Fillable New York State Health Insurance Program (NYSHIP) Domestic (City University of New York)

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New York State Health Insurance Program (NYSHIP) Domestic (City University of New York)

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EMPLOYEE BENEFITS DIVISION
New York State Health Insurance Program (NYSHIP)
Domestic Partner Enrollment Application
PS-425 (3/17)
PLEASE READ PAGES 4-6 BEFORE YOU COMPLETE AND SUBMIT THIS APPLICATION.
EMPLOYEE INFORMATION
1. Last Name First Name MI
2. Social Security Number
3. Sex
Male Female
4. Street Address City State Zip
5. Date of Birth
6. Telephone Numbers
Primary: ( ) Work: ( )
8. I wish to add my Domestic Partner to: Medical Dental Vision
DOMESTIC PARTNER INFORMATION
9. Last Name First Name Date of Birth Sex Social Security Number
10. Domestic Partner 65 or Older: Yes No
NOTE: Domestic Partners 65 or Older MUST be enrolled in Medicare Parts A and B to avoid a reduction of benefits
11. Domestic Covered under Medicare: Yes No Medicare Claim Number:
SECT
ION A
You and your Domestic Partner must be able to answer “YES” to all of the statements below and be able to
provide the required documentation in order for your Domestic Partner to qualify for coverage under NYSHIP.
Yes
□ We are each 18 years of age or older.
□ We are not related in a manner that would bar marriage in New York State.
□ I am not legally married to anyone else. If I am divorced, I am submitting a divorce decree for my prior
marriage. Legal separation does not constitute a termination of marriage.
□ My Domestic Partner is not legally married to anyone else. If he or she is divorced, I am submitting a divorce
decree for his or her prior marriage. Legal separation does not constitute a termination of marriage.
□ Neither I, nor my partner, have had a Domestic Partner enrolled in NYSHIP within the last year.
□ We have shared the same residence for at least the last six months and have included proof of cohabitation as
described in Section B of this form.
□ We have had an exclusive mutual commitment to share responsibility for each other’s welfare and financial
obligations for at least the last six months and we expect that commitment to last indefinitely. We included
proof of joint responsibility for basic financial obligations as described in Section B of this form.
□ I, the enrollee, understand that I am required to file a completed Form PS-425.4, Termination of Domestic
Partnership, within 30 days of the date my domestic partnership ends or when I no longer can provide proof of
one or more of the above requirements.
NYS Department of Civil Service NYSHIP Domestic Partner Enrollment Application
Albany, NY 12239 PS-425 (3/17)
SECTION B
You are required to submit documentation as outlined below. In addition to providing proof of your eligibility for
Domestic Partner coverage at the time of application, you are required to maintain the ability to provide proof of
eligibility for as long as you wish to continue to cover your Domestic Partner as your dependent in NYSHIP. You may
also be required to periodically provide proof of your Domestic Partner’s eligibility. If at any time, you cannot provide
proof of eligibility of your Domestic Partner as your dependent, then your partnership is no longer in effect and you
must complete and submit Form PS-425.4, Termination of Domestic Partnership.
Your domestic partnership is considered to be in effect as of the earliest documented date that you and your Domestic
Partner were both living together and financially interdependent. This date will be referred to as your “Partnership
Establishment Date,” and will be used to determine when your Domestic Partner may be enrolled in NYSHIP coverage.
If you provide separate proofs of cohabitation and financial interdependence that are at least six months old, your
domestic partnership will be considered established as of the date of the more recent of those proofs. All establishing
proofs must verify your domestic partnership has been in place for a minimum of six months. Additionally, you will be
required to provide a financial proof that is fewer than six months old to confirm the partnership is still in place.
Proof of Joint Responsibility for Basic Financial Obligations. You must submit two forms of proof from the list
below. One of these proofs must be at least six months old on the date you submit this form. The second proof from
this list must be dated within six months of the date you submit this form, and must be a different form of proof than
the older proof submitted. For example, if you provide a statement from your joint bank account as your first form of
proof, you may not provide a more recent statement from the same bank account as second form of proof.
