Dependent Verification PO Box IRVING, TX FAX:

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1 Dependent Verification PO Box IRVING, TX July 5, 2016 Enrollee Name Street Street2 City, St, Zip Dear NYSHIP enrollee, PC or Mobile Upload: FAX: Go green at REFERENCE NUMBER: EID RESPOND BY: AUGUST 19, 2016 The New York State Health Insurance Program (NYSHIP) has contracted with the independent firm, HMS Employer Solutions (HMS), to verify that dependents enrolled in NYSHIP meet the Program s eligibility requirements. In order for your dependent(s) to continue to receive benefits under NYSHIP, your action is required. You must submit proof of their eligibility to HMS so that it is received by August 19, As a reminder, eligible dependents are defined in the NYSHIP General Information Book as: Your spouse, including a legally separated spouse. *Note: If you are divorced or your marriage has been annulled, your former spouse is not eligible, even if a court orders you to maintain coverage. Your domestic partner if you are both 18 years or older; have been in the partnership for at least six months; are both unmarried; are not related in a way that would bar marriage; have shared the same residence and have been financially interdependent for at least six months; and have an exclusive mutual commitment (which you expect to last indefinitely) to share responsibility for each other s welfare and financial obligations. Your child up to age 26. Coverage may be extended past the age of 26 if the child is incapable of selfsupport by reason of mental or physical disability; is unmarried; and was incapacitated before the age at which dependent coverage would otherwise be terminated. Coverage may also be extended past the age of 26 for an unmarried child who is a full time student, had four years of service in a branch of the U.S. Military between the ages of 19 and 25 and is not eligible for other employer group coverage. Up to four (4) years of military service may be deducted from the child s age until the adjusted eligibility age equals 26. A child is defined as your natural child; stepchild; child of your domestic partner; legally adopted child, including a child in a waiting period prior to finalization of adoption; or your other child. An other child must be chiefly dependent upon you; reside with you; and be a child for whom you have assumed legal responsibility in place of the parent. The other child must have met the above requirements before age 19. A detailed list of documents required to prove eligibility of your dependent(s) can be found on the reverse side of this letter. Copies of the documents and the enclosed Verification Form must be received by HMS by AUGUST 19, If after reading the attached Frequently Asked Questions (FAQ) you still have questions, please feel free to call HMS at from 8am to 11pm Eastern Time, Monday through Friday. Thank you for your cooperation with this important effort to control health care plan costs. Para asistencia en español, por favor comuníquese con HMS Employer Solutions al (over)

2 REQUIRED DOCUMENTS All required documents MUST contain the date (including year), enrollee name, and dependent's name. Personal information such as Social Security Numbers, account numbers, and financial information should be marked out for confidentiality. FOR SPOUSE: A copy of your marriage certificate AND one of the following: A copy of the front page of your most recently filed 2015 federal tax return (form 1040) confirming this dependent is your spouse A document dated within the last 60 days showing current joint financial responsibility such as a recurring monthly household bill or statement of account. The document must list your spouse's name, the date and your mailing address. Note: Health care bills will not be accepted as proof of eligibility as health care coverage is being verified. FOR DOMESTIC PARTNER: A copy of the Affidavit of Domestic Partnership PS (available on AND copies of two (2) proofs of joint responsibility for basic financial obligations dated within the last six (6) months. See PS for acceptable proofs required from lists A and B. AND a copy of one (1) proof of cohabitation dated within the last six (6) months. The proof must specify the residential address. A PO Box or other mailing only address will not be accepted. See PS for acceptable proofs. FOR CHILDREN UP TO AGE 26 AND DISABLED CHILDREN: A copy of the child s birth certificate, hospital birth record, or adoption certificate naming you or your spouse as the child's parent FOR OTHER CHILDREN: A copy of the Statement of Dependence PS 457 form (available on AND A copy of your claiming this child as a dependent OR if you do not claim the dependent, a letter from a CPA or an attorney stating that the dependent could be claimed on your tax return under current IRS regulations if you chose to do so. A document showing current residency such as a statement of account (such as a bank statement or investment statement) or school or daycare paperwork. The document must list the child s name, a date within 6 months and your mailing address. FOR MILITARY DEPENDENTS: A copy of the child s birth certificate, hospital birth record, or adoption certificate naming you or your spouse as the child's parent AND A copy of the schedule indicating full time status in an accredited educational institution. Please note: The schedule must list the student s name, the name of the institution, a 2016 term and indicate fulltime status. Note for Stepchild: If you are covering a stepchild, you must also provide documentation of your current relationship to the child s parent as requested above.

3 Verification Form Return this form with the required documentation Name: Enrollee name Reference Number: EID PC or Mobile Upload: FAX: According to our records, the following dependent(s) require verification at this time: Does this person meet the definition of an eligible dependent? Enrolled Dependent Name Relationship YES NO dep_1 dep_2 dep_3 If not eligible, please indicate the date of ineligibility. For dependents that do not meet the definition of an eligible dependent, no documentation is required and the ineligible dependent will be removed from all health care coverage retroactively to January 1, ** Please note that due to federal regulations, dependents covered under a NYSHIP Medicare plan will be removed from coverage on a prospective basis by the Department of Civil Service as soon as administratively possible. ** To complete the verification process for eligible dependents, simply follow these steps: Collect copies of all required documents (listed on page 2) for each enrolled dependent. Sign and date the signature box below. Submit this form together with copies of all required documents to HMS Employer Solutions so they are received by August 19, Please ensure a copy of this form is included with all documents submitted. For faster processing, please submit required documents by uploading them via the web portal, or by faxing them to If the web and fax are unavailable to you, documents may be mailed to HMS Employer Solutions, P.O. Box , Irving, TX Please do not mail original documents. By my signature on this form, I certify to NYSHIP that (1) all information on this form is true, correct, and current as of the date signed and (2) all REQUIRED DOCUMENTS that are submitted are authentic. I understand any attempt to maintain coverage for an ineligible dependent will be subject to appropriate disciplinary action. Signature of Enrollee: Date:

