What Does the Essential Plan Cover? Benefits, Costs by Tier, and 2026 Changes

New York’s Essential Plan covers doctor visits, hospital stays, emergency and urgent care, prescription drugs, mental health and substance use treatment, maternity care, dental, vision, lab work, rehabilitation therapies, and preventive screenings for adults ages 19 to 64 who earn too much for Medicaid but need affordable coverage.¹ Most enrollees pay no monthly premium and no deductible, and copays for services are either $0 or very low depending on income.

Medical Services Included

Preventive care is free for every enrollee regardless of income. That includes routine exams and screenings that carry an “A” or “B” recommendation from the U.S. Preventive Services Task Force, such as screenings for depression, anxiety, substance use, tobacco use, breast cancer, and osteoporosis.²

Beyond prevention, the plan pays for:

Inpatient hospital admissions and outpatient hospital services, including surgery.
Emergency room visits and ambulance transport, which are covered at any provider, in network or not.³
Urgent care visits.
Diagnostic lab work, X-rays, and imaging.
Physical, occupational, and speech therapy, generally up to 60 combined visits per condition per plan year.⁴
Chiropractic services.
Home health care, up to 40 visits per plan year.⁴
Durable medical equipment and hearing aids, with hearing aid replacement limited to once every three years.⁵

What You Pay by Income Tier

The Essential Plan is split into tiers tied to income. Every tier has a $0 annual deductible.⁶ The lower your income, the less you pay out of pocket.

Plans 2, 3, and 4: Lowest-Income Enrollees

These tiers serve people with individual incomes below roughly $23,540, with the exact bracket depending on household size. All three carry $0 monthly premiums and a $200 annual out-of-pocket maximum. Primary care visits, specialist visits, emergency room trips, hospital stays, urgent care, and therapies all cost $0.⁶

The main differences between the three are prescriptions and transportation. In Plan 4 (incomes below roughly $11,770 for an individual), all drugs including over-the-counter medications are free, and non-emergency medical transportation is covered. Plan 3 (roughly $11,770 to $16,243) charges $1 for generics and $3 for brand-name drugs and keeps the transportation benefit. Plan 2 (roughly $16,245 to $17,655) matches Plan 3’s prescription copays but drops the non-prescription drug benefit and routine transportation.⁶

Plan 1: Moderate-Income Enrollees

Plan 1 covers individuals with incomes roughly between $17,656 and $23,540. It charges a $20 monthly premium and caps annual out-of-pocket spending at $2,000. Cost-sharing is higher: $15 for primary care, $25 for a specialist, $75 for an emergency room visit or ambulance, $150 per hospital admission, and $25 for urgent care.⁶ Prescriptions cost $6 for generics, $15 for preferred brand-name drugs, and $30 for non-preferred brands.¹ Durable medical equipment and hearing aids carry 5% coinsurance under Plan 1 and are free under the lower tiers.

Plan 200-250: Higher-Income Tier

Created in April 2024 under a federal waiver, this tier extended coverage to people earning between 200% and 250% of the federal poverty level. It has $0 premiums, $0 deductibles, and a $2,000 out-of-pocket maximum, with copays matching Plan 1.⁷ This tier is being eliminated on July 1, 2026 (see below).

Prescription Drug Coverage

The plan uses a three-tier formulary: generic, preferred brand-name, and non-preferred brand-name. Plan 4 enrollees pay nothing. Plans 2 and 3 pay $1 for generics and $3 for brand-name drugs. Plan 1 pays $6, $15, and $30 respectively.⁶ Mail-order prescriptions for a 90-day supply cost 2.5 times the retail copay.³

Standard utilization controls apply. Prior authorization is required for some drugs, quantity limits cap how much can be dispensed, and step therapy may require trying a cheaper drug first. A mandatory generic policy means pharmacies must dispense the generic version when one exists, absent a specific exception.⁸

