ameriflex - Messiah College

Transcription

www.flex125.com
www.flex125.com
AMERIFLEX
®
Your Key to Savings
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• 24/7 INTERACTIVE VOICE RESPONSE (IVR): 888.868.3539 (option 2, option 2 for automated account balances and claims status)
A Plan That Enhances Your Benefits
• TOLL-FREE PHONE: 888.868.3539 (option 2, option 3, 8:30 a.m. to 5:30 p.m. E.S.T.)
If you’re one of the many people who spend money on medical expenses, day care for
• WEB: www.flex125.com (select Employees from the Flex menu and then view your account activity)
dependents, or parking and transit, a Flexible Spending Account (FSA)—Medical, Dependent
• E-MAIL CUSTOMER SERVICE: service@flex125.com
Day Care, or Commuter—can make these expenses more affordable. One or all of these
• FAX: 800.282.9818
valuable benefits are available through your employer’s flexible benefits plan.
• MAIL: 302 Fellowship Rd., Suite 100, Mount Laurel, NJ 08054
—Every year more than 48 million employees nationwide enroll in a FSA program.
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AmeriFlexRX
Leverage the purchasing power of your FSA even further with AmeriFlexRx. Even better, orders of
$15.00 or more are shipped for FREE, specially priced items provide extra savings, and all
orders are shipped within two business days.
And now . . . maximize your convenience, save time, and start shopping!
E N R O L L M E N T
K I T
Two Assets That Work Even Better
IN TANDEM
• How the AmeriFlex Plan Works
TABLE OF CONTENTS
The information in this kit is presented for informational purposes only and is not
intended as legal, tax, accounting, or other professional advice. Individuals concerned
about their own individual tax situation are encouraged to consult with a professional
advisor. Furthermore, the information in this kit is also subject to change at any time
as laws and regulations change.
Click on half-moon tabs on any page to return to the Table of Contents.
• Eligible Expenses
• Funding Your Account
• Claims Process
• The AmeriFlex Convenience Card®
• FSA Election Changes
• Tax Implications
• Enrollment Form
• AmeriFlexRX
We’ve enhanced the purchasing power of the AmeriFlex Convenience Card® by providing
AmeriFlexRx, the AmeriFlex online drugstore.
• Convenient 24/7 access
• Even deeper discounts with AmeriFlexRx Value Brand
• Free shipping on orders over $15.00
• Items are shipped within two business days
AMERIFLEX ®
AMERIFLEX ®
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AMERIFLEX ®
FSA ENROLLMENT/ continued
How the AmeriFlex Plan Works
A D D I T I O N A L C A R D S (only applicable if your employer has chosen this option)
If you wish to have an AmeriFlex Convenience Card® issued for a spouse or dependent, please be sure your spouse or dependent
meets the IRS eligibility guidelines below:
(1) For federal tax purposes, a spouse is defined as “. . . a person of the opposite sex who is a husband or wife.” Same sex domestic partners are
not considered spouses for purposes of FSA administration. A person residing in the employee’s home, who the employee provides over half of
their support, who is not the employee’s spouse under applicable state law, and who is not a family member, is considered a dependent under
Internal Revenue Code 152(a) without regard to 152(b)(1), (b)(2), and (d)(1)(B).
(2) For purposes of Medical FSAs, dependent includes any relative of the participant for whom the participant provides over half of their support
for the calendar year. A relative includes children, parents, stepchildren, siblings, aunts, uncles, cousins, and in-laws of the participant. Relatives
do not need to reside with the participant in order to be dependents, nor do they need to be a certain age or infirmity; they need only to be
persons for whom the participant has provided over half of their support.
Spouse Name:
If you participate, you will elect to have a specified amount of “pre-tax” money deducted
from your paycheck each pay period. These dollars are subtracted from your gross earnings
before taxes and put into a Flexible Spending Account to cover eligible out-of-pocket costs.
Once you submit a claim for a qualified expense, you will be reimbursed from this account.
—Lower your taxable income; pay less tax; increase your take-home pay.
—Participation is the equivalent of getting a raise.
The following table illustrates how you save by participating in a Flexible Spending Account:
Without This Plan
Address to issue card:
Telephone:
Soc. Sec. Number:
Date of Birth:
All dependents must be over the age of 18 in order to receive the AmeriFlex Convenience Card®.
Dependent Name:
Gross pay (annual)
$30,000.00
Gross pay (annual)
$30,000.00
Tax Withholding (est. @25%)
$ 7,500.00
• Eligible expense
$ 1,000.00
Take-home pay
$22,500.00
Taxable income
$29,000.00
$ 1,000.00
$ 7,250.00
New take-home pay
$21,500.00
New take-home pay
$21,750.00
• Result (increased take-home pay)
$
(if different from participant)
Telephone:
Soc. Sec. Number:
Date of Birth:
Dependent Name:
Telephone:
Soc. Sec. Number:
Date of Birth:
Each AmeriFlex Convenience Card® is issued for a term of three years. Remember that existing cardholders will not receive a new card (unless
the current card is scheduled to expire). Cards will simply be “reloaded” for the next plan year with your new election. Upon expiration, AmeriFlex
will automatically issue new cards to participants who re-enroll in the new plan year. For new participants, your AmeriFlex Convenience Card®
will be sent to your home adress in a plain white envelope.
AU T H O R I Z AT I O N AG R E E M E N T F O R AC H D E B I T S / C R E D I T S
I, hereby, authorize AmeriFlex, LLC, hereafter called ADMINISTRATOR, to initiate debits and/or credits to or from my bank account indicated below
at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit and credit the same to such account with the
agreement that the only debits to be made will be for the sole purpose of correcting a prior FSA reimbursement error. I acknowledge the origination
of ACH transactions to or from my account must comply with the provisions of U.S. law.
Depository Name:
The information in this table is for descriptive purposes only and is not intended to reflect your own personal tax situation.
State:
Routing Number:
Zip:
Account Number:
(always nine digits)
CHECK EXAMPLE
Checking Account
Savings Account
If you would prefer, please attach a voided check.
ROUTING NUMBER
Medical Spending Account Eligible Expenses
A medical FSA is used to pay for healthcare expenses not covered under your medical or other
insurance plan. The IRS determines eligible expenses. IRS-qualified expenses may include:
• Co-pays, deductibles, and other payments you are responsible for under your
medical plan
• Charges that may not be covered by your medical plan such as:
– Routine exams
– Dental care
– Orthodontia
(check with your Employer to determine if Orthodontia is allowed in your plan and what reimbursement method is used)
Account Name:
City:
ACCOUNT NUMBER
CHECK NUMBER
The authorization is to remain in full force and effect until the ADMINISTRATOR has received written notification from the employee named above
of the termination in such time and in such manner as to afford the ADMINISTRATOR and DEPOSITORY a reasonable opportunity to act on it.
Date:
250.00
Eligible Expenses
SELECT ONE:
With This Plan
Signature:
Upon receipt, the Federal Reserve requires 14 business days to perform the initial approval of the ACH information. After this time, AmeriFlex will be
directly depositing all claim reimbursements into the bank account provided two days after every processing date determined by your employer.
It may take up to 5 business days to have your reimbursements appear in your account, depending upon the automated clearing house utilized
by your bank. We suggest that you contact your bank to confirm when these funds become available in your account. AmeriFlex shall not be
responsible for any checks or other debt payments you make whereby you have assumed these funds are available.
– Eyecare: Lasik, glasses, contact lenses
– Hearing aids
– Well-baby care
• Miscellaneous expenses such as:
– Many over-the-counter drugs; e.g., pain relief, sleep aids, allergy treatments
– Transportation, tolls, and parking to receive medical care
– Individual psychiatric or psychological counseling
– Diabetic equipment and supplies
– Durable medical equipment
– Qualified medical products or services prescribed by a doctor
Some examples of ineligible expenses include insurance premiums, teeth whitening, prescription
drugs for male-pattern baldness, and most cosmetic procedures. A more comprehensive list of
eligible medical and over-the-counter expenses is available on the AmeriFlex website.
AMERIFLEX 302 FELLOWSHIP RD., SUITE 100, MOUNT LAUREL, NEW JERSEY 08054 www.flex125.com
CALL TOLL-FREE: 888.868.FLEX (3539) FAX: 800.282.9818
AMERIFLEX ®
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Dependent Day Care Spending Account Eligible Expenses
With a Dependent Day Care Account, you can set aside pre-tax payroll deductions to reimburse
the expenses associated with day care for your qualified dependents. Eligible expenses must meet
the following qualifications:
• The care of the dependent must enable you and your spouse to be employed.
• The amount to be reimbursed must not be greater than your spouse’s income or your
income, whichever is less.
• The child must be under 13 years old and must be your dependent under federal tax rules.
• The services may be provided in your home or another location, but not by someone who
is your minor child or dependent for income tax purposes (e.g., an older child)
• If the services are provided by a day care facility that cares for six or more children
simultaneously, the facility must comply with state and local day care regulations.
• Services must be for the physical care of the child, not for education, meals, etc.
Qualified dependent care expenses also include costs for the care of a spouse or other adult
dependent who lives in your home and is incapable of self-care, has gross income below the
exemption amount in IRS Code 151, is dependent on you for over half of their support, and is
not anyone else’s qualifying child (e.g., an invalid parent). The same rules that apply for child
care apply to the care of other dependents, except the dependent need not be under age 13.
AMERIFLEX
®
FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM
Company Name:
Employee Name:
Telephone:
Employee Address:
City:
State:
Employee Social Security Number:
Date of Birth:
Zip:
Plan Year:
Date of Hire:
Effective Date:
The Company and I hereby agree that my cash compensation will be redirected by the amounts set forth below for each pay period during the
plan year (or during such portion of the year as remains after the date of this agreement). I understand that if I do not return this form to my
employer by my effective date, it shall constitute my election to waive participation in all flexible spending programs under my employer’s
Flexible Benefits Plan and therefore cause me to pay non-reimbursable medical, dependent care, and/or commuter expenses (if any) with aftertax dollars.
E M P L O Y E E ’ S F L E X I B L E B E N E F I T P E R PA Y D E D U C T I O N / A L L O C A T I O N
Medical Flexible Spending Account
Per pay contribution $
Date of first payroll
$
Annual contribution $
Number of remaining pays
Maximum ANNUAL contribution
For more details on dependent day care eligible expenses, reference IRS Publication 503—Child
and Dependent Care Expenses, available on the AmeriFlex website.
