New York State Health Insurance Transaction Form (PS-404)

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

To avoid paying retroactive premiums, submit the PS-404 as soon as possible at the start of your employment. All new employees have a 28-day waiting period for enrollment.

This form is fillable.

1. You must complete boxes 1–11 with your personal information. In Box 12, indicate if any of the information in Boxes 1–11 is new and needs to be updated on your NYSHIP record. Please also indicate which of the boxes contains updated information and a date of the change (if applicable). NOTE: Use the Marital Status Date to show the date of marriage, separation or divorce when any of those marital statuses are selected (detailed instructions are located on pages 3-4 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.  

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

CSEA and DC-37 employees:

28-day waiting period for health insurance. Enrollment after 28 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:

28-day waiting period for health insurance, dental, and vision benefits. Enrollment after 28 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:

28-day waiting period for health insurance and vision benefits. Enrollment after 28 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.

• 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.