Employee eligibility tools and worksheets

The School Employees Benefits Board (SEBB) Program provides eligibility worksheets to determine and provide required notification of employee eligibility for the employer contribution toward SEBB benefits.

ESSB 6189 Guidance In accordance with Senate Bill 6189 benefits must be maintained into the 2020-21 school year for employees who had eligibility for the employer contribution toward SEBB benefits as of February 29, 2020. That is the date Governor Inslee declared a state of emergency. The protections in SB 6189 continue until Governor Inslee’s state of emergency is lifted. SEBB Organizations must continue to provide the employer contribution toward SEBB benefits for employees who qualify for the protections of SB 6189 unless the employment relationship terminates. The SEBB Organization determines when the employment relationship has ended with an employee.

Providing notice of the determination of eligibility

SEBB organizations must provide written notice of the determination of eligibility (or ineligibility) for the employer contribution toward SEBB 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.

An employee eligible for SEBB benefits 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.

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

The eligibility worksheets serve as the approved method for determining eligibility for SEBB benefits and providing required notification, per SEBB 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 SEBB 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 or revision in work pattern resulting in either gaining or losing eligibility.
C-series	The C-series worksheets 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 from certain types of leave, after employment ended due to layoff, for the next school year, or within the same school year.
E-series	The E-series worksheets are for employees adding eligible dependents to SEBB 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 SEBB benefits, not the A-1 (new hire).
A break in SEBB 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.
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, 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-1	Newly hired employees anticipated to work at least 630 hours in the current school year	Transferring to or from another SEBB organization without a break in SEBB benefits*, use A-5 Moving to another position within the same SEBB organization, use the appropriate B series worksheet, if necessary Being rehired within the same school year, use D-5
A-2	Newly hired employees NOT anticipated to work at least 630 hours in the current school year	Transferring to or from another SEBB organization without a break in SEBB benefits*, use A-5 Moving to another position within the same SEBB organization, use the appropriate B series worksheet, if necessary
A-3	Newly hired employees NOT anticipated to work at least 630 hours in the current school year due to time of hire in the school year, but who are anticipated to work at least 630 hours in the next school year with the same SEBB Organization	Transferring to or from another SEBB organization without a break in SEBB benefits*, use A-5
A-4	Newly hired employees NOT anticipated to work at least 630 hours in the current school year, but belongs to a group which has locally negotiated eligibility criteria with the SEBB Organization	Transferring to or from another SEBB organization without a break in SEBB benefits*, use A-5
A-5	Benefits-eligible employees transferring from one SEBB organization to another without a break in SEBB benefits This worksheet applies to both SEBB organizations which are losing and gaining the employee.	Transferring with a break in SEBB benefits*, use A-1, A-2, A-3, or A-4, whichever is appropriate

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

B-series for employees who have a change in work pattern resulting in either gaining or losing eligibility

Worksheet	Use this worksheet for...	Use a different worksheet if the employee is...
B-1	Existing employees who were not initially determined to be benefits-eligible but experience a change or revision in work pattern and are now either: Anticipated to work at least 630 hours in the school year, or Will remain ineligible, despite an increase in work hours	A new hire, use the appropriate A-series worksheet No longer anticipated to work at least 630 hours in the school year, use B-3 Experiencing a change in work pattern that will apply to a new school year, use D-3 or D-4, whichever is appropriate
B-2	Review of an employee's hours worked, which indicates the employee has actually worked 630 hours in the school year	Now anticipated to work at least 630 hours in the school year due to revision of work pattern, use B-1
B-3	Revision of an employee's work pattern such that they are no longer anticipated to work 630 hours in the school year	Now anticipated to work at least 630 hours in the school year, use B-1 Experiencing a change in work pattern that will apply to a new school year, use D-3 or D-4, whichever is appropriate

C-series for benefits-eligible employees who are leaving work temporarily or permanently

Worksheet	Use this worksheet for...	Use a different worksheet if the employee is...
C-1	Benefits-eligible employees who are leaving work to go on certain types of approved leave or when employment ends due to layoff. Approved leave includes, leave without pay (LWOP), workers' compensation, Paid Family and Medical Leave (PFML which is not concurrent with FMLA), active military duty (USERRA), applying for disability retirement, and appealing a grievance.	Going on FMLA or PFML, which is concurrent with FMLA, use C-2
C-2	Benefits-eligible employees who cease active work and are approved for the federal Family Medical Leave Act (FMLA) or Paid Family and Medical Leave Program (PFML) which is concurrent with FMLA.	Approved for PFML that is not concurrent with FMLA, use C-1
C-3	Benefits-eligible employees who are leaving work due to the employment relationship being terminated	Losing eligibility due to a change in work pattern, use B-3 Losing eligibility due to going on approved leave or when employment ends due to layoff, use C-1
C-4	Employees leaving work due to retirement who may be eligible for PEBB retiree insurance coverage	Applying for disability retirement, use C-1
C-5	Survivors of a deceased employee

D-series for employees who are returning to work

Return to work includes returning from leave, for the next school year, or within the same school year.

Worksheet	Use this worksheet for...	Use a different worksheet if the employee is...
D-1	Employees who lost eligibility for the employer contribution due to leaving work on certain types of approved leave, or when employment ended due to layoff and are now returning to work Approved leave includes, leave without pay (LWOP), workers' compensation, Paid Family and Medical Leave (PFML which is not concurrent with FMLA), active military duty (USERRA), applying for disability retirement, and appealing a grievance. Watch a video on how to complete the D-1 worksheet.	Returning to work from approved LWOP and was not eligible before going on leave, use D-2 Currently eligible and has a change in work pattern associated with returning from LWOP, use B-3 ** Employees returning from LWOP do not receive a worksheet if they maintained eligibility while on leave.
D-2	Employees who were not eligible for the employer contribution before going on approved leave without pay (LWOP), and are now returning to work	Returning to work after having lost eligibility due to LWOP, use D-1 Currently eligible and has a change in work pattern associated with returning from LWOP, use B-3
D-3	Employees returning to work the next school year for the same SEBB Organization and type of position but are not anticipated to work at least 630 hours in the school year (2-year look-back)	A new hire, use the appropriate A-series worksheet
D-4	Employees who are not currently eligible, are returning to work the next school year for the same SEBB Organization, and who are: Anticipated to work at least 630 hours in the new school year, or Presumed to eligible due to a two-year look-back	A new hire, use the appropriate A-series worksheet
D-5	Employees who lost eligibility due to employment ending and are returning to work for the same SEBB Organization in the: The same school year in which their employment ended, or The next school year (if their employment ended in August of the previous school year)	Rehired in the next school year but their employment ended in any month other than August of the previous school year, use the appropriate A-series worksheet

E-series for employees adding eligible dependents to coverage

Worksheet	Use this worksheet for...	Use a different worksheet if the employee is...
E-1	Employees requesting to add eligible dependent(s) to coverage	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 coverage

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