Plan information

Anthem Blue Cross and Blue Shield (Anthem) is a wholly owned subsidiary of Anthem, Inc. (Anthem).

• As a leader in managed healthcare services for the public sector, Anthem Corporation’s subsidiary health plans provide healthcare coverage exclusively to low-income families, seniors and people with disabilities.
• Anthem is an award-winning Prepaid Health Service Plan (PHSP) that provides and manages government-sponsored health insurance programs to eligible members in the five boroughs of New York City as well as Nassau, Suffolk, Westchester and Putnam counties.
• Currently, we provide Child Health Plus (CHPlus), Medicaid Managed Care (MMC) and Managed Long-Term Care (MLTC) services to over 400,000 members and are one of the largest health plans in New York City.

We’re dedicated to improving the quality of life of each member by providing the best and most reliable healthcare to the communities we serve. Our extensive community outreach efforts were recognized by the American Association of Health Plans’ Community Leadership Award.

Essential Plan

The Essential Plan is a health benefit coverage program for low- to moderate-income residents who would otherwise be ineligible to purchase coverage through the Health Insurance Marketplace or to qualify for Medicaid or Child Health Plus.

To qualify for the Essential Plan through Anthem Blue Cross and Blue Shield, individuals must:

1. Live in New York in the following counties of our service area:
   • New York City boroughs (Bronx, Brooklyn, Manhattan, Queens, Staten Island)
   • Putnam County
   • Nassau County
2. Be between the ages of 19 and 64 years old.
3. Not be pregnant
   • Pregnant women are not eligible for Essential Plan because they qualify for Medicaid Essential Plan members are required to report their pregnancy and the NY State of Health will determine their eligibility for Medicaid at that time.
4. Be U.S. citizens earning more than the Medicaid eligibility threshold, but less than 200% of the Federal Poverty Level (FPL); or be lawfully present immigrants (i.e., green card holders and those seeking refugee status), earning less than 200% of the FPL.

For more information on eligibility, enrollment and coverage, view the Essential Plan provider manual .

Health Home Care Management for Medicaid Members with Chronic Conditions

New York state (NYS), following CMS approval, initiated a Health Home program for Medicaid members with chronic medical and behavioral conditions effective January 2012. Health Home eligibility criteria requires members to have one or more of the following:

• Two or more chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25 or other chronic conditions)
• One qualifying chronic condition (e.g., HIV/AIDS) and the risk of developing another
• One serious mental illness

What is a health home?

• A Health Home is a care management service model whereby all of a patient’s caregivers communicate with one another so that all needs are addressed in a comprehensive manner. This is done primarily through a dedicated care manager who oversees and provides access to all of the services the patient needs to ensure he or she receives everything necessary to stay healthy, out of the emergency room and out of the hospital.
• Health Home Care Managers provide comprehensive, integrated medical and behavioral healthcare management to Medicaid-enrolled adults with chronic conditions to ensure access to appropriate services, improve health outcomes, prevent hospitalizations and emergency room visits and avoid unnecessary care.
• Health records are shared (either electronically or paper) among providers so that services are not duplicated or neglected.
• The health home services are provided through a network of organizations — providers, health plans and community-based organizations. When all the services are considered collectively, they become a virtual Health Home.

How it works

The care manager works with the member to complete the Health Home Patient Information Sharing Consent Form to ensure enrollment. By signing the form, they agree to share their health information with:

• His or her primary care provider, specialists, and home health providers.
• Other types of community-based service providers.
• Anthem Blue Cross and Blue Shield (Anthem).

To ensure coordination of care, the member has one point of contact. The care manager will schedule the patient’s appointments, coordinate transportation, follow up to confirm appointments were kept, track outcomes and more.

How can I join the Health Home program as a provider in New York State?

You can voluntarily join an existing entity, or you can form a group with other providers. You must apply to the state to become a certified entity where one provider is identified as the lead applicant.

For more information about Health Home for Medicaid members, please visit the Health Homes FAQ page on the NYSDOH website .

Related resources

For full details regarding Health Home and other plan information for Anthem Blue Cross and Blue Shield members, please refer to the provider manual.

Provider tools & resources

• Log in to Availity
• Launch Provider Learning Hub
• Learn about Availity
• Prior Authorization Lookup Tool
• Prior Authorization Requirements
• Claims Overview
• Reimbursement Policies
• Provider Manuals, Policies & Guidelines
• Referrals
• Provider Training Academy
• Forms
• Pharmacy Information
• Provider News & Announcements

Interested in becoming a provider in the Anthem network?

We look forward to working with you to provide quality services to our members.

© 2023 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of HealthPlus, LLC, an independent licensee of the Blue Cross and Blue Shield Association.

* Availity, LLC is an independing company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

* CarelonRx, Inc. is and independent company providing pharmacy benefit management services on behalf of the health plan.

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