3-Month Extension Of Health Insurance Coverage For Dependent Students

Unmarried dependent full time students, between the ages of 19-25 may continue health insurance coverage up to 3 months upon the successful completion of a semester or as a graduating dependent student.

The enrollee must be able to provide verification of the dependent's graduation or verification of successful completion of classes for the semester. "Successful completion" means that the student attended classes through the last scheduled date of classes of the semester.

Dependent student's who withdraw from school after classes have begun for the semester, must provide documentation of the date of withdrawal of classes. Coverage ends on the last day of the month in which the dependent attended classes as a full-time student.

The dependent student will have 60 days following the last day of the three-month extension of benefits to apply to the Employee Benefits Division for COBRA continuation (Consolidated Omnibus Budget Reconciliation Act).

NOTE: The three month extension is not available to dependents whose eligibility has been extended beyond age 25 due to military service.

Procedure For Applying For A 3-Month Extension Of Health Insurance Coverage For Dependent Students:

  1. You must complete a New York State Health Insurance Transaction Form (PS 404) and submit a letter from the school verifying your dependent has graduated, the date classes ended and the graduation date. If dependent is not graduating, verify the last date of classes upon the successful completion of a semester.
  2. The PS 404 Form: Complete the PS 404 form so that your dependent can be removed from your health insurance file at the end of the 3-month extension. Please complete Employee Information, numbers 1 through 8; Section G, Dependent Information, check D to delete your dependent from your file; and on the back of the form, under Authorization, please sign and date the form. FAILURE TO REMOVE YOUR DEPENDENT FROM YOUR HEALTH INSURANCE FILE WILL PREVENT COBRA COVERAGE FOR YOUR DEPENDENT.
  3. The completed PS 404 form and verification of graduation letter must be returned to:

    Human Resource Services - Benefits Office
    Stony Brook University
    390 Administration Building
    Stony Brook, New York
    11794-0751
  4. You have 60 days from the end date of your dependent?s coverage to apply for COBRA coverage. The Employee Benefits Division will automatically send a COBRA application to your home address at the end of the 3 month extension.
  5. You may obtain the PS 404 form on the HRS website www.stonybrook.edu/hr, follow the link to "Forms and Publications" and click on "Benefits", then New York State Health Insurance Transaction Form (Non-Student Employees).

If you have questions, please call the Benefits Office at (631) 632-6180.