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MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Adaptive equipment for a major disability, such as a spinal cord injury, can be reimbursed. Adaptive equipment to assist you with activities of daily living (ADL) for persons with arthritis, lupus, fibromyalgia, etc., can be reimbursed. Medical expenses incurred before an adoption is finalized will qualify. If the child qualifies as your tax dependent when the services/items are provided. (Adoption fees and other nonmedical expense incurred in connection with adoption assistance may qualify for an adoption assistance credit (under Code § 23) or for reimbursement under an adoption assistance program (under Code § 137).)  Inpatient treatment, including meals and lodging provided by  Transportation expenses associated with attending outpatient meetings, including AA groups, if attending on a doctor’s advice. Eligible expenses include products and home improvements to treat severe allergies. Examples include:  Pillows, mattress covers, etc. to alleviate an allergic condition Note: See Capital Expenses for important information and guidance. Services must be prescribed and rendered by a licensed health care provider to treat a specific illness or disorder. The expenses do not qualify if the remedy is a food or substitute for food that the person would normally consume in order to meet nutritional requirements. Eligible medical expenses include, but are not limited to:  Artificial insemination (intracervical, intrauterine,  Sperm bank storage/fees* for artificial insemination *NOTE: Storage fees should not exceed twelve months If your baby requires a special formula to treat an illness or disorder, the difference in cost between the special formula and routine baby formula can be reimbursed. Page 1 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Fees for temporary storage may qualify under some circumstances, such as where the blood is collected as part of the diagnosis, treatment, or prevention of an existing or imminent medical condition (e.g. in advance of scheduled surgery for use in a possible transfusion). Fees for indefinite storage, just in case the blood might be needed, would not be considered medical care. “Temporary” is not defined; however, one consideration might be whether the blood is stored and used within the same year. Monthly or annual fees that your provider may charge for improved access, 24/7 availability and more “personalized” care are not considered medical care and cannot be reimbursed under a health care FSA. The incremental cost of Braille books and magazines that exceeds the price for regular books and magazines is an eligible expense. A capital expense (permanent or portable) can be reimbursed if its purpose is to provide medical care for you, your spouse or dependent. Expenses for improvements or special equipment added to your home can be reimbursed if the main purpose of the item is medical care. How much is reimbursed depends on the extent to which the expense permanently improves the property and whether others benefit. The amount paid for the improvement is reduced by the increase in the value of your home or property. The difference between the costs of the improvement minus the increased value equals the eligible expense. If the value of your home or property is not increased by the improvement, the entire cost is an eligible expense.  Widening or otherwise modifying doorways, hallways and  Installing railings, support bars, or other modifications to  Kitchen modifications, including lowering cabinets and other  Electrical and plumbing modifications  Exterior grading of the property to provide access to your The list above is not exhaustive. If expenses are similar to those listed above, and are incurred to adapt a personal residence to yours or your spouse’s or dependent’s condition, the expenses are eligible subject to the terms noted above. Expenses must be reasonable, and directly related to the medical condition. Costs that are incurred for architectural or aesthetic reasons are not eligible. Page 2 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Payments for medical care can be reimbursed. Fees for other services Under IRS rules, insurance premiums cannot be reimbursed under a health FSA. Cannot be reimbursed by secondary insurance or any other source. Cannot be reimbursed by secondary insurance or any other source. Cosmetic procedures to improve or enhance appearance are not eligible. A cosmetic procedure or service necessary to improve a deformity arising from a congenital abnormality, personal injury from accident or trauma, or to restore appearance related to treatment for another medical diagnosis or condition can be reimbursed. If counseling is provided to treat a medical or mental diagnosis and is rendered by a licensed provider. Eligible expenses include psychotherapy, bereavement and grief counseling, sex counseling, etc. Life coaching, career counseling and marriage counseling do not qualify. Only for a short duration and if prescribed for a specific medical condition, such as part of a rehabilitation program after surgery. Cannot be reimbursed by secondary insurance or any other source. Expenses for cosmetic dentistry, such as teeth whitening or bleaching, porcelain veneers, or bonding are not eligible for reimbursement. Over the Counter diaper rash creams are qualified if prescribed by a physician. In addition to all expenses for care not reimbursed by any other source, eligible expenses include fees for:  Charges by your physician for letters of medical necessity to  Physician tele-advice, including email communication If the doula is a licensed health care professional who renders medical care, his or her fees can be reimbursed. Page 3 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Amounts paid for an inpatient’s treatment at a therapeutic center for drug addiction will qualify. See Alcoholism/Drug/Substance Abuse Treatment Must be prescribed to treat a specific medical condition, such as the presence of middle/inner ear tubes. Includes prescription sunglasses and reading glasses (even those purchased over-the-counter). Please note that product protection plans, or warranties, and clip-on sunglasses are not eligible for reimbursement. Will qualify to the extent that procedures are intended to overcome an inability to have children and are performed on you, your spouse, or your dependent. Examples are IVF (in vitro fertilization – including temporary storage of eggs or sperm), surgery (including an operation to