EmblemHealth

What EmblemHealth does

EmblemHealth is a New York-based not-for-profit health insurer founded in 1937, headquartered at 55 Water Street, that provides a full-spectrum portfolio of health benefits — Medicare Advantage and Medicare Supplement plans, the $0-premium Essential Plan, Medicaid Managed Care (Enhanced Care), Health and Recovery Plan (HARP), Child Health Plus, individual and family marketplace plans, and employer, labor-union, and government-employee group coverage — to consumers, employers, and government purchasers across 25 New York State counties. The company's differentiating infrastructure includes an affiliated multi-site physician group (AdvantageCare Physicians / ACPNY), four Neighborhood Care community centers (Cambria Heights, Harlem, Chinatown, East New York) for in-person enrollment and wellness support, and dedicated member technology (myEmblemHealth mobile app, online portal, telehealth). Operational technology includes the IBM Fraud and Abuse Management System (FAMS) for claims analytics and provider benchmarking, and CMS-compliant machine-readable price transparency files.

EmblemHealth generates revenue primarily through recurring monthly premiums and government program reimbursements across Medicare (Parts A, B, and D), Medicaid, and Qualified Health Plan lines. Distribution is omnichannel: toll-free phone sales segmented by buyer type (Individual/Family, Medicare, Employer/Labor), online enrollment via shop.emblemhealth.com, mail-in applications, in-person licensed representative appointments, and Neighborhood Care centers. Enterprise and government segments are served through direct field sales, anchored by a high-profile co-administration agreement with UnitedHealthcare for the NYCE PPO health plan covering approximately 750,000 New York City municipal workers and pre-Medicare retirees — expected to deliver $1 billion in annual savings to NYC.

In late 2025 the company restructured its pharmacy benefit management through a multi-party collaboration with Prime Therapeutics, Judi Health (cloud platform), and Amazon Pharmacy (preferred home delivery), introducing transparent specialty-drug pricing, real-time referral technology, and free same-day prescription delivery. Supporting brand extensions include the Vitality WellSpark wellness program (Medicare), SilverSneakers fitness benefit, and partnerships with HSS (effective January 2026) to deepen specialty provider access. The business has recently navigated a $2.5 million New York Attorney General settlement over 'ghost network' behavioral-health directories and a $3.8 million unpaid-overtime wage settlement covering 2016-2025.

Name

EmblemHealth

Legal name

EmblemHealth

Website

https://emblemhealth.com

Company type

Private

Founded year

1937

Operating status

Operating

Headcount range

1,001–5,000 employees

Short description

EmblemHealth is a New York-based not-for-profit health insurer offering Medicare, Medicaid, Essential, individual, employer, and government/labor plans across 25 NY counties, anchored by a co-administration deal with UnitedHealthcare covering ~750,000 NYC municipal workers via the NYCE PPO plan.

Ownership category

akta.pro rank

Product category

Health Insurance

NAICS

Direct Health and Medical Insurance Carriers (524114), Direct Life, Health, and Medical Insurance Carriers (52411)

SIC

Accident & Health Insurance (6321)

akta.pro primary industry

Medicare Supplement (Medigap) (FSAIAEAG)

akta.pro secondary industries

ACA Marketplace (On-Exchange) Individual Plans (FSAIAEAA), Employer Wellness & Population Health Programs (HLAEAAAH)

Keywords

• Health insurance plans
• Medicare Advantage plans
• Medicaid managed care
• Employer group coverage
• Pharmacy benefit management

Headquarters

HQ city

New York

HQ country

United States

HQ region

North America

Offices8 records

Markets served

GTM type

B2B and B2C

Offering type

Services

Cost components

Personnel, Operations, Others, Technology or R&D, Marketing or Sales

Revenue model

1. Health Insurance Premiums: EmblemHealth generates revenue primarily through collecting premiums from members enrolled in its various health plans including Medicare Advantage, Medicare Supplement, Essential Plan, Medicaid, Individual & Family Plans, and employer/group plans. Premium revenue is recurring, paid monthly by members, employers, or government programs.
2. Government Program Reimbursements: Revenue from government programs including Medicare (Parts A, B, and D), Medicaid, Child Health Plus (CHPlus), and Health and Recovery Plan (HARP). Reimbursements are based on per-member capitated rates or fee-for-service depending on program.
3. Pharmacy Benefit Management: Revenue from managing pharmacy benefits including specialty medications through partnerships with Prime Therapeutics and Amazon Pharmacy, providing transparent pricing and competitive rates on prescription drugs.

