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Individual & Family Plans

These insurance plans for members under age 65, with benefits such as doctor visits, lab tests, prescription drugs, and hospital visits are available based on age, income, and residency status.
Essential Plan is a health plan for New Yorkers, which costs much less than other health plans. It offers the same essential benefits as other health plans. NYSOH determines eligibility for Essential Plans is for lower income individuals who don't qualify for Medicaid or Child Health Plus.

Who is eligible for Essential Plan? (source: NYSOH)

• Person must be less than age 65 at the beginning of the plan year
• Like the other programs and insurance offered through the Marketplace, the person must reside in New York State
• Not be eligible for Medicaid or Child Health Plus (CHPlus)
• Have income between 138%-200% of the FPL or less than 138% of the FPL and ineligible for Medicaid due to immigration status.
• Not be eligible for affordable Minimum Essential Coverage (MEC).
• Individuals eligible for the Essential Plan are not eligible to receive Advance Premium Tax Credits.
• Pregnant women are NOT eligible for Essential Plan because they are eligible for Medicaid.

How much does Essential Plan cost? (source: NYSOH)

- It costs NOTHING or $20 premium per month, which is less than a dollar a day per person.
- Only premium for optional Essential Plan plus Dental & Vision varies each year.
- Premiums for optional vision and dental coverage will vary across carriers.
- Most costs for covered services in Essential Plan are standardized.
- There is no deductible for any of the Essential Plan variations
- Premium, co-pays and maximum out of pocket limits will be the same across carriers.

Do you pay deductible for Essential Plans?

- It has NO DEDUCTIBLE, so the plan starts paying for your health care right away
- You get FREE PREVENTIVE CARE like routine doctor exams and screenings to keep you healthy. (NYSOH)

What does Essential Plan cover?

The same services covered by other plans, including:

• doctor visits, including specialists • tests ordered by your doctor • prescription drugs • inpatient and outpatient care at a hospital • and more (NYSOH)

What are Essential Plan Options?

The Official Health Plan Marketplace (NYSOH) provides four Essential Plan Options (based on FPL – Federal Poverty Level)
Essential Plans
NewYork State Of Health Final 2020 Health Plan Updates Broker Webinar Slide 21

All plans cover the Essential Health Benefits. Applicants with income above 138% FPL have the choice of selecting:

• An Essential Plan with just the Essential Health Benefits (this coverage will not have dental or vision coverage), or
• An Essential Health Benefits plus Adult Vision and Dental services for an additional cost by their selected health insurance company), or
• An Essential Plan and a separate Stand-Alone Dental Plan (person will have a standard EP that covers an Essential Health Benefits only and a separate Stand-Alone Dental plan offered by one of the dental companies in the NY State of Health Marketplace)

Enrollment Periods

• Essential Plan will have continuous open enrollment.
• Applicants are able to enroll all year long and change their plan anytime throughout the year.
• Unlike Medicaid, there is no continuous coverage for EP, therefore, enrollees are required to report changes in circumstance within 30 days and eligibility will be re-determined during the 12-month enrollment period.
• Eligibility for the Essential Plan will be re-evaluated 12 months after the enrollee's recent determination. Renewal will be revolving based on the 12-month coverage end date.
When selecting an Essential Plan carrier consider benefits:
Facts About Public Charge
Qualified Health Plans
Qualified Health Plans or Metal Plans are available in four metal tiers – platinum, gold, silver and bronze - which are easy to compare in terms of premium, deductible, and MOOP (Max out of pocket). All plans on The Official Health Plan Marketplace cover doctor's visits; hospital stays; emergency care; maternity and newborn care; mental health and substance abuse disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services, chronic disease management and pediatric dental and vision. Preventive care such as routine office visits and recommended screenings are free. Some plans include additional benefits such as adult dental and vision coverage.

Consumers who enroll in a QHP through the marketplace may be eligible for Advanced Premium Tax Credits (APTCs) to reduce the monthly cost of coverage. APTCs are based on projected annual income at the time of application and, under federal rules, consumers must now reconcile the amount of tax credit they are eligible to receive based on actual annual income when they file their federal tax return. Form 1095-A provides the information needed to complete this task.

Form 1095-A will also be sent to households that did not apply for tax credits, were not eligible for tax credits at the time of application, or were eligible and choose not to apply them. This provides these households with a final opportunity to claim a premium tax credit. Form 1095-As are not required and will not be sent to consumers who enrolled in Medicaid, Child Health Plus, a catastrophic plan or a stand-alone dental plan offered through the marketplace.
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