Services and Expenses Eligible for Reimbursement Under the

Flexible Spending Account (FSA) Program

For FSA services listed for Medical Reimbursement in this document as eligible (or that meet the “potentially eligible” requirements) are eligible for reimbursement, if the services are:

· Rendered by a health care professional appropriately licensed or certified in the state in which he or she practices; and

· Performed within the scope of the health care professional’s license.

*Please note all “potentially eligible expenses” require a letter of medical necessity (LMN) from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms from 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. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed.

Eligible OTC Medical Care Expenses

Eligible items include medicines or products that alleviate 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. Claims for OTC medicines and products must include an adequate receipt accompanied by a completed claim form.

An adequate receipt states the name of the medicine or product, the date and the amount paid. You do need to provide a statement from a medical provider if the product is a dual-purpose product.

**Please note that stockpiling OTC medicines or items is not allowed and that requests for quantities deemed by Johnson County Government as stockpiling will be denied.

Dual-Purpose Products

Certain OTC products and other potentially eligible products are considered dual-purpose products, such as vitamins and supplements. That is 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 eligible for reimbursement, but require a Letter of Medical Necessity (LMN) stating your specific diagnosis or medical condition, a recommendation to take the specific product to treat your condition, and documentation of the product and cost. A LMN form is provided to assist you in meeting all required information for approval.

Documentation for Claims

All claims must include required documentation that notes Patient name, type of service, date of service, services provided, charges, insurance payments and patient responsibility. Explanation of Benefits (EOBs) from your insurance provider is a great source that provides all required information. OTC receipts must be clearly identified with product name to reimburse. If not clear the member must note what was purchased or provide a copy of the packaging.

Credit Card receipts, estimated statements pending insurance and balance due statements are not acceptable forms of documentation. These forms of documentation do meet IRS guidelines with all applicable information. The amount paid must be substantiated as amount owed to be reimbursed, it cannot be based on estimation.

Examples of Reimbursable Medical Expenses

Review the expenses in the following list that apply to you and your family. You may be surprised by the types of eligible expenses that can be included under the flexible spending account. If any of these are out-of-pocket expenses not reimbursed by insurance, you can pay for them with pre-tax dollars through the 125 Tax Savings Plan.

Dental

Artificial teeth

Biteplate

Braces

Dental exams

Dentures

Extractions

Fluoride treatment

Oral surgery

Orthodontia

Root canals

Fees and Services

Ambulance

Anesthesia

Checkups

Chiropractors

Christian Science

Practitioner’s fee

Co-payments

Diagnostic fees

Emergency room fee

Fee for practical nurse

Fee for licensed

Osteopaths

Deductibles associated

with health insurance

Home health care

Hospital bills

Obstetrical expenses

Office visits

Physician fees

Private nurses

Routine physicals

Hearing

Hearing devices

Hearing devices

batteries

Hearing examinations

Medical Equipment

Artificial limbs

Communication devices for

hearing impaired

Crutches

Mastectomy-related special

bras (over and above a

normal bra)

Modification of a vehicle for

handicapped

Wheelchair

Medicine

Insulin

Prescribed medicine

Birth control pills

Over the counter medicines

(for treating a specific

ailment)

Therapy

Alcoholism and drug

addiction treatment

Physical therapy

Psychiatric care

Psychologist’s fees

Speech therapy

Vision

Contact lenses

Contact lens solutions

Eyeglasses

Eye exam

LASIK/Laser eye surgery

Seeing-eye dog and its

upkeep

Special education for the

blind

Miscellaneous

Acupuncture

Braille books and magazines

Care for mentally ill child

Chiropractor fees

Diabetic supplies

Home improvements or

modifications for medical

condition

Infertility treatments

Lead-base paint removal

Mileage to/from health care

Facility

Orthopedic shoes

Oxygen

Pregnancy test

Parking at a health care

facility

Transportation expenses

Tuition at special school for

the handicapped

Ineligible Medical Expenses (merely beneficial for good health)	Examples
Cosmetic treatment	Wrinkle cream, age spots, some dermatology visits
Cosmetics	Makeup, lipstick, baby oil, lotions
Electrolysis or hair removal	Either by physician or OTC
Feminine Hygiene Products	Tampons and pads
FMLA or form completion fees	No fees to doctor for completion of FMLA paperwork
Food	Food is necessary for livelihood, not qualified even for dietary purposes
Hygiene products	Shampoos, conditioners, soap, toothpaste, toothbrushes
Late payment fees or missed appointment fees
Massage Therapy	SEE DUAL PURPOSE LIST
Nutritional and dietary supplements	OTC for general health – see dual purpose list
Over the counter	If used to treat general health or to prevent
Skin Care	Soaps, lotions, lip balm
Taxes	Taxes for OTC or travel expenses
Teeth Bleaching/whitening	Considered cosmetic
Vitamins	OTC for general health- see dual purpose list
Weight Reduction aids	appetite suppressants

Dual Purpose Services or Products	Documentation or Specification Required
Weight Loss programs	Must have Letter of Medical Necessity – See benefit forms
Fitness club dues	Must have Letter of Medical Necessity for each member– See benefit forms (must be for a specific medical diagnosis)
Incontinence Supplies	Must have Letter of Medical Necessity – See benefit forms
Massage Therapy	Must have Letter of Medical Necessity – See benefit forms
Naturopathic care	Must have Letter of Medical Necessity – See benefit forms
Nutritionist	Must have Letter of Medical Necessity – See benefit forms
Dual Purpose Services or Products	Documentation or Specification Required
Orthopedic Shoes	Must have Letter of Medical Necessity – See benefit forms, cost of coverage is additional amount above normal pair of shoes
Orthotics	Must have Letter of Medical Necessity – See benefit forms
Sunscreen	Only 45 SPF or higher
Supplements and herbals	Must have Letter of Medical Necessity – See benefit forms
Travel Expenses	Plane fares and hotels less taxes. Must have Letter of Medical Necessity – See benefit forms
Vitamins	Must have Letter of Medical Necessity – See benefit forms

Letter of Medical Necessity (LMN) – Under the Internal Revenue Service (IRS) rules, some health care services and products are only eligible for reimbursement from your Flexible Spending Account when your doctor or other licensed health care provider certifies they are medically necessary.

Your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific treatment needed and how this treatment will alleviate your medical condition. A form is provided on the benefits website under forms.