|

Rpgconsultants.com

Flexible Spending Accounts Eligible Expense Guide
Healthcare & Dependent Care

Eligible Expense Guide
This guide will provide a detailed listing of a healthcare and dependent care FSA spending
account. It lists general expenses allowed by the Internal Revenue Service (IRS), however, it is
not an exhaustive list and if you have a question regarding an expense not listed, please call the
RPG Consultants FSA Department at (212) 947-4800 ext. 215.
How to use this guide

1. Healthcare & Dependent Care: Sections contain an easy-to-read chart listing common
expenses.
2. Expense Type: Expenses are displayed alphabetically within their category. Examples of the
expense are listed beneath the expense.
3. Eligible for Reimbursement: This guide will state if the expense is generally reimbursable
from your FSA. However, there are certain exceptions or requirements for many expenses. It is
important that you read the Special Exceptions or Requirement
related to the expense.
4. Special Exceptions or Requirements: Follow the instructions provided to ensure your
particular expense is eligible.
Tip: To quickly search for an expense, click the search icon and type in the item
You are looking for. Example: You're searching for glasses, just type in ‘eye glasses.'

General rules for eligible expenses
In order for RPG Consultants to consider an expense eligible, the expense must:
• Be allowed by the IRS;
• Be allowed by your employer's FSA plan;
• Be incurred during your employer's plan year or during the 2 ½ month extension period, if
allowed by your employer's plan;
• Be for you or a qualified dependent
• Not be reimbursed through another plan
• Not be used as a dependent day care credit or healthcare deduction on your personal tax
return.
To obtain reimbursement for an eligible healthcare or dependent care expense, you must
complete a reimbursement request, which can be found on our web site www.rpgny.com and
must be accompanied by a detailed receipt or other supporting documentation.
Definition of a qualifying dependent
Healthcare and dependent care expenses must be for you or a qualified dependent in order to
be eligible for your FSA.
The definition of "dependent." Please note:
Generally speaking, a qualifying child must:
• Reside with you for more than half the year1;
• Be younger than 27 years of age
• Not provide over half of his/her own support.

A dependent who does not satisfy the requirements for a qualifying child may meet the
requirements for a qualifying relative. A qualifying relative is an eligible individual if:
• You provide more than half of the individual's support;
• The individual is not a qualifying child of you or any other taxpayer.
Please note that any questions regarding the status of an individual as either a
qualifying child or a qualifying relative must be discussed with a qualified tax advisor in
conjunction with the provisions of your employer's plan.

Healthcare Expenses

Eligible healthcare expenses generally include amounts paid for the diagnosis, care, mitigation,
treatment, or prevention of disease or illness and for treatments affecting any part or function of
the body. Any expense recommended for the bettering of an individual's general health or
wellbeing is not eligible (example: vitamins/supplements).
Eligible expenses must be for you, your spouse, children, and any other person who is a
qualified dependent as defined by the IRS.
ATTENTION!

Doctor's Statement: Certain expenses wil require a doctor's statement indicating the specific
medical disorder, the specific treatment needed, and how this treatment will alleviate the
medical condition. For your convenience, RPG Consultants has created a doctor's statement
form that is printed at the end of this document.
Healthcare Expense List
Special Exceptions A
AA, Alcoholism, Drug or Substance
Payment to a treatment center Abuse Treatments for alcohol or substance abuse is an eligible medical expense. This includes meals and lodging provided by the center during inpatient medical treatment Check your employer's specific FSA plan to make sure this expense is covered. Acne treatments are eligible
when prescribed by a doctor.
Doctor's statement required.
You may submit healthcare expenses for an adopted child once it becomes your qualified dependent, including healthcare

