Policy/Memo 139r4

Number: Policy Memo 139r4
Date Issued: July 22, 2010
Date Revised: September 6, 2024
Subject: Required Dependent Proofs

PURPOSE:

Identify the documentation that must be collected as proof of eligibility before adding a dependent to New York State Health Insurance Program (NYSHIP) coverage and clarify the procedure for timely submission of proofs.

BACKGROUND:

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.

POLICY:

Dependents’ eligibility must be verified prior to NYSHIP enrollment. Proof of eligibility must be provided to add a dependent, even if they were previously covered under NYSHIP. The Department of Civil Service may request verification of dependent eligibility for auditing purposes. If a dependent loses eligibility under the terms of NYSHIP, the dependent must be removed from the enrollee’s plan. 

Required Proofs

Prior to enrolling a dependent on a NYSHIP plan, all enrollees must provide both (A) proof of their dependent’s identity and (B) proof of the dependent’s relationship to the enrollee as outlined below.

A. Proofs of Identity
To ensure proper payment of claims, an enrollee must submit documentation that clearly identifies their dependent. The following proofs of identity must be provided for all dependents added to coverage:

• Birth Certificate
  
  • Government issued photo identification (ID), such as a drivers’ license or passport, may be submitted in place of a birth certificate for a spouse or domestic partner when a birth certificate is not available; the document must include the dependent’s name and date of birth.
    • A government issued photo ID does not satisfy requirements to add a dependent child to coverage since these documents do not demonstrate proof of relationship to the enrollee.
  • When a spouse is unable to provide a birth certificate or government issued photo ID, alternate forms of identification described in the acceptable documentation guidelines provided by United States Citizenship and Immigration Services (USCIS) on Form I-9 may be submitted to EBD for review.

• Social Security Number - for federal reporting purposes and pursuant to union contract, enrollees must provide their dependents’ Social Security Number (SSN) or Taxpayer Identification Number (TIN). Enrollees do not need to provide a copy of their dependents’ Social Security card. 
  • If a spouse or domestic partner has not been issued an SSN or TIN 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 health benefits administrator (HBA) should contact EBD each time the form is needed. The HBA must retain the completed Affidavit as they would any other required proof.
    • In NYBEAS the HBA should use a placeholder SSN (e.g., 888-88-8888). The enrollee must provide the HBA with the spouse or domestic partner’s SSN if one is later issued and the HBA should correct NYBEAS.
  • If a dependent child does not have an SSN, the HBA should leave the SSN field blank until the enrollee can provide the HBA with the child’s SSN.

• Medicare Member Identification Number (MBI), if applicable - enrollees must provide the MBI if the dependent is enrolled in Medicare Parts A and/or Part B, but they do not need to provide a copy of their dependents’ Medicare card.

B. Proofs of Relationship to the Enrollee
Dependent eligibility in NYSHIP is limited to specific dependent types as defined in 4 CRR-NY 73.1 of the NYS Regulations and State collective bargaining agreements. As such, an enrollee must demonstrate through documentation the relationship between the enrollee and their dependent. In addition to the proofs of identity listed above, the following proofs of relationship must be submitted for each dependent type:

Spouse

• Copy of marriage certificate; and
• Proof of joint financial obligation containing names of both the enrollee and spouse and which confirms both the enrollee and spouse are responsible parties for the same financial obligation. This requirement is waived if the marriage took place less than one year prior to the date of request.

Domestic Partner

• Completed and notarized NYSHIP Domestic Partner Enrollment Application (PS-425); and
• Required proofs of residence and joint financial obligation listed on PS-425.

Natural Child

• Birth Certificate confirming the NYSHIP enrollee is the parent.
  • When a birth certificate is not available to add a dependent child to coverage, a court order indicating the enrollee’s status as the father has been adjudicated by a court or a Voluntary Acknowledgment of Paternity that has been 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.

Stepchild or Child of a Domestic Partner

• Birth Certificate confirming the enrolled spouse or domestic partner is the parent.
  • If the spouse or domestic partner is not currently enrolled in coverage, the enrollee must also provide the required proofs for the spouse or domestic partner.

Adopted Child

• Adoption papers that include the child’s name and list the enrollee as the adoptive parent. 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 pending adoptive parent may be provided.

"Other" Child - an "other" child is defined as any child other than the enrollee’s own child, adopted child, 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 their financial support from the enrollee. Refer to NYSHIP Policy Memo 88r1 for more information.

• Completed NYSHIP Statement of Dependence for "Other" Children (PS-457); and
• Other required proofs listed in PS-457.

Disabled Dependents Age 26 or Older

• NYSHIP Statement of Disability for Dependents (PS-451) approved by the Empire Plan or NYSHIP HMO; and
• Other required proofs listed on PS-451.

Dependent Child with Military Service - dependent children who served in the military prior to age 26 may have their eligibility under NYSHIP extended for a period of time equivalent to their military service, up to four years, if they are enrolled in school full-time.

• Copy of the dependent’s DD-214 Certificate of Release or Discharge from Active Duty; and
• Proof of full-time student status (e.g., a letter from the registrar).
  
  

Timely Submission of Proofs

The date of request and date of event determine the effective date of coverage. Requests to add a dependent to coverage are subject to a late enrollment waiting period unless they are submitted within 30 days of an applicable qualifying event (e.g., marriage, birth of a child, or a dependent’s loss of other coverage). The employee’s signature date on the NYSHIP Health Insurance Transaction Form for NYS & PE Employees (PS-404) or NYSHIP Health Insurance Transaction Form for Participating Agencies (PAs) (PS-503) is considered the "date of request." From the date of request, the employee has an additional 30 days to provide the appropriate dependent proofs to the agency HBA or the Business Services Center (BSC) for the dependent’s enrollment to be effective as of the date of the qualifying event.

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 as the signature date on the newly provided form will be used as the date of request.

Exception for Newborns:

A request to add a newborn child to coverage made within 30 days of the birth should be processed upon submission of a signed PS-404 or PS-503, even if proofs are not available.

The HBA must follow up with the enrollee to obtain required proofs.  If documentation cannot be provided for a newborn child, the HBA should contact EBD for guidance.

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