Manage Your Flexible Benefits (FSA, HSA, HRA, TSA Resources)
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Claim Forms
To request reimbursement for eligible expenses, complete the claim form for your plan below. Follow the instructions outlined on the form.
Direct Deposit Form
If you would like claims reimbursements to be directly deposited into your checking or savings account, complete the Direct Deposit Authorization Form below. Instructions on how to submit your authorization are included on the form.
Medical Determination Form
Some expenses must be medically necessary in order to be eligible for reimbursement. Along with your claim, you must submit a Medical Determination Form completed by your health care provider. To learn if your expense requires this form, see eligible expenses.
Benefit Access Debit Card Replacement Form
To request replacement of your access card, or order an additional card, complete the form below. Follow the instructions outlined on the form.
Eligible Expenses
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Medical Expenses: Health Care FSA, HRA and HSA
There are thousands of eligible expenses for tax-free purchase with a Health Care Flexible Spending Account (FSA), Health Reimbursement Arrangement (HRA) and Health Savings Account (HSA), including prescriptions, doctor’s office copays, health insurance deductibles, and coinsurance.
The list below outlines medical expenses the IRS typically considers eligible for tax deduction. These expenses can be reimbursed through your health care flexible spending account (FSA), health reimbursement arrangement (HRA) or health savings account (HSA).
To be eligible, medical expenses must be medically necessary. The IRS defines an eligible medical expenses as one incurred primarily to alleviate or prevent physical or mental defect or illness. This includes the costs of equipment, supplies, and diagnostic devices, as well as dental expenses, some insurance premiums and transportation costs. This does not include expenses that are merely beneficial to general health, such as vitamins or a vacation.
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Eligible Medical Expenses
*Items marked are "potentially eligible expenses" that require a Note of Medical Necessity from your health care provider to qualify for reimbursement.
Baby/Child to Age 13
- Lactation Consultant*
- Lead-Based Paint Removal
- Special Formula*
- Tuition: Special School/Teacher for Disability or Learning Disability*
- Well Baby Care
Dental Services
- Dental X-Rays
- Dentures and Bridges
- Exams/Teeth Cleaning
- Extractions and Fillings
- Gum Treatment
- Oral Surgery
- Orthodontia/Braces
Hearing
- Hearing Devices and Batteries
- Hearing Exams
Lab Exams/Tests
- Blood Tests and Metabolism Tests
- Body Scans
- X-Rays
- Cardiographs
- Laboratory Fees
Vision Services
- Eye Examinations
- Eyeglasses
- Contact Lenses and Contact Lens Supplies
- Laser Eye Surgeries
- Prescription Sunglasses
- Radial Keratotomy/LASIK
Medical Procedures/Services
- Acupuncture
- Alcoholism (inpatient and outpatient treatment)
- Ambulance
- Drug Addiction
- Hair Loss Treatment*
- Hospital Services
- Infertility Treatment
- In Vitro Fertilization
- Physical Exam (non employment related)
- Reconstructive Surgery (if medically necessary due to congenital defect or accident)
- Service Animals*
- Sterilization/Sterilization Reversal
- Transplants (including organ donor)
- Transportation*
- Vaccinations/Immunizations
- Vasectomy and Vasectomy Reversal
Medical Equipment/Supplies
- Air Purification Equipment*
- Arches/Orthotic Inserts
- Contraceptive Devices
- Crutches and Wheel Chairs
- Elastic Bandages and Wraps
- Exercise Equipment*
- First Aid Supplies
- Hospital Bed*
- Mattresses*
- Medic Alert Bracelet or Necklace
- Nebulizers
- Orthopedic Shoes*
- Oxygen*
- Pregnancy Test Kits
- Post Mastectomy Clothing
- Prosthesis
- Syringes
- Wigs*
Medication
- Insulin
- Prescription Drugs
Obstetric Services
- Doulas*
- Lamaze Class
- Midwife Expenses
- OB/GYN Exams
- OB/GYN Prepaid Maternity Fees (reimbursable after date of birth)
- Pre and Postnatal Treatments
Practitioners
- Allergist
- Chiropractor
- Christian Science Practitioner
- Dermatologist
- Homeopath or Naturopath*
- Optometrist
- Osteopath
- Physician
- Psychiatrist or Psychologist
Therapy
- Alcohol and Drug Addiction
- Counseling (not marital or career)
- Exercise Programs*
- Hypnosis*
- Massage*
- Occupational
- Physical
- Smoking Cessation Programs*
- Speech
- Weight Loss Programs*
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Ineligible Expenses
*Items marked are "potentially eligible expenses" that require a Note of Medical Necessity from your health care provider to qualify for reimbursement.