expenses incurred during the adoption process, such as physical examinations. Air Purifier or Humidifier (for allergy relief) Allergy Relief • Prescription and over-the- counter allergy medicines • Allergy shots Allergy Relief Doctor's statement required.
• Electro-static air purifier • Humidifier • Home/auto air conditioners • Air filters • Special vacuum cleaners • Special pillows, mattress covers, etc. to alleviate an allergic condition Ambulance Service Artificial Limb (prosthesis) or Teeth (dentures) Artificial Insemination • Fertility exams
• Embryo replacement and
storage
• Egg donor: recipient's medical
expenses (recipient must be
FSA participant or participant's
dependent and the charges are
covered by a medical plan)
• In-vitro fertilization
• Sperm bank/semen storage for
artificial insemination
• Sperm implants due to sterility
• Sperm washing
• See also "Fertility Treatments"
B
Birth Control / Family Planning
• Norplant or Depo-Provera • Ovulation kits • Condoms • Spermicides • Birth control pills, patches or rings • Diaphragm or IUD • Tubal ligation • Vasectomy The birth control list is not exhaustive. Blood Storage Fees for storing blood for surgery in the near future are an eligible medical expense. Body scanning performed as a • CT body scanning preventive or proactive • Full body scanning healthcare measure for healthy • Whole body scanning individuals who have no
symptoms or suspicion of
disease is not an eligible

expense.
Body scans ordered by your
doctor for a specific medical
purpose are eligible.
Doctor's statement required.
Braces and other Orthodontics Breast pumps are reimbursable
under limited circumstances. To
be an eligible expense, the
participant must have a
diagnosed disease, injury or
illness, and the breast pump
must be directly related t treating
or alleviating that diagnosed
condition.
Doctor's statement required.
C
Childbirth-Related
New parent or newborn child • Childbirth prep classes care classes are NOT
• Midwife or doula fees • Maternity girdles (for back pain) or special support hose (for leg circulation) • Home pregnancy tests • Ovulation kits Chiropractor fees Fees for "ritual" circumcision
performed by a non-healthcare
provider (e.g., a rabbi, mohel)
are NOT eligible.
Prescription contact lenses only. Fees for storing umbilical cords
for surgery in the near future are
an eligible medical expense.
Fees for storing umbilical cords
for use in the indefinite future
are NOT an eligible expense.
Cosmetic Surgery and Procedures A cosmetic surgery or procedure • Cosmetics (make-up) can be an eligible expense if it is • Dental veneers, bonding, tooth necessary to improve a whitening/bleaching deformity that arises from, or is directly related to, a birth defect, • Tattooing and ear/body piercing a disfiguring disease or an injury • Removal of tattoos resulting from an accident or trauma. Some of these • Blepharoplasty procedures/treatments may be • Sclerotherapy covered under alternative uses • Facials, chemical peels Doctor's statement required.
• Botox or Collagen injections • Breast implants, lifts • Hair transplants or electrolysis Counseling Counseling must be performed • Psychotherapy and to alleviate or prevent a physical or mental defect or illness. Eligibility is determined by the • Bereavement and grief nature of the treatment and not the license of the practitioner.

Marriage counseling is not an
eligible expense unless
performed for the purpose of
alleviating or preventing a
physical or mental defect or
illness
D
Dancing Lessons, Swimming
The cost of dancing lessons, swimming lessons, etc., even if a doctor recommends them for the general improvement of one's health, is NOT an eligible medical expense.
Diabetic Supplies • Cotton balls • Alcohol swabs • Glucose tablets • Glucometer and test strips • Needles (lancets) • Syringes • Glucagon emergency kit • Ketone urine test strips • Training classes Dental Care and Prevention • Cleaning • X-rays • Fillings • Braces or other orthodontics • Extractions • Dentures • Bonding and sealants for dentures • Crowns • Porcelain veneers (if allowed by dental plan, i.e., not cosmetic) Dental Treatment - Cosmetic • Teeth whitening or bleaching Diaper Service Diapers for a disabled child,
other than a newborn, may be
eligible, and ONLY if needed to
relieve the effects of a particular
disease. Doctor's statement
required.
Fees include the portion of the • Anesthesiologist expense not paid for by other • Chiropodists health insurance (the "out-of- • Chiropractor pocket" portion) • Christian Science Practitioner Late fees, finance fees, missed appointments, etc. are NOT
• Dermatologist eligible medical expenses. • Gynecologist • Naturopath • Neurologist • Obstetrician • Oculist • Oncologist • Ophthalmologist/Optometrist • Optician • Orthopedist

