What Is This Form For?
To enroll in the New York State Health Insurance Program (NYSHIP) Opt-out Program.
You are only eligible to Opt-Out if you are already covered by an employer-sponsored group health insurance that is not NYSHIP. Employees that meet the Opt-out requirements will receive an incentive payment, currently $1,000 for Individual Opt-out ($38.47 over 26 bi-weekly paychecks) or $3,000 for Family Opt-out ($115.39 over 26 bi-weekly paychecks).
Download the Form:
Use to enroll in the NYSHIP Opt-out program.
Is This Form Mandatory?
No. Only if you are eligible and wish to enroll in the Opt-out program.
When to Submit
If you are a new employee enrolling in the Opt-out Program, forms must be received by the BSC before your negotiating unit deadline. If the forms are not received by the deadline, will not be honored and could impact eligibility in subsequent years.
Negotiating Unit Deadlines:
- CSEA or DC-37 employees: Opt-out forms must be submitted within the 42-day waiting period.
- PEF or NYSCOPBA employees: Opt-out forms must be submitted within the 56-day waiting period.
- M/C employees: Opt-out forms must be submitted within the 56-day waiting period.
How to Complete This Form
This form is fillable.
- Complete the entire form by typing in your information in each of the fields.
- Print the form.
- Sign and date the "Attestation" section on page 2.
- Attach proof of other employer-sponsored group health insurance. Acceptable proofs documents include a copy of your health insurance card or a letter from your insurance carrier.
- Complete the Health Insurance Transaction Form (PS-404) to include with your completed PS-409 Opt-out Attestation Form.
- Send your original, signed PS-409 and PS-404 with copies of all required proof documents to the BSC.
Where to Submit this Form
BSC Benefits Administration
W. Averell Harriman State Office Campus
1220 Washington Avenue
Building 5, Floor 4
Albany, NY 12226-1900
Contact the BSC Benefits Team
Still have questions? Try the BSC Help Center where you can send a question to our support team or search a database of FAQs.