New York State Health Insurance Transaction Form (PS-404)
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What Is This Form For?

To enroll in the New York State Health Insurance Program (NYSHIP) or to make changes to your existing benefits.

Download the forms:

Is This Form Mandatory?

Yes.  All employees must complete this form, even if you intend to decline coverage or enroll in the Opt-out program.


Opt-Out Program: 

Employees who have other employer-sponsored group health insurance may be eligible to enroll in the Opt-out program and receive a bi-weekly incentive payment. To enroll, you must also complete the NYS Health Insurance Opt-Out Form (PS-409)

 

visit the Opt-Out Information page

When to Submit

To avoid paying retroactive premiums, submit the PS-404 as soon as possible at the start of your employment.

How to Complete This Form

This form is fillable.

  1. Complete sections 1-10 and the applicable questions in sections 11-13 (detailed instructions are located on page 2-3 of the form). 
  2. Print the form.
  3. Sign and date the "Authorization" section on page 2. 
  4. Gather your required proof documents: Be sure to include copies of all required proof documents for you (the employee) and all your eligible dependents. See Acceptable Proof Documents List
  5. Send your original, signed PS-404 with copies of all required proof documents to the BSC.  

Where to Submit This Form

Email:

[email protected]


Fax:

518-457-1879


Mail:

BSC Benefits Administration

W. Averell Harriman State Office Campus

1220 Washington Avenue

Building 5, Floor 4

Albany, NY 12226-1900

Waiting Periods


CSEA and DC-37 employees:

42-day waiting period for health insurance. Enrollment after 42 days will result in a 5-pay period waiting period before such coverage becomes effective and health insurance contributions being deducted on a post-tax basis. Dental and vision benefits have a 28-day waiting period. To enroll in these benefits, you must enroll directly through your union as they administer these benefits.

PEF and NYSCOPBA employees:

56-day waiting period for health insurance, dental, and vision benefits. Enrollment after 56 days will result in a 5-pay period waiting period before such coverage becomes effective and health insurance contributions being deducted on a post-tax basis.

M/C employees:

56-day waiting period for health insurance and vision benefits. Enrollment after 56 days will result in a 5-pay period waiting period before such coverage becomes effective and health insurance contributions being deducted on a post-tax basis. Dental coverage begins on the first day of the month following 6 full months of employment.

Important Plan Information

  • Employees may select the Empire Plan or one of many participating Health Maintenance Organizations (HMO).
  • The cost for health insurance is deducted from an employee’s bi-weekly paycheck. Health insurance premiums deductions begin from employee’s paycheck 2 pay periods (28 days) prior to the effective date of coverage.

  • PEF, M/C, and NYSCOPBA employees who leave state service or change to CSEA or DC-37 negotiating units, health insurance coverage continues for 28 days from the last day of the last pay period in which they worked.

  • For CSEA and DC-37 employees who leave state service or change to PEF, M/C, or NYSCOPBA negotiating units, health insurance coverage continues 28 days from their last day worked as a CSEA or DC-37 employee.

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.

Contact us by phone:
Local  (518) 457-4272
Contact us by email:
Mailing Address:

BSC Benefits Team
1220 Washington Ave
Building 5, Floor 6
Albany, NY 12226-1900

Contact us by fax:
(518) 457-1879