EMPLOYEE BENEFITS DIVISION
NYS HEALTH INSURANCE TRANSACTION FORM
PS-404 (9/15)
INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.
EMPLOYEE INFORMATION
(All employees must complete)
First Name
MI
2. Social Security Number
3. Sex
Male
Female
City
State
Zip
1. Last Name
4. Street Address
5. Date of Birth
8. Marital Status
Single
6. Telephone Numbers
Primary (
)
Work (
)
Married
Divorced
Marital Status Date
Widowed
Separated
9. Covered under Medicare?
Self:
Yes
No
7. Work location and address
Spouse/Domestic Partner:
Yes
No
Child:
Yes
No
10.
DEPENDENT INFORMATION
Must be provided when choosing to enroll or opt-out of NYSHIP family coverage (use additional sheets if necessary)
Check One: A (Add), D (Delete) or C (Change)
Check all that apply: M (Medical), D (Dental), and V (Vision)
Last Name
A
D
C
A
D
C
A
D
C
A
D
C
11.
First Name
MI
Relationship
Date of Event
Date of Birth
Sex
Address (if different)
M
D
V
M
D
V
M
D
V
M
D
V
NEW OR NEWLY ELIGIBLE EMPLOYEES: CHOOSE ONE OF THE FOLLOWING OPTIONS (A, B OR C)
A. Enroll in NYSHIP Coverage: Choose options 1 or 2 and complete box 3
Medical (10) (Select Empire Plan or HMO)
1. Individual Enrollment
Empire Plan
HMO Code
Medical (10)
2. Family Enrollment
Empire Plan
(Complete box 10)
3.
Social Security
Number
Name _______________
(Select Empire Plan or HMO)
HMO Code
Elect Pre-Tax Status for Premium deduction
Name _______________
Dental (11)
Vision (14)
Dental (11)
Vision (14)
Elect Post-Tax Status for Premium deduction
Please read the Pre-Tax Contribution program materials.
B. Elect the Opt-out program (if eligible): Complete boxes 1 and 2
1.
Individual Opt-out
Family Opt-out
2.
Elect Pre-Tax Status for Premium deduction
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
Elect Post-Tax Status for Premium deduction
Please read the Pre-Tax Contribution program materials.
C. Decline NYSHIP Coverage
12.
Medical(10)
Dental (11)
Vision (14)
TO CHANGE OR CANCEL COVERAGE CHOOSE FROM THE BOXES BELOW
Medical (10)
A. Change Coverage:
Change to FAMILY (Complete box 10)
Marriage
Domestic Partner
Newborn
Request coverage for dependents not previously covered
Previous coverage terminated (proof required)
Dependent returned to full-time student status
(Dental and Vision only)
Other
B. Voluntarily Cancel Coverage:
Dental (11)
Vision (14)
Date of Event:
Change to INDIVIDUAL
Divorce
Termination of Domestic Partnership (Attach completed PS-425.4)
Only dependent ineligible due to age
I voluntarily cancel coverage for my dependents
Only dependent died
Only dependent married (Dental and Vision only)
Only dependent graduated (Dental and Vision only)
Other
Medical (10)
Dental (11)
Vision (14) Qualifying Event:
NOTE: If you are enrolled in the Pre-Tax Contribution Program, your ability to make mid-year changes may be limited.
NYS Department of Civil Service
Albany, NY 12239
13.
Health Insurance Transaction Form
Page 2 - PS-404 (9/15)
ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW
Change NYSHIP Option
Change to:
HMO Code
Individual Opt-out
Elect Opt-out (if eligible)
Change Pre-Tax Status
Empire Plan
HMO Name
Family Opt-out
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
Change to:
14.
Pre-Tax
Post-Tax
Submit during the Pre-Tax Contribution Selection Period
(November 1-30)
LEAVE WITHOUT PAY AND RETIREMENT STATUS
LEAVE WITHOUT
PAY
RETIREMENT
I wish to continue coverage while I am on authorized leave.
Medical
Dental
Vision
I understand that I will be billed and must pay for this coverage.
Medical
Dental
Vision
I do not wish to continue coverage while I am on authorized
leave. I wish to resume my coverage upon return to the payroll.
I understand the requirements for continuing medical insurance coverage as a retiree and wish to
continue my coverage.