Dependent Care Spending Account
$
Commuter Reimbursement Account Eligible Expenses
Commuter Reimbursement Account
Commuter Reimbursement Accounts allow you to set aside pre-tax income to pay for qualified
parking, transit, and commuter highway vehicle expenses related to your transportation to
and from work.
$
• Parking expenses are expenses incurred to park your vehicle on or near the business
premises of the employer or expenses incurred to park your car at a location from which you
commute to work by (a) mass transit facilities, (b) a commuter highway vehicle, or (c) car-pool.
• Transit expenses are those incurred for a pass, token, fare card, voucher, or similar item
(a pass) for transportation (a) on mass transit facilities, whether or not publicly owned, or
(b) provided by a person in the business of transporting persons for compensation or hire
if such transportation is provided in a vehicle with a seating capacity of at least six adults
(excluding the driver).
• Commuter highway vehicle (van-pool) expenses are those incurred for transportation in a
commuter highway vehicle when traveling between your residence and place of employment.
A commuter highway vehicle is any highway vehicle with a seating capacity of at least six
adults (not including the driver), and for which at least 80% of the mileage is for purposes of
transporting employees between their residence and their places of employment, and where
the number of employees is, on average, at least half of the adult seating capacity of the
vehicle (not including the driver).
PA R KING
Maximum MONTHLY contribution
T R A N S I T
$
I U N D E R S TA N D T H AT:
(1) My accounts will not automatically renew. During each annual open enrollment period, I understand that I must complete a new enrollment
form indicating my account contributions for the new plan year.
(2) I cannot change or revoke this agreement at any time during the plan year unless I have a change in family status (including marriage,
divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, or such other
events as the Plan Administrator determines will permit a change or revocation of an election).
(3) The Plan Administrator may reduce, cancel, or otherwise modify this agreement in the event he/she believes it is advisable in order to satisfy
certain provisions of the Internal Revenue Code.
This agreement is subject to the terms of the Company’s Flexible Benefits Plan, as amended from time to time, which shall be governed under
applicable laws, and revokes any prior agreement relating to such plan(s).
By signing this form I agree to the terms and procedures listed herein.
I was given the opportunity to participate in this Flexible Benefits Plan, and I have decided not to participate at this time.
Employee Signature
Date
AMERIFLEX ®
through
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Tax Implications
Funding Your Account
Will pre-taxing have an impact on Social Security benefits?
The maximum amount you can contribute to your FSA depends on the type of account you select.
Your employer determines the maximum annual election for your Medical Flexible Spending Account
while the government sets the maximum amount for your Dependent Day Care Spending Account
and Commuter Reimbursement Account.
Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for
most employees, the reduction in Social Security benefits is insignificant when compared to
the value of paying lower taxes now.
Dependent Day Care Tax Filing
On your tax return you must report the correct name, address, and taxpayer identification number
(TIN) of your dependent care provider. If your dependent care provider is exempt from federal
income taxation, you are not required to report the TIN; however, you must report the correct name
and address of the exempt provider and write “tax-exempt” in the space provided for the TIN.
Tax Credits vs. Dependent Care Spending Accounts
If you participate in a Dependent Care Spending Account, you cannot claim credits on your income
tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the
amount of other dependent care expenses that you can claim for purposes of tax credits. Before
you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or
the Dependent Care Spending Account is best for you. Refer to the following federal tax forms and
publications for more information (available at www.irs.gov):
• Form 2441 (Child and Dependent Care Expenses)
• Form 1040 Schedule EIC and IRS Publication 596 (Earned Income Credit)
• Form 8812 and IRS Publication 972 (Child Tax Credit)
• Frequently Asked Questions
Determining Account Contributions
• Medical: Your employer determines the maximum allowable contribution for your Medical Flexible
Spending Account. Within that maximum, you determine your contribution for yourself and your
eligible dependents based on expenses you expect to incur in the upcoming plan year. Your annual
contribution is then divided by your number of pay periods, and that amount will be deducted pretax each pay period.
• Dependent Day Care: Federal law has set the maximum allowable contribution per calendar
year for a Dependent Day Care Spending Account as follows:
– $5,000 for a married couple filing jointly
– $5,000 for a single parent
– $2,500 for a married person filing separately
NOTE: While most employers follow the IRS limit for dependent day care plans, some have selected a lower annual maximum benefit.
You should check with your employer to determine the limit for your dependent day care plan.
• Commuter: The maximum amount you may contribute to a Commuter Reimbursement Account
is determined by the IRS. These amounts may change annually, so ask your employer for current
maximums for parking expenses, transit passes, and commuter highway vehicle expenses.
The Use-It-or-Lose-It Rule
If you contribute dollars to a reimbursement account and do not use all the money you deposit,
you will lose any remaining balance in the account at the end of the eligible claims period. A very
important thing to remember is that the rule exists because the IRS has established strict guidelines
for plans with tax advantages.
Claims Process
To be reimbursed for any expense, you must first file a claim. You can file a claim in two ways,
either manually or electronically. To file a claim manually, simply complete a claim form and mail
or fax it to AmeriFlex along with substantiation of the claim. Acceptable forms of substantiation include
itemized receipts and the Explanation of Benefits (EOB) from your insurance carrier.
Information required on all claim requests include: the date of service, the product or service
description, prescription drug names and numbers, the total dollar amount being requested, the
service provider’s name, and, in the case of dependent day care requests, the provider’s signature
and tax ID or Social Security number.
When you submit a claim by fax or mail, your reimbursement will either be mailed or directdeposited into your bank account, whichever you prefer. To eliminate the hassles of paper, faxing,
and the time delays of mailing, simply use your AmeriFlex Convenience Card®.
AMERIFLEX ®
AMERIFLEX ®
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Your Card Account Balance and Transaction Receipts
• What if there’s not enough money in my account?
If you charge more than the available balance in your account, the transaction will be denied.
You can find your balance online at www.flex125.com or by calling the AmeriFlex Interactive
Voice Response System, which is available 24/7. Review your account balance regularly to
avoid denied charges.
• Do I need the receipts?
SMART
SIMPLE
and Convenient
The AmeriFlex Convenience Card®
The AmeriFlex Convenience Card® is a MasterCard® debit card providing electronic access to your
FSA funds.The card provides the convenience of a single debit card with access to all of your accounts.
Your AmeriFlex Convenience Card® gives you easy access to the funds in your Flexible Spending
Account(s). It works just like any other debit card, but with three important differences:
• First, its use is limited to specific merchants* and to expenses deemed eligible by your plan.
• Second, you cannot use it at an ATM or to obtain “cash back” when making a purchase.
• Third, you are not given a PIN with this card. Should a merchant or provider ask you for
a PIN, simply explain that this card does not require one. If given the option between debit
and credit at the terminal, choose “credit.”
*Every merchant that accepts MasterCard® is assigned an MCC Code based on their type of business. Only a limited
number of these codes apply to merchants providing products or services eligible for FSAs. Use of the AmeriFlex Convenience
Card® is limited to day care providers; medical care providers such as hospitals, doctors’ offices, optometrists, dentists,
orthodontists, pharmacies, or other merchants providing prescription and over-the-counter eligible products; and CRA merchants
such as parking garages or metro-card machines. In other words, your card cannot be used at non-qualified businesses such
as gas stations, retailers, convenience stores, etc. For example: aspirin is an eligible expense in your Medical Flexible Spending
account; however, you cannot purchase aspirin at your local convenience store because that type of business does not have an
eligible MCC code. You would need to purchase your aspirin at your local pharmacy or other qualifying business to use the
card. However, under new regulations, if the merchant has an IRS approved inventory management system that provides SKU
level data on the item, it can automatically determine if an expense is eligible, eliminating the MCC code restriction. Check
with your local retailer to find out if they already have or may be adding this system.
AMERIFLEX ®
Possibly, so please save all of your itemized receipts! For certain expenses, AmeriFlex may need
additional information, including receipts, to verify eligibility of the expense and to comply with
IRS rules. That’s why it’s important for you to save all receipts, then fax or mail them promptly
if requested. Failure to comply could jeopardize the tax-exempt status of your account and
cause the card to be deactivated.
FSA Election Changes
What if I want to make a change to my FSA Election?
The latest set of cafeteria plan regulations develops a process for determining if a participant
is allowed to make a change in election during the plan year. A change in status must have
occurred and that event must fall into one of the following categories:
• Change in provider (Dependent Day Care only)
• Change in cost of day care (Dependent Day Care only)
• Change in legal marital status
• Change in number of dependents
• Change in employment status
• Change in work schedule (increase or decrease in hours)
• Dependent satisfies (or ceases to satisfy) requirements for eligibility
The election change must be consistent with the status-change event. A change is consistent with
the event for Medical Flexible Spending Accounts if the following occurs:
• The employee, spouse, or dependent is gaining or losing eligibility for health coverage.
• The election change corresponds with that gain or loss of coverage.
For Commuter Reimbursement Accounts, elections can be made for a period as short as one month.
Check with your human resources department to see how often you can change your CRA election.
Employee Termination/Claims Procedure
AmeriFlex will deactivate the terminated employee’s AmeriFlex Convenience Card® on the date
notified of the termination. Any eligible expenses incurred, and not yet submitted for reimbursement,
prior to or on the date of termination, must be filed using a manual claim form and must be received
by AmeriFlex within 90 days of the termination date.
AMERIFLEX ®
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Your Card Account Balance and Transaction Receipts
• What if there’s not enough money in my account?
If you charge more than the available balance in your account, the transaction will be denied.
You can find your balance online at www.flex125.com or by calling the AmeriFlex Interactive
Voice Response System, which is available 24/7. Review your account balance regularly to
avoid denied charges.
• Do I need the receipts?
SMART
SIMPLE
and Convenient
The AmeriFlex Convenience Card®
The AmeriFlex Convenience Card® is a MasterCard® debit card providing electronic access to your
FSA funds.The card provides the convenience of a single debit card with access to all of your accounts.
Your AmeriFlex Convenience Card® gives you easy access to the funds in your Flexible Spending
Account(s). It works just like any other debit card, but with three important differences:
• First, its use is limited to specific merchants* and to expenses deemed eligible by your plan.
• Second, you cannot use it at an ATM or to obtain “cash back” when making a purchase.
• Third, you are not given a PIN with this card. Should a merchant or provider ask you for
a PIN, simply explain that this card does not require one. If given the option between debit
and credit at the terminal, choose “credit.”
