Forms and publications

Below you will find manuals, user guides, and resources related to the PAY1 insurance system, the Benefits 24/7 online enrollment system, accounting, correcting employer errors, appeals, and HCA Support. Employee enrollment resources, such as guides and forms, certification forms for dependents, and many other resources are also available to download.

When printing forms to share with employees, also provide the PEBB nondiscrimination statement and language access notice.

PAY1 insurance system

PAY1 manuals and resources

The following resources are for benefits administrators (BAs).

• Pay1 access and password assistance
• Manuals for state agencies and full-benefits employer groups:
  • Chapter 1: Introduction to the PAY1 System
  • Chapter 2: Enroll, Waive, Plan Changes, Dual Enrollment
  • Chapter 3: Termination, Reinstatement, and Transfers
  • Chapter 4: Termination, Reinstatement, and Transfers
  • Updating salaries for LTD in PAY1 (For employer groups only, not state agencies.)
• Manuals for higher education and medical-only employer groups:
  • Chapter 1: Introduction to the PAY1 System
  • Chapter 2: Enroll, Waive, Plan Changes, Dual Enrollment
  • Chapter 3: Termination, Reinstatement, and Transfers
• Dependent enrollment and verification instructions
• PAY1 codes and fields:
  • Medical and dental plan codes
  • Enrollment and termination reason codes
  • Life insurance fields on A.41 screen
  • Codes for all countries
• First working day of the month/effective date of coverage table 2023 | 2024
• Lower limit calendar 2023 | 2024
  • PEBB Policy 19-1A: Termination due to loss of eligibility or enrollment error 2023 | 2024
• State share cutoff dates for state agencies 2023 (2024 state share dates can be found in the 2024 accounting manual.)
  • State share keying instructions 2023

For employer groups who do not enter enrollment in PAY1: 

• Processes and procedures manual

• Insurance Eligibility Adjustment Form 

These resources can also be found on the PAY1 insurance system webpage.

Benefits 24/7

Benefits 24/7 manuals and resources

The Benefits 24/7 online enrollment system will not be available until launch, which is anticipated to occur in January 2024. However, the Benefits 24/7 training environment is currently available.

The following resources are for benefits administrators (BAs).

• Benefits 24/7 (Login is not available until launch in January 2024)
• Benefits 24/7 manuals
  • Chapter 1: Introduction to Benefits 24/7
  • Chapter 2: Managing Benefits 24/7
  • Chapter 3: Managing employee accounts
• Benefits 24/7 FAQ
• First working day of the month/effective date of coverage table 2023 | 2024
• Lower limit calendar 2023 | 2024
  • PEBB Policy 19-1A: Termination due to loss of eligibility or enrollment error 2023 | 2024

Benefits 24/7 training environment: 

• Benefits 24/7 training environment
• Benefits 24/7 training environment login user guide

For employer groups who do not enter enrollment in the insurance system:

• Insurance Eligibility Adjustment Form

Learn more on the Administering PEBB in Benefits 24/7 webpage.

Accounting

Accounting manuals and resources

The accounting manuals contain the current year's invoicing dates along with other accounting-related guidance. The accounting manual for state agencies also contains the state share cutoff dates. 

• Accounting manuals:
  • State agencies 2023 | 2024
  • Institutions of higher education 2023 | 2024
  • PEBB participating employer groups 2023 | 2024
• 2024 billing/invoicing dates (and state share dates for state agencies) can be found in the accounting manual for your employer type.
  • 2023 Billing file schedule for institutions of higher education
  • 2023 Invoice dates for all other employer types
  • 2023 State share cutoff dates (dates not to key for state agencies)
    • 2023 State share keying instructions
• 2023 State payroll reconciliation resources (PEBB accounting/OFM/HRMS)
• Lower limit calendar 2023 | 2024

These resources can also be found on the Accounting webpage.

Correcting PEBB employer errors

Correction resources for state agencies and institutions of higher education

• Correcting employer errors webpage
• Failure to enroll accurately
• Failure to enroll in default coverage
• Failure to timely notify newly eligible employee

Correction resources for employer groups

• Correcting employer group errors webpage

Appeals

Appeals resources for state agencies and institutions of higher education

• PEBB Appeals process map
• Employee Request for Review/Notice of Appeal form
• Authorization for Release of Information

Learn more on the Appeals process webpage.

Appeals resources for employer groups

• Appeals process for employer groups webpage

HCA Support

HCA Support is a secure, web-based correspondence program that allows you to send documents and communicate directly with O&T, PEBB Accounting, and other departments within the PEBB Program by using the ​​​​designated tile named, "Benefits administrator inquiry".

