it has also taken steps to ensure that members have access to comprehensive care management including services that address medical, social and behavioral health needs. For example, in 2017, MetroPlus and H+H established a housing taskforce to connect H+H patients in need of affordable and supportive housing, including those that are MetroPlus members. As a result, over 300 MetroPlus members have been housed. Increasing use of primary care and specialty care services by insured patients at H+H healthcare facilities directly supports H+H’s strategic plan toward fiscal stability.

Despite MetroPlus’ and H+H’s efforts, the majority of MetroPlus members use health care providers other than H+H. The share of MetroPlus spending at H+H facilities declined from 40 percent in fiscal year (FY) 2019 to 39.1 percent in FY 2021 and rebounded in FY 2022 to 42.6 percent, but has yet to reach the H+H target of 45 percent (see Figure 3).

FIGURE 3 – Share of MetroPlus Medical Spending at H+H

Note: Third quarter data of each fiscal year.

Sources: MetroPlus Health Plan; OSC analysis

As part of its outreach efforts to obtain new members, MetroPlus directs individuals that are not eligible or cannot afford insurance to the NYC Care program, a financial assistance program which provides a broad range of health care services at H+H facilities on a sliding scale fee.

In line with the DOH’s efforts toward statewide Medicaid payment reform, H+H and MetroPlus have entered an agreement that incentivizes reimbursements based on quality and cost effectiveness of care, from a model that reimburses based on volume. This value-based payment (VBP) arrangement requires H+H to take on the medical risk of all covered services for all eligible patients within the VBP arrangement, even if that care is provided outside of the H+H system. MetroPlus makes a payment to H+H after settling the net amount remaining after paying for all medical expenses associated with the VBP arrangement. The risk sharing payables were $199 million and $428 million in FY 2021 and FY 2020, respectively.

In 2020, during the first wave of the COVID-19 pandemic, MetroPlus ranked the highest of 15 Medicaid Managed Care plans across the State in the DOH’s quality incentive program which assesses performance covering a wide range of quality measures.  

Wind Down of the Federal Public Health Emergency

When the PHE expires, the continuous enrollment provision will conclude as well as other enrollment flexibilities granted during the PHE. According to federal guidance, the DOH will need to return to regular eligibility and enrollment operations and complete all renewals within 14 months, a daunting process as Medicaid enrollment has reached record levels and renewals have not been processed in almost two and a half years. In preparation for the sunset of the PHE, the State has provided tools to assist stakeholders to inform enrollees about renewing their coverage. MetroPlus has developed strategies for education and outreach to its membership to maintain the enrollment growth achieved during the pandemic. It is likely that enrollment in these plans will decline when the process of member renewals returns to normal procedures and some members will not renew or become ineligible for coverage. However, the State fiscal year 2023 Enacted Budget includes provisions that expand eligibility in public health plans offered through MetroPlus. 

If MetroPlus is successful in adding newly eligible members to its plans it might offset any potential loss in enrollment. MetroPlus enrollment is at levels it has never reached before, but this will be challenging to maintain during the wind down of the PHE. MetroPlus in coordination with H+H is working to facilitate rapid reenrollment in Medicaid for those still eligible, and shift those who lose eligibility to Essential Plan coverage. MetroPlus is engaging City and State partners to continue to ease these transitions through effective use of public benefits data and eligibility flexibilities still available from the federal government to maintain members’ insurance coverage and prevent lapses in care. Continued collaboration with New York State remains critical to aid this effort. 

Additionally, H+H must continue to provide quality care and maintain efforts to improve patient satisfaction, such as keeping appointment wait times low, to continue to attract MetroPlus members. These efforts will enable H+H to work toward its goal of 45 percent of MetroPlus medical spending and therefore help to successfully execute on its strategic plan.