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PEBB benefit eligibility tools and worksheets

Find the tools you need to help determine employee eligibility (based on the employee's situation).

Determining eligibility

PEBB provides the following method to determine eligibility for the employer contribution toward benefits for employees of state agencies and higher education institutions. The method:

Facilitates decisions compliant with RCW and WAC.
Provides required notice and information to employees.
Confirms receipt of the required notice and information
Provides guidance and suggestions for the employer and employee.

Find recent guidance on PEBB eligibility related to COVID-19.

Step 1	Choose the worksheet below that describes the employee's situation. Additional information is provided to guide you to other worksheets that may be more appropriate for the employee's situation.
Step 2	Click on the title of the specific worksheet that describes the employee or employee's situation. The worksheet will display in Excel.
Step 3	Complete the worksheet electronically. Do not save worksheets to your computer, as they are updated often and employees may be issued outdated information.
Step 4	With the exception of the A-5 worksheet, the employee must sign their completed worksheet. If the employee is not with you to sign their worksheet, send them a completed worksheet and request a returned, signed copy or an email confirming receipt.
Step 5	File the worksheet electronically or as a hard copy for your use and review by PEBB.

Worksheets

"A" series: For new hires

Worksheet	If the employee is...
A-0: Affordable Care Act employee status code
A-1: Newly hired hourly and salaried employees	Transferring to or from another agency, use A-5 Moving to another position within the same agency, use B-4 Returning from layoff, use D-2a
A-2: Newly hired seasonal employees	Transferring to or from another agency, use A-5 Moving to another position within the same agency, use B-5 Returning from layoff, use D-2b * The A-2 should also be used when returning for a second consecutive season (and was not eligible the first season).
A-3: Faculty	Transferring to/from another agency, use A-5 Returning from layoff, use D-2c Returning within 12 months of losing benefits, use D-3
A-4: Elected and full-time appointed officials	Newly elected or newly appointed
A-5: Employee who transfers to another agency	Transferring with a break in PEBB coverage, use the A-1, A-2, A-3, or A-4 (whichever is appropriate) Moving to another position within the same agency, use B-4 or B-5 Returning from layoff, use D-2a, D-2b, or D-2c NOTE: The A-5 worksheet has been updated with clarification on how to determine if an employee has had a break in coverage when moving from one PEBB employer to another.
COVID-19 employee eligibility notification template	Hired specifically due to COVID-19 and meets the criteria as detailed in PEBB Resolution 2020-03, use the template. Hired for reasons not specific to COVID-19/PEBB Resolution 2020-03, use the appropriate A series worksheet.

"B" series: For existing employees who have a change in employment status

Worksheet	If the employee is...
B-1: Retrospective review or increase in anticipated work pattern (hourly/salaried and seasonal employees)	Not eligible when first hired but has had a change in work pattern that requires review.
B-2: Faculty second consecutive quarter/semester or increase in anticipated work pattern	Not eligible when first hired but has had a change in work pattern that requires review, or Q/S-Q/S faculty working second consecutive quarter or semester.
B-2a: Faculty next quarter/semester review	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: Faculty requesting two-year averaging
B-3a: Faculty two-year averaging review (to maintain benefits)	Establishing eligibility through two-year averaging, use B-3
B-4: Hourly or salaried benefits-eligible employee who changes positions or experiences a reduction in work hours	Transferring to another agency, use A-5 Changing position due to layoff, use B-6
B-5: Seasonal benefits-eligible employee who changes positions or experiences a reduction in work hours	Transferring to another agency, use A-5 Changing position due to layoff, use B-7
B-6: Hourly or salaried benefits-eligible employee who has a change in employment status due to layoff	Not changing positions due to layoff, use B-4 Returning from a layoff with a break in PEBB coverage*, use D-2a Losing employment due to layoff, use C-7
B-7: Seasonal benefits-eligible employee who has a change in employment status due to layoff	Not changing positions due to layoff, use B-5 Returning from a layoff with a break in PEBB coverage, use D-2b Losing employment due to layoff, use C-7 A break in PEBB coverage is one full calendar month in which the employee does not receive the employer contribution

"C" series: For benefits-eligible employees who are leaving work

Worksheet	If the employee is...
C-1: Employee who is currently eligible for benefits and leaving work on approved leave 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: Employee who is currently eligible for benefits and ceases active work during approved FMLA	Approved for PFML that is not concurrent with FMLA, use the C-1
C-3: Quarter/semester-to-quarter/semester faculty who is leaving work for a summer or off-quarter/semester
C-4: Seasonal employee currently eligible for benefits who is leaving work for the off-season
C-5: Employee who is called to active military duty for less than 31 days
C-6: Employee who is called to active duty for 31 days or more
C-7: Employee currently eligible for benefits who is ending employment with your agency due to layoff	Leaving employment due to layoff and reverting or changing employment to an ineligible position, use B-6 or B-7
C-8: Employee currently eligible for benefits who loses eligibility for the employer contribution or is leaving work	Separating due to disability (and applying for disability retirement), use C-10
C-9: Employee retiring	An instructional year faculty who retires and return to work as a quarter/semester-to-quarter/semester faculty, use D-6
C-10: Employee applying for disability retirement
C-11: Employee deceased	This is information for a survivor of the deceased employee

"D" series: For employees who are returning to work

Worksheet	If the employee is...
D-1: Employee who is returning from active military duty, educational leave, LWOP, or time-loss benefits under worker's compensation	Returning from layoff, use D-2a, D-2b, or D-2c
D-2a: Hourly/salaried employee who is returning to work after layoff	Returning to work from an anticipated end date, use A-1
D-2b: Seasonal employee who is returning to work after layoff	Returning to work from an anticipated end date, use A-2
D-2c: Faculty who is returning to work after layoff
D-3: Faculty who is returning 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 employee who is returning the next season 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	Returning to work after 12 months of losing the employer contribution, use A-3