Form Ps-404 - Nys Health Insurance Transaction Form Page 4
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4NYS Department of Civil Service
Instructions for NYS Health Insurance Transaction Form
Albany, NY 12239
PS-404 (9/15)
ANNUAL
Change NYSHIP Option: Complete during annual Option Transfer Period or with a
Box 13
qualifying event (for example, change of address outside of HMO area.)
OPTION TRANSFER
REQUEST(S)
Elect Opt-out: Enrollees in the Opt-out program must reenroll annually during the
Option Transfer Period in order to continue to receive incentive payments.
Change Pre-Tax Status: Existing enrollees can only change pre-tax status during
the annual Pre-Tax Open Enrollment Period in November.
Box 14
LEAVE WITHOUT PAY
LEAVE WITHOUT PAY: You must complete this section if you are going on leave
AND
without pay and want to cancel coverage when you leave the payroll.
RETIREMENT STATUS
RETIREMENT: You must complete this section if you are leaving the payroll due to
retirement to indicate your decision to continue or defer your health coverage as a
retiree. Also complete PS-406.2, Deferred Health Insurance for Retirees
(Indefinitely) if you request deferment. Check the box to acknowledge that Dental
and/or Vision coverage is available under COBRA, if applicable.
AUTHORIZATION
You must SIGN and DATE this form.
AGENCY/EBD USE ONLY
This section is for Agency and/or EBD use only and is provided to assist with updating the enrollee’s record on NYBEAS.
Action/Reason
Transaction that HBA will enter in NYBEAS.
Event date that resulted in the enrollee requesting a change to benefits.
Date of Event
Example: first day worked, first day on leave, date of birth, date of marriage.
Hire Date
Original date of hire or rehire. (Only needed for new enrollment).
st
The first day the enrollee is eligible for coverage.
Date of 1
Eligibility
Percentage Working
Enrollee’s percentage on payroll.
Sick Leave Information - # Hours
Number of sick leave hours for enrollee at time of retirement.
Sick Leave Information - Hourly
Enrollee’s hourly rate of pay based on annual salary at the time of retirement.
Rate of Pay
Date Entered on NYBEAS
Date HBA processes the transaction on NYBEAS.
Effective Date
The effective date assigned to the transaction by NYBEAS.
Note: When updating NYBEAS, use the Date in the Authorization Box as Date of Request.
EXAMPLES OF DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
Note: ALL employees and dependents must provide copies of his or her birth certificate and Social Security card
Spouse
Domestic Partner
Children
Copy of marriage certificate; for
Completed PS-457 (Statement of
Completed PS-425 (Domestic Partner
marriages dated more than one
Dependence) and required
series) and required documentation
year prior, proof of current joint
documentation, if applicable
ownership/financial obligation
For changes of coverage, copy of
Completed PS-451 (Statement of
For changes of coverage, copy of death
marriage certificate, divorce order
Disability) and required documentation,
certificate or PS-425.4 (Domestic Partner
or death certificate
if applicable
series)
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