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
Commissioner
PA20-15
TO: Participating Agency Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: Revised Form PS-451, NYSHIP Statement of Disability for Dependents
DATE: September 15, 2020
The Employee Benefits Division (EBD) has revised form PS-451, NYSHIP Statement of Disability for Dependents. Effective immediately, please discontinue use of all prior PS-451 forms, including all forms bearing the previous name, Statement of Disability Dependent 19 Years or Older. The new version of this form is attached to this memo and posted to the Publications & Forms section of HBA Online.
Brief Overview of Changes:
- Updated form title – Renamed NYSHIP Statement of Disability for Dependents for consistency and clarity.
- Instructions to the enrollee have been updated – Removed redundant text and identified the requirements more clearly.
- Removed Part B HBA section – HBAs are no longer required to sign off on this form.
- Section headers – Removed lettered section labels and replaced with titles and brief instructions.
- Updated physician instructions – New language from UnitedHealthcare is being used.
- Plan Administrator (formerly Insurer) portion moved – Now shares the same page as enrollee information (replaced the previous Part B HBA section), so the physician portion has its own separate page.
- Added Fields
- Enrollee SSN under Enrollee Information
- Disability certified through date in Plan Administrator Portion
- Removed fields
- Relationship to enrollee
- Permanent residence with the enrollee
- Permanently Disabled (reviewed every 7 years at minimum)
The revisions to form PS-451 are intended to make the form more comprehensive and user friendly by clarifying instructions and simplifying eligibility requirement language. These changes were done to make the application more understandable and easier for enrollees to submit as well as easier for EBD staff to review. The substantive eligibility requirements and process to (re)certify disabled dependent children have not changed.
As a reminder, enrollees must still submit a completed Health Insurance Transaction form (PS-503) when adding or recertifying a dependent. For an “other” child, a completed Statement of Dependence for “Other” Children form (PS-457) and any required proofs must also be maintained on file. Two months prior to the disabled dependent child’s recertification date in NYBEAS, EBD will send a letter notifying the enrollee they are required to recertify their disabled dependent.
For more information regarding disabled 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 questions after reviewing this memo and the HBA Manual, 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.