Pricing tiers

Go-to-market motion3 records

Distribution channels6 records

Marketing channels6 records

Core offering

EmblemHealth is a not-for-profit health insurer offering a portfolio of health insurance products to individuals, families, Medicare beneficiaries, Medicaid enrollees, employers, labor unions, and government purchasers in New York. Core offerings include Medicare Advantage and Supplement plans, the $0 premium Essential Plan, Medicaid/HARP/Child Health Plus state-sponsored programs, individual and family Qualified Health Plans, and employer and government group coverage, supported by the myEmblemHealth mobile app, telehealth, Neighborhood Care community centers, and pharmacy benefit services through Prime Therapeutics, Judi Health, and Amazon Pharmacy.

Product overview

EmblemHealth is a not-for-profit health insurer offering a comprehensive portfolio of health insurance products and services primarily serving New York residents. The portfolio spans individual and family plans including the $0 premium Essential Plan, state-sponsored programs (Medicaid, HARP, Child Health Plus), Medicare Advantage and Supplement plans, and employer group coverage for businesses, labor unions, and government employees. Supporting these core insurance products are digital member services including the myEmblemHealth app and telehealth capabilities, community-based Neighborhood Care centers, and AdvantageCare Physicians (ACPNY) for primary and specialty care. The company also partners with Prime Therapeutics, Judi Health, and Amazon Pharmacy for pharmacy benefit management and home delivery services. The NYCE PPO plan, administered jointly with United Healthcare, serves approximately 750,000 NYC municipal workers and retirees.

Differentiator

Problem solved

Functional benefit

Brands

• AdvantageCare Physicians (ACPNY): A physician network providing primary and specialty care services to EmblemHealth members.
• Neighborhood Care
• WellSpark
• VIP Medicare Plans
• myEmblemHealth

Products and services

• Essential Plan A $0 monthly premium health plan for adults 19-64 in New York who meet income and other qualifications, offering a large provider network with no referrals required to see specialists and an OTC card benefit.
• Individual & Family Plans Qualified Health Plans offered to individuals and families in New York providing a range of benefits and access to top providers, including marketplace and off-exchange plan options with potential financial assistance eligibility.
• State-Sponsored Programs (Medicaid, HARP, Child Health Plus) State-sponsored health coverage for income-eligible individuals and families including Enhanced Care (Medicaid Managed Care), Enhanced Care Plus (HARP) for behavioral health, and Child Health Plus (CHPlus) for children under 19, with $0 premiums for eligible participants.
• Medicare Advantage Plans Medicare Advantage Prescription Drug plans (VIP plans) meeting a wide range of needs and budgets with no referrals required to see specialists, including dental, vision, hearing, and prescription drug coverage for Medicare beneficiaries in New York.
• Medicare Supplement Plans Medigap policies supplementing Original Medicare (Parts A and B) to cover deductibles, coinsurance, and copays, offered in Plans A, B, C, F, F+, G, G+, and N with coverage for basic benefits, skilled nursing, foreign travel emergency, and excess charges.
• Employer Group Plans Flexible health coverage solutions for employers including small groups, large groups, and labor unions, providing customizable benefits packages for employees in New York.
• Government and Labor Plans Specialized health plans for government employees including City of New York Employees, New York State Employees, Federal Employees, and union-specific plans such as 1199SEIU Preferred Premier & Preferred Plus and TWU Local 100 Premier Dental Plan.
• AdvantageCare Physicians (ACPNY) Network of physicians providing primary care and specialty services under a Whole You Care Approach, offering in-person and telehealth visits across multiple locations in New York to EmblemHealth members.
• Neighborhood Care Community-based health and wellness centers offering free public health and wellness classes, in-person health plan support, and neighborhood-specific locations in Cambria Heights, Harlem, Chinatown, East New York, and other areas.
• Pharmacy Benefit with Prime Therapeutics, Judi Health, and Amazon Pharmacy A pharmacy benefit collaboration featuring Judi Health's cloud-based technology platform with Amazon Pharmacy as the preferred home delivery pharmacy partner, providing transparent pricing, competitive specialty medication rates, digital cost visibility tools, and free prescription delivery including same-day options for EmblemHealth members.
• Telehealth / Virtual Care Virtual care options allowing members to access healthcare remotely through telehealth visits with providers, including how-to-enroll guidance and 24/7 availability for certain services.

Quantifiable outcome

• $1 billion in annual savings for NYC municipal workers through NYCE PPO plan
• +3 more outcomes

Named customers5 records

Segments7 records

Ideal customer profiles5 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature5 records

Partnerships

Nine partnerships are on record, tiered minor and core.

