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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).
On this page
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.
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 Do not save worksheets to your computer, as they are updated often and employees may be issued outdated information.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... |
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A-0: Affordable Care Act employee status code | |
A-1: Newly hired hourly and salaried employees |
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A-2: Newly hired seasonal employees |
* The A-2 should also be used when returning for a second consecutive season (and was not eligible the first season). |
A-3: Faculty |
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A-4: Elected and full-time appointed officials |
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A-5: Employee who transfers to another agency |
* 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. |
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"B" series: For existing employees who have a change in employment status
Worksheet | If the employee is... |
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B-1: Retrospective review or increase in anticipated work pattern (hourly/salaried and seasonal employees) |
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B-2: Faculty second consecutive quarter/semester or increase in anticipated work pattern |
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B-2a: Faculty next quarter/semester review |
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B-3: Faculty requesting two-year averaging | |
B-3a: Faculty two-year averaging review (to maintain benefits) |
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B-4: Hourly or salaried benefits-eligible employee who changes positions or experiences a reduction in work hours |
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B-5: Seasonal benefits-eligible employee who changes positions or experiences a reduction in work hours |
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B-6: Hourly or salaried benefits-eligible employee who has a change in employment status due to layoff |
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B-7: Seasonal benefits-eligible employee who has a change in employment status due to layoff |
* A break in PEBB coverage is one full calendar month in which the employee does not receive the employer contribution
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"C" series: For benefits-eligible employees who are leaving work
Worksheet | If the employee is... |
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C-1: Employee who is currently eligible for benefits and leaving work on approved leave or appealing a dismissal |
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C-2: Employee who is currently eligible for benefits and ceases active work during approved FMLA |
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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 |
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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 |
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C-8: Employee currently eligible for benefits who loses eligibility for the employer contribution or is leaving work |
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C-9: Employee retiring |
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C-10: Employee applying for disability retirement |
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C-11: Employee deceased |
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"D" series: For employees who are returning to work
Worksheet | If the employee is... |
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D-1: Employee who is returning from active military duty, educational leave, LWOP, or time-loss benefits under worker's compensation |
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D-2a: Hourly/salaried employee who is returning to work after layoff |
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D-2b: Seasonal employee who is returning to work after layoff |
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D-2c: Faculty who is returning to work after layoff | |
D-3: Faculty who is returning within 12 months of losing the employer contribution |
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D-5: Seasonal employee who is returning the next season from an off-season with no employer contribution |
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D-6: Instructional year faculty who retires and returns to a quarter/semester-to-quarter/semester faculty position |
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"E" series: For eligible dependents
Worksheet | If the employee is... |
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E-1: Dependent eligibility |
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E-2: Dependents with disabilities and extended dependents |
Contact
Contact PEBB Outreach & Training through FUZE or call 1-800-700-1555 if you need assistance or cannot find a worksheet relevant to your situation.