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Blank New York Ps 409 PDF Form

The New York PS 409 form is an Opt-out Attestation Form that allows employees to waive their enrollment in the New York State Health Insurance Program (NYSHIP) if they have other employer-sponsored health insurance. By completing this form, eligible employees can receive a financial incentive for opting out of coverage. To get started on your application, please fill out the form by clicking the button below.

Article Guide

The New York PS 409 form, officially known as the Opt-out Attestation Form, is a critical document for employees participating in the New York State Health Insurance Program (NYSHIP). This form allows eligible employees to opt out of individual or family health coverage in exchange for a financial incentive, specifically $1,000 for individual coverage and $3,000 for family coverage. To qualify for this opt-out program, employees must demonstrate that they are covered under another employer-sponsored group health insurance plan. The form requires detailed information, including the employee's personal details, the alternate health insurance provider, and the effective date of that coverage. Furthermore, employees must attest to their understanding of the program's requirements, including the necessity to report any changes that could affect their eligibility. The PS 409 form must be completed and submitted alongside the PS 404 Enrollment Form, and it is essential for both newly eligible employees and those currently enrolled in NYSHIP during the Annual Option Transfer Period. Failure to comply with these requirements may hinder the processing of their request for health insurance coverage, emphasizing the importance of timely and accurate submission.

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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
_____/_____/______	Home (	)	Work (	)
Marital Status	Married		Divorced	Marital Status Date
Single	Widowed		Separated

Agency Name and Address

NYSHIP HEALTH BENEFITS OPT-OUT ELECTION

Complete this section if you are newly eligible or currently enrolled in NYSHIP.

Employees must attest below that they are covered under other employer-sponsored group health insurance coverage other than the State of New York as of the opt out effective date, to be eligible for the Opt-out Program (CSEA employees, see your HBA for additional eligibility information).

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 opt-out).

Other employer-sponsored group health insurance information (must be provided)

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 Opt-out Program materials and instructions and I attest to the following:

•I am covered under another employer-sponsored group health plan other than the State of New York that is in effect as of the opt out effective date and have provided my alternate plan information.

•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 Opt-out Program.

Employee’s Signature (Required) ________________________________ Signature Date (Required) ___/____/_____

NYS Department of Civil Service	Opt-out	Attestation Form
Albany, NY 12239	Page 2	– PS 409 (10/12)

Employees who can demonstrate and attest to having other employer-sponsored group health insurance may elect to opt out of NYSHIP’s Empire Plan or Health Maintenance Organizations. Employees who elect to opt out of NYSHIP will receive $1,000 for waiving Individual coverage or $3,000 for waiving Family coverage. This amount will be credited to bi-weekly paychecks as taxable income over the plan year. Unless newly eligible to enroll, employees must be enrolled in NYSHIP Individual or Family coverage prior to April 1st of the previous plan year to be eligible to opt out of that coverage. This enrollment cannot have been subject to late enrollment. In order to participate, employees must have other employer-sponsored group health insurance.

There are two circumstances when employees may elect to opt out of coverage; as newly eligible for the Opt-out Program, and, for currently enrolled employees, during the Annual Option Transfer Period. Only employees who experience a qualifying event will be allowed to withdraw their Opt-out election and enroll in a health insurance plan mid-year. See instructions below.

INSTRUCTIONS:

Newly eligible employees: Employees may enroll in the Opt-out Program no later than their first date of NYSHIP eligibility. Employees must sign the PS-409 Opt-out Attestation Form and complete a PS-404 Enrollment Form.

Current enrollees: Eligible enrollees may elect the Opt-out Program during the Annual Option Transfer Period for each plan year. Employees must sign the PS-409 Opt-out Attestation Form and complete a PS-404 Enrollment Form.

During mid-year: Employees who experience a Qualifying Event (QE) must notify their personnel office within thirty (30) days of the QE date in order to enroll in a health insurance plan without a waiting period. Employees must complete a PS404 Enrollment Form.

