Department of Civil Service

NY17-05
PE17-03
PA17-04
SEHP17-02
PAEX17-04

TO: Health Benefits Administrators of New York State Agencies
FROM: Employee Benefits Division
SUBJECT: Redesigned Domestic Partner Application
DATE: March 6, 2017

The Employee Benefits Division (EBD) has redesigned its Domestic Partner Application (form PS-425) in an effort to make the application process easier to understand for both enrollees and Health Benefits Administrators (HBA). This new form should be used by all NYSHIP employers, including all participating agencies and participating employers. Please begin to use this form immediately and recycle any printed blank copies you may have in your office. A fillable version of the form is also available online.

Previously, an enrollee who requested to add his or her Domestic Partner to medical, dental, or vision coverage was required to complete a series of three forms (PS-404, PS-425.1. and PS-425.3). Enrollees are now only required to complete a single consolidated form (PS-425). Additionally, the form includes simple instructions that are designed to walk the enrollee though each step of the application process.

EBD has also simplified the documentation requirements. We now ask that enrollees provide one form of proof of cohabitation older than six months, and one form of financial proof that is older than six months. These proofs are used to establish the date the domestic partnership began. Additionally, the enrollee must provide a second form of financial proof from within the last six months to confirm the partnership is still in effect. There is no age limit for the older proofs, and the older financial proof may also be used as proof of cohabitation if a shared residential address is clearly listed.

When calculating the effective date of coverage, the domestic partnership is considered to be in effect as of the earliest documented date that the enrollee and his or her Domestic Partner were both living together and financially interdependent. This date is referred to as the “Partnership Establishment Date.” If the enrollee provides separate proofs of cohabitation and financial interdependence, which confirm the relationship has existed for at least six months, the domestic partnership will be considered “established” as of the date of the more recent proof.

The Domestic Partner becomes an eligible dependent six months after the Partnership Establishment Date. If an enrollee requests Domestic Partner coverage within 30 days of the first eligibility date the dependent is not subject to a late enrollment period. If an enrollee submits his or her request after the 30-day window, a late enrollment period will be imposed.

For example, if an enrollee requests Domestic Partner coverage on October 15 by providing the following documents to their HBA:

• completed and signed Domestic Partner Enrollment Application (PS-425)
• copy of their joint lease dated March 1
• copy of joint auto loan agreement signed April 8 and
• copy of a joint bank account statement dated September 15

The joint lease and joint auto loan agreement serve as proof of cohabitation and financial interdependence, respectively. These proofs, being a minimum of six months old, are used to establish the date the domestic partnership began. The date of the more recent proof, April 8, is considered to be the Partnership Establishment Date. Therefore, the Domestic Partner becomes an eligible dependent on October 8, which is exactly six months after the Partnership Establishment Date. Since the enrollee requested Domestic Partner coverage within 30 days of the first day of eligibility the Domestic Partner may be added effective October 8. The bank account statement from September is simply used to confirm the partnership is still in effect.

If you have questions about the new form or processing a Domestic Partner Enrollment Application, please contact the HBA Helpline at 518-474-2780.