Forms and publications

Below you will find manuals, user guides, and resources related to the Benefits 24/7 online enrollment system, accounting, correcting SEBB organization errors, appeals, and HCA Support. Employee enrollment resources, such as guides and forms, certification forms for dependents, and many other resources are also available to download.

When printing forms to share with employees, also provide the SEBB nondiscrimination statement and language access notice.

Benefits 24/7

Benefits 24/7 manuals and resources

The following resources are for benefits administrators (BAs).

• Benefits 24/7
• Benefits 24/7 manuals
  • Chapter 1: Introduction to Benefits 24/7
  • Chapter 2: Managing Benefits 24/7
  • Chapter 3: Managing employee accounts
• Eligibility file specifications
  • Eligibility upload error messages
• Lower limit calendar
  • Policy 19-1A: Termination due to loss of eligibility or enrollment error

Learn more on the Administering SEBB in Benefits 24/7 webpage.

Accounting

Accounting manuals and resources

The accounting manual contains the current year's invoicing dates along with other accounting-related guidance.

• Accounting training manual
  • Sample of district billing file with adjustments
• SEBB Program monthly billing cycle
• Lower limit calendar

These resources can also be found on the Accounting webpage.

Supplemental benefits billing resources

Life and accidental death and dismemberment (AD&D) insurance

MetLife manages billing and processes enrollment and claims for SEBB life and accidental death and dismemberment insurance.

• Life and AD&D administration manual
• SEBB list bill process and guidelines
• SEBB paper list bill example
• SEBB bill record layout
• SEBB remit record layout
• Enrollment and supplemental billing guide for new employers joining SEBB

Long-term disability (LTD) insurance

The Standard manages billing and processes claims for SEBB long-term disability insurance (LTD).

• SEBB LTD Administration Manual
• LTD employer portal
  • LTD employer portal guide
  • Employer portal demonstrative videos
• Portal authorization instructions
• LTD premium calculation
• Sample invoice
• Payment letter

Flexible Spending Arrangements (FSAs) and the Dependent Care Assistance Program (DCAP)

Navia manages billing and processes claims for the SEBB Program's Medical Flexible Spending Arrangement (FSA), Limited Purpose FSA, and the Dependent Care Assistance Program.

• Access the Navia Employer Portal
  • Administering FSAs/DCAP through Navia's Employer Portal (presentation)
  • Navia consolidated file specifications

These resources can also be found on the Accounting webpage.

Correcting SEBB organization errors

Error correction resources

• SEBB Error Correction Guidelines
• Sample correction/recourse letters
  • Failure to enroll in default coverage
  • Failure to enroll accurately
  • Failure to provide eligibility notification timely

Learn more on the Correcting SEBB organization errors webpage.

Appeals

Appeals form and resources

• SEBB Appeals process map
• Employee Request for Review/Notice of Appeal form
• Authorization for Release of Information

Learn more on the Appeals process webpage.

HCA Support

HCA Support is a secure, web-based correspondence program that allows you to send documents and communicate directly with O&T, SEBB Accounting, and other departments within the SEBB Program by using the ​​​​designated tile named, "Benefits administrator inquiry".

HCA Support resources

It's important that BAs use the designated tile named, "Benefits administrator inquiry". Using the "General Support" tile will lead to a delayed response, as your inquiry will be initially routed to units at HCA that are outside of O&T.

• HCA Support
  • HCA Support user guide

Employees and dependents

Enrollment guide, forms, and resources

Employees are encouraged to complete enrollment online using Benefits 24/7. However, the forms provided below can also be used for employee and dependent enrollment.

