Form Ps 404 – Fill Out and Use This PDF

The PS-404 form, also known as the Health Insurance Transaction Form for NYS & PE Employees, is designed for New York State and Participating Employer employees to enroll in, change, or cancel their health insurance coverage. This form facilitates various transactions including enrollment in medical, dental, and vision coverage, opting out, or making changes to existing coverage. For those needing to update their health insurance coverage or make significant changes, completing the PS-404 form accurately is essential. Ready to update your health insurance coverage? Click the button below to fill out the PS-404 form today.

Get Form Now Download PDF

Form Ps 404 PDF Details

Navigating employee benefits, especially health insurance, can be complex, but the PS-404 form aims to simplify the process for New York State (NYS) and Participating Employer (PE) employees. This comprehensive document, revised in September 2020, serves as a pivotal Health Insurance Transaction Form covering a myriad of options and changes an employee might encounter throughout their tenure. From enrolling in new coverage to adjusting existing plans, the form facilitates a wide range of transactions including opting into or out of Pre-Tax Contribution Programs, selecting individual or family enrollment under the New York State Health Insurance Program (NYSHIP), and opting out entirely. Moreover, it addresses changes in coverage or voluntarily canceling coverage due to qualifying life events, such as marriage or divorce, and includes sections for adding or updating dependent information. The form underscores the importance of timely and accurate completion, as it requires personal information, elects coverage options, and mandates an employee's acknowledgment of understanding their choices and the repercussions of declining or altering coverage. With spaces for employee signature and agency use, the PS-404 form is a critical tool in managing the intricate details of an employee's health insurance benefits, reminding employees of the importance of staying informed about their benefits and ensuring they make choices that best fit their needs and circumstances.

Question	Answer
Form Name	Form Ps 404
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	ps 404 insurance, 404 form, form nys transaction, ps 404 pdf

Form Preview Example

EMPLOYEE BENEFITS DIVISION

Health Insurance Transaction Form for

NYS & PE Employees

PS-404 (9/2020)

INSTRUCTIONS: READ AND COMPLETE BOTHSIDES/PAGES. PLEASE PRINT AND CHECK THE APPROPRIATE CHOICES.

EMPLOYEE INFORMATION

(All employees must complete)

Last Name

First Name

Social Security Number

Sex

Male

Female

PermanentAddress

City

State

Zip

Street

Mailing Address (If different)

City

State

Zip

Street

Work Location &Address

City

State

Zip

Street

Date of Birth

Telephone

Numbers

Primary (

)

Work (

)

Personal Email Address

10.

Marital Status

Single

Married

Widowed

Divorced

Separated

Marital Status

Date

11.

Covered under Medicare?

Self:

Yes

Spouse/Domestic Partner:

Yes

Child:

Yes

12.

ELECT ORDECLINE COVERAGE

A. Choose a Pre-Tax election

Elect Pre-TaxStatus for Premium deduction

ElectAfter-Tax Status forPremium 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 aNYSHIPCoverageOption (Choose option 1, 2, 3or 4)

1. Individual Enrollment

Medical (10)

(Select Empire Planor HMO)

Dental (11)

Vision (14)

Empire Plan

HMO Code

Name

2. FamilyEnrollment

Medical (10)

(Select Empire Planor HMO)

Dental (11)

Vision (14)

(Complete box14 on page 2)

Empire Plan

HMO Code

Name

3. Opt-outProgram

Individual Opt-out

Family Opt-out (Complete box 14)

Dental (11)

Vision (14)

(NYS Medical only)

If choosing Opt-out, you must also complete the PS-409 Opt-out Attestation Form.

4. Decline Coverage

Medical (10)

Dental (11)

Vision (14)

13.

CHANGE OR CANCEL EXISTING COVERAGE

Change Coverage:

Medical (10)

Dental (11)

Vision (14)

DateofEvent:

Change to FAMILY (Complete box 14)

Change to INDIVIDUAL

Marriage

Divorce

Domestic Partner

Termination ofDomestic Partnership (Attach completed PS-425.4)

Newborn

Only dependent ineligible due to age

Request coverage for dependents not previously covered

I voluntarily cancel coverage for my dependents

Previous coverage terminated (proof required)

Only dependent died

Dependentreturned to full-time student status

Only dependent married (Dental and Vision only)

(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 14 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 changesduring the Annual Option Transfer Period or when experiencing a PTCP qualifying event.

Page 1 of 2

Department of Civil Service	Health Insurance Transaction Form
Albany, NY 12239	PS-404 (9/2020)

14.	DEPENDENT INFORMATION

Must be provided when choosing to enroll or opt-out of NYSHIPfamilycoverage(useadditional sheets if necessary)

	Check One: A (Add), D (Delete) or C (Change)	Date of Event:
	Check all that apply:M (Medical), D (Dental), andV (Vision)	Date of Event:
	Check all that apply:M (Medical), D (Dental), andV (Vision)

	Last Name	First Name	MI	Relationship	Date of Birth	Sex	Address (if different)	Social Security
	Last Name	First Name	MI	Relationship	Date of Birth	Sex	Address (if different)	Number
								Number
A	M
D	D
C	V
A	M
D	D
C	V
A	M
D	D
C	V
A	M
D	D
C	V

15.	ENTERANNUAL OPTION TRANSFER REQUEST(S)BELOW
Change NYSHIP Option	Change to:	Empire Plan	HMO Code	HMO Name:


Elect Opt-out	Individual Opt-out		Family Opt-out	If choosing Opt-out, youmust also complete the
(NYS Medical only)				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

# Hours

Hourly Rate of Pay

Date Entered on

NYBEAS

Effective Date

HBA Signature (Required):

Date:

Page 2 of 2

Department of Civil Service Albany,	Instructions for NYS Health Insurance Transaction Form
NY 12239	PS-404 (9/2020)

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 InsuranceTransaction 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.

