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n Reimbursement and Documentation Requirements
n Examples of Qualifying Health Care Expenses
n Non-qualifying Health Care Expenses
Reimbursement and documentation requirements
REIMBURSEMENT REQUIREMENTS
All health care claims must be submitted and
Reimbursement may be made only for expenses n You must substantiate the expense as
substantiated when they are incurred.
that are for "medical care" as defined by the required by federal regulations in accordance EXPENSES ARE INCURRED WHEN YOU
Internal Revenue Service and as interpreted and with the health care "Documentation ARE PROVIDED WITH THE HEALTH CARE
applied by the Plan Administrator. To be reim- THAT GIVES RISE TO THE HEALTH CARE
bursed under a Health Care Spending Account: Note: You wil be reimbursed only to the extent
EXPENSES AND NOT WHEN YOU ARE
n You, your spouse or eligible dependent must that the expense has not been reimbursed and FORMALLY BILLED OR CHARGED FOR OR
incur the expense.
that you wil not seek reimbursement under any PAY FOR THE EXPENSES.
other plan covering health benefits.
DOCUMENTATION REQUIREMENTS (Other than over-the-counter products; See inside for details on over-the-counter products.)
If the expense is covered by insurance, submit the
n A credit card statement is NOT acceptable
included in the total treatment cost for expense to the insurance carrier first. Once the orthodontia and require a ful y completed claim insurance carrier processes the claim and sends n A cancel ed check alone is NOT acceptable
form with proper substantiation of the service. If the Explanation of Benefits (EOB) statement to these services are incurred during the Plan Year you, you can submit it with the claim form to n Staple a legible copy of the substantiation to the
of your election, they are considered eligible.
substantiate the claim.
back of the claim form. Il egible copies wil delay Initial Fee vs. Down Payment
If the expense is not covered by insurance, the the processing of your claim.
It is a common practice for providers to require claim form must be accompanied by an itemized an initial fee before the start of the orthodontia statement of services from the Provider, which
Reimbursement of Orthodontia Claims
treatment. This expense is eligible for should include the fol owing information as Under a health care flexible spending account reimbursement with a ful y completed claim required by federal regulations: plan, expenses must be "incurred" before they may form and proper substantiation of the service. 1. Provider name and address
be reimbursed. Orthodontia services are The expense must be paid for during the Plan recognized as being different from other health 2. Patient name
Year of your election. A down payment is not care services in that there is general y a pre- 3. Date the expense was incurred
eligible for reimbursement because it does not payment component and the treatment period may 4. A description of the service or supply
represent services that have been incurred.
span several years. This makes it difficult to match 5. Amount charged
costs with dates that the actual services are Monthly Payments
The monthly liability for orthodontic treatment
Keep a copy of the claim form and the original
incurred. Guidelines for substantiating these claims may be substantiated by the fol owing: substantiation for your records.
are outlined as fol ows: n A coupon from an orthodontist coupon If a service is performed by someone other than
booklet indicating monthly payments a physician, and an EOB is not submitted, then
If there is coverage under a dental plan, payment n A paid receipt indicating the payment date in addition to the information in items 1-5
wil be reduced by the amount paid by the dental n A monthly statement that indicates the above, a statement from an attending physician
coverage. If you have dental insurance that covers monthly payment amount must be submitted stating that a specific medical
orthodontia, submit an Explanation of Benefits condition is present and that treatment is
(EOB) from the carrier with a completed claim FULL PAYMENT OF ORTHODONTIC
necessary for the condition.
form. Note: Orthodontia differs from other
dental procedures that require the actual service
If payment is made in ful for the treatment, and With respect to certain services, e.g. massage
to be performed within the Plan Year.
proof of payment is included with the completed therapy, the length of the treatment plan must
claim form, the ful payment wil be reimbursed also be included.