- Cosmetic Surgery/Procedures
- Dancing/Exercise/Fitness Programs
- Diaper Service
- Electrolysis
- Personal Trainers
- Health Club Dues*
- Insurance Premiums and Interest
- Long Term Care Premiums (HSA only)
- Marriage Counseling
- Maternity Clothes
- Swimming Lessons
- Teeth Whitening/Bleaching
- Vitamins or Nutritional Supplements
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Over-the-Counter Expenses: Health Care FSA, HRA and HAS
Many over-the-counter (OTC) treatments are also eligible now because the Coronavirus Aid, Relief and Economic Security (CARES) Act removed the requirement for a physician’s prescription or Letter of Medical Necessity for many OTC items.
There are a variety of items that are not generally eligible for reimbursement you should know. Please find a list of Eligible and Ineligible Items here.
The easiest way to purchase eligible items is with your Benefit Access Debit Card. The card is valid where VISA is accepted for payment.
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Dual-Purpose OTC Items
A Medical Determination Form completed by your health care provider listing the diagnosis of your medical condition and the recommendation of the OTC drug is required for reimbursement.
- Anti-baldness / hair loss / hair replacement such as Rogaine—only if to replace hair loss due to a medical condition (e.g., cancer treatment) and not for balding due to age
- Glucosamine / Chondrotin for arthritis or other medical condition—not reimbursable if taken for overall joint health
- Herbal supplements used to treat a specific disease—such as St. John’s Wort for depression
- Retin-A and other acne medicines—not reimbursable if used for cosmetic purposes such as wrinkle reduction
- Vitamins are not an eligible expense, unless prescribed by a physician to treat a specific medical condition—for example, iron to treat, not prevent, anemia; calcium supplements to treat, not prevent, osteoporosis. A doctor’s note detailing the specific medical condition will be required for reimbursement
- Weight loss / dietary supplements—must be for a specific medical condition such as obesity
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Dependent Care Expenses: FSA only
To be eligible for reimbursement, dependent care expenses must be for an eligible dependent and for care that allows the FSA participant to work or look for work. The expenses listed below are typically considered eligible by the IRS. These expenses can be reimbursed through your dependent care FSA. For a complete listing, see IRS Publication 503 on irs.gov.
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Child Care
Child care provided by a baby sitter, day care facility or before or after school program, as well as summer day camp, are eligible. Extracurricular activities such as dance or piano lessons are not eligible.
Child Care Expenses
- After school programs
- Babysitting (someone else's home)
- Babysitting (your home)
- Before school programs
- Child care
- Nursery school
- Preschool
- Sick child care
- Summer day camp
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Senior Care
Senior care provided by a sitter or a day care facility is eligible if the senior is considered an eligible adult. See Eligible Dependent. Medical care, nursing care and transportation costs are not eligible.
Senior Care Expenses
- Adult day care
- Elder care (in your home)
- Elder care (outside your home)
- Senior day care
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Non-Reimbursable Dependent Care Expenses
Show more about non-reimbursable dependent care expenses. The following expenses are not reimbursable through a dependent care FSA.
Child Care
- Extracurricular activities such as music lessons
- Private school tuition (for kindergarten and up)
- Overnight camp
- Transportation to and from eligible care
- Tutoring
Senior Care
- Day nursing care
- Medical care
- Nursing home care
- Transportation to and from eligible care
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Additional Notes
- If married, both you and your spouse must be actively employed. If one spouse is actively employed, the other spouse must be incapable of self-care or a full-time student.
- The funds to be used from your dependent care FSA must not exceed the lesser of your or your spouse's earned income for the plan year.
- Care 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 dependent child).