• Osteopath • Otorhinolaryngologist • Pediatrician • Physician • Podiatrist • Psychiatrist • Physiotherapist • A physical without diagnosis or not covered by insurance • Consultations • Transfer of medical records • Any expense a doctor may charge to write a letter describing the medical condition and how a recommended item will treat that condition This list is not exhaustive. Drugs/Medicines – Prescriptions Prescription drugs must be prescribed by a certified physician and must be purchased legally within the U.S. (See: Health Expenses Incurred Outside of the USA for travel or extraordinary circumstances.) Drugs/Medicines - Over-the-Counter See the OTC Guide at the end of this section for more information. Drug Addiction Treatment E
Electrolysis or Hair Removal
Maybe Electrolysis or hair
removal can be an eligible
expense if it is necessary to
improve a deformity that arises
from, or is directly related to, a
birth defect, a disfiguring
disease or an injury resulting
from an
accident or trauma.
Doctor's statement required.
Eyeglasses and Eye Care Vision insurance premiums and • Eye examinations non-prescription sunglasses are • Contact lenses, fitting fee, not eligible medical expenses.
replacement lenses Non-prescription cosmetic • Contact lens solution contact lenses (change eye • Reading glasses, color only) and non-prescription • Prescription glasses, sunglasses are NOT eligible.
prescription sports goggles, *Surgery is eligible if done prescription sunglasses, scuba primarily to promote the masks or safety glasses* correct function of the eye. A • Artificial eye and polish doctor's statement may • Radial keratotomy, laser be required to document the surgery or other vision condition being treated. correction surgery *
F
Fees for a facility, such as a hospital or similar • Nursing Home institution, are eligible expenses • Rehabilitation Facility if the main reason for • Home for Mentally or Physically being there is to receive medical Feminine Hygiene Sanitary napkins are an eligible • Sanitary napkins (pads & expense if used during the recovery from childbirth, surgery or for treatment of other medical condition. Doctor's statement required. Fertility Treatments • Artificial insemination • Fertility exams • Embryo replacement and storage • Egg donor: recipient's medical expenses (recipient must be FSA participant or participant's dependent and the charges are covered by any medical plan) • In-vitro fertilization • Sperm bank/semen storage for artificial insemination • Sperm implants due to sterility • Sperm washing • Reverse vasectomy • Reverse tubal ligation Fluoride Treatments Funeral Expenses G
Genetic Testing
Genetic testing performed to
detect possible birth defects is
an eligible expense.
Testing to determine a child's
gender is NOT eligible.
• Cost of the animal
• Care of the animal
H
Hair Transplant
Surgical hair transplants can be
an eligible expense if it
is necessary to improve a
deformity that arises from, or
is directly related to, a birth
defect, a disfiguring disease or
an injury resulting from an
accident or trauma.
Doctor's statement required.
Health Screenings The cost of a public health screening (i.e., VDRL, cholesterol, diabetes glucose, blood pressure, etc.) is an eligible medical expense. • Purchase price and maintenance cost for hearing aid • Batteries needed to operate the hearing aid • Television or telephone adapter for the deaf • Lip reading lessons • Hearing exams Hospital Services/Fees The amount left after insurance has paid their part I
Insurance Co-Pays
Insurance Premiums
Insurance premiums that are • Any medical, dental or vision paid for projected medical insurance premium (HMO, expenses are not eligible expenses, but may be claimed • Long-term care insurance on tax forms. Please consult with your tax advisor for • Medicare (parts A, B & D) • Life insurance Expense Type
• Disability insurance premiums Reimbursement
• Warranties
• COBRA premiums
L
Laboratory Fees
• Blood tests • Cardiographs • Metabolism test • Stool exams • Spinal test • Urinalysis • X-ray exams • Pap smears • Cholesterol test • Thyroid profile • Storage fees for blood taken for surgery in the near future (not long-term storage) • Laboratory handling fees Lodging Lodging at a hospital or similar institution is an eligible • Nursing Home expense if the primary reason • Rehabilitation Facility for being there is to receive medical care Lodging (receiving medical care The cost of lodging not provided while away from home) in a hospital or similar institution while away from home* is an eligible medical
expense if:
• the lodging is primarily for and
essential to medical care
• medical care is provided by a doctor in a licensed
hospital or medical care facility equivalent of a
licensed hospital
• the lodging is not lavish or extravagant under the
circumstances
• there is no significant element of personal pleasure, recreation or vacation in the travel away from home.
