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.

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, and returning for the next season).

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

Worksheet

Use this worksheet for...

 Use a different worksheet if the employee is...

A-1
  • Newly hired hourly and salaried employees
  • Transferring to or from another employer without a break in PEBB benefits*, use A-5
  • Moving to another position within the same employer, use B-4
  • Returning from layoff, use D-2a

A-2

 
  • Newly hired seasonal employees, and
  • Seasonal employees returning for a second consecutive season when they were not eligible during their first season
  • Transferring to or from another employer without a break in PEBB benefits*, use A-5
  • Moving to another position within the same employer, use B-5
  • Returning from layoff, use D-2b

A-5
  • All employees transferring to another PEBB employer
  • Transferring with a break in PEBB benefits*, use A-1 or A-2 (whichever is appropriate)
  • Moving to another position within the same employer, use B-4 or B-5
  • Returning from layoff, use D-2a, or D-2b

* 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

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

B-1
  • Existing hourly/salaried employees who were not initially determined to be benefits-eligible but has a change or revision in work pattern, and
  • Existing seasonal employees who were not initially determined to be benefits-eligible but has a change or revision in work pattern in their first season

 

B-4
  • Hourly or salaried benefits-eligible employees who experience a change in their current position (e.g. reduction of work hours), and
  • Hourly or salaried benefits-eligible employees who move to a new position at the same employer
  • Transferring to another employer without a break in PEBB benefits*, use A-5
  • Changing position due to layoff, use B-6

B-5
  • Benefits-eligible seasonal employees who experience a change in their current position (e.g. reduction of work hours), and
  • Benefits-eligible seasonal employees who move to a new position at the same employer
  • Transferring to another employer without a break in PEBB benefits*, use A-5
  • Changing position due to layoff, use B-7

B-6
  • Benefits-eligible hourly or salaried employees who change positions or experience a reduction in work hours due to layoff with no break in PEBB benefits*
  • Not changing positions due to layoff, use B-4
  • Returning from a layoff with a break in PEBB benefits*, use D-2a
  • Losing employment due to layoff, use C-7

B-7
  • Benefits-eligible seasonal employees who change positions or experience a reduction in work hours due to layoff with no break in PEBB benefits*
  • Not changing positions due to layoff, use B-5
  • Returning from a layoff with a break in PEBB benefits*, use D-2b
  • Losing employment due to layoff, use C-7

* 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

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

C-1
  • All benefits-eligible employees who are leaving work on approved leave without pay (LWOP), approved educational leave, receiving time-loss benefits under workers' compensation, or appealing a dismissal
  • Going on FMLA, use C-2
  • Going on PFML which is concurrent with FMLA, use C-2
  • Going on military leave, use C-5 or C-6

C-2
  • All benefits-eligible employees who cease active work during approved FMLA (or PFML which is concurrent with FMLA)
  • Approved for PFML which is not concurrent with FMLA, use C-1

C-4
  • Benefits-eligible seasonal employees who are leaving work for the off-season

 

C-5
  • All employees called to active military duty for less than 31 days

 

C-6
  • All employees called to active military duty for 31 days or more

 

C-7
  • All benefits-eligible employees whose employment is ending due to a layoff
  • Leaving employment due to layoff and reverting or changing employment to an ineligible position, use B-6 or B-7

C-8
  • All benefits-eligible employees who lose eligibility for the employer contribution or are leaving work
  • Separating due to disability (and applying for disability retirement), use C-10

C-9
  • All employees leaving employment due to retirement who may be eligible for PEBB retiree insurance coverage
  

C-10
  • All employees applying for disability retirement who may be eligible for PEBB retiree insurance coverage, and
  • Retirees who return to work and then retire again

 

C-11
  • Survivors of a deceased employee
  

D-series worksheets for employees who are returning to work

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

D-1
  • All employees who are returning to work from active military duty, educational leave, LWOP, or time-loss benefits under workers' compensation
  • Returning from layoff, use D-2a or D-2b

D-2a
  • Hourly and salaried employees who are returning to work after a layoff
  • Returning to work from an anticipated end date, use A-1

D-2b
  • Seasonal employees who are returning to work after a layoff
  • Returning to work from an anticipated end date, use A-2

D-5
  • Seasonal employees who are returning to work from an off-season with no employer contribution
  • Returning to a different position, use B-5

E-series worksheets for employees adding eligible dependents to PEBB benefits

Worksheet

Use this worksheet for...

Use a different worksheet if the employee is...

E-1
  • Employees requesting to add eligible dependent(s) to PEBB benefits
  • 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 PEBB benefits
  

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

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