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The Essential Plan is a  New York health insurance program for state residents who don't qualify for Medicaid or the Child Health Plus Program. There are a total of 5 Plan options and each option is based on your household income level. 

New York State (NYS) created this program to fill the coverage gap many individuals and families have as they do not qualify for Medicaid but cannot afford full premium coverage. 

 

 

 

How to Enroll in the NY Essential Plan

  • Contact us at our toll-free number (888)215-4045 and we will first help you determine if you are eligible. Once we determine your eligibility, we compare all available Health insurance companies offering the essential plan in your region. Our comparison will ensure that your current doctor is part of the network as well as compare network size to determine if the hospitals and labs of your choice are included in the network
  • You have the option to visit each carrier to review their plans however you won't be able to compare plans side by side
  • The New York State of Health is another enrollment option. You can go direct or we can enroll you in the plan of your choice

 

 

What Does the Essential Plan Cost?

All plans have removed their monthly premium requirements making the essential plan a free New York Health Plan! There are 5 plan options, each based on your current income. There are no family plans, only individual coverage.  Children are not eligible f however, if the parent(s) qualify, children are most likely eligible for Child Health Plus (we provide enrollment services for Child Health Plus).

 

 

Are You Eligible?

There are three qualifying elements for you to be eligible. They are:

  1. Income requirements
  2. Residency and Immigration Status
  3. Aging In and Aging Out

Income limits are related to your family size. The following chart explains how your income and family size are structured.

Household Size
Maximum Annual Income
1*$37,650
2$51,100
3$64,550
4**$78,000
* (150% to 250% FPL)
** Add $13,450 for each additional member of your family

 

 

Residency Requirements

Low and moderate-income families that are residents of New York State and legal immigrants are eligible for the Essential Plan program.

All five plans don't have a monthly premium, yet plan benefits are generous and provide the ten essential health benefits mandated by the Affordable Care Act. The following are the different variations:

Essential Plan 1 - Individuals with income greater than 150% and less than or equal to 200% of the FPL.

Essential Plan 2 - Individuals with income greater than 138%  and less than or equal to 150% of the FPL.

Essential Plan 3 - Individuals with income equal to or greater than 100%  and less than or equal to 138% of the FPL and not eligible for Medicaid due to immigration status.

Essential Plan 4 - Individuals with income below 100% of the FPL and not eligible for Medicaid due to immigration status.

Essential Plan 5 -  Individuals with income greater than 200%  and less than or equal to 250% of the FPL.

 

 

Aging In & Aging Out of the Essential Plan

If you are an adult that is between 19 and 65 years of age then you can participate in the program. Children under age 19 may qualify for Child Health Plus and those that are past age 65 are usually covered by Medicare.

 

 

What Is Covered 

Under the Affordable Care Act, all insured people should receive health care including the 10 minimum essential coverage. The NY State of Health Essential Plan also features the same 10 health essentials.

 

10 Minimum Essential Coverage

  1. Ambulatory patient services (outpatient care).
  2. Emergency Services (given in an emergency room or urgent care facility).
  3. Hospitalization (when you stay in the hospital for more than 24 hours, fewer hours are covered under ambulatory services).
  4. Maternity and newborn care.
  5. Mental health service and drug or alcohol addiction treatment (treated as any other medical illness).
  6. Prescription drugs.
  7. Rehabilitative services and devices (e.g. Physical therapy is one of the services and a brace is an example of a device).
  8. Laboratory services include X-rays, CAT scans, ultrasounds, and such.
  9. Preventative services
  10. Pediatric services (not applicable to New York State Essential Plan as kids under 19 are covered by Child Health Plus).

 

 

NYS Essential Plans 1 and 2

To qualify for either plan 1 or 2 your household income must be between 138% and 200% of the federal poverty level, be a United States citizen living in New York State, and not enrolled in Medicare or Medicaid or be under the age of 19 or older than 65.

BenefitsEssential Plan 1 Costs & Co-paysEssential Plan 2 Costs & Co-pays
Individual Deductible$0 (Med/Rx combined)$0 (Med/Rx combined)
Individual Maximum Out-of-Pocket$360 (Med/Rx combined)$200 (Med/Rx combined)
Inpatient Hospital Care$150$0
Emergency Care$75$0
Urgent Care$25$0
Outpatient Hospital Services$50$0
X-rays and Labs$25$0
Advanced Imaging$25$0
PCP Office Visits$15$0
Specialist Office Visits$25$0
Adult Dental$0$0
Adult Vision$0$0
Non-Prescription DrugsNot CoveredNot Covered
Non-Emergency TransportationNot CoveredNot Covered
Generic drugs$6$1
Preferred Brand Drugs$15$3
Non-Preferred Brand and Specialty$30$3

 

 

NYS Essential Plans 3 and 4

To qualify for Essential Plan 3 or Essential Plan 4, you must first meet all of the requirements of plans 1 and 2, and you must be a legal permanent resident immigrant living in New York State.

