Fillable PS-409 NYSHIP Opt Out Transaction Form INSTRUCTIONS: READ BOTH SIDES

Fill Online, Printable, Fillable, Blank PS-409 NYSHIP Opt Out Transaction Form INSTRUCTIONS: READ BOTH SIDES Form

Use Fill to complete blank online STATE UNIVERSITY OF NEW YORK COLLEGE OF AGRICULTURE AND TECHNOLOGY AT COBLESKILL pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PS-409 NYSHIP Opt Out Transaction Form INSTRUCTIONS: READ BOTH SIDES

On average this form takes 7 minutes to complete

The PS-409 NYSHIP Opt Out Transaction Form INSTRUCTIONS: READ BOTH SIDES form is 1 page long and contains:

  • 0 signatures
  • 10 check-boxes
  • 24 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State University of New York College of Agriculture and Technology at Cobleskill

BROWSE STATE UNIVERSITY OF NEW YORK COLLEGE OF AGRICULTURE AND TECHNOLOGY AT COBLESKILL FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
EMPLOYEE BENEFITS DIVISION
OPT-OUT PROGRAM ATTESTATION FORM
PS-409 (11/15)
EMPLOYEE INFORMATION
Name
Social Security Number
Negotiating Unit
Street Address City State Zip
Date of Birth
Telephone Numbers
Home ( ) Work ( )
Agency Name and Address
Married
Widowed
Divorced
Separated
Marital Status Date
NYSHIP HEALTH BENEFITS OPT-OUT ELECTION
You must attest to having other employer-sponsored group health insurance to be eligible for the Opt-out Program. Other
employer-sponsored group health coverage cannot be:
• The result of your or your spouse’s, domestic partner’s or parent’s employment relationship with NYS, or
• The result of your own employment with a NYSHIP Participating Agency (PA) or Participating Employer (PE)
If you are eligible to Opt-out, please check one:
I have other coverage as a dependent
I have other coverage through my own employment
My other coverage is not NYSHIP coverage. I am
electing to Opt-out of Individual coverage in
exchange for a $1,000 taxable payment ($38.47 over
26 biweekly paychecks).
My other coverage is not NYSHIP coverage. I am
electing to Opt-out of Individual coverage in exchange
for a $1,000 taxable payment ($38.47 over 26 biweekly
paychecks).
My other coverage is not NYSHIP coverage. I am
electing to Opt-out of Family coverage in exchange
for a $3,000 taxable payment ($115.39 over 26
biweekly paychecks).
My other coverage is NYSHIP through an employer
other than New York State. I understand that I am
only eligible to Opt-out of Individual coverage in
exchange for a $1,000 taxable payment ($38.47 over
26 biweekly paychecks).
My other coverage is not NYSHIP coverage. I am
electing to Opt-out of Family coverage in exchange for
a $3,000 taxable payment ($115.39 over 26 biweekly
paychecks).
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 ___________________________________________________
(You must provide either a copy of your health insurance card or a letter from your employer or other health insurance provider confirming current coverage).
ATTESTATION
I have read the Opt-out Program materials and instructions and I attest to the following:
• I meet the qualifications to elect the Health Insurance Opt-out Program.
• I understand that I must promptly report changes that may impact my eligibility or payment amount (e.g., loss of other
employer-sponsored coverage, divorce, death, last dependent loses eligibility for NYSHIP coverage) If I fail to do so, I am
responsible for any Opt-out Program payments made to me in error. I understand that Opt-out Program payments made t
o
m
e in error may be recovered as special deductions of up to $200 from my biweekly paycheck.
• 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 through NYS or another NYSHIP employer, and that I must provide proof of
my dependent’s eligibility when enrolling each year.
• I understand that this election is for only one plan year. I must submit the PS-404 and PS-409 again during the next Option
Transfer Period if I am eligible and choose to continue in the Opt-out Program.
Employee’s Signature (Required) ________________________________ Signature Date (Required) ______________
HBA’s Signature (Required) ________________________________ Signature Date (Required) ______________
NYS Department of Civil Service Opt-out Program Attestation Form
Albany, NY 12239 Page 2 – PS-409 (11/15)
INSTRUCTIONS TO ELECT OPT-OUT:
Employees may elect to opt out of coverage when newly eligible for the Opt-out Program and, for currently enrolled
employees, during the annual Option Transfer Period.
Newly eligible 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 Program Attestation Form and the
PS-404 Health Insurance Transaction Form.
Current enrollees: Eligible enrollees may elect the Opt-out Program during the annual Option Transfer Period for
each plan year. Employees must have been enrolled in NYSHIP Individual or Family health benefits prior to April 1
of the previous plan year or when newly eligible if after April 1 to be eligible to opt out of coverage. Employees must
complete and sign the PS-409 Opt-out Program Attestation Form and the PS-404 Health Insurance Transaction
Form.
NOTE: If an employee maintained continuous enrollment in a NYSHIP health plan, and changed 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 may be eligible for the family Opt-out incentive payment for the
following plan year. If the request to change health plan coverage is subject to late enrollment, the employee would
only be eligible for the individual Opt-out incentive payment.
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 PS-404 Health Insurance Transaction Form.
Additionally, employees enrolled in the Opt-out Program 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 satisfying a late enrollment waiting
period. Opt-out enrollees who experience a qualifying event but fail to notify their personnel office within thirty (30)
days of the date of event may enroll in a NYSHIP health plan after satisfying a late enrollment waiting period.
Employees must complete a PS-404 Health Insurance Transaction Form to request enrollment.
Opt-out enrollees who have not experienced a PTCP qualifying event may not enroll in a NYSHIP health plan for
the remainder of the plan year. They must remain in the Opt-out Program and wait for the next Annual Option
Transfer Period to enroll in a NYSHIP health plan.
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PS-409 NYSHIP Opt Out Transaction Form INSTRUCTIONS: READ BOTH SIDES

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 November 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document