Acceptable proofs are as follows:
• Joint mortgage or lease agreement
• Joint ownership of residence
• Joint wills or designation of the Domestic Partner as executor and/or primary beneficiary
• Designation of the Domestic Partner as beneficiary for life insurance or retirement benefits
• Designation of the Domestic Partner as durable power of attorney
• Mutual grant of authority to make health care decisions (e.g., health care power of attorney)
• Joint obligation on a loan (may submit a creditor’s affidavit for a personal loan)
• Joint ownership of a brokerage investment account
• Joint insurance policy (homeowners’ or renters’ policy)
• Joint ownership or lease of a motor vehicle
• Joint financial responsibility for child care (e.g., school tuition, guardianship)
• Joint household budget for the purpose of receiving government benefits
• Status as an authorized signatory on the partner’s bank account, credit card or charge card
• Designation of one partner as the representative payee for the other’s government benefit
• Joint bank, joint credit card or joint charge card account
Proofs such as a motor vehicle insurance policy listing the Domestic Partner as a driver or a phone bill listing the
Domestic Partner as a user are not acceptable.
Proof of Cohabitation. You must submit at least one form of proof from the list below to prove that you and your
Domestic Partner reside together. All documents submitted for proof of cohabitation must be at least six months old
on the date you submit this form. This proof may be one document on which both names appear or two separate
documents that specify each partner’s residential address. Your proofs must contain a residential address. A P.O.
Box is not an acceptable proof.
Acceptable proofs are as follows:
• Bank statement mailed to residential address
• Pay check stub
• Driver’s license or automobile registration showing residential address
• Insurance benefits statement mailed to residential address
• Joint membership statement mailed to residential address (e.g., church or other organization)
• Joint mortgage or lease agreement
• Joint ownership of residence
• Tax return listing residential address
• Telephone/Utility bill mailed to residential address
•
Registration as a domestic partnership in a New York State municipality that has established such a procedure
NYS Department of Civil Service NYSHIP Domestic Partner Enrollment Application
Albany, NY 12239 PS-425 (3/17)
SECTION C
The citation below from the Internal Revenue Code (IRC) may be helpful in determining if your Domestic Partner
is a federally qualified dependent for tax purposes. It is recommended that you seek the advice of a tax
professional before you complete this affidavit.
According to IRC Section 152 (d)(1)(c), the Domestic Partner of a NYSHIP enrollee may be considered a federally
qualified dependent if the NYSHIP enrollee “provides over one-half of the individual’s support for the calendar
year.” A Domestic Partner must also reside in the same household as the enrollee in order to be considered a
federally qualified dependent.
Name of Dependent Social Security Number
□ DOES fully qualify as my dependent under Internal Revenue Code Section 152. Checking this box is my official
affirmation to NYSHIP that I am not subject to federal tax withholding for any imputed income resulting from
benefits extended to my Domestic Partner. I understand that I will be required to complete Form PS-425.3,
Dependent Tax Affidavit, if my Domestic Partner’s status under IRC Section 152 changes at any time.
□ DOES NOT qualify as my dependent under Internal Revenue Code Section 152. Checking this box is my official
affirmation to NYSHIP that I am responsible for reporting and paying federal tax on any imputed income
resulting from benefits extended to my Domestic Partner. I understand that if I am enrolled in the Pre-Tax
Contribution Program, that the dependent portion of the cost of my NYSHIP family coverage will be taken on a
post-tax basis because my dependent is not federally qualified. I understand that I will be required to complete
PS-425.3, Dependent Tax Affidavit, if my dependent’s status under IRC Section 152 changes at any time.
Personal Privacy Protection Law Notification
The information you provide on this application is requested for the principal purpose of administering the New York
State Health Insurance Program, Dental Program, Vision Program, and/or Employee Benefit Fund Program. This
information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law. Failure to provide the
information requested may prevent the Department from processing this application. This information will be maintained
by the Employee Benefits Division, NYS Dept. of Civil Service, Albany, NY 12239. For information related to the
Personal Privacy Protection Law, call (518) 457-9375. For more information concerning the Domestic Partnership
Program, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
I, the enrollee, and my Domestic Partner, understand that any false or misleading statements made in Sections A, B or C
of this NYSHIP Domestic Partner Enrollment Application will subject me to financial responsibility for any benefits paid
on behalf of my partner and/or my partner’s children. I understand that false statements may result in disciplinary action
by my employer and/or result in criminal and/or civil penalties and in other legal actions such as the prosecution of
insurance fraud.
Print Name (Enrollee):
Enrollee Signature:
(sign in the presence of notary)
Date
Print Name (Domestic Partner):
Domestic Partner;
(sign in the presence of notary)
Date
Subscribed and sworn to before me on this day of ,
NOTARY PUBLIC:
EMPLOYEE BENEFITS DIVISION
Instructions for NYSHIP
Domestic Partner Enrollment Application
T
he following information pertains to enrollment under the New York State Health Insurance Program
(NYSHIP) for Domestic Partners of individuals enrolled through New York State.
