The New York PS 409 form is a vital document for employees who are considering opting out of the New York State Health Insurance Program (NYSHIP). This form serves as an attestation by employees that they have alternative employer-sponsored group health insurance coverage and hence are choosing to opt-out of NYSHIP's coverage for either individual or family plans. By submitting this form, employees can avail themselves of an incentive in the form of a taxable amount credited to their bi-weekly paychecks—$1,000 for individual coverage and $3,000 for family coverage opt-out. However, this opt-out decision is not to be taken lightly, as it is bound by strict eligibility criteria and deadlines. Employees are required to prove coverage under another employer-sponsored health plan as of the opt-out effective date. Additionally, the form mandates employees to immediately report any changes that might affect their eligibility for the opt-out program. Such meticulous documentation underscores the importance of understanding one's eligibility, the procedure for opting out, and the potential financial implications. The process outlined involves completing the PS 409 Opt-out Attestation Form, and for those not newly eligible, also a PS 404 Enrollment Form, either during their initial eligibility period or the Annual Option Transfer Period. Special provisions are also discussed for employees who might need to re-enroll in NYSHIP mid-year due to qualifying events, emphasizing the necessity of timely communication with personnel offices to avoid gaps in coverage. Designed with the well-being and informed choices of state employees in mind, the PS 409 form is a crucial piece of documentation for those seeking to make informed decisions about their health insurance options.
Question | Answer |
---|---|
Form Name | New York Form Ps 409 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | nys civil service forms ps 409, taxable, enrollees, ATTESTATION |
State of New York
Department of Civil Service
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION 2013 OPT OUT ATTESTATION FORM
PS 409 (10/12)
EMPLOYEE INFORMATION
Name
Street Address |
City |
State |
Zip |
Date of Birth |
Telephone Numbers |
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_____/_____/______ |
Home ( |
) |
Work ( |
) |
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Marital Status |
Married |
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Divorced |
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Marital Status Date |
Single |
Widowed |
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Separated |
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Agency Name and Address
NYSHIP HEALTH BENEFITS
Complete this section if you are newly eligible or currently enrolled in NYSHIP.
Employees must attest below that they are covered under other
Check one:
I am electing to opt out of Individual coverage in exchange for a $1,000 taxable amount.
I am electing to opt out of Family coverage in exchange for a $3,000 taxable amount (dependent information must be provided when electing Family
Other
Name of covered employee_____________________________ Covered employee’s Date of Birth_____________________
Covered employee’s SSN__________________ Name of covered employee’s employer________________________________
Effective date of alternate health insurance coverage_________________________________________________________
Name and Address of alternate health insurance coverage _____________________________________________________
________________________________________________________
ATTESTATION
All employees complete this section
I have read the
•I am covered under another
•I understand that I must promptly report changes to information I have provided above which may impact my eligibility.
•I understand that I may choose to opt out of Family coverage only if I have NYSHIP eligible dependents.
•I understand that this election is for 2013 only.
•I meet the qualifications to elect the Health Insurance
Employee’s Signature (Required) ________________________________ Signature Date (Required) ___/____/_____
NYS Department of Civil Service |
Attestation Form |
|
Albany, NY 12239 |
Page 2 |
– PS 409 (10/12) |
Employees who can demonstrate and attest to having other
There are two circumstances when employees may elect to opt out of coverage; as newly eligible for the
INSTRUCTIONS:
Newly eligible employees: Employees may enroll in the
Current enrollees: Eligible enrollees may elect the
During
By signing the
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)
or
This form is invalid if it is not signed and submitted along with a completed PS 404.