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FSA Eligible Expenses
This site, and the content herein, are designed specifically for clients of ASIFlex.
This information is not deemed to function as a Summary Plan Description (SPD).
If there is any conflict between this information and your SPD, your SPD will
override this information. and Expenses Eligible for Reimbursement under the
Flexible Spending Program:
For the HCFSA, services listed in this document are eligible for reimbursement, if
the services are:
• rendered by a health care professional appropriately licensed or certified in the state in • performed within the scope of the health care professional's license. For the DCFSA, services listed in this document are eligible for reimbursement, if
the services are:
• for an individual you claim as a dependent on your Federal Tax return who is under 13 or • necessary to allow you and your spouse, if married, to work, look for work or attend Condition/Type of Account Eligible Potentially Expenses for operations that are not legal do not qualify. 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. adopted child who is claimed as a
dependent are eligible. Care must be
for the adopted child and incurred
while the child qualifies as your
dependent. Your child's medical care
expenses are eligible only during the
adoption process as long as the child
qualifies as your dependent.
meals and lodging provided by a licensed addiction center. • Outpatient care • Transportation expenses associated with attending outpatient meetings, including AA groups, if attending on a doctor’s advice. home improvements to treat severe allergies. Examples include: • Electro-static air purifier • Humidifier • Home air conditioners • Pillows, mattress covers, etc. to Note: See CAPITAL EXPENSES for important information and guidance. rendered by a licensed health care provider to treat a specific illness or disorder. • Fertility exams • Artificial insemination (intracervical, intrauterine, intravaginal) • In-vitro/In-vivo fertilization • Gift • Sperm bank storage/fees for NOTE: Storage fees should not exceed twelve months. • Sperm implants • Sperm washing • Reverse vasectomy • Embryo replacement and NOTE: Storage fees should not exceed twelve months. • Egg donor charges for recipient• Embryo transfer Condition/Type of Account Eligible Potentiall to treat an illness or disorder, the difference in cost between the special formula and routine baby formula can be reimbursed. claimed on your Federal Income Tax return. • Demuelon • Ortho-Novum • Genora Ovcon • Levelen • Ovral • Loestrin Syntex • Lo-Ovral • Tri-Levelen Modicon • Tri-Norinyl • Nordette Triphasil • Norinyl • Also Included: you are storing blood for use during scheduled elective surgery. Storage 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. for regular books and magazines is an eligible expense. Use of a breast pump is not an eligible expense. Condition/Type of Account Eligible Potentially any individual who is incapable of self-care and can be claimed on your Federal Tax return. Payment in advance is not covered.
You can only be reimbursed for
expenses that have been incurred.
care and can be claimed on your Federal Tax return. Payment in advance is not covered.
You can only be reimbursed for
expenses that have been incurred.
Overnight camp is not eligible. However, if you are able to show separate billing for day services only, you may submit it as a child care claim. portable) can be reimbursed if its purpose is to provide medical care for 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 cost 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. Use the Capital Expense Worksheet to determine if your expense is eligible. modifying doorways, hallways and stairways including lowering cabinets and other equipment This list 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. Please refer to IRS Publication 502 for additional information, including operation and upkeep. A bris performed in the home by a Rabbi is not an eligible expense. cannot be reimbursed under a health care FSA. Cannot be reimbursed by secondary insurance or any other source. Cannot be reimbursed by secondary insurance or any other source. Can be reimbursed if there is a specific medical condition that the cord blood is intended to treat. Indefinite storage “just in case” is not an eligible expense. 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. Condition/Type of Account Eligible tentially This includes daycare as well as in-home babysitters for children under age 13, or any individual who is incapable of self-care and can be claimed on your Federal Tax return. Payment in advance is not covered.
You can only be reimbursed for
expenses that have been incurred.
