Essential Plan Information


Essential Plan Update: Important Changes in April 2024


Overview

NY State of Health's Essential Plan includes comprehensive benefits with $0 monthly premiums and very low-cost sharing. The Essential Plan:

  • Has no deductible, so the plan starts paying for your health care right away.
  • Covers comprehensive benefits, including dental and vision, inpatient and outpatient hospital care, prescription drugs and more.
  • Covers free preventive care like routine exams and screenings.
  • Has continuous open enrollment, meaning you can enroll at any time during the year through NY State of Health.
     

Eligibility

Individuals are eligible for the Essential Plan if they are:

  • New York State residents 
  • Lawfully present in the U.S. 
  • 19-64 years old 
  • Not eligible for Medicaid or Child Health Plus 
  • Not eligible for employer and other coverage 
  • Able to meet the Essential Plan annual income requirements listed in the table below

 

Essential Plan Eligibility
Household Size
Most You Can Make in 2024
1$37,650
2$51,100
3$64,550
4$78,000

 

Enroll

There are three ways to enroll in the Essential Plan through NY State of Health:
•    Apply through the NY State of Health website
•    By phone at 1-855-355-5777 (TTY: 1-800-662-1220)
•    With the free help of a trained and certified Enrollment Assistor or Broker
 
Have this information ready for each member of your family:
•    Birth dates
•    Social security numbers or, for legal immigrants, document numbers if you have them
•    Employment, income, and health insurance information

Learn more about enrolling.


Essential Plan Renewals

You may need to take action each year to keep your health insurance.  Learn more about Essential Plan renewals.


Essential Plan Resources

Cost Sharing for Health Care Services, Prescription Drugs, Dental and Vision

Cost Sharing for Health Care Services
Cost Sharing for Health Care ServicesAnnual individual income:
below $15,060 - $22,590
Annual individual income:
$22,591- $37,650
Monthly Premium$0$0
Annual Deductible$0$0
Preventive Care$0$0
Primary Care Physician Visit$0$15
Specialist Visit$0$25
Inpatient Hospital Stay per admission$0$150
Behavioral Health Outpatient Visit$0$15
Behavioral Health Inpatient Visit per admission$0$150
Emergency Room$0$75
Urgent Care$0$25
Physical Therapy, Speech Therapy, Occupational Therapy$0$15
Prescription Drugs
Prescription DrugsAnnual individual income:
below $15,060 - $22,590*
Annual individual income:
$22,591- $37,650
Generic$1$6
Preferred Brand$3$15
Non-Preferred Brand$3$30

*$0 for individuals with income below $15,060

Dental and Vision
 Annual individual income:
below $15,060 - $22,590
Annual individual income:
$22,591- $37,650
Dental and Vision Cost Sharing$0$0

 

Additional Resources

 

Eligibility Changes 

Eligibility rules have changed and more New Yorkers are now eligible for the Essential Plan! This change started in April 2024.

If you previously enrolled in a Qualified Health Plan and are now eligible for the Essential Plan, you may have questions about how this change will affect you.

Do I need to do anything to start my Essential Plan coverage with $0 monthly premiums?

If you’re currently in a Qualified Health Plan you don’t have to take any action to move to the Essential Plan, unless you want to change health insurers.

If the Essential Plan is offered by the health plan that offers your current Qualified Health Plan:

  • NY State of Health moved you to the Essential Plan automatically.  You will receive an email about this change.

  • Look for a notice from your health plan.  It will have your new Essential Plan ID card.  It will also have information about your benefits and available providers.

If the Essential Plan is not offered in your county by the health plan that offers your current Qualified Health Plan:

  • You will need to choose a new health plan.  You will receive an email about this change.  If you do not choose a new plan, one will be chosen for you.
  • To choose a new health plan, log into your nystateofhealth.ny.gov account, call the Customer Service Center at 1-855-355-5777, or contact a certified enrollment assistor.
  • After you are enrolled in a new health plan, they will send you a notice.  It will have your new Essential Plan ID card.  It will also have information about your benefits and available providers.

You have the option to change your health plan.  For more information about changing health plans, please contact our Customer Service Center at 1-855-355-5777 or a certified enrollment assistor.

Will I be able to keep my same doctors and other health care providers?

Most health care providers who accept your Qualified Health Plan will likely accept the same insurer’s Essential Plan.

  • To make sure, call your health care provider to confirm they accept your new Essential Plan health insurance.
  • You can also use the NYS Provider & Health Plan Look-Up tool to find Essential Plan options that work with your current health care providers.

You have the option to change your health plan.  For more information about changing health plans, please contact our Customer Service Center at 1-855-355-5777 or a certified enrollment assistor.

Will the cost-sharing payments I have already made for the Qualified Health Plan apply to my new Essential Plan health insurance?

Yes.  This means that any out-of-pocket costs you paid, including copayments, coinsurance, and deductible, for your Qualified Health Plan will apply to your Essential Plan maximum out-of-pocket limit.

Can I keep my Qualified Health Plan instead of changing to the Essential Plan?

Yes.  You have the choice to keep your Qualified Health Plan.  However, your premium tax credit will no longer apply.  You will be responsible for the full premium cost without financial assistance.

I have other questions.  How can I find answers?

NY State of Health wants to make this change as easy as possible for you.  We are here to help.  If you have questions, you can:

  • Contact a certified enrollment assistor.
  • Call the NY State of Health Customer Service Center at 1-855-355-5777.  Customer Service Center representatives are available Monday through Friday from 8:00am to 8:00pm and on Saturday from 9:00am to 1:00pm.

 

Read more details about this change.

Use the Essential Plan Expansion Communications Tool Kit to help promote this change.