NYS Health Insurance Transaction Form for Retirees, 2025

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4.9 out of 5

28 votes

The document is a New York State Health Insurance Transaction Form for retirees, vestees, preferred list members, and dependent survivors. It provides instructions for completing the form, which includes sections for personal information, enrollment in coverage, changes or cancellations of existing coverage, dependent information, previous coverage details, and authorization. The form requires enrollees to provide necessary documentation when adding dependents and outlines the implications of declining or canceling coverage.

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Click ‘Get Form’ to open the NYS Health Insurance Transaction Form for Retirees in our editor.
Begin by filling out the Enrollee Information section. Enter your last name, first name, and social security number. Ensure you provide your date of birth and contact details accurately.
Indicate your marital status and whether you are covered under Medicare. If any information has changed, check the appropriate box.
Proceed to the Enrollment Coverage section. Choose between Individual or Family Enrollment and specify your preferred plan (Empire Plan or HMO).
If changing or canceling existing coverage, complete the relevant sections detailing the date of event and type of change.
For dependent information, list all dependents accurately, indicating if you are adding, deleting, or changing their status.
Finally, review all entries for accuracy before signing and dating the document at the end.

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Versions	Form popularity	Fillable & printable
2018	4.9 Satisfied (28 Votes)
2013	4.8 Satisfied (193 Votes)

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Who is eligible for Nyship?

POLICY. An unmarried dependent child who is age 19 or over, but under age 25, is eligible for NYSHIP dental and vision coverage if he or she is a full-time student at an accredited secondary or preparatory school, college or other educational institution.

Do NYS retirees get reimbursed for Medicare?

If you have family coverage under NYSHIP, NYSHIP will also reimburse you for the standard Part B premium (and any Part B IRMAA) paid to SSA for any Medicare-primary dependent, provided the dependent is not reimbursed by another source or the premium is not paid by another entity.

What are the retirement benefits for NY State employees?

The Benefit If you retire with 20 or more years of service credit, your retirement benefit will be 2 percent of your Final Average Salary (FAS) for each year of service credit. With less than 20 years of service credit, your benefit will be 1.66 percent of your FAS for each year of service credit.

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Is there a penalty for not having health insurance in New York?

The fee for not having health insurance (sometimes called the Shared Responsibility Payment or mandate) ended in 2018. This means you no longer pay a tax penalty for not having health coverage. If you dont have health coverage, you dont need an exemption to avoid paying a tax penalty.

What kind of insurance do you get when you retire?

If youre retired and have Medicare and Group health plan (retiree) coverage from a former employer, generally Medicare pays first for your health care bills, and your Group health plan coverage pays second.

Is health insurance mandatory in NY?

The Affordable Care Act (ACA) requires almost every individual and each of his or her dependents to have health insurance coverage.

How much do NYS retirees pay for health insurance?

What portion of the cost of health insurance must I pay as a retiree? Your premium cost for health insurance coverage is the same as that of an active employee. Currently, the State pays 84-88% of the cost of individual coverage and 69-73% of the additional cost for family coverage in the NYS Empire Plan.

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.