The Smarter Choice

We are the smarter choice for higher education faculty and staff. Our plans address tough issues like keeping retirees’ benefits up to par and coverage for adjunct faculty members.

We know that when it comes to health coverage, college and university decision makers have lots of options. But when it comes to quality and affordable health coverage, you'll find EmblemHealth is head and shoulders above the competition.

Higher education HR professionals turn to us for care that responds to the needs of their faculty and staff. These industry insiders know EmblemHealth understands and respects the needs of higher education institutions and that we offer:

Competitive, flexible and affordable health coverage.

Prices vary, but the level of attentive care offered by the providers in our networks and the overall service our members receive will never vary — no matter which plan you select.

Quality care offered by quality providers.

Our vast network of New York’s top doctors and our connections with the region’s premier hospitals means our members can get the care they want and need.

Access to the little things that mean a lot.

Whether its 24/7 customer service, access to urgent care or Web-based tools that help put our members in the driver’s seat, help is always just a call or click away.

Tools to help your faculty and staff stay healthy, get well and live better.

If your faculty and staff have their sights set on a healthier future, our health and wellness programs can help them meet their goals.

Our plans

  • Offer a wide selection of flexible benefit designs and cost-sharing options to help you get the most for your institution's precious health care dollars.
  • Deliver real value by providing your members with access to our extensive provider network of top doctors, specialists and top medical professionals throughout the tristate area.
  • Offer your faculty and staff entry to hospital networks that includes nearly every acute-care hospital in the region, including Memorial Sloan-Kettering Cancer Center, Northern Westchester Hospital Center, St. Frances Heart Center and many others.
  • Incorporate online tools and digital resources that let our members take a more active role in maintaining their own health and get the information needed to do so in an instant.
  • Can include an impressive array of industry-recognized, preventive care and wellness programs. We take health and wellness seriously: in 2011, the National Committee for Quality Assurance awarded accreditation to our wellness programs.

Get your faculty and staff the care they deserve with EmblemHealth.

Quality Networks Mean Quality Care for Your Faculty and Staff

Our robust medical network provides access to a wide range of medical practitioners, including:

  • Primary care physicians and specialists, including pediatricians, cardiologists, oncologists and more.
  • Behavioral and mental health services provided through an alliance with ValueOptions®
  • Other essential providers, including skilled nursing facilities, medical equipment and vision care.
  • Clinical labs, such as Quest Diagnostics.

Our hospital networks include every acute-care hospital, including Memorial Sloan-Kettering Cancer Center, Northern Westchester Hospital Center, St. Frances Heart Center and many others.

Administrative Services Only (ASO) Arrangements

ASO Doctor and PatientOur ASO arrangements offer higher education institutions claims processing and customer service for a low per-member administrative fee, plus the quality care and competitive fee schedules available through the EmblemHealth National Network.

EmblemHealth case management services enable your institution to take advantage of our medical management and member assistance capabilities through all aspects of cases — even the most complex.

Flexible Benefits Designs

EmblemHealth gives your institution choice and flexibility. Our broad selection of plans gives you the flexibility to offer multiple options to your faculty and staff.

Our PPO and InBalance PPO (Preferred Provider Organization) plans feature the EmblemHealth National Network and combine family-friendly benefit designs with freedom of provider choice. No referrals are required. They also offer members out-of-network coverage for additional out-of-pocket costs. The InBalance option lowers group premiums by applying member cost-sharing for certain services received in-network.

Our EPO and InBalance EPO (Exclusive Provider Organization) plans provide access to the EmblemHealth National Network and offer family-friendly, in-network-only benefits that make these plans attractive and affordable. No referrals are required. The InBalance option lowers group premiums by increasing member cost-sharing for certain services.

