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: To enroll in the Opt-out program if you already have alternative employer-sponsored health insurance.
: Provides a direct PDF download of the PS-409 Health Benefits Opt-Out Election. Submission Details
: This is often submitted alongside the PS-404 Health Insurance Transaction Form to declare your change in coverage status.
You can download the directly from official New York State resources. This form is used by eligible employees to officially opt out of the New York State Health Insurance Program (NYSHIP) in exchange for a taxable payment ($1,000 for Individual or $3,000 for Family coverage). Download Links
: Access the most current version of the PS-409 and related transaction forms like the PS-404 .
: You must provide proof of other employer-sponsored coverage to qualify for the incentive payment. Benefits Forms - Business Services Center
: To enroll in the Opt-out program if you already have alternative employer-sponsored health insurance.
: Provides a direct PDF download of the PS-409 Health Benefits Opt-Out Election. Submission Details
: This is often submitted alongside the PS-404 Health Insurance Transaction Form to declare your change in coverage status.
You can download the directly from official New York State resources. This form is used by eligible employees to officially opt out of the New York State Health Insurance Program (NYSHIP) in exchange for a taxable payment ($1,000 for Individual or $3,000 for Family coverage). Download Links
: Access the most current version of the PS-409 and related transaction forms like the PS-404 .
: You must provide proof of other employer-sponsored coverage to qualify for the incentive payment. Benefits Forms - Business Services Center