Essential Plan 200-250 vs Essential Plan 1
Before we can answer what are the differences between Essential Plan 200-250 vs Essential Plan 1, it’s best first to understand what the Essential Plan is, how it came into being, and who it benefits.
What is the Essential Plan, How it Came into Being, and Who Benefits?
Before 2016, the New York State Health Insurance Exchange, known as the New York State of Health, began to notice that residents with incomes between 138% to 200% of the federal poverty level, were purchasing health insurance plans that were drastically subsidized, in which the premiums they were paying were in most cases $0. This was a good thing, however, these insurance plans were unaffordable to use for this population because the copayments and deductibles were so high that people who had these plans didn’t continue them as they were cost-prohibitive to use.
These persons then became a large uninsured population in New York. Without insurance, they often ended up either not receiving the care they needed, or in emergency rooms which cost the state a great deal of money.
The solution was to create a plan covering persons who didn’t qualify for Medicaid yet couldn’t afford to use standard health insurance plans. These persons had incomes between 138% to 200% of the federal poverty level. With that understanding, in 2016 the state created the Essential Plan program, consisting of 4 health insurance plans that were based on income and in some cases, immigration status. Each of these plans had drastically reduced copays and deductibles to make them affordable to use. They also started with a 20 dollar monthly premium but since 2023 that has been reduced to a $0 premium
In 2023 the state exchange created the essential plan 200–250 because they understood that roughly 200, 000 New York residents with incomes between 200% to 250% of the federal poverty level were either uninsured or couldn’t afford to use their standard insurance plans. This new plan helped a great deal of New York residents afford and keep coverage.
What is the Essential Plan 1?
Out of the 4 Essential plans, Essential Plan 1 requires that an individual have an income of 150% to 200% of the federal poverty level, be a US Citizen, be over 19 and under 65, and not qualify for Medicaid.
What is the Essential Plan 200–250?
Essential Plan 200–250 is almost identical to Essential Plan 1 yet the income levels are higher. Whereas the Essential Plan 200-250 requires your income to be just that, with 200%-250% of the federal poverty level. The other requirements are identical.
What’s the Difference: Essential Plan 200-250 vs Essential Plan 1
The only difference between Essential Plan 1 and Essential Plan 200–250 is the cost of using these plans. You will find that in a calendar year, the most you can spend out of your pocket on Essential Plan 1 is $360. Essential plan 200–250, it’s possible that you can spend a total of $2000 on medical expenses. To compare the actual costs associated with each plan, please use the enclosed table.
To qualify for either plan 1 or 5 your household income must be between 138% 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.
Benefits Essential Plan 1 Costs & Co-pays Essential Plan 200-250 Costs & Co-pays
Individual Deductible $0 (Med/Rx combined) $0 (Med/Rx combined)
Individual Maximum Out-of-Pocket $360 (Med/Rx combined) $2,000 (Med/Rx combined)
Inpatient Hospital Care $150 $150
Emergency Care $75 $75
Urgent Care $25 $25
Outpatient Hospital Services $50 $50
X-rays and Labs $25 $25
Advanced Imaging $25 $25
PCP Office Visits $15 $15
Specialist Office Visits $25 $25
Adult Dental $0 $0
Adult Vision $0 $0
Non-Prescription Drugs Not Covered Not Covered
Non-Emergency Transportation Not Covered Not Covered
Generic drugs $6 $6
Preferred Brand Drugs $15 $15
Non-Preferred Brand and Specialty $30 $30
Common Questions
Are Essential Plan 1 and Essential Plan 200–250 available in all counties?
Yes, however not every insurance company is available in all NY counties. please use the following link to find out which insurance company is offering the Essential Plan in your county.
Does every insurance company in New York State need to offer both Essential Plan 1 and Essential Plan 200-250?
Yes, they are required by law to make all 5 plans available.
Is the application process the same for Essential Plan 1 and Essential Plan 200-250?
Yes, the application process is the same for all plans.
What if I’m covered under Essential Plan 1 and my income increases so that I’m now eligible for Essential Plan 200–250?
You would need to contact the New York State of Health and inform them of the change in your income. You can also expect your out-of-pocket maximum cost to increase as well as the overall cost of using the insurance.
What if I can’t afford the costs associated with the Essential Plan 200–250, can I move to the Essential Plan 1?
Unfortunately, the plans are based on income, so you may not switch plans, unless your income drops, though NYSOH will require proof of your new income.
Conclusion
New York State has made the cost of purchasing and using New York health insurance more affordable by creating the Essential Plan program. Within that program, Essential Plan 1 and Essential Plan 200-250 are the two most popular plans. Essential Plan 200-250 vs Essential Plan 1 is a broad comparison of the application process, the benefits, costs, and copayments of these two plans.