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.

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, including when an employee has lost eligibility.

Eligibility criteria

Eligibility for PEBB benefits must be determined according to the criteria in WAC 182-12-114 and 182-12-131.

When should the notice be provided?

The notice should be provided within a reasonable time frame as part of the hiring process. Employees who meet the eligibility criteria, have 31-days after they become eligible for PEBB benefits to complete and submit required enrollment forms indicating their enrollment elections. 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.

The notice of loss of eligibility should be provided within a reasonable time frame in accordance with the reason/circumstance for the loss of eligibility; such as termination, failure to maintain eligibility, retirement, etc.

What tools are approved for determining and providing required notice of eligibility?

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.

Worksheet Series	When to use these worksheets
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. The worksheet will open as an Excel file.
- To ensure you select 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).
- Please be advised that there may be accessibility issues when attempting to open the eligibility worksheets using certain web browsers. To ensure the best possible experience, it is recommended that you use Google Chrome when accessing the eligibility worksheets. If you encounter any issues, please try using a different browser or contact Outreach & Training for assistance.
Step 2: Complete the worksheet in Excel, not by hand. The worksheets contain built-in formatting to assist in making eligibility determinations.
- 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.
- When entering a date in a cell, use this format MM/DD/YYYY (e.g., 07/16/2023).
Step 3: Provide a copy of the completed worksheet to the employee in a non-modifiable format, such as print or PDF. Retain a hard copy or electronic record (e.g., 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.

Return to this page each time you need to access and complete eligibility worksheets.

Accessing the eligibility worksheets from this page means you'll 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.