Fillable 2018EmpireHealthTransactionform INSTRUCTIONS: READ BOTH SIDES

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2018EmpireHealthTransactionform INSTRUCTIONS: READ BOTH SIDES

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EMPLOYEE BENEFITS DIVISION
PA
HEALTH INSURANCE TRANSACTION FORM
PS-503 (6/16
)
INSTRUCTIONS: READ AND COMPLETE BOTH SIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.
EMPLOYEE INFORMATION
(All employees must complete)
1.
Last Name
First Name
MI
Social Security Number
3.
Sex
Male Female
4. Mailing Address (If PO Box, complete box 5)
City
State
Zip
5.
Home Address (If different from mailing address)
City
State
Zip
6. Date of Birth
7. Telephone Numbers
Home ( ) Work ( )
8. Work location and address
9.
Marital Status
Single
Married
Widowed
Divorced
Separated
Marital Status Date
10.
DEPENDENT INFORMATION
Must be provided to enroll in family coverage
(use additional sheets if necessary)
Check One: A (Add), D (Delete), C (Change), M (Medicare) Date of Event: -
Last Name First Name MI Relationship Date of Birth Sex
Address (if different)
Social Security
Number
A
D
C
M
A
D
C
M
A
D
C
M
A
D
C
M
11.
MEDICARE INFORMATION
A. Covered under
Medicare?
Self Medicare ID Number: -
Dependent Name: - Medicare ID Number: _
B. Is enrollee or dependent reimbursed for Medicare by another entity? Self Dependent
12.
NEW OR NEWLY ELIGIBLE EMPLOYEES: CHOOSE ONE OF THE FOLLOWING OPTIONS (A OR B)
C. Enroll in New York State Health Insurance Plan (NYSHIP) Coverage: Choose options 1 or 2
1. Individual Enrollment
Empire Plan Excelsior Plan
2. Family Enrollment (Complete box 10)
Empire Plan Excelsior Plan
D. Decline New York State Health Insurance Plan (NYSHIP) Coverage
13.
TO CHANGE OR CANCEL COVERAGE CHOOSE FROM THE BOXES BELOW
A. Change Coverage:
Qualifying Event: -
Date of Event: -
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
Other: -
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
Other: -
B. Voluntarily Cancel Coverage: Qualifying Event: Date of Event: -
Open Enrollment 2019 **
NYS Department of Civil Service PA Health Insurance Transaction Form
Albany, NY 12239 Page 2 - PS-503 (6/16)
14.
CORRECT SOCIAL SECURITY NUMBER
Correct Social Security Number
Incorrect SSN: -
Correct SSN: -
15.
PREVIOUS COVERAGE INFORMATION
If you were previously covered under
NYSHIP or another health insurance
plan
, please complete this section
and attach proofs (i.e. insurance bill
or letter stating former coverage).
Previous ID Number: -
Date Coverage Terminated:
-
Enrollee’s Name Under
Which Previously Covered
Last Name
First Name
MI
16.
RETIREMENT STATUS
Retirement/
Vestee Status
I understand the requirements for continuing coverage as a retiree or vestee
and wish to continue my coverage.
I understand the requirements for continuing coverage as a retiree or vestee
and wish to defer my coverage.
Change Retiree
Payment Status
Change to:
Pension Deduction (Rate: / )
Direct Payment to Agency
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 info
rmation 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) 457-5754
or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
AUTHORIZATION
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 Date of Event Hire Date
Date of
1
st
Eligibility
Percentage
Working
Agency Code
Eligibility Lost
Date
Retirement System Retirement Tier Registration #
Date Entered on
NYBEAS
Effective Date
HBA Signature (Required): -
Date: -
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NYS Department of Civil Service Instructions for NYS PA Health Insurance Transaction Form
Albany, NY 12239 PS-503 (6/16)
ENROLLEE AND DEPENDENT INFORMATION
Boxes 1–9
Employee Information
You must complete boxes 1 – 9 with your personal information.
Note: Use the Marital Status Date to show the date of marriage, separation or
divorce when those marital statuses are selected.
Box 10
Dependent
Information
Check the box to add (A) or delete (D) dependents, to change (C) dependent
information or confirm a dependent is Medicare primary (M). Complete all
dependent information including date of birth.
Additional documentation may be required to add the dependent.
Box 11
