Required Documentation for Contract College Health Plans

In addition to completing the PS-404 enrollment form for medical and/or dental, you must provide documentation to support you and/or your dependent’s eligibility for coverage.

How To Submit Documentation

Send the PS-404 enrollment and supporting documentation to:

HR Services and Transitions Center (HRSTC)
395 Pine Tree Road
East Hill Office Building, Suite 130
Ithaca, New York 14850

Please note: Foreign documentation is accepted if translated by the employee (i.e. marriage certification, birth certificate, divorce decree and death notice).

Documentation Deadlines

HR Services and Transitions Center must receive the required documentation and a completed PS-404 form from the employee within 28 days of the date of hire in a benefits-eligible position, or within 30 days of a qualifying event to enroll in or make changes to contract college health plans.

Medical

Failure to apply within the appropriate 28 days or 30 days will result in a 10-week waiting period from when the required documentation and PS-404 form are received. No coverage is available during the waiting period.

If these deadlines are missed, an employee can make limited changes to the medical plan during the annual option transfer period. Documentation and application(s) are still required during this period.

Dental

Failure to apply within the appropriate 28 days or 30 days will result in a waiting period with coverage effective the first day of the following month from when the required documentation and PS-404 form are received. No coverage is available during the waiting period.

Types of Documentation

Employee (self)

To enroll an employee, NYS requires:

Copy of birth certificate and
- Non-US citizens or US citizens born abroad - if the birth certificate is unavailable, then a copy of the visa and/or passport is accepted
Copy of Social Security card or ITIN (Individual Taxpayer Identification Number)

Spouse

To enroll a spouse, NYS requires:

Copy of birth certificate and
- Non-US citizens or US citizens born abroad - if the birth certificate is unavailable, then a copy of the visa and/or passport is accepted
Copy of marriage certificate, and
If the marriage took place over one year ago, proof of a current joint ownership/finances that lists both you and your spouse must be provided, such as:
- your prior year joint tax return,
- copy of your most current bank statement,
- or a copy of your most recent mortgage statement or homeowner’s policy.

Domestic Partner

To enroll a domestic partner, NYS requires:

Copy of birth certificate and
- Non-US citizens or US citizens born abroad - if the birth certificate is unavailable, then a copy of the visa and/or passport is accepted
Completed forms in the Domestic Partner Series (PS-425) with acceptable proofs as required in the application.

Children

To enroll natural, adopted, or stepchildren, NYS requires:

Copy of birth certificate required.
If adding a newborn, the footprint page from the hospital may be used temporarily to enroll the child. If footprints are provided for a newborn, a copy of the birth certificate must be submitted within 60 days of the birth of a child.
If applicable, a court order confirming custody for adopted dependent(s).
If applicable, proof of disability (a completed PS-451 – Statement of Disability).

To enroll "Other" children, NYS requires:

Copy of birth certificate required.
If adding a newborn, the footprint page from the hospital may be used temporarily to enroll the child. If footprints are provided for a newborn, a copy of the birth certificate must be submitted within 60 days of the birth of a child.
If applicable, proof of disability (a completed PS-451 – Statement of Disability).
Required residence and support (a completed PS-457 - Statement of Dependence).

Paternity

When adding a natural or stepchild to your plan, the New York State Department of Civil Service requires documentation to establish paternity when a father is not married to a child’s mother and/or the father’s name is not listed on the child’s birth certificate. In these scenarios, the father is required to produce one of the following documents to add the child to NYSHIP coverage:

The child’s birth certificate noting their status as the father;
A court order noting that their status as the father has been adjudicated by a court;
A voluntary acknowledgment of Paternity that has been executed and filed with the County Registrar of the county in which the child was born (all states have a paternity acknowledgment process; if the child was born in another state, the enrollee may produce a filed Voluntary Acknowledgment of the Paternity from the other state.)

Additional Documentation

This summary does not account for all enrollment situations. Depending on the circumstances, additional documentation may be required to support a dependent's eligibility.

While every attempt has been made to ensure the accuracy of this Summary, in the event of any discrepency the Summary Plan Description and Plan Document will prevail.

Contract College