Medicaid Vs. Essential Plan: What’s the Difference?
Learn the differences between Medicaid and the Essential Plan, including costs, eligibility, benefits, and how to apply.
Medicaid is a New York state program that offers health insurance to individuals with qualifying income.
The Essential Plan is affordable health insurance for New Yorkers. It’s for individuals over the age of 19 who do not qualify for Medicaid and are looking for low-cost health insurance.
Understanding the differences between these two coverage options is key to getting access to care that fits your income, age, and health needs.
Income Limits
Your income determines which health plan you may qualify for, and each program has its own limits.
Medicaid
For a single adult, the 2026 income limit is about $22,025 per year.
For families, the limit is higher. It increases as your household size grows.
Example:
- If you are single and earn $20,000 per year, you may qualify.
- If you have a family of four and earn $40,000 per year, you may also qualify.
Learn more about Medicaid.
The Essential Plan
The Essential Plan is for people who earn more than Medicaid allows.
For a single adult, the 2026 income limit is about $31,920 per year. For a family of four, the limit is about $66,000 per year.
Example:
- If you earn $30,000 per year and do not qualify for Medicaid, you may qualify for the Essential Plan.
- If your family of four earns $65,000 per year, you may qualify for the Essential Plan.
Learn more about the Essential Plan.
Why income matters
Income limits are based on Modified Adjusted Gross Income (MAGI). This includes wages, tips, and other taxable income. Checking your income is the first step to finding the right plan.
Learn more about Medicaid household income.
Cost
Both programs keep health care costs low. They remove deductibles and keep monthly payments free or low. This means you can see a doctor, get medicine, and stay healthy without worrying about expensive medical bills.
Medicaid
- Monthly Premium: $0
- Deductible: None
- Co-pays: Very low or no co-pays for most services
If you qualify, your health coverage is free. Most doctor visits and prescriptions cost nothing or just a small co-pay. So you can focus on your health, not your bills.
The Essential Plan
- Monthly Premium: Most people pay $0 or very little each month.
- Deductible: None
- Co-pays: Very low or no co-pays
Most people pay little or nothing for the Essential Plan. Costs if any, depend on your income.
Coverage and Benefits
Both Medicaid and the Essential Plan include these benefits to help you stay healthy:
- Doctor Visits See your doctor for checkups, sick visits, and ongoing care. Both plans cover primary care and specialists.
- Preventive Care Stay healthy with screenings, vaccines, and annual exams. These services are covered at no cost to you.
- Hospital Stays If you need to stay in the hospital, both plans cover your care. This includes surgery and emergency services.
- Mental Health and Substance Use Services Support for mental health is included. Both plans cover counseling, therapy, and treatment support.
- Dental and Vision Care Keep your teeth and eyes healthy. Both plans include dental checkups, cleanings, and vision exams. Glasses may also be covered.
- Lab Tests Blood work and other lab tests are covered. These help your doctor check your health and diagnose problems.
- Prescription Drugs Get the medicines you need. Both plans cover most prescriptions, including generic and brand-name drugs. If you are a Medicaid member, you will have Medicaid prescription coverage through NYRx, the Medicaid Pharmacy Program.
Medicaid vs. Essential Plan: coverage comparison
| Benefit | Medicaid | Essential Plan |
|---|---|---|
| Doctor Visits | ✔ Covered | ✔ Covered |
| Preventive Care | ✔ Covered | ✔ Covered |
| Hospital Stays | ✔ Covered | ✔ Covered |
| Prescription Drugs | ✔ Covered | ✔ Covered |
| Mental Health | ✔ Covered | ✔ Covered |
| Substance Abuse Help | ✔ Covered | ✔ Covered |
| Dental Care | ✔ Covered | ✔ Covered |
| Vision Care | ✔ Covered | ✔ Covered |
| Lab Tests | ✔ Covered | ✔ Covered |
| Gia® Virtual Care | ✔ Covered | ✔ Covered |
Extra benefits you may get
Some plans may include more than the basics. You may also get:
- Transportation to medical appointments Rides to and from your doctor visits
- Help with quitting smoking Support and tools to help you stop smoking
- Nutrition counseling Tips and guidance to eat healthy and feel your best
- Gia virtual care and plan management Access to your Member ID card and 24/7 virtual care
Age and Eligibility
Many people qualify for one of these two health insurance programs, but rules are different for each plan.
Medicaid
- Available to people of all ages
- Includes children, adults, seniors, and people with disabilities
- Citizenship or immigration status matters, but there are special rules for some groups
Undocumented non-citizens aged 65 and older may qualify. This is an important option for older adults who cannot get other coverage.
Examples:
- A child under the age of 18 can qualify if the family meets income limits
- A senior 65 years of age or older may qualify even if they are undocumented, under special rules
The Essential Plan
- For adults ages 19–64
- You must be a U.S. citizen or lawfully present in the country
- You must not be eligible for Medicaid, Medicare, or employer-based insurance
Children and seniors do not qualify for this plan. Children may qualify for Medicaid or Child Health Plus. Seniors may qualify for Medicaid, Medicare, or a dual-eligible plan
Examples:
- If you are 35 years old and earn $30,000 per year, you may qualify for the Essential Plan.
- If you are 65 or older, you cannot get the Essential Plan, but you may qualify for Medicaid or Medicare.
Which Program Is Right for You?
Your income and age determine which of the two health plans you qualify for.
The only way for New Yorkers to know is to check their eligibility.
Check your eligibility
Call 1-800-TALK-MVP (825-5687) TTY 711 to speak with an MVP representative. English and Spanish-speaking representatives are available.
If you’d like an MVP representative to call you, complete the form below. We’ll call you to guide you through your options.
You can also learn more about Medicaid or the Essential Plan, or use our interactive tools to see what you qualify for.