Initial Evaluation Fees
up to your health care election amount. The n A paid receipt is acceptable when submitting Orthodontia services initial y performed, such as payment must be made during the Plan Year of claims for prescription drugs or copays if it moldings, diagnostic record keeping, and your election.
contains the required five items listed above.
consultation, etc. are reimbursable when incurred if Important Note: Reimbursement of full
n A credit card receipt must contain the required the expenses are separate from the contracted payment is ONLY available if it is the only
five items listed above.
treatment. These expenses are typical y not method of payment that the Orthodontist offers.
Your Benefits At Work
Examples of qualifying health care expenses
pay for contact lenses needed for health care reasons. You may include in health care expenses the amount You can also include the cost of equipment and materi- You may include in health care expenses foods that are you pay for a legal abortion.
als required for using contact lenses, such as saline solu- prescribed by a medical practitioner to treat a specific tion and enzyme cleaner. See also Eyeglasses and Laser il ness or ailment and if the foods do not substitute for Eye Surgery on this page.
normal nutritional requirements. The amount that may You may include in health care expenses the amount qualify is limited to the amount by which the cost of the you pay for acupuncture. COSMETIC SURGERY and PROCEDURES
special food exceeds the cost of commonly available ver- You may include in health care expenses the amounts sions of the same product. A note from an attending you pay for cosmetic surgery ONLY IF the surgery or You can include in health care expenses amounts you physician recommending it to treat a specific medical procedure is necessary to correct a deformity arising pay for an inpatient's treatment at a therapeutic center condition is required. from (or directly related to) (1) a congenital for alcohol addiction. This includes meals and lodging abnormality (2) personal injury resulting from an GUIDE DOG
provided by the center during treatment.
accident or trauma, or (3) a disfiguring disease. You may include in health care expenses the cost of a You can also include in health care expenses transporta- Procedures such as face lifts, hair transplants, hair guide dog for the visual y-impaired or hearing-impaired. tion costs you pay to attend meetings of an Alcoholics removal (electrolysis) and liposuction general y are Amounts you pay for the care of the dog are also health Anonymous Club in your community if your attendance is NOT qualifying health care expenses.
care expenses.
pursuant to medical advice that membership in the Alco- holics Anonymous Club is necessary for the treatment of a disease involving the excessive use of alcoholic liquors.
You may include in health care expenses the amount You can include in health care expenses fees you pay for you pay to buy or rent crutches.
treatment at a health institute only if the treatment is prescribed by a physician and the physician issues a You may include in health care expenses amounts you statement that the treatment is necessary to al eviate a pay for ambulance service.
You may include in health care expenses the amounts physical or mental defect or il ness in the individual you pay for dental treatment. This includes fees paid to receiving the treatment.
ARTIFICIAL LIMB or PROSTHESIS
dentists, X-rays, fil ings, braces, extractions and dentures. You may include in health care expenses the amount Note: Al substantiation for dental services must include
HEARING AIDS
you pay for an artificial limb.
the date of service, the name of the provider and a You may include in health care expenses the cost of a description of the service.
hearing aid and the batteries you buy to operate it.
You can include in health care expenses the amount paid for artificial teeth.
You may include in health care expenses the cost of You may include in health care expenses amounts you body scans, pregnancy kits, ovulation monitors, and on- pay for inpatient care if the main reason for being there site health fairs that check blood pressure, cholesterol is to receive health care.
You may include in health care expenses birth control and bone density tests.
pil s prescribed by your doctor. You may also include the cost of condoms and spermicides.
You may include the cost of a lactation consultant if you You may include in health care expenses amounts you are having lactation problems and cannot breast-feed BRAILLE BOOKS, MAGAZINES
pay for legal health care services provided by: your child. A note from an attending physician stating You may include in health care expenses the part of the n obstetricians n gynecologists n anesthesiologists that a medical condition exists must be submitted.
cost of Brail e books and magazines for use by a visual y n surgeons n pediatricians n dermatologists impaired person that is more than the cost for regular n psychiatrists n podiatrists n osteopaths printed editions.
You may include expenses that relate to childbirth and n ophthalmologists n neurologists not child rearing. Expenses for a coach or significant BREAST PUMPS
Psychiatric care. You may also include amounts you pay
other are NOT includable.