Dental and Vision

Every tier includes dental and vision benefits. Dental coverage spans preventive, routine, and major care, and vision coverage includes eye exams, glasses, and contact lenses.⁹ Under Plans 2, 3, and 4, every dental and vision service is $0.¹ Plan 1 enrollees pay a $15 copay for dental visits and eye exams and 10% coinsurance for lenses, frames, and contacts.⁶

Mental Health and Substance Use Treatment

The plan covers mental health and substance use disorder care without annual session limits, and outpatient care does not require a referral. Covered services include inpatient psychiatric care, outpatient therapy and rehabilitation, crisis intervention, inpatient detoxification, opioid treatment, and continuing day treatment. Teletherapy is available through in-network providers who offer video sessions.¹⁰

Under Plan 1, an outpatient behavioral health visit costs $15 and an inpatient admission costs $150. Under Plans 2, 3, and 4, both are $0.⁶ New York law requires cost-sharing for behavioral health to comply with the federal Mental Health Parity and Addiction Equity Act, so these costs cannot exceed those for comparable medical services.⁴ Enrollees who have difficulty accessing behavioral health care can call CHAMP, the state’s independent ombudsman, at (888) 614-5400.²

Maternity and Reproductive Health

Prenatal care, labor, delivery, and postpartum care are all covered. As of April 2024, all cost-sharing is waived during pregnancy and for a 12-month postpartum period.¹¹ Pregnant enrollees who report their pregnancy to NY State of Health can stay in the Essential Plan rather than switching to Medicaid, though they may choose Medicaid if they prefer.

Beyond maternity care, the plan covers contraception (pills, IUDs, injections, implants, and emergency contraception), sterilization procedures, abortion, STI and HIV testing and treatment, well-woman exams, and an initial infertility evaluation. Advanced infertility treatments such as IVF are not covered.¹²

Non-Emergency Transportation

Plans 3 and 4 include non-emergency medical transportation at no cost, covering personal vehicle, bus, taxi, ambulette, or public transit rides to and from medical appointments. Members arrange rides through Medical Answering Services.¹³ Plans 1, 2, and 200-250 do not include routine transportation; ambulance transfers between facilities are covered only when a patient’s condition makes other transport medically unsafe.¹⁴

Network and Referral Rules

The Essential Plan covers in-network providers only. The one exception is emergency services, which are covered at any hospital or provider regardless of network status. Using an out-of-network provider for non-emergency care means higher costs or no coverage. Referrals are generally not required, though prior authorization may be needed for certain services and for out-of-network care.³

What Is Changing on July 1, 2026

Federal legislation (H.R. 1, signed in July 2025) cut Essential Plan funding by $7.5 billion annually, forcing New York to scale back the program.¹⁵ On March 20, 2026, the federal Centers for Medicare and Medicaid Services approved New York’s request to terminate its Section 1332 waiver and revert the Essential Plan to a Basic Health Program under the Affordable Care Act.¹⁶

The practical effects on July 1, 2026:

People earning between 200% and 250% of the federal poverty level (roughly $31,920 to $39,900 for a single person) lose Essential Plan coverage. About 450,000 New Yorkers fall into this group.¹⁷
The roughly 1.3 million enrollees with incomes below 200% FPL keep their coverage under the Basic Health Program.¹⁶
DACA recipients at or below 138% FPL move to Medicaid. Higher-income DACA recipients who are pregnant also move to Medicaid. Other higher-income DACA recipients will no longer qualify for any NY State of Health program.¹⁷
Pregnant enrollees with due dates before January 1, 2027, stay in the Essential Plan. Those due on or after that date transition to Medicaid on July 1, 2026.¹⁸

Enrollees losing coverage can switch to a Qualified Health Plan through the NY State of Health marketplace. The enrollment window opened May 16, 2026, and runs through August 30, 2026; enrolling by that deadline allows coverage to be made retroactive to July 1. The state Department of Health estimated the average Qualified Health Plan would cost about $220 to $250 per month after tax credits, with an average annual deductible around $2,150.¹⁹

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