*The amount you include as medical expenses may not exceed $50 per night per person. Lodging is included for a person
for whom transportation expenses are a medical expense because that person is traveling with the person receiving medical
care. (e.g., a parent traveling with a sick child is allowed up to $100.00 per night as a medical expense for lodging).
Meals are NOT an eligible medical expense in this instance.
M
Marijuana
New parent or newborn child • Childbirth prep classes care classes are NOT eligible
(Lamaze) • Midwife or doula fees • Maternity girdles (for back pain) or special support hose (for leg circulation) • Home pregnancy tests • Ovulation kits Meals Meals at a hospital or similar institution are eligible • Nursing Home expenses if the main reason for • Rehabilitation Facility being there is to receive medical care. Medical Alert Bracelet Medical Supplies Expenses paid for medical supplies used to aid a person • Thermometers suffering from physical • Heating pad/pack, ice pack defect/illness are eligible • Back braces or supports medical expenses. • Wheelchairs, walkers, canes, *These items require a doctor's
• Truss
• Diabetic supplies
• Orthopedic shoes (partial
reimbursement)
• Blood pressure kit
• Glucose kit
• Cholesterol testing kit
• Inclinator*
• Reclining chair*
• Special mattress (partial
reimbursement)*
• Physician's scales*
• Bed boards*
• Educational materials related to
a diagnosed illness*
N
Nutritional Supplements
Nutritional supplements
prescribed by a doctor for the
treatment of a specific medical
condition are eligible.
Doctor's statement required
O
Orthodontics
Over-the-Counter Medicines/Drugs Over-the-counter medicines, intended for medical use only and not merely to benefit the participant are an eligible medical expense. An itemized receipt showing the name of drug, date purchased and purchase price is required with the claim form. A doctor's statement may be required for certain items. See the end of this section for a detailed list of over-the-counter drugs. • Oxygen tanks
• Oxygen equipment
P
Penile Implants
A penile implant is an eligible
expense only if impotence is due
to such organic causes as
trauma, post-prostatectomy or
diabetes
. Doctor's statement required.
Personal Hygiene Products • Toothpaste, toothbrush, mouthwash, floss • Deodorant • Shampoo, conditioner, hair spray • Bath soap, hand soap • Shaving cream Prescription Drugs Prescription drugs are an eligible expense if prescribed by a doctor and purchased in the United States Psychiatric Care Eligible expenses include the cost of supporting a mentally ill dependent at a specially equipped medical center where the dependent receives medical care R
S
Sales Tax or Shipping & Handling
Costs for sales tax and shipping or handling fees associated with an eligible expense Stop-Smoking Program Over-the-counter (OTC) items for smoking cessation are eligible Surgery, Non-Cosmetic *These items require a doctor's
• Physical therapy statement.
• Occupational therapy • Speech therapy* • Chiropractor fees • Massage therapy* • Hydrotherapy* • Hypotherapy* • Patterning exercises for mentally disabled persons* • Radiation therapy • Chemotherapy • Counseling • Telephone Counseling Transplants, organ or tissue • Surgical, hospital, laboratory and transportation fees • Cost to transfer medical records in order to find organ donors Transportation for Medical Care Current mileage rate for 2006 is • Mileage for personal automobile 18 cents per mile. • Parking fees and tolls The following information must • Bus, taxi, train, plane fare be included with the • Ambulance service request for mileage reimbursement: • Amount of miles. • Date of transportation. • Name of provider U
Umbilical Cord Storage
Fees for storing umbilical cords for surgery in the near future are an eligible medical expense
Fees for storing umbilical cords for use in the indefinite future are NOT an eligible expense
Vitamins and Dietary Supplements
Vitamins or other supplements
prescribed by a doctor for the
treatment of a specific medical
condition are eligible.
Doctor's statement required.
W
Water Fluoridation Units and Water Pik
Maybe Items prescribed by a
doctor for the treatment of a
specific medical condition are
eligible.
Doctor's statement required.
Weight Loss Program The weight loss program must
treat a medical condition
diagnosed by a healthcare
provider. (Examples: obesity,
diabetes, high blood pressure)
Only program fees are eligible.
Doctor's statement required
The cost of a weight loss
program to improve your general
health and appearance is NOT
an eligible expense. The cost of
food is NOT an eligible expense.
• Purchase price of wheelchair • Operating cost of wheelchair Wigs or toupees are eligible
expenses if recommended
by a physician for the mental
health of a person who has lost
his/her hair due to disease.
Doctor's statement required
X
X-Ray Fees