You may include the cost of a breast pump if there is a for psychiatric care. This includes the cost of supporting medical reason. Expenses MAY NOT be included if
a mental y il dependent at a special y equipped health LASER EYE SURGERY
only used for convenience, scheduling or other personal care center where the dependent receives health care. You can include in health care expenses the amount you reasons. A note from an attending physician stating that See Psychoanalysis and Transportation on back. pay for surgery to improve vision, such as radial a medical condition exists must be provided.
Services provided by an independent social worker keratotomy or other laser eye surgery, if it is done (LISW) must be accompanied by a note from an attend- primarily to promote the correct function of the eye.
ing physician stating that a medical condition exists.
Special equipment. You may include in health care
expenses the cost of special hand controls and other You may include in health care expenses the amounts you special equipment instal ed in a car for the use of a You can include in health care expenses amounts you pay for laboratory fees that are part of your health care.
person with a disability.
pay for an inpatient's treatment at a therapeutic center Special design. The amount by which the cost of a car
for drug addiction. This includes meals and lodging at You may include in health care expenses tuition fees you special y designed to hold a wheelchair is more than the the center during treatment.
pay to a special school for a child who has severe cost of a regular car is a health care expense.
learning disabilities caused by mental or physical You may include amounts you pay for eyeglasses and impairments, including nervous system disorders. Your You may include in health care expenses fees you pay to contact lenses you need for health care reasons. You doctor must recommend that the child attend the a chiropractor for health care.
may also include fees paid for eye examinations.
school. See Schools, Special, on back. You may also include tutoring fees you pay on your doc- CHRISTIAN SCIENCE PRACTITIONERS
tor's recommendation for the child's tutoring by a teacher You may include in health care expenses fees you pay to You can include the cost of the fol owing procedures to who is special y trained and qualified to work with chil- Christian Science practitioners if payments are for overcome your inability to have children: dren who have severe learning disabilities.
health care.
n Procedures such as in vitro fertilization (including temporary storage of eggs or sperm).
LEGAL FEES
n Surgery, including an operation to reverse prior You may include in health care expenses legal fees paid You can include in health care expenses amounts you surgery that prevents you from having children.
to authorize treatment for mental il ness. However, if part of the legal fees include, for example, guardianship requires a prescription and is fil ed by a licensed The following are examples of OTC products that do not
or estate management fees, you may not include that need a written prescription but must be accompanied by
part in health care expenses.
Over-the-Counter: You may include in health care
a physician's diagnosis and recommendation:
LODGING (See Nursing Home, this page)
expenses amounts you pay for certain OTC products n Weight loss drugs to treat a specific disease (including You may include in health care expenses the cost of meals (including medicines and drugs). OTC products must be and lodging at a hospital or similar institution if your substantiated by a receipt from a third party with the n Orthopedic shoes (the cost of orthopedic shoes may be main reason for being there is to receive health care.
provider name and address, patient name, purchase date, reimbursed for the extra cost over non-orthopedic shoes) name of the product and the amount imprinted (not
n Glucosamine/Chondroitin for an arthritic condition You may be able to include the cost of lodging not handwritten) on the receipt. If a receipt for an OTC
n St. John's Wort – for depression provided in a hospital or similar institution. You can product does not contain the name of the product, Benefit n OTC Hormone Therapy for treatment of menopause include the cost of such lodging while away from home Concepts wil require additional third-party substantiation symptoms such as hot flashes and night sweats if you meet al of the fol owing requirements: (e.g. a box top that includes the name of the product and n Dietary supplements or herbal medicines to treat a n The lodging is primarily for and essential to health care.
a price tag matching the price on the receipt).
specific medical condition under narrow circumstances n The health care is provided by a doctor in a licensed Example: A medical practitioner tel s an individual to
hospital or in a health care facility related to, or the Also, for purchases made on or after January 1,
take 1000 mg of vitamin B-12 to treat a specific medical equivalent of, a licensed hospital.