*Every merchant that accepts MasterCard® is assigned an MCC Code based on their type of business. Only a limited
number of these codes apply to merchants providing products or services eligible for FSAs. Use of the AmeriFlex Convenience
Card® is limited to day care providers; medical care providers such as hospitals, doctors’ offices, optometrists, dentists,
orthodontists, pharmacies, or other merchants providing prescription and over-the-counter eligible products; and CRA merchants
such as parking garages or metro-card machines. In other words, your card cannot be used at non-qualified businesses such
as gas stations, retailers, convenience stores, etc. For example: aspirin is an eligible expense in your Medical Flexible Spending
account; however, you cannot purchase aspirin at your local convenience store because that type of business does not have an
eligible MCC code. You would need to purchase your aspirin at your local pharmacy or other qualifying business to use the
card. However, under new regulations, if the merchant has an IRS approved inventory management system that provides SKU
level data on the item, it can automatically determine if an expense is eligible, eliminating the MCC code restriction. Check
with your local retailer to find out if they already have or may be adding this system.
AMERIFLEX ®
Possibly, so please save all of your itemized receipts! For certain expenses, AmeriFlex may need
additional information, including receipts, to verify eligibility of the expense and to comply with
IRS rules. That’s why it’s important for you to save all receipts, then fax or mail them promptly
if requested. Failure to comply could jeopardize the tax-exempt status of your account and
cause the card to be deactivated.
FSA Election Changes
What if I want to make a change to my FSA Election?
The latest set of cafeteria plan regulations develops a process for determining if a participant
is allowed to make a change in election during the plan year. A change in status must have
occurred and that event must fall into one of the following categories:
• Change in provider (Dependent Day Care only)
• Change in cost of day care (Dependent Day Care only)
• Change in legal marital status
• Change in number of dependents
• Change in employment status
• Change in work schedule (increase or decrease in hours)
• Dependent satisfies (or ceases to satisfy) requirements for eligibility
The election change must be consistent with the status-change event. A change is consistent with
the event for Medical Flexible Spending Accounts if the following occurs:
• The employee, spouse, or dependent is gaining or losing eligibility for health coverage.
• The election change corresponds with that gain or loss of coverage.
For Commuter Reimbursement Accounts, elections can be made for a period as short as one month.
Check with your human resources department to see how often you can change your CRA election.
Employee Termination/Claims Procedure
AmeriFlex will deactivate the terminated employee’s AmeriFlex Convenience Card® on the date
notified of the termination. Any eligible expenses incurred, and not yet submitted for reimbursement,
prior to or on the date of termination, must be filed using a manual claim form and must be received
by AmeriFlex within 90 days of the termination date.
AMERIFLEX ®
2
8
AmeriFlexRX
Leverage the purchasing power of your FSA even further with AmeriFlexRx. Even better, orders of
$15.00 or more are shipped for FREE, specially priced items provide extra savings, and all
orders are shipped within two business days.
And now . . . maximize your convenience, save time, and start shopping!
E N R O L L M E N T
K I T
Two Assets That Work Even Better
IN TANDEM
• How the AmeriFlex Plan Works
TABLE OF CONTENTS
The information in this kit is presented for informational purposes only and is not
intended as legal, tax, accounting, or other professional advice. Individuals concerned
about their own individual tax situation are encouraged to consult with a professional
advisor. Furthermore, the information in this kit is also subject to change at any time
as laws and regulations change.
Click on half-moon tabs on any page to return to the Table of Contents.
• Eligible Expenses
• Funding Your Account
• Claims Process
• The AmeriFlex Convenience Card®
• FSA Election Changes
• Tax Implications
• Enrollment Form
• AmeriFlexRX
We’ve enhanced the purchasing power of the AmeriFlex Convenience Card® by providing
AmeriFlexRx, the AmeriFlex online drugstore.
• Convenient 24/7 access
• Even deeper discounts with AmeriFlexRx Value Brand
• Free shipping on orders over $15.00
• Items are shipped within two business days
AMERIFLEX ®
AMERIFLEX ®
9
5
Tax Implications
Funding Your Account
Will pre-taxing have an impact on Social Security benefits?
The maximum amount you can contribute to your FSA depends on the type of account you select.
Your employer determines the maximum annual election for your Medical Flexible Spending Account
while the government sets the maximum amount for your Dependent Day Care Spending Account
and Commuter Reimbursement Account.
Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for
most employees, the reduction in Social Security benefits is insignificant when compared to
the value of paying lower taxes now.
Dependent Day Care Tax Filing
On your tax return you must report the correct name, address, and taxpayer identification number
(TIN) of your dependent care provider. If your dependent care provider is exempt from federal
income taxation, you are not required to report the TIN; however, you must report the correct name
and address of the exempt provider and write “tax-exempt” in the space provided for the TIN.
Tax Credits vs. Dependent Care Spending Accounts
If you participate in a Dependent Care Spending Account, you cannot claim credits on your income
tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the
amount of other dependent care expenses that you can claim for purposes of tax credits. Before
you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or
the Dependent Care Spending Account is best for you. Refer to the following federal tax forms and
publications for more information (available at www.irs.gov):
• Form 2441 (Child and Dependent Care Expenses)
• Form 1040 Schedule EIC and IRS Publication 596 (Earned Income Credit)
• Form 8812 and IRS Publication 972 (Child Tax Credit)
• Frequently Asked Questions
Determining Account Contributions
• Medical: Your employer determines the maximum allowable contribution for your Medical Flexible
Spending Account. Within that maximum, you determine your contribution for yourself and your
eligible dependents based on expenses you expect to incur in the upcoming plan year. Your annual
contribution is then divided by your number of pay periods, and that amount will be deducted pretax each pay period.
• Dependent Day Care: Federal law has set the maximum allowable contribution per calendar
year for a Dependent Day Care Spending Account as follows:
– $5,000 for a married couple filing jointly
– $5,000 for a single parent
– $2,500 for a married person filing separately
NOTE: While most employers follow the IRS limit for dependent day care plans, some have selected a lower annual maximum benefit.
You should check with your employer to determine the limit for your dependent day care plan.
• Commuter: The maximum amount you may contribute to a Commuter Reimbursement Account
is determined by the IRS. These amounts may change annually, so ask your employer for current
maximums for parking expenses, transit passes, and commuter highway vehicle expenses.
The Use-It-or-Lose-It Rule
If you contribute dollars to a reimbursement account and do not use all the money you deposit,
you will lose any remaining balance in the account at the end of the eligible claims period. A very
important thing to remember is that the rule exists because the IRS has established strict guidelines
for plans with tax advantages.
Claims Process
To be reimbursed for any expense, you must first file a claim. You can file a claim in two ways,
either manually or electronically. To file a claim manually, simply complete a claim form and mail
or fax it to AmeriFlex along with substantiation of the claim. Acceptable forms of substantiation include
itemized receipts and the Explanation of Benefits (EOB) from your insurance carrier.
Information required on all claim requests include: the date of service, the product or service
description, prescription drug names and numbers, the total dollar amount being requested, the
service provider’s name, and, in the case of dependent day care requests, the provider’s signature
and tax ID or Social Security number.
When you submit a claim by fax or mail, your reimbursement will either be mailed or directdeposited into your bank account, whichever you prefer. To eliminate the hassles of paper, faxing,
and the time delays of mailing, simply use your AmeriFlex Convenience Card®.
AMERIFLEX ®
AMERIFLEX ®
4
10
Dependent Day Care Spending Account Eligible Expenses
With a Dependent Day Care Account, you can set aside pre-tax payroll deductions to reimburse
the expenses associated with day care for your qualified dependents. Eligible expenses must meet
the following qualifications:
• The care of the dependent must enable you and your spouse to be employed.
• The amount to be reimbursed must not be greater than your spouse’s income or your
income, whichever is less.
• The child must be under 13 years old and must be your dependent under federal tax rules.
• The services may be provided in your home or another location, but not by someone who
is your minor child or dependent for income tax purposes (e.g., an older child)
• If the services are provided by a day care facility that cares for six or more children
simultaneously, the facility must comply with state and local day care regulations.
• Services must be for the physical care of the child, not for education, meals, etc.
Qualified dependent care expenses also include costs for the care of a spouse or other adult
dependent who lives in your home and is incapable of self-care, has gross income below the
exemption amount in IRS Code 151, is dependent on you for over half of their support, and is
not anyone else’s qualifying child (e.g., an invalid parent). The same rules that apply for child
care apply to the care of other dependents, except the dependent need not be under age 13.
AMERIFLEX
®
FLEXIBLE SPENDING ACCOUNT ENROLLMENT FORM
Company Name: Messiah College
Employee Name:
Telephone:
Employee Address:
City:
State:
Plan Year: 7/1/2013
Employee Social Security Number:
Date of Birth:
Zip:
Date of Hire:
Effective Date:
The Company and I hereby agree that my cash compensation will be redirected by the amounts set forth below for each pay period during the
plan year (or during such portion of the year as remains after the date of this agreement). I understand that if I do not return this form to my
employer by my effective date, it shall constitute my election to waive participation in all flexible spending programs under my employer’s
Flexible Benefits Plan and therefore cause me to pay non-reimbursable medical, dependent care, and/or commuter expenses (if any) with aftertax dollars.
E M P L O Y E E ’ S F L E X I B L E B E N E F I T P E R PA Y D E D U C T I O N / A L L O C A T I O N
Medical Flexible Spending Account
$ 2500.00
For more details on dependent day care eligible expenses, reference IRS Publication 503—Child
and Dependent Care Expenses, available on the AmeriFlex website.
Dependent Care Spending Account
$ 5000.00
Commuter Reimbursement Account Eligible Expenses
Commuter Reimbursement Account
PA R KING
Per pay contribution $ n/a
Date of first payroll n/a
Commuter Reimbursement Accounts allow you to set aside pre-tax income to pay for qualified
parking, transit, and commuter highway vehicle expenses related to your transportation to
and from work.
$ n/a
Annual contribution $ n/a
Per pay contribution $ n/a
Number of remaining pays n/a
Date of first payroll n/a
Annual contribution $ n/a
Number of remaining pays n/a
• Parking expenses are expenses incurred to park your vehicle on or near the business
premises of the employer or expenses incurred to park your car at a location from which you
commute to work by (a) mass transit facilities, (b) a commuter highway vehicle, or (c) car-pool.
• Transit expenses are those incurred for a pass, token, fare card, voucher, or similar item
(a pass) for transportation (a) on mass transit facilities, whether or not publicly owned, or
(b) provided by a person in the business of transporting persons for compensation or hire
if such transportation is provided in a vehicle with a seating capacity of at least six adults
(excluding the driver).
• Commuter highway vehicle (van-pool) expenses are those incurred for transportation in a
commuter highway vehicle when traveling between your residence and place of employment.
