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New York Essential Plan

Essential Plan

Updated for 2018: The Essential Plan is a  New York health insurance program for lower-income state residents that don't qualify for Medicaid or the Child Health Plus Program. There are a total of 4 Essential Plan options and each option is based on your household income level. Two of those Essential Plan options include dental and vision coverage while the remaining two options offer you the opportunity to purchase dental and vision coverage as a rider. Monthly premiums range from $0 to $46 per month.

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

 

Are You Eligible for the Essential Plan?

There are three qualifying elements for you to be eligible for  the NY Essential Plan. 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.

Essential Plan Family Size & Income Eligibility

 Household Size  Maximum Annual Income
  1* $24,120
 2 $32,480
 3 $40,840
  4** $49,200
*  (150% to 200% FPL)
** Add $8,280 for each additional member of your family 

 

Essential Plan Residency Requirements

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

Essential Plan 1 premiums are $20 per person per month and Essential Plan 2 costs $0, yet plan benefits are generous and provide you the ten essential health benefits mandated by the Affordable Care Act. Following are the different variations of the NYS Essential Plan:

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.

 

Aging In & Aging Out

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 past age 65 are usually covered by Medicare.

 

What Is Covered Under an Essential Plan?

Under the Affordable Care Act, certain minimum coverage is guaranteed to all insured people. The NY State of Health Essential Plan also features the same 10 health essentials. These are:

 

  1. Ambulatory patient services (outpatient care).
  2. Emergency Services (given in an emergency room of urgent care facility).
  3. Hospitalization (when you stay in the hospital 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 device (e.g. Physical therapy is one of the services and a brace is an example of a device).
  8. Laboratory services including 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).

 

Essential Plan 1 and Essential Plan 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.

PLAN NAME Essential Plan 1 Costs & Co-pays Essential Plan 2 Costs & Co-pays
Individual Deductible $0 (Med/Rx combined) $0 (Med/Rx combined)
Individual Maximum Out-of-Pocket $2,000 (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 PCP: $15 SPC: $25 OP Facility: $25 $0
Advanced Imaging $25 $0
PCP Office Visits $15 $0
Specialist Office Visits $25 $0
Adult Dental NC/Covered Not Covered/$15 if covered Not Covered/$0 If covered
Adult Vision NC/Covered Not Covered/$15 if covered Not Covered/$0 if covered
Non-Prescription Drugs Not Covered Not Covered
Non-Emergency Transportation Not Covered Not Covered
Generic drugs $6 $1
Preferred Brand Drugs $15 $3

Non-Preferred Brand and Specialty

$30 $3

 

 

Essential Plan 3 and Essential Plan 4

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

Plan Name Essential Plan 3 Costs  Essential 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 Dental Covered at no cost Covered at no cost
Adult Vision Covered at no cost Covered at no cost
Non-prescription Drugs Covered at no cost Covered at no cost
Non-emergency transportation Covered at no cost Covered at no cost
Prescription drugs $1 $0
Preferred brand drugs $3 $0
Non-preferred brand drugs and Specialty $3 $0

 

Essential Plan Plus

If you are a United States citizen who lives in New York State, there are features you can add to your basic coverage. They are vision and dental services. They are available for Essential Plan 1 and 2 and are called Essential Plan Plus.

 

Dental Benefits

Dental coverage is both for preventative care and routine care. If you sign up for the plus plan your oral care benefits include:

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

 

Essential Plan Vision Care Benefits

In addition, 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.

There is an additional cost for the Essential Plan Plus ranging from $30 to $46 per month per person.

 

Insurers offering Essential Plan 

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

  • Affinity Health Plan
  • Crystal Run Health Plan
  • 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
  • Wellcare of New York
  • YourCare Health Plan

 

Insurers Offering Essential Plan Vs. Essential Plan Plus (Vision and Dental Included)

Plan Name

Essential Plan

Essential Plan Plus (Vision and Dental Included)

Affinity Health Plan

X

X

Crystal Run Health Plan

X

X

EmblemHealth (Part of the HIP GHI family of plans)

X

X

Excellus Blue Cross Blue Shield

X

X

Fidelis Care

X

HealthFirst

X

X

HealthNow Blue Cross Blue Shield of Western New York

X

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

X

X

Independent Health

X

MetroPlus Health

X

X

Molina Healthcare

X

X

MVP

X

United Healthcare

X

X

Univera Healthcare

X

X

WellCare of New York

X

X

YourCare Health Plan

X

X

 

 

2018 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 2018.  Be advised that due to the changing healthcare landscape ,  carriers may  exit  the marketplace i.e. Affinity just announced their departure from the individual marketplace for 2018. Please Contact Vista for further information.

