MEDICAL EXPENSE CLAIM FORM Flex Plan Benefits PO Box 24859, San Jose CA 95154-4859 Phone: (408) 353-0215 Fax: (408) 318-6510
HOW TO FILE A MEDICAL EXPENSE CLAIM If covered by insurance, submit claim to insurance company first. Fill out a Medical Expense Claim Form. SIGN AND DATE THE FORM. Attach itemized receipts, Explanation of Benefits from the insurance company, and/or statements showing dates of service and types of service provided Mail, fax or email the claim form, along with copies of your receipts to: Flex Plan Benefits PO Box 24859 San Jose, CA 95154-4859 Fax: (408) 318-6510 Email: jeri@flexplanbenefits.com Please note: the IRS does not consider cancelled checks, credit card receipts or cash register receipts as acceptable proof that the expense was incurred, with the exception of cash register receipts for over-the-counter medicines. See back page for a list of eligible medical expenses. If you need help, or have a question, please contact Flex Plan Benefits at (408) 353-0215 M:\125\FORMS\medical claim form packet Merge - Individual.doc jt As of January 22, 2018
Medical Expense Reimbursement Plan Changes highlighted What s covered under this plan, and what s not? If contributions will be made to a Health Savings Account for/by you in 2018, this list does not apply. Instead, only dental, vision and diagnostic procedures are covered. If you are not eligible for the Company s group health insurance, this list does not apply. Instead, only dental and vision are covered. Acupuncturists Ambulance Service Birth Control Body Scans / Diagnostic Procedures Braces Chiropractors Contact Lenses Cosmetic Surgery Counseling Crutches Dentistry Doctor Visits Education Eyeglasses False Teeth Fertility Treatments Guide Dogs Hand Sanitizer Health Club Dues Hearing Aids Naturopathy Hospitalization Illegal Operations or drugs Insulin Treatment Insurance Premiums Laboratory Services Lactation Consultant Lactose Intolerance Massage Therapy Medical Supplies Medicine Mileage Naturopathic Care Nursing Assistance The IRS officials reiterated their position that since birth control affects the function of the body, it qualifies as a medical expense. This includes condoms and spermicides. Diagnostic procedures qualify as medical care. There doesn t have to be an underlying medical condition. Items such as body scans, pregnancy kits, ovulation monitors, and on-site health fairs that check blood pressure, cholesterol and bone density are all expenses that qualify. Covered, see Orthodontia for details Covered, including items needed for maintenance, such as contact lens solution. Not Covered, unless deemed medically necessary, as resulting from a disease. Covered, if provided to treat a medical or mental diagnosis and is rendered by a licensed provider. Eligible expenses include psychotherapy, bereavement and grief counseling, sex counseling, etc. Covered, unless the work is done for cosmetic purposes, such as teeth-whitening Not Covered, unless recommended by a doctor to treat a learning disability. Doctor s note is required. Covered, including maintenance. Covered, including maintenance. Does not include soaps, lotions or other personal hygiene items that include sanitizing ingredients. Not Covered, including hearing aid batteries. Covered If the naturopathic doctor is licensed by the state of California (DN or DNM). Not Not covered, under this portion of the plan. Health, Dental, and Vision insurance premiums are covered under the Premium Only Plan automatically. Not Covered, unless prescribed by a physician. DairyCare, Digestive Advantage, Lactaid. Medical supplies such as bandages, nasal strips, blood sugar kits & monitors, contact lens solutions & supplies, blood glucose machines & strips, first aid kits, hot & cold packs, Ace wraps, thermometers, arch & insole supports, diabetic supplies & equipment. Doctor-prescribed medicines are See Transportation. Covered If the naturopathic doctor is licensed by the state of California (DN or DNM). Breast pumps and breast feeding aids are now covered.
