Eligibility worksheets

The Public Employees Benefits Board (PEBB) Program provides eligibility worksheets for state agencies and higher-education institutions to determine and provide required notification of employee eligibility for the employer contribution toward PEBB benefits.

Review the COVID-19 notices for guidance related to PEBB eligibility.

Providing notice of the determination of eligibility

Employers must provide written notice of the determination of eligibility (or ineligibility) for the employer contribution toward PEBB benefits to an employee upon hire and when an employee experiences a change in eligibility. The notice should be provided within a reasonable time frame as part of the hiring process.

Employees who meet the eligibility criteria must complete and submit all required enrollment forms and dependent verification (if applicable), to their payroll or benefits office no later than 31-days after becoming eligible. However, eligible employees must have no less than ten calendar days after the date of receiving notice to elect coverage.

For example, if an employee’s date of eligibility is September 3 and they are provided notice of eligibility:

  • No later than September 24, the employee has until October 4 to make elections (31 days after September 3).
  • On September 30, the employee will have until October 10 to make elections.

Employers must determine eligibility of employees (and dependents) for the employer contribution toward PEBB benefits in accordance with Title 182 WAC and any additional policies, procedures, or written guidance issued by the PEBB Program (WAC 182-12-113).

The eligibility worksheets serve as the approved method for determining eligibility for PEBB benefits and providing required notification, per PEBB Policy 11-1.

  • The eligibility worksheets:
    • Serve as a record that the employer has provided the required notification,
    • Facilitate decisions compliant with RCW and WAC,
    • Provide required notice and information to employees, and
    • Provide guidance and suggestions for the employer and employee.

The PEBB Program may request review of completed worksheets.

Using the A through E-series eligibility worksheets

See the table below for a description of each worksheet series.

A-series

The A-series worksheets are for all new hires, including transferring employees.

B-series

The B-series worksheets are for employees who have a change in employment
status or revision of work pattern
resulting in either gaining or losing eligibility.

C-series

The C-series are for benefits-eligible employees who are leaving work temporarily
or permanently
(e.g, approved leave, layoff, termination, retirement, death).

D-series

The D-series worksheets are for employees who are returning to work (e.g., approved
leave, layoff, faculty returning within 12 months, returning for the next season, faculty
returning from retirement).

E-series

The E-series worksheets are for employees adding eligible dependents to PEBB benefits.

Follow the steps below when using eligibility worksheets.

  • Step 1: Select the worksheet in the tables below that best describes the employee's situation. To ensure you've selected the appropriate worksheet, review the guidance provided in the third column of each table. For example, the A-5 worksheet should be used for a transferring employee who does not experience a break in PEBB benefits, not the A-1 (new hire).
    A break in PEBB benefits is one month or more in which the employee does not receive the employer contribution.
  • Step 2: The worksheet will open as an Excel file, which contains built-in formatting to assist in making eligibility determinations. Complete the worksheet in Excel, not by hand. If the employee is eligible for PEBB benefits, use the First working day of month/effective date of coverage table to help determine the date benefits begin, which must be entered when completing the worksheet.
  • Step 3: Provide a copy of the completed worksheet to the employee in a non-modifiable format (e.g., print or PDF). Retain a hard copy or electronic record (i.e. email confirming receipt), indicating how and when the worksheet was provided to the employee.
    Employees should sign, date, and return the completed worksheet to the employer as ​indicated on the worksheet.

Pro Tip!
Return to this page each time you need to access and complete eligibility worksheets
to stay compliant with current rules and policies and avoid issuing incorrect eligibility determinations and outdated information to employees. While the worksheets are updated on an annual basis (effective every January), updates can occur at any time, so they should not be saved to your desktop for future use.

Eligibility worksheets

A-series for new hires

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

A-0

  • Determining if employees meet the federal definition of full-time for reporting purposes (Affordable Care Act (ACA) employee status code)

 

A-1

  • Newly hired hourly and salaried employees
  • Transferring to or from another employer without a break in PEBB benefits*, use A-5
  • Moving to another position within the same employer, use B-4
  • Returning from layoff, use D-2a

A-2

 

  • Newly hired seasonal employees, and
  • Seasonal employees returning for a second consecutive season when they were not eligible during their first season
  • Transferring to or from another employer without a break in PEBB benefits*, use A-5
  • Moving to another position within the same employer, use B-5
  • Returning from layoff, use D-2b

A-3

  • Newly hired faculty
  • Transferring to or from another employer without a break in PEBB benefits*, use A-5
  • Returning from layoff, use D-2c
  • Returning within 12 months of losing benefits, use D-3

A-4

  • Newly elected and full-time appointed officials, justices, and judges

 

A-5

  • All employees transferring to another PEBB employer
  • Transferring with a break in PEBB benefits*, use A-1, A-2, A-3, or A-4 (whichever is appropriate)
  • Moving to another position within the same employer, use B-4 or B-5
  • Returning from layoff, use D-2a, D-2b, or D-2c

* A break in PEBB benefits is one month or more in which the employee does not receive the employer contribution.

Use the COVID-19 employee eligibility notification template for employees hired specifically due to COVID-19 and who meet the criteria as detailed in PEBB Resolution 2020-03.

B-series worksheets for employees who have a change in employment status

Worksheet

 

Use this worksheet for...

Use a different worksheet if the employee is...