Ou Consumer Direct PPO and Consumer Direct EPO plans provide access to the EmblemHealth National Network and offer low group premiums based on higher-than-customary member deductibles. These high-deductible health plans help groups offset member costs with tax-saving Health Savings Accounts (HSAs).1

Our CompreHealth EPO provides in-network-only benefits with no referrals required, and offers access to the EmblemHealth NY Metro Network, with leading physicians and other medical practitioners across New York City and Nassau, Suffolk and southern Westchester counties. In addition to physicians in private practice, it features multispecialty physician group practices that offer a broad range of medical services, often under one roof, as well as access to the metro area’s leading hospitals.

Our Dental Plans provide a choice of three programs featuring different benefit designs, network size and cost-sharing responsibilities, ranging from paid-in-full network coverage to in-network discounts on more costly services.

Our Pharmacy Benefit Services, available by separate rider, provides a wide range of retail and mail-order prescription drug benefits, as well as an extensive formulary of drugs covered by the prescription plan.

Your EmblemHealth sales representative will work closely with you to help put together a benefit plan design that best serves the needs of your institution.

1 HSAs are options the group may add to its HDHP plan. Groups must make arrangements for the HSA before offering it to their members.

Get your plan, your way with EmblemHealth. Let us help you find or build a plan to meet both your budget and the needs of your institution's faculty and staff.

We'll work closely with you to tailor a coverage solution that fits within your budget and shows your faculty and staff that you care — like we do — about all the things that go into a great health plan.

Your Plan, Your Way — The EmblemHealth Shared Administrative Advantage Program

At EmblemHealth, we understand that as health care costs continue to rise, it's more challenging than ever for your faculty and staff, hard-working New Yorkers, to get the most out of their health care dollar.

By combining EmblemHealth's extensive provider network with your health care plan, the Shared Administrative Advantage (SAA) program is a health care option designed to help you get your staff members the quality care they deserve — at an affordable price.

You're in the driver's seat

You can customize your own health plan to the needs of your faculty and staff, who will benefit from:

  • Provider discounts
  • An extensive provider network — nationwide
  • Premier hospitals in New York State
  • A seamlessly administered plan
  • Quality care

Cost Savings

We know that each higher education institution is unique, so we don't limit the SAA program to colleges or universities of a particular size. Whether you're a small or large institution, the overall cost of your care can go down when you use the SAA network of practitioners.

Because we have extensive and long-standing partnerships with health care professionals and facilities in New York State, we can pass on great discounts to your faculty and staff. Let us prove
it to you.

When we meet, we'll present two extensive analyses of your groups's health care expenditures:

  • Complimentary claim repricing based on an analysis of your claims history. We'll show you in precise dollar amounts what your real health coverage costs are and how much your group could save with the SAA program.
  • A head-to-head comparison of every provider and facility in your current network to demonstrate the EmblemHealth network advantage.

Schedule a meeting at your convenience. E-mail us at or call 877-411-3625.

Great Provider Network

The EmblemHealth Shared Administrative Advantage program offers access to hospitals throughout New York State, including some of the nation's most recognized cancer centers, such as Memorial Sloan-Kettering Cancer Center and Roswell Park Cancer Institute.

Your faculty and staff will also have discounted access to some of the largest medical groups in the New York area, such as Allied Pediatrics of New York, Crystal Run Healthcare, ProHealth Care Associates LLP, Mount Kisco Medical Group, PC and WESTMED Medical Group, just to name a few.

By using our provider network, you get peace of mind that your group is saving on costs while your staff members are receiving quality care.

Coordinated Care

Our partnership with our providers extends beyond claims payments. We provide end-to-end support.

We use effective and proven management tools to help practitioners guide their patients' through the health care process. We encourage the use of clinical practice guidelines and we regularly review current medical literature to assess the safety and efficacy of new and existing technologies.

Plus, nurse care managers provide review and case management when members are hospitalized or receive skilled nursing facility care, rehabilitation, home care or hospice services. They can assist the coordination of care by multiple providers across different health care systems, so the member can concentrate on getting better.

Your Role and Our Role

The EmblemHealth SAA program keeps your group in control of faculty and staff benefits and allows you to take advantage of our operational expertise.

We will seamlessly integrate the SAA program into your existing medical plan. Our professional and highly experienced account managers will provide ongoing support how and when you need it.

