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We totally get it — health insurance is confusing! There are all kinds of names and terms for things that can make it difficult to tell them apart.

Lots of New Yorkers aren’t sure about the difference between the Essential Plan and Medicaid. And it makes total sense — they can seem pretty similar at first glance.

New York’s Essential Plan is different from Medicaid. We’re here to explain the differences between the two.

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What is New York’s Essential Plan?

The Essential Plan is part of an initiative established by the Affordable Care Act that gives states the ability to offer more affordable health insurance options to low-income residents who don’t qualify for Medicaid and other public health insurance plans.

In New York, this more affordable option is called the Essential Plan. The Essential Plan has no or low premiums, no deductible, and starts paying for health care costs right away.

There are a few eligibility requirements that have to be met in order to qualify for the Essential Plan. To qualify for the Essential plan, you have to:

  • Be a resident of New York State
  • Be a legal resident of the United States
  • Be between 19–64 years old
  • Not be eligible for Medicaid or Child Health Plus plans
  • Not be eligible for employer-based or other health insurance options

There are income-related requirements, too. As of April 1, 2024, New Yorkers can now qualify for the Essential Plan if they earn up to 250% of the federal poverty line.

The federal poverty line changes each year and depends on the size of your household. For 2024, New Yorkers are eligible for the Essential Plan based on these annual household income limits:

  • $37,650 for a single person
  • $51,100 for a family of two
  • $64,550 for a family of three
  • $78,000 for a family of four

What is Medicaid?

Medicaid is both a federal and a state program that offers health care insurance to individuals and families who qualify. Different states call Medicaid different names. In New York, it’s pretty simple — Medicaid is just called New York Medicaid.

In order to qualify for New York Medicaid, you have to:

  • Be a resident of New York
  • Be a U.S. national, permanent resident, or legal alien

You also have to be one of the following in order to qualify for Medicaid:

  • Pregnant
  • Responsible for a child
  • Blind
  • Have a disability or a family member in your household with a disability
  • Be 65 or older

Like the Essential Plan, there are also income-related qualifications, too. You could be eligible for New York Medicaid if you meet these income limits before taxes:

  • $19,392 for a single person
  • $26,228 for a family of two
  • $33,064 for a family of three
  • $39,900 for a family of four

The U.S. government has this handy tool that can help you figure out whether or not you qualify for Medicaid.

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The difference between NY’s Essential Plan and Medicaid

As you probably saw, the main differences between New York’s Essential Plan and Medicaid are how people qualify.

The Essential Plan and Medicaid have different eligibility and income requirements. Generally, you have to have a more restricted income in order to qualify for Medicaid. You also have to meet a few more eligibility requirements.

The Essential Plan and Medicaid are different programs, so they cover different services differently. But, in general, both the Essential Plan and Medicaid are designed to cover common health care services.

The Essential Plan basically helps fill the gap between Medicaid and private insurance (the kind you buy on the marketplace or get through work, for example).

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Got more questions?

Still not quite sure what to make of the difference between the Essential Plan and Medicaid? We don’t blame you — it’s not easy to understand! That’s why we’re always here to help.

Whether you have questions about qualifying or need help enrolling, just get in touch! Call our Member Services line at (855) 809-4073 or stop by one of our many offices throughout the five boroughs. Helping our members meet their health care needs is what we do best.

Get covered today.

Call us any day of the week!

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