Definitive Guide

The Definitive Guide to The Essential Plan

Health insurance is, well, complicated to say the least! Especially if you’re a creative freelancer or gig worker, it can be really tricky to figure out what you qualify for.

As our President and CEO Dr. Talya Schwartz explains, here at MetroPlusHealth we get it. “Gig and freelance workers make up roughly 34% of the New York City workforce, but many of these workers struggle to access the resources they need to survive and thrive in the City.”

The gaps between private health insurance (the kind usually accessed through employment) and public options like Medicaid mean that freelancers and lower-income earners are usually stuck in a tough spot. They often don’t have access to or can’t afford private insurance, but make too much money to qualify for public insurance at the same time.

“In a city of millions, everyone has different needs but needs health care in some form. It’s a unifying thread, a safety net all of us need to live and thrive in this great City.”

Roger Milliner

Chief Growth Officer of MetroPlusHealth

Enter New York State’s Essential Plan.

The Essential Plan is a New York State health insurance program that was launched in 2015 to fill exactly those gaps. This year, the Essential Plan is expanding to include even more New Yorkers than before. As Spectrum News explains, this means that “almost 100,000 people in New York” could now qualify for the program.

Read on to learn more about the Essential Plan, who qualifies, the benefits it covers, and more.

Essential Plan

What is the 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 premium, no deductible, and starts paying for health care costs right away.

Who is eligible for the Essential Plan?

There are just 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 also income eligibility requirements for the Essential Plan, which expanded significantly this year to include many more New Yorkers.

Previously, in order to qualify New Yorkers could earn no more than 200% of the federal poverty line. 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:

$30,120 for a single person
$40,880 for a family of two
$51,640 for a family of three
$62,400 for a family of four

Have more family members than that? Calculate your household’s income limit by adding $10,760 for each additional person.

What benefits are included in the Essential Plan?

We know you have a lot of questions when it comes to deciding if the Essential Plan is right for you.

You might be wondering what benefits are included in the Essential Plan. You might need to know if the Essential Plan covers important services like prescription medication, urgent care, and dental and vision services. The good news is that the Essential Plan covers these services and more.

Overall, the Essential Plan covers the same services as other health insurance plans. Here’s a look at some of the specific care and services covered under the Essential Plan:

Preventative care
Emergency care
Prescription drugs
Mental health services
and more!

How much does the Essential Plan cost?

The Essential Plan has no premium, no deductible, and starts paying for health care costs right away. You might have to pay a small amount for some services depending on your household’s exact income, but the costs are low (like $150 for a hospital stay).

Even though the income qualifications for the Essential Plan depend on family size, you have to be at least 19 years old to qualify. Children can’t be covered by the Essential Plan because they’re eligible for other health insurance programs like Children’s Medicaid and Child Health Plus.

How do I apply for the Essential Plan?

It’s never too late to apply for the Essential Plan! New Yorkers can enroll in the Essential Plan year-round.

You can enroll in the Essential Plan by calling the MetroPlusHealth Member Services line at (855) 809-4073 or stopping by one of our many offices throughout the five boroughs, from Staten Island to The Bronx.

We even have special Marketplace Facilitated Enrollers who have been specially certified to help New Yorkers like you understand and enroll in programs like the Essential Plan.

Because it’s an income-qualified program, you have to let the state know of any changes throughout the year that could impact your eligibility. But don’t worry, we can help you with that, too.

Just get in touch! We’re always here to help.

Hopefully with everything you’ve read here, the Essential Plan feels more accessible and understandable than before.

Qualifying is a highly individualized process, but it’s one that’s well worth exploring. The potential cost savings are huge, and you can enroll any time.

Let New York’s health insurance program work for you!