- If the services are provided by a day care facility that cares for six or more individuals at the same time, the facility must comply with state day care regulations.
Eligible Dependents
Qualifying Child
A qualifying child must be your child, grandchild, stepchild, foster child or adopted child; brother, half-brother or stepbrother; sister, half-sister or stepsister; nephew or niece; or the child or grandchild of any of the relatives listed above.
The qualifying child will:
- Reside with you for more than half the calendar year (Disregard temporary absences due to illness, education, business, vacation, or military service. You must maintain a home for the person during the temporary absence and the person must be expected to return after the absence.)
- Be under the age of 13, or physically or mentally incapable of self care, when the dependent care is provided (If the child is 13 or older and physically or mentally incapable of self care, he/she must regularly spend at least 8 hours a day in your home and not file a joint tax return with his/her spouse for the calendar year.)
- Provide no more than 50% of his/her own support for the calendar year
- Be a citizen, national or resident of the United States; or a resident of Canada or Mexico (unless the child is adopted)
Qualifying Adult
A qualifying adult must be your father, grandfather or stepfather; mother, grandmother or stepmother; uncle or aunt; or son-, daughter-, father-, mother-, brother- or sister-in-law or, any other person who will reside with you for more than half the year (while not in violation of local law). Disregard temporary absences due to illness, education, business, vacation, or military service. You must maintain a home for the person during the temporary absence and the person must be expected to return after the absence.
The qualifying adult will:
- Regularly spend at least eight hours a day in your home
- Not file a joint tax return with his/her spouse for the calendar year (unless the qualifying relative is your spouse)
- Not be claimed by any other person as a qualifying child for the calendar year
- Be a citizen, national or resident of the United States; or a resident of Canada or Mexico (unless the person is an adopted child)
The FSA participant will:
- Provide more than 50% of this person's support for the calendar year
NOTE: An FSA participant can not be a qualifying person or child for another person.
FSA/HRA FAQ
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Are over-the-counter (OTC) drugs eligible for reimbursement?
Many over-the-counter (OTC) treatments are eligible now because the Coronavirus Aid, Relief and Economic Security (CARES) Act removed the requirement for a physician’s prescription or Letter of Medical Necessity for many OTC items.
Healthcare debit cards cannot be used to purchase OTC drugs and medicines. If a healthcare debit card is used to pay for these items, the transaction will be denied at the point of sale. In this case, you will need to pay for the expense out-of-pocket and submit a claim, along with an NMN or a prescription, to be reimbursed.
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What is a Medical Determination Form?
The IRS requires that expenses for medical procedures and services, and all OTC drugs be medically necessary in order to be eligible for reimbursement. This means they must be primarily to alleviate or prevent physical or mental defect or illness. Medical Determination Form completed by your health care provider listing the diagnosis of your medical condition and the recommendation of the treatment is required for reimbursement.
Some services or drugs may have dual purpose. For example, a procedure may generally be deemed cosmetic in nature but may also be used to treat a medical condition. In order to show that such a treatment is medically necessary, the IRS requires you submit a note from your provider, or a Medical Determination Form explaining your diagnosis and the recommendation for treatment.
For a list of services and OTC drugs requiring a Medical Determination Form, see the eligible expenses list. If your expense requires a letter for reimbursement, download the Medical Determination Form, have your provider complete the form, and submit it with your claim.
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Does my doctor need to recommend a drug or a treatment for the item or service to be reimbursable?
In some cases, prescription drugs and medical services must be prescribed as medically necessary by your health care provider for those items to be reimbursable.
A note from your provider listing the diagnosis of the medical condition and the treatment recommendation, called a Medical Determination Form must be submitted with your claim. Over-the-counter drugs also require a Note of Medical Necessity (NMN) from your provider.
HSA FAQ
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What can HSA funds be used to cover?
HSA distributions are tax-free if used for IRS qualified health care expenses. Eligible health care expenses include services and items such as the following:
- Doctor's office visits
- Over-the-counter (OTC) medications
- Services not covered by insurance such as LASIK eye surgery
For a more detailed list refer to Internal Revenue Code Section 213(d) on irs.gov.