OTC Guide

The Internal Revenue Service (IRS) allows reimbursement of some over-the-counter (OTC)
medicines and products from a Healthcare FSA when the OTC product is used for medical
purposes. Below is a description of the three IRS-defined categories for OTC: eligible, dual
purpose, and ineligible items, followed by product examples for each category.
Submitting healthcare OTC reimbursement requests

Reimbursement for any expense must follow the existing rules regarding Healthcare FSAs, with
some minor adjustments made to accommodate receipts and appropriate use. The expense
must:
• Be incurred during your period of coverage.
• Be for you or an eligible dependent.
• Not be reimbursed through another plan.
• Be accompanied by a detailed receipt. A detailed receipt must provide the name of the
medicine or product, the date, and the amount paid. If your supermarket or pharmacy
receipt does not include this information, you will need to have this information
documented by your supermarket or pharmacy.
• Be reasonable in quantity.

Eligible OTC Expenses

Eligible items include medicines or products that alleviate Examples of each
or treat injuries or illness for you and your dependents.
These drugs and products are NOT cosmetic in nature, or
merely beneficial to your general health. The products
listed here are examples, and do NOT constitute an
endorsement or an exhaustive listing of reimbursable OTC
products. You do not need to purchase national-brand
products. You can purchase generic, store-brand
products.
ALL ITEMS IN BOLD NOW REQUIRE A DOCTOR'S NOTE.


Type of Product

Allergy Prevention and Treatment
Actifed * Allerest * Benadryl * Chlor-Trimetron * Claritin * Contac * Nasalcrom * Sudafed * Pseudoephedrine Aspirin * Advil * Children's Motrin * Ibuprofen * Motrin * Naprosyn * Tylenol * Tylenol PM * Midol * Pamprin * Premysyn PMS * Acetaminophen Antacids and Acid Reducers
Alka Seltzer * Alka Seltzer PM * AXID AR * Gas-X * Maalox * Mylanta * Tums * Pepcid AC * Prilosec OTC * Tagamet HB * Zantac 75 Aleve * Aspercreme * BenGay * Tylenol Arthritis Antibiotics (topical)
Bacitracin * Triple Antibotic Ointment Anticandial (yeast)
Femstat 3 * Gyne-lotrimin * Mycelrx-7 * Monistate 3 * Vagistat-1 Antidiarrheal and Laxatives
Ex-Lax * Immodium AD * Kaopectate * Pepto-Bismol Antifungal Creams
Lamisil AT * Lotramin AF * Micatin Actidil * Actifed * Allerest * Benadryl * Claritin * Chlor-Trimetron * Contac * Drixoral * Sudafed * Tavist-1* Triaminic Anti-itch Lotions and Creams
Bactine * Benadryl * Caldecort * Caladryl * Calamine * Cortaid * Hydrocortisone * Lanacort * Lamisil AT * Lotramin AF Asthma Medicines
Bronkaid * Primatene Mist Cold Sore/Fever Blister Remedies
Cold and Flu Remedies
Actidil* Actifed * Advil Cold and Sinus * Afrin * Alka Seltzer Cold and Flu * Afrinol * Aleve Cold and Sinus * Children's Advil Cold * Dayquil * Dimetane * Dristan Long Lasting * Drixoral * Neo-Synephrine-12 Hour * Nyquil * Orrivin * Pediacare * Sudafed * Tavist-D * Thera-Flu * Triaminic * Tylenol Cold and Flu Contact Lens Supplies Allergan * Bausch & Lomb * Opti-One Contraceptive Products Pregnancy Tests * Spermicides* Condoms Cough Suppressants or Expectorants
Robitussin * Vicks 44 Claritin-D * Neo-Synephrine * Sudafed Dehydration Remedies
Diaper Rash Medication
Balmax * Desitin Allergan * Bausch & Lomb * Visine First Aid Supplies Bandages * First aid kits * Cold/hot packs for injuries * Rubbing alcohol * Ace wraps * Splints Hemorrhoidal Preparations
Preparation H * Hemorid * Tronolane Lactose Intolerance Aids
Migraine Relief
Advil Migraine * Motrin Migraine * Excedrin Motion Sickness Aids
Dramamine * Marizine Advil * Aleve * Bayer * Ibuprofen * Motrin * Naprosyn * Naproxen Ophthalmic Preparations
Akwa Tears * Muro 128 Sinus Products
Smoking Cessation Products Commit * Nicoderm CQ * Nicorette * Nicotrol Sunburn Relief
Solarcaine * Water Gel Topical Steroids
Wart Removal Products
Compound W * Scholl Clear Away * Wart-Off Wound Care