2011, you must provide additional substantiation for
OTC products that are classified as "drugs and
condition or to take vitamin B for scurvy.
n The lodging is not lavish or extravagant under the n Fiber supplements under narrow circumstances – not medicines." For these products, you must also submit
a written prescription (or a copy of a prescription)
reimbursable if taken daily as a supplement to a normal n There is no significant element of personal pleasure, diet, but reimbursable if taken to treat a specific medical recreation, or vacation in the travel away from home.
each time you send us a claim for reimbursement.
condition for a limited time. The amount you include in health care expenses for A prescription is defined as a written or electronic order The following are examples of OTC products that are
lodging cannot be more than $50 for each night for each for a medicine or drug that (1) meets the legal person. Lodging is included for a person for whom trans- requirements of a prescription in the state in which you portation expenses are a health care expense because incur the expense and (2) is issued by an individual who n Medicated shampoos that person is traveling with the person receiving the is legal y authorized to issue a prescription in that state.
n Toothbrushes (electric
health care. For example, if a parent is traveling with a or otherwise) even if a n One-a-day vitamins Here are some OTC products that are classified as
sick child, up to $100 per night can be included as a dentist recommends a n Mouthwashes, rinses "drugs and medicines" and will require a written
health care expense for lodging. Meals are not included.
n Feminine products prescription (examples in parenthesis):
n Face cream, moisteners Do not include the cost of your lodging while you are
n Acne treatments n Diaper rash creams and suntan lotion away from home for health care treatment if you do not n Al ergy medicines receive that treatment from a doctor in a licensed hospital The list of excluded items is for il ustrative purposes (Alavert, Claritin) n Diarrhea medicine or in a medical care facility related to, or the equivalent only and is not al inclusive. There may be other OTC n Analgesics (Advil, (Imodium, Kaopectate) of, a licensed hospital or if that lodging is not primarily for products in addition to these that are not reimbursable.
Aspirin, Tylenol, Motrin) n Expectorants or essential to the medical care you are receiving.
n Antacids (Maalox, (Comtrex, Robitussin) Advance purchases of OTC products may be Prilosec OTC, Zantac) n First aid cream reimbursable; however, advance purchases are limited to n Antibiotic Ointments n Hemorrhoid treatments a quantity of six of each item, e.g. six bottles of aspirin You may include in health care expenses amounts paid (Bacitracin, Neosporin, or six boxes of Band-Aids, etc.
for admission and transportation to a medical conference n Laxatives (ex-lax) if the medical conference concerns the chronic il ness of MENTALLY RETARDED, SPECIAL HOME FOR
n Antihistamines n Sinus medications you, your spouse, or your dependent. The costs of the You may include in health care expenses the cost of (Benadryl, Claritin) medical conference must be primarily for and necessary keeping a mental y retarded person in a special home, n Anti-itch creams n Sunburn creams and to the medical care of you, your spouse, or your not the home of a relative, on the recommendation of a (Benadryl, Cortaid, dependent. You must spend the majority of your time at psychiatrist to help the person adjust from living in a Ivarest, Calamine n Throat lozenges the conference attending sessions on medical mental hospital to community living.
(Cepacol, Chloraseptic) information. The cost of meals and lodging while n Cold medicine (Comtrex, n Toothache and teething attending the conference is not a health care expense.
NORPLANT INSERTION and REMOVAL
pain relievers (Orajel) MEDIC ALERT BRACELET or NECKLACE
n Cough suppressants n Wart remover treatments NURSING HOME
You may include the cost of a medic alert bracelet or (Pediacare, Robitussin, You may include in health care expenses the cost of health necklace if it is prescribed by a physician for treatment of n Yeast infection care, including meals and lodging, for yourself, your spouse, a medical condition. Renewal fees are not reimbursable.
medications (Monistat) or your dependents in a nursing home or home for the aged, (Dimetapp, Sudafed) if the main reason for being there is to get health care.
