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Policy/Memo 139r2

Number: Policy Memo 139r2
Date Issued: July 22, 2010
Date Revised: July 29, 2021
Subject: Required Dependent Proofs


Identify the documentation that must be collected as proof of eligibility before adding a dependent to NYSHIP.


To prevent the extension of coverage to ineligible dependents, this policy memo confirms the documents that enrollees must present to add dependents to NYSHIP coverage.


For All Dependents Other Than Newborns
Dependents’ eligibility must be verified prior to NYSHIP enrollment. This documentation must be provided even if a dependent was previously covered under NYSHIP. In addition, the Department of Civil Service may periodically request dependent eligibility be verified on an ongoing basis for auditing purpoes.

The date of request and date of event dictate the effective date of coverage. When an employee submits a signed Health Insurance Transaction Form for NYS & PE Employees (PS-404) or PA Health Insurance Transaction Form (PS-503), the employee’s signature date is considered the “date of request.” From the date of request, the employee has 30 days to provide the appropriate dependent proofs to the agency Health Benefits Administrator (HBA) or the Business Services Center (BSC) in order for the transaction to be processed

If the enrollee does not provide required proofs within 30 days of submitting the request, he or she will be required to submit a new PS-404 or PS-503 form and the dependent will be subject to a late enrollment waiting period. Requests for exceptions to this policy should be forwarded to the Employee Benefits Division (EBD) for consideration.

If documentation cannot be provided, please contact EBD for assistance.

For Dependents who are Newborns
A newborn child should be added to the plan immediately upon submission of a signed PS-404 or PS-503, even if proofs are not available. The HBA or BSC must then follow up with the enrollee to obtain required proofs once available.

Please note, the HBA or BSC should contact EBD if a request to add a newborn child is submitted more than 30 days after the birth of the child.

If documentation cannot be provided, please contact EBD for assistance.

Please see the table below for required proofs for all dependent types.


Summary of NYSHIP Required Proofs


Domestic Partner


Other Child*

Copy of Birth Certificate**

Social Security Number***

Medicare Claim Number (if enrolled in Medicare)

Copy of Marriage Certificate

Completed  NYSHIP Domestic Partner Enrollment Application (PS-425)


Other required proofs listed in PS-425

Adopted Child

Adoption papers that include the child’s name and list the enrollee as the legal guardian. If the adoption has not yet been finalized, a copy of the filed petition of adoption that includes the child’s name and lists the enrollee as the legal guardian.


 Completed NYSHIP Statement of Dependence for “Other” Children (PS-457)

Other required proofs listed in PS-457

For Disabled Dependents Age 26 or older

 NYSHIP Statement of Disability for Dependents (PS-451)

Proof of joint financial obligation from within the last year****

(i.e. tax return, bank account statement)

For Military Extension*****

Copy of DD-214

 Proof of full time student status

Age 19 - 25 for Dental and Vision only

Proof of full time student status


* An ‘other’ child is defined as any child other than the enrollee’s own child, adopted or stepchild, or the child of the enrollee’s domestic partner. For such a dependent to be eligible, the child must reside permanently in the enrollee’s home and receive more than 50 percent of his or her support from the enrollee. Refer to NYSHIP Policy Memo 88r1 for more information.

**A court order noting that the enrollee’s  status as the father has been adjudicated by a court; or a Voluntary Acknowledgment of Paternity that has been executed and filed with a county registrar may be used in place of a birth certificate to prove the child’s relationship to the enrollee. Refer to NYSHIP Policy Memo 142 for more information.

*** Enrollees do not need to provide a copy of their dependents’ Social Security card. However, for federal reporting purposes enrollees must provide their dependents’ Social Security Number (SSN). If a dependent has not been issued an SSN by the federal Social Security Administration because they are not eligible for one, the enrollee may complete and return the “Affidavit for a Dependent Who is Not Eligible for a Social Security Number.” The HBA should use a placeholder SSN (e.g. 888-88-8888 or 999-99-9999) for the dependent in place of an actual SSN for NYBEAS purposes. The enrollee must provide the HBA with a real SSN if one is later issued, and the HBA should update NYBEAS accordingly.

**** This proof must contain the names of the enrollee and the spouse. This requirement is waived for marriages occurring less than one year ago.

***** Dependent children who served in the military prior to age 26 may have their eligilbity under NYSHIP extended for a period of time equivalent to their military service, up to four years. For example, a dependent with three years of military service from age 17 to 20 may be eligible for NYSHIP coverage until the age of 29.