Notification requirements
The Public Employees Benefits Board (PEBB) Program provides eligibility worksheets for participating employer groups to determine and provide required notification of employee eligibility for the employer contribution toward PEBB benefits.
On this page
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.
Eligibility for PEBB benefits must be determined in accordance with Title 182 WAC and any additional policies, procedures, or written guidance issued by the PEBB Program. However, employer groups may have different eligibility criteria, if approved by the PEBB Program and outlined in Appendix A of your organization's Interlocal Agreement.
When should the notice be provided?
The notice should be provided within five business days of a newly eligible employees first day of work and when an employee experiences a change in eligibility (Section 5(b) of the Interlocal Agreement).
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.
What tools are available 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. Employer groups may either use the eligibility worksheets provided or create their own notification document that aligns with 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 or other methods of notification.
Using the A through E-series eligibility worksheets
See the table below for a description of each worksheet series.
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A-series |
The A-series worksheets are for all new hires, including transferring employees. |
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B-series |
The B-series worksheets are for employees who have a change in employment |
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C-series |
The C-series are for benefits-eligible employees who are leaving work temporarily |
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D-series |
The D-series worksheets are for employees who are returning to work (e.g., approved |
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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.
- Some participating employer groups may have an approved benefit waiting period, which impacts the date an employee's benefits begin. Review your organization's Interlocal Agreement to determine if a waiting period applies to your eligible employees.
- 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.
Eligibility worksheets
A-series for new hires
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Worksheet |
Use this worksheet for... |
Use a different worksheet if the employee is... |
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A-1 |
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A-2
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A-5 |
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* A break in PEBB benefits is one month or more in which the employee does not receive the employer contribution.
B-series worksheets for employees who have a change in employment status
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Use this worksheet for... |
Use a different worksheet if the employee is... |
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B-1 |
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B-4 |
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B-5 |
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B-6 |
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B-7 |
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* A break in PEBB benefits is one month or more in which the employee does not receive the employer contribution.
C-series worksheets for benefits-eligible employees who are leaving work
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Use this worksheet for... |
Use a different worksheet if the employee is... |
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D-series worksheets for employees who are returning to work
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Worksheet |
Use this worksheet for... |
Use a different worksheet if the employee is... |
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E-series worksheets for employees adding eligible dependents to PEBB benefits
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Worksheet |
Use this worksheet for... |
Use a different worksheet if the employee is... |
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