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
NY21-05
PE21-03
TO: New York State Agency Health Benefit Administrators Health Benefits Administrators of Participating Employers
FROM: Employee Benefits Division
SUBJECT: Revised Form PS-404, Health Insurance Transaction Form for NYS & PE Employees
DATE: March 25, 2021
The Employee Benefits Division has revised form PS-404, Health Insurance Transaction Form for NYS & PE Employees. Please discontinue use of all prior PS-404 forms. The new version of the form is attached to this memo and available under the Publications & Forms tab of on HBA Online, as well as NYSHIP Online under the Forms tab.
What’s New:
- Updated form title – Now Health Insurance Transaction Form for NYS & PE Employees.
- Added field
- Personal Email Address
The new PS-404 form includes an additional field under the “Employee Information” section to enter an enrollee’s Personal Email Address, listed as item number 9. The change was made in an effort to move towards paperless communication and is especially important for people with limited access to agencies and facilities. This will allow HBAs and EBD to maintain an additional electronic mode of contact with enrollees.
Personal email addresses should be collected or confirmed whenever an enrollee makes changes to their account using this form. It is the HBA’s responsibility to update NYBEAS with this information and keep the file current. This information should be updated for all enrollees, if possible.
You may add multiple email addresses and categorize based on what kind of email is being included. If you do include more than one email, indicate the enrollee’s preferred account to be used.
For more information 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.
Attachments:
PS-404 Health Insurance Transaction Form for NYS & PE Employees
PS-404 Health Insurance Transaction Form for NYS & PE Employees, Instructions for NYBEAS processing