MEDICAL INFORMATION PLAN
Note: Reimbursement for insulin does not require a
Do not include the cost of meals and lodging if the
You may include in health care expenses amounts paid reason for being in the home is personal or family. You to a plan that keeps your health care information by may include in health care expenses only the part of the computer and that can give you the information when Here are some OTC products that are not classified
cost that is for health care or nursing care.
you need it.
as "drugs and medicines" and will not require a
written prescription (examples in parenthesis):
MEDICAL MONITORING and TESTING DEVICES
n Arthritis gloves You may include in health care expenses wages and other You may include the costs of such devices as blood n Bandages for torn or n Elastic bandages (Ace) amounts you pay for nursing services. Services need not be pressure monitors, syringes and glucose kits.
injured skin (Curad, performed by a nurse as long as the services are of a kind general y performed by a nurse. This includes services MEDICINES or DRUGS
n Blood-pressure n Glucose-monitoring connected with caring for the patient's condition, such as Both prescribed and over-the-counter (OTC) medicines monitoring devices giving medication or changing dressings, as wel as bathing or drugs are reimbursable if they are primarily for medical n Blood-sugar test kits n Hearing aids and and grooming the patient. These services can be provided care. A medicine or drug is not reimbursable if it is merely in your home or another care facility.
beneficial to general health or a toiletry or a cosmetic. n Liquid adhesive for Medicines or drugs whether prescribed or over-the-counter General y, only the amount spent for nursing services is a if imported into the United States are NOT reimbursable.
health care expense. If the attendant also provides n Contact lenses, n Orthopedic shoe inserts Medicines or drugs that are legal at the state or local level, personal and household services, these amounts must be materials and equipment n Pregnancy test kits divided between the time spent performing household but il egal at the federal level are also not reimbursable.
n Contraceptives n Reading glasses and personal services and the time spent for nursing Prescribed: You may include in health care expenses
(Spermicidal Foam) n Sunscreen SPF 15 or services. Additional y, certain expenses for household amounts you pay for medicines and drugs that require a higher and broad spectrum services or for the care of a qualifying individual incurred prescription, or for insulin. A prescribed drug is one that n Dentures and denture CONTINUED ON BACK Examples of qualifying health care expenses, continued
NURSING SERVICES (continued)
n teaches Brail e to a visual y-impaired child.
to al ow you to work may qualify for the child and n teaches lip reading to a hearing-impaired child.
Amounts paid for transportation primarily for and dependent care credit. See IRS Publication 503, Child and n gives remedial language training to correct a condition essential to health care qualify as health care expenses.
Dependent Care Expenses. caused by a birth defect.
You May Include
You may also include in health care expenses part of the The cost of meals, lodging, and ordinary education supplied n bus, taxi, train, or plane fare, or ambulance service.
amount you pay for that attendant's meals. Divide the food by a special school may be included only if the main reason n actual car expense, such as gas and oil. Do not expense among the household members to find the cost of for the child's being there is the resources the school has for include expenses for general repair, maintenance, the attendant's food. Then apportion that cost in the same relieving the mental or physical disability.
depreciation, and insurance.
manner, as in the preceding paragraph. If you had to pay You may not include the cost of sending a problem child
n parking fees and tol s.
additional amounts for household upkeep because of the to a special school for benefits the child may get from the n parent's transportation expenses if a parent must go attendant, you can include the extra amounts. This includes course of study and the disciplinary methods.
with a child who needs health care.
extra rent or utilities you pay because you moved to a larger n transportation expenses of a nurse or other person apartment to provide space for the attendant.
SMOKING CESSATION PROGRAMS
who can give injections, medications, or other Employment Taxes. You may include social security tax,
You may include in health care expenses the cost of a treatment required by a patient who is traveling to FUTA, Medicare tax and state employment taxes you pay program to stop smoking. get health care and is unable to travel alone.
for a nurse, attendant, or other person who provides n transportation expenses for regular visits to see a health care as a health care expense. For further mental y il dependent, if these visits are You may include in health care expenses the cost of a information on employment tax responsibilities of recommended as a part of treatment.
legal sterilization (a legal y performed operation to make household employers, see IRS publication 926, Household Note: For ALL of the items listed above, a legible copy
a person unable to have children).
Employer's Tax Guide.
of the substantiation from the health care provider
MUST be attached to the claim form.
