Essential Plan Summaries

The table below summarizes the network and benefit plans for our Essential Plan members.

HIP Commercial Network and Plan Summary for 2019
Enhanced Care Prime Network

Network Plan
Name
Plan
Type
PCP Req'd Referral Req'd Deductibles
(Ind/ Family)
PCP/
Special/
ER Copay

OON

Coverage

MOOP
(Ind/
Family)
Service Area Co-ins.

Enhanced Care

Prime

Network1

Essential Plan 1 HMO Yes Yes N/A $15/$25/$75 No $2,000 8 county

Yes, for

certain

services

Enhanced Care

Prime

Network1

Essential Plan 1

Plus

HMO Yes Yes N/A $15/$25/$75 No $2,000 8 county

Yes, for

certain

services

Enhanced Care

Prime

Network1

Essential Plan 2 HMO Yes Yess N/A $0 copay No $200 8 county No

Enhanced Care

Prime

Network1

Essential Plan 2

Plus

HMO Yes Yes N/A $0 copay No $200 8 county No

Enhanced Care

Prime

Network1

Essential Plan 3 HMO Yes Yess N/A $0 copay No $200 8 county No

Enhanced Care

Prime

Network1

Essential Plan 4 HMO Yes Yess N/A $0 copay No $0 8 county No

ER = emergency room; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; Req'd = Required; Co-ins. = Co-insurance

8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk, & Westchester counties.

1Enhanced Care Prime Network members traveling outside of the United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be held responsible for payment.

 

Essential Plan
The Essential Plan is a low-cost plan for adult individuals available on the NY State of Health Marketplace. As with Qualified Health Plans (QHPs), the Essential Plan includes all benefits under the 10 categories of the ACA-required Essential Health Benefits. Premiums for the Essential Plan are either $0 or $20.

The Essential Plan includes members from two already-existing member populations – a subset of the current QHP EmblemHealth Silver population and the current Medicaid Aliessa population. The Aliessa population is New York’s legally residing immigrant population. Eligible individuals in the Aliessa population, who previously were only eligible for coverage through state-only-funded Medicaid, will transition into the Essential Plan. Essential Plan members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada, and the Northern Mariana Islands.

 

Eligibility
The Essential Plan covers adult individuals only. If eligible, spouses and children must enroll into Essential Plan separately under an individual policy. To qualify for the Essential Plan, individuals must:

  • Be a New York state resident.
  • Be between the ages of 19 and 64 (U.S. citizens) or 21 to 64 (legally residing immigrants).
  • Not be eligible for Medicare, Medicaid, Child Health Plus, affordable health care coverage from an employer, or another type of minimum essential health coverage.
  • Be either:
    • A U.S. citizen (residing in New York) with an income between 138% and 200% of the federal poverty level (FPL). 
      • These individuals were formerly eligible for a QHP Silver Plan, but will now transition to Essential Plan based on income status.
    • Legally residing immigrant with an income of less than 138% of FPL.
      • These individuals were formerly eligible for Medicaid, but have been transitioned to Essential Plan based on immigration status (also known as Aliessa population).
  • Not be pregnant or eligible for long-term care. In both of these cases, members would be eligible for Medicaid instead of the Essential Plan.

 

Covered Services
Ten categories of essential health benefits are covered with no cost-sharing (no deductible, copay, or coinsurance) on preventive care services, such as screenings, tests, and shots. For more information, please see the Preventive Health Guidelines located on our Health and Wellness webpage. Information in our guidelines comes from medical expert organizations, such as the American Academy of Pediatrics, the U.S. Department of Health and Human Services, the Advisory Committee on Immunization Practices, and the Centers for Disease Control and Prevention (CDC).

Unlike QHP Standard Plans, some Essential Plan members are also eligible for adult vision and dental benefits for a small additional monthly cost. The Aliessa population receives six additional benefits at no extra cost. These include: dental, vision, non-emergency transportation, non-prescription drugs, orthopedic footwear, and orthotic devices.

Chapter 6 2019 Provider Networks and Member Benefit Plans