INSTRUCTIONS
FOR THE PS-404
NYS HEALTH INSURANCE TRANSACTION
FORM
PS-404 I
(6/01L)
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All enrollees
must complete |
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Complete
appropriate sections. The employee is entitled to make separate choices
regarding their medical, dental and vision coverage. They may decline any
of the three, all of the three, or none of the three different coverage
options. Also, they many enroll in family coverage in one benefit and
individual coverage in another. Reminder:
Enrollees with a Benefit Fund (CSEA, UUP and DC-37) receive their dental
and vision benefits through that Fund. Do not enter dental and vision
information on NYBEAS for these
enrollees. |
New Enrollees (also
complete 10.G for family coverage)
Note: for new enrollments
in a Health Maintenance Organization (HMO), complete an HMO form in addition to
this form.
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10.A |
Request
Enrollment – Individual |
Check box to
enroll in individual coverage. Check Medical, Dental and/or Vision boxes
for coverage being enrolled. |
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10.B |
Request
Enrollment – Family |
Check box to
enroll in family coverage. Check Medical, Dental and/or Vision boxes for
coverage being enrolled. |
|
10.C |
Elect Pre-Tax
Status? |
New Enrollees
choose to enroll in or decline the Pre-Tax Contribution Program for
medical coverage. |
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10.D |
Decline
Coverage |
Check box to
decline coverage. Check Medical, Dental and/or Vision boxes for coverage
being declined. |
Cancellation or
Change in Coverage
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10.E |
Voluntarily
Cancel Coverage |
The enrollee
is entitled to make separate decisions regarding their medical, dental and
vision coverage. Enrollees may cancel or change their dental and/or vision
coverage(s) at any time during the year. Pre-tax medical enrollees may
only cancel coverage during the Pre-Tax Open Enrollment Period, or with a
qualifying event (enter the qualifying event). If you are going on
Leave Without Pay, also complete |
|
10.F |
Change
Coverage |
Check this box
to change from Individual to Family, or from Family to Individual
coverage. Pre-tax medical enrollees may only change their coverage from
Family to Individual during the Pre-Tax Open Enrollment Period, or with a
qualifying event (check the qualifying event and enter the Date of Event).
Check Medical, Dental, and/or Vision boxes for coverage being
changed. |
|
10.G |
Add/Change/Delete
Dependents |
Check the box
to add or delete dependents or to change dependent information. Check
Medical, Dental, and/or Vision boxes that apply. Complete all dependent
information including date of birth. Additional documentation may
be required to add the dependent. |
|
10.H |
Change Medical
Benefit Plan |
Complete
during annual Option Transfer Period or with a qualifying event (for
example, change of address outside of HMO
area.) |
|
10.I |
Change Pre-Tax
Status |
Existing
enrollees can only change pre-tax status during the annual Pre-Tax Open
Enrollment Period in November. |
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AUTHORIZATION |
Employees must
SIGN and DATE this form. |
EXAMPLES OF
DOCUMENTATION REQUIRED TO PROCESS YOUR TRANSACTION
|
Employees |
Spouse/Domestic
Partner |
Children |
|
Copy of Birth
Certificate |
Copy of Birth
Certificate |
Copy of Birth
Certificate |
|
Copy of Social
Security Card |
Copy of Social
Security Card |
Copy of Social
Security Card |
|
|
Copy of
Marriage Certificate or Complete PS-425 series Domestic Partner, if
Applicable |
Completed
PS-451 - Statement of Disability and Required Documentation, if
Applicable |
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For Changes of
Coverage, copy of Marriage Certificate, Divorce Order, Death Certificate,
PS-425.4 (Domestic Partner), as appropriate |
Completed
PS-457 - Statement of Dependence and Required Documentation, if
Applicable |