By signing the Opt-out Attestation, you elect to receive $3,000 (Family coverage waived), or $1,000 (Individual coverage waived); this amount will be credited to your bi-weekly paycheck as taxable income over the plan year.

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.

➤ PDF File

Form Specifications

Fact Name	Details
Form Purpose	The PS 409 form serves as an attestation for employees opting out of NYSHIP coverage due to other employer-sponsored health insurance.
Eligibility Criteria	To be eligible, employees must be covered by another group health plan and must have been enrolled in NYSHIP prior to April 1st of the previous plan year.
Opt-out Incentives	Employees can receive $1,000 for waiving Individual coverage or $3,000 for waiving Family coverage, credited as taxable income.
Governing Law	This form is governed by Section 163 of the New York State Civil Service Law and the Personal Privacy Protection Law.
Qualifying Events	Employees can withdraw their opt-out election and enroll in a health plan mid-year only if they experience a qualifying event.
Submission Requirements	The form must be signed and submitted alongside a completed PS 404 Enrollment Form to be considered valid.
Annual Enrollment	Current enrollees may opt out during the Annual Option Transfer Period by signing the PS 409 form and completing the PS 404 form.
Contact Information	For assistance, employees may contact their Agency Health Benefits Administrator or call the Department of Civil Service at (518) 457-5754.

New York Ps 409: Usage Guidelines

Completing the New York PS 409 form is essential for employees wishing to opt out of the NYSHIP health insurance program. This process requires careful attention to detail to ensure that all necessary information is accurately provided. Follow the steps below to fill out the form correctly.

Begin by entering your Name, Street Address, City, State, and Zip Code in the designated fields.
Fill in your Date of Birth and Telephone Numbers (both home and work).
Select your Marital Status from the options provided: Married, Divorced, Single, Widowed, or Separated.
Provide the Date of your marital status if applicable.
Enter the Agency Name and Address where you are employed.
In the NYSHIP Health Benefits Opt-Out Election section, check the appropriate box for your coverage choice: Individual or Family.
If opting out of Family coverage, ensure you provide the necessary dependent information.
Complete the section regarding Other Employer-Sponsored Group Health Insurance by filling in the following:

Name of covered employee
Date of Birth of covered employee
Social Security Number of covered employee
Name of covered employee’s employer
Effective date of alternate health insurance coverage
Name and Address of alternate health insurance coverage

Read the attestation section carefully. Confirm that you meet all the requirements by checking the statements provided.
Sign and date the form in the designated areas to validate your submission.

Once you have completed the PS 409 form, ensure it is submitted along with a completed PS 404 Enrollment Form. This submission is crucial for processing your opt-out request and receiving the applicable taxable amount in your paychecks. Keep a copy for your records.

Your Questions, Answered

What is the purpose of the New York PS 409 form?

The New York PS 409 form, also known as the Opt-out Attestation Form, serves to allow eligible employees to opt out of the New York State Health Insurance Program (NYSHIP) if they have alternative employer-sponsored health insurance. By opting out, employees can receive a financial incentive—$1,000 for waiving individual coverage or $3,000 for waiving family coverage. This form ensures that employees attest to their other health insurance coverage and comply with the program's requirements.

Who is eligible to complete the PS 409 form?

Eligibility to complete the PS 409 form is twofold. First, newly eligible employees can enroll in the Opt-out Program when they first qualify for NYSHIP. Second, current enrollees may opt out during the Annual Option Transfer Period. It's important to note that employees must be covered under another employer-sponsored group health plan as of the opt-out effective date to qualify. Additionally, those who experience a qualifying event may withdraw their opt-out election and re-enroll in a health insurance plan mid-year.

What information must be provided on the PS 409 form?

When filling out the PS 409 form, employees must provide specific information regarding their alternative health insurance coverage. This includes the name and date of birth of the covered employee, their Social Security Number, the name of their employer, and the effective date of the alternate coverage. Employees must also attest to their understanding of the program's requirements and confirm that they are indeed covered by another plan.

What happens if an employee opts out of NYSHIP coverage?