How to Apply
Submit the following items to the appropriate office:
•
Form PS-425, Domestic Partner Enrollment Application, with supporting documentation as noted on
the form.
• Photocopy of your Domestic Partner’s Birth Certificate;
• Your Domestic Partner’s Social Security Number;
• Your Domestic Partner’s Medicare Claim Number and enrollment dates (if applicable); and
• Photocopy of your and/or your Domestic Partner’s divorce decree (if applicable).
You must submit Form PS-404, in addition to this application, if you wish to add any of your Domestic Partner’s
children to your NYSHIP coverage.
Applications filed without all of these items will not be processed. If all required documentation is not submitted
within 30 days of the signed Form PS-425, it will not be accepted. A new Form PS-425 will need to be
completed, and the later signed request will be used as the date of request.
For Active Employees: Submit the required forms and proofs to your agency HBA.
For R
etirees: Submit the required forms and proofs to the New York State Department of Civil Service,
Employee Benefits Division, Albany, NY 12239.
Section A – Domestic Partner Eligibility Requirements
Y
ou and your Domestic Partner must affirm “Yes” to each of the statements listed in Section A in order for your
Domestic Partner to qualify for coverage under NYSHIP. If you cannot affirm “Yes” to each statement, your
Domestic Partner is not eligible for coverage under NYSHIP.
S
ection B – Required Proofs
T
o cover your Domestic Partner in NYSHIP, you must submit proof of joint responsibility for basic financial
obligations and proof of cohabitation.
For proof of joint responsibility for basic financial obligations, you must submit two documents from the list
included on Form PS-425. One of these proofs must be at least six months old on the date you submit your
PS-425. The second proof from this list must be dated within six months of the date that you submit your PS-
425, and must be a different form of proof than the older proof submitted. For example, if you provide a
statement from your joint bank account as your first form of proof, you may not provide a more recent
statement from that same bank account as the second form of proof.
For proof of cohabitation, you must submit at least one document from the list included on Form PS-425. You
may submit one document on which both names appear or two separate documents that specify each partner’s
residential address. Proofs of cohabitation must contain a residential address, not a PO Box. All documents
submitted for proof of cohabitation must be at least six months old on the date you submit your PS-425.
Your domestic partnership is considered to be in effect as of the earliest documented date that you and your
Domestic Partner were both living together and financially interdependent. This date will be referred to as your
“Partnership Establishment Date,” and will be used to determine when your Domestic Partner may be enrolled
in NYSHIP coverage. If you provide separate proofs of cohabitation and financial interdependence that are at
least six months old, your domestic partnership will be considered established as of the date of the more
NYS Department of Civil Service Instructions for NYSHIP Domestic Partner Enrollment Application
Albany, NY 12239 PS-425 (3/17)
recent of those proofs. All establishing proofs must verify your domestic partnership has been in place for a
minimum of six months. Additionally, you will be required to provide a financial proof that is fewer than six
months old to confirm the partnership is still in place.
Section C – Federally Qualified Dependent Status and Pre-Tax Contribution Program (PTCP)
Federally Qualified Dependent Status
When enrolling a Domestic Partner, you must state whether he or she is your federally qualified dependent.
The federal Internal Revenue Code (IRC) includes criteria that determine whether your Domestic Partner
should be considered a federally qualified dependent. You should consult your tax advisor if you have
questions as to whether your Domestic Partner is a federally qualified dependent or if you have questions
regarding the effect of these requirements on your taxes. It is important you correctly report your Domestic
Partner’s status, as incorrect reporting can have serious negative tax implications.
If your Domestic Partner is a federally qualified dependent, check the first box in Section C.
If your Domestic Partner is not a federally qualified dependent, check the second box in Section C. In this case
the fair market value of your Domestic Partner’s coverage, referred to as imputed income, is considered to be
a taxable fringe benefit. The State is required to calculate and report imputed income to the Internal Revenue
Service (IRS) for its enrollees who provide NYSHIP coverage for non-federally qualified Domestic Partners.
The imputed income will increase your taxable gross income for federal and state income taxes, as well as
Social Security and Medicare payroll taxes. Refer to the appropriate group below for information on how
imputed income is handled for State enrollees:
• For Active Employees covering a non-federally qualified dependent, a biweekly imputed income
amount will be reported to the New York State Office of the State Comptroller for each payroll period.
This amount is considered to be additional income for tax purposes only. Additional withholding taxes
will be calculated and withheld based upon the reported imputed income. This imputed income is not an
amount added to your total premium paid. It is additional taxable income based upon the fair market
value of the non-federally qualified dependent’s coverage. Check with your agency HBA for an
approximation of the fair market value for State-administered health coverage.
