FSA Eligible Expenses

Transcription

1 The following is a summary of common expenses for Health Care Flexible Spending Accounts (FSAs) and Dependent Care Flexible Spending Accounts (FSAs). Please refer to your employer's Summary Plan Description (SPD) for your specific plan details. This list is not intended to be exhaustive and should only be used as a general guide. Expenses contained in this list may be denied if the supporting claims documentation is insufficient or shows that the expense was incurred for services not considered medically necessary. Payment of claims will be based on all applicable regulations, the employer's plan design and information on the claim form. Due to frequent updates to the regulations governing FSAs, this list does not guarantee reimbursement, but instead is to be utilized as a guide for the submission of claims. : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and AA Meetings, transportation to Abortion Acne treatment (RX) Acupuncture/Acupressure Adaptive Equipment (LM) Adoption Fees Adoption, Pre-Adoption Medical Expenses Adult Daycare After-School Care or Extended Day Programs (Supervised activities after school) Agency Fee (Paid in order to receive dependent care) Dependent Care Air Conditioner (CG) Air Purifier (CG) Airborne (RX) Alcoholism Treatment Allergy Medicines (RX) Alli (RX) Alternative Healers (RX) Ambulance Analgesics (RX) Antacids / Acid Reducers (RX)

2 FSA Eligible Expenses : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Anti-Arthritis (RX) Anti-Itch Creams (RX) Anti-Snore guards (RX) Antibiotic Ointments (RX) Anti-Diarrheal (RX) Antifungal Products (RX) Antihistamines (RX) Arch Supports Arm Sling Arthritis gloves Artificial Limbs Aspirin (RX) Assisted Living Asthma Treatments Athletic Mouth Guards Au Pair Automobile Modifications (LM) Baby Formula (Difference in cost between the special formula and regular formula will qualify) (LM) Baby Oil Baby Powder Babysitter (Inside or outside participant's household if claiming payment on tax returns) Back-up or Emergency Care Bactine (RX) Bandages, elastic Bandages, non-medicated Bandages, medicated (RX) Beds, Mattresses (LM) Bedside Commodes Before-School Care or Extended Day Programs (Supervised activities before school)

3 FSA Eligible Expenses : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Biofreeze (RX) Birth Control Pills (RX) Birth Control Devices (RX) Birthing Classes Blood Storage (LM) Blood-Pressure Monitoring Devices Blood-Sugar Test Kits and Test Strips Boarding School Body Scans Breast Pumps and Supplies Breast reconstruction Surgery (Following mastectomy) Breathe Rite Strips (RX) Bug Spray Caffeine Pills Calamine Lotion (RX) Callous Removers Caltrate (RX) Cane, Walking Capital Expenses (LM) Cardiac Therapy Carpal Tunnel Wrist Supports Cast Covers Chairs, Ergonomic (LM) (Difference in cost between ergonomic chair and a regular chair would qualify) Chairs, Reclining (LM) (Difference in cost between specialized recliner and a regular recliner would qualify) Chauffeur Chelation Therapy Childbirth Classes Chiropractic Adjustments Chondroitin (RX) Cialis (RX) Circumcision Claritin (loratadine) (RX)

4 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Co-Payments Cold Medicine (RX) Cold Sore Medicine (RX) Cold/Hot Packs Companion Animals (LM) Compression Stockings (RX) Concierge Medical Fees Condoms Contact Lenses Contact Lens Solution Controlled Substances (In violation of federal law) Cord Blood Storage (LM) Corneal Ring Segments Cosmetics Cotton Balls Cough Drops/Suppressants (RX) Counseling (Marriage Counseling Doesn t Qualify) CPAP Machine and Headgear Crowns, Dental Crutches Custodial Care Day Camp Daycare (Children age 12 and under) Deductibles Decongestants (RX) Dental Care, cosmetic Dental Floss Dental Implants Dental Sealants Dental Treatment Denture Brush Denture Cleaners

5 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Dentures and Denture Adhesives Diabetic Socks (RX) (Difference in cost between special socks and regular socks will qualify) Diabetic Supplies Diagnostic Items and Services Diaper Rash Ointments and Creams (RX) Diapers or Diaper Service (LM) Diarrhea Medicine (RX) Diet Foods Dietary Supplements (RX) Disabled Dependent, Care of Disabled Qualifying Child (Age 12 and under) Discount Programs Doula Drug Addiction Treatment Drug Overdose, treatment of Drug Screening Ear Piercing Ear Plugs (RX) Ear Wax Removal Products (RX) Eczema Lotions and Creams (RX) Egg Donor Fees (LM) Eggs and Embryos, storage fees (LM) Elder Care Electrolysis or Hair Removal Electrolyte Replacements (RX) Elevator (CG) Epsom Salt (RX) Exercise Equipment (LM) Exercise Programs (LM) Expectorants (RX) Extended Daycare Eye Drops (RX)