reverse prior surgery preventing someone from having children), shots, treatments, and GIFT (gamete intrafallopian transfer). Expenses paid to or for an in vitro surrogate do not qualify, nor do egg donor expenses unless preparatory to a procedure performed on you, your spouse, or a dependent. Fees paid for a fitness program may be an eligible expense if prescribed by a physician and substantiated by his or her statement that treatment is necessary to alleviate a medical problem. Expenses of buying, training, and maintaining a guide dog used by a physically disabled person would qualify; this includes the expenses of food and inoculation. Veterinary fees for such animals also qualify as medical care. Gift cards are not an eligible expense, even if these cards are provided by a medical provider such as an eye glass store or a pharmacy. Requires a Letter of Medical Necessity and a statement from the individual stating "but for" the medical condition listed in the letter of medical necessity, he or she would not have joined the health club/gym. These memberships can only be reimbursed as services are provided, so services for an entire month (or year) cannot be reimbursed until the end of that month (or year). Page 4 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Includes the cost of the hearing aid and its batteries, as well as repair and maintenance. Homeopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a Health FSA.
Homeopathic medicines used for treatment of a specific illness or disorder can be reimbursed. May qualify if the primary purpose is medical care and the expense would not be incurred “but for” this purpose. A letter of medical necessity is required. Will qualify if performed by a professional to treat a medical condition, or for other medical purposes (e.g. smoking cessation); won’t qualify if for general stress relief, personal enjoyment, or other personal purposes. To show the expense is primarily for medical care, a letter of medical necessity from a medical practitioner recommending it to treat a specific medical condition is required. Includes those recommended for overseas travel Under IRS rules, insurance premiums cannot be reimbursed under a health FSA Services rendered by a licensed health care provider can be reimbursed. To show the expense is primarily for medical care, a letter of medical necessity from a medical practitioner recommending it to treat a specific medical condition is required. Expenses may qualify to the extent that instruction relates to birth and not childrearing. The fee should apportioned to exclude instruction in topics such as newborn care. Expenses for coach or significant other do not qualify. Will qualify because the procedure is done primarily to promote the correct function of the eye. Expenses for removing lead-based paints from surfaces in your home to prevent a child who has, has had, or is in danger of lead poisoning from eating the paint can be reimbursed. To show the expense is primarily for medical care, a letter of medical necessity from a medical practitioner recommending it to treat a specific medical condition is required. These surfaces must be in poor repair or be within a child’s reach. The cost of repainting the affected area(s) is not an eligible expense. If you cover the area with wallboard or paneling instead of removing the lead paint, these items will be treated as capital expenses. The portion of tuition/tutoring fees covering services rendered specifically for your child's severe learning disabilities caused by mental or physical impairments (such as nervous system disorders, or closed head injuries) and paid to a special school or to a specially-trained teacher may be reimbursed under a Health FSA if prescribed by a physician. Page 5 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Eligible
Eligible
Legal fees may qualify as medical care if they bear a direct or proximate relationship to the provision of medical care – for example, if the medical care could not have been provided without legal assistance. Fees for legal services retained to authorize treatment for mental illness may qualify. But legal fees for management of guardianship estate for conducting the affairs of the person being treated or other fees that aren’t necessary for medical care o not qualify; neither does divorce costs. Fees or advance payments made to a retirement home or continuing care facility are not eligible expenses. Up to $50 per night is eligible if the following conditions are met:  The lodging is primarily for, and essential to, medical care  The medical care is provided by a doctor in a licensed hospital or medical care facility related to/equivalent to a licensed hospital  The lodging is not lavish or extravagant  There is no significant element of personal pleasure or leisure Your companion’s lodging can be reimbursed if he or she is accompanying the patient (you or your eligible dependents) for medical reasons and it meets the criteria listed above. Meals are not eligible for reimbursement. Example: Parents traveling with a sick child, up to $100 per night ($50 per person) may be reimbursed, as well as lodging and pre and post-hospitalization for bone marrow transplants. The cost of a special home or step-down facility for your mentally handicapped dependent, recommended by a psychiatrist to help your dependent adjust after inpatient mental health care to community living can be reimbursed. Under IRS rules, insurance premiums cannot be reimbursed under a Therapeutic Massage treating a specific medical condition can be reimbursed under a Health FSA. The words “therapy” or “therapeutic” must be included in the description of the service. Gratuities are not reimbursable. A letter of medical necessity from a medical practitioner is required. Will qualify if recommended by a medical practitioner in connection with treating a medical condition. Amounts paid to a plan that maintains electronic medical information for you, your spouse or dependents are eligible for reimbursement under a Health FSA. Costs associated with copying or transferring medical records to a new provider are eligible for reimbursement. Expenses for medical services prescribed by physicians or other health care providers acting within their scope of licensure can be reimbursed under a Health FSA. Page 6 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Eligible
Eligible
Please contact Medcom to find out the reimbursable mileage rate and what to submit for reimbursement. Naturopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a Health FSA.
