Provider Alert: MetroPlusHealth Ends PCP Referral Requirement for Gold Plan
07/06/2026
MetroPlusHealth Gold Plan: PCP Referrals No Longer Required for In-Network Specialists (Effective June 1, 2026)
What Happened
MetroPlusHealth has announced a significant change to its Gold Plan, the insurance product designed for New York City municipal employees — the workforce that keeps city services running. Effective June 1, 2026, referral requirements have been waived for all Gold Plan members seeking care from participating in-network specialists. Members no longer need to obtain a referral from their primary care provider before booking a specialist appointment. MetroPlusHealth has communicated this change directly to Gold Plan members as well.
What Providers Should Watch For
While the referral requirement has been removed, prior authorization requirements remain fully in effect and are unchanged. Providers should not assume that the waiver of referrals extends to prior authorization — these are two separate requirements, and any services that previously required prior authorization still do. Failing to obtain required prior authorizations will continue to result in claim denials regardless of referral status.
On the care coordination side, the expectation is that providers continue to document specialist visits in the member's chart and coordinate care with other treating providers as they would have before. The removal of the referral step is about reducing administrative friction for members — it is not a signal to reduce clinical communication between care team members.
What to Do
Update your front desk and billing staff so they are aware that Gold Plan members presenting for specialist care do not need to produce a PCP referral as of June 1, 2026. Verify plan membership at the time of service as you normally would. Continue to check prior authorization requirements for each service through your standard process — nothing in this update changes that workflow.
If a Gold Plan member was previously denied access or turned away due to a missing referral for dates of service on or after June 1, 2026, that situation may warrant a review.
For questions about this change or to clarify which members are enrolled in the Gold Plan, contact MetroPlusHealth Provider Relations Operations at providerrelationsops@metroplus.org.