6 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Eye Examinations, Eyeglasses, Equipment, Materials, and Repair Face Creams Face Lifts Feminine Hygiene Products Fever-Reducing Medications (RX) Fiber Supplements (RX) FICA and FUTA taxes of Day-Care Provider Field Trips Finance Charges First Aid Cream (RX) First Aid Kits Fitness Programs (LM) Flavoring for Medication Fluoride Rise (RX) Flu Shots (LM) Food (Difference in cost between special food and regular food would qualify) Foreign Countries, Medical Care Received in Funeral Expenses Gauze Pads Genetic Testing (LM) Glasses Glucosamine (RX) Glucose-monitoring equipment Guide dog, other service animal Hair Colorants Hand Lotion Hand Sanitizer (RX) Headache Medications (RX) Healing Ointments (RX) Health Club Fees (LM) Health Institute Fees (LM) Health Screenings

7 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Hearing Aids Heating Pad Hemorrhoid Treatments (RX) Herbs (RX) Holistic or Natural Healers (Rx) Home Diagnostic Kits / Tests Home Improvements (LM) Home Medical Equipment (LM) Homeopathic Products (RX) Hormone Replacement Therapy (HRT) (RX) Hospital Services Household Help Humidifier (RX) Hydrotherapy (LM) Hypnosis (LM) Hysterectomy Illegal Operations and Treatments Immunizations Incontinence Supplies Insect-Bite Creams and Ointments (RX) Insulin Insurance Premiums (Individually owned policy, including dental, health, long-term care, Medicare, short-term medical, supplemental, vision and more.) HRA In-Vitro Fertilization (LM) Kindergarten Kleenex Lab Fees Lactation Consultant (LM) Lactose Intolerance Supplies (Rx) Lamaze Classes Language Training (LM) (Child with dyslexia or an otherwise disabled child) Laser Eye Surgery; Lasik Laser Hair Removal

8 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Late Fees Late Payment Fees Late Pickup Fee Latex Gloves Laxatives (RX) Lead-Based Paint Removal (Surfaces must be in poor repair and within a child's reach) Learning Disabilities (LM) Legal Fees (LM) (To authorize treatment for mental illness) Levitra (RX) Lice Treatments (RX) Lifeline Screenings Lifetime Care Liquid adhesive (For small cuts) Lodging at a Hospital or Similar Institution Lodging, other (LM) (Up to $50 per night) Long-term Care Expenses Looking for Work (Care that enables the employee and/or spouse to look for work) Lotions Lubricants (Rx) Lumbar Support Chair Cushions (RX) Makeup Marijuana or other Controlled Substances (In violation of federal law) Massage Therapy (LM) Mastectomy-Related Special Bras Maternity Clothing Mattresses (In Rare Cases) Meals at a Hospital or Similar Institution (When included in the cost of inpatient care) Meals not at a Hospital or Similar Institution

9 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Meals of a Companion Mederma (RX) Medical Alert Bracelet or Necklace Medical Information Plan (Plan that maintains electronic medical information) Medical Records Charges Medical Services Medical Supplies Medicated Lip Products (RX) Menstrual Relief (RX) Mentally Handicapped Special Home (LM) Midwives Migraine Medications (RX) Mileage Charged by Dependent Care Provider Mileage to Bring the Dependent to Daycare Mileage Incurred (Traveling for Medical Reasons) Mineral Supplements (RX) Missed Appointment Fees Morning-After Contraceptive Pills (RX) Motion Sickness Patches or Wristband RX Motion Sickness Medications (RX) Mouthwash Multivitamins (RX) Nanny (Only Day Care Portion) Nasal strips or sprays (RX) Naturopathic Care (LM) Nebulizer Needle Container Neti pots Newborn Nursing Services (rmal and healthy baby) Nicotine gum or patches (RX) rplant Insertion or Removal Nursing Care and Services (LM) (Private Duty Nursing)