Plan NameEssential Plan 3 CostsEssential Plan 4 Costs
Individual Deductible$0$0
Individual Maximum Out-of-pocket$200$0
Inpatient Hospital Care$0$0
Emergency Care$0$0
Urgent Care$0$0
Outpatient Hospital Services$0$0
X-ray/Labs$0$0
Advanced Imaging$0$0
PCP Office Visits$0$0
Specialist Office Visits$0$0
Adult DentalCovered at no costCovered at no cost
Adult VisionCovered at no costCovered at no cost
Non-prescription DrugsCovered at no costCovered at no cost
Non-emergency transportationCovered at no costCovered at no cost
Prescription drugs$1$0
Preferred brand drugs$3$0
Non-preferred brand drugs and Specialty$3$0

 

 

NYS Essential Plan 5

To qualify for either plan 5, your household income must be between 200% and 250% of the federal poverty level, be a United States citizen living in New York State, and not enrolled in Medicare or Medicaid or be under the age of 19 or older than 65.
BenefitsEssential Plan 5 Costs & Co-pays
Individual Deductible$0 (Med/Rx combined)
Individual Maximum Out-of-Pocket$2,000 (Med/Rx combined)
Inpatient Hospital Care$150
Emergency Care$75
Urgent Care$25
Outpatient Hospital Services$50
X-rays and Labs$25
Advanced Imaging$25
PCP Office Visits$15
Specialist Office Visits$25
Adult Dental$0
Adult Vision$0
Non-Prescription DrugsNot Covered
Non-Emergency TransportationNot Covered
Generic drugs$6
Preferred Brand Drugs$15
Non-Preferred Brand and Specialty$30

 

Dental Benefits

Dental coverage is both for preventative care and routine care. benefits include:

  • Two Cleanings per year
  • Oral Exams including X-rays
  • Fillings
  • Extractions
  • Emergency care
  • Orthodontics
  • Dentures
  • Fixed bridges

 

 

Vision Care Benefits

Also, your vision care benefits include:

  • One annual eye exam per year
  • Other diagnostic exams performed by an eye doctor
  • Lenses or contacts once a year (more often if medically necessary
  • Frame one time per year unless there is a medical need

 

 

Insurers offering Essential Plan 

The following health insurance companies are participating in the NY State of Health Essential Plans:

  • Affinity Health Plan
  • CDPHP
  • EmblemHealth (Part of the HIP GHI family of plans)
  • Excellus Blue Cross Blue Shield
  • Fidelis Care
  • Healthfirst
  • HealthNow Blue Cross Blue Shield of Western New York
  • HealthPlus HP (formerly known as Empire Blue Cross Blue Shield Health Plus)
  • Independent Health
  • MetroPlus Health
  • Molina Healthcare
  • MVP
  • United Healthcare
  • Univera Healthcare

 

 

2024 Essential Plan Insurers and the Counties They Operate In 

Below is a table listing the Major New York Essential Plan carriers and the respective counties they operate in as of 2024. This list is horizontally scrollable  →

CountyAnthem BCBS HealthPlusCDPHPEmblem HIPExcellus BlueCross BlueShieldFidelis CareHealthfirstHighmark BCBSIndependent HealthMetroPlus Health PlanAffinity by Molina HealthcareMVP Health CareUnited HealthcareUnivera Healthcare
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond
Rockland
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
St Lawrence
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming
Yates

 

 

Choosing the Right Plan for You and Your Family

Most counties in New York State have more than one Essential Plan health insurance company for you to choose from. Since many insurance companies have contracts with different doctors and hospitals, it may be that your preferred doctor and hospital are not on every plan offered. When you shop for a plan, check to ensure that your doctor(s) and preferred hospital are part of the provider network.

 

 

Carrier Summary of Benefits and Formulary Listing

While the Essential plan only has five options that are based on income. Each carrier often includes additional benefits such as telehealth, teledoc, gym reimbursement programs, and wellness programs to create brand awareness and attract clientele. Below is a listing of carriers that have made their plan summaries and pharmacy formulary listings available.

