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:
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Health Insurance Transaction Form (PS-404)
Use to sign up for health insurance or make changes to your existing benefits.
Download
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Documentation Requirements for the Health Insurance Transaction Form (PS-404)
This outlines the documentation that must be collected as proof of eligibility before enrolling in NYSHIP for medical, dental, and vision. Revised May 2024.
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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).
When to Submit
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.
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
Email:
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:
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. 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).
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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.
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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.
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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:
Contact us by email:
Mailing Address:
Human Resources, BSC Records Management
Building 5, Floor 4
W. Averell Harriman State Office Campus
1220 Washington Ave
Albany, NY 12226-1900