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. Covered services include, but are not limited to: • Bridges • Cleanings • Crowns • Dental implants • Dentures • Endodontic care (root canal) • Extractions • Fillings • Orthodontia • Periodontal services • Routine prophylaxis • Sealants • X-rays Expenses for cosmetic dentistry, such as teeth whitening or bleaching, porcelain veneers, or bonding are not eligible for reimbursement. To relieve or ameliorate the effect of a particular illness or disease on you, your disabled child or dependent, who would not need this product “but for” the medical condition. In addition to all expenses for care not reimbursed by any other source, eligible expenses include fees for: • Out-of-network providers • Charges by your physician for letters of medical necessity to schools, etc. professional who renders medical care, his or her fees can be reimbursed. See CONTROLLED SUBSTANCES, PRESCRIPTION DRUGS and OTC meals and lodging provided by a licensed addiction center. • Outpatient care • Transportation expenses associated with attending outpatient meetings, including AA groups, if attending on a doctor’s advice. Condition/Type of Account Eligible Potentiall Must be prescribed to treat a specific medical condition, such as the presence of middle/inner ear tubes. Payments made to a special school for a mentally impaired or physically disabled person qualify as reimbursable if the main reason for using the school is its resources for relieving the disability. This includes teaching Braille to a visually impaired person, teaching lip reading to a hearing impaired person, and giving remedial language training to correct a condition caused by a birth defect. Adult must live with you at least 8 hours a day and be claimed as a dependent on your Federal Tax return. 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. Condition/Type of Account Eligible Potentiall A letter of medical necessity is not required, but please see OTC. an eligible expense if prescribed by a physician and substantiated by his or her statement that treatment is necessary to alleviate a medical problem. Food may be eligible if prescribed by a medical practitioner to treat a specific illness or ailment and if the food does not substitute for normal nutritional requirements. However, the amount that may qualify for reimbursement is limited to the amount by which the cost of the food exceeds the cost of commonly available versions of the same product. Condition/Type of HCFSA Eligible Potentiall Condition/Type of Account Eligible Potentiall 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). 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 HCFSA. treatment of a specific illness or disorder can be reimbursed. Condition/Type of Account Eligible Potentiall cannot be reimbursed under a health care FSA. Condition/Type of Account Eligible Potentiall prevent a child who has, has had, or is in danger of lead poisoning from eating the paint can be reimbursed. These surfaces must be in poor repair and 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. 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 HCFSA if prescribed by a physician. Examples of eligible expenses include: Legal fees paid to authorize treatment for mental illness are eligible expenses.
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: a doctor in a licensed hospital or medical care facility related to/equivalent to a licensed hospital of personal pleasure or leisure in the travel. 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. Condition/Type of Account Eligible Potentiall specific illness, injury, trauma or condition. electronic medical information for you, your spouse or dependents are eligible for reimbursement under an HCFSA. provider are eligible for reimbursement. prescribed by physicians or other health care providers acting within their scope of licensure can be reimbursed under a HCFSA. your medical provider is reimburseable through the HCFSA at the rate of $.18 per mile in 2006 and $.20/mile for services provided in 2007. To submit a claim for mileage expenses, please list the number of miles, the date of service and the expected reimbursement amount. No other documentation is required. Condition/Type of Account Eligible Potentiall licensed health care professional who provides this care for the treatment of aspecific illness or disorder for you, your spouse or dependent can be reimbursed under a HCFSA. covered under your major medical plan may be reimbursed under an HCFSA. 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 your, your spouse’s or dependent’s condition, including: • Monitoring vital signs • Assessing responses to prescribed treatments, and documenting those assessments in written notes If the individual providing nursing services also provides household and personal services, only those charges related to actual nursing care are eligible expenses. 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. 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 Nutritional services related to the treatment and guidance of a specific diagnosis or medical condition can be reimbursed. Condition/Type of Account Eligible Potentiall See Orthodontia Quick Reference Guide for more information. Eligible dental or vision over-the-counter expenses, such as denture care products, and contact lens cleaning and soaking solutions may be reimbursed. Condition/Type of Account Eligible Potentiall by family members, the expense to hire someone to perform patterning exercises is an eligible expense. eligible if the diagnosis of impotence is due to organic causes, such as diabetes, post-prostatectomy complications, or spinal cord injury. The up-front fee may qualify if it is an expense that must be paid in order to obtain care. However, the fee can only be reimbursed proportionately over the duration of the agreement to employ the dependent care provider, such as an au pair. The weekly stipend, as well as other work-related expenses, may also qualify as an expense for the care of a qualifying individual. discomfort of pregnancy may be reimbursed under a HCFSA. Examples include: • Maternity girdles • Elastic hosiery • Maternity support belts costs paid for prescription drugs are an eligible expense. co-payments or co-insurance as well as the costs for prescription drugs that may not be covered under FEHB, such as drugs that treat erectile dysfunction.