 

 

 

Affinity Essential Plan

Affinity By Molina Healthcare

 

 

CDPHP Health Insurance

CDPHP Health Plan

 

 

EmblemHealth Essential Plan

EmblemHealth (Part of the HIP GHI family of plans)

 

 

Excellus Essential Plan

Excellus Blue Cross Blue Shield

 

 

Fidelis Care Essential Plan

Fidelis Care

 

 

HealthFirst Essential Plan

HealthFirst 

 

Highmark Blue Cross Blue Shield

 

 

Anthem HealthPlus (formerly known as Empire Blue Cross Blue Shield Health Plus)

 

 

Independent Health Essential Plan

Independent Health

 

 

Metroplus Essential Plan

MetroPlus Health

 

 

MVP Essential Plan

MVP

 

 

United Healthcare Essential Plan

United Healthcare

 

 

Univera Essential Plan

Univera Healthcare

 

 

Eligible Enrollment Dates

Unlike other plans available under the Affordable Care Act, you can enroll in a  New York State Essential Plan any time throughout the year. 

 

 

Frequently Asked Questions

 

How do you qualify for the NY Essential Plan?

You may qualify if you're between ages 19 and 64 and earning between $20,121 and $37,650 annually, or if your family meets the income eligibility. Check the Eligibility Chart to see if you may qualify.

How do I prove my income?

During the application process, you will need to provide specific documents proving your household income, such as a filed tax return, paycheck stubs, and if you’re unemployed, proof of unemployment income, to name a few.

What is the income limit?

Income limits are between $20,121 and$37,650 annually for a single person. 

What documents do I need?

You will need to verify income and the most common documents used are payroll stubs, tax returns, and if applicable unemployment income.

Can I enroll at any time of the year?

Yes, as long as you meet the income threshold and qualifying guidelines.

Can I qualify for if I am unemployed?

Yes, just be sure to prepare your Unemployment Benefit documents so your qualification can be calculated accurately.

Can a student be on the plan?

Yes, as long as they are 19 years old and above, and their income and eligibility requirements meet the threshold to qualify.

Can I get an Essential Plan even if I’m not in New York?

No. They are only available to New York residents.

How long do I need to be a New York resident to get an Essential Plan?

No specific duration is required for individuals to qualify. You just need proof that you are currently residing in New York State.

Does my immigration status matter? 

It does. However, most immigrants can qualify if they meet other eligibility requirements. These requirements include:

  • You became a citizen or you have DACA status (Deferred Action for Childhood Arrivals)
  • You are a legal permanent resident
  • A lawfully present resident
  • In a valid and non-immigrant status, such as a visiting student with a valid visa.

Do I qualify if I’m a freelancer and my income is not stable?

New York freelancers may qualify based on their estimated annual income at the time of applying. Make sure to prepare your latest proof of income before the start of the application process.

When does my essential plan coverage begin?

The essential will always have a start date of the 1st  of the month 

Can I still enroll in an Essential Plan even though I have a serious health problem?

Yes. Just like all Obamacare plans, you cannot be denied enrollment or discriminated against based on pre-existing health conditions, ensuring accessibility to coverage for individuals with serious health problems.

How long is the application process?

The application process can take around 20-45 minutes and it is highly advisable to receive assistance from one of our qualified agents

What kind of information do I need to give when I apply for an Essential Plan?

You will need to provide your address, social security number, and income history. Additionally, documents verifying U.S. citizenship, New York state residency, and date of birth may be required.

I’m pregnant, can I be covered by the NYS Essential Plan?

No, but that is because you are eligible for coverage under the New York State Medicaid Program.

What does the Plan cover?

It covers the 10 essential health benefits required by law and it's a free NY health insurance plan. It's meant for people of New York who earn too much for Medicaid but don’t make enough to get Qualified Health Plans.

Can my employer pay for my NYC Essential Plan insurance?

No, employers are prohibited from reimbursing premiums to employees. Additionally, if there is an employer-sponsored health insurance plan that is deemed affordable, then the essential plan is not an option for you.

 I’m an employer, can I get the Plan for my employees?

No, as they are not offered to businesses; however, if your business doesn't offer medical insurance to all employees, then your employees can get their own NY health insurance plan, including the Essential Plan, as long as the employees qualify for it.

Can an employee get an Essential Plan?

Yes, but only if the employer-sponsored plan is deemed unaffordable according to  Affordable Care Act (ACA) standards. If the premium exceeds 8.39% of the employee’s household income, it is considered unaffordable.

If my employer offers health insurance, can I instead choose an Essential Plan?

