Essential Plan

Medicaid

The Essential Plan is offered through UnitedHealthcare Community Plan. It's for lower income individuals in New York who meet the income or citizenship status requirements.

To find out if UnitedHealthcare Community Plan is offered in your county, please call 1-888-617-8979. A representative will contact you to schedule an appointment to help you apply.

Albany, Bronx, Broome, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Jefferson, Kings, Lewis, Livingston, Madison, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Seneca, St. Lawrence, Suffolk, Tioga, Ulster, Warren, Wayne, Westchester, Wyoming, and Yates.

Mga Pakinabang at Feature

Coverage Types

Essential Plan 1 Standard: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level.

Essential Plan 1 Native American/Alaskan: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level.  Designed for Native American or Alaskan Native Individuals.

Essential Plan 1 Plus: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level. Includes Dental and Vision benefits.

Essential Plan 1 Native American/Alaskan Plus: Coverage for those ages 19-64 who earn 151-200% of the Federal Poverty Level. Includes Dental and Vision benefits. Designed for Native American or Alaskan Native Individuals.

Essential Plan 2 Standard: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level.

Essential Plan 2 Native American/Alaskan: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level. Designed for Native American or Alaskan Native Individuals.

Essential Plan 2 Plus: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level. Includes Dental and Vision benefits.

Essential Plan 2 Native American/Alaskan Plus: Coverage for those ages 19-64 who earn 139-150% of the Federal Poverty Level. Includes Dental and Vision benefits. Designed for Native American or Alaskan Native Individuals.

Essential Plan 3: Coverage for those ages 21-64 who are "Legally Present" but not eligible for Medicaid, earning 100-138% of the Federal Poverty Level.

Essential Plan 4: Coverage for those ages 21-64 who are "Legally Present" but not eligible for Medicaid, earning less than 100% of the Federal Poverty Level.

Monthly plan premium will apply for all Essential Plan 1 Standard and Essential Plan Plus plans.

Medical Services: Copays will apply for all Essential Plan 1 plan types.

Inpatient Hospital Services: Copays will apply for all Essential Plan plans.

Emergency Medical Services: Copays will apply for all Essential Health Plan plans.

Outpatient Hospital/Facility Services: Copays will apply for all Essential Plan plans.

Preventive and Primary Care Services: PCP/Specialist copay per visit (based on type of physician performing the service) will apply for all Essential Plan plans.

Physician /Professional Services: Copays will apply for all Essential Plan plans.

mga inireresetang gamot: Copays will apply for all Essential Plan plans.

* Copays may vary. Alaskan Natives and American Indian members are exempt from co-pays and co-insurance. Refer to Subscriber Contract in Member Information section for more details regarding copays and coinsurance.

Get the care you need to stay healthy – or to get better if you are injured or sick. That includes:

  • Pagpili ng Doktor. Use "Doctor Lookup" to see if your doctor is in our network or to find a new one.
  • Mga gamot. Prescription drugs are covered with a small copay.
  • Dental*. We cover cleanings, checkups and dental work.
  • Mga Pagpapatingin Habang Walang Sakit. Annual checkups can help keep you healthy.
* Dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans.

If you have special health care needs, you can count on us. Our plan will provide the extra care and services needed. Kabilang sa mga benepisyo ang:

  • Kalusugan ng pag-iisip. Saklaw ang pagpapayo at iba pang mga panggagamot.
  • Pamamahala sa kaso. Kung kwalipikado ka, kumuha ng personal na tulong sa pamamahala sa mga kundisyon ng kalusugan.
  • Asthma and COPD Care. Exams, testing and supplies are covered.

Make sure your sight, teeth, speech and hearing are at their best. Kabilang sa mga benepisyo ang:

  • Vision. Covers eye exams and glasses.**
  • Dental. We cover cleanings, checkups and dental work.**
  • Hearing. Screenings and therapies, if needed, are provided.