HCA Support resources

It's important that BAs use the designated tile named, "Benefits administrator inquiry". Using the "General Support" tile will lead to a delayed response, as your inquiry will be initially routed to units at HCA that are outside of O&T.

• HCA Support
  • HCA Support user guide

Employees and dependents

Enrollment guide, forms, and resources

• Employee Enrollment Guide 2023 | 2024
• Employee Enrollment/Change form 2023 | 2024
• Employee Enrollment/Change form - medical only 2023 | 2024
• LTD Enrollment/Change form
• MetLife Enrollment/Change form (for electing supplemental life and AD&D insurance and adding beneficiaries)
  • MetLife Beneficiary Designation form (for adding or updating beneficiaries only)
• FSA and DCAP Midyear Enrollment form 2023
• 2024 FSA and DCAP Open Enrollment form

Learn more on the Newly eligible employees webpage.

Dependent forms and resources

• Dependent enrollment and verification instructions
• Declaration of Tax Status form 2023 | 2024
• Extended Dependent Certification form
• Certification of a Child with a Disability form
• PEBB Policy 31-1: Dependent verification 2023 | 2024
• PEBB Policy 33-1: Additional verification requirements for partners of a legal union
• PEBB Policy 36-1: Certifying eligibility for a dependent child with a disability who is age 26 or older 2023 | 2024
• PEBB Policy 37-1: Certifying eligibility for an extended dependent child 

Learn more on the Dependents webpage.

Premium surcharges

• Premium Surcharge Help Sheet 2023 (Help Sheet information for 2024 can be found in the 2024 Premium Surcharge Attestation Change form.)
• Premium Surcharge Change form 2023 | 2024
• Spousal Plan Calculator (print version) 2023 | 2024
• Spousal Plan Calculator tool (interactive tool) 2023 | 2024

Additional premium surcharge resources

• Attestations Report instructions (for BAs with PAY1 access)

Learn more on the Premium surcharges webpage.

Life and accidental death and dismemberment (AD&D) insurance

Life and AD&D forms and resources

• Life and AD&D Administration Manual
• Certificate of Coverage (COC)
• MetLife Advantages
  • Empathy services for beneficiaries
• MetLife's MyBenefits portal
  • Employees can use the MyBenefits portal to add/update beneficiaries and elect/change supplemental coverages.
• MetLife Enrollment/Change form
• Beneficiary Designation form
• Cancellation of Supplemental Life and AD&D Insurance form
• Notification of Enrollment Extension form for supplemental life
• Privacy Notice

Learn more on the Life and AD&D webpage.

Long-term disability (LTD) insurance

LTD forms and resources

• LTD Administration Manual
• Plan Booklet
• Enrollment/Change form
• Evidence of Insurability form
• Claim Packet
  • Employer's Statement (LTD claims)
• Claim Information Sheet (employer groups only)
• LTD error or discrepancy correction form

Learn more on the LTD webpage.

Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)

FSA and DCAP forms and resources

For employees of state agencies and higher education institutions only.

• 2024 FSA and DCAP Open Enrollment form
• Midyear Enrollment form 2023
• FSA and DCAP Claim form 2023
• Change in Status form 2023
• Agency Transfer form 2023
• FSA Termination form 2023
• Find additional forms and documents on Navia's website.

Learn more on the FSA and DCAP webpage.

Additional forms and resources

Apple Health (Medicaid)

• CHIP and PEBB/SEBB coverage options

  • Annual CHIPRA Notice template 2023

Dual enrollment

• Dual enrollment Q&A for BAs

Learn more on the Newly eligible employees webpage.

Health Savings Account (HSA)

• Employee Authorization for Payroll Deduction for HSA 2023 | 2024
• Beneficiary Designation form
• Find additional forms and documents on HealthEquity's website.

Learn more on the Medical plans with health savings accounts webpage.

Premium payments

• Premium Payment Plan Election/Change form
• Electronic Debit Service (EDS) Agreement

Learn more on the Paying for benefits and the Premium payment plan (IRC Section 125) webpages.

PEBB Continuation Coverage

COBRA and Unpaid Leave resources

• Initial notice of COBRA and Continuation Coverage rights 2023
• Continuation Coverage Election Notice 2023

Learn more on the COBRA and Unpaid Leave webpages.

PEBB retiree insurance

PEBB retiree insurance resources

• Retiree Enrollment Guide 2023 | 2024
• PEBB retiree health insurance checklist

Learn more on the Retiring and PEBB Retiree Insurance webpage.