EmblemHealth's Essential Plan is a no-deductible HMO plan with a $0 monthly premium. There are five versions of this plan, and eligibility depends on income and other factors. The Essential Plan is available at any time of year, but only if you enroll on the NY State of Health Marketplace. All Essential Plans offer adult vision and dental coverage.
Who's eligible: Qualifying adult individuals age 19 to 64 (there is no family plan) living within the five New York City boroughs, Nassau, Suffolk, and Westchester.
Benefits, premiums (monthly cost), and out-of-pocket costs: All five versions of the Essential Plan include all the essential health benefits, but at different out-of-pocket costs. For benefits, view plan documents below.
Financial assistance: Cost savings are built into these plans through a premium of $0, no deductible, and copays as low as $0. No tax credits or additional financial assistance is offered with this plan.
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EmblemHealth Essential Plan (with Adult Dental and Vision)
- DENTAL
- VISION
- Generic Drugs
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Benefits Summary
| Referrals info | Not required for specialist visits |
| $0 premium info | Pay $0 for your medical plan, depending on your income and other factors |
| No deductible info | Pay only a copay or nothing at all to use your health benefits |
| Low or no copays info | Pay as little as $0 to see a doctor or get your prescription medicine |
| Dental and vision coverage | Covered in full |
| $0 preventive care info | Fully covered. No out-of-pocket costs (no copay, coinsurance, or deductible) for your annual physical, immunizations, and screenings such as a colonoscopy and cervical screening |
| 10 essential health benefits | Coverage for all services required under health care reform, such as doctor visits, hospital care, prescription drugs, lab services, maternity care, and mental health and substance use services |
| $0 telemedicine info | At no extra cost, consult with virtual pcps, dermatologists, mental health professionals and on demand 24/7 general medical physicians about non-urgent medical needs, from a phone, computer, or tablet |
| Three-tier pharmacy benefits info | Coverage for generic (i) and brand-name medications, with your share of the costs |
| Gym reimbursement | Reimbursement up to $400 per calendar year |
| Wellness programs | Get help to eat better, quit smoking, manage a condition, or have a healthy pregnancy |
| Essential 200-250 and Essential 1 copay (Primary care doctor/specialist/emergency room) | $15 / $25 / $75 |
| Essential 2, 3, 4 copay (Primary care doctor/specialist/emergency room) | $0 / $0 / $0 |
Find a Doctor
Our Essential Plan provides network-only coverage through EmblemHealth's Enhanced Care Prime network.
Our Essential Plan is an HMO plan, which means you should:
- Seek non-emergency care from doctors, hospitals and facilities in the Enhanced Care Prime network only, in order for your care to be covered
- Choose a primary care physician (PCP) from the Enhanced Care Prime network. Members can choose or change their PCP by signing in to or registering for a secure online account or by calling 888-447-7703, Monday through Friday, from 8 am to 6 pm
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Summary of Benefits and Coverage -
Essential Plan 200-250
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Summary of Benefits and Coverage - Essential Plan 1
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Summary of Benefits and Coverage - Essential Plan 2
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Summary of Benefits and Coverage - Essential Plan 3
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Summary of Benefits and Coverage - Essential Plan 4
Cost Calculator
Since our Individual/Family and Essential Plans offer network-only coverage, members are responsible for the total cost of non-emergency care they receive outside their plan’s provider network.
Use the FAIR Health Calculator* to estimate the cost of non-emergency medical services and procedures by zip code.
*FAIR Health, Inc. is an independent nonprofit organization that uses actual provider charges when calculating fees. FAIR Health ensures that its fee information is accurate and complete. Please review the privacy policy and terms and conditions posted on the FAIR Health website.
