Essential Plan 1, 2, 3 and 4: Who Gets Which Plan and What Each One Costs

Essential Plan 1, 2, 3 and 4 side by side

This is the 2026 cost-sharing chart for the four versions, as EmblemHealth publishes it for its own Essential Plan. Fidelis Care lists the same pattern: primary care at $0 or $15, specialists at $0 or $25, a hospital stay at $0 or $150, depending on the version. The state sets the benefit design, so the amounts do not change from one carrier to the next.

Urgent care follows the same split: $25 on Essential Plan 1, $0 on the other three. Outpatient mental health is $15 on Essential Plan 1 and $0 on the rest. Preventive care, maternity care, dental and vision carry no copay on any version. What the Essential Plan covers.

How NY State of Health decides which number you get

The application decides it, from two facts: your household income against the federal poverty level, and your immigration category. You never see a menu of versions and you cannot ask for a different one. If your income or status changes, the version changes with it.

The 2026 income ceilings for each version, by household size, as EmblemHealth prints them:

Those are 200%, 150%, 138% and 100% of the 2026 poverty guidelines, counted as yearly household income before taxes. A citizen or green card holder below about 138% usually lands in Medicaid rather than the Essential Plan, which is why Essential Plan 2 starts above the Medicaid line. What counts as income.

What changed on July 1, 2026

Until that date there was a fifth version for incomes above 200% and up to 250% of the poverty level. New York had run it under a federal Section 1332 waiver. The July 2025 federal budget law removed the premium tax credit money that paid for it, the state asked to end the waiver, and federal regulators approved the return to Basic Health Program authority on March 23, 2026, according to the state Health Department.

The result, in the state’s own figures: about 450,000 New Yorkers in that tier became ineligible on July 1 and were moved toward marketplace plans, while about 1.3 million enrollees below 200% kept the Essential Plan. On October 28, 2026 the Department said NY State of Health had renewed about 60% of the affected people into other coverage.

Versions 1 through 4 did not change. If you hold one of them, your copays are the ones in the table above. If you were in the 200% to 250% tier, your options now.

Essential Plan 1 vs 2: is the difference worth worrying about?

For most people, no. The gap is a few copays and a yearly cap of $360 against $200. A person on Essential Plan 1 who sees a primary care doctor four times, a specialist twice and fills a generic every month pays $60, $50 and $72, or $182 for the year. The same year on Essential Plan 2 costs $12 in drug copays.

Where Essential Plan 1 can bite is a hospital stay ($150) or an emergency room visit ($75) landing in the same month as other bills. The $360 cap stops it there. Count your copays against it: once you reach $360 in a calendar year, the plan pays the rest.

Two things matter far more than the version number:

• The carrier’s network. Healthfirst, Fidelis Care, MetroPlus, EmblemHealth and others offer the same benefit design with different doctors and hospitals. Healthfirst Essential Plan · Fidelis Care Essential Plan · EmblemHealth and MetroPlus.
• Whether your income is reported correctly. A household just over 150% is placed in Essential Plan 1. If the income on file is too high, a correction can move you to Essential Plan 2.

Is Essential Plan 3 or 4 Medicaid?

No. Essential Plan 3 and 4 are the Essential Plan, sold through the same carriers, for lawfully residing immigrants whose category keeps them out of federally funded Medicaid even though their income is in the Medicaid range. EmblemHealth’s chart lists them for ages 21 to 64. They carry no visit copays, and Essential Plan 4 has no drug copays either.

Why this is worth knowing: a letter or a card that says “Essential Plan 4” is not a mistake, and it is not a downgrade from Medicaid. The benefits are comprehensive and the card works like any insurance card at in-network providers.

What may change: from January 1, 2027, federal funding for the Essential Plan is limited, among immigrants, to green card holders, certain Cuban and Haitian entrants and citizens of the Compact of Free Association nations. NY State of Health has said it notifies affected enrollees directly. If you hold Essential Plan 3 or 4 and have a status other than a green card, read every notice and see immigrant coverage in 2027. Essential Plan vs Medicaid.

Pregnancy cancels the copays

If you are pregnant, you can stay on the Essential Plan instead of moving to Medicaid, and cost sharing drops to zero, according to NY Health Access. Coverage continues for 12 months after the birth. Report the pregnancy to NY State of Health as soon as you know, because the change is not automatic until it is reported.

Where this table stops working

The amounts above are the 2026 figures as two carriers publish them. Carriers post their 2027 summaries of benefits during open enrollment, and the state can adjust cost sharing between years. If a copay on your card does not match this table, the carrier’s 2027 summary of benefits is the document to trust, and the question to ask the carrier is direct:

“Which Essential Plan version am I in for 2027, and what are my copays for a primary care visit, a specialist and a generic prescription?”

The other honest limit: the version number tells you what a visit costs, not whether you can get the visit. Network size, specialist waits and which hospitals take your plan vary far more between carriers than copays vary between versions. Apply any month at NY State of Health, online or at 1-855-355-5777. The Essential Plan has no enrollment season. The full Essential Plan guide · How marketplace plans work above 200%.