Essential Plan vs. Medicaid in New York: What's the Difference?
Looking for affordable health insurance in New York?
You may be wondering whether Medicaid or the Essential Plan
is the right coverage option for you.
Both programs help eligible New Yorkers access quality,
affordable health care, but they have different eligibility
requirements, income guidelines, and coverage details.
Understanding these differences can help you explore your
options and prepare to apply for health insurance.
Fidelis Care offers both
Medicaid Managed Care
and the
Essential Plan
to eligible New Yorkers.
What Is the Difference Between Medicaid and the Essential Plan?
Medicaid and the Essential Plan are health insurance programs
available to eligible New York residents. Both offer comprehensive
health coverage, including preventive care, doctor visits,
hospital services, and prescription medications.
The primary difference is who qualifies for each program.
Medicaid generally serves individuals and families who meet
applicable income and other eligibility requirements.
The Essential Plan may be available to individuals who
do not qualify for Medicaid but meet Essential Plan
eligibility guidelines.
Eligibility also depends on factors such as age,
household size, immigration status, and access
to other health coverage.
Essential Plan vs. Medicaid: Side-by-Side Comparison
The chart below highlights important differences and
similarities between Medicaid Managed Care and
the Essential Plan in New York.
| What to Compare
|
Medicaid
|
Essential Plan
|
| Who May Qualify?
|
Eligible New Yorkers who meet Medicaid income
and other program requirements.
|
Eligible New Yorkers who generally do not qualify
for Medicaid or Child Health Plus.
|
| Income Eligibility
|
Varies by household size, age, and Medicaid
eligibility category.
|
Generally above 138% and up to 200% of the
Federal Poverty Level for standard adult
eligibility categories; exceptions apply.
|
| Monthly Premium
|
Generally $0 for Medicaid Managed Care.
|
$0 for eligible members.
|
| Deductible
|
Generally no deductible for Medicaid Managed Care.
|
No deductible.
|
| Doctor Visits
|
Covered primary care and specialist services,
subject to applicable program rules.
|
Covered primary care and specialist services;
copayments may vary by category.
|
| Hospital and Emergency Care
|
Covered, subject to applicable benefit requirements.
|
Covered, subject to applicable benefit requirements.
|
| Prescription Drugs
|
Covered through applicable Medicaid pharmacy
arrangements and program rules.
|
Covered, subject to formulary and applicable
cost-sharing requirements.
|
| Dental and Vision
|
Covered services available according to
applicable Medicaid benefits.
|
Dental and vision benefits included,
subject to applicable coverage terms.
|
| Enrollment Period
|
Year-round for eligible individuals.
|
Year-round for eligible individuals.
|
| Eligibility Determination
|
NY State of Health or the appropriate
Medicaid agency.
|
NY State of Health.
|
Important: This comparison is intended
for general educational purposes. Specific eligibility,
covered services, copayments, and other requirements
depend on the applicable program and plan documents.
Medicaid vs. Essential Plan Income Guidelines in New York
Household income is an important factor in determining
eligibility for Medicaid and the Essential Plan.
Income guidelines are generally based on the
Federal Poverty Level (FPL), which is updated annually.
For many adults ages 19 through 64, Medicaid income
eligibility is generally based on a threshold of
138% of the Federal Poverty Level, although different
rules and income limits apply to certain populations.
The Essential Plan generally serves eligible adults
with household incomes above 138% and up to 200%
of the Federal Poverty Level. Certain individuals
may qualify for Essential Plan 3 or 4 under
different eligibility rules, including qualifying
immigration circumstances.
Because income limits vary by household size
and eligibility category, review the current
program guidelines before applying.
Do Medicaid and the Essential Plan Offer the Same Benefits?
Medicaid and the Essential Plan share many important
covered health services, but they are not identical.
Specific benefits, cost-sharing requirements,
and coverage rules can differ.
Both programs generally provide access to:
- Preventive care and routine checkups
- Primary care and specialist visits
- Hospital and emergency services
- Prescription medications
- Dental and vision services
- Maternity and prenatal care
- Mental health and substance use disorder services
- Laboratory tests, X-rays, and diagnostic services
Some services may have additional coverage requirements,
prior authorization rules, or copayments depending
on the program and applicable benefit documents.
Is Medicaid or the Essential Plan Better?
Neither program is automatically better for everyone.
The right coverage depends on your eligibility,
health care needs, and available options.
Both programs offer affordable health coverage,
but differences in eligibility, covered services,
provider networks, and out-of-pocket costs
may affect your experience.
NY State of Health determines which program
you may qualify for based on your application.
If you're eligible for Medicaid, you generally
cannot choose the Essential Plan instead
simply based on personal preference.
Can You Switch Between Medicaid and the Essential Plan?
Changes in household income, family size,
age, or other circumstances may affect
your eligibility for health coverage.
For example, an individual who no longer
qualifies for Medicaid because of an increase
in household income may become eligible
for the Essential Plan.
Similarly, someone enrolled in the Essential Plan
whose household income decreases may become
eligible for Medicaid.
