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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 (NYS), Participating Employer (PE), Participating Agency (PA), and Student Employee Health Plan (SEHP) Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Release of Revised Domestic Partner Enrollment Application Form PS-425
DATE: December 19, 2019

The Employee Benefits Division (EBD) has updated the Domestic Partner Enrollment Application Form (PS-425). Effective immediately, please discontinue use of all prior PS-425, PS-427, PS-427.1, PS-427.3, and PS-427.4 Forms for Domestic Partner enrollment, dependent tax affidavits, and termination of domestic partnership.
NYS Agencies, PEs, and PAs will now all use the PS-425, PS 425.3, and PS-425.4 Forms for Domestic Partner enrollment, dependent tax affidavits, and termination of domestic partnership.

Brief Overview of Changes:
Combined PS-425 Series for NYS, PE, and PA Agencies: The Domestic Partner application has been consolidated under one form to be used by all NYS, PE, and PA employees and retirees.

Additional Medicare Information: The Form now includes fields where the enrollee can provide the Medicare Card Number (Medicare Beneficiary Identifier, or MBI) and enrollment dates for Medicare Part A and Part B for their Domestic Partner.

Enrolling Children of a Domestic Partner: A reminder has been added that enrollees must submit a PS-404 or PS-503 to add their Domestic Partner’s child(ren).

Clarify Section A: Language has been added to Section A to clarify the proofs that must be submitted in the event either Domestic Partner has been previously married.

Inclusive Language: EBD revised the language in Section A of the Form to read “they/their” instead of “his/her” to encompass gender-neutral language.

Clarified “Acceptable Proofs”: The list of acceptable proofs in Section B of the Form has been revised and updated for clarity.

Updated Personal Privacy Protection Law Notification: EBD updated the phone number to contact for more information about the Personal Privacy Protection Law.

“How to Apply” section: EBD has revised and expanded the “How to Apply” section on page 4 to clarify what required proofs must be submitted with the application.

New PS-425 Instructions: The new combined PS-425 Form instructs enrollees where to submit their application and proofs depending on their work status and the type of employer they work for or retired from. Instructions can be found on page 4 under the section “Where to Submit Your Application and Proofs”.

Revised Imputed Income Information: EBD has revised the information on page 6 regarding the assessment of imputed income to include how imputed income will be reported to the IRS for non-federally-qualified dependents according to the enrollee’s work status and the type of employer they work for or retired from.

When Domestic Partner Coverage Begins: The Form now includes information on the effective dates of coverage when adding a Domestic Partner for PA and PE active employees and retirees.

If you have any questions, please contact the HBA Help Line at 518-474-2780; representatives are available between the hours of 9:00 am to 4:00 pm, Monday through Friday.