Dual Purpose Items

Certain OTC items are called dual purpose. Reimbursable Use
Excluded Use
That's because for some individuals the
product is used to alleviate a medical
condition, while others use the product for
general health and wellbeing. These
products may be reimbursed through a
Healthcare FSA, but require a medical
provider's note stating your specific
diagnosis or medical condition and a
recommendation to take the specific
OTC medicine to treat your condition.
You must also provide an adequate
receipt.
Type of Drug or Product
T Acne Products
Chronic acne under treatment by Occasional outbreak or blemish a physician Dietary/Nutritional/Herbal Supplements Diagnosis of a specific medical Routine use for general health Feminine Hygiene Products Post surgery or childbirth use for personal hygiene Fiber Supplements Diagnosis of a specific medical Routine use for general health Monitoring a specific condition Tracking heart rate during exercise for general purposes Joint Supplements Diagnosis of a specific medical Routine use for general health condition, such as arthritis Lactose Intolerance Supplements Diagnosis of a specific medical Routine use for general health OTC Hormone Therapy Diagnosis of a specific medical Routine use for general health Pre-Natal Vitamins When prescribed by a doctor Routine use for general health Snoring Cessation Aids Diagnosis of a specific medical condition, such as sleep apnea Diagnosis of skin cancer or other Prevention of sunburn medical condition Vitamins and Minerals Diagnosis of a specific medical Routine use for general health Weight Loss Products Diagnosis of obesity Any weight loss without diagnosis of obesity
Dependent Care Expenses

Most work-related expenses incurred for the care of a qualified person will be eligible for
reimbursement through a dependent care FSA. Your expenses must be for the well-being and
protection of a qualifying dependent while you and your spouse, if married, work or look for
employment.
Definition of ‘work-related'

The following employment rules apply to dependent care FSAs:
• You must be employed full-time or part-time, depending on your employer's plan, or
actively looking for work;
• If married, both you and your spouse must work unless your spouse is looking for work,
is a full-time student or is disabled;
• Unpaid volunteer or volunteer work for a nominal salary does not qualify as employment.

Full-time Student Definition: You are a full-time student if you are enrolled at and attend a
school for the number of hours or classes that the school considers full-time. You must have
been a student for some part of each of five calendar months during the year, but the months do
not have to have been consecutive. The term "school" does not include on-the-job training
courses, correspondence schools, or Internet courses/schools.
Children of Divorced or Separated Parents: A child can be the qualifying individual of only
one parent in one year. Dependent care expenses for the custodial parent may be employment
related expenses if the child: (1) receives over one-half of his/her support from one or both
parents; and (2) is in the custody of one or both parents for more than one-half of the calendar
year.
Who Qualifies To Receive Dependent Care?
In general, and subject to the rules of your employer's plan, the following rules apply to a
qualifying person:
• The individual must be your qualifying dependent (child or relative) as defined by the
IRS.
• If the individual is your child, he or she must be under the age of 13 unless physically or
mentally unable to care for him- or herself.
• If the individual is your spouse, he or she must be physically or mentally unable to care
for him- or herself.
Individuals not able to dress, clean, or feed themselves, or who require constant attention to
prevent injury to themselves or others because of physical or mental problems are considered
unable to care for themselves.
Please note: Simply being unable to work, perform normal household functions, or care for
minor children does not mean an individual is incapable of caring for him- or herself.
Who Qualifies To Provide Dependent Care?

