Key points
- On July 1, 2026 the Essential Plan income ceiling fell from 250 percent to 200 percent of the federal poverty level.
- The 2026 income limits are $31,920 for a household of one, $43,280 for two, $54,640 for three and $66,000 for four.
- A behavioral health outpatient visit costs $0 for individual income up to $23,940 and $15 for income from $23,941 to $31,920.
- Essential Plan drug coverage runs through each health plan's own formulary, not through NYRx, so ADHD medication rules differ by plan.
- Marketplace plans bought through NY State of Health are New York-regulated, so state parity law, the 10-business-day appointment rule and DFS external appeal apply.
New York's coverage options for adults who earn too much for Medicaid changed in the middle of 2026. If you are reading older articles, or an insurer page that has not been updated, the income figures will be wrong. This article gives the position as of October 2026 and shows what each option means for the costs of ADHD care.
What changed on July 1, 2026
The Essential Plan (EP) is New York's low-cost coverage for adults who do not qualify for Medicaid. From 2024 it had covered people with income up to 250 percent of the federal poverty level under a federal waiver. In March 2026 the Department of Health announced that the federal government had approved ending that waiver, effective July 1, 2026, and returning the program to its earlier legal basis.
According to the Department of Health:
- About 1.3 million people with income under 200 percent of the poverty level kept the Essential Plan.
- About 450,000 people with income between 200 and 250 percent lost eligibility and became eligible for Qualified Health Plans instead.
- The State's stated reason was a 2025 federal law that removed about half of the program's funding, along with the expiration of enhanced federal premium tax credits at the end of 2025.
- The State said people moved to a Qualified Health Plan mid-year would have their deductible cut in half.
Any page that still shows a single-person limit of $39,900 is out of date.
Who qualifies for the Essential Plan now
You must be a New York resident, lawfully present, aged 19 to 64, not eligible for Medicaid or Child Health Plus, without access to employer or other coverage, and within the income limit.
| Household size | 2026 income limit |
|---|---|
| 1 | $31,920 |
| 2 | $43,280 |
| 3 | $54,640 |
| 4 | $66,000 |
The plan has a $0 monthly premium and a $0 deductible, and enrollment is open all year.
What ADHD care costs on the Essential Plan
Cost sharing depends on which of two income tiers you fall in. Figures are from the NY State of Health Essential Plan page as read in October 2026.
| Service | Individual income up to $23,940 | Individual income $23,941 to $31,920 |
|---|---|---|
| Behavioral health outpatient visit | $0 | $15 |
| Specialist visit | $0 | $25 |
| Generic prescription | $1 | $6 |
| Preferred brand prescription | $3 | $15 |
| Non-preferred brand prescription | $3 | $30 |
Prescriptions are $0 for individuals with income below $15,960.
Stimulants cannot be refilled, so each fill is a new prescription with its own copay. On the higher tier, a generic filled once a month comes to $72 a year in copays, plus the visit copays.
Essential Plan drug coverage is not NYRx
This is a common point of confusion. Medicaid members get their drugs through NYRx, one statewide program with one preferred drug list. Essential Plan members do not. Their drug coverage runs through the formulary of the health plan they chose.
So the NYRx rules described in New York Medicaid and adult ADHD do not carry over. Before you pick or change an Essential Plan insurer, look up your medication on that insurer's current Essential Plan formulary and check three things: whether the drug is listed, which tier it is on, and whether it needs prior authorization or has a quantity limit.
If your income is above the limit: Qualified Health Plans
Qualified Health Plans (QHPs) are the private plans sold through NY State of Health in metal tiers. For ADHD care, four facts matter.
- Mental health care is an essential health benefit. Every Marketplace plan covers mental health services, with no yearly or lifetime dollar limits and no surcharge for a pre-existing condition.
- New York law applies. QHPs bought through NY State of Health are New York-regulated, so the state coverage mandate and parity rules described in does insurance cover adult ADHD care in New York apply, along with DFS external appeal.
- Costs are higher. The Department of Health notes that QHPs may carry monthly premiums, higher deductibles and higher out-of-pocket costs than the Essential Plan. With a deductible, you may pay the full negotiated rate for psychiatric visits until it is met, depending on the plan design.
- Networks and formularies differ by insurer. Check both before enrolling.
Open enrollment dates for 2027 coverage were not confirmed on the NY State of Health site at the time of writing. Check the site or call for current dates.
Comparing the two for ADHD care
| Feature | Essential Plan | Qualified Health Plan |
|---|---|---|
| Premium | $0 | Varies by plan and income |
| Deductible | $0 | Varies, can be substantial |
| Psychiatric visit | $0 or $15 | Plan copay or coinsurance, sometimes after deductible |
| Drug list | Insurer's EP formulary | Insurer's QHP formulary |
| 10-business-day appointment standard | Applies | Applies |
| Enrollment | Year-round | Open enrollment or a qualifying event |
When no one in the network has an opening
The State's appointment standard has applied to the Essential Plan since July 1, 2025: a first outpatient behavioral health appointment within 10 business days. If your plan cannot provide one, the remedy starts with an access complaint to the insurer. The steps and limits are in New York's 10-business-day rule. Essential Plan complaints go to (855) 355-5777.
Getting help with enrollment
NY State of Health lists its help line as 1-855-355-5777 (TTY 1-800-662-1220), Monday to Friday 8 am to 8 pm and Saturday 9 am to 1 pm. Confirm hours on its site. The Essential Plan page also names a provider and health plan look-up tool for checking which plans a clinician takes.
Income near a cutoff is worth reporting accurately and promptly, because it decides both eligibility and your cost-sharing tier. For which coverage this practice works with, see the fees and insurance page.
Questions
Was the Essential Plan eliminated in 2026?
No. The income ceiling was lowered from 250 percent to 200 percent of the federal poverty level on July 1, 2026. The Department of Health said about 1.3 million people under the new limit kept their coverage.
What is the Essential Plan income limit for a single person in 2026?
$31,920, which is 200 percent of the federal poverty level. Pages that still show $39,900 reflect the limit that applied before July 1, 2026.
How much does a psychiatrist visit cost on the Essential Plan?
A behavioral health outpatient visit is $0 for individual income up to $23,940 and $15 for income from $23,941 to $31,920, according to NY State of Health. There is no deductible.
Is ADHD medication covered the same way on the Essential Plan as on Medicaid?
No. Medicaid drug coverage runs through NYRx and one statewide list. Essential Plan drug coverage runs through each health plan's own formulary, so coverage and prior authorization rules for a given medication can differ between insurers.
I lost Essential Plan eligibility in July 2026. What are my options?
People with income between 200 and 250 percent of the poverty level became eligible for Qualified Health Plans through NY State of Health. Those plans must cover mental health care but may have premiums and deductibles. NY State of Health can explain what financial help applies to you.
Sources
- NY State of Health: Essential Plan (update: changes as of July 2026)
- NYS Department of Health: Federal approval to preserve health coverage (press release, March 23, 2026)
- NYS Department of Health: NYRx pharmacy benefit information for members (revised September 2025)
- HealthCare.gov: Mental health and substance abuse coverage
- NYS Department of Health and Department of Financial Services: Network adequacy consumer fact sheet (July 1, 2025)
- NYS Department of Financial Services: Behavioral health insurance rights
