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.
GOVERNOR
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
COMMISSIONER
DANIEL E. WALL
EXECUTIVE
DEPUTY COMISSIONER
PA03-02
TO: Participating Agency Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: New Health Form PS 503.1
DATE: January 10, 2003
This memo is to advise you of the new PA Health Insurance Transaction Form PS-503.1(10/02). A duplicating master of this form is included with this memo. The new form can also be downloaded from the HBA web site at www.cs.state.ny.us/ebdonline. The October 2002 version of the form should be used for all transactions and will take the place of the previous carbon-set format of the PS-503.1. Any remaining stock of the old form should be discarded.
Outlined below are the changes in the PS-503.1, with the corresponding section numbers:
Sect. 8 – Marital Status date (must be completed if status is anything other than single)
Sect. 9 – Medicare information (only used when Medicare is primary)
Sect. 10 C – Declination of Benefits
Sect. 10 F - Change of Coverage (reasons now listed)
Sect. 10 G – More detailed information for dependents and field for the dependent’s social Security numbers
Sect. 10 H – Pension deduction rate of contribution and change to retiree payment status
Sect. 12 - Leave Without Pay and Retirement/Vestee information
Sect. 13 - Card request information
Located on the second page in the Agency/EBD Use Only section is the Action/Reason field, formerly the txn code, and the Retirement Tier. In the Action/Reason field you should use the same codes that you would use when entering transactions on NYBEAS (ex: ENR/REG, CCO/VOL, DEP/ADD, CAN/VOL). Non-NYBEAS agencies can continue to use the transaction codes found in the Pink section of the Participating Agency Manual of Procedures when completing this section.
Agencies that submit transactions to the Employee Benefits Division for processing should include a completed PS-516, Transaction Transmittal Form for Participating Agencies, when sending transactions to the Department of Civil Service. A duplicating master of this form is attached for your use.
If you have any questions/problems completing this form, contact the PA Operations Unit:
Gail Schultz 518-485-6619
Theresa Bartlett 518-457-5847
Darci Jo Riddle 518-457-5766
Jessica Dougrey 518-485-6618