Participant: «Emp_Name»
Department: «Dept»
Flex Spending
Program - 2008
1/14/2008
Please read this information regarding your
Flexible Spending Account (FSA) carefully.
Claim Form Submission
· Submit claim forms to the Finance Department (Courthouse, Room 158).
· Minimum of $25.00 reimbursement, unless for the balance of your Flex Spending account.
· Choice of payment: mailed to you or the vendor, or returned to your department financial person/AP Clerk.
· Submit claims no more than twice within the month.
· Please list your Department, and Division if applicable. (i.e. Assr, Justice-Juv, Hlth-AC)
· Phone number (in case we need to contact you).
· Your signature on the claim form.
· A 2008 form is attached. Please use this form for 2008 expenses. An electronic version is available on the County Intranet.
Medical Documentation Requirements
· Medical expense documentation must be originals (not copies) and show:
· Name of provider
· Name of patient
· Date of service (not date of payment)
· Applied insurance payments.
· An Explanation of Benefits (EOB) from Pacific Source is the best documentation.
· Copies of checks are not acceptable medical documentation.
· Co-payments for medical services must include:
· Providers name printed or stamped on receipt.
· Charges for missed appointments are not reimbursable.
· Prescriptions
· Original Rx receipt must show:
o Name of patient, date of purchase, Rx number, cost
· Itemized store receipt acceptable IF, ALL the above criteria is met
· Over The Counter Items
· Itemized store receipt listing product by name.
· Please circle in ink (highlighter fades printer ink on some receipts)
Child Care Documentation Requirements
· Must be a Daycare provider, not an activity, program, class, or any type of lessons. Gymnastics, swimming, dance or music lessons are not acceptable.
· Original provider invoices or billings must include name of provider, date of service, amount and dependent names.
· Amount to be reimbursed cannot exceed actual account balance.
· Daycare provider cannot be under the age of 19.
· Daycare provider cannot be a tax dependent of the employee/participant.
Claims without the appropriate documentation will be returned to you by way of a confidential envelope sent to your department. If you have questions regarding any of this information or your account balance, feel free to contact Deanna Pratt by email or ext. 5251.
1/14/2008
Flex Spending Medical Plan
The general rules for determining an eligible medical expense are:
· The Internal Revenue Service (IRS) must recognize the expense as a tax-deductible item.
· The expense is not fully reimbursed under any employer-sponsored or personal insurance coverage.
· Expenses must be incurred during the period of January 1st – December 31st.
· The expense is for medical care or for the treatment of a medical condition; treatments/medications that are merely beneficial to general good health are not reimbursable.
1/14/2008
Eligible Medical Expenses:
1/14/2008
· Acupuncture (excluding remedies and treatments prescribed by acupuncturist)
· Alcoholism treatment
· Ambulance
· Artificial Limbs/Teeth
· Birth control pills, contraceptives
· Birth prevention surgery
· Blood sugar test kit
· Braces
· Chiropractors
· Christian Science practitioner’s fees
· Contact lenses and solutions
· Co-payments
· Costs for physical or mental illness confinement
· Crutches
· Deductibles
· Dental Fees (bleaching excluded)
· Dentures
· Diagnostic fees
· Drug and medical supplies (i.e. syringes, needles, etc.)
· Eyeglasses prescribed by your doctor
· Eye examination fees
· Eye surgery (cataracts, LASIK, etc.)
· Glucose test strips
· Hearing devices and batteries
· Hospital bills
· Immunizations
· Insulin
· Laboratory fees
· Laser eye surgery
· Medical-alert bracelet
· Naturopath
· Obstetrical expenses
· Oral surgery
· Orthodontic fees
· Orthopedic devices/shoes
· Oxygen
· Physician fees
· Prescribed medicines
· Psychiatric care
· Psychologist’s fees
· Radial keratotomy
· Routine physicals and other non-diagnostic services or treatments
· Smoking cessation programs
· Special deaf communication equipment
· Sterilization fees
· Surgical fees
· Vaccines
· Wheelchair
· Wigs
· X-rays
1/14/2008
Items requiring a letter from your physician detailing the medical necessity for these procedures/products before reimbursement:
1/14/2008
· Dietary supplements
· Smoking cessation over-the-counter drugs
· Massage Therapy
· Weight-loss over-the-counter drugs
· Weight-loss programs
· Vitamins
1/14/2008
Over-the-counter items:
1/14/2008
· Allergy medicine
· Antacids
· Aspirin
· Bactine
· Betadine solution
· Cold medicines
· Cough drops
· First aid cream
· Hydrogen peroxide
· Incontinence supplies
· Menstrual pain/cramp relief
· Nasal sinus sprays/strips
· Pain reliever
· Pregnancy test kits
· Reading glasses
· Rubbing alcohol
· Sleeping aids
· Special ointment for sunburns
· Spermicidal foam
· Suppositories/creams for hemorrhoids
· Thermometers
· Throat lozenges
· Tiger balm
· Topical creams for gingivitis
· Visine
· Wart remover treatments
1/14/2008
Flex Spending Dependent Care Plan
Expenses that do qualify for reimbursements:
· Dependent care expenses you incur, for a child under the age of 13 whom you may claim as a dependent.
· Registration fees to a daycare facility as long as the fees are allocable to actual care and not described as materials or other fees.
· Nursery schools
· Food and incidental expenses (diapers, activities, etc.) that are included in your daycare bill.
· Expenses paid to relative are eligible. However, the relative cannot be under the age of 19 or a tax dependent of the participant.
Expenses that do not qualify for reimbursements:
· Gymnastics, swimming, dance or music lessons
· Overnight camp
· Care during non-working hours
· Nursing homes
· Elementary school expenses for a child in first grade or higher are not eligible. Kindergarten fees are almost always an education expense and should never be reimbursed under a dependent care plan.
1/14/2008
1/14/2008