Employees who opt out of NYSHIP coverage will receive a taxable amount credited to their bi-weekly paychecks throughout the plan year. Specifically, those who waive individual coverage will receive $1,000, while those who waive family coverage will receive $3,000. It is crucial for employees to remain aware of their eligibility status and report any changes in their health insurance coverage promptly, as this can impact their participation in the Opt-out Program.

Common mistakes

Failing to provide complete employee information. Ensure that all fields, including name, address, and date of birth, are filled out accurately.
Not checking the correct opt-out option. Make sure to select either Individual or Family coverage based on your situation.
Leaving out alternate health insurance details. It is essential to include the name of the covered employee and their employer.
Not providing the effective date of the alternate health insurance coverage. This date is crucial for processing your application.
Missing the attestation section. All employees must complete this section to confirm their understanding and eligibility.
Failing to report changes in eligibility. If your circumstances change, you must notify the appropriate office promptly.
Overlooking the requirement for NYSHIP eligible dependents. If opting out of Family coverage, ensure that you have eligible dependents.
Not signing and dating the form. The application is invalid without your signature and the date of submission.
Submitting the form without a completed PS-404 Enrollment Form. Both forms are necessary for the opt-out process.

Documents used along the form

The New York PS 409 form is an important document for employees wishing to opt out of the New York State Health Insurance Program (NYSHIP) in exchange for a financial incentive. Alongside this form, several other documents are commonly used to ensure a smooth application process. Below is a list of these forms, each serving a specific purpose in the context of health insurance enrollment and opt-out procedures.

PS-404 Enrollment Form: This form is required for both newly eligible employees and current enrollees who wish to opt out of NYSHIP. It collects essential information about the employee's health coverage and must be completed alongside the PS 409 form.
Health Benefits Administrator (HBA) Contact Information: Employees may need to refer to their HBA for specific guidance on eligibility and enrollment procedures. This document typically includes contact details and instructions for reaching out to the appropriate personnel.
Qualifying Event Notification Form: If an employee experiences a qualifying event, such as marriage or the birth of a child, this form must be completed to update their health insurance coverage. It allows for changes to be made mid-year without a waiting period.
Opt-out Program Materials: This document provides detailed information about the Opt-out Program, including eligibility criteria, the amount of financial incentive, and instructions on how to apply. Employees should read this material carefully before making their decision.
Proof of Other Coverage Documentation: Employees opting out of NYSHIP must provide evidence of their other employer-sponsored health insurance. This documentation can include a copy of the insurance card or a letter from the employer confirming coverage.
Personal Privacy Protection Law Information: This document outlines the rights of employees regarding the privacy of their personal information. It explains how the information provided on the forms will be used and the protections in place to safeguard it.

Each of these documents plays a crucial role in the process of opting out of NYSHIP. Ensuring that all forms are completed accurately and submitted on time is essential for employees to receive their benefits and maintain compliance with state regulations. Understanding the purpose of each document can help streamline the enrollment process and avoid potential issues.

Similar forms

The New York PS 409 form is an important document for employees opting out of the New York State Health Insurance Program (NYSHIP). Several other forms serve similar purposes, focusing on health insurance benefits and employee coverage options. Here’s a list of documents that share similarities with the PS 409 form:

PS 404 Enrollment Form: This form is required for employees to enroll in health insurance plans. Like the PS 409, it collects essential information about the employee and their health coverage options.
PS 404A Change Form: Used to report changes in health insurance coverage. Similar to the PS 409, it ensures that the employee's coverage information is up-to-date.
PS 409A Opt-out Election Form: This form allows employees to opt out of NYSHIP under specific conditions, just like the PS 409, but may focus on different eligibility criteria.
PS 409B Dependent Coverage Form: This document is used when adding dependents to an employee's health plan. It shares the same purpose of managing health insurance benefits.
PS 422 Health Insurance Application: Employees use this form to apply for health insurance coverage. It is similar in that it collects personal and insurance information.
PS 423 Health Insurance Termination Form: This form is used when an employee wishes to terminate their health insurance. Like the PS 409, it requires confirmation of the employee's current coverage status.
PS 424 Continuation of Coverage Form: This form allows employees to continue their health insurance after leaving employment. It parallels the PS 409 in terms of managing health insurance benefits.
PS 425 COBRA Election Form: This document is used for electing COBRA continuation coverage. It serves a similar purpose by allowing employees to maintain health coverage after certain events.
PS 426 Health Insurance Waiver Form: This form is used when an employee waives health insurance coverage. It is akin to the PS 409 in that it requires an attestation of alternative coverage.