• Free Market HealthminorStrategic or Co-development Partner · 7 May 2026Free Market Health co-presented with Prime Therapeutics and EmblemHealth at Asembia's AXS26 Summit on specialty pharmacy care improvements including digital navigation tools and AI-enabled solutions for specialty pharmacy networks.
• Hospital for Special Surgery (HSS)coreStrategic or Co-development Partner · 10 December 2025New agreement effective January 1, 2026 includes Hospital for Special Surgery in EmblemHealth's healthcare network for the NYCE PPO health plan. Provides NYC municipal workers access to high-quality orthopedic care and expanded provider network.
• Prime TherapeuticscoreTechnology or Integration · 3 November 2025EmblemHealth partnered with Prime Therapeutics for pharmacy benefit management, utilizing Judi Health's cloud-based technology platform. The collaboration provides transparent pricing, competitive rates on specialty medications, digital tools for cost visibility, and access to Prime's pharmacy network with real-time referral technology.
• Amazon PharmacycoreTechnology or Integration · 3 November 2025Amazon Pharmacy designated as EmblemHealth's preferred home delivery pharmacy partner, offering free home delivery of prescriptions including same-day options, 24/7 pharmacist support, and competitive specialty medication rates. Part of the Prime Therapeutics pharmacy benefit collaboration.
• Judi HealthcoreTechnology or Integration · 3 November 2025Judi Health provides cloud-based technology platform powering EmblemHealth's pharmacy benefit collaboration with Prime Therapeutics, enabling transparent pricing, competitive rates on specialty medications, and digital tools for cost visibility for EmblemHealth members.
• UnitedHealthcarecoreStrategic or Co-development Partner · 30 September 2025EmblemHealth and UnitedHealthcare co-administer the NYCE PPO health plan for approximately 750,000 NYC municipal workers and pre-Medicare retirees, replacing the previous GHI Comprehensive Benefits Plan. Expected to save NYC $1 billion annually.
• AdvantageCare Physicians (ACPNY)coreStrategic or Co-development PartnerAdvantageCare Physicians is EmblemHealth's affiliated physician group practice providing primary and specialty care through multiple locations. Part of EmblemHealth's Whole You Care Approach offering integrated healthcare services.
• WellSpark (Vitality)minorStrategic or Co-development PartnerWellSpark wellness programs provide health coaching, wellness rewards, and lifestyle management resources for EmblemHealth Medicare members as part of the Vitality WellSpark offering.
• SilverSneakersminorOthersSilverSneakers fitness program available to EmblemHealth Medicare Supplement plan members, providing access to fitness facilities and classes. Tivity Health Inc. program included as member benefit.

Scale indicators7 records

Recent moves6 records

Expansion highlights6 records

Broad incumbents

• Humana: Major Medicare Advantage-focused national carrier with a comparable Medigap and MA portfolio depth that EmblemHealth matches locally but exceeds nationally.
• UnitedHealth Group (UnitedHealthcare): Largest US health insurer and current co-administration partner of the NYCE PPO plan with EmblemHealth, providing national-scale context for member-services capabilities and the enterprise group product set EmblemHealth competes against in NY.
• Centene Corporation: National managed care leader with deep Medicaid and Marketplace exposure through its Fidelis Care and other subsidiaries, competing with EmblemHealth in NY's state-sponsored programs and representing the scale ceiling in the segment.

Direct peers

• MVP Health Care: Regional not-for-profit insurer operating across New York and Vermont with Medicare Advantage, Medicaid, and individual plans competing head-to-head with EmblemHealth for upstate NY employer and government accounts.
• CDPHP (Capital District Physicians' Health Plan): Capital-region NY not-for-profit health plan offering HMO, Medicare Advantage, and employer products overlapping EmblemHealth's Albany and upstate NY service area with comparable mid-market and government customer mix.
• Independent Health: Buffalo-based not-for-profit health plan offering HMO, Medicare Advantage, and Medicaid products in New York with a similar value-based provider contracting approach to EmblemHealth.
• Excellus BlueCross BlueShield: Not-for-profit BCBS licensee covering upstate and central New York with Medicare, individual, and employer plans competing in the same 25-county footprint EmblemHealth serves.
• Healthfirst: New York-based not-for-profit health insurer offering Medicaid, Medicare Advantage, and Essential Plan products across the same New York metropolitan counties as EmblemHealth with similar dual-eligible focus.
• Fidelis Care (Centene subsidiary): Major New York insurer offering Medicaid Managed Care, Medicare Advantage, Child Health Plus, and Essential Plan — directly overlapping EmblemHealth's state-sponsored and individual product portfolio in the same NY geography.

Emerging players

• Oscar Health: Technology-forward ACA Marketplace and individual plan operator with significant New York market share, competing against EmblemHealth in the Individual & Family plan segment with a digital-first member experience.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat6 records

Key risks5 records

Key highlights7 records

Customer concentration

• Xx.com/emblemhealth
• YouTubeyoutube.com/user/emblemhealth
• Facebookfacebook.com/EmblemHealth
• LinkedInlinkedin.com/company/emblemhealth
• Instagraminstagram.com/emblemhealth

Revenue estimate

Valuation estimate

Number of profiles

Profiles2 records

Subsidiaries1 record

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments1 record

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about EmblemHealth