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What is the Essential Plan

The Essential Plan is a Free New York health insurance program for state residents who don't qualify for Medicaid but cannot afford full premium coverage. There is a total of 5 Plans and each plan is based on your household income. 

 

How to Enroll in the NY Essential Plan

There are three main ways that you can enroll in a plan:

Contact Us Directly at our toll-free number (888)215-4045 and we will determine your eligibility. We'll then compare all available health insurance companies offering the plan in your area. Our comparison will make sure that your current doctors, hospitals, and labs are all part of the network 

Visit Each Health Insurance Company's Website to review their plans, however, you won't be able to compare their plans with those of other health insurance carriers.   

Visit the New York State of Health is another enrollment option. Unfortunately, plans are not displayed online

 

Are You Eligible?

 To be eligible. you must meet the following:

1. Income requirements
2. Residency Requirements 
3. Age Requirements

 

Income Requirements

To qualify, your income needs to be at a certain level.   Please use the following chart to determine your income eligibility 

Residency Requirements

There are two residency requirements.

1. You must be one of the following: A US Citizen, a permanent resident, or a holder of a work Visa. For non-US Citizens, you will need to prove residency status by providing a copy of your alien resident card or your work visa.
2. To prove that you're a New York State Resident, you will need to provide a copy of your New York driver's Licence or a New York Non-Driver ID Card. No other forms of identification are acceptable  

 

Age Requirements

You must be an adult between the ages of 19 and 64 to participate. Children are not eligible, though if they are under age 19, they most likely qualify for Child Health Plus

 

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 mandatory health benefits.

Medical Benefits

• Doctors office visits
• Emergency room visits
• Hospital stays
• Having a baby and caring for a newborn
• Mental health care; drug & alcohol treatment for addiction
• Prescription drugs
• Therapies such as; Physical, occupational, and rehabilitative. Also medical devices
• Lab services such as blood work, xrays, CAT scans, and others
• Preventative care such as; well-care visits, cancer screening, diabetes testing, and so forth

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

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

 

The 5 Essential Plans

There are a total of 5 essential plans and the main differences between each plan are their copayments and cost sharing levels. Your annual household income determines which plan you qualify for.

 

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.

 

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.

 

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.

 

 

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  →

 

Essential Plan Insurers and Their Benefits

While every health insurance company must offer the same basic coverage for medical, dental, and vision care, many also provide extra benefits like telehealth, teledoc services, gym reimbursements, and wellness programs to enhance brand recognition and attract customers. Following is a list of health insurance companies that have disclosed their plan summaries and pharmacy formulary listings.

Affinity Health Plan

CDPHP

EmblemHealth

Excellus Blue Cross Blue Shield

Fidelis Care

Healthfirst

HealthNow Blue Cross Blue Shield of Western New York

Empire Healthplus

Independent Health

MetroPlus Health

MVP

United Healthcare

Univera Healthcare

 

How to Choose the Right Plan

Most counties in New York State have more than one 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.

 

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?

If you're 19 to 64 years old and earn between $20,121 and $37,650 annually, or if your family meets the income eligibility, check the Eligibility Chart to see if you 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 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 qualify for the program?

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.

Im currently covered under a Qualified health plan and my income has dropped, can i switch to the essential plan?

Yes as long as your income falls between the income limits then you can apply

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 coverage begin?

Coverage will always start on the 1st of the month.

Can I still enroll 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?

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 still 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 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 plan, including the Essential Plan, as long as the employees qualify for it.

Can an employee qualify?

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 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 will my plan expire and when do I renew my plan?

Unlike qualified health plans, which expire at the end of the calendar year, Essential Plans last for 12 months from the start date. For example, if your start date is July 1, your plan will expire on June 30 of the following year. You must take action one month before the expiration date if you wish to renew your plan.

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 this program have out-of-network benefits?

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

Are dental and vision covered under the 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 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?

It 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)?

Since there are 5 different plans, The maximum out-of-pocket for all plans are as follows: Plan 1 - $360, Plans 2&3 - $200, Plan 4 - $0, Plan 5 - $2,000.

Can I use this program 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 this program 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 plan cover that?

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

Is vasectomy covered?

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. Is that a covered expense?

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 Qualified Health Plan (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 are covered?

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

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. 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 coverage throughout the 62 counties of New York.

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

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

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

 

Closing

The Essential Plan is a cost-effective health plan available to those who earn too much to qualify for Medicaid while providing all of the essential health benefits required by law.