A commuter highway vehicle is any highway vehicle with a seating capacity of at least six
adults (not including the driver), and for which at least 80% of the mileage is for purposes of
transporting employees between their residence and their places of employment, and where
the number of employees is, on average, at least half of the adult seating capacity of the
vehicle (not including the driver).
T R A N S I T
$ n/a
I U N D E R S TA N D T H AT:
(1) My accounts will not automatically renew. During each annual open enrollment period, I understand that I must complete a new enrollment
form indicating my account contributions for the new plan year.
(2) I cannot change or revoke this agreement at any time during the plan year unless I have a change in family status (including marriage,
divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, or such other
events as the Plan Administrator determines will permit a change or revocation of an election).
(3) The Plan Administrator may reduce, cancel, or otherwise modify this agreement in the event he/she believes it is advisable in order to satisfy
certain provisions of the Internal Revenue Code.
This agreement is subject to the terms of the Company’s Flexible Benefits Plan, as amended from time to time, which shall be governed under
applicable laws, and revokes any prior agreement relating to such plan(s).
By signing this form I agree to the terms and procedures listed herein.
I was given the opportunity to participate in this Flexible Benefits Plan, and I have decided not to participate at this time.
Employee Signature
Date
AMERIFLEX ®
through 6/30/2014
11
3
AMERIFLEX ®
FSA ENROLLMENT/ continued
How the AmeriFlex Plan Works
A D D I T I O N A L C A R D S (only applicable if your employer has chosen this option)
If you wish to have an AmeriFlex Convenience Card® issued for a spouse or dependent, please be sure your spouse or dependent
meets the IRS eligibility guidelines below:
(1) For federal tax purposes, a spouse is defined as “. . . a person of the opposite sex who is a husband or wife.” Same sex domestic partners are
not considered spouses for purposes of FSA administration. A person residing in the employee’s home, who the employee provides over half of
their support, who is not the employee’s spouse under applicable state law, and who is not a family member, is considered a dependent under
Internal Revenue Code 152(a) without regard to 152(b)(1), (b)(2), and (d)(1)(B).
(2) For purposes of Medical FSAs, dependent includes any relative of the participant for whom the participant provides over half of their support
for the calendar year. A relative includes children, parents, stepchildren, siblings, aunts, uncles, cousins, and in-laws of the participant. Relatives
do not need to reside with the participant in order to be dependents, nor do they need to be a certain age or infirmity; they need only to be
persons for whom the participant has provided over half of their support.
Spouse Name:
If you participate, you will elect to have a specified amount of “pre-tax” money deducted
from your paycheck each pay period. These dollars are subtracted from your gross earnings
before taxes and put into a Flexible Spending Account to cover eligible out-of-pocket costs.
Once you submit a claim for a qualified expense, you will be reimbursed from this account.
—Lower your taxable income; pay less tax; increase your take-home pay.
—Participation is the equivalent of getting a raise.
The following table illustrates how you save by participating in a Flexible Spending Account:
Without This Plan
Telephone:
Soc. Sec. Number:
Date of Birth:
All dependents must be over the age of 18 in order to receive the AmeriFlex Convenience Card®.
Dependent Name:
Gross pay (annual)
$30,000.00
Gross pay (annual)
$30,000.00
$ 7,500.00
$ 1,000.00
Take-home pay
$22,500.00
Taxable income
$29,000.00
$ 1,000.00
$ 7,250.00
New take-home pay
$21,500.00
New take-home pay
$21,750.00
• Result (increased take-home pay)
$
Telephone:
Soc. Sec. Number:
Date of Birth:
Dependent Name:
Telephone:
Soc. Sec. Number:
Date of Birth:
Each AmeriFlex Convenience Card® is issued for a term of three years. Remember that existing cardholders will not receive a new card (unless
the current card is scheduled to expire). Cards will simply be “reloaded” for the next plan year with your new election. Upon expiration, AmeriFlex
will automatically issue new cards to participants who re-enroll in the new plan year. For new participants, your AmeriFlex Convenience Card®
will be sent to your home adress in a plain white envelope.
AU T H O R I Z AT I O N AG R E E M E N T F O R AC H D E B I T S / C R E D I T S
I, hereby, authorize AmeriFlex, LLC, hereafter called ADMINISTRATOR, to initiate debits and/or credits to or from my bank account indicated below
at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit and credit the same to such account with the
agreement that the only debits to be made will be for the sole purpose of correcting a prior FSA reimbursement error. I acknowledge the origination
of ACH transactions to or from my account must comply with the provisions of U.S. law.
Depository Name:
The information in this table is for descriptive purposes only and is not intended to reflect your own personal tax situation.
State:
Routing Number:
Zip:
Account Number:
(always nine digits)
CHECK EXAMPLE
Checking Account
Savings Account
If you would prefer, please attach a voided check.
ROUTING NUMBER
Medical Spending Account Eligible Expenses
A medical FSA is used to pay for healthcare expenses not covered under your medical or other
insurance plan. The IRS determines eligible expenses. IRS-qualified expenses may include:
• Co-pays, deductibles, and other payments you are responsible for under your
medical plan
• Charges that may not be covered by your medical plan such as:
– Routine exams
– Dental care
– Orthodontia
(check with your Employer to determine if Orthodontia is allowed in your plan and what reimbursement method is used)
Account Name:
City:
ACCOUNT NUMBER
CHECK NUMBER
The authorization is to remain in full force and effect until the ADMINISTRATOR has received written notification from the employee named above
of the termination in such time and in such manner as to afford the ADMINISTRATOR and DEPOSITORY a reasonable opportunity to act on it.
Date:
250.00
Eligible Expenses
SELECT ONE:
With This Plan
Signature:
Upon receipt, the Federal Reserve requires 14 business days to perform the initial approval of the ACH information. After this time, AmeriFlex will be
directly depositing all claim reimbursements into the bank account provided two days after every processing date determined by your employer.
It may take up to 5 business days to have your reimbursements appear in your account, depending upon the automated clearing house utilized
by your bank. We suggest that you contact your bank to confirm when these funds become available in your account. AmeriFlex shall not be
responsible for any checks or other debt payments you make whereby you have assumed these funds are available.
– Eyecare: Lasik, glasses, contact lenses
– Hearing aids
– Well-baby care
• Miscellaneous expenses such as:
– Many over-the-counter drugs; e.g., pain relief, sleep aids, allergy treatments
– Transportation, tolls, and parking to receive medical care
– Individual psychiatric or psychological counseling
– Diabetic equipment and supplies
– Durable medical equipment
– Qualified medical products or services prescribed by a doctor
Some examples of ineligible expenses include insurance premiums, teeth whitening, prescription
drugs for male-pattern baldness, and most cosmetic procedures. A more comprehensive list of
eligible medical and over-the-counter expenses is available on the AmeriFlex website.
AMERIFLEX ®
www.flex125.com
www.flex125.com
AMERIFLEX
®
Your Key to Savings
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• 24/7 INTERACTIVE VOICE RESPONSE (IVR): 888.868.3539 (option 2, option 2 for automated account balances and claims status)
A Plan That Enhances Your Benefits
• TOLL-FREE PHONE: 888.868.3539 (8:30 a.m. to 8:00 p.m. E.S.T.)
If you’re one of the many people who spend money on medical expenses, day care for
• WEB: www.flex125.com (select Employees from the Flex menu and then view your account activity)
dependents, or parking and transit, a Flexible Spending Account (FSA)—Medical, Dependent
• E-MAIL CUSTOMER SERVICE: service@flex125.com
Day Care, or Commuter—can make these expenses more affordable. One or all of these
• FAX: 800.282.9818
valuable benefits are available through your employer’s flexible benefits plan.
• MAIL: 302 Fellowship Rd., Suite 100, Mount Laurel, NJ 08054
—Every year more than 48 million employees nationwide enroll in a FSA program.
I
T
AMERIFLEX ® 302 Fellowship Road, Suite 100, Mount Laurel, New Jersey 08054 Toll-free: 888.868.FLEX (3539) E-mail: info@flex125.com
OTC
FAQ
CHANGES TO
OTC Rules Frequently Asked Questions|
QUICK REFERENCE GUIDE
www.flex125.com
1
Background:
Questions & Answers:
On March 23, 2010, President Barack Obama
signed into law a massive piece of legislation aimed
at reforming the nation’s health care system. The
new law, called the Patient Protection and Affordable
Care Act (PPACA), contains numerous provisions,
many of which will not go into effect for several years.
Q/What is the new OTC law?
An important part of the law, however, will go into
effect on January 1, 2011. This particular provision
changes how health flexible spending account
(FSA), health savings account (HSA), and health
reimbursement account (HRA) participants are
reimbursed for certain types of over-the-counter
(OTC) health care expenses. The following FAQ
outlines the details of this new provision based
upon the guidance that has already been provided
by the Internal Revenue Service. Click here
<http://www.flex125.com/af_site/company_info/fo
rms/OTC2011.pdf> for a one-page summary of
the new OTC rule.
A/PPACA mandates that expenses incurred for OTC medicines
and drugs (with the exception of insulin) will not be eligible for
reimbursement under a health FSA or HRA unless you have a
valid prescription for same.
On September 3, 2010, the Internal Revenue Service issued Notice
2010-59 and Revenue Ruling 2010-23, which explained in some
detail how this new rule will work. Some of the information that
follows is based on this new guidance.
Q/What changes on January 1, 2011?
A /As of January 1, 2011, you will need to provide a valid prescription
to your pharmacy in order to pay for OTC drugs and medicines with
your FSA or HRA debit card.
If you instead wish to purchase OTC medicines and drugs out-ofpocket and file for reimbursement with AmeriFlex, you will need to
submit a valid prescription with your claim.
Q/ What if my health plan year starts in November? Will the rule still
apply to me on January 1?
A / Yes. The new law goes into effect on January 1, 2011 and will apply
to the tax year, not the plan year. So, regardless of when your plan year
starts, the rule will apply to you (and everyone else) for all purchases
made on or after January 1.
OTC
FAQ
CHANGES TO
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2
Q & A continued
Q / What about expenses incurred during the grace period
(January 1, 2011 – March 15, 2011)?
Q / Will this new rule affect how I pay for my regular
prescriptions?
A / The new law goes into effect for everyone on January 1, 2011.
Regardless of whether you are using 2010 or 2011 funds, the
rule will still apply for all expenses incurred after January 1, and
you will still be required to follow the new procedure for
reimbursement of OTC medicines and drugs.
