Fillable Ps404 INSTRUCTIONS: READ BOTH SIDES

Fill Online, Printable, Fillable, Blank Ps404 INSTRUCTIONS: READ BOTH SIDES Form

Use Fill to complete blank online NEW YORK STATE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ps404 INSTRUCTIONS: READ BOTH SIDES

On average this form takes 32 minutes to complete

The Ps404 INSTRUCTIONS: READ BOTH SIDES form is 2 pages long and contains:

  • 0 signatures
  • 41 check-boxes
  • 107 other fields

Country of origin: US
File type: PDF

Free fillable forms for New York State

BROWSE NEW YORK STATE 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
 
Page 1 of 2
EMPLOYEE BENEFITS DIVISION
Health Insurance Transaction Form
for NYS & PE Employees
PS-404 (9/19)
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
2. Social Security Number
3. Sex
Male Female
4. Permanent Address
Street
City
State
Zip
5. Mailing Address (If different)
Street
City
State
Zip
6. Work Location & Address
Street
City
State
Zip
7. Date of Birth
8. Telephone Numbers
Primary ( ) Work ( )
9. Marital Status
Single Married Widowed Divorced Separated
Marital Status
Date
10. Covered under Medicare? Self: Yes No Spouse/Domestic Partner: Yes No Child: Yes No
11.
ELECT OR DECLINE COVERAGE
A. Choose a Pre-Tax election
1. Elect Pre-Tax Status for Premium deduction 2. Elect After-Tax Status for Premium deduction
You are only eligible for Pre-Tax deductions if newly eligible or if requested during the Pre-Tax Contribution Program (PTCP) Election Period
B. Select a NYSHIP Coverage Option (Choose option 1, 2, 3 or 4)
1. Individual Enrollment
Medical
(10) (Select Empire Plan or HMO)
Empire Plan HMO Code Name
Dental (11) Vision (14)
2. Family Enrollment
(Complete box 13 on page 2)
Medical
(10) (Select Empire Plan or HMO)
Empire Plan HMO Code Name
Dental (11) Vision (14)
3. Opt-out Program
(NYS Medical only)
Individual Opt-out Family Opt-out (Complete Box 13)
If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.
Dental (11) Vision (14)
4. Decline Coverage Medical (10) Dental (11) Vision (14)
12.
CHANGE OR CANCEL EXISTING COVERAGE
A. Change Coverage:
Medical (10) Dental (11) Vision (14)
Date of Event:
Change to FAMILY
(Complete box 13)
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:
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:
NOTE: If you are indicating a change in marital status to Divorced or Separated, please be sure to update the address information for the dependent in Box 13 if applicable.
B. Voluntarily Cancel Coverage: Medical (10) Dental (11) Vision (14) Qualifying Event:
NOTE: If you are enrolled in the PTCP, you may make changes during the Annual Option Transfer Period or when experiencing a PTCP qualifying event.
NYS Department of Civil Service Health Insurance Transaction Form
Albany, NY 12239 Page 2 - PS-404 (9/19)
Page 2 of 2
13.
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)
Date of Event:
Last Name First Name MI Relationship Date of Birth Sex Address (if different)
Social Security
Number
A
D
C
M
D
V
A
D
C
M
D
V
A
D
C
M
D
V
A
D
C
M
D
V
14.
ENTER ANNUAL OPTION TRANSFER REQUEST(S) BELOW
Change NYSHIP Option
Change to: Empire Plan HMO Code HMO Name:
Elect Opt-out
(NYS Medical only)
Individual Opt-out Family Opt-out
If choosing Opt-out, you must also complete the
PS-409 Opt-out Attestation Form.
Change Pre-Tax Status
Change to: Pre-Tax After-Tax
Submit during the Pre-Tax Contribution
Program Election Period
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, Employee Benefits Division, Department of Civil Service, Albany, NY 12239; (518) 473-1977. For information relating only
to the Personal Privacy Protection Law, call (518) 457-9375.
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 USE ONLY
Retirement Tier Registration #
Sick Leave Information
Date Entered on
NYBEAS
Effective Date
# Hours Hourly Rate of Pay
HBA Signature (Required): Date:
NYS Department of Civil Service Instructions for NYS Health Insurance Transaction Form
Albany, NY 12239 PS-404 (9/19)
NYSHIP Program Information Resources
To enroll in benefits or to change your current benefits, you will most likely be required to submit proofs of eligibility for
coverage or evidence of a qualifying event with the completed and signed Health Insurance Transaction Form PS-404.
Learn more about these additional requirements in the following publications:
• General Information Book (GIB)
Eligibility, enrollment, required forms and proofs of eligibility
• Planning for Option Transfer
The Pre-Tax Contribution Program (PTCP)
• Choices
Your plan options under NYSHIP (Empire Plan, NYSHIP HMO or the Opt-out Program) and the benefits
included with each one
In many situations, you will also be required to complete, sign and submit additional forms and proofs. For detailed
instructions on what will be required, please refer to your GIB and any additional forms and form instructions for
