Essential Plan is a health plan for New Yorkers that is significantly less expensive than other health plans. It provides the same essential benefits as other health insurance plans. The New York State Department of Health determines eligibility for essential plans for low-income individuals who do not qualify for Medicaid or Child Health Plus.
Who qualifies for the Essential Plan? (source: NYSOH)
The participant’s age at the start of the plan year cannot exceed 65.
- The applicant must be a resident of New York State, just like with the other Marketplace insurance and programs.
- Not qualify for Child Health Plus or Medicaid (CHP).
- Not qualify for affordable Minimum Essential Coverage (MEC);
- The Essential Plan is not available to people who qualify for advance premium tax credits.
- Due to their Medicaid eligibility, pregnant women are NOT eligible for the Essential Plan.
What is the cost of the Essential Plan? (source: NYSOH)
- It is FREE or a $20 monthly premium, or less than $1 per person per day.
- The only premium that varies yearly is for the optional Essential Plan plus Dental and Vision.
- Different providers will charge different premiums for optional vision and dental coverage.
- The majority of Essential Plan covered service expenses are standardized.
- For any Essential Plan variant, there is no deductible.
- Regardless of the carrier, premiums, co-pays, and maximum out-of-pocket amounts will be uniform.
Do you have an Essential Plans deductible?
- It has NO DEDUCTIBLE, so the plan immediately begins to pay for your medical treatment.
- You receive FREE PREVENTIVE CARE, such as regular checkups and screenings from the doctor, to keep you healthy. (NYSOH)
What are Essential Plan Options?
The Official Health Plan Marketplace (NYSOH) provides four Essential Plan Options (based on FPL – Federal Poverty Level)
The Essential Health Benefits are covered by all four categories of essential plans. The following options are available to applicants whose income is greater than 138% of FPL:
- An Essential Plan with only the Essential Health Benefits (this coverage does not include dental or vision coverage);
- An Essential Health Benefits plan with adult vision and dental services provided by their chosen health insurance provider for an additional fee; 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)
In contrast to Medicaid, the Essential Plan does not provide continuous coverage; as a result, enrollees must report changes in circumstance within 30 days, and eligibility will be re-evaluated during the 12-month enrollment period.
The Essential Plan will also have continuous open enrollment, allowing applicants to sign up at any time of the year and change their plan at any time.
Based on the end of the 12-month coverage period, renewal will be revolving.
What is covered under Essential Plans?
As defined in Section 1302 of the ACA, essential health benefits include at least the following general categories:
- Free preventive care
- Inpatient care
- Outpatient services
- Maternity and newborn care
- Emergency services
- Lab and imaging
- Prescription drugs
- Vision and Dental
- Rehabilitative and habilitative services
- Mental health and substance use disorder services
- Wellness and chronic disease management services
Source: Essential Plan At a Glance Card – English.pdf (ny.gov)