A / No. You will still be able to use your FSA or HRA funds to
pay for regular prescription medications with your FSA/HRA
debit card (the AmeriFlex Convenience Card), just as you have
in the past. You may also continue to use your AmeriFlex
Convenience Sleeve to pay for standard prescription items.
Q / What if I incur the expense before January 1 but do not request
reimbursement until after January 1? Will I be required to submit a
prescription?
A / Any expenses for OTC medicines or drugs incurred before
January 1, 2011 will NOT require a prescription for
reimbursement even if the claim is made on or after that date.
Q / Will I need a prescription to purchase OTC medicines or drugs
as of January 1, 2011?
A / Only if you want to use FSA or HRA funds to pay for these
items.
OTC
FAQ
CHANGES TO
www.flex125.com
3
Q & A continued
Q/Does this new law apply to HSAs?
A/Yes, but because HSAs operate differently than health
FSAs or HRAs, the effect on accountholders will be different.
Debit cards tied to HSAs will still work for OTC medicines
and drugs, but it will be the sole responsibility of the
accountholder to have a record of prescriptions for those
items. If the accountholder does not have a prescription for
OTC medicines or drugs purchased with HSA dollars on or
after January 1, 2011, the accountholder must pay the 20%
HSA excise tax on ineligible items.
Q/What exactly is considered an OTC “medicine or drug”?
A/The IRS did not provide specific guidance regarding
what is to be considered a medicine or drug under this new
law. Nevertheless, at this time we can be reasonably certain
that the following categories of items are considered
medicines/drugs and therefore will require a prescription
effective January 1, 2011 in order to receive reimbursement
from an FSA or HRA:
• Antacids
• Allergy and sinus medications
• Anti-diarrheals
• Anti-gas
• Anti itch and insect bites
• Baby rash ointments and creams
• Cold sore remedies
• Cough, cold and flu medications
• Digestive aids
• Feminine anti-fungal/anti-itch
• Laxatives
• Motion sickness medications
• Pain relievers
• Respiratory treatments
• Sleep aids and sedatives
• Stomach remedies
As further guidance is provided, we will share additional details
and information with you.
Q/What is not considered an OTC “medicine or drug”?
A/At this time, we are reasonably certain that the following
categories of items are not considered “medicines or drugs”
under this new rule and therefore will not require a prescription
in order to receive reimbursement from an FSA or HRA. You will
be able to use your FSA/HRA debit card to pay for these items
at a pharmacy or drug store, just as you have in the past:
• Acne creams
• Anti-fungal foot medication
• Antiseptics and wound cleaners
• Band Aids
• Condoms
• Braces and supports
• Catheters
OTC
FAQ
CHANGES TO
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4
Q & A continued
• Denture adhesives
• Diabetic testing and aids
• Diagnostic tests and monitors
• Elastic bandages and wraps
• Eye care and contact lens supplies
• Family planning kits
• Fiber laxatives
• First aid supplies
• Hearing aid batteries
• Infant electrolytes and dehydration solutions
• Infant teething pain supplies
• Insulin and diabetic supplies
• Nebulizers
• Orthopedic aids
• Ostomy products
• Reading glasses
• Smoking deterrents
• Syringes
• Thermometers
• Wheelchairs, walkers, and canes
As further guidance is provided, we will share additional
details and information with you.
Q/What is the new procedure for reimbursement of these
expenses? What do I need to do?
A/Beginning January 1, 2011, pharmacy systems will be
modified to comply with the new law and your FSA/HRA
debit card can only be used for the purchase of OTC medicines
or drugs if you present a valid prescription for them.
In order to get reimbursed from your FSA or HRA for the purchase
of these items, you will need to file a manual claim and send it to
AmeriFlex along with a copy of a prescription. This will enable us to
approve the claim and reimburse you for the amount you spent on
the eligible OTC purchase.
Remember, all eligible expenses that do not fall under the definition
of an OTC medicine or drug will not require any additional paperwork.
You will still be able to use your FSA/HRA debit card to pay for these
expenses, just as you have in the past.
For example, you will still be able to use your FSA debit card to buy
Band Aids and contact lens solution because these items are not
medicines or drugs, and you will not need to obtain a prescription or
file a manual claim after the fact.
OTC
FAQ
CHANGES TO
www.flex125.com
5
Plan Ahead, Save Money
We Are Here to Help
Whether you have an FSA, HSA, or HRA, don’t
forget that many of the expenses for which most
participants currently use their accounts will not be
impacted by this law. Regular prescriptions, along
with many other OTC items that are not considered
medicines or drugs, will not be subject to this rule,
and you will therefore still be able to pay for these
other expenses with your AmeriFlex Convenience
Card® and without the need to submit a prescription.
Additionally, you can still use your AmeriFlex
Convenience Card® for all other health care-related
expenses such as doctor or hospital visits, provided
such items are covered under your plan(s). Of course,
whether or not you are required to submit paperwork
for your health care expenditures, bear in mind that
it is always a good idea to save your receipts as
proof that your FSA, HSA, or HRA funds were used
to pay for an eligible expense under your plan.
AmeriFlex is here to help you understand and comply with the new
rules that will be introduced as part of the health care reform law.
As additional guidance is provided by the federal agencies, we will
continue to share information with you. In the meantime, please do
not hesitate to contact us with any questions that you may have.
Although the new law does add another step to
the process of getting reimbursed for certain OTC
medicines and drugs, planning ahead to obtain a
doctor’s prescription and submitting the extra
paperwork that is now required can still save you
quite a bit of money in the long run—and is therefore
still worth the extra effort required under the new law.
888.868.FLEX (3539) | www.flex125.com
Do you want to voice your opinion about the new OTC provision?
We understand that the new law is not a welcome change for many of our clients
and participants. While we at AmeriFlex intend to do everything within our power
to minimize any inconvenience that may result from the new OTC provision, we
recognize that you may wish to voice your concerns about how the new law will
affect you and your family.
Click here: http://www.congress.org/congressorg/issues/basics/?style=comm
for information on how to share your thoughts with elected officials from your
home state.
CHANGES TO
OTC Rules
OVERVIEW/ NEW IN 2011
www.flex125.com
Background:
OTC
2011
On March 23, 2010, President Barack Obama signed into law a massive piece of legislation aimed at reforming the
nation’s health care system. The new law, called the Patient Protection and Affordable Care Act (PPACA), contains
numerous provisions, many of which will not go into effect for several years. An important part of the law, however, will
go into effect on January 1, 2011. This particular provision changes how health flexible spending account (FSA), health
savings account (HSA), and health reimbursement account (HRA) participants are reimbursed for certain types of
over-the-counter (OTC) health care expenses. The following is a brief overview of the changes that will occur effective
1/1/2011. Click here <http://www.flex125.com/af_site/company_info/forms/OTC_FAQ.pdf> for a more detailed FAQ.
Summary of the new OTC law:
PPACA mandates that expenses incurred for OTC medicines and drugs (with the exception of insulin) will not be
eligible for reimbursement under a health FSA or HRA unless you have a prescription.
Effective date:
The new OTC law will apply to all purchases made on or after January 1, 2011. The new law will apply to the tax year,
not the plan year. This means that even if your plan year starts in November 2010, the rule will still apply to you (and
everyone else) beginning January 1.
New claims reimbursement procedure:
Effective January 1, you will be able to use your FSA/HRA debit card to pay for over-the-counter medicines and drugs
at pharmacies only if you provide a valid prescription for the OTC medicines and drugs to the pharmacy, which must
then follow its usual procedures for prescribed drugs or medicines.
Manual Claims:
Manual reimbursements for OTC medicines or drugs will require the submission of a valid prescription along with the
claim for processing.
What is considered an OTC “medicine or drug”?
The IRS did not provide specific guidance regarding what is to be considered a medicine or drug under this new law.
Nevertheless, at this time we can be reasonably certain that certain categories of items will be considered medicines/drugs
and therefore will require a prescription effective January 1, 2011 in order to receive reimbursement from an FSA or
HRA. These include: allergy and sinus medications; cough, cold and flu medications; digestive aids; pain relievers;
sleep aids; and stomach remedies. Click here <http://www.flex125.com/af_site/company_info/forms/OTC_FAQ.pdf>
for a more detailed list.
Will this affect the use of my FSA/HRA debit card for other purchases?
No. You will still be able to use your FSA/HRA debit card for many common health care expenses that are not
considered OTC medicines and drugs under the new law. These include: Band Aids; diabetic testing and aids; eye
care and contact lens supplies; first aid supplies; insulin and diabetic supplies; reading glasses; and thermometers.
Click here <http://www.flex125.com/af_site/company_info/forms/OTC_FAQ.pdf> for a more detailed list.
And remember, regular prescriptions will not be subject to this rule, so you will still be able to pay for your prescription
drugs with your AmeriFlex Convenience Card® just as you have in the past. You will also be able to use your AmeriFlex
Convenience Card for doctor and hospital visits, as well as dental and vision care, provided such items are covered
under your plan(s).
We are here to help:
Please feel free to contact us with any questions or concerns that you may have.
888.868.FLEX (3539) | www.flex125.com
ELIGIBLE EXPENSES
Quick Reference Guide
Locate expense categories and coverage availability (YES/NO/MAYBE). Click on category
for link to more detailed guidelines. OTC eligibility information follows in this document.
