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The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.

New York State of Opportunity

Acting Commissioner


TO: New York State Agency Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: Release of Revised Health Insurance Transaction Form PS-404
DATE: January 24, 2018

The Employee Benefits Division (EBD) has updated the Health Insurance Transaction Form (PS-404). Effective immediately, discontinue use of all prior PS-404 forms and destroy copies of outdated forms maintained in your office. The most current PS-404 can be found on HBA Online as well as the Civil Service website. 

Brief Overview of Changes:

Combined PS-404 for NYS and PEs: The updates to the PS-404 eliminates form duplication for NYS agencies and Participating Employers (PE). 

Streamlined PS-404 Instructions: EBD has simplified the PS-404 instructions. Certain information, that was already addressed in enrollee publications, such as the General Information Book, Planning for Option Transfer and Choices, was removed and enrollees are directed to review the information in these publications.

Permanent Address and Mailing Address: EBD revised the form to include a permanent address and mailing address, in order to accommodate enrollees who may receive mail at a different location than their physical address. This is important because a P.O. Box address alone is not a valid address to ensure enrollment in Medicare or a NYSHIP HMO. If the enrollee uses a P.O. Box, a physical address must be provided. NOTE: For NYBEAS processing, use the Address Type of “Home” to indicate the address where the enrollee receives their mail. Use the Address Type of “Permanent” to list the physical residence, only when different from the mailing address.

More Effective Layout: The PS-404 was restructured based upon the frequency of enrollee requests. Enrolling in NYSHIP or changing a NYSHIP option was grouped together on the front of the PS-404 and Dependent Information and Annual Option Transfer information was placed on the back.

Retirement and Leave Sections Removed: EBD eliminated little used or incorrectly used Retirement and Leave sections on the PS-404. 

Please refer to the guidance below regarding the elimination of the “Leave of Absence” and “Retirement” sections with the new PS-404. 

How does an Enrollee continue, change or cancel coverage into Retirement? 

  • Enrollees who meet the requirements for continuing health insurance under NYSHIP are not required to sign a PS-404.  Enrollees should only complete the PS-404 at the time of retirement when; canceling their coverage voluntarily, making changes to/from family coverage, or changing their plan option.
  • Enrollees Deferring their Retiree coverage, should complete a PS-406.2 “Deferred Health Insurance for Retirees”. 

Employee changes made at the time of Retirement should be forwarded to EBD for processing after the enrollee’s Retirement has been posted to NYBEAS. 

How does an Enrollee Cancel or Suspend Coverage while on a Leave of Absence?

  • Enrollees going on a Leave of Absence who wish to Cancel their coverage, should complete the PS-404, Box #12B.  They should indicate, “Suspend coverage while on Leave” in the “Qualifying Event” portion if they wish their coverage to resume upon returning to the payroll.  Or, they should indicate “Cancel Coverage” in the “Qualifying Event” portion on the form if they wish to permanently cancel their coverage.  Their coverage will not resume when they return to the payroll. 

 If you have any questions, please contact the HBA Help Line at 518-474-2780 from 9:00 am to 4:00 pm.