4 PLEASE RETAIN THIS FAQ FOR YOUR REFERENCE Please submit ALL REQUIRED DOCUMENTS AND SIGNED VERIFICATION FORM so they are received by August 19, 2016 using any of the following methods (we recommend the first two for faster processing): Visit and upload your documents using a computer or mobile device. Submit your documents 24 hours a day, 7 days a week via our toll-free fax at Submit your documents (do not send original documents) via mail to: HMS Employer Solutions, P.O. Box , Irving, TX This checklist will help you complete the verification process: Keep your reference number throughout the review in order to check your status online at Include a COPY of the Verification Form with ALL documents submitted. Ensure each document is a LEGIBLE BLACK and WHITE COPY of the document. Please note: documents submitted to HMS will not be returned. When mailing paper documents DO NOT STAPLE or HIGHLIGHT. FREQUENTLY ASKED QUESTIONS Q1. Why is the New York State Health Insurance Program (NYSHIP) conducting a Dependent Eligibility Verification Audit? The NYSHIP is sensitive to the rising costs of health care for its enrollees and feels this verification audit is necessary to help make sure its health benefit plans are compliant with state law, competitive, and cost effective. The verification audit was included in the Fiscal Year 2016 Enacted New York State Budget and will help NYSHIP manage overall plan costs, which benefits all enrollees. Q2. Who is HMS Employer Solutions (HMS)? HMS Employer Solutions is an independent third party cost containment company with whom NYSHIP has contracted with to verify the eligibility of dependents covered under its health benefit plans. HMS specializes in verifying health plan eligibility and has reviewed verification documentation for millions of dependents for some of the largest public and private employers in the United States. Q3. The documentation required contains sensitive information. Is this process secure? Protecting personal information is a priority to NYSHIP and HMS. In compliance with applicable U.S. (federal) and state regulations, information and documentation submitted to HMS for the Dependent Eligibility Verification Audit is stored, processed, and protected by physical, electronic, and procedural safeguards. When submitting your tax documentation, only the top portion which includes the names of the enrollee, spouse, and any dependent child(ren) is required. Please mark out Social Security Numbers, as well as any income information. All documents are securely stored for six months following completion of the verification audit. Upon expiration of the retention period, all documents and electronic files will be securely destroyed by HMS, and a Certificate of Destruction will be supplied to NYSHIP. Please note that documents submitted to HMS will NOT be returned. HMS meets all of the professional and legal standards associated with providing service to employers, including the Health Insurance Portability and Accountability Act (HIPAA), Employee Retirement Income Security Act (ERISA), and disposal rules as enforced by the Federal Trade Commission. In addition, every employee of HMS submits to a thorough and multi tiered background check. Only HMS employees directly involved in the NYSHIP Dependent Eligibility Verification Audit will have access to these documents.

5 Q4. Do I need to send original documents? No. Please do not send your original documents; a copy is sufficient. If the document is two sided or has multiple pages, ensure you copy all pages and both sides of the paper. Q5. Where do I go for more information regarding the Dependent Eligibility Verification Audit or to find out where I can obtain copies of the documents I need? Visit us online at for details regarding the audit, tools to assist you in locating and submitting your documentation, and more. This secure site is compatible with your mobile device. Q6. How will I know if my information has been accepted and my dependents are verified? Once your documentation has been received by HMS, you may check the status of each of your dependents by logging on to In addition, you will receive written communication indicating that you have completed the dependent verification process or if additional information is needed. Ultimately, it is your responsibility to ensure that your documents were successfully received. Q7. What happens if I do not submit all required documents by the verification deadline? If you do not submit complete documentation for your dependents by the deadline, or if you knowingly submit false information for enrolled dependents, one or all of the following actions may occur: The affected dependent(s) for whom complete documentation has not been submitted will be removed from coverage retroactively to January 1, Please note that due to federal regulations, dependents covered under a NYSHIP Medicare plan will be removed from coverage on a prospective basis by the Department of Civil Service as soon as administratively possible. NYSHIP may seek to recover claims paid during the period that the ineligible dependent was covered. NYSHIP is ultimately responsible for determining how best to handle each individual case. Q8. May I provide my documents to my Health Benefits Administrator (HBA), Human Resources Department or the New York State Department of Civil Service Employee Benefits Division (EBD)? No. HBAs, Human Resources, or EBD will not be able to forward your documents to HMS or provide enrollees with copies of previously submitted documents. The only way to ensure that all documents are logged appropriately and the eligibility of your dependents is verified is to submit your supporting documentation to HMS. Please do not call EBD with questions or for assistance with the verification audit, as this is an independent review. If you have questions, you should call (866) Monday Friday, 8am 11pm ET. Q9. Can an exception be granted to allow my ineligible dependent to stay covered? No. Only dependents that currently satisfy the plan s eligibility definition can remain covered. If the dependent is no longer eligible because of a recent qualifying event, (e.g., divorce, child reaches age limit), see your HBA or Human Resources representative for Consolidated Omnibus Budget Reconciliation Act (COBRA) details. Requests for COBRA must be submitted within 60 days of a COBRA qualifying event. Q10. I prefer communications rather than mailed letters. Can I elect to receive follow up communications about the verification process through instead? Yes. To go green and receive all future communications electronically, please go to the My Account tab at and enter your address in the My Information section. Once you validate your address as correct, you will be prompted to log back into the site where you may then click on the Enable Paperless button to activate electronic communications.

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