2024 Essential Plan
The Essential Plan offers health insurance for eligible low-income New Yorkers who do not qualify for Medicaid, Child Health Plus or minimum essential coverage through an employer. Members in an Essential Plan have access to the Enhanced Care Prime Network.
There are five variations of the Essential Plan: Essential Plan 200-250, 1, 2, 3, and 4. Depending on the individual’s income and other eligibility criteria, they will be enrolled in the variation that they qualify for.
As of April 1, 2024, there is a new variant of the Essential Plan called Essential Plan 200-250. This is in addition to the existing Essential Plans 1-4. The new variant is nearly identical to Essential Plan 1; the only difference is the member’s maximum out-of-pocket expense. See the updated 2024 Summary of Companies, Lines of Business, Networks, and Benefit Plans for details on the Essential Plan.
This variant expands Essential Plan eligibility to individuals who have an annual income of 200 – 250% of the Federal Poverty Level (FPL). Prior to April 1, 2024, this annual income level would have qualified someone for an individual and family plan with a cost-share reduction, but they would still have a monthly premium. All Essential Plan variations, including the new Essential Plan 200-250, have no monthly premium or deductible and low-to-no cost-shares!
What this means for our providers
- More members using the Enhanced Care Prime Network.
- Reimbursement will be consistent with Essential Plan 1 and 2.
- Simple administration with no referrals.
Benefits for members
Please share this with your staff and any patients you think can take advantage of the features of this new variant:
- No monthly premiums and annual deductibles.
- $2,000 maximum out-of-pocket.
- No referrals required.
- Preventive care at no cost.
- Robust network with top hospitals.
- Telemedicine at no cost with Teladoc® Primary360.
- Gym reimbursement. Eligible members can earn up to $200 in reimbursement per six-month period (Jan. 1 – June 30 and July 1 – Dec. 31) each calendar year if they complete 50 workouts each period.
- Wellness program.
Beginning Jan. 1, 2025 (delayed from Oct. 1. 2024), EmblemHealth will cover doula services in hospital, clinic, and community settings for Medicaid, Health and Recovery Plan (HARP), and Essential Plan members who are pregnant, birthing, and postpartum (for up to 12 months after the delivery date). For more information see Improving Health Outcomes With Doula Services.
In preparation for this new benefit, EmblemHealth is now inviting doulas to join our provider networks. If you are interested in partnering with EmblemHealth, please contact medicaidproduct@emblemhealth.com.