I understand the requirements for continuing medical insurance coverage as a retiree and wish to
defer my coverage. (A completed PS-406.2 must be attached.)
I understand that I will receive an application for COBRA continuation of Dental and/or Vision
coverage automatically.
Personal Privacy Protection Law Notification
The information you provide on this application is requested in accordance with Section 163 of the New York State Civil Service Law for
the principal purpose of enabling the Department of Civil Service to process your request concerning health insurance coverage. This
information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e) and
(f). Failure to provide the information requested may interfere with our ability to comply with your request. This information will be
maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For information
concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your
Health Benefits Administrator. If, after calling your Health Benefits Administrator, you need more information, please call (518) 4575754 or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
AUTHORIZATION
I have read the Pre-Tax Contribution Program materials and the Opt-out Attestation Form (if applicable), and have made my selection on
Page 1 of this document. I understand that if my coverage is declined or canceled, I may subject myself and/or my dependents to waiting
periods if I decide to enroll at a later date and may forfeit the right to such coverage after leaving State service (vest, retirement, etc.). I
am aware of how to obtain a current Summary of Benefits and Coverage for the NYSHIP option I have selected. I understand that my
failure to provide required proof(s) within 30 days may delay the availability of benefits for me or any dependent for whom I fail to provide
such proof. Any person who makes a material misstatement of fact or conceals any pertinent information shall be guilty of a crime,
conviction of which may lead to substantial monetary penalties and/or imprisonment, as well as an order for reimbursement of claims. I
certify that the information I have supplied is true and correct. I hereby authorize deduction from my salary or retirement
allowance of the amount required, if any, for the coverage indicated above.
Employee Signature (Required):
Date:
AGENCY/EBD USE ONLY
Action/Reason
Retirement Tier
Date of Event
Hire Date
Registration #
HBA Signature (Required):
Date of 1st Eligibility
Percentage
Working
Sick Leave Information
# Hours
Hourly Rate of Pay
Agency Code
Date Entered on
NYBEAS
Date:
Neg.
Unit
Retirement
System
Effective Date
State of New York
Department of Civil Service
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION
2015 OPT OUT ATTESTATION FORM
PS 409 (11/14)
EMPLOYEE INFORMATION
Name
Social Security Number
Street Address
City
Date of Birth
_____/_____/______
Marital Status
Single
Telephone Numbers
Primary (
)
Work (
)
Married
Divorced
Marital Status Date
Widowed
Separated
Negotiating Unit
State
Zip
Agency Name and Address
NYSHIP HEALTH BENEFITS OPT-OUT ELECTION
Employees must attest that they are covered under another employer-sponsored group health insurance plan to be eligible for the
NYSHIP Opt-out Program. (CSEA and PEF employees may be subject to additional contract provisions/stipulations and should consult
with their Health Benefits Administrator before electing Opt-out).
Check one:
I have other NYSHIP coverage and I am electing to Opt-out of Individual coverage in exchange for a $1,000 taxable amount.
(New York State employees may not maintain two NYSHIP family plans, regardless if one plan is the Opt-out program)
I have other employer-sponsored group health insurance coverage that is not NYSHIP coverage, and I am electing to Opt-out of
Individual coverage in exchange for a $1,000 taxable amount.
I have other employer-sponsored group health insurance coverage that is not NYSHIP coverage, and I am electing to Opt-out of
Family coverage in exchange for a $3,000 taxable amount. I understand that all dependent information must be provided when
electing Family opt-out.
Other employer-sponsored group health insurance information must be provided as indicated below:
Name of covered employee ________________________________________ Covered employee’s Date of Birth
Covered employee’s SSN
___/____/_____
__ __ __ - __ __ - __ __ __ __
Name of covered employee’s employer
__________________________________________________________
Effective date of other group health insurance coverage
__________________________________________________________
Name and Address of alternate health insurance coverage
__________________________________________________________
ATTESTATION
I have read the Opt-out Program materials and instructions and I attest to the following:
•
•
•
•
•
I am covered under another employer-sponsored group health plan that is in effect as of the date I opt-out of NYSHIP coverage
and I have provided accurate information regarding my other employer-sponsored coverage.
I understand that I must promptly report changes to information I have provided above which may impact my eligibility (e.g.,
loss of other employer-sponsored coverage, divorce, death, last dependent loses eligibility for NYSHIP coverage) and if I fail
to do so, I am responsible for any Opt-out payments made to me in error.
