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
NY20-26
PE20-23
PA20-17
SEHP20-11
PAEX20-15
TO: Health Benefit Administrators of NYS Agencies, PAs, and PEs
FROM: Employee Benefits Division
SUBJECT: Revised Form PS-452, Application for Waiver of Empire Plan Premium
DATE: November 30, 2020
The Employee Benefits Division (EBD) has revised form PS-452, Application for Waiver of Empire Plan Premium. Effective immediately, please discontinue use of all prior PS-452 forms, including all forms bearing the previous name Application for Waiver of Premium. 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:
- Elimination of minimum disability period requirement (six bi-weekly payroll periods for bi-weekly groups or three-months for monthly groups)
- Bi-weekly groups: the enrollee is no longer required to have been totally disabled for six bi-weekly payroll periods before a waiver may take effect.
- Monthly groups: the enrollee is no longer required to have been totally disabled for a minimum of three-months before a waiver may take effect.
- Updated form title – Renamed Application for Waiver of Empire Plan Premium for consistency and clarity.
- Added Eligibility Requirements to Form – Clarified that only Empire Plan enrollees are eligible and outlined eligibility requirements.
- Instructions to the enrollee have been updated
- Outlined instructions with more detail and information about when an enrollee may apply
- Added What’s Next to guide the enrollee through the process
- Added checkbox to determine if enrollee is applying for a new waiver or an additional waiver
- Added Personal Privacy Law and HIPAA language
- Section headers
- Removed lettered section labels and replaced with titles and brief instructions
- Employing Agency no longer has a section to complete
The revisions to form PS-452 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 process more understandable and easier for enrollees.
For more information regarding Waiver of Empire Plan Premium, 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.