B-1

  • Existing hourly/salaried employees who were not initially determined to be benefits-eligible but has a change or revision in work pattern, and
  • Existing seasonal employees who were not initially determined to be benefits-eligible but has a change or revision in work pattern in their first season

 

B-2

  • Faculty who were not eligible for the employer contribution when hired on a quarter-to-quarter or semester-to-semester (Q/S-Q/S) basis and are now anticipated to work a second consecutive quarter/semester, and
  • Faculty who have an increase in anticipated work pattern
 

B-2a

  • Determining if a Q/S-Q/S faculty meets the eligibility requirements to maintain the employer contribution for the next quarter/semester
  • Using two-year averaging, use B-3a
  • Taking the next quarter/semester off as their summer or off-quarter/semester, use C-3

B-3

  • Q/S-Q/S Faculty requesting if they are potentially eligible to receive the uninterrupted employer contribution for an academic year through two-year averaging

 

B-3a

  • Determining if a Q/S-Q/S faculty meets the eligibility requirements to maintain benefits through two-year averaging review
  • Establishing eligibility through two-year averaging, use B-3

B-4

  • Hourly or salaried benefits-eligible employees who experience a change in their current position (e.g. reduction of work hours), and
  • Hourly or salaried benefits-eligible employees who move to a new position at the same employer
  • Transferring to another employer without a break in PEBB benefits*, use A-5
  • Changing position due to layoff, use B-6

B-5

  • Benefits-eligible seasonal employees who experience a change in their current position (e.g. reduction of work hours), and
  • Benefits-eligible seasonal employees who move to a new position at the same employer
  • Transferring to another employer without a break in PEBB benefits*, use A-5
  • Changing position due to layoff, use B-7

B-6

  • Benefits-eligible hourly or salaried employees who change positions or experience a reduction in work hours due to layoff with no break in PEBB benefits*
  • Not changing positions due to layoff, use B-4
  • Returning from a layoff with a break in PEBB benefits*, use D-2a
  • Losing employment due to layoff, use C-7

B-7

  • Benefits-eligible seasonal employees who change positions or experience a reduction in work hours due to layoff with no break in PEBB benefits*
  • Not changing positions due to layoff, use B-5
  • Returning from a layoff with a break in PEBB benefits*, use D-2b
  • Losing employment due to layoff, use C-7

* A break in PEBB benefits is one month or more in which the employee does not receive the employer contribution.

C-series worksheets for benefits-eligible employees who are leaving work

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

C-1

  • All benefits-eligible employees who are leaving work on approved leave without pay (LWOP), approved educational leave, receiving time-loss benefits under workers' compensation, or appealing a dismissal
  • Going on FMLA, use C-2
  • Going on PFML which is concurrent with FMLA, use C-2
  • Going on military leave, use C-5 or C-6

C-2

  • All benefits-eligible employees who cease active work during approved FMLA (or PFML which is concurrent with FMLA)
  • Approved for PFML which is not concurrent with FMLA, use C-1

C-3

  • Quarter/semester-to-quarter/semester faculty who are leaving work for a summer or off-quarter/semester

 

C-4

  • Benefits-eligible seasonal employees who are leaving work for the off-season

 

C-5

  • All employees called to active military duty for less than 31 days

 

C-6

  • All employees called to active military duty for 31 days or more

 

C-7

  • All benefits-eligible employees whose employment is ending due to a layoff
  • Leaving employment due to layoff and reverting or changing employment to an ineligible position, use B-6 or B-7

C-8

  • All benefits-eligible employees who lose eligibility for the employer contribution or are leaving work
  • Separating due to disability (and applying for disability retirement), use C-10

C-9

  • All employees leaving employment due to retirement who may be eligible for PEBB retiree insurance coverage
  • An instructional year faculty who retires and return to work as a quarter/semester-to-quarter/semester faculty, use D-6

C-10

  • All employees applying for disability retirement who may be eligible for PEBB retiree insurance coverage, and
  • Retirees who return to work and then retire again

 

C-11

  • Survivors of a deceased employee
 

D-series worksheets for employees who are returning to work

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

D-1

  • All employees who are returning to work from active military duty, educational leave, LWOP, or time-loss benefits under workers' compensation
  • Returning from layoff, use D-2a, D-2b, or D-2c

D-2a

  • Hourly and salaried employees who are returning to work after a layoff
  • Returning to work from an anticipated end date, use A-1

D-2b

  • Seasonal employees who are returning to work after a layoff
  • Returning to work from an anticipated end date, use A-2

D-2c

  • Faculty who are returning to work after a layoff

 

D-3

  • Faculty who are returning to a faculty position within 12 months of losing the employer contribution
  • Returning to work after 12 months of losing the employer contribution, use A-3

D-5

  • Seasonal employees who are returning to work from an off-season with no employer contribution
  • Returning to a different position, use B-5

D-6

  • Instructional year faculty who retires and returns to a quarter/semester-to-quarter/semester faculty position within 12 months of losing the employer contribution due to retirement
  • Returning to work after 12 months of losing the employer contribution, use A-3

E-series worksheets for employees adding eligible dependents to PEBB benefits

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

E-1

  • Employees requesting to add eligible dependent(s) to PEBB benefits
  • Enrolling a disabled or extended dependent, use E-2

E-2

  • Employees requesting to add a dependent child with a disability (age 26 or older) or an extended dependent to PEBB benefits
 

Contact

Outreach & Training
Contact O&T if you need assistance or cannot find a worksheet relevant to your situation.
Phone: 1-800-700-1555
Secure messaging: HCA Support