You must attach an explanation of benefits (EOB) for any item covered by any insurance you have.
These services are not allowable under my and/or my spouse’s and/or dependent’s insurance policy for the following reason(s):
ITEMIZED INVOICES AND AN EXPLANATION
OF BENEFITS FROM INSURANCE COMPANY
MUST BE ATTACHED.
GENERAL
Requests for reimbursement may be submitted at any time.
Semi-monthly reimbursement will be made directly to you.
Reimbursement checks will be issued two times during the
month (see the current reimbursement claims processing
schedule at: hr.state.wy.us/EGI).
If you apply for reimbursement of expenses that the IRS later
determines to be ineligible, those reimbursements may be taxed
as ordinary income and IRS penalties may apply. Similar
treatment may apply to overpayment of reimbursed expenses
that have already been reimbursed from some other source.
MEDICAL REIMBURSEMENT
Eligible expenses are qualified medical/dental expenses of the
employee, spouse, and dependent(s) that are not eligible for
reimbursement from any other source. Expenses that are
eligible for reimbursement under a health insurance plan should
not be included on this form. A list of typical IRS approved
medical/dental expenses is documented in your Flexible Benefit
Plan Booklet. General information on the Flexible Benefits
Reimbursement Accounts as well as claims status may be
obtained by contacting the Employees’ Group Insurance Office
at 777-6835 or 1-800-891-9241.
WRAP AROUND MEDICAL REIMBURSMENT
This is intended to complement the Health Savings Account.
Taking the Wrap Around does NOT enroll you in a Health
Savings Account This option does not reimburse services
covered by the health insurance including deductibles,
coinsurance, and prescription drug expenses for the High
Deductible Health Plan (HDHP).
I request reimbursement from the Flexible Benefits
Reimbursement Account(s) for the expenses itemized above. I
hereby certify that I have read and understand the guidelines on
this form and that these expenses must qualify for
reimbursement under the Internal Revenue Code as outlined on
the form.
DEPENDENT DAY CARE REIMBURSEMENT
Expenses to provide care for your eligible dependents may
qualify for reimbursement. Eligible dependents include children
under age 13, a disabled child, a disabled spouse, or a dependent
disabled parent.
To be eligible, you must be working while your dependents
receive care. Also, if you are married, your spouse must be:
− A wage earner, or
− A full-time student for at least 5 months during the year, or
− Disabled and unable to provide for his or her own care.
Expenses eligible for reimbursement are those incurred to enable
you to be gainfully employed, and include covered charges by:
− Licensed nursery schools and day care centers
− Individual – other than your dependents – who provide care
for your children in or outside your home, or for your
disabled spouse or dependent parent in your home.
Under IRS Regulations, qualified individuals can receive a tax
credit for dependent care costs. This credit is claimed on your
personal tax return. You CANNOT claim the tax credit for any
dependent care costs reimbursed from the Flexible Benefits
Reimbursement Account.
I further certify that these expenses are not eligible for
reimbursement from any other source. I also understand that
reimbursement expenses cannot be claimed as credits or
deductions on my personal tax return.
Submit Claims to:
Employees’ Group Insurances
Attn: Cafeteria Plan Section
2001 Capitol Avenue B3
Cheyenne, WY 82002
(307) 777-6835