** Vision and dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans. Malalapat ang pagbabahagi ng gastos para sa mga nasa planong Essential Plan Plus.

Partial reimbursement ($400/200 every 6 months) for facility fees if member attains at least 50 visits.

Gym Reimbursement Forms: English | Espanol

Get the medical care and equipment you need to recover safely at home. Kabilang sa mga benepisyo ang:

  • Care Coordinator. Someone to get you the services you need to recover safely.
  • Personal Care. Services to help you heal after illness or injury.
  • Kagamitan at Mga Supply. Ang medikal at pangkaligtasang kagamitan sa tahanan ay sinasaklaw.
  • Nurse Visits. Care after surgery or illness to recover at home.

Kung minsan, maaaring kailanganin mo ng kaunting karagdagang tulong sa paggamit ng iyong planong pangkalusugan. Para sa mga pagkakataong iyon, maaari kang umasa sa:

  • Member Services M-F 8:00am to 6:00pm EST. When you call Member Services you will be connected with a specially trained Advocate. They will help you get the most from your health plan. For example, your Advocate is equipped to answer your questions, resolve issues, help set up doctor appointments and directly connect you with services available to you.
  • Nutrition Coaching. Helpful advice to improve your diet.

Asthma and COPD Care

Individual care to help control asthma, allergies or COPD symptoms.

Do you or your child have trouble managing asthma, allergies or COPD symptoms? A nurse who specializes in breathing issues can really help. You'll get a customized treatment plan and medicine to:

  • Manage flare-ups.
  • Reduce symptoms.
  • Let you or your child stay active.

Pagpili ng Doktor

You get a primary care physician (PCP), who is your main doctor. Use the Doctor Lookup tool to see if your doctor is in our network.

If you don't have a doctor or if your doctor is not in our network, we can help you find a new one close to you.

Ang iyong PCP ay ang iyong pangunahing doktor para sa:

  • Pampigil na pangangalaga.
  • Panggagamot kung mayroon kang sakit o pinsala.
  • Mga referral sa mga espesyalista para sa ilang partikular na kundisyon.

Dental/Vision Care*

Dental Care*

Checkups are covered. Exams and cleanings every six months help keep teeth and gums strong and healthy. If there is a dental problem that needs to be fixed, that's covered as well.

Vision Care*

See life more clearly with routine eye exams and glasses, if needed. We also include:

  • Mga inireresetang lens.
  • Medicaid approved frames.
  • New eyeglasses every two years.

This benefit is offered by March Vision care.

*Vision and dental benefits are available through purchase of Essential Plus plans or as a standard benefit in Essential Plan 3 and 4 plans; these benefits are not available for Essential Plan 1 and 2 Standard Plans.

Diabetic Supplies

If you have diabetes, you may need insulin, needles, wipes and glucose strips. Sinasaklaw namin ang lahat ng iyon at higit pa.

Ang aming plano ay may kasama ring mahuhusay na serbisyo upang tulungan kang mapamahalaan ang iyong diabetes, kabilang ang:

  • Classes on keeping diabetes in control.
  • Pag-coordinate sa pangangalaga ng doktor.
  • Nutrition and diet.

Matibay na Medikal na Kagamitan

Ang iyong kalusugan at kaligtasan sa tahanan ay mahalaga.

Our plan covers medical equipment ordered by your doctor or case manager. This can include supplies like:

  • Diabetic supplies.
  • Mga kama sa ospital.
  • Wheelchairs or walkers.

Pangangalaga sa Pandinig

Ang problema sa pandinig ay maaaring makaapekto sa iyong pang-araw-araw na pamumuhay sa maraming paraan. Kabilang sa aming plano ang mga serbisyo at suporta upang matulungang protektahan ang iyong pandinig.

Sinasaklaw ng aming plano ang:

  • Exams, therapy and tests.
  • Hearing aids and batteries.

Pagkakaospital

This plan pays for all expenses related to a hospital stay, so you can rest and heal.