JUMP
TO OTC
INFO
AMERIFLEX
click here
• Acne Medicine/Treatment YES
• Domestic Partners MAYBE
• Optometrist YES
• Acupuncture YES
• Drug Addiction (see Alcoholism)
• Organ Donor YES
• Air Conditioning, Air Filter, Purifier,
Humidifier MAYBE
• Durable Medical Equipment (DME) YES
• Orthodontia YES
• Ear Piercing NO
• Orthopedic Shoes YES
• Alcoholism Treatment YES
• Educational Classes NO
• Over–the–Counter Medications YES
• Ambulance YES
• Electrolysis NO
• Oxygen YES
• Anesthesiology YES
• Eyeglasses/Supplies (e.g., storage case,
replacement cost), Warranties YES
• Parking (see Transportation)
• Arch Support MAYBE
• Artificial Insemination MAYBE
• Exercise Equipment MAYBE
• Personal Use Items MAYBE
• Artificial Limb YES
• Experimental Drugs YES
• Physical Exam for Caregiver NO
• Artificial Teeth YES
• Fertility YES
• Physical Therapy YES
• Asthma Equipment YES
• Flu Shot YES
• Prescription Drugs YES
• Birth Control YES
• Funeral Expenses NO
• Prosthesis YES
• Birthing Coach NO
• Guide Dog or Animal YES
• Psychiatric YES
• Bleaching of the Teeth MAYBE
• Gynecologists YES
• Psychoanalysis YES
• Blood Donation YES
• Handicapped Persons (see Schools)
• Psychologist YES
• Braille Books/Magazines YES
• Health Club MAYBE
• Breast Augmentation NO
• Health Screenings YES
• Breast Implant Removal MAYBE
• Hearing Aids YES
• Breast Pump (Purchase or
Rental) MAYBE
• Holistic/Homeopathy Practitioner MAYBE
• Breast Reduction MAYBE
• Human Guide YES
• Capital Expenses MAYBE
• Hypnosis MAYBE
• Car Modifications MAYBE
• Insurance Premiums NO
• Childbirth Classes (Lamaze) MAYBE
• Laboratory Fees YES
• Chiropody YES
• LASIK Eye Surgery YES
• Chiropractors YES
• Late Fees Payments NO
• Christian Science Practitioner MAYBE
• Learning Disability (see Schools)
• Circumcision YES
• Legal Fees MAYBE
• COBRA Premiums NO
• Telephone Consultation
(Physicians’ Fees) YES
• Lifetime Care Advance Payments NO
• Collagen Injections MAYBE
• Television MAYBE
• Lodging/Trips MAYBE
• Contact Lenses, Solutions, and
Supplies YES
• Transplants YES
• Marijuana NO
• Transportation MAYBE
• Massage Therapy MAYBE
• Tuition MAYBE
• Maternity Charges YES
• Tutoring MAYBE
• Maternity Clothes NO
• Umbilical Cord Blood MAYBE
• Mattresses MAYBE
• UVR Treatments YES
• Meals MAYBE
• Vaccinations YES
• Medical Plan Information YES
• Vasectomy YES
• Medical Services YES
• Varicose Vein Surgery MAYBE
• Medicines YES
• Weight Loss Drugs MAYBE
• Dermatology YES
• Mentally Retarded (Special
Home for) MAYBE
• Weight Loss Programs MAYBE
• Diabetic Equipment/Supplies YES
• Mouth Guards YES
• Diagnostic Services YES
• Neurologist Fees YES
• Diapers/Diaper Service MAYBE
• Nursing Home MAYBE
• Dietitian MAYBE
• Nursing Services YES
• DNA Testing NO
• Nutritional Supplements MAYBE
• Copays/Coinsurance YES
• Cosmetic Treatment MAYBE
• Counseling MAYBE
• CPR Classes NO
• Dancing Lessons MAYBE
• Deductibles YES
• Dental Treatment YES
• Denturist YES
• Hospital Services YES
• Personal Trainers MAYBE
• Schools, Special MAYBE
• Smoking Cessation Program YES
• Speech Therapy YES
• Sperm Storage MAYBE
• Stem Cell Storage MAYBE
• Sterilization YES
• Substance Abuse (see Alcoholism)
• Sunglasses MAYBE
• Swim Therapy MAYBE
• Taxes YES
• Telephone MAYBE
• X-ray Fees YES
PAGE 2
ELIGIBLE EXPENSES
Click to return to page one.
Click to jump to OTC info.
AMERIFLEX
www.flex125.com
Acne Medicine/Treatments/Yes: Acne medicines and treatments are eligible expenses.
Acupuncture/Yes: Fees paid for acupuncture are eligible medical expenses.
Air Conditioning, Air Filter, Purifier, Humidifier/Maybe: The cost of these items, if recommended by a physician as treatment for a specific medical condition,
is an eligible expense. If the value of the home increases then these amounts are not reimbursable.
Alcoholism Treatment/Yes: Payments to a treatment center for alcohol or drug addiction are eligible medical expenses. This includes meals and lodging
provided by the center during medical treatment.You may include transportation costs incurred to attend Alcoholics Anonymous (AA) meetings recommended by
the attending physician, when submitted with supporting documentation.
Ambulance/Yes: Fees for ambulance service are covered.
Anesthesiology/Yes: Fees for anesthesiology are covered.
Arch Support/Maybe: Qualifies as a medical expense only if prescribed by a physician as treatment and when submitted with documentation supporting a
specific medical condition.
Artificial Insemination/Maybe: See Fertility
Artificial Limb/Yes: Expenses for the purchase of an artificial limb qualify as medical expenses.
Artificial Teeth/Yes: You can include in medical expenses the amount you pay for artificial teeth.
Asthma Equipment/Yes: Nebulizers or peak flow meters prescribed for treatment of asthma are eligible expenses.
Birth Control/Yes: Expenses associated with the purchase of birth control purchased over the counter or prescribed by a doctor are eligible expenses (e.g., IUD,
diaphragm, Norplant, condoms).
Birthing Coach/No: Expenses associated with a birthing assistant/coach for women in labor are not considered eligible medical expenses.
Bleaching of the Teeth/Maybe: See Cosmetic Treatment
Braille Books/Magazines/Yes: The cost of braille books and magazines for use by visually impaired persons qualifies as a medical expense. Eligible expenses
include only the amounts over the cost of the product in its standard form.
Breast Augmentation/No: Expenses related to breast augmentation (such as implants or injections) are not reimbursable because the procedure is considered
cosmetic in nature.
Breast Implant Removal/Maybe: The removal of breast implants that are defective or are causing a medical problem are reimbursable.
Breast Pump (Purchase or Rental)/Maybe: The cost of a breast pump is considered a medical expense if the pump needs to be used to treat a medical
condition.
Breast Reduction/Maybe: Medical expenses related to breast reduction surgery are reimbursable only if the physician substantiates that the procedure is
medically necessary, i.e., to prevent or treat an illness or disease.
Capital Expenses/Maybe: Amounts paid for special equipment installed in your home for improvement qualify as medical expenses if there is documentation
from a physician that the equipment is mainly needed for or as a result of a specific medical condition. If the capital expenditure increases the value of the
property, the excess value is not reimbursable. Improvements made to accommodate a residence for a person’s disability do not usually increase the value of the
residence, and the full cost is usually reimbursable. Only reasonable costs to accommodate a personal residence for a disabled condition are considered medical
care. Additional costs for personal motives, such as for architectural or aesthetic reasons, are not reimbursable.
Car Modifications/Maybe: Special hand controls and other special equipment installed in a car for use by a disabled person qualify as medical expenses.
Childbirth Classes (Lamaze)/Maybe: Some of the expenses may qualify. Expenses for instructions relating to the birth of the child are eligible for the mother to
be. Fees for instruction in topics such as newborn care are not eligible. Expenses for the coach or significant other do not qualify.
Chiropody/Yes: Fees paid to a chiropodist (chiropractic foot doctor) for medical care are eligible expenses.
Chiropractors/Yes: Fees paid to a chiropractor are eligible.
Christian Science Practitioner/Maybe: Fees paid to a Christian Science practitioner are eligible expenses when treatment is rendered for a specific medical
condition.
Circumcision/Yes: Circumcision is a covered medical expense. This procedure is also covered if performed in the member’s home by a rabbi.
COBRA Premiums/No: Premiums paid for COBRA benefits are not a covered expense.
Collagen Injections/Maybe: Collagen injections are considered to be cosmetic, however, may be covered if medically necessary (e.g., for treatment of severe
acne).
Contact Lenses, Solutions and Supplies/Yes: Expenses, including shipping and handling incurred for the purchase of contact lenses, qualify if the contact
lenses are needed for medical reasons. Amounts paid for contact lens solutions and supplies qualify as medical expenses. Fees paid for eye exams are also
eligible.
Copays/Coinsurance/Yes: A copay or coinsurance fee qualifies as a medical expense.
Cosmetic Treatment/Maybe: Generally, medical expenses paid for unnecessary, i.e., elective, cosmetic treatment are not covered. (This applies to any
procedure that is directed at improving the patient’s appearance and that does not meaningfully promote the proper functioning of the body or prevent or treat an
illness or disease.) Examples of non-covered cosmetic surgery procedures include breast augmentation, chemical electrolysis, face lift, hair transplant, liposuction, and tattoo removal. Expenses incurred for cosmetic surgery necessary to improve a deformity arising from or directly related to a congenital abnormality, a
personal injury or a disfiguring disease qualifies as eligible medical expenses.
Counseling/Maybe: Amounts paid for counseling which is medically necessary to treat a specific medical or mental illness is covered.Marriage counseling and
Family counseling are not covered expenses.
PAGE 3
ELIGIBLE EXPENSES
AMERIFLEX
www.flex125.com
CPR Classes/No: CPR classes are not considered "medically necessary"; therefore, the expense is not reimbursable under FSA.
Dancing Lessons/Maybe: Amounts paid for dancing lessons do not normally qualify as medical expenses. But the expense may qualify if recommended to
treat a specific medical condition (such as part of a rehabilitation program after surgery).
Deductibles/Yes: Deductibles qualify as medical expenses.
Dental Treatment/Yes: Amounts paid for dental treatments qualify as medical expenses. This includes fees paid to dentists for X-rays, fillings, braces, extractions, dentures, caps, crowns, fluoride treatment, implants, etc. In addition, the installation and monthly rental charges for fluoride treatments to home water
qualify as medical expenses when prescribed by a physician or dentist. However, the amount should be limited to the cost allocable to the current plan year.
Denturist/Yes: Fees paid to a denturist qualify as health care expenses when services are for the treatment of a specific medical condition.
Dermatology/Yes: Fees paid to a dermatologist for medical care qualify as medical expenses.
Diabetic Equipment and Supplies/Yes: Medical expenses may include amounts paid for the following equipment and supplies for treatment of diabetes;
glucose monitor, urine/blood test strips, insulin and syringes and alcohol swabs.
Diagnostic Services/Yes: Fees paid for diagnostic services, as prescribed by a physician, are eligible medical expenses.
Diapers—Diaper Service/Maybe: Amounts paid for adult diapers or a diaper service, qualify as a medical expense if prescribed by a physician to relieve the
effects of a specific medical condition. Diaper expenses for handicapped individuals beyond infancy are also covered.
Dietitian/Maybe: Fees paid to a dietitian are eligible when referred by a physician for treatment of a specific medical condition.
DNA Testing/No: DNA testing for paternal responsibility is not considered an eligible expense.
Domestic Partners/Maybe: Medical expenses incurred by domestic partners are usually not eligible for reimbursement from an FSA. Members should consult
with their plan sponsors on domestic partner coverage.