• School Employee Enrollment Guide
• The following school employee enrollment and change forms can be used by eligible employees of SEBB organizations:
  • School Employee Enrollment form
  • School Employee Change form
• The following school employee enrollment/change form can be used by employees of SEBB employer groups who contract with the SEBB Program to offer medical-only benefits to their eligible employees:
  • School Employee Enrollment/Change form - Medical only groups
• LTD Enrollment/Change form

Employees may use the following forms to complete their enrollment in supplemental life and supplemental accidental death and dismemberment (AD&D) insurance and to elect participation in a flexible spending arrangement (FSA) or the Dependent Care Assistance Program (DCAP). Enrollment in these benefits cannot be completed using Benefits 24/7.

• MetLife Enrollment/Change form (for electing supplemental life and AD&D insurance and adding beneficiaries)
  • MetLife Beneficiary Designation form (for adding or updating beneficiaries only)
• FSA and DCAP Midyear Enrollment form

Learn more on the Employee enrollment webpage.

Dependent forms and resources

• Certification of a Child with a Disability form
• Extended Dependent Certification form
• Declaration of Tax Status form
• SEBB Policy 31-1: Verifying dependent eligibility before enrollment
• SEBB Policy 33-1: Additional verification requirements for partners of a legal union
• SEBB Policy 36-1: Certifying eligibility for a dependent child with a disability who is age 26 or older
• SEBB Policy 37-1: Certifying eligibility for an extended dependent child

Learn more on the Dependents webpage.

Premium surcharges

• Premium Surcharge Attestation Change form
• Spousal Plan Calculator (print version)
• Spousal Plan Calculator (interactive tool)

Learn more on the Premium surcharges webpage.

Life and accidental death and dismemberment (AD&D) insurance

Life and AD&D forms and resources

• Life and AD&D Administration Manual
• Life insurance COC's
  • Certificate of Coverage (COC) (at least 630 hours)
  • Certificate of Coverage (COC) (less than 630 hours)
• AD&D insurance COC's
  • Certificate of Coverage (COC) (at least 630 hours)
  • Certificate of Coverage (COC) (less than 630 hours)
• MetLife Advantages
  • Empathy services for beneficiaries
• Employees can use MetLife's MyBenefits portal to add/update beneficiaries and elect/change supplemental coverages or they can use the forms provided below.
  • MetLife Enrollment/Change form
  • Beneficiary Designation form
  • Cancellation of supplemental life and AD&D insurance form
• Notification of enrollment extension form for supplemental life
• Privacy notice

Learn more on the Life and AD&D webpage.

Long-term disability (LTD) insurance

LTD forms and resources

• LTD Administration Manual
• LTD plan booklet
• Enrollment/Change form
• Evidence of Insurability
• Claim packet
• LTD error or discrepancy correction form

Learn more on the LTD webpage.

Flexible Spending Arrangements (FSAs) and Dependent Care Assistance Program (DCAP)

FSA and DCAP forms and resources

• Midyear Enrollment form
• FSA and DCAP Claim form
  • DCAP Recurring Claim form
• Change in Status form
• School Employment Transfer form
• FSA Termination form
• Find additional forms and documents on Navia's website.

Learn more on the FSA and DCAP webpage.

Additional forms and resources

Apple Health (Medicaid)

• Apple Health fact sheet
• CHIP and PEBB/SEBB coverage options

  • Annual CHIPRA Notice template

Dual enrollment

• Dual enrollment across programs FAQ

Learn more on the Employee enrollment webpage

Health Savings Account (HSA)

• Employee Authorization for Payroll Deduction for HSA
• Beneficiary Designation
• Find additional HSA forms and documents on HealthEquity's website.

Premium payments

• Premium Payment Plan Election/Change
• Electronic Debit Service (EDS) Agreement

SEBB Continuation Coverage

COBRA and Unpaid Leave resources

• Initial notice of COBRA and Continuation Coverage rights
• Continuation Coverage Election Notice

Learn more on the COBRA and Unpaid Leave webpages.

PEBB retiree insurance

PEBB retiree insurance resources

• Retiree Enrollment Guide
• PEBB retiree health insurance checklist

Learn more on the Retirees website.