Essential Plan 1 Essential Plan 2 Essential Plan 3 ...

Summary of Essential Plan Costs and Benefits Essential Plan 1 Annual individual income: $17,656 - $23,540 Essential Plan 2 Annual individual income: $16,245 - $17,655 Essential Plan 3 Annual individual income: $11,770 - $16,243 Essential Plan 4 Annual individual income: Below $11,770 Premium (per month) $20 $0 $0 $0 Deductible (per year) $0 $0 $0 $0 Maximum Out-of-Pocket Limit $2,000 $200 $200 $200 Cost Sharing Preventive Care $0 $0 $0 $0 Primary Care Physician $15 $0 $0 $0 Specialist $25 $0 $0 $0 Inpatient Facility (including behavioral health) $150 per admission $0 per admission $0 per admission $0 per admission Outpatient behavioral health $15 $0 $0 $0 Outpatient Facility $50 $0 $0 $0 Emergency Room $75 $0 $0 $0 Ambulance $75 $0 $0 $0 Urgent Care $25 $0 $0 $0 Surgeon $50 $0 $0 $0 Physical Therapy, Occupational Therapy, Speech Therapy $15 $0 $0 $0 Durable Medical Equipment and Supplies 5% coinsurance $0 $0 $0 Hearing Aids 5% coinsurance $0 $0 $0 Non-emergency transportation Not covered Not covered $0 $0 Adult Dental* (preventive, routine and major dental care)

Durable Medical Equipment and Supplies 5% Coinsurance $0 $0 $0 Hearing Aids 5% Coinsurance $0 $0 $0 Non-emergency transportation Not covered Not covered $0 $0 Adult Dental* (preventive, routine and major dental care) $15 $0 $0 $0 Vision Care – Exams* $15 $0 $0 $0 Vision Care – Lenses and Frames* 10% Coinsurance $0 $0 $0

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Transcription of Essential Plan 1 Essential Plan 2 Essential Plan 3 ...

1 Summary of Essential Plan Costs and Benefits Essential Plan 1 Annual individual income: $17,656 - $23,540 Essential Plan 2 Annual individual income: $16,245 - $17,655 Essential Plan 3 Annual individual income: $11,770 - $16,243 Essential Plan 4 Annual individual income: Below $11,770 Premium (per month) $20 $0 $0 $0 Deductible (per year) $0 $0 $0 $0 Maximum Out-of-Pocket Limit $2,000 $200 $200 $200 Cost Sharing Preventive Care $0 $0 $0 $0 Primary Care Physician $15 $0 $0 $0 Specialist $25 $0 $0 $0 Inpatient Facility (including behavioral health) $150 per admission $0 per admission $0 per admission $0 per admission Outpatient behavioral health $15 $0 $0 $0 Outpatient Facility $50 $0 $0 $0 Emergency Room $75 $0 $0 $0 Ambulance $75 $0 $0 $0 Urgent Care $25 $0 $0 $0 Surgeon $50 $0 $0 $0 Physical Therapy, Occupational Therapy, Speech Therapy $15 $0 $0 $0 Durable Medical Equipment and Supplies 5% coinsurance $0 $0 $0 Hearing Aids 5% coinsurance $0 $0 $0 Non-emergency transportation Not covered Not covered $0 $0 Adult Dental* (preventive, routine and major dental care)

2 $15 $0 $0 $0 Vision Care Exams* $15 $0 $0 $0 Vision Care Lenses and Frames* 10% coinsurance $0 $0 $0 Vision Care Contact Lenses* 10% coinsurance $0 $0 $0 Non-prescription drugs Not covered Not covered $1 $0 Prescription Drugs Tier 1 $6 $1 $1 $0 Tier 2 $15 $3 $3 $0 Tier 3 $30 $3 $3 $0 (Note that copays for mail order prescription drugs are times retail copays above for 90-day supply) *Where dental and vision benefits are available for Essential Plan 1 & 2 members, enrollees pay extra for the benefits. All Essential Plan 3 & 4 enrollees have these benefits included. Essential Plan Eligibility for families: Essential Plan 1 Essential Plan 2 Essential Plan 3 Essential Plan 4 Family of 2 $23,896 - $31,860 $21,983 - $23,895 $15,930 - $21,982 Below $15,930 Family of 3 $30,135 - $40,180 $27,724 - $30,134 $20,090 - $27,723 Below $20,090 Family of 4 $36,375 - $48,500 $33,465 - $36,374 $24,250 - $33,464 Below $24,250 To estimate eligibility for larger families, go to the View Plans Now tool on the NY State of Health website: A full list of Essential Plan benefits and cost sharing is available here

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