Medicare Information
In row A, check the appropriate box if you or a dependent are covered under
Medicare and then enter your Medicare ID and or the Medicare ID of your
dependent and their name. In row B check the appropriate box(es) if you and/or
your dependent covered under Medicare have your monthly fees reimbursed to
you from an entity other than NYSHIP
NEW ENROLLEES
Boxes 12
(A-B)
New or Newly Eligible
Employee Coverage
Options
Complete appropriate sections. You may choose to enroll in or decline coverage.
Check with your HBA for which plan or plans you are eligible to choose (Empire
or Excelsior plan).
12.A.1
Individual Enrollment
Check Empire Plan or Excelsior Plan based on your option available.
12.A.2
Family Enrollment
(must also complete
dependent information
in box 12)
Check Empire Plan or Excelsior Plan based on your option available.
12.B
Decline NYSHIP
Coverage
Check box to decline coverage.
CHANGE IN COVERAGE OR VOLUNTARILY CANCEL COVERAGE
Box 13.A Change Coverage
Check this box to change from Individual to Family or from Family to Individual
coverage.
Box 13.B
Voluntarily Cancel
Coverage
Choose this box when electing to voluntarily cancel your coverage.
Box 14
Correct Social Security
Number
If your Social Security Number is incorrect in our system please put the incorrect
number and correct numbers here so it can be fixed.
Box 15
Previous Coverage
Information
If you are enrolling in coverage because your other coverage ended, complete all
information in this box.
Box 16
Retirement/Vestee
Status
Retirement: You must complete this section if you are to indicate your decision to
continue or cancel/defer your health coverage as a retiree.
Change Retiree
Payment Status
Check the first box if you wish to adjust your pension deduction rate. Then, enter
the new rate you would like deductions to be taken at.
Check the second box if you are currently being billed monthly and would like to
have your deductions taken directly out of your pension check. You will also need
to submit a Pension Deduction Authorization Form along with this document.
(Check first with your HBA regarding the availability of pension deduction)
AUTHORIZATION
You must SIGN and DATE this form.
NYS Department of Civil Service Instructions for NYS PA Health Insurance Transaction Form
Albany, NY 12239 PS-503 (6/16)
AGENCY/EBD USE ONLY
This section is for Agency and/or EBD use only and is provided to assist with updating the enrollee’s record on NYBEAS.
Action/Reason
Transaction that HBA will enter in NYBEAS.
Date of Event
Event date that resulted in the enrollee requesting a change to benefits.
Example: first day worked, first day on leave, date of birth, date of marriage.
Hire Date
Original date of hire or rehire. (Only needed for new enrollment).
Date of 1
st
Eligibility
The first day the enrollee is eligible for coverage.
Percentage Working
Enrollee’s percentage on payroll.
Date Entered on NYBEAS
Date HBA processes the transaction on NYBEAS.
Effective Date The effective date assigned to the transaction by NYBEAS.
Note: When updating NYBEAS, use the Date in the Authorization Box as Date of Request.
EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
Note: ALL employees and dependents must provide copies of his or her birth certificate
Spouse
Domestic Partner
Children
Copy of marriage certificate; for
marriages dated more than one
year prior, proof of current joint
ownership/financial obligation
Completed PS-425 (Domestic Partner
series) and required documentation
Completed PS-457 (Statement of
Dependence) and required
documentation, if applicable
For changes of coverage, copy of
marriage certificate, divorce order
or death certificate
For changes of coverage, PS-425.4
(Domestic Partner series) or copy of
death certificate
Completed PS-451 (Statement of
Disability) and required documentation,
if applicable
Copy of Social Security Card
Copy of Social Security Card
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2018EmpireHealthTransactionform INSTRUCTIONS: READ BOTH SIDES

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Completed 24 February 2020

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