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:
This outlines the documentation that must be collected as proof of eligibility before enrolling in NYSHIP for medical, dental, and vision.
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.
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).
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.
- Complete sections 1-10 and the applicable questions in sections 11-13 (detailed instructions are located on page 2-3 of the form).
- Print the form.
- Sign and date the "Authorization" section on page 2.
- 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.
- Send your original, signed 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
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.
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.