Essential Plan

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Essential Plan



The Essential Plan is offered by UnitedHealthcare through the NY State of Health Marketplace. It’s for lower income individuals in New York who meet the income or citizenship status requirements.

To find out if UnitedHealthcare Community Plan is offered in your county, please call 1-888-617-8979. A representative will contact you to schedule an appointment to help you apply.

 

The Essential Plan is offered by UnitedHealthcare through the NY State of Health Marketplace

This plan is available in the following counties: Albany, Bronx, Broome, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Jefferson, Kings, Lewis, Livingston, Madison, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Seneca, St. Lawrence, Suffolk, Tioga, Ulster, Warren, Wayne, Westchester, Wyoming and Yates.

Benefits & Features

  • Coverage Types


    Essential Plan 1 Standard
    : Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level.

    Essential Plan 1 Native American/Alaskan: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level.  Designed for Native American or Alaskan Native Individuals.

    Essential Plan 1 Plus: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level. Includes Dental and Vision benefits.

    Essential Plan 1 Native American/Alaskan Plus: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level. Includes Dental and Vision benefits.  Designed for Native American or Alaskan Native Individuals.

    Essential Plan 2 Standard: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level.

    Essential Plan 2 Native American/Alaskan: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level.  Designed for Native American or Alaskan Native Individuals.

    Essential Plan 2 Plus: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level. Includes Dental and Vision benefits.

    Essential Plan 2 Native American/Alaskan Plus: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level. Includes Dental and Vision benefits.  Designed for Native American or Alaskan Native Individuals.

    Essential Plan 3: Coverage for those ages 21-64 who are “Legally Present” but not eligible for Medicaid, earning 100-138% of the Federal Poverty Level.

    Essential Plan 4: Coverage for those ages 21-64 who are “Legally Present” but not eligible for Medicaid, earning less than 100% of the Federal Poverty Level.

  • Premium


    Monthly plan premium will apply for all Essential Plan 1 Standard and Essential Plan Plus plans. 

  • Copays*


    Medical Services:
    Copays will apply for all Essential Plan 1 plan types.

    Inpatient Hospital Services: Copays will apply for all Essential Plan plans.

    Emergency Medical Services: Copays will apply for all Essential Health Plan plans.

    Outpatient Hospital/Facility Services: Copays will apply for all Essential Plan plans.

    Preventive and Primary Care Services:  PCP/Specialist copay per visit (based on type of physician performing the service) will apply for all Essential Plan plans.

    Physician /Professional Services: Copays will apply for all Essential Plan plans.

    Prescription Drugs: Copays will apply for all Essential Plan plans.

    * Copays may vary.  Alaskan Natives and American Indian members are exempt from co-pays and co-insurance.  Refer to Subscriber Contract in Member Information section for more details regarding copays and coinsurance.

  • Well and Sick Care


    Get the care you need to stay healthy — or to get better if you are injured or sick. That includes: 

     

     

    • Choice of Doctor. Use “Doctor Lookup” to see if your doctor is in our network or to find a new one.
    • Medicines. Prescription drugs are covered with a small copay.
    • Dental*. We cover cleanings, checkups and dental work.
    • Well Visits. Annual checkups can help keep you healthy.

     

     

     


    * Dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans.   

  • Care for Conditions


    If you have special health care needs, you can count on us. Our plan will provide the extra care and services needed. Benefits include:

    • Mental Health. Counseling and other treatments are covered.
    • Case Management. If you qualify, get personal help managing health conditions.
    • Asthma and COPD Care. Exams, testing and supplies are covered.

  • Vision, Dental and Hearing Care


    Make sure your sight, teeth, speech and hearing are at their best. Benefits include:

     

    • Vision. Covers eye exams and glasses.** 
    • Dental. We cover cleanings, checkups and dental work.**
    • Hearing. Screenings and therapies, if needed, are provided.

     

     

     

    ** Vision and dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans.   Cost sharing will apply for those in Essential Plan Plus plans.  

  • Gym Membership Reimbursement

    Partial reimbursement ($400/200 every 6 months) for facility fees if member attains at least 50 visits.

    Gym Reimbursement Forms: English | Espanol

  • Home Care and Supplies


    Get the medical care and equipment you need to recover safely at home. Benefits include:

     

     

    • Care Coordinator. Someone to get you the services you need to recover safely.
    • Personal Care. Services to help you heal after illness or injury.
    • Equipment and Supplies. In-home medical and safety equipment are covered.
    • Nurse Visits. Care after surgery or illness to recover at home.

     

     

  • Extra Support


    Sometimes you might need a little extra help using your health plan. For those times, you can rely on: 

     

     

    • Member Services M-F 8:00am to 6:00pm EST. When you call Member Services you will be connected with a specially trained Advocate. They will help you get the most from your health plan.  For example, your Advocate is equipped to answer your questions, resolve issues, help set up doctor appointments and directly connect you with services available to you.
       
    • Nutrition Coaching. Helpful advice to improve your diet.

     

     

     

     

     

  • Asthma and COPD Care

    Asthma and COPD Care

    Individual care to help control asthma, allergies or COPD symptoms.

    Do you or your child have trouble managing asthma, allergies or COPD symptoms? A nurse who specializes in breathing issues can really help. You’ll get a customized treatment plan and medicine to:

    • Manage flare-ups.
    • Reduce symptoms.
    • Let you or your child stay active. 

  • Choice of Doctor

    Choice of Doctor

    You get a primary care physician (PCP), who is your main doctor. Use the Doctor Lookup tool to see if your doctor is in our network.

