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The New York PS 409 form is an essential document for employees looking to opt out of the New York State Health Insurance Program (NYSHIP). This form allows eligible employees to receive financial incentives for waiving their health insurance coverage if they have alternate employer-sponsored group health insurance. For those opting out of individual coverage, a taxable amount of $1,000 is offered, while opting out of family coverage provides $3,000. To complete the form, employees must provide personal details such as their name, address, and contact information, as well as information about their alternate health insurance plan. The form also requires an attestation confirming that the employee is indeed covered under another plan and understands the implications of opting out. Important deadlines exist for newly eligible employees and those currently enrolled, ensuring that they can participate in the program during specific enrollment periods. The PS 409 form plays a vital role in helping employees navigate their health insurance options while maximizing their benefits.
Similar forms
- Form PS-404 Enrollment Form: This form is required for employees to enroll in the New York State Health Insurance Program (NYSHIP). Like the PS-409, it collects essential employee information and is necessary for processing health insurance enrollment, ensuring that employees receive the appropriate coverage.
- Form PS-410 Health Insurance Waiver: Similar to the PS-409, this form allows employees to waive health insurance coverage under specific conditions. Both forms require employees to attest to having other health insurance coverage, helping to confirm eligibility for opting out of NYSHIP.
- Form PS-411 Dependent Enrollment Form: This form is used to enroll dependents in NYSHIP. It shares similarities with the PS-409 in that it collects personal information and requires attestation regarding eligibility, ensuring that dependents are covered under the employee's health plan.
- Form PS-412 Change of Status Form: Employees use this form to report changes in their health insurance status, such as marriage or divorce. Like the PS-409, it emphasizes the importance of timely reporting to maintain accurate health insurance coverage.
- Form PS-413 Health Insurance Coverage Information: This document provides details about the health insurance options available to employees. It parallels the PS-409 in that it helps employees understand their coverage choices and the implications of opting out of NYSHIP.
- Form PS-414 Qualifying Event Notification: This form is used to notify the agency of qualifying events that may affect health insurance coverage. It is similar to the PS-409 as both require employees to report changes that impact their eligibility for health benefits.
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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 |
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_____/_____/______ |
Home ( |
) |
Work ( |
) |
|
Marital Status |
Married |
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Divorced |
|
Marital Status Date |
Single |
Widowed |
|
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 |
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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.
Common mistakes
When filling out the New York PS 409 form, one common mistake is failing to provide complete information about the alternate health insurance coverage. Employees must specify the name of the covered employee, their date of birth, and Social Security number. Omitting any of these details can lead to delays or rejection of the application. Ensure that every section is filled out thoroughly to avoid complications.
Another frequent error involves misunderstanding the eligibility requirements. Employees must be covered under another employer-sponsored group health plan to opt out of NYSHIP. If you are not currently enrolled in such a plan, you will not qualify for the opt-out program. It is crucial to verify your coverage before submitting the form.
People often overlook the requirement to report any changes in their insurance status promptly. The form clearly states that employees must inform their agency of any changes that may impact eligibility. Ignoring this responsibility can result in penalties or loss of benefits. Stay proactive and communicate any changes as soon as they occur.
Lastly, many individuals forget to sign and date the form. This step is essential; without a signature, the form is considered invalid. Double-check that you have completed all necessary sections, including your signature, before submission. A simple oversight can jeopardize your opt-out election.
More About New York Ps 409
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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, is designed for employees who are eligible for the New York State Health Insurance Program (NYSHIP). By completing this form, employees can opt out of NYSHIP coverage if they have other employer-sponsored health insurance. In exchange for waiving their coverage, they can receive a taxable amount of $1,000 for individual coverage or $3,000 for family coverage, credited to their bi-weekly paychecks.
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Who is eligible to use the PS 409 form?
Eligibility for the PS 409 form is primarily for employees who are newly eligible for NYSHIP or those who are currently enrolled in NYSHIP. To qualify, employees must demonstrate that they are covered under another employer-sponsored group health plan. Additionally, current enrollees can only opt out during the Annual Option Transfer Period or if they experience a qualifying event. It is essential that employees have been enrolled in NYSHIP prior to April 1st of the previous plan year to be eligible for opting out.
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What steps must be taken to complete the PS 409 form?
To successfully complete the PS 409 form, employees must fill out their personal information, including their name, address, and contact details. They must then indicate their choice to opt out of either individual or family coverage. Importantly, employees must provide details about their alternate health insurance coverage, including the name of the covered employee, their date of birth, and the employer's information. After completing the form, employees are required to sign and date it, confirming their understanding of the program and their eligibility.