If your employer-sponsored health insurance is too expensive (greater than 8.39% of your income), you can choose to decline the employee-sponsored plan and get an NYC Essential plan, as long as your income meets the eligibility threshold.

What happens if my income changes during the year?

You’ll need to update your income details in your NY State of Health portal so they can properly calculate your eligibility. Failure to report significant income changes may lead to tax implications.

Can I cancel anytime?

Yes, just be sure that you have new coverage in place so you’re not left without an active health insurance plan

Can I backdate my start date?

If you don't have an existing health insurance policy, then yes, your coverage will be retroactive to the 1st of the current month. If you have an existing plan, then your policy will become effective the first of the following month, if you applied before the 15th, otherwise, your plan will become effective the following month thereafter. 

Can I switch carriers anytime I choose?

Yes, you can cancel your Essential Plan and switch to a different carrier anytime you choose, as long as your income is still within the threshold. 

What if my Primary Care Physician (PCP) leaves the network mid-coverage?

You can choose another provider or cancel your current Plan and Enroll in a new plan that has your doctor in-network.

I only need 3 months of coverage. can I cancel after that?

Yes, you can cancel your plan at any time. However,  it’s recommended to secure a new health plan before canceling your Plan, for a smoother transition and continued coverage. 

I am under my parent's plan right now and I’m turning 26 tomorrow. Should I enroll immediately to qualify?

You can enroll anytime you like, as long as your income is within the qualifying income threshold. 

When do I renew?

The plan will renew after 1 year.

What happens if I miss a premium payment?

All plans are now zero premium.

When do I get my Member ID card?

Typically, your health insurance member ID card arrives 7-10 days after enrollment, but this timing can vary. If it hasn't arrived within that period, contact your insurance provider for assistance.

Do I need to get referrals to see a specialist?

You don’t need referrals to see a specialist.

Does the Essential Plan have out-of-network benefits?

They do not have out-of-network benefits, except for emergencies.

Are dental and vision covered under the NYC Essential Plan?

Yes, dental and vision are covered, but make sure to check the summary of benefits for a complete listing of covered services

Do I need to select a PCP (primary care physician)?

No. You are not required to select a primary care physician. 

What’s the difference between an Essential Plan and Medicaid?

The Essential Plan is a New York exclusive plan for individuals with slightly higher income than Medicaid. It features a zero premium and moderate cost-sharing expenses

How much does the Essential Plan cost?

They have a zero premium and are subsidized by the state of New York.

How much is a mail-order generic prescription?

Since there are 4 different plan options, copayments for mail-order generic prescription drugs for a 30-day supply are as follows: Plan 1 - $15, Plans 2 & 3 - $2.50, and Plan 4 has a zero copay

What is the deductible?

The Essential Plan has a $0 deductible.

Are there any hidden charges in this plan?

All of the costs associated with plan usage can be found in the summary of benefits. And you always have the opportunity to contact your health insurance carrier with questions regarding plan costs

How can I get specialty care?

You can receive care directly from your specialist. Please note that procedures and drugs ordered by the specialist may be subject to prior authorization.

Is preventative care free?

Yes, preventative care such as office visits, screenings, and immunizations is free.

What is the MOOP (maximum out-of-pocket)  for the Essential Plans?

Since there are 4 different plans, The maximum out-of-pocket for all plans are as follows: Plan 1 - $360, Plans 2&3 - $200, and Plan 4 - $0

Can I use my Essential Plan to replace my broken wheelchair?

You can use your plan to buy a replacement wheelchair at 5% coinsurance. However, prior authorization may be needed in some cases.

Is Acupuncture covered?

Acupuncture is not an essential health benefit in New York, and is not covered.

Do I need to get prior authorization for my hospital stay to be free?

Yes, you do need prior authorization from your health insurance carrier for your hospital stay to be cost-free.

How much is the emergency room care in case I ever need one?

Emergency Room copayments under the 4 offered plans are as follows. Plan 1 has a $75 copay, while Plans 2-4 have a zero copay

Are blood tests covered if it’s not ordered by my PCP (primary care physician)?

No. Only blood tests ordered by your PCP are covered under. 

Is my dialysis covered?

Hemodialysis and Renal Dialysis are both covered benefits.

 I am a diabetic. Does the essential plan cover my insulin pump?

Insulin pumps fall under the durable medical equipment category, which is a covered expense. However, strict guidelines and regulations need to be followed before prior authorization is granted.

My procedure needs anesthesia. does my essential plan cover that?

Anesthesia needed for a procedure ordered by your specialist is fully covered.

Is vasectomy covered by the essential plan?

