Essential Plan vs Medicaid in New York: Which One You Get, and What Changes Between Them

Which one will the application give you?

The application gives you Medicaid if your income is low enough for it, and the Essential Plan if you earn slightly too much for Medicaid but stay at or below 200% of the poverty level. You never choose between them. NY State of Health screens you for Medicaid, the Essential Plan and Child Health Plus at once, from household income, age and immigration status.

That makes a Medicaid result good news. Medicaid is the broadest coverage in New York, and if the application puts you there instead of the Essential Plan, you have not been downgraded.

Income here means household income before taxes, projected for the year you are applying for. Retirement contributions, HSA contributions and deductible self-employment expenses reduce it. If your pay moves around, use what you reasonably expect for the year and correct it later.

Where are the income lines in 2026?

The lines are multiples of the 2026 federal poverty guidelines, which start at $15,960 for one person and add $5,680 for each additional person. Medicaid for most working-age adults without dependent children ends around 138%; the Essential Plan runs from there to 200%.

Each additional person adds $5,680 to 100% FPL. Annual figures, before taxes.

Two groups break this table. Pregnant women qualify for Medicaid at substantially higher incomes, so report a pregnancy on the application. Children under 19 are not eligible for the Essential Plan at all; they go to Medicaid or Child Health Plus, which covers children regardless of immigration status. Every program’s line is in one place on 2026 income limits.

How do the two compare, line by line?

On cost the two look almost identical; on coverage and rules they do not.

Both cover doctor visits, hospital and emergency care, prescriptions, labs, and mental health and substance use treatment. The Essential Plan also covers preventive care with no cost sharing, and dental and vision for most enrollees; confirm with your carrier. Medicaid adds long-term care, which no other program in the state covers, and in many cases transportation to appointments. On the Essential Plan, copays depend on the version: Essential Plan 1 charges $15 for primary care and $25 for a specialist, Essential Plans 2 and 3 have $0 visits and small drug copays, and Essential Plan 4 has none.

What do the Essential Plan 3 and 4 versions have to do with Medicaid?

Essential Plan 3 and 4 cover people below the Medicaid line who cannot get federally funded Medicaid because of their immigration category. They are the Essential Plan, run through the same carriers, not Medicaid, even though they reach the same income band.

The numbers are the four current versions of the program, not old labels; since the 200% to 250% tier ended on July 1, 2026 there are exactly four, all at $0 a month with no deductible. Essential Plan 1 is for lawfully present adults above 150% up to 200% of the poverty level and is the only one with visit copays: $15 primary care, $25 specialist, $75 emergency room, $150 hospital stay, capped at $360 a year. Essential Plan 2 runs from above the Medicaid line to 150%, with $0 visits, $1 to $3 drug copays and a $200 cap. Essential Plan 3 reaches 138% and Essential Plan 4 100% for lawfully residing immigrants 21 to 64; Plan 3 has only $1 to $3 drug copays and Plan 4 none. These are the 2026 amounts in EmblemHealth’s chart for the state-set design. Essential Plan 1, 2, 3 and 4 side by side.

This is also why “I probably don’t qualify” is wrong so often. New York covers some immigrants through state-funded arrangements that federal rules would exclude. If you are undocumented, neither program is your door, but NYC Care and hospital financial assistance are, and neither asks about status.

What happens at the age edges?

At 19 and at 65, the answer changes. Under 19, the Essential Plan does not apply: children go to Medicaid or Child Health Plus. At 65, Medicare becomes the primary coverage and the Essential Plan ends.

Medicaid continues past 65, but under different rules. For people 65 and older, and for applications based on disability or long-term care, Medicaid applies an asset test that the working-age categories do not, and the application goes to the local department of social services instead of NY State of Health. In New York City that is the Human Resources Administration. If income is low, Medicare and Medicaid together, called dual eligibility, is worth asking about. Medicare vs Medicaid · How Medicaid works in New York.

What happened to the 200% to 250% band?

Until July 1, 2026, the Essential Plan reached 250% of the poverty level. The federal funding that paid for the 200% to 250% band ended and New York did not replace it, so the ceiling returned to 200%. About 450,000 New Yorkers lost Essential Plan eligibility and were moved toward marketplace plans, most with tax credits that cut the premium sharply. Sharply cut is not zero: that group now pays a premium and has a deductible.

If your income is at or below 200%, nothing changed for you. If you were in the eliminated band, check the plan you were placed in, because automatic placement optimizes for continuity, not cost. The state said it was working with insurers so that anyone moved mid-year would see their deductible cut in half. Open enrollment for 2027 coverage runs November 1 to January 31. Your options now.

How do you move between them when income changes?

Crossing a line moves you to another program; it does not end your coverage. Both programs accept changes in any month.

If you got care during a gap in coverage, hospital financial assistance still applies: at or below 200% of the poverty level a New York hospital may not charge an uninsured patient out of pocket, between 201% and 300% no more than 10% of the Medicaid rate, and between 301% and 400% no more than 20%. How to apply for it. To find your own percentage of the poverty level, use the federal poverty level chart; for the seven Essential Plan insurers in the city compared on state ratings and complaint data, see Essential Plan insurers compared.