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.
ANDREW M. CUOMO
Governor
LOLA W. BRABHAM
Acting Commissioner
NY20-07
PE20-04
PA20-04
SEHP20-03
PAEX20-04
TO: All Health Benefits Administrators (HBA)
FROM: Employee Benefits Division
SUBJECT: Revised Form PS-457, NYSHIP Statement of Dependence for "Other" Children
DATE: April 30, 2020
The Employee Benefits Division (EBD) has revised form PS-457, NYSHIP Statement of Dependence for “Other” Children. Effective immediately, please discontinue use of all prior PS-457 forms, including all forms bearing the previous name, Statement of Dependence for Participation in the Health Insurance Program. The new version of the form is available on HBA Online at: https://www.cs.ny.gov/forms/ps457.pdf
The substantive eligibility requirements for “other” children have not changed. “Other” children, a class which includes any child who is not the enrollee’s own natural-born child, step-child, adopted child, or child of the enrollee’s domestic partner, must live with the enrollee and receive at least 50% of their financial support from the enrollee to be eligible.
The revisions to form PS-457 are intended to make the form more user friendly by clarifying eligibility and documentary requirements. Most notably, EBD has eliminated questions on the form that were not relevant to the eligibility determination process. Additionally, enrollees are now asked to submit proof of residence, rather than proof of financial support, for “other” children age 19 and older. However, the eligibility requirements have not changed. EBD has also reworded the question regarding the duration of the “other” child’s status, as previous verbiage often resulted in vague or unclear responses from enrollees. All of these changes were done in an effort to make the application easier for enrollees to submit and easier for HBAs and EBD staff to review.
As a reminder, enrollees must still submit a completed Health Insurance Transaction form (PS-404 or PS-503) when adding or recertifying a dependent.
For more information regarding “Other” children, including eligibility requirements, please refer to your NYSHIP General Information Book or the HBA Manual for your group: https://www.cs.ny.gov/employee-benefits/hba/manual/
If you have any further 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.