requirements specific to your request.
EMPLOYEE INFORMATION
Boxes 1 – 10
Employee
Information
You must complete boxes 1 – 10 with your personal information.
Note: Use the Marital Status Date to show the date of marriage, separation or
divorce when any of those marital statuses are selected.
Boxes 11 (A-B)
Elect or Decline
Coverage
Complete appropriate sections. You are entitled to make separate choices
regarding your medical, dental and vision coverage. You may enroll in or decline
any or all three. (Exception: Enrollment in the Student Employee Health Plan
[SEHP] includes medical, dental, and vision coverage). You may also enroll in
Family coverage for one benefit in Individual coverage for another.
Reminder: Enrollees with an Employee Benefit Fund (CSEA, DC-37, UCS and
UUP) receive their dental and vision benefits through that fund. If you are a
member of one of these groups, you may not enroll for NYSHIP dental or vision
benefits.
ELECT OR DECLINE COVERAGE
Note: If you choose a NYSHIP HMO, the HMO may require you to complete an additional enrollment form.
11.A.1
11.A.2
Pre-Tax Contribution Program (PTCP)
Status
New enrollees must make an election (Pre-Tax or After-Tax)
for medical coverage. The PTCP applies to all NYS groups
and select Participating Employers (PE). If you work for a
PE, contact your HBA to learn if your employer participates
in the PTCP and if you are eligible to enroll. If you are a new
enrolling after your waiting period or more than 30 days after
a qualifying event, you will need to wait until the annual
PTCP Election Period to enroll. The PTCP Election Period
coincides with the annual Option Transfer Period. Until then,
your deductions will be taken out after taxes.
11.B.1
Individual Enrollment
Check box to enroll in Individual coverage. Check Medical,
Dental and/or Vision boxes for coverage selected.
11.B.2
Family Enrollment
Check box to enroll in Family coverage. Check Medical,
Dental and/or Vision boxes for coverage selected.
11.B.3
Elect the Opt-out Program
(NYS Medical Only)
Check box to enroll in the Opt-out Program (See your HBA
or your plan materials for eligibility requirements). Also
complete PS-409, Opt-out Attestation Form.
11.B.4
Decline NYSHIP Coverage
Check box to decline coverage. Be sure to check the
appropriate boxes for the coverage type declined.
NYS Department of Civil Service Instructions for NYS Health Insurance Transaction Form
Albany, NY 12239 PS-404 (9/19)
CHANGE IN COVERAGE OR VOLUNTARILY CANCEL COVERAGE
Box 12.A Change Coverage
Check this box to change from Individual to Family or from Family to Individual
coverage. If you are enrolled in PTCP, you may only change coverage from Family
to Individual during the annual Option Transfer Period, or within 30 days of a PTCP
qualifying event (check the qualifying event and enter the Date of Event). Check
Medical, Dental, and/or Vision boxes for coverage being changed. In the event that
you are indicating a change in your marital status to divorced or separated, please
update the dependent’s new address, if applicable, in the Dependent Information
section (Box 13).
Box 12.B
Voluntarily Cancel
Coverage
You are entitled to make separate decisions regarding your medical, dental and
vision coverage. You may cancel or change your dental and/or vision coverage(s)
at any time during the year. If you are enrolled in PTCP, you may only cancel
coverage during the annual Option Transfer Period, or within 30 days of a PTCP
qualifying event (enter the qualifying event).
DEPENDENT INFORMATION
Box 13
Dependent
Information
Check the box to add or delete a dependent or to change a dependent’s
information. Check Medical, Dental and/or Vision boxes that apply. Complete all
dependent information and provide the dependent’s Social Security Number.
Additional documentation is required to add the dependent.
ANNUAL OPTION TRANSFER REQUEST(S)
Box 14
Annual
Option Transfer
Request(s)
Change NYSHIP Option: Complete during annual Option Transfer Period or with a
qualifying event (for example, change of address outside of HMO area).
Elect Opt-out: Enrollees electing the Opt-out Program must complete a PS-409,
Opt-out Attestation Form. If you are selecting Family Opt-out, you must have been
enrolled in NYSHIP Family coverage beginning April 1 of the current plan year.
(See your HBA or your plan materials for additional eligibility requirements.)
Change Pre-Tax Status: Existing enrollees can only change PTCP status during
the annual PTCP Election Period, which coincides with the annual Option Transfer
Period.
AUTHORIZATION
You must SIGN and DATE this form.
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

Ps404 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 23 April 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document