County Affinity Health Plan Crystal Run Health Plan Emblem Health Excellus Blue Cross Blue Shield Fidelis Care Health First Health Now Health plus HP Molina Health care MVP United Health care Univera Health care Well Care of New York Your Care Health Plan
Albany X X X X
Allegany X X X X
Bronx X X X X X X X
Broome X X X
Cattaraugus X  X X X
Cayuga X X X
Chautauqua X  X X X X
Chemung X X X
Chenango X X X
Clinton X X
Columbia X X X
Cortland X X X
Delaware X X
Dutchess X X X X
Erie X  X X X X
Essex X X X
Franklin X X X
Fulton X X X
Genesee X X X X
Greene X X X
Hamilton X X
Herkimer X X
Jefferson X X X X
Kings X X X X X X X
Lewis X X X X
Livingston X X X X
Madison X X X
Monroe X X X X
Montgomery X X
Nassau X X X X X X
New York X X X X X X X
Niagara X X X
Oneida X X X X
Onondaga X X X X
Ontario X X X X
Orange X X X X X X
Orleans X X X X
Oswego X X X
Otsego X X
Putnam X
Queens X X X X X X X
Rensselaer X X X
Richmond X X X X X X
Rockland X X X X
Saint Lawrence X X X X
Saratoga X X X
Schenectady X X X
Schoharie X
Schuyler X X
Seneca X X X
Steuben X X
Suffolk X X X X X
Sullivan X X X
Tioga X X X
Tompkins X X X
Ulster X X X X
Warren X X X
Washington X X
Wayne X X X
Westchester X X X X X
Wyoming X  X X X
Yates X X X

 

Choosing the Right Essential 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 an Essential Plan check to insure 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 four 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 to attract clientele. Below is a listing of carriers that have made their plan summaries and pharmacy formulary listings available.

Affinity Health Plan

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

MVP

United Healthcare

Univera HealthCare

WellCare of New York

YourCare Health Plan of New York

 

Essential Plan Enrollment Process

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

 

Frequently Asked Essential Plan Questions

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

When is enrollment? – Open enrollment is year-round.

What happens if I miss a premium payment? – Since premiums are paid in advance, if you miss a premium payment (if you pay premiums) you will lose your coverage for the next month. But, you can re-enroll at any time without penalty.

I have a copay and deductible, are any services free? Yes! Preventative care like a routine physical and some screening tests are not subject to the copay and deductible.

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.

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
  • 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.

How much does the Essential plan health insurance cost?

Individuals with income

  •  at or below 138% of the Federal Poverty Level (FPL) will have no premium.
  • higher than 138% - (less than or equal to)150% of the FPL will have no premium unless they select a plan with dental and vision.
  • greater than 150%- (less than or equal to) 200% of the FPL will have a premium of $20 per individual per month and a higher premium if selecting dental and vision plan.

 

2018 Essential Plan Updates

For 2018, there will be a total of 15 health insurance carriers offering essential plan coverage throughout the 62 counties of New York.

Putnam and Schoharie will only have one carrier each in their county; HealthPlus HP (Empire BlueCross BlueShield) and Excellus respectively.  The following 8 counties will have 2 Essential Plan carriers in their area: Clinton, Delaware, Hamilton, Herkimer, Montgomery, Schuyler, Steuben, Washington.

The Essential Plan will have a new carrier, Molina healthcare of New York. Molina is primarily a Medicaid Managed Care (MMC) and Child Health Plus (CHPlus) carrier but for 2018, they will be offering the Essential Plan  and the Essential Plan Plus options in Cortland, Onondaga and Tompkins County.

 

Closing

The Essential plan is a cost effective NYS 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 info@nyhealthinsurer.com