Nys ps 404 form 2025

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The document is the NYS Health Insurance Transaction Form (PS-404) used by employees of the State of New York to manage their health insurance coverage. It includes sections for employee information, requests for enrollment or changes in coverage, dependent information, previous coverage details, and options for continuing coverage during leave or retirement. The form also emphasizes the importance of providing accurate information and understanding the implications of declining or canceling coverage.

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Click ‘Get Form’ to open the NYS PS 404 form in our editor.
Begin by filling out the Employee Information section. Enter your first name, middle initial, last name, social security number, sex, date of birth, and contact details including your home telephone number.
Next, indicate your marital status by checking the appropriate box. If applicable, provide information regarding Medicare coverage.
In the Request Enrollment section, select whether you are requesting individual or family enrollment and choose your preferred medical plan (Empire Plan or HMO).
Complete the Dependent Information section if enrolling dependents. Ensure to check whether you are adding, deleting, or changing coverage for each dependent.
Review the Previous Coverage Information section if you have had prior health insurance plans and provide necessary details.
Finally, read through the authorization statement at the end of the form. Sign and date it to confirm that all information is accurate before submitting.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (221 Votes)
2019	4.3 Satisfied (52 Votes)
2017	4.2 Satisfied (78 Votes)
2017	4.4 Satisfied (129 Votes)
2014	4.3 Satisfied (76 Votes)
2011	4.8 Satisfied (49 Votes)
2007	4.6 Satisfied (43 Votes)
2006	4 Satisfied (54 Votes)
2001	4.1 Satisfied (28 Votes)

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What is the waiting period for health insurance in NY?

42-day waiting period for health insurance.

How to opt out of NYS health insurance?

You must submit a completed Health Insurance Transaction (PS-404) and Opt-out Attestation (PS-409) forms to us to enroll in the Opt-out program. Please note, it is no longer necessary to re-enroll in the Opt-Out program each year.

Does Nyship cover gym memberships?

Health and wellness programs, as well as discounts on gym memberships, weight loss services, hearing aids, and more. Drug coverage through retail pharmacies and our home delivery drug program.

Who qualifies for NY State of Health?

Qualified Health Plans are available through NY State of Health to individuals who are: New York State residents. Lawfully present in the U.S. Not eligible for Medicaid, the Essential Plan or Child Health Plus.

What are NYS employee benefits?

Health Care Coverage Employees and eligible dependents can choose from a variety of health insurance plans available at an affordable, low premium cost through enrollment in the Empire Plan or a Health Maintenance Organization (HMO). Employees are also provided family dental and vision plans at no additional cost.

What is EBD in insurance?

Elderly, Blind, and Disabled Waiver (EBD)

Does Nyship work out of state?

NYSHIP HMO coverage is available only if you live or work in New York State. NYSHIP HMOs only offer coverage in their approved service areas. Be sure you understand how enrolling in a MAP outside of NYSHIP will affect your NYSHIP benefits.

What is Nybeas?

Civil Service is responsible for maintaining the New York Benefits Eligibility and Accounting System (NYBEAS), the system of record for member enrollment and eligibility information.

Nys ps 404 form 2025

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