What Is the Essential Plan? NYC’s $0 Premium Health Insurance Explained

Here are the eligibility requirements for the Essential Plan. You must:

• Be a resident of New York State
• Be a legal resident of the United States
• Be between 19 and 64 years old
• Not be eligible for Medicaid or CHP programs
• Not be eligible for employer-based or other health insurance options
• Meet the annual income requirement

The annual income requirement varies by income and the size of your household. In New York State, you can earn up to 200% of the federal poverty line and still qualify for an Essential Plan. That means as a single person, you can earn up to $31,920 and still qualify for low- to no-cost health insurance.

It may sound too good to be true, but the Essential Plan covers all of your basic health insurance services and more. This includes:

• Preventive Care
• Emergency Care
• Urgent Care
• Prescription Drugs
• Dental and Vision Care

Beyond the basics, you also get access to benefits that support you and your overall well-being. This includes things like gym reimbursements and a wellness card, which gets members up to $400 a year to spend on nutritious foods and other health essentials.

MetroPlusHealth offers the Essential Plan, which is made up of four categories. The Essential Plan offers premium health care with no or low premiums, but eligibility, benefits, and cost-sharing may vary depending on the plan that fits your needs and budget.

Essential Plan 4 is a true no-cost health insurance plan available to individuals and families who make below 100% of the federal poverty level. It offers $0 premiums, deductibles, and out-of-pocket costs. That means that you get everything – from annual checkups, to specialist visits, to urgent care and prescription drugs, 100% free.

To be eligible for Essential Plan 4, certain income limits must be met.

• Individuals: below 15,960
• Families of 2: below $21,640
• Families of 3: below $27,320
• Families of 4: below $33,000

Essential Plan 3 is also a $0 premium plan, although it does come with minimal costs. The only costs associated with Essential Plan 3 are:

• $200 out-of-pocket maximum
• $1 – $3 for prescription drugs

The income eligibility limits for Essential Plan 3 are:

• Individuals: $15,960 – $22,025
• Families of 2: $21,640 – $29,864
• Families of 3: $27,321 – $37,702
• Families of 3: $33,001 – $45,540

Essential Plans 3 and 4 are only for legally residing immigrants who are ineligible for Medicaid solely due to immigration status. Undocumented immigrants cannot qualify for Essential Plans 3 and 4, and citizens who would normally qualify for these plans would instead qualify for Medicaid.

Essential Plan 2 is logistically the same as Essential Plan 3; it’s a $0 premium plan with minimal costs – $200 out-of-pocket max and $1 – $3 for prescription drugs. However, any New York State resident who meets the income requirements may qualify, including lawfully residing immigrants.

The income requirements for Essential Plan 2 are:

• Individuals: $22,026 – $23,940
• Families of 2: $29,856 – $32,460
• Families of 3: $37,703 – $40,980
• Families of 4: $45,541 – $49,500

Essential Plan 1 is built for the highest eligible income tier and is also available to lawfully residing immigrants in New York State. Premiums and deductibles are still free, but there are some costs associated, including:

• $360 out-of-pocket maximum
• $15 to see your primary care physician
• $25 to see a specialist
• $75 for an ambulance ride or emergency room visit
• $6 – $30 for prescription drugs
• $25 for urgent care
• $75 for ER visits

The income limits associated with Essential Plan 1 are:

• Individuals: $23,941 – $31,920
• Families of 2: $32,461 – $43,280
• Families of 3: $40,981 – $54,640
• Families of 4: $49,501 – $66,000

The Essential Plan ensures that all New Yorkers, regardless of income, have their basic health needs covered, and then some. Health and wellness go beyond doctor’s visits and access to prescription drugs. The Essential Plan meets those needs by offering holistic benefits, including gym reimbursements of up to $200 and access to a wellness card offering up to $112 each quarter to spend on healthy groceries and other over-the-counter items.