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.

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:

Experience-Rated

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.

Prospective-Rated
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.

Retrospective-Rated
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.

Community-Rated

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.

Flexibility

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 highereducation@emblemhealth.com.