Fillable Nyship Opt-Out Program Attestation Form (Page 2 of 2) in pdf

NYS Department of Civil Service

Opt-out Program Attestation Form

Albany, NY 12239

Page 2 – PS-409 (11/15)

INSTRUCTIONS TO ELECT OPT-OUT:

Employees may elect to opt out of coverage when newly eligible for the Opt-out Program and, for currently enrolled

employees, during the annual Option Transfer Period.

Newly eligible employees may enroll in the Opt-out Program no later the last day of the new employee waiting

period for coverage. Employees must complete and sign the PS-409 Opt-out Program Attestation Form and the

PS-404 Health Insurance Transaction Form.

Current enrollees: Eligible enrollees may elect the Opt-out Program during the annual Option Transfer Period for

each plan year. Employees must have been enrolled in NYSHIP Individual or Family health benefits prior to April 1

of the previous plan year or when newly eligible if after April 1 to be eligible to opt out of coverage. Employees must

complete and sign the PS-409 Opt-out Program Attestation Form and the PS-404 Health Insurance Transaction

Form.

NOTE: If an employee maintained continuous enrollment in a NYSHIP health plan, and changed coverage from

Individual coverage to Family coverage due to a qualifying event (e.g., requests to cover a new spouse within 30

days from the date of marriage), the employee may be eligible for the family Opt-out incentive payment for the

following plan year. If the request to change health plan coverage is subject to late enrollment, the employee would

only be eligible for the individual Opt-out incentive payment.

INSTRUCTIONS TO ENROLL IN NYSHIP HEALTH BENEFITS

Employees who participate in the Opt-out Program may enroll in NYSHIP health benefits during the next annual

Option Transfer Period. Employees must complete a PS-404 Health Insurance Transaction Form.

Additionally, employees enrolled in the Opt-out Program who experience a PTCP qualifying event, such as a

change in family status (e.g., marriage, birth, death or divorce) or loss of coverage, must notify their personnel office

within thirty (30) days of the event date in order to enroll in a health plan without satisfying a late enrollment waiting

period. Opt-out enrollees who experience a qualifying event but fail to notify their personnel office within thirty (30)

days of the date of event may enroll in a NYSHIP health plan after satisfying a late enrollment waiting period.

Employees must complete a PS-404 Health Insurance Transaction Form to request enrollment.

Opt-out enrollees who have not experienced a PTCP qualifying event may not enroll in a NYSHIP health plan for

the remainder of the plan year. They must remain in the Opt-out Program and wait for the next Annual Option

Transfer Period to enroll in a NYSHIP health plan.

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.