Background

HISTORY

The Affordable Care Act, passed in 2010, gave states the option of creating a Basic Health Program, a health benefit for low-income residents whose income is above the Medicaid income limit, but below 250% of the Federal Poverty Level (FPL).

NYS has taken this option and created the Essential Plan in NY. The Essential Plan became available through the NY State of Health Marketplace during the 2015 open enrollment period for coverage beginning January 2016.

WHO ADMINISTERS THE PROGRAM

The Essential Plan is administered by the New York State Department of Health.

FUNDING

The Essential Plan is primarily funded with federal funds, with some state funds as well.

Summary of Essential Plan

The Essential Plan is designed to be a more affordable option for health insurance than the Qualified Health Plans. Essential Plan coverage is available to people with incomes up to 250% FPL who are not eligible for other public health programs, such as Medicaid, Child Health Plus and Medicare; not have access to health insurance through an employer; be between the ages of 19 and 64; and not be incarcerated.

There are different “levels” of Essential Plan coverage, EP 200-250, EP 1, EP 2, EP 3 and EP 4.  All provide the same benefits package; the different levels have different cost-sharing requirements.

EP 3 and EP 4 are for individuals with household incomes below 138% FPL who are lawfully present in the United States, but do not qualify for federally-funded Medicaid due to their immigration status, may be eligible for the Essential Plan.

EP 4 is for individuals with household incomes below 100% FPL.

EP 3 is for individuals with household incomes between 100-138% FPL

EP 2 is for individuals with household incomes between 138-150% FPL.

EP 1 is for individuals with household incomes between 150-200% FPL.

EP 200-250 is for individuals with household incomes between 200-250% FPL. This expanded level took effect April 1, 2024.

Beginning June 22, 2023, NYS implemented a 12-month continuous coverage period for Essential Plan enrollees.  While enrollees must report changes in income and household size during their 12-month coverage period, they will maintain health insurance coverage for 12 months, even if changes to their incomes and/or household size place them outside of the Essential Plan limits.  If their income places them above the Essential Plan limits, they would maintain coverage through the Essential Plan; if their income places them below the Essential Plan guidelines, they may be transitioned to Medicaid.

All Essential Plan coverage is provided through Health Maintenance Organizations (HMO), which requires that members use in-network providers, except in case of emergency or if the plan approved out -of -network providers. There are no premiums or deductibles for Essential Plan coverage. Preventive care, dental, and vision, are available at no cost to the member; there may be cost-sharing for other covered benefits.