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What happens if an employee’s circumstances change after opting out?
If an employee's circumstances change, they must promptly report these changes to their personnel office. This is crucial, as any changes could impact their eligibility for the Opt-out Program. Employees who experience a qualifying event, such as a change in employment status or family situation, may be allowed to withdraw their Opt-out election and enroll in a health insurance plan mid-year. To do so, they must notify their personnel office within thirty days of the qualifying event.
Misconceptions
Understanding the New York PS 409 form is crucial for employees considering opting out of NYSHIP health coverage. However, several misconceptions can lead to confusion. Here are eight common misunderstandings about the PS 409 form:
- It’s only for new employees. Many believe that only newly hired employees can use the PS 409 form. In reality, current employees can also opt out during the Annual Option Transfer Period.
- Opting out means losing all health coverage. Some think that by opting out, they will have no health insurance at all. Instead, they can maintain other employer-sponsored group health insurance while receiving a cash incentive.
- The cash incentive is tax-free. There is a misconception that the $1,000 or $3,000 received for opting out is tax-free. In fact, this amount is considered taxable income and will be reflected in bi-weekly paychecks.
- All employees are automatically eligible. Not every employee can opt out. Employees must demonstrate that they have other employer-sponsored group health insurance to qualify for the program.
- Changes in coverage do not need to be reported. Some employees believe they can ignore changes to their health insurance status. However, it’s essential to report any changes promptly, as they can impact eligibility.
- Opting out is permanent. Many think that once they opt out, they cannot return to NYSHIP coverage. Employees can re-enroll during qualifying events or the next Annual Option Transfer Period.
- Dependent information is not necessary. For those opting out of Family coverage, it’s a common misconception that they do not need to provide dependent information. This information is mandatory to process the Family opt-out.
- The form can be submitted without a signature. Some employees may overlook the importance of signing the PS 409 form. A signature is required for the form to be valid and processed.
Being aware of these misconceptions can help employees navigate the opt-out process more effectively and make informed decisions about their health insurance options.
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Key takeaways
When filling out the New York PS 409 form, consider these key takeaways:
- Eligibility Requirements: You must be covered under another employer-sponsored group health plan to opt out of NYSHIP.
- Financial Incentives: Opting out of Individual coverage earns you $1,000, while opting out of Family coverage provides $3,000.
- Timely Submission: Newly eligible employees must submit the form by their first date of NYSHIP eligibility.
- Annual Enrollment Period: Current employees can opt out during the Annual Option Transfer Period.
- Change Reporting: You must report any changes to your alternate health insurance coverage that could affect your eligibility.
- Signature Requirement: The form is invalid without your signature and must be submitted alongside the completed PS 404 Enrollment Form.
- Mid-Year Changes: Only employees who experience a qualifying event can withdraw their opt-out election mid-year.
- Taxable Income: The amounts received for opting out will be credited to your bi-weekly paycheck as taxable income.
- Privacy Notice: Information provided is protected under the Personal Privacy Protection Law and is used solely for processing your health insurance request.
New York Ps 409: Usage Guide
Completing the New York PS 409 form is an important step 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. Below are the steps to help you fill out the form correctly.
- Gather Necessary Information: Before starting, collect all required information, including your personal details and the details of your alternate health insurance coverage.
- Fill Out Employee Information: Write your full name, street address, city, state, zip code, date of birth, and telephone numbers (home and work) in the designated fields.
- Indicate Marital Status: Check the appropriate box for your marital status—Married, Divorced, Single, Widowed, or Separated. If applicable, provide the date of your marital status change.
- Provide Agency Information: Enter the name and address of your agency.
- Select Opt-Out Election: Choose between opting out of Individual coverage for $1,000 or Family coverage for $3,000. Ensure you understand the implications of your choice.
- Complete Alternate Health Insurance Information: Provide the name of the covered employee, their date of birth, Social Security Number, employer's name, effective date of alternate coverage, and the name and address of the alternate health insurance.
- Read the Attestation: Carefully read the attestation section. This section outlines your responsibilities and confirms your eligibility for the Opt-out Program.
- Sign and Date the Form: Sign your name in the required space and write the date of your signature. This step is crucial for the validity of the form.
- Submit the Form: Ensure that the completed PS 409 form is submitted along with a completed PS 404 Enrollment Form to your agency's designated office.
Once you have completed these steps, your form will be processed, and you will receive the appropriate opt-out amount in your bi-weekly paycheck. If you have any questions or need further assistance, reach out to your Agency Health Benefits Administrator for guidance.