Medical care or services that are not covered under your major medical plan may be reimbursed under a Health FSA. Nursing services for a normal, healthy newborn are not an eligible expense. Nursing services are an eligible expense, whether provided in your home or another facility. The nurse need not be an R.N. or L.P.N., so long as the services rendered are of a kind generally performed by a nurse. These include services directly related to caring for and monitoring you, your spouse’s or dependent’s condition, including:  Changing dressings and providing wound care  Assessing responses to prescribed treatments, and documenting those assessments in written note If the individual providing nursing services also provides household and personal services, only those charges related to actual nursing care are eligible expenses. Expenses for medical care in a nursing home for you, your spouse and dependent(s), including meals and lodging may be reimbursed if the main purpose of the stay is to receive medical care. If the primary reason for confinement is personal (i.e., you or your spouse or dependent needs assistance with activities of daily living, safety issues, etc.), only the portion of the cost that is directly related to medical care or nursing services may be reimbursed. Dietary, nutritional, and herbal supplements, vitamins, and natural medicines are not reimbursable if they are merely beneficial for general health. However, they may be reimbursable if recommended by a medical practitioner to treat a specific medical condition. Nutritional services related to the treatment and guidance of a specific diagnosis or medical condition can be reimbursed. Will qualify if it treats or alleviates a medical condition. A letter of medical necessity is required. Contact Medcom Customer Service for additional details. Page 7 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
 Over the Counter (OTC) drugs and medicines, such as pain relievers, cold & flu remedies, and anti–inch ointments qualify only if prescribed by a physician.  OTC items such as band-aids, thermometers, crutches, contact lens cleaning solution, hot & cold packs, and diabetic supplies are qualifying expenses and do not require a prescription from a physician. This includes the expenses of oxygen and oxygen equipment for breathing problems caused by a medical condition. Items that relieve or reduce the discomfort of pregnancy may be reimbursed under a Health FSA. Examples include: Fees paid to get access to drugs at a reduced cost are not eligible for reimbursement under a Health FSA. Actual costs paid for prescription drugs are an eligible expense. Eligible expenses include deductibles, co-payments or co-insurance as well as the costs for prescription drugs. IRS regulations state that any drug imported into the United States by a consumer is not eligible for reimbursement under an FSA. If the tests are designed to assess symptoms of a medical diagnosis, they are eligible for reimbursement. Examples include clinic and hometesting kits for blood pressure, glaucoma, cataracts, hearing, cholesterol, etc. Includes the cost of supporting mentally ill dependent at a special Will qualify if provided for medical care, and not just for the general improvement of mental health, relief of stress, or personal enjoyment, nor if the expense of stems from training to be a psychoanalyst. To show the expense is primarily for medical care, a letter from a medical practitioner recommending it to treat a specific medical condition is normally required. Will qualify if the expense is for medical care, and not just for the general improvement of mental health, relief of stress, or personal enjoyment. To show the expense is primarily for medical care, a note from a medical practitioner recommending it to treat a specific medical condition is normally required. Page 8 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Corneal ring segments (removable plastic half-rings that correct vision) would also qualify. Will qualify when purchased for first-aid purposes (e.g. when purchased in first-aid quantities in a pharmacy or first-aid section of a retail store). Expenses to train or procure any guide dog, signal dog, or other animal individually trained to provide assistance to you, your spouse or dependent with a disability can be reimbursed under a Health FSA. Shipping and handling charges for medical needs, such as mail-order prescriptions are eligible. Amounts paid for drugs used to stop smoking would qualify with a If prescribed by a physician to treat a special illness or ailment, and not merely as a substitute for normal nutritional requirements. The amount that can be reimbursed is limited to the amount that the special food exceeds the cost of commonly available versions of the same product. Fees for temporary storage might qualify, but only to the extent necessary for immediate conception. Storage fees for undefined future conception probably aren’t considered to be for medical care. “Temporary” is not defined; however one consideration might be whether it is stored and used within the same year. A fee that is simply the cost of belonging to the program won’t qualify. Expenses for specific medical services might qualify. Won’t qualify if used to maintain general health or for other personal reasons. May qualify if used to treat or alleviate a specific medical condition (e.g. melanoma) and if the expense would not have been incurred “but for” the condition, but only the excess cost of the specialized garment over the cost of ordinary clothing will qualify. To show the expense is primarily for medical care, a letter from a medical practitioner recommending the item to treat a specific medical condition is required. Won’t qualify if to maintain general health or for other personal reasons (e.g. as a toiletry or a cosmetic). May qualify if used to treat or alleviate a specific medical condition, and if the expense would not have been incurred “but for” the condition. A personal history of skin cancer might qualify, but family history or other genetic propensity would not be sufficiently imminent for the expense to qualify as medical care, a note from a medical condition is normally required. Must be prescribed if incurred after December 31, 2010. Page 9 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
