Resources for Brokers & Consultants
Plan Information, Applications, References & Online Quoting Support
Health Insurance
- Claim Form - Rx
- COBRA Form
- Domestic Partnership Declaration
- Gym Reimbursement Form
- Incapable Dependent Child Certification Form
- Late Paperwork Form
- Letter of Certification - Sole Proprietor
- Submission Checklist
- Waiver of Coverage Form
- Young Adult Election-Eligibility Form
- 2019 Small Group Underwriting Guidelines
- 2019 Claim Form
- Small Group Late Submission Acknowledgement Form
- Waiver Form
- 2022 Individual Underwriting Guidelines
- CAI EFT Form
- 2020 Prime/Select Care/Millennium Network Comparison
- Benefit Description - Employee Assistance Program
- Benefit Description - Rx Program FAQs (an excerpt from EmblemHealth FAQs)
- Benefit Description - Women's Preventive Services - Effective 8-1-12
- 2020 AdvantageCare Physicians Overview
- 2020 Hospital Comparison
- EmblemHealth COVID19 FAQ
- EmblemHealth ACP Information
- EmblemHealth Teladoc Information
- 2021 Small Group Silver Value Benefit Summary
- 2021 Small Group Silver Premier Benefit Summary
- 2021 Small Group Silver Plus HSA Benefit Summary
- 2021 Small Group Platinum Value Benefit Summary
- 2021 Small Group Platinum Premier Benefit Summary
- 2021 Small Group Platinum PPO Benefit Summary
- 2021 Small Group Gold Value Benefit Summary
- 2021 Small Group Gold Premier Benefit Summary
- 2021 Small Group Gold PPO Benefit Summary
- 2021 Small Group Gold EPO-Virtual Benefit Summary
- 2021 Small Group Bronze Value Benefit Summary
- 2021 Small Group Bronze Premier Benefit Summary
- 2021 Small Group Bronze Plus HSA Benefit Summary
- 2021 QHP Formulary
- 2021 Small Group Formulary
- 2021 Q4 Rate Sheet and Plan Overviews
- 2022 Small Group Bronze Plus HSA Benefit Summary
- 2022 Small Group Bronze Premier-M Benefit Summary
- 2022 Small Group Bronze Premier P Benefit Summary
- 2022 Small Group Bronze Premier P Benefit Summary
- 2022 Small Group Bronze Value M Benefit Summary
- 2022 Small Group Bronze Value P Benefit Summary
- 2022 Small Group Bronze Value S Benefit Summary
- 2022 Small Group Gold PPO Benefit Summary
- 2022 Small Group Gold Premier M Benefit Summary
- 2022 Small Group Gold Premier P Benefit Summary
- 2022 Small Group Gold Premier S Benefit Summary
- 2022 Small Group Gold Value M Benefit Summary
- 2022 Small Group Gold Value P Benefit Summary
- 2022 Small Group Gold Value S Benefit Summary
- 2022 Small Group Gold Virtual EPO M Benefit Summary
- 2022 Small Group Gold Virtual EPO N Benefit Summary
- 2022 Small Group Platinum PPO N Benefit Summary
- 2022 Small Group Platinum Premier M Benefit Summary
- 2022 Small Group Platinum Premier P Benefit Summary
- 2022 Small Group Platinum Premier S Benefit Summary
- 2022 Small Group Platinum Value M Benefit Summary
- 2022 Small Group Platinum Value P Benefit Summary
- 2022 Small Group Platinum Value S Benefit Summary
- 2022 Small Group Silver Plus HSA Benefit Summary
- 2022 Small Group Silver Premier M Benefit Summary
- 2022 Small Group Silver Premier P Benefit Summary
- 2022 Small Group Silver Premier S Benefit Summary
- 2022 Small Group Silver Value M Benefit Summary
- 2022 Small Group Silver Value P Benefit Summary
- 2022 Small Group Silver Value S Benefit Summary
- 2022 Individual Bronze D Benefit Summary
- 2022 Individual Gold D Benefit Summary
- 2022 Individual Gold Premier D Benefit Summary
- 2022 Individual Gold Value D Benefit Summary
- 2022 Individual Platinum D Benefit Summary