Drug Addiction—See Alcoholism
Durable Medical Equipment (DME)/Yes: The cost associated with the purchase or rental of durable medical equipment that is prescribed by a medical
practitioner to alleviate or treat a specific medical condition qualifies as an eligible expense. Costs can include: bed wetting alarm, blood pressure kit, chair* ,
crutches, hearing aids, medical alert equipment, and oral hygiene equipment.*Reimbursement is only for the amount that exceeds the cost of a similar or regular
product. Letter of medical necessity only needed for items that have a dual purpose (e.g. chair, sheets, oral hygiene equipment).
Ear Piercing/No: Expenses associated with ear or body piercing is not eligible medical expenses.
Educational Classes/No: Educational classes are not eligible medical expenses (care for a newborn, breast feed, cope with diabetes, etc.).
Electrolysis/No: See Cosmetic Treatment
Eyeglasses/Supplies (e.g., storage case, replacement cost)/Yes: Amounts paid for prescription vision/sports eyewear, supplies (i.e., eyeglasses, goggles,
sunglasses) for a medical condition qualify as a medical expense. Fees paid for eye exams are also eligible. Tinting of prescription eyewear qualifies as an
eligible medical expense.
Exercise Equipment/Maybe: Exercise equipment may be covered when prescribed by a physician as treatment for a specific medical condition. Exercise
equipment used for improvement of general health is not covered.
Experimental Drugs/Yes: Legal experimental treatments and procedures are eligible.
Fertility/Yes: Medical expenses associated with the treatment of infertility, including shots, in vitro fertilization and artificial insemination incurred by the
member, are reimbursable. Semen and embryo storage associated with an active attempt to conceive are also eligible for reimbursement. Note: donor expenses
incurred by the member (egg donation, sperm donation) are eligible during active treatment only, if expenses are not covered by a medical plan. The cost of an
ovulation kit qualifies as an eligible medical expense.
Flu Shot/Yes: Flu shots are eligible medical expenses.
Guide Dog or Animal/Yes: The cost of a guide dog or other animal to be used by the visually impaired or hearing impaired qualifies as a medical expense.
The cost of a dog or other animal trained to assist persons with other physical disabilities can also be covered. Amounts paid for the care of these specially
trained animals are also eligible medical expenses.
Gynecologists/Yes: Fees paid to a gynecologist for medical care are eligible medical expenses.
Health Club/Maybe: Dues paid to a health club, YMCA, YWCA or spas are allowable with documentation from the attending physician stating that the
membership expenses are for treatment of a specific medical condition. Reimbursement is only eligible for the individual membership and for the component
that is related to a single year. Any dues that carry over to a subsequent year would violate the IRS rule of constructive receipt. Dues paid for steam baths for
your general health or to relieve physical or mental discomfort not related to a particular medical condition are not eligible. Dues must be for a new membership,
if the participant was already a member before the physicians prescription, it is ineligible.
Health Screenings/Yes: See Diagnostic Services
Hearing Aids/Yes: The costs of hearing aids and batteries qualify.
Holistic—Homeopathy Practitioner/Maybe: Fees paid to a holistic or homeopathy doctor are eligible when treatment is provided for a specific medical
condition.
Hospital Services/Yes: Amounts paid for hospital services that are not covered under a medical plan qualify as medical expenses (e.g., upgrade from
semi-private to private room, fees charged for parents to stay with a child, etc.). (Also see Lodging/Trips)
Human Guide/Yes: Expenses for a human guide - to take a blind child to school for example – are reimbursable.
Hypnosis/Maybe: Hypnosis is considered a medical expense when it is prescribed by a physician as treatment for a specific medical or mental condition.
PAGE 4
ELIGIBLE EXPENSES
AMERIFLEX
www.flex125.com
Insurance Premiums/No: Amounts paid as premiums to purchase health care coverage are not eligible medical expenses. This also includes COBRA,
Medicare A&B premiums.
Laboratory Fees/Yes: Amounts paid for laboratory fees that are part of your medical care are eligible medical expenses.
LASIK Eye Surgery/Yes: Expenses associated with LASIK/PRK or radial keratotomy surgery to correct impaired vision are eligible.
Late Fees Payments/No: Late fees associated with payment of medical expenses are not eligible.
Learning Disability—See Schools, Special
Legal Fees/Maybe: Legal fees may qualify as medical care if they bear a direct or proximate relationship to the provision of medical care to you, your spouse
or your dependent.
Lifetime Care Advance Payments/No: Prepayments of life care fees or founders fees paid monthly or as a lump sum under an agreement with a retirement
home are not eligible expenses.
Lodging—Trips/Maybe: The cost of meals and lodging at a hospital or similar institution qualify as medical expenses if the main reason for being there is to
receive medical care. Expenses incurred for transportation to another city are eligible health care expenses if the trip is primarily for and essential to receiving
medical services. You may also be able to include up to $50 (refer to IRS Publication 502) per person, per night for lodging.You cannot include in medical
expenses amounts you pay for a trip or vacation taken for a change in environment, improvement of morale or general improve-ment of health, even if a doctor
recommends the trip.
Marijuana/No: Expenses associated with marijuana when purchased or used under state laws for treatment of a medical condition are not eligible for
reimbursement. This drug remains illegal under federal law and does not qualify as a Sec. 213 medical expense.
Massage Therapy/Maybe: Massage therapy is covered if the member submits documentation from a physician confirming that massage therapy is prescribed
as treatment of a specific medical condition. The physician should also include the frequency and duration of the therapy. Massage therapy for general health
does not qualify as a medical expense.
Maternity Charges/Yes: Amounts paid to physicians for delivery charges quality as eligible expenses.
Maternity Clothes/No: The cost of maternity clothing is not an eligible expense.
Mattresses/Maybe: Amounts paid for a mattress or special bedding for a person with documentation supporting a medical condition is a medical expense, but
only for the amount that exceeds the cost of similar regular bedding. Proof of the cost of regular bedding is necessary to pay the expense.
Meals/Maybe: Meals associated with inpatient medical care are eligible expenses.
Medical Plan Information/Yes: Payments for services to keep your medical information so that it can be retrieved from a computer data bank are an eligible
medical expense. Fees associated with copying medical records are also eligible.
Medical Services/Yes: Eligible medical expenses for treatment of specific medical conditions include fees paid to Doctors, Surgeons, Specialists, or other
medical practitioners.
Medicines/Yes: Eligible medical expenses include amounts paid for prescribed medicines and drugs. A prescribed drug is one that requires a written order by a
medical practitioner and is dispensed through a pharmacy for its use by an individual. You may include expenses you pay for delivery charges, postage and
handling of mail-order prescribed drugs. Also see the Over-the-Counter Drugs section.
Mentally Retarded (Special Home for)/Maybe: Expenses associated with keeping a mentally retarded person in a special home (not the home of a relative)
on the recommendation of a psychiatrist to help the person adjust from life in a mental hospital to community living is an eligible expense.
Mouth Guards/Yes: Occlusal guards prescribed by a dentist to prevent a person from grinding his/her teeth at night are eligible expenses.
Neurologist Fees/Yes: Fees paid to a neurologist for treatment of a specific condition qualify as medical care and are eligible for reimbursement.
Nursing Home/Maybe: Medical expenses associated with the cost of medical care provided in a nursing home or home for the aged for an employee, spouse
or dependent are eligible for reimbursement (i.e., with a bill from a provider or facility for medical services). This includes the cost of meals and lodging in the
home if the main reason for being there is to receive medical care. Non-medical expenses are not eligible.
Nursing Services/Yes: Wages and other amounts paid for nursing services are eligible medical expenses. This includes services connected with caring for the
patient’s condition, such as dispensing medications changing dressings, bathing and grooming the patient. Only the amount spent for nursing services is a
medical expense. If the attendant also provides personal and household services, these amounts must be divided between the times spent performing household and personal services and the time spent for nursing services. However, certain expenses for household services or for the care of a qualifying individual
incurred to allow an employee to work may qualify for the child and dependent care credit. See Publication 503, Child and Dependent Care Expenses.
Nutritional Supplements/Maybe: Special foods or nutritional supplements are only covered if there is supporting documentation from a physician that they
were prescribed as treatment for a specific medical condition.
Optometrist/Yes: See Contact Lenses & Eye Glasses
Organ Donor/Yes: Donor’s expenses that are paid by the FSA enrollee are eligible for reimbursement.
Orthodontia/Yes: Out-of-pocket Orthodontia expenses are eligible. However, depending on how your FSA is designed, your plan may reimburse advanced or
“up-front” expenses for orthodontia made through a payment plan or it may reimburse only after the expense has been incurred and services rendered. Please
contact your Employer to see how your plan reimburses for orthodontic care. Prepaid expenses are subject to proof of payment, (i.e., cancelled check, bill from
provider indicating payments or credit card receipt) and require that a copy of the orthodontia treatment contract be submitted with the initial claim.
Orthopedic Shoes/Yes: Amounts paid for special shoes are eligible medical expenses, but for the amount that exceeds the cost of regular footwear.
Over–the–Counter Medications/Yes: See Over-the-Counter Section
Oxygen/Yes: Amounts paid for oxygen or oxygen equipment to relieve breathing problems caused by a medical condition is eligible.
Parking—See Transportation
PAGE 5
ELIGIBLE EXPENSES
AMERIFLEX
www.flex125.com
Personal Trainers/Maybe: Fees paid to personal trainers are eligible for reimbursement if recommended by a medical practitioner to treat a specific medical
condition. The use of personal trainers for improvement of general health is not covered.
Personal Use Items/Maybe: Personal use items used primarily to prevent or alleviate a physical or mental defect or illness are an eligible medical expense
when accompanied with documentation supporting a specific medical condition. For example, the full cost of a wig purchased upon the advice of a physician for
the mental health of a patient who has lost all of his/her hair from disease, can be included as medical expenses.
Physical Exam for Caregiver/No: Expenses for a physical exam for a potential caregiver are not expenses for the care of a qualifying individual, nor do they fit
into the definition of a household expense.
Physical Therapy/Yes: Physical therapy is covered only if the member submits documentation from a physician confirming that physical therapy is prescribed
as treatment for a specific medical condition. The physician should also include the frequency and duration of the therapy.
Prescription Drugs/Yes: See Medicines
Prosthesis/Yes: See Artificial Limb
Psychiatric/Yes: Amounts paid for psychiatric care are eligible for reimbursement. This includes fees associated with the care of a qualifying individual in a
specially equipped medical center where the dependent receives medical care when prescribed by a physician.
Psychoanalysis/Yes: Amounts paid for psychoanalysis qualify as medical expenses.
Psychologist/Yes: Fees paid to a psychologist for medical care are eligible medical expenses when submitted with documentation supporting a specific
medical condition.