    If you don't have a doctor or if your doctor is not in our network, we can help you find a new one close to you. 

    Your PCP is your main doctor for:

    • Preventive care.
    • Treatment if you are sick or injured.
    • Referrals to specialists for certain conditions.

  • Dental/Vision Care*

    Dental/Vision Care*

    Dental Care* 
    Checkups are covered.

    Exams and cleanings every six months help keep teeth and gums strong and healthy. If there is a dental problem that needs to be fixed, that’s covered as well.

    Vision Care*
    See life more clearly with routine eye exams and glasses, if needed. We also include:

    • Prescription lenses.
    • Medicaid approved frames.
    • New eyeglasses every two years.

    This benefit is offered by March Vision care.

    *Vision and dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans.   

  • Diabetic Supplies

    Diabetic Supplies

    If you have diabetes, you may need insulin, needles, wipes and glucose strips. We cover all that and more.

    Our plan also steps up with services  to help you manage your diabetes, including:

    • Classes on keeping diabetes in control.
    • Coordinating doctor care.
    • Nutrition and diet. 

  • Durable Medical Equipment

    Durable Medical Equipment

    Your health and safety at home are important.

    Our plan covers medical equipment ordered by your doctor or case manager. This can include supplies like:

    • Diabetic supplies.
    • Hospital beds.
    • Wheelchairs or walkers. 

  • Hearing Care

    Hearing Care

    Trouble hearing can affect your everyday life in many ways. Our plan includes services and support to help protect your hearing. 

    Our plan covers: 

    • Exams, therapy and tests.
    • Hearing aids and batteries. 

  • Hospitalization

    Hospitalization

    This plan pays for all expenses related to a hospital stay, so you can rest and heal.

    Hospitalization coverage includes:

    • Nursing care.
    • Room and board.
    • Supplies and equipment.
    • Treatment and therapies.
    • Diagnostic tests and exams.

    And after you leave the hospital, you are not alone. We make sure you get follow-up care to continue healing at home.

  • Medicines

    Medicines

    Our plan covers prescription drugs and refills with a small copayment. Your copay is:

     

    Essential Plan

    1

    2

    3

    4

    Generic

    $6

    $1

    $1

    $0

    Tier 2

    $15

    $3

    $3

    $0

    Tier 3

    $30

    $3

    $3

    $0

     

    Over-the-counter medicines with a written order from your doctor are available for a copayment for each medicine.And we make getting your medicine easy. You can fill your prescriptions at:

    • Local pharmacies.
    • Services that deliver right to your door.

  • Member Services

    Member Services

    Sometimes you might need a little help understanding your health care options. With us, you have someone you can call 24/7. We’ll answer your questions simply and completely.

    We can also help you find:

    • Home care providers.
    • Dentists and vision providers.
    • Adult day health centers.

  • Mental Health*

    Mental Health*

    Mental health is as important as physical health. That’s why we have coverage for both.

    Required care is 100% covered. This includes:

     

     

    • Behavioral therapy.
    • Substance abuse treatment.
    • Medications.

     

     

    * Copays will apply for Essential Plan 1.
    * Alaskan Natives and American Indian members are exempt from co-pays and co-insurance.  

  • Nurse Visit

    Nurse Visit

    Sometimes you may need continued care after you leave the hospital or urgent care. If your health is at risk after a serious illness, surgery or injury, a nurse will visit you at home to:

    • Provide medical care for you.
    • Answer your questions and concerns.

  • Outpatient Services

    Outpatient Services

    Knowing what’s wrong and finding it early can make all the difference. Our plan covers:

    • Labs and testing.
    • X-rays, scans and other imaging.

    We’ll help you get the information needed to help improve your health or be your best. 

  • Residential Care

    Residential Care

    After a serious illness, surgery or injury, you may extra nursing and therapy.  If needed, our plan covers short stays in a rehabilitation center where you can heal.  Included are:

    • Nursing home services.
    • 24-hour nursing care.
    • Help with activities of daily living.
    • Physical, occupational and speech therapy.

  • Respite Care

    Respite Care

    Do you have family members or friends who care for you at home? If so, we want to support their hard work too. That’s why we provide respite care to give your caregivers a rest. Respite care offers caregivers time away from their loved one who is ill or has special care needs.  

  • Shots and Immunizations

    Shots and Immunizations

    Routine shots help keep you healthy. So, our plan covers:

    • Recommended shots and vaccines.  
    • Diagnostic tests and exams.

  • Well Visits

    Well Visits

    Well visits with your doctor can help you stay healthy. These visits can catch health problems early, so they can be treated. Preventive services include:

    • Checkups for adults and children.
    • Well-baby care.
    • Care for women expecting a baby.
    • Routine shots and tests.
    • Mammograms.

Enrollment

Call to apply today.

The Essential Plan specialists can answer questions and help you apply.

Monday - Friday 8 a.m. - 8 p.m. EST.

1-888-617-8979

TTY: 711


Get the details.

Visit the Essential Plan site for more information on eligibility and enrollment.

New York State of Health Marketplace

Already a member?

Member Services: Monday - Friday 8:00 a.m. to 6:00 p.m. EST
Benefits: Monday - Friday 8:00 a.m. to 6:00 p.m. EST

1-866-265-1893

TTY: 711


You have access to our member-only website. Print ID cards and more. View our handbook below.

Member Website 

Member Resources

2018 Subscriber Contracts

To learn more about applying for health insurance, including Medicaid, Child Health Plus, Essential Plan, and Qualified Health Plans through NY State of Health, The Official Health Plan Marketplace, visit www.nystateofhealth.ny.gov or call  1-855-355-5777.