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

Essential Plan

Call Now to See if You May Qualify for the New York Essential Plan (888)215-4045

 

Updated for 2020: 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.

 

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 comparing 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

There are a total of 4 Essential plan options and the premium is based on eligibility, income, and if you include dental and vision coverage. 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)

Plan
Monthly Premium
Essential Plan 1$20
Essential Plan 1 Plus (with Dental and Vision )$46
Essential Plan 2$0
Essential Plan 2 Plus (with Dental and Vision)$26

 

 

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*$24,980
2$33,820
3$42,660
4**$51,500
* (150% to 200% FPL)
** Add $8,840 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 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 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 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.

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 LabsPCP: $15 SPC: $25 OP Facility: $25$0
Advanced Imaging$25$0
PCP Office Visits$15$0
Specialist Office Visits$25$0
Adult Dental NC/CoveredNot Covered/$15 if coveredNot Covered/$0 If covered
Adult Vision NC/CoveredNot Covered/$15 if coveredNot Covered/$0 if covered
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

 

 

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

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  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
  • Wellcare of New York
  • YourCare Health Plan

 

 

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

Plan NameEssential PlanEssential Plan Plus (Vision and Dental Included)
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
WellCare of New York
YourCare Health Plan

 

 

2020 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 PlanCDPHPEmblem HealthExcellus Blue Cross Blue ShieldFidelis CareHealth FirstHealth NowHealth plus HPIndependent HealthMetroPlus HealthMolina Health careMVPUnited Health careUnivera Health careWell Care of New YorkYour Care Health Plan
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 to 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

 

 

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

 

 

Wellcare Essential Plan

WellCare of New York

 

 

YourCare Essential Plan

YourCare Health Plan of New York

 

 

Essential Plan Eligible Enrollment Dates

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.

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 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 plans.

 

 

2020 Essential Plan Updates

For 2020, there will be a total of 16 health insurance carriers offering essential plan coverage throughout the 62 counties of New York.

The following 5 counties will have 2 Essential Plan carriers in their area: Hamilton, Herkimer, Otsego, Schoharie, and Schuyler.

The Essential Plan has lost a carrier for 2020. Crystal Run Health Plan has been sold in Orange and Sullivan county and has decided to shutter their Exchange plans including the Essential Plan.

 

 

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