Any opinions on NY State's Essential Plan?

[NYCFire]

Hi all,

Long time lurker, first time poster.
I live in NYC and have been FIRE'd for several years. My COBRA coverage expires in 2018 and I'm looking at ACA plans. In NY State, there is expanded Medicaid. The Medicaid income level for single taxpayers (like me) is approx. $15,000. Above that income level to approx. $25,000 you MUST enroll in the Essential health plan. Above that income level is the usual ACA. The Essential plan has significantly lower premiums of zero to $20 per month. My question for the forum is this: Does anyone have experience using the Essential plan? I ask this since I can easily 'arrange' my taxable income such that my MAGI is < $25,000. Where I live (NYC), I have heard that Medicaid coverage can have a nightmarish quality. Is the Essential plan similarly bad?
Please - no comments on whether it is 'right' for me to 'arrange' my income between my taxable and non-taxable accounts.
Thanks!

[jim584672]

I am on a NYS Medicaid managed care plan and it has been good. The Essential plan is basically the same but without vision or dental. All my doctors from work are in the plan so it is good for me. The dental benefit is very minimal, almost worthless, in my plan.

You should look online to see the doctor networks and formularies for the plans.

[NYCFire]

Thanks for the info. It looks like my current general physician is on the Essential Fidelis plan. So that's good.
But what about specialists and diagnostics? Last year I hurt my arm and needed to see a orthopedic specialist I also needed an CT scan for kidney stones. Have you any experience with specialists and expensive diagnostic in the Essential plan?

[jim584672]

I have seen 3 specialists who are in the plan. I had these from my work plan and luckily they are in my current plan. Even with good work insurance I had to wait several weeks to get a new appointment being a new patient. Since I was already in no problems making appointments.

[NYCFire]

This is very good info - thanks!

I looked at the different Essential plans, but obviously, it is difficult to determine if I will even need a specialist and if so, who the specialist will be.

[a60dan]

Does anyone have recent experience with the New York Essential Plan, specifically with claims out of your local "in network" area?

I realize this is an old post, but it's specific to NY state.

Our recently retired friends were BOTH recently hospitalized out of state within the US.

It sounds like they were covered in full, most likely because they were exceptions under the "emergency services".

Our situation for a 3-4 year "bridge" to Medicare coverage is:[LIST][*]COBRA ~$17K/year including the $5200 deductible[*]Essential Plan at ~$4K out of pocket maximum for both

We have had very infrequent short hospital stays, likely to increase as we age.

I think it's a really good plan. We hope to travel, and I don't want to blow any "perceived savings" in one "out of network" hospital stay while on an out of state/country trip.


Real world experience appreciated.


This is a current contract according to the Excellus BCBS web site:

https://www.excellusbcbs.com/documen...=1604082319792

[jim584672]

I was supposed to go the Essential Plan but COVID happened and they locked everyone into Medicaid until the health emergency is over.

[pb4uski]

If you're going to manage your income to qualify for the NY Essential Plan ($34k for a household of two from what I'm reading) I wonder if you would be better off with an ACA plan with subsidies.

In VT at that $34k level of income for 2 you could get an BCBS ACA bronze plan for $0 premium or a silver plan for $256-317/month and those BCBS plans are no problem when traveling since BCBS is nationwide.

[Sunset]

For out of country, I'd add a travel plan for backup medical insurance and evacuation.

[pb4uski]

+1 I hadn't noticed that some of their travel might be out-of-country.

[a60dan]

We are 3 weeks in to Excellus NY Essential Plan 1.

$2000 out of pocket max for EACH of us because they are separate plans. $0 premium due to COVID-19.

Household taxable income must be less than ~$34480.

The (local, in network) coverage is better than our employer high deductible plan that would have cost ~$17K because we always hit the deductible.

We did buy trip insurance when we recently traveled to Mexico which included evacuation etc.

Ironically, the letter that came 1/12 stating that my employer plan was terminated effective 12/31/2021 listed several ACA Premium Tax Credit (PTC) plans and the Essential Plans.

I’m still wrapping my head around this concept, but it seems to be a great bridge to Medicare.

Much to my surprise, Medicare will be more costly for premiums.

[jim584672]

Gov. Hochul proposed increasing the Essential Plan up to 250% FPL from 200% FPL for next year.