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.
KATHY HOCHUL
Governor
TIMOTHY R. HOGUES
Commissioner
NY25-04
PE25-04
PA25-04
SEHP25-01
TO: All Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Updated PS-457 Form for NYSHIP Dependent Enrollment or Recertification
DATE: March 5, 2025
This memo advises of changes made to the PS-457, Enrollment or Recertification of an “Other” Child as a NYSHIP Dependent Form, previously referred to as NYSHIP Statement of Dependence for “Other” Children. Please begin using this version immediately.
In addition to this form name and branding being updated, please note new clarifications regarding appropriate proof accepted to verify the enrollee provides at least 50% financial support of the dependent. Only the following will be accepted:
- A signed and completed copy of the most recently filed federal tax return claiming the “other” child as a dependent. There must be a signature; you can only accept if all pages are submitted (monetary amounts may be blacked out for privacy purposes).
- A letter from a licensed CPA (Certified Public Accountant) or an attorney, confirming that the enrollee can claim the dependent on their current federal tax return; letters from a general tax preparer or tax preparation service cannot be accepted.
- A court order proving legal guardianship. Notarized letters from a parent cannot be accepted as this is not considered legal guardianship.
The enrollee must check all three boxes under the enrollee statement. If any box is left unchecked, the child cannot be added to coverage or recertified.
If you have questions about this memo, contact the HBA Helpline at 518-474-2780.