Form Ps-409 - Opt-Out Program Attestation - Department Of Civil Services

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EMPLOYEE BENEFITS DIVISION

OPT-OUT PROGRAM ATTESTATION FORM

PS-409 (11/15)

EMPLOYEE INFORMATION

Name

Social Security Number

Negotiating Unit

Street Address

City

State

Zip

Date of Birth

Telephone Numbers

Agency Name and Address

Home (

)

Work (

)

Marital Status

Married

Divorced

Marital Status Date

Separated

Single

Widowed

NYSHIP HEALTH BENEFITS OPT-OUT ELECTION

You must attest to having other employer-sponsored group health insurance to be eligible for the Opt-out Program. Other

employer-sponsored group health coverage cannot be:

•

The result of your or your spouse’s, domestic partner’s or parent’s employment relationship with NYS, or

•

The result of your own employment with a NYSHIP Participating Agency (PA) or Participating Employer (PE)

If you are eligible to Opt-out, please check one:

I have other coverage as a dependent

I have other coverage through my own employment

My other coverage is not NYSHIP coverage. I am

electing to Opt-out of Individual coverage in

exchange for a $1,000 taxable payment ($38.47 over

My other coverage is not NYSHIP coverage. I am

26 biweekly paychecks).

electing to Opt-out of Individual coverage in exchange

for a $1,000 taxable payment ($38.47 over 26 biweekly

My other coverage is not NYSHIP coverage. I am

paychecks).

electing to Opt-out of Family coverage in exchange

for a $3,000 taxable payment ($115.39 over 26

biweekly paychecks).

My other coverage is NYSHIP through an employer

My other coverage is not NYSHIP coverage. I am

other than New York State. I understand that I am

electing to Opt-out of Family coverage in exchange for

only eligible to Opt-out of Individual coverage in

a $3,000 taxable payment ($115.39 over 26 biweekly

exchange for a $1,000 taxable payment ($38.47 over

paychecks).

26 biweekly paychecks).

Other employer-sponsored group health insurance information must be provided as indicated below:

Name of covered employee ____________________________________

Covered employee’s Date of Birth ______________

Covered employee’s SSN

_________________________

Name of covered employee’s employer

___________________________________________________

Effective date of other group health insurance coverage

___________________________________________________

Name and Address of alternate health insurance coverage

___________________________________________________

(You must provide either a copy of your health insurance card or a letter from your employer or other health insurance provider confirming current coverage).

ATTESTATION

I have read the Opt-out Program materials and instructions and I attest to the following:

•

I meet the qualifications to elect the Health Insurance Opt-out Program.

•

I understand that I must promptly report changes that may impact my eligibility or payment amount (e.g., loss of other

employer-sponsored coverage, divorce, death, last dependent loses eligibility for NYSHIP coverage) If I fail to do so, I am

responsible for any Opt-out Program payments made to me in error. I understand that Opt-out Program payments made to

me in error may be recovered as special deductions of up to $200 from my biweekly paycheck.

•

I understand that I may choose to opt out of Family coverage only if I have NYSHIP eligible dependents and I am not

enrolled in NYSHIP as a dependent or enrollee through NYS or another NYSHIP employer, and that I must provide proof of