Schools, Special/Maybe: Payments to a special school for a mentally impaired or physically disabled person qualify as eligible health care expenses if the main
reason for using the school is its resources for relieving the disability. Costs can include: teaching Braille to a visually impaired child, teaching lip reading to a hearing
impaired child, giving remedial language training to correct a condition caused by a birth defect.The cost of meals, lodging and ordinary education supplied by a
special school can be covered medical expenses only if the main reason for the child being there is the resources the school has for relieving the mental or
physical disability.
Smoking Cessation Program/Yes: Expenses associated with the cost of a stop-smoking program are eligible health care expenses and do not require letter of
medical necessity.
Speech Therapy/Yes: Expenses associated with speech therapy are eligible when prescribed as treatment for a medical condition (e.g., autism or dyslexia).
Sperm Storage/Maybe: Fees paid for storage of sperm for treatment of infertility are eligible health care expenses. Storage fees paid for non-medical reasons
are ineligible.
Stem Cell Storage/Maybe: This expense is reimbursable if used in treatment of a specific medical condition. The cost to collect, freeze and store stem cell
would also be eligible as long as a specific medical condition is present. The amount that is not covered under regular medical coverage would be a reimbursable expense.
Sterilization/Yes: The cost of obtaining a legal sterilization or to reverse sterilization is an eligible health care expense.
Substance Abuse—See Alcoholism
Sunglasses/Maybe: The cost of prescription sunglasses are allowable.
Swim Therapy/Maybe: Expenses associated with swim therapy or a swim club membership when prescribed by a medical practitioner as treatment for a
specific medical condition (e.g., rheumatoid arthritis) are eligible health care expenses. Swim lessons to learn the fundamentals of swimming are not eligible
health care expenses.
Taxes/Yes: Taxes incurred for medical services or products qualify as eligible health care expenses (e.g., sales tax and state hospital bill surcharges).
Telephone/Maybe: Expenses associated with enhancing a telephone to accommodate a deaf person or persons with disabilities are eligible health care
expenses.
Telephone Consultation (Physicians’ Fees)/Yes: Fees charged by physicians for telephone consultations are eligible health care expenses. The phone charge
is also an eligible expense.
Television/Maybe: Expenses associated with the cost of modifying a television to assist a handicapped person are eligible health care expenses. Cost may
include an adapter that attaches to a regular television. It may also include the cost of a specially equipped television. Eligible reimbursement is the cost
associated with the specialization over the cost of a similar standard model.
Transplants/Yes: See Organ Donor
Transportation/Maybe: Amounts paid for transportation primarily for, and essential to, medical care qualifies as medical expenses when submitted with
documentation supporting a specific medical condition. Included are: ambulance services, buses, car rentals, parking fees, plane fare, taxis, tolls, and personal
car—(16.5 cents a mile) effective calendar year 1/1/10. Transportation expenses can be covered for a nurse who provides medical services to the patient who is
traveling to get medical care and is unable to travel alone. Transportation expenses to see a mentally ill dependent are covered, if the visits are recommended as
a part of the treatment. Commuting expenses for a physically disabled person are not covered. IRS Publication 502 indicates that transportation expenses to
travel to another city will not qualify as an eligible expense when a member elects the destination.
Tuition/Maybe: Expenses charged for medical care included in the tuition of a college or private school are eligible health care expenses if the charges are
separately stated in the bill provided by the school. Medical coverage premiums attached to a college tuition or private school bill do not qualify as an eligible
expense.
Tutoring/Maybe: Tutoring fees paid on a doctor’s recommendation for a child’s tutoring by a specialized teacher qualify as medical expenses with documentation supporting a specific medical condition.
Umbilical Cord Blood/Maybe: Expense is reimbursable if used in treatment of a medical condition. The amount not covered under regular medical coverage
would be a reimbursable expense. The cost to collect, freeze and store umbilical cord blood would be eligible as long as a medical condition is present.
PAGE 6
ELIGIBLE EXPENSES
AMERIFLEX
www.flex125.com
UVR Treatments/Yes: UVR treatments are eligible expenses when recommended by a physician for a medical condition (e.g., chronic psoriasis).
Vaccinations/Yes: Amounts paid for vaccinations or immunizations against disease are eligible health care expenses.
Vasectomy/Yes : Medical expenses paid for a legal vasectomy are covered.
Varicose Vein Surgery/Maybe: Expenses associated with the removal of varicose veins prescribed by a doctor for treatment of a specific medical condition are
eligible health care expenses. Removal for cosmetic purposes is not an eligible expense.
Weight Loss Drugs/Maybe: Weight loss drugs prescribed by a physician to treat a medical condition (e.g., morbid obesity, hypertension) are eligible for
reimbursement. Weight loss drugs associated with general weight loss are not eligible for reimbursement.
Weight Loss Programs/Maybe: Medical expenses paid for a weight loss program prescribed by a doctor for treatment of a specific medical condition (e.g., high
blood pressure, heart disease) are covered. Reimbursement should be only for the component that is related to a single calendar year. The member should
submit documentation from the attending physician prescribing the weight loss program confirming that it was medically necessary for a specific medical
condition and not for general health enhancement.
X-ray Fees/Yes: X-ray fees associated with medical care qualify as eligible health care expenses.
This document is provided for informational purposes only and is not intended as legal advice nor does it reflect specific limitations on eligible expenses under a
particular employer-sponsored plan. No liability, expressed or implied, is assumed by AmeriFlex for reliance upon this eligibility list for tax-exempt determination
of specific expenses nor shall this document operate as a promise of reimbursement or remuneration of any kind. If you are unsure about the eligibility of an
expense, please don’t hesitate to contact AmeriFlex or consult your own tax professional.
PAGE 1/OTC
ELIGIBLE EXPENSES
AMERIFLEX
www.flex125.com
ELIGIBLE OVER-THE-COUNTER MEDICATIONS
This list is not an exhaustive list and is only intended to provide examples of some of the most common brand names of OTC medications.
Common Brand Names
Type of Medication
Allergy Prevention & Treatment
Anesthetics
Antacids and Acid Reducers
Anticandial
Antidiarrheal and Laxatives
Anti-fungal
Antihistamines
Benadryl, Sudafed, Actifed, Claritin, Chlora Trimaton & Nasalcrom
Sucrets, Halls and other throat lozenges; Bactine and it’s equivalents; Aspercreme and other topical
anesthetics.
Gas-X, Maalox, Mylanta, Tums, AXID AR, Pepcid AC, Pepto Bismal, Prilosec OTC, Tagamet HB, & Zantac
75AXID AR, Prilosec OTC, Tagamet HB & Zantac 75
Femstat 3, Gyne-Lotrimin, Mycelrx-7, Monistat 3, 7, & Vagistat-1
Ex-Lax, Pepto-Bismol, Immodium A.D. & Kaopectate
Femstat, Gyne-Lotrimin, Lotrimin, Lamisil AT, Lotramin AF, Monistat & MicatinActidil Syrup & Capsules,
Actifed, Allerest, Benadryl, Claritin, Chlor-Trimeton, Contac, Dimetane, Drixoral, Nyquil, Sudafed, Tavist-1 &
Triaminic
Anti-itch Lotions and Creams (e.g., for athletes
foot, jock itch, bug bites, poison ivy)
Bactine, Caldecort, Cortaid, Hydrocortisone, & Lanacort, Calamine Lotion, Benadryl Cream, Caladryl, Cortaid,
Hydrocortisone, Lamisil AT, Lotramin AF & Micatin
Asthma
Primatene, Bronkaid
Cold Sore/Fever Blister
Abreva, Carmex
Condoms and Other Contraceptive Devices
Trojans, Magnum, VGF Filmn& Delfen Contraceptive Foam
Contact Lenses Solutions & Eyecare
Aosept, Allergan, Bausch & Lomb, Boston, Renu, Occuclear, Opti-Free, Visine
Robitussin, Vicks 44, Chloraseptic
Actidil Syrup & Capsules, Actifed, Allerest, Advil Cold and Sinus, Afrin, Afrinol, Aleve Cold & Sinus, Alka
Seltzer Cold & Flu, Benadryl, Children’s Advil Cold, Claritin, Chlor-Trimeton, Contac, Dimetane, Drixoral,
Duration, Dristan Long Lasting, Neo-Synephrine- 12 Hour, nyquil, Orrivin, Sudafed, Tavist-D, Tylenol Cold &
Flu, Thera-flu, Sudafed, Tavist-1 & Triaminic
Balmax and Desitin
Home-based kits for pregnancy, blood glucose for diabetics and similar test kits
Ocu Hist
Ace Bandages, Band-Aids, Bandage Tape, thermometers, Medical Gloves, Gauze, Neosporin, Rubbing
Alcohol & Visine
Rid, Nix
Preparation H, Hemorid & Tronolane
Cough Suppressants
Decongestant/ Nasal Decongestant and Cold
Remedies
Diaper Rash Ointments
Diagnostic Tests
Eye Drops for Allergy/Cold Relief
First Aid Supplies
Head Lice Treatment
Hemorrhoid Treatments
Internal Analgesic/Antipyretic
Incontinence Supplies
Liniments
Medical Monitoring
Medical Products & Devices
Advil, Aleve, Children’s Motrin, Nuprin, Excedrin, Tylenol & Bayer
Depends
BenGay, Tiger Balm and Flexall
Services & Bracelets specifically for medical information
Blood Pressure Monitor, Glucose Tester, HIV Test, Cholesterol Test, Diabetic Supplies, Crutches, Ovulation
Monitor & Pregnancy Testing Kits
Menstrual Cycle Medications
Migraine
Motion Sickness Medication
Nicotine Gum or Patches & Smoking
Cessation Aids
Pain Relief
Parasite Treatment
Poison Ivy Protection
Sleep Aids
Smoking Cessation
Toothache & Teething Pain Relievers
Midol, Pamprin & Premysyn PMS
Advil Migraine Liqui-gels, Excedrin Migraine, Motrin Migraine Pain
Dramamine & Marizine
Nicorette, Nicotrol & Nicodin
Wart Removal Medications
Compound W, Tinamed
Actron, Advil, Aleve, Aspirin, BC Powder, Motrin, Nuprin, Orudis, Solarcaine, Tylenol
Pin-X, EZScrub and other similar items for intestinal worms, ringworm, etc
Ivy Block
Unisom, Sominex, Excedrin PM, and Nyquil
Commit, Nicoderm CQ, Nicorette, Nicotrol
Orajel

ameriflex - Messiah College

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