The New York PS 409 form is an attestation form used by employees to opt out of the New York State Health Insurance Program (NYSHIP) when they have other employer-sponsored health insurance coverage. By completing this form, employees can receive a financial incentive for waiving their health insurance coverage, which can be a significant benefit for those who qualify. Understanding the requirements and implications of this form is essential for making informed decisions about your health insurance options.
The New York PS 409 form, officially known as the Opt-out Attestation Form, is a crucial document for employees enrolled in the New York State Health Insurance Program (NYSHIP) who wish to opt out of their health coverage. This form allows eligible employees to attest that they have alternative employer-sponsored group health insurance, which is a requirement for participating in the Opt-out Program. By completing this form, employees can receive a financial incentive, either $1,000 for waiving Individual coverage or $3,000 for waiving Family coverage, credited to their bi-weekly paychecks as taxable income. The form requires essential employee information, including name, contact details, and marital status, as well as details about the alternative health insurance coverage. It is important for employees to understand that this election is valid for the 2013 plan year only, and changes to their insurance status must be reported promptly. The PS 409 form must be signed and submitted along with a PS 404 Enrollment Form to ensure compliance with the eligibility requirements. For those newly eligible or currently enrolled, the timing of the application is critical, as it must be completed within specific enrollment periods or following qualifying events. The information provided is protected under New York State law, ensuring that personal privacy is maintained throughout the process.
Understanding the New York PS 409 form is crucial for employees considering opting out of the New York State Health Insurance Program (NYSHIP). However, several misconceptions often arise regarding this form. Below is a list of seven common misunderstandings, along with clarifications for each.
This form is available to both new and current employees. Current employees can opt out during the Annual Option Transfer Period.
Employees can opt out of NYSHIP only if they have other employer-sponsored group health insurance. They do not lose all health coverage.
The amounts received for opting out—$1,000 for individual coverage and $3,000 for family coverage—are considered taxable income.
Opting out is limited to specific times: when newly eligible or during the Annual Option Transfer Period. Mid-year changes are only allowed after a qualifying event.
Employees must provide details about their other employer-sponsored health insurance to be eligible for the opt-out program.
Employees who experience a qualifying event can withdraw their opt-out election and enroll in a health insurance plan without waiting.
Completing the PS 409 form is mandatory for those who wish to participate in the Opt-out Program. Failure to submit the form can lead to ineligibility.
By addressing these misconceptions, employees can make informed decisions regarding their health insurance options and ensure they meet the necessary requirements for the NYSHIP Opt-out Program.
When filling out the New York PS 409 form, follow these guidelines to ensure accuracy and compliance.
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
_____/_____/______
Home (
)
Work (
Marital Status
Married
Divorced
Marital Status Date
Single
Widowed
Separated
Agency Name and Address
NYSHIP HEALTH BENEFITS OPT-OUT ELECTION
Complete this section if you are newly eligible or currently enrolled in NYSHIP.
Employees must attest below that they are covered under other employer-sponsored group health insurance coverage other than the State of New York as of the opt out effective date, to be eligible for the Opt-out Program (CSEA employees, see your HBA for additional eligibility information).
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 opt-out).
Other employer-sponsored group health insurance information (must be provided)
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 Opt-out Program materials and instructions and I attest to the following:
•I am covered under another employer-sponsored group health plan other than the State of New York that is in effect as of the opt out effective date and have provided my alternate plan information.
•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 Opt-out Program.
Employee’s Signature (Required) ________________________________ Signature Date (Required) ___/____/_____
NYS Department of Civil Service
Opt-out
Attestation Form
Page 2
– PS 409 (10/12)
Employees who can demonstrate and attest to having other employer-sponsored group health insurance may elect to opt out of NYSHIP’s Empire Plan or Health Maintenance Organizations. Employees who elect to opt out of NYSHIP will receive $1,000 for waiving Individual coverage or $3,000 for waiving Family coverage. This amount will be credited to bi-weekly paychecks as taxable income over the plan year. Unless newly eligible to enroll, employees must be enrolled in NYSHIP Individual or Family coverage prior to April 1st of the previous plan year to be eligible to opt out of that coverage. This enrollment cannot have been subject to late enrollment. In order to participate, employees must have other employer-sponsored group health insurance.
There are two circumstances when employees may elect to opt out of coverage; as newly eligible for the Opt-out Program, and, for currently enrolled employees, during the Annual Option Transfer Period. Only employees who experience a qualifying event will be allowed to withdraw their Opt-out election and enroll in a health insurance plan mid-year. See instructions below.
