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New York Essential Plan. The #1 most affordable health plan in NY

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Updated for 2023: Income limits have been increased making more New York State residents eligible for the Essential Plan. All Essential Plans now include Dental and Vision Coverage at no additional cost.  Additionally, the monthly premium of twenty dollars for Essential Plan 1 has been removed. All four essential plans will now have a zero premium.

The Essential Plan is a  New York health insurance program for 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. 

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. 

 

TABLE OF CONTENTS

 

 

How to Enroll in the Essential Plan

Before Enrolling in an Essential plan, you may want to review the eligibility requirements, however, your options to enroll include the following:

  • 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 then compare all of the 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?

Starting in 2021 all Essential plans have removed their monthly premium requirements and are now free! There are a total of 4 Essential plan options, each based on your current income. There are no family plans with the essential plan, only individual coverage.  Children are not eligible for the Essential Plan, however, if the parent(s) qualify for the Essential then the children are most likely eligible for Child Health Plus (we provide enrollment services for Child Health Plus)

 

 

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 is structured.

Household Size
Maximum Annual Income
1*$29,160
2$39,440
3$49,720
4**$60,000
* (150% to 200% FPL)
** Add $10,280 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.

All four Essential 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. 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 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 an Essential Plan?

Under the Affordable Care Act, a certain level of 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 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).

 

 

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.

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$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$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

 

 

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 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

 

 

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

 

 

Essential Plan 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.

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 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

 

 

2023 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 2020. This list is horizontally scrollable  →

CountyAffinity Health PlanBlueCross Blue Shield of Western New YorkCDPHPEmblem HealthEmpire BlueCross BlueShield HealthPlusExcellus Blue Cross Blue ShieldFidelis CareHealth FirstIndependent HealthMetroPlus HealthMolina Health careMVPUnited Health careUnivera Health care
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       
Saint Lawrence          
Saratoga         
Schenectady         
Schoharie           
Schuyler           
Seneca          
Steuben           
Suffolk       
Sullivan         
Tioga         
Tompkins          
Ulster        
Warren         
Washington          
Wayne          
Westchester      
Wyoming          
Yates          

 

 

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 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 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 attract clientele. Below is a listing of carriers that have made their plan summaries and pharmacy formulary listings available.

 

 

 

Affinity Essential Plan

Affinity Health Plan

 

 

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 

 

 

HealthNow Essential Plan

HealthNow Blue Cross Blue Shield of Western New York

 

 

Empire Essential Plan

HealthPlus HP 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

 

 

Essential Plan 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 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.

Would I still qualify if I'm self-employed? - Yes, the program is open to Freelancers, independent contractors, the self-employed, and all persons who don't have an affordable health insurance option available to them at their place of employment. Additionally, for persons out of work, you still may qualify.

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

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? Beginning in 2021, all Essential plans have removed the monthly premium, making the plan free

 

 

2023 Essential 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 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 Essential plan offering to a total of 28 counties, of which 10 of those counties are the Affinity by Molina Healthcare Essential Plan. Those 10 counties are; Bronx, Kings, Nassau, New York, Orange, Queens, Richmond, Rockland, Suffolk, and Westchester

 

 

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]

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