I understand that I may choose to opt out of Family coverage only if I have NYSHIP eligible dependents and I am not enrolled
in NYSHIP as a dependent or enrollee elsewhere.
I understand that this election is for 2015 only. In order to enroll in the Opt-out Program for 2016, I must submit the PS-404
and PS-409 again during the next Option Transfer Period.
I meet the qualifications to elect the Health Insurance Opt-out Program.
Employee’s Signature (Required) ________________________________ Signature Date (Required) ___/____/_____
NYS Department of Civil Service
Albany, NY 12239
Opt-out Attestation Form
Page 2 – PS 409 (11/14)
Eligible employees who attest to having other employer-sponsored group health insurance may elect to opt out of
NYSHIP coverage in exchange for an incentive payment. Employees who elect to opt-out of NYSHIP will receive
$1,000 ($38.47 over 26 biweekly paychecks) for Individual Opt-out or $3,000 ($115.39 over 26 biweekly paychecks) for
Family Opt-out. This amount will be credited to biweekly paychecks as taxable income over the plan year. Employees
who elect to opt out of NYSHIP and have other NYSHIP coverage are only eligible for the individual incentive payment.
Unless newly eligible to enroll, employees must have been enrolled in NYSHIP Individual or Family health benefits
prior to April 1st of the previous plan year to be eligible to opt-out of coverage.
Newly eligible employees must make their Opt-out election prior to the end of the NYSHIP waiting period if they are a
new State employee or within 30 days of the effective date of a change in bargaining unit representation. If an employee
maintains continuous enrollment in NYSHIP, and changes coverage from Individual coverage to Family coverage due to
a qualifying event (e.g., requests to cover a new spouse within 30 days from the date of marriage) the employee would be
eligible for the family incentive payment for the following plan year. If the request to change coverage is subject to late
enrollment, the employee would only be eligible for the individual incentive payment.
There are two circumstances when employees may elect to opt out of coverage; when newly eligible for the Opt-out and,
for currently enrolled employees, during the Annual Option Transfer Period. Late submissions will not be accepted.
INSTRUCTIONS TO OPT-OUT:
Newly eligible employees: Employees may enroll in the Opt-out Program no later the last day of the new employee
waiting period for coverage. Employees must complete and sign the PS-409 Opt-out Attestation Form and the PS-404
Enrollment Form.
Current enrollees: Eligible enrollees may elect the Opt-out Program during the Annual Option Transfer Period for each
plan year. Employees must complete and sign the PS-409 Opt-out Attestation Form and the PS-404 Enrollment Form.
INSTRUCTIONS TO ENROLL IN NYSHIP HEALTH BENEFITS
Employees who participate in the Opt-out Program may enroll in NYSHIP health benefits during the next Annual Option
Transfer Period. Employees must complete a PS404 Enrollment Form.
Additionally, employees who experience a PTCP qualifying event, such as a change in family status (e.g., marriage,
birth, death or divorce) or loss of coverage must notify their personnel office within thirty (30) days of the event date in
order to enroll in a health plan without a waiting period. Employees who experience a qualifying event but fail to notify
their personnel office within thirty (30) days of the event, may enroll in NYSHIP health benefits after a late enrollment
waiting period. Employees must complete a PS404 Enrollment Form to request enrollment.
Employees who have not experienced a PTCP qualifying event, may not enroll in NYSHIP health benefits arbitrarily.
They must remain in the Opt-out Program and wait for the next Annual Option Transfer Period to enroll in NYSHIP
health benefits.
The information you provide on this application is requested in accordance with Section 163 of New York State Civil Service Law for the principal purpose of enabling
the Department of Civil Service to process your request concerning health insurance coverage. This information will be used in accordance with Section 96 (1) of the
Personal Privacy Protection Law, particularly subdivisions (b), (e) and (f). Failure to provide the information requested may interfere with our ability to comply with
your request. This information will be maintained by the Director of the Employee Benefits Division, NYS Department of Civil Service, Albany, NY 12239. For
information concerning the Personal Protection Law, call (518) 457-9375. For information related to the Health Insurance Program, contact your Agency Health
Benefits Administrator. If, after calling your Agency Health Benefits Administrator, you need more information, please call (518) 457-5754
or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
This form is invalid if it is not signed and submitted along with a completed PS 404.