10 FSA Eligible Expenses : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Nursing Home Nutritional supplements (RX) Nutritionist (LM) Obstetrical Expenses Occlusal guards Occupational Therapy Online or Telephone Consultation (Medical practitioner's fee) Operations Optometrist Oral Care Products (RX) (e.g. Anbesol, Orajel) Orthodontia Orthopedic Shoes (RX) (Excess cost between orthopedic shoes and regular shoes will qualify) Orthotic Inserts (Custom -made and over-the-counter) Osteopath Fees Ostomy Supplies (RX) Over-the-Counter-Medications (RX) Overnight Camp Ovulation Monitor Oxygen and Equipment Pain Relievers (RX) Parking Fees and Tolls (Related to medical care received) Pedialyte (RX) Pedometer (RX) Pediculicide (e.g. Nix, Rid) Penile Implants (LM) Perfume Peroxide (RX) Personal Grooming Items Personal Trainer Fees (LM) Physical Exams

11 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Physical therapy Pillows; Lumbar Support (LM) Placement Fees (For finding a dependent care provider) Pregnancy test Kits Prenatal Vitamins (RX) Prepaid Fees for Dependent Care (Cannot be reimbursed until care is provided) Preschool/Nursery school Prescription Drug Discount Programs Prescription Drugs/Medicines (RX) Prescription Drugs/Medicines (Obtained from other countries) Preventive Care Screenings Probiotics (RX) Product Replacement Plans/Warranties Propecia (LM) Prosthesis Psychiatric Care Psychoanalysis (LM) Psychological Care (LM) Q-tips Radon Mitigation (LM) Reading Glasses Recliner Chairs (LM) (Difference in cost between specialized recliner and a regular recliner would qualify) Reflexology (LM) Registration Fee (Cannot be reimbursed until care is provided) Relative (Payments to a relative for dependent care) Retin-A (LM) Rogaine (LM) Rubbing alcohol (RX) Safety Glasses (RX)

12 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Schools and Education, Residential (LM) Schools and Education, Special (LM) Screening Tests Seeing-Eye Dog/Other Service Animal Self-Employment (Dependent care expense incurred in connection with) Shampoos (RX) (RX) Shaving cream or lotion Shipping and Handling Fees (When in connection with medical equipment/items) Sick-Child Facility Sinus Medications (RX) Sleep Aids (RX) Smoking-Cessation Medications (RX) Smoking-Cessation Programs Soaps Special Foods (Difference in cost between special food and regular food would quailfy) (RX) Speech Therapy (LM) Sperm Storage Fees (LM) Spermicidal Foam (RX) Spouse of Employee (Payments to a spouse for dependent care) Stem Cell Harvesting and/or Storage (LM) Sterilization Procedures Sterilization Reversal St. Johns Wort (RX) Student Health Fee Substance Abuse Subway Fare (In connection with medical care received) Summer Day Camp Summer School

13 FSA Eligible Expenses : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Sunburn Creams and Ointments (RX) Sunglasses (RX) Sunglasses, Clip-on Sunscreen (Only SPF 15 and above will qualify) Sunscreen, Cosmetics/Similar Products with Supply Fees Support Hose/TED stockings Surgery (n Cosmetic) Surrogate/Gestational Carrier Expenses Tanning Salon/Equipment (LM) Taxes on Medical Services and Products Taxi Fare (In connection to medical care received) Teeth Whitening Telephone for Hearing-Impaired Persons Television for Hearing-Impaired Persons Thermometers Throat Lozenges (RX) Toiletries Toll bridges (In connection with medical care received) Toothache/Teething Pain Relievers (RX) Toothbrushes Toothpaste Transplants Transportation Expenses (In connection with medical care received) Treadmill (LM) Tuition Expenses Tuition for Special-Needs Program (LM) Tutoring Programs

14 : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessity is provided to our office. The expense must be used to (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Ultrasound, Pre-Natal Umbilical Cord Freezing/Storage (LM) Unemployment (Dependent care that enables the employee and/or spouse to look for work) Vaccines Varicose Vein Treatment (LM) Vasectomy Vasectomy Reversal Veneers Veterinary Services (For a guide dog or other service animal) Viagra (RX) Vitamins (RX) Walkers Warranties/Insurance on a Product Wart remover treatments (RX) Water Fluoridation (LM) Water Pik Weight Loss Drugs (RX) Weight-Loss Programs (LM) Weight-Loss Surgery (LM) Wheelchair/Wheelchair Accessories Whirlpool Bath (LM) Wigs (LM) X-Ray Fees Yeast Infection Medications (RX)