Healthy Baby. You cannot include the cost of nursing
services for a normal healthy baby. But you may be able You may include in health care expenses the cost and Do Not Include
to take a credit for child care expenses. See IRS repair of special telephone equipment that lets a hearing n transportation expenses to and from work, even if Publication 503 for more information. You also may be impaired person communicate over a regular telephone.
your condition requires an unusual means of able to take the child tax credit. n transportation expenses if; for non medical reasons OCCLUSAL GUARDS to prevent teeth grinding
You may include the cost of equipment that displays the only, you choose to travel to another city, (such as a audio part of television programs as subtitles for hearing resort area), for an operation or other health care OPERATIONS or SURGERY
impaired persons. This may be the cost of an adapter that prescribed by your doctor.
You may include in health care expenses amounts you attaches to a regular set. It also may be the excess cost of pay for legal operations that are not for unnecessary Tax Tip: Instead of deducting actual car expenses, you may
a special y equipped television over the cost of the same cosmetic surgery. take 23 cents per mile for each mile you use your car for model regular television set.
health care reasons in 2012. Add the cost of tol s and parking THERAPY or COUNSELING
to this amount. You may include in health care expenses amounts you You may include in health care expenses amounts you pay for oxygen or oxygen equipment to relieve breathing pay for therapy or counseling you receive as medical You can include in health care expenses the amount you problems caused by a medical condition.
treatment. It must be necessary to treat a specific medical pay for a vasectomy.
condition. If you do not submit an EOB as
WEIGHT LOSS PROGRAM
You may include in health care expenses payments for substantiation, then a note from an attending
The program must be prescribed by a physician. The
psychoanalysis. You may not include payments for physician stating that a medical condition exists and
physician must substantiate that a medical condition
psychoanalysis that you must get as part of your training the length of the treatment plan must be submitted.
exists. You cannot include the cost of a weight loss
to be a psychoanalyst.
Counseling for marital or relationship issues is NOT
program for your general health, even if your doctor prescribes the program.
"Patterning" exercises. Payments you make to someone
You may include in health care expenses amounts you for giving "patterning" exercises to a mental y retarded pay to a psychologist for health care. child are deductible. These exercises consist mainly of You may include in health care expenses amounts you Counseling for marital or relationship issues is NOT
coordinated physical manipulation of the child's arms pay for an autoette or a manual or motorized wheelchair and legs to imitate crawling and other normal used mainly for the rehab of sickness or disability, and not just to provide transportation to and from work. The cost of operating and keeping up the autoette or You may include in health care expenses payments to a wheelchair is also a health care expense.
special school for a mental y impaired or physical y You may include in health care expenses payments you disabled person if the main reason for using the school is X-RAY FEES
make for surgical, hospital laboratory, and transportation its resources for relieving the disability. You may include, You may include in health care expenses amounts you expenses for a donor or a possible donor of a kidney or for example, the cost of a school that: pay for x-rays you get for health care reasons.
other organ.
Non-qualifying health care expenses
The fol owing expenses are NOT qualifying health care expenses and may NOT be reimbursed through the Health Care FSA:
HEALTH CLUB DUES
DANCING or SWIMMING
PERSONAL USE ITEMS
CONTACT LENS INSURANCE
EXPENSES INCURRED AS A
MEDICINES or DRUGS
TREATMENT FOR VARICOSE VEINS
PURCHASE OF A TANNING BED
PURCHASED OUTSIDE of the
for a skin condition
COUNSELING FOR MARITAL or
VACATIONS and TRIPS
ITEMS and SERVICES THAT ARE
TEETH WHITENING or
MERELY BENEFICIAL TO GENERAL
MINOXIDIL or ROGAINE
EXERCISE PROGRAMS and
VACUUM CLEANERS, PILLOWS, or
ILLEGAL OPERATIONS and
BREAST IMPLANT REPAIR
HEALTH SPA MEMBERSHIPS
FILTERS, in the case of allergies
2012 Benefit Concepts BCIF502 Corp (12-11)

Source: http://www.benefitconcepts.com/Collateral/Documents/English-US/HC%20BCIF502%2012_2011%20corp.pdf