Vasectomy services are covered. For Plan 1, You will pay a $50 facility fee and another $50 copay for the surgeon. This surgery, however, is fully covered by plans 2-4.

I am morbidly obese and in need of a gastric bypass. Does the essential plan cover that?

Fortunately, New York is one of the states that follow the ACA mandate for health insurance carriers to cover Bariatric Surgery. 

What’s the difference between a metal plan and an Essential Plan?

Metal plans are standardized health insurance options available nationwide, categorized by the following levels; bronze, silver, gold, and platinum. The Essential Plans are specific to New York, offering zero-premium coverage for individuals with limited income who do not qualify for Medicaid.  Despite the significant premium difference between essential and metal plans, both types cover the 10 essential health benefits required under Obamacare.

I have a copay, are any services free?

Yes! Preventative care like a routine physical and some screening tests is not subject to the copay.

What medical services does the Essential Plan cover?

The plans cover the same mandatory services covered by other plans sold in New York. These services are known as Essential Health Benefits. In broad terms, this includes:

  • Doctor visits, including specialists
  • Tests ordered by your doctor
  • Prescription drugs
  • Inpatient and outpatient care at a hospital

Can I get the plan for my family?

Only adults ages 19 and up can qualify. Additionally, each qualifying family member would have an individual policy. Family members under 19 may qualify for Child Health Plus. 

Can the plan cover my child?

Yes, if they are 19 and older, but each qualified child requires a separate plan since it’s a one-person policy. Children under 19 may be eligible for Child Health Plus.

 

 

2024 Plan Updates

Updated for 2024: New York is expanding its offerings with the Essential Plan 5 This plan brings significant changes in the income eligibility levels, which have been increased from 200% of the Federal Poverty Level (FPL) to 250%. This relates to a dollar amount increase in annual income from $30,000 to $37,650. Federal regulators have approved this expansion for 5 years, which will be in effect from 2024 to 2028. The plan is expected to benefit around 70,000 New Yorkers enrolled in other Qualified Health Plans and 12,000 Deferred Action for Childhood Arrivals (DACA) individuals enrolled in Medicaid/Child Health Plus (CHPlus). Additionally, about 20,500 currently uninsured New Yorkers should now be eligible for this new plan

Essential Plan applicants that don't have an active health plan in place, will have a retroactive date for the 1st of the month. Example. You don't have an active health insurance policy and applied on 11/16, your plan effective date will be 11/1

Income limits have been increased making more New York State residents eligible for the Essential Plan. All Plans now include Dental and Vision Coverage at no additional cost.  Additionally, the monthly premium of twenty dollars for Plan 1 has been removed. All five plans will now have a zero premium.

For 2024, there will be a total of 13 health insurance carriers offering essential plan coverage throughout the 62 counties of New York.

CDPHP will be offering its services to more counties namely Chenango, Delaware, Dutchess, Hamilton, Herkimer, Jefferson, Lewis, Madison, Oneida, Otsego, St. Lawrence, and Ulster.

Emblemhealth will further expand its reach and offer plans in Dutchess, Orange, Putnam, and Rockland Counties.

Independent Health will be halting its plans offered in Niagara and will be offering its services solely in Erie County.

 

 

2023 Plan Updates

For 2023, there will be a total of 14 health insurance carriers offering essential plan coverage throughout the 62 counties of New York.

The following 16 counties will have 1 Essential Plan carrier in their area: Allegany, Broome, Cattaraugus, Chautauqua, Chenango, Erie, Genesee, Livingston, Monroe, Ontario, Orleans, Putnam, Seneca, Tioga, Wayne, and Westchester. 

EmblemHealth is now offering the NYC essential plan in Orange, Dutchess. Rockland and Putnam counties, for a total of 12 out of 62 New York counties

Molina Healthcare, a relatively new carrier in New York (who recently purchased YourCare Health Plan of New York) has expanded its plan offering to a total of 28 counties, of which 10 counties are the Affinity by Molina Healthcare Plan. Those 10 counties are; Bronx, Kings, Nassau, New York, Orange, Queens, Richmond, Rockland, Suffolk, and Westchester.

Highmark Inc., a national health and wellness organization, announced its completion of affiliation with Healthnow New York Inc. and will now be offering Medicaid and the essential plan to New Yorkers in 8 counties.

 

Closing

Offered by the New York State of Health, the Essential plan is a cost-effective NY health insurance plan available to those who earn too much to qualify for Medicaid while providing all of the essential health benefits required by law.

"Vista Health Solutions" www.nyhealthinsurer.com Tel (888)215-4045 Email [email protected]