INSTRUCTIONS:
Newly eligible employees: Employees may enroll in the Opt-out Program no later than their first date of NYSHIP eligibility. Employees must sign the PS-409 Opt-out Attestation Form and complete a PS-404 Enrollment Form.
Current enrollees: Eligible enrollees may elect the Opt-out Program during the Annual Option Transfer Period for each plan year. Employees must sign the PS-409 Opt-out Attestation Form and complete a PS-404 Enrollment Form.
During mid-year: Employees who experience a Qualifying Event (QE) must notify their personnel office within thirty (30) days of the QE date in order to enroll in a health insurance plan without a waiting period. Employees must complete a PS404 Enrollment Form.
By signing the Opt-out Attestation, you elect to receive $3,000 (Family coverage waived), or $1,000 (Individual coverage waived); this amount will be credited to your bi-weekly paycheck as taxable income over the plan year.
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.
The New York PS 409 form is an attestation form that allows eligible employees to opt out of the New York State Health Insurance Program (NYSHIP) if they have other employer-sponsored group health insurance. By opting out, employees can receive a financial incentive, which is $1,000 for waiving individual coverage or $3,000 for waiving family coverage.
Eligibility for the PS 409 form includes employees who are newly eligible for NYSHIP or currently enrolled in the program. Employees must have other employer-sponsored group health insurance in effect as of the opt-out effective date. Additionally, employees must have been enrolled in NYSHIP prior to April 1st of the previous plan year, unless they are newly eligible.
To complete the PS 409 form, employees must provide the following information:
Employees who opt out of NYSHIP coverage will receive a taxable amount credited to their bi-weekly paychecks. The amount is $1,000 for waiving individual coverage and $3,000 for waiving family coverage. This amount is distributed over the plan year as taxable income.
Employees may withdraw their opt-out election and re-enroll in a health insurance plan mid-year only if they experience a qualifying event. A qualifying event includes situations such as marriage, divorce, or loss of other health coverage. Employees must notify their personnel office within thirty (30) days of the qualifying event to avoid a waiting period.
Newly eligible employees must submit the PS 409 form no later than their first date of NYSHIP eligibility. Current enrollees can opt out during the Annual Option Transfer Period for each plan year. If a qualifying event occurs, employees must notify their personnel office within thirty (30) days to make changes without a waiting period.
For more information regarding the PS 409 form and the Health Insurance Program, employees can contact their Agency Health Benefits Administrator. If additional assistance is needed, they may call the New York State Department of Civil Service at (518) 457-5754 or 1-800-833-4344, available between 9:00 a.m. and 4:00 p.m.
Filling out the New York PS 409 form is a straightforward process that allows employees to opt out of certain health insurance coverage in exchange for a financial incentive. To ensure that the form is completed accurately, follow the steps outlined below carefully.
Filling out the New York PS 409 form can be straightforward, but many people make common mistakes that can lead to delays or issues. One frequent error is failing to provide complete personal information. It’s crucial to fill in all fields, including your name, address, and telephone numbers. Incomplete sections may result in the form being rejected.
Another mistake is not checking the correct opt-out election. Employees must choose between Individual or Family coverage. Selecting the wrong option can cause confusion later on, especially regarding the amount of taxable income credited to paychecks.
Additionally, some individuals overlook the requirement to provide information about their alternate health insurance. This includes the name of the covered employee, their date of birth, and their Social Security number. Missing this information can invalidate the application and prevent participation in the Opt-out Program.
Not signing the form is another common oversight. The employee's signature is mandatory, and without it, the form cannot be processed. Be sure to double-check that the signature is included before submission.
Moreover, some employees fail to understand the importance of reporting changes. If there are any updates to the information provided, such as changes in health insurance coverage, these must be reported promptly. Ignoring this can affect eligibility for the Opt-out Program.
Another mistake involves misunderstanding the eligibility criteria. Employees must be enrolled in NYSHIP prior to April 1st of the previous plan year to qualify for opting out. Many applicants are unaware of this requirement, leading to disappointment when their application is denied.
Lastly, some individuals do not submit the PS 404 Enrollment Form along with the PS 409. Both forms are necessary for processing the opt-out request. Failing to include the PS 404 can result in the entire application being considered invalid.
Here are key takeaways about filling out and using the New York PS 409 form:
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