consumer is not eligible for reimbursement under an FSA. are eligible for reimbursement. Examples include clinic and home testing kits for blood pressure, glaucoma, cataracts, hearing, cholesterol, etc. Condition/Type of HCFSA Eligible Potentiall If a physician requires radon mitigation in your home due to a medical condition caused or aggravated by an unacceptable level of radon, some expenses may be eligible. However, if the home’s value is increased due to the mitigation, some or all of the expenses may not be reimbursable. Use the Capital Expense Worksheet to determine how much of the expense is eligible. Condition/Type of Account Eligible Potentiall individually trained to provide assistance to you, your spouse or dependent with a disability can be reimbursed under a HCFSA. medical needs, such as mail-order prescriptions. 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. your spouse or dependent has a cancer or blood dyscrasia diagnosis that requires chemotherapy or whole body radiation which may affect future ability to conceive children. with melanoma or other skin cancer, systemic lupus erythematosus (SLE), acute cutaneous lupus (ACLE) or other significant dermatologic conditions may be eligible with a letter of medical necessity from your doctor. The clothing is reimbursed for the difference between “normal” apparel and this specially-constructed clothing up to 33% of the total cost. The receipt must show the purchase was from an accredited sun-protective company such as Solumbra® or Coolibar®. Condition/Type of Account Eligible Potentiall No, if just to improve general health or May be reimbursed under a HCFSA for treatment of certain skin disorders, such as eczema and psoriasis. Taxes on medical services and products may be reimbursed under a HCFSA. This includes local, state, service and other taxes. enhance the brightness of your teeth are cosmetic and cannot be reimbursed.
equipment for you, your spouse or dependent with a hearing impairment are eligible for reimbursement under a HCFSA. Expenses for equipment that displays the audio of television programming as subtitles for hearing impaired persons are eligible for reimbursement under a HCFSA. The eligible expense is limited to the cost that exceeds the cost of a non-adapted set. train fare for travel to and from receiving medical care, including health care providers, hospitals and pharmacies can be reimbursed. Effective January 1, 2006, the standard mileage rate is 18 cents per mile for use of an automobile to obtain medical care. 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 note, for the months of January through August of 2005, the standard mileage rate was 15 cents per mile for use of an automobile to obtain medical care. The standard mileage rate was 22 cents per mile during the months of September through December 2005. Plane fare must not be merely for convenience. Transportation to and from the dependent care location provided by the daycare or service. In some cases, transportation expenses of the following persons may be reimbursed: can give injections, medications or other treatment required by a patient traveling to get medical care and who is unable to travel alone 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. Condition/Type of Account Eligible Potentiall plan’s usual, customary and reasonable (UCR) charges may be reimbursed under a HCFSA if the underlying expense is eligible. physician to monitor fetal growth, and/or to diagnose, treat or monitor a pregnancy-related condition is a covered expense under your HCFSA, 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. Condition/Type of Account Eligible Potentiall are not an eligible expense under a HCFSA. Condition/Type of Account Eligible Potentiall The full cost of a wig purchased because the patient has lost all of his or her hair from disease or treatment.

Source: http://www.ashland.or.us/Files/ASI%20Flex%20Eligible%20Expenses.pdf