Here's how your group and EmblemHealth work together for a well-run health plan that focuses on your staff members and keeps your costs down.

Your Employer Group Will Provide: EmblemHealth Will Provide:
Member Services Out-of-Network
Provider Services
Provider Services
Enrollment process Care management Care management
Enrollment and eligibility maintenance Utilization management Utilization management
ID card issuance Prior authorizations Prior authorizations
Explanation of benefits issuance Claims adjudications Claims adjudications
Benefit file maintenance Claims payments Claims payments
  Explanation of payments Explanation of payments
    Medical record reviews
    Customer service
    Provider directory and lookup
    Network management


How SAA Works

With over 75 years of experience providing quality health care coverage in New York State, we have established solid relationships with doctors and hospitals in our region and are well-positioned to manage our providers' expectations.

EmblemHealth will continue to adjudicate claims for network practitioners and facilities the way they are accustomed to. With consistent claims pricing and seamless claims payments, network doctors can focus on providing care and not be concerned with how and when their claims will be paid.

This translates into provider satisfaction and deep discounts to your faculty and staff.

The Program, Step-by-Step

  • The plan member easily finds a network provider through our provider lookup tool, available through your group's Web site.
  • The member receives care from a network provider.
  • The member is only responsible for the applicable copay, deductible, coinsurance and noncovered service charges.
  • The network provider sends the claim to EmblemHealth.
  • EmblemHealth applies network benefits and claim adjudication edits at our discounted rate.
  • EmblemHealth transfers the claim file to your group for confirmation.
  • EmblemHealth pays the network provider.
  • Your group adjudicates and pays the out-of-network provider.

Find the Funding Solution for Your College or University

An EmblemHealth representative can help you explore the various funding methods we offer to find one that meets your bottom-line objectives.

The most common conventional and alternative options include:


Historical claims experience is used as the basis for projecting future claims and determining the premium. These arrangements include pooling of individual high-cost claims to protect against the effects of catastrophic claims.

Availability: Institutions with 51 or more eligible enrollees.

These arrangements enable self-insured institutions to take advantage of the quality care and competitive provider reimbursement rates available through EmblemHealth’s National Network. This program offers claims processing and customer service for a low per-enrollee administrative fee. Anticipated claims experience is evaluated for a future policy period based on an institution’s actual experience and the performance of the EmblemHealth pool for similar businesses. The cost of the plan is determined and fixed in advance of the policy period, and the institution is not eligible for any retroactive rate refunds. Losses (deficits) are not carried forward.

Availability: Institutions with 51 or more eligible enrollees.

This approach evaluates and measures past claims data to estimate future costs of providing benefits based on actual experience. The institution is eligible for retroactive rate refunds when the earned premium exceeds the plan's overall expenses.

Availability: Institutions with 1,000 or more eligible enrollees; these arrangements are subject to underwriting review and approval.

Deferred Premium

Eligible institutions are allowed to remit a percentage of their gross earned premium on a monthly basis, called the "payment rate." The difference between the payment rate and the gross earned premium rate is "callable" by EmblemHealth at a later date, depending upon claims experience and other factors.

Availability: Subject to underwriting review and approval.


This methodology combines overall medical cost per plan to determine a standard premium rate for that plan.

Availability: All institutions with fewer than 51 eligible enrollees and all faculty and staff enrolled in EmblemHealth HMO plans.

Administrative Services Only (ASO)

Administrative Services Only (ASO) enhances cash flow by allowing the institution to reimburse EmblemHealth solely on the basis of paid claims plus administrative fees. This rating arrangement is not insured and the institution is responsible for all claim payments and administrative charges associated with the plan. Stop-loss insurance is recommended for all ASO accounts, but is required for those with less than 1,000 eligible enrollees. You retain the flexibility of securing your own stop-loss quote through a vendor of your choosing or having EmblemHealth request a quote through one of its preferred vendors.

Availability: Institutions with 250 or more eligible enrollees.