Nurses Aid Nutritional Supplements Organ Donation Orthodontia Orthopedics Osteopaths Over-the-Counter Medicines Over-the-Counter Supplies Physical Examinations Physical Therapists Podiatrists Psychics Psychiatrists/Psychoanalysts Psychologists Smoking-Cessation Program Substance Abuse Treatment Sunscreen Surrogate Mother Teeth Whitening Transportation Expense Travel Vaccines Vision Correction Surgery Vitamins Water Fluoridation or Pik Weight-Loss Program Wheelchair Whirlpool Baths X-Rays If you pay someone to do both medical nursing and housework, you can only be reimbursed for the cost of the nursing assistance. Not Covered, unless taken to treat a specific medical condition. Doctor s determination that the supplement is for a specific condition is necessary. Payments for surgical, hospital, laboratory, and transportation expenses for an organ donor qualify as medical care. (Pub.502). Orthodontic treatment. Generally, orthodontists require around 25% down, followed by equal installments over 2-3 years. The payment contract you receive from the orthodontist can be submitted, along with your claim form, once each year. You will then be reimbursed monthly for your expenses. If prescribed, the increase in cost of orthopedic shoes over a standard pair of shoes is also covered. Not Covered, unless prescribed by a doctor to treat a specific medical condition (all non-prescription medicines, such as antacids, allergy, pain or cold medications, & eye drops require a prescription). Non-prescription medical supplies, such as insulin, antiseptics, arch supports, bandages, Band-Aids, cholesterol equipment/supplies, cold/hot packs, crutches, first aid kits, ankle/joint supports, orthotic inserts, rubbing alcohol, thermometers, and diagnostic items such as blood sugar tests/blood pressure equipment. Not Cost for the program and for the drugs prescribed to alleviate nicotine withdrawal is covered, including nicotine gum and nicotine patches. Covered, if SPF 15 or higher. Not Paying a surrogate to carry a baby is not providing medical care for the employee or his or her spouse or dependents, Not Covered, unless tooth discoloration was caused by disease, birth defect or injury. Doctor s note required. If you use your car to get medical care, you can claim 18 per mile for 2018 (17 per mile for 2017) for travel to and from the place you receive care, plus any parking or tolls. Not Travel your doctor prescribes for rest or change is not covered. See Transportation above. Eye surgery to correct defective vision, including laser procedures such as LASIK and radial keratotomy, corrects a dysfunction of the body, and therefore, is covered. Not Covered, normally, if taken for general health. Doctor s determination that the vitamins are necessary to treat a specific medical condition is required. Not covered, unless prescribed by a physician to treat a specific medical condition. Not Covered, unless diagnosed as obese by a physician. The cost of food associated with a weight loss program is not covered. Normally, fees associated with personal trainers and health spas are not covered. Covered, including maintenance. Not Covered, unless prescribed by a doctor to treat a specific condition, reduced by the percentage of personal use, and limited to the amount that exceeds increase in home value. Any expense that is reimbursable by an insurance company, or by any other source, is not a covered expense. Qualifying medical expenses must be for yourself, your spouse or any dependents you can claim on your federal tax return, and must be incurred during the Plan Year. If you have any questions please contact: Flex Plan Benefits PO Box 24859, San Jose CA 95154-4859 Phone: (408) 353-0215 Fax: (408) 318-6510
FLEXIBLE SPENDING PLAN 2018 MEDICAL EXPENSE CLAIM FORM The claims listed on this form are for the year 2018 If the employee or dependent is covered by insurance, please attach the Explanation of Benefits. Attach itemized receipts or statements. Submit signed Medical Expense Claim Form to: FLEX PLAN BENEFITS PO Box 24859 San Jose, CA 95154-4859 Email: jeri@flexplanbenefits.com Phone: (408) 353-0215 Fax: (408) 318-6510 LAST NAME FIRST MI NAME OF EMPLOYER PHONE EXT. EMAIL ADDRESS Please list each item separately # Name of Patient Date of Service Relationship* Service Provider Describe Expense Amount 1 2 3 4 5 6 7 8 9 10 11 12 Subtotal: $0.00 Subtotal from page 2: $0.00 TOTAL CLAIM AMOUNT: $0.00 I request payment from my Medical Expense Flexible Spending Plan for the above item(s). I certify that neither I, nor my spouse, nor my dependents have previously been reimbursed, that these items are not reimbursable from any other source, that the above information is true and correct to the best of my knowledge, and that this is a legitimate claim. I understand that reimbursed expenses cannot be claimed on my personal income tax return. January 22, 2018 EMPLOYEE SIGNATURE DATE *D-Parent = Dependent Parent (Must qualify as a dependent on your Federal Tax Return). Please keep a copy of this form for your personal records
MEDICAL EXPENSE CLAIM FORM (Page 2) 2018 Name: Company: Please list each item separately # Name Date of Service Relationship* Service Provider Describe Expense Amount 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 * D-Parent = Dependent Parent (Must qualify as a dependent on your Federal Tax Return) Page 2 Subtotal: $0.00 Please keep a copy of this form for your personal records Flex Plan Benefits PO Box 24859, San Jose CA 95154-4859 (408) 353-0215 Fax (408) 318-6510