Hospitalization coverage includes:

  • Pangangalaga ng isang nurse.
  • Kwarto at matutuluyan.
  • Mga supply at kagamitan.
  • Panggagamot at mga therapy.
  • Mga diagnostic na pagsusuri at eksaminasyon.

At pagkalabas mo sa ospital, hindi ka mag-iisa. Titiyakin naming makakakuha ka ng follow-up na pangangalaga upang maipagpatuloy ang pagpapagaling sa tahanan.

Medicines

Our plan covers prescription drugs and refills with a small copayment. Your copay is:

Essential Plan
1 2 3 4
Generic $6 $1 $1 $0
Tier 2 $15 $3 $3 $0
Tier 3 $30 $3 $3 $0

Over-the-counter medicines with a written order from your doctor are available for a copayment for each medicine. And we make getting your medicine easy. You can fill your prescriptions at:

  • Local pharmacies.
  • Services that deliver right to your door.

Mga Serbisyo para sa Miyembro

Sometimes you might need a little help understanding your health care options. With us, you have someone you can call 24/7. We'll answer your questions simply and completely.

Maaari ka rin naming tulungang humanap ng:

  • Home care providers.
  • Dentists and vision providers.
  • Adult day health centers.

Mental Health*

Mental health is as important as physical health. That's why we have coverage for both.

Required care is 100% covered. This includes:

  • Therapy para sa kalusugan ng pag-iisip na apektado ng pag-uugali.
  • Panggagamot sa pang-aabuso sa gamot.
  • Medications.

* Copays will apply for Essential Plan 1.

Nurse Visit

Sometimes you may need continued care after you leave the hospital or urgent care.

If your health is at risk after a serious illness, surgery or injury, a nurse will visit you at home to:

  • Provide medical care for you.
  • Answer your questions and concerns.

Outpatient Services

Napakainam na malaman nang maaga pa lang kung ano ang problema.

Sinasaklaw ng aming plano ang:

  • Mga laboratoryo at pagsusuri.
  • Mga x-ray, scan at iba pang imaging.

We'll help you get the information needed to help improve your health or be your best.

Residential Care

After a serious illness, surgery or injury, you may need extra nursing and therapy.

If needed, our plan covers short stays in a rehabilitation center where you can heal. Included are:

  • Nursing home services.
  • 24-hour nursing care.
  • Help with activities of daily living.
  • Physical, occupational and speech therapy.

Respite na Pangangalaga

Mayroon ka bang mga kapamilya o kaibigan na nag-aalaga sa iyo sa tahanan?

Kung mayroon, hinihiling naming suportahan sila sa kanilang pagsusumikap. That's why we provide respite care to give your caregivers a rest. Ang respite na pangangalaga ay nag-aalok sa mga caregiver ng pansamantalang bakasyon malayo sa kanilang mga mahal sa buhay na may karamdaman o mga espesyal na pangangailangan sa pangangalaga.

Shots and Immunizations

Routine shots help keep you healthy.

So, our plan covers:

  • Recommended shots and vaccines.
  • Mga diagnostic na pagsusuri at eksaminasyon.

Mga Pagpapatingin Habang Walang Sakit

Well visits with your doctor can help you stay healthy. These visits can catch health problems early, so they can be treated.

Kabilang sa mga serbisyong pang-iwas sa sakit ang:

  • Checkups for adults and children.
  • Well-baby care.
  • Care for women expecting a baby.
  • Routine shots and tests.
  • Mga mammogram.

Mga Mapagkukunan ng Miyembro

2019 Subscriber Contracts

Tingnan ang Mga Available na Mapagkukunan

To learn more about applying for health insurance, including Medicaid, Child Health Plus, Essential Plan, and Qualified Health Plans through NY State of Health, The Official Health Plan Marketplace, visit www.nystateofhealth.ny.gov or call  1-855-355-5777.

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