• For Retirees covering a non-federally qualified dependent, the State will issue a 1099-MISC to you and
the IRS at the end of the tax year. This form reports the fair market value of the non-federally qualified
dependent’s coverage as additional income which may increase your total tax liability for the year.
Check with the Employee Benefits Division for an approximation of the fair market value for State-
administered health coverage.
Please note, incorrectly reporting your Domestic Partner’s status as a federally qualified dependent constitutes
fraud and could have serious negative tax implications.
Pre-Tax Contribution Program (PTCP)
State employees who cover a federally qualified Domestic Partner may have their full premium contribution for
the cost of Family health insurance coverage deducted from their wages before taxes are withheld.
If you are enrolled in the PTCP, but your Domestic Partner is not a federally qualified dependent, the cost of
Individual coverage will be deducted from your paycheck before taxes have been withheld, while the cost of
dependent coverage will be deducted on a post-tax basis.
Under the PTCP, once you elect to change your coverage to Family Coverage to add a federally qualified
Domestic Partner, you may not change your election back to Individual coverage unless you experience a
qualifying event (such as a terminated partnership), the consistency rule is satisfied, and the change is
requested within 30 days of the qualifying event.
NYS Department of Civil Service Instructions for NYSHIP Domestic Partner Enrollment Application
Albany, NY 12239 PS-425 (3/17)
Other Pertinent Information
When Domestic Partner Coverage Begins
Your Domestic Partner is first eligible for coverage six months after your Partnership Establishment Date.
If you apply for Domestic Partner coverage within 30 days of the date of first eligibility (six months after your
Partnership Establishment Date), your Domestic Partner may be enrolled in NYSHIP coverage on the date of
first eligibility.
If you apply for Domestic Partner coverage more than 30 days after the date of first eligibility, your Domestic
Partner will be subject to a late enrollment period. Refer to the appropriate group below for information on
when Domestic Partner coverage begins after a late enrollment period.
• For Active Employees, Domestic Partner coverage begins on the first day of the fifth pay period
following the pay period in which you apply.
• For Retirees, Domestic Partner coverage begins on the first day of the third month following the month
in which you apply.
Domestic Partners and Medicare
Your Domestic Partner must enroll in Medicare Parts A and B when one of the following occurs:
• Your Domestic Partner turns 65 years old;
• Your Domestic Partner has completed the Medicare 30-month coordination period for end-stage renal
disease; or
• You are enrolled in coverage as a retiree and your Domestic Partner qualifies for Medicare prior to age
65 due to a disability or amyotrophic lateral sclerosis (ALS).
If you are enrolled in NYSHIP coverage as an active employee, your Domestic Partner is not required to enroll
in Medicare if he or she is eligible due to disability and under age 65.
If your Domestic Partner meets one of the criteria listed above and is required to enroll in Medicare, you must
provide your Domestic Partner’s Medicare Claim Number and dates of enrollment in Medicare Part A and Part
B. If you are a Retiree, send this information to: New York State Department of Civil Service, Employee
Benefits Division, Albany, NY 12239. For all other enrollees, you should submit this information to your agency
HBA. Your Domestic Partner’s benefits will be drastically reduced if you do not follow these requirements.
Domestic Partnership Terminations
NYSHIP dependent coverage for your Domestic Partner will end on the date your domestic partnership ends or
when you are no longer able to provide proof of your Domestic Partner’s continued eligibility as required by
NYSHIP. In addition, when covering a child of a Domestic Partner, the child’s coverage will end upon
termination of your domestic partnership. You must complete and submit Form PS-425.4, Termination of
Domestic Partnership, within 30 days of the date the relationship ends or cannot be documented. This form
can be obtained in your personnel office or can be found on the NYS Department of Civil Service website:
https://www.cs.ny.gov/forms/ps425-4.pdf.
If you do not file Form PS-425.4 on a timely basis, you will be liable for claims paid for services rendered on
and after the date the domestic partnership ended. Failure to remove an ineligible Domestic Partner may result
in disciplinary action by your employer or prosecution for insurance fraud.
Note: You may not enroll another Domestic Partner or reenroll the same Domestic Partner until one year after
the date the Termination of Domestic Partnership form is filed. Your former Domestic Partner’s 60-day
eligibility period for applying for COBRA continuation coverage starts on the date the relationship terminates,
not the date you file Form PS-425.4.
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Completed 18 December 2020

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