Dependent care can be provided by:
• Any individual not claimed as a tax dependent by you or your spouse.
• Your child who is at least 19 years of age by the end of the plan year.
• A child, adult or elder care center. If the center serves seven or more children or adults,
the center must comply with all applicable state and local regulations.
The care provider must have a Social Security Number, Employer Identification Number (EIN), Individual Taxpayer Identification Number (ITIN) or a Taxpayer Identification Number (TIN). Eligible for Dependent Care Expense
Special Exceptions or
Eligible For Reimbursement Requirements
Activity Fees from Care Provider Fees paid to a dependent care center for special activities are • Dancing or swimming lessons NOT eligible expenses, unless
• Art supplies • Entertainment incidental to, and cannot be separated from, the cost of caring for a dependent After-School Programs Before-School Programs Care Provided at a Provider's
Home
Care Provided by a Relative
The following are NOT eligible
expenses:
• Payments made to a dependent
for whom you or your spouse
claim as an tax exemption, or
• Payments made to your child
who was under the age of 19 at
the end of the year
Care Provided in Your Home
Day camps can include theme-based camps, such as soccer camp or computer camp and may be an employment-related expense if incurred for the care of a qualifying individual which enables the employee to be gainfully employed Dependent Care Centers If the center serves seven or • Child day care more children or adults, the • Adult or elder care facility center must comply with all applicable state and local regulations Nursery school fees, including pre-Kindergarten, are eligible expenses even if educational services are provided. A pro-rated portion for the
‘daytime' care provided by an
overnight camp is NOT an
eligible expense
Maybe Overnight dependent care is eligible if you are required to travel overnight for work-related reasons, and your spouse, if married, is unable to be home with the child Application Fees, Agency Fees, Expenses that relate to, but are not directly for, the care of a qualifying individual, such as application fees, agency fees (e.g., for Au Pairs), and deposits, may be for the care of a qualifying individual and may be employment-related expenses if the taxpayer is required to pay the expenses to obtain the related care. The expense is incurred when the participant is provided with the care that gives rise to the expenses, and not when the participant is formally billed or charged for or pays for the care Tuition for Kindergartner or Higher Tuition fees for kindergarten or
higher are NOT eligible
expenses. If dependent care is
provided as part of the tuition (for
example, for before and after
school care), only the cost of
caring for the child is eligible.
A separation must be made
between the fees for child care
and educational services.
Doctor's Statement Form for Healthcare Expense The Internal Revenue Service requires a doctor's statement be provided for certain healthcare expenses in order to be reimbursed from your healthcare Flexible Spending Account (FSA). The doctor's statement must indicate the specific medical disorder, the specific treatment needed, and how this treatment will alleviate the medical condition. RPG Consultants has developed the following form to assist you and your healthcare provider in providing the information we need in order to process your reimbursement request. Your provider can also write a letter on his or her letterhead, as long as the letter includes all the information on this form. For fast and accurate processing of your reimbursement request, please make sure to include this doctor's statement form or your provider's letter along with an itemized receipt or other documentation. Employee Name Place of Employment Recommended Treatment How will the recommended treatment alleviate the diagnosis or symptoms? _ How long is the treatment required? _ Provider Address Provider Telephone # _ Provider Signature _

Source: https://www.rpgconsultants.com/pdf/fsa_medical_and_dependent_care_-section_125_fsa_forms/RPG_FSA_Eligible_Expense_Guide_2015%20(ID%20501574).pdf