		EMPLOYEEINFORMATION

Boxes 1 – 11	Employee	You must complete boxes 1 – 11 with your personal information.
	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 12 (A-B)	Elect or Decline	Complete appropriate sections. You are entitled to make separate choices
	Coverage	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.

12.A.1	Pre-Tax Contribution Program (PTCP)	New enrollees must make an election (Pre-Tax or After-Tax)
12.A.2	Status	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.
12.B.1	Individual Enrollment	Check box to enroll in Individual coverage. Check Medical,
		Dental and/or Vision boxes for coverage selected.
12.B.2	Family Enrollment	Check box to enroll in Family coverage. Check Medical,
		Dental and/or Vision boxes for coverage selected.
12.B.3	Elect the Opt-out Program	Check box to enroll in the Opt-out Program (See your HBA
	(NYS Medical Only)	or your plan materials for eligibility requirements). Also
		complete PS-409, Opt-out Attestation Form.
12.B.4	Decline NYSHIP Coverage	Check box to decline coverage. Be sure to check the
		appropriate boxes for the coverage type declined.

Department of Civil Service	Instructions for NYS Health Insurance Transaction Form
Albany, NY 12239	PS-404 (9/2020)

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. 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 14).

Box 13.B	Voluntarily Cancel	You are entitled to make separate decisions regarding your medical, dental and
	Coverage	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 14	Dependent	Check the box to add or delete a dependent or to change a dependent’s
	Information	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 15	Annual		Change NYSHIP Option: Complete during annual Option Transfer Period or with a
	Option Transfer		qualifying event (for example, change of address outside of HMO area).
	Request(s)
			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.

How to Edit Form Ps 404 Online for Free

form nys transaction can be completed easily. Simply try FormsPal PDF editing tool to complete the job promptly. We are focused on making sure you have the absolute best experience with our tool by regularly presenting new features and upgrades. Our tool is now a lot more intuitive thanks to the newest updates! Now, filling out PDF documents is easier and faster than ever before. It just takes just a few easy steps:

Step 1: Open the PDF doc inside our tool by clicking the "Get Form Button" in the top area of this webpage.

Step 2: When you access the PDF editor, there'll be the form prepared to be filled in. Aside from filling out various fields, you may also perform some other actions with the file, including adding any textual content, modifying the original textual content, adding illustrations or photos, putting your signature on the document, and a lot more.

This form requires particular data to be entered, so you need to take whatever time to provide precisely what is requested:

1. Complete your form nys transaction with a group of major blank fields. Gather all of the information you need and be sure absolutely nothing is forgotten!

2. Right after completing this section, head on to the subsequent part and complete all required particulars in all these blanks - Family Enrollment, Complete box on page, Medical, Select Empire Plan or HMO, Empire Plan, HMO Code Name, Dental, Vision, Optout Program, NYS Medical only, Individual Optout, Family Optout Complete box, If choosing Optout you must also, Dental, and Vision.

The right way to fill in 404 form stage 2

3. This third step is normally straightforward - complete all of the fields in Must be provided when choosing to, Date of Event, Last Name, First Name MI, Relationship Date of Birth, Sex, Address if different, Social Security, Number, A D C A D C A D C A D C, M D V M D V M D V M D V, ENTER ANNUAL OPTION TRANSFER, Change NYSHIP Option Change to, Empire Plan, and HMO Code to conclude this part.

Must be provided when choosing to, Empire Plan, and Last Name of 404 form

4. Filling in I have read the PreTax, Employee Signature Required, Date, Retirement Tier, Registration, AGENCY USE ONLY, Sick Leave Information, Hours, Hourly Rate of Pay, Date Entered on, NYBEAS, Effective Date, HBA Signature Required, Date, and Page of is vital in the next form section - be sure to take the time and fill out each and every blank!

When it comes to AGENCY USE ONLY and Date Entered on, be certain you review things in this current part. These two are certainly the most important fields in the document.

Step 3: Reread the details you have typed into the blanks and then click the "Done" button. Make a 7-day free trial option at FormsPal and obtain instant access to form nys transaction - with all adjustments kept and accessible in your personal account. We do not share or sell the information that you type in whenever dealing with forms at our site.

Form Ps 404 – Fill Out and Use This PDF

Form Ps 404 PDF Details

Form Preview Example

How to Edit Form Ps 404 Online for Free

Form Ps 404 isn’t the one you’re looking for?

Related Documents