Each of these forms plays a crucial role in managing employee health benefits, ensuring that all necessary information is collected and processed efficiently.

Dos and Don'ts

When filling out the New York PS 409 form, it's important to follow some guidelines to ensure a smooth process. Here are six things you should and shouldn't do:

Do read all instructions carefully before starting the form.
Don't leave any required fields blank; incomplete forms can cause delays.
Do provide accurate information about your alternate health insurance coverage.
Don't forget to sign and date the form; an unsigned form is invalid.
Do check the deadlines for submitting your form to ensure you meet them.
Don't submit the form without also completing the PS 404 Enrollment Form, if required.

Misconceptions

Understanding the New York PS 409 form is essential for employees considering opting out of NYSHIP coverage. However, several misconceptions can lead to confusion. Here are seven common misconceptions clarified:

Opting out means losing all health coverage. Many believe that opting out of NYSHIP means they will have no health coverage at all. In reality, employees must already be covered by another employer-sponsored health plan to qualify for the opt-out program.
Only new employees can opt out. Some think that only newly hired employees can participate in the opt-out program. Current employees can also opt out during the Annual Option Transfer Period.
Opt-out payments are not taxable. A common misunderstanding is that the payments received for opting out are tax-free. However, the $1,000 or $3,000 received is considered taxable income and will be reflected in bi-weekly paychecks.
Changes in coverage do not need to be reported. Employees may assume that once they submit the PS 409 form, they do not need to report changes. It is crucial to promptly report any changes that could affect eligibility for the opt-out program.
There is no deadline for opting out. Some employees believe they can opt out at any time. In fact, there are specific deadlines, particularly for newly eligible employees and during the Annual Option Transfer Period.
All employees are automatically eligible. It is a misconception that all employees can opt out without meeting specific criteria. Only those who can demonstrate coverage under another employer-sponsored group health plan are eligible.
Opting out is permanent. Many think that once they opt out, they cannot re-enroll in NYSHIP until the next enrollment period. Employees can withdraw their opt-out election and enroll mid-year only if they experience a qualifying event.

Being informed about these misconceptions can help employees make better decisions regarding their health insurance options. Always refer to the official guidelines and consult with your Agency Health Benefits Administrator for personalized assistance.

Key takeaways

Filling out and using the New York PS 409 form requires careful attention to detail. Here are some key takeaways to help guide you through the process:

Eligibility Confirmation: Ensure you are covered under another employer-sponsored group health insurance plan, as this is a requirement to opt out of NYSHIP.
Opt-out Amounts: If you choose to opt out of Individual coverage, you will receive $1,000, while opting out of Family coverage grants you $3,000. This amount is taxable.
Timely Submission: Complete the PS 409 form as soon as you are eligible or during the Annual Option Transfer Period. Late submissions may not be accepted.
Required Signatures: Your signature on the form is mandatory. Without it, the form will be considered invalid.
Reporting Changes: Promptly report any changes to your health insurance status, as these may affect your eligibility to participate in the Opt-out Program.
Dependents: If opting out of Family coverage, ensure that you have eligible dependents enrolled in NYSHIP.
Mid-year Enrollment: If you experience a qualifying event, notify your personnel office within 30 days to enroll in a health insurance plan without a waiting period.
Form Completeness: Ensure that all required sections of the form are filled out completely, including alternate health insurance information.
Contact Information: If you have questions, reach out to your Agency Health Benefits Administrator or the Department of Civil Service for assistance.

By keeping these points in mind, you can navigate the PS 409 form process more effectively and ensure that you receive the benefits you are entitled to.