No, if just to improve general health or appearance. Taxes on medical services and products may be reimbursed under a Health FSA. This includes local, state, service and other taxes. Teeth whitening products or services to enhance the brightness of your teeth are cosmetic and cannot be reimbursed. Expenses associated with purchasing or repairing special telephone equipment for you, your spouse or dependent with a hearing impairment are eligible for reimbursement under a Health FSA. Expenses for equipment that displays the audio of television programming as subtitles for hearing impaired persons are eligible for reimbursement under a Health FSA. The eligible expense is limited to the cost that exceeds the cost of a non-adapted set. See Capital Expenses Car mileage, bus, taxi, and subway or train fare for travel to and from receiving medical care, including health care providers, hospitals and pharmacies can be reimbursed. Plane fare must not be merely for convenience. To ensure your transportation claim is approved, be sure to submit your receipt(s) or an itemization of your travel with the claim that coincides with the service(s) rendered. Please contact Medcom for the rate at which mileage can be reimbursed and what is needed to obtain reimbursement for these expenses. In some cases, transportation expenses of the following persons may be reimbursed:  A parent who must go with a child who needs medical care  A nurse or other person who can give injections, medications or other treatment required by a patient traveling to get medical care and who is unable to travel alone  Visits to see your mentally ill dependent, if part of a treatment Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA. Excursions taken for a change in environment, general health improvement etc., even those taken on the advice of your health care provider are not an eligible expense. Medical expenses in excess of your plan’s usual, customary and reasonable (UCR) charges may be reimbursed under a Health FSA if the underlying expense is eligible. An ultrasound ordered by your physician to monitor fetal growth, and/or to diagnose, treat or monitor a pregnancy-related condition is a covered expense under your Health FSA, even if your health plan does not provide reimbursement. An ultrasound not ordered or performed by a physician or other licensed professional, and/or not intended to diagnose, treat or monitor a pregnancy-related condition is not an eligible expense. Page 10 of 11 
MEDICAL FSA EXPENSES – QUALIFYING, POTENTIALLY QUALIFYING,
& INELIGIBLE ITEMS

Condition/Type of
Eligible Potentially
Additional Information
Service/Expense
Expense Eligible* Eligible
Collection and storage as a precaution to treat a disease or condition that might possibly develop in the future, just in case it is needed, Is not medical care. But might qualify if there is an existing or imminently probably disease that the umbilical cord blood is intended to treat. For example, the costs of storing cord blood where a newborn as a birth defect and where the cord blood would be needed in the near future might qualify. Will qualify if prescribed by a physician to treat a medical condition. Fees paid to gain access to a vision network, or to a reduced fee structure are not an eligible expense under a Health FSA. See Insurance Premiums Will only qualify if there is a specific medical condition (e.g. B-12 deficiency). A letter of medical necessity is required. Will qualify if the weight-loss program is recommended by a physician to treat a specific medical condition (such as obesity, heart disease, or diabetes) and is not simply to improve general health. However, the costs of food associated with a weight-loss program (such as special prepackaged meals) would not qualify, since it just meets normal nutritional needs. To show the expense is primarily for medical care, a note from a medical practitioner recommending it to treat a specific medical condition is required. The full cost of a wig purchased because the patient has lost all of his or her hair from disease or treatment. Will qualify if prescribed by a medical practitioner. Please always consult your Summary Plan Description for expenses that apply to your Plan specifically. Expenses listed on this document may vary based on your Employer’s Plan Document. *Please note: all "potentially eligible expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse or dependent are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function, and the duration of the recommended treatment. This letter must be submitted with every claim and must be signed by a licensed medical physician. Page 11 of 11 

Source: http://s108252178.onlinehome.us/forms/Eligible_FSA_Expenses.pdf

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