Nonqualified distributions will be taxed as part of gross income and will incur a 20% penalty. After age 65, the 20% penalty is dropped, though the distribution is still treated as taxable income.
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How much can I contribute each year to my HSA?
Please refer to our Health Savings Account Education Guide. More about how much I can contribute each year to my HSA. The 2021 maximum annual contribution is $3,600 for single coverage and $7,200 for family coverage. In 2022, those maximum annual contributions will increase to $3,650 for single and $7,300 for family.
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Can I make contributions if I am not enrolled in a QHDHP for the entire year?
Yes. Full year statutory contribution limits are permissible, but the HSA owner must maintain eligibility throughout the "testing period," which runs from the last month of the initial eligibility year through the end of the 12-month period following that month.
In 2019, the maximum annual contributions are $3,500 for single coverage and $7,000 for family coverage.
If HSA owners are not eligible for this entire testing period, they must include in their gross income the contributions made for the months when they were not otherwise qualified. This amount will also be subject to a 10% penalty. The tax and penalty do not apply if the HSA owner is no longer HSA-eligible because of death or disability.
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If one or both spouses have family coverage, how is the contribution limit computed?
If either spouse has family coverage under a QHDHP, both are treated as having family coverage.
The 2019 maximum statutory contribution limit is $7,000 for family coverage. Whether each spouse opens an individual account or one spouse opens an account, the collective total must not exceed the family maximum.
Benefit Access Debit Card FAQ
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How will the card work at discount stores and supermarkets?
First, confirm that the retailer can accept FSA cards by reviewing our participating retailer list. To find a retailer who can accept your Benefit Access debit card, review the IIAS Merchant List.
Then follow this process:
- Take prescriptions, vision products and other health care purchases to the register at checkout to let the clerk ring them up.
- Present your card or swipe it for payment.
- If the card swipe transaction is approved (e.g., there are sufficient funds in the account and at least some of the products are FSA-eligible), the amount of the FSA-eligible purchases will be deducted from your account balance. The clerk will then ask for another form of payment for the non-FSA-eligible items.
- If the card swipe transaction is declined, the clerk will ask for another form of payment for the total amount of the purchase. (File a claim for reimbursement for these expenses).
- The receipt will identify the FSA-eligible items and may also show a subtotal of the FSA-eligible purchases. In most cases, you will not receive requests for receipts for FSA-eligible purchases made in participating discount stores or supermarkets.
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How do I create a PIN for my Benefits Access Card?
- Please call 866-898-9795.
- The automated system will walk you through the prompt to create your own self-selected PIN for your Benefits Access Card.
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Am I required to use a PIN to access funds in my account?
No. You can continue to use your Benefits Access Card as you always have—no change required, by simply swiping the card and providing a signature.
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I have more than one card; does each card have its own PIN?
No. The PIN is the same for all cards issued to you. If you choose this option, make sure other family members are aware of the PIN. Alternatively, other family members can continue to pay using the signature process.
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If I don’t know my PIN or have not yet selected one can I still use my card?
Yes. Simply let the merchant know that you wish to pay using the signature process (credit) and they will direct you accordingly.
When I swipe my Benefits Access debit card, what options do I have to complete the payment?
Once you swipe your card at the point of purchase, choose "Credit" or "Debit" on the keypad:
- Choosing "Credit" will require only your signature.
- Choosing "Debit" will require you to enter your PIN.
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Will I be able to receive cash back or access my accounts via ATM with this new PIN option?
No. PINs will only allow you to pay for eligible goods and services as they do today. Cash back and ATM transactions will not be allowed.
Keep in mind, the use of a PIN is not required to access your funds via the Benefits Access Card. You can continue to use your Benefits Access Card as you always have by simply swiping your card and providing a signature.
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Why did I get a receipt request letter when I used my debit card?
You may have received a letter asking for a receipt to verify the eligibility of a purchase. We do all we can to automatically verify your debit card transactions, as required by the IRS. However, if we’re unable to, you will receive a letter or email requesting itemized receipts for card transactions. More about why I got a receipt request letter when I used my debit card
We want to help you understand and/or reduce these letters, so here are a few things you should know.
How to AVOID receiving a letter:
- If you have a deductible plan with co-insurance, don’t use your debit card to pay