Report changes in your circumstances to
NY State of Health or the agency managing
your eligibility so your coverage options
can be reviewed.
How to Apply for Medicaid or the Essential Plan in New York
Eligible New Yorkers can apply for Medicaid
and the Essential Plan throughout the year.
You generally do not need to wait for
an annual Open Enrollment period.
You can explore available coverage options
and apply through
NY State of Health
,
The Official Health Plan Marketplace.
Some Medicaid applicants must apply through
their local Department of Social Services
or another designated enrollment process.
A Fidelis Care representative can also
help you understand available coverage
options and the enrollment process.
Need Help Exploring Your Health Coverage Options?
Not sure whether Medicaid or the Essential Plan
may be available to you?
Fidelis Care can help you explore
your health coverage options and
understand the next steps.
Explore the New York Essential Plan.
Frequently Asked Questions: Essential Plan vs. Medicaid
Find answers to common questions about
Medicaid and Essential Plan eligibility,
benefits, costs, and enrollment in New York.
What is the difference between Medicaid and the Essential Plan in New York?
Medicaid and the Essential Plan are separate
health insurance programs with different
eligibility requirements.
Medicaid generally serves eligible individuals
and families who meet applicable Medicaid
income and program rules.
The Essential Plan generally provides coverage
to eligible New Yorkers who do not qualify
for Medicaid or Child Health Plus.
Both programs offer comprehensive health coverage,
but benefits, eligibility rules, and
out-of-pocket costs may differ.
Is the Essential Plan the same as Medicaid?
No. The Essential Plan and Medicaid are
different health insurance programs.
Although both offer affordable coverage
and many similar benefits, they have
different eligibility requirements
and program rules.
What are the income limits for Medicaid vs. the Essential Plan?
For many adults ages 19 through 64,
Medicaid eligibility is generally based
on household income up to 138% of the
Federal Poverty Level.
The Essential Plan generally covers
eligible adults above 138% and up to
200% of the Federal Poverty Level,
although exceptions apply.
Different Medicaid eligibility categories
and certain Essential Plan categories
have additional requirements.
Review our
2026 Essential Plan Income Guidelines
for more information.
Is Medicaid or the Essential Plan better?
Neither program is automatically better.
Your eligibility, health care needs,
covered benefits, and available providers
are important considerations.
NY State of Health determines
which program you may qualify for
based on your application and
applicable eligibility requirements.
Do Medicaid and the Essential Plan have monthly premiums?
The Essential Plan has a $0 monthly premium and no deductible
for eligible New Yorkers. Depending on the Essential Plan
category, certain covered services may have low copayments.
Medicaid Managed Care generally has no monthly premium
for eligible members. Some Medicaid services may have
applicable copayments or other coverage requirements.
Review the relevant plan documents for details.
Do Medicaid and the Essential Plan cover dental, vision, and prescription drugs?
Yes. Both programs provide access to covered dental,
vision, and prescription drug services. However,
specific benefits, provider networks, formularies,
and coverage requirements may differ.
For more information, explore
Medicaid coverage
and
Essential Plan benefits
through Fidelis Care.
Can I switch from Medicaid to the Essential Plan?
You may become eligible for the Essential Plan
if your circumstances change and you no longer
qualify for Medicaid.
For example, an increase in household income
may affect your Medicaid eligibility and
make the Essential Plan an available option.
However, eligibility also depends on age,
immigration status, access to other coverage,
and applicable program requirements.
Report changes to
NY State of Health
or the agency managing your Medicaid eligibility
so your coverage options can be reviewed.
What happens if my income increases or decreases?
Changes in household income can affect your eligibility
for Medicaid or the Essential Plan.
If your income increases, you may no longer qualify
for Medicaid but could become eligible for the
Essential Plan or another health coverage option.
If your income decreases, you may become eligible
for Medicaid.
Other factors, including household size and
eligibility category, may also affect your coverage.
Report changes promptly to NY State of Health
or the appropriate Medicaid agency.
Review our
2026 Essential Plan Income Guidelines
to learn more about household income limits.
Can I choose between Medicaid and the Essential Plan?
Eligibility for Medicaid and the Essential Plan
is determined by applicable program requirements,
rather than personal preference alone.
If you qualify for Medicaid, you generally cannot
choose the Essential Plan instead simply because
you prefer its benefits or provider network.
NY State of Health or the appropriate Medicaid agency
determines your program eligibility. Once eligible,
you may be able to select from available health plans
participating in that program.
How do I apply for Medicaid or the Essential Plan in New York?
Eligible New Yorkers can apply for Medicaid and
the Essential Plan throughout the year.
Many applicants can apply through
NY State of Health
,
The Official Health Plan Marketplace.
Some Medicaid applicants must apply through
their local Department of Social Services
or another designated enrollment process.
You can also contact Fidelis Care at
1-888-FIDELIS (1-888-343-3547)
,
TTY: 711, for assistance understanding
your available health coverage options.
Additional Medicaid and Essential Plan Resources
Learn more about Medicaid and the Essential Plan in New York,
including eligibility requirements, income guidelines,
covered benefits, and enrollment options.