EmblemHealth offers conventional and alternative funding arrangements and will consider special funding arrangements as requested by prospective institutions — including ASO self-insurers — contingent upon the size of the group.

EmblemHealth Network Access Program: Consider Leasing

Want to deliver a plan that realizes cost savings and hassle-free benefits administration? Look no further. The EmblemHealth Network Access Program offers all these benefits and more.

You can lease our hospital network, medical network — or both. Your faculty and staff gain access to quality care delivered by EmblemHealth's extensive network of world-class physicians, hospitals and acute care hospitals. With the EmblemHealth Network Access Program you get:

Discounted Access to Our Providers

Our longstanding relationships with participating providers allow us to negotiate sizable payment discounts. Consider:

  • Medical network reimbursement schedule produces discounts of 75 to 80 percent of RBRVS (Resource-Based Relative Value Scale).
  • Hospital network reimbursement schedule, which produces savings of 40 to 60 percent.


Network Access gives you the flexibility to choose how to price claims, which gives you complete control over your benefits administration. Lease our hospital network, medical network or both.

Extensive Networks That Provide Quality Care

Our medical network provides access to a wide range of medical practitioners, including:

  • Primary care physicians and specialists, including pediatricians, OB/GYNs, cardiologists, oncologists and more
  • Mental health inpatient and outpatient services provided through an alliance with ValueOptions®
  • Ancillary providers, including skilled nursing facilities, medical equipment and vision care
  • Clinical laboratories, such as Quest Diagnostics

Our hospital network includes nearly every acute care hospital, including Memorial Sloan-Kettering Cancer Center, Northern Westchester Hospital Center, St. Frances Heart Center and many others.

Security You Can Trust

Network Access uses the HIPAA 837 format and a secure Web pricing portal to ensure that your claims transmittals are secure and confidential.

Claims Pricing Options

You may utilize one or both of the following claims pricing options:

EmblemHealth Pricing Online Pricing by Client
For clients who want to submit claims electronically, EmblemHealth prices systemically and returns them for processing and payment. Authorized benefit administration staff can sign onto a secure web site to price claims at their own convenience via remote Internet access to the EmblemHealth Network Access provider claims re-pricing system.

Value-Added Health and Wellness Programs

EmblemHealth's Healthy Discounts Program offers your group discounts on weight-loss and exercise programs, hearing aids, massage therapy and more, to help your group members get healthy and stay healthy at no additional cost. And healthy members can mean lower claims costs.

For more information about the program, contact an EmblemHealth representative. Email us at

Shawn McLoughlin
Director of Sales Operations

Shawn McLoughlin joined EmblemHealth in November 2010 from Segal Consulting, where he served as National Director of Sales and Marketing and was a key member of their Higher Education Practice team.

As Director of Sales Operations, he is responsible for new business development, lead generation, association partnerships and proposals.

Shawn has 14 years of experience working with institutions and has been an active member of College and University Professional Association for Human Resources and the National Association of College and University Business Officers. He frequently represents EmblemHealth at conferences and events as a sponsor, speaker or exhibitor.

In addition to managing Sales Operations’ activities for the higher education team, he supports initiatives in the labor, not-for-profit and individual markets.

Shawn earned a Bachelor of Arts from the University of Maryland.


Matthew Maines, RHU
Senior Marketing Representative

Matthew Maines joined EmblemHealth in April 2010 after 20 years of experience in health plan sales and more than a decade specializing in large account sales, implementation and funding methods.

As Senior Marketing Representative, he is responsible for new sales to large groups — including higher education, labor and municipal markets — and to deliver and develop health care solutions through an extensive network of consultants.

Prior to joining EmblemHealth, Matthew was a five-time quarterly leader for sales/retention in western New York at Blue Cross Blue Shield of WNY. In addition, he was responsible for sales and growth for large self-insured labor groups while at Anthem Benefit Administrators.

Matthew graduated from State University of New York at Buffalo with a Bachelor of Arts degree and is an active member of the CUPA-HR Upstate Chapter.