- 2022 Individual Silver Bold D Benefit Summary
- 2022 Individual Silver D Benefit Summary
- 2022 Individual Silver Value D Benefit Summary
- 2022 Small Group Formulary
- 2021 Network Overview
- 2021 Small Group Underwriting Guidelines
- 2021 Small Group Bronze $4500
- 2021 Small Group Bronze $5400 HSA
- 2021 Small Group Bronze $7300
- 2021 Small Group Gold $0
- 2021 Small Group Gold $1000
- 2021 Small Group Gold $1250
- 2021 Small Group Gold $2000
- 2021 Small Group Platinum $0 Option 1
- 2021 Small Group Platinum $0 Option 2
- 2021 Small Group Silver $0
- 2021 Small Group Silver $3000
- 2021 Small Group Silver $3250 HSA
- 2021 Small Group Silver $5000
- 2021 Q1 Pro Plan Rate Sheet
- 2021 Q1 Pro Plus Plan Rates
- 2021 Q2 Pro Plus Plan Rates
- 2021 Q2 Pro Plan Rates
- 2021 Q3 Pro Plan Rates
- 2021 Q3 Pro Plus Plan Rates
- 2021 Q4 Pro Plan Rates
- 2021 Q4 Pro Plus Plan Rates
- 2022 Q1 Pro Plan Overview and Rates
- 2022 Q1 Pro Plus Plan Overview and Rates
- 2022 Q2 Pro Plan Overview and Rates
- 2022 Q2 Pro Plus Plan Overview and Rates
- 2020 Q3 Small Group Rates - NYC and Long Island (Regions 4 and 8)
- 2020 Q4 Small Group Rates - NYC and Long Island (Regions 4 and 8)
- 2021 Q1 Small Group Rates-NYC (Region 4)
- 2021 Q1 Small Group Rates-Mid-Hudson (Region 3)
- 2021 Q1 Small Group Rates-Long Island (Region 8)
- 2021 Q2 Small Group Rates-Mid-Hudson (Region 3)
- 2021 Q2 Small Group Rates-Metro (Region 4)
- 2021 Q2 Small Group Rates-Long Island (Region 8)
- 2021 Q3 Small Group Rates-Long Island (Region 8)
- 2021 Q3 Small Group Rates-Metro (Region 4)
- 2021 Q3 Small Group Rates-Mid-Hudson (Region 3)
- 2021 Q4 Small Group Rates-Metro (Region 4)
- 2021 Q4 Small Group Rates-Long Island (Region 8)
- 2022 Q1 Small Group Rates-Long Island (Region 8)
- 2022 Q1 Small Group Rates-Mid-Hudson (Region 3)
Dental Insurance
- Benefit Description - ENHANCED
- Benefit Description - HIGH
- Benefit Description - MEDIUM
- Benefit Description - PREMIER
- Benefit Description - Preventive Incentive Rider - HIGH
- Benefit Description - Preventive Incentive Rider - MEDIUM
- Benefit Description - Vision Plan - Davis Vision (Included with Dental Plan)
- Fast Facts
- Online Services for Plan Subscribers
- Provider Listing - Downstate NY (Use of On-Line Provider Link Recommended)
- Provider Listing - Find a Dentist On-line (Instructions)
- Provider Listing - Upstate NY Region (Use of On-Line Provider Link Recommended)
- Benefit Description - Unlimited
- Teledentistry Guide
- Rates - Dental - 2022
Vision Insurance
Hospital Indemnity
Life Insurance
Disability Insurance
- APPLICATION FORMATTING - PAGE ORDER - ALL POLICIES
- Application Instructions - Business Overhead Expense
- Application Instructions and Checklist - All Policies
- Enrollment Application - Agreement - UN 2550 AG 2-12 NY
- Enrollment Application - Authorization - UN 2550 AU 2-12 NY
- Enrollment Application - Conditional Receipt - UN 2550 CR 2-12 NY
- Enrollment Application - Health Questionnaire - UN 2550 HQ 2-12 NY
- Enrollment Application - Lifestyle Questionnaire - UN 2550 LQ 2-12 NY
- Enrollment Application - Notice of Insurance Information Practices - UN 2550 NI 2-12 NY
- Enrollment Application - Occupation and Financial Information - UN 2550 DI FI 10-11 NY
- Enrollment Application - Personal Information - UN 2550 PI 10-11 NY
- Enrollment Application - Policy Details - UN 2550 DI 10-11 NY
- Enrollment Application - Producers Statement - UN 2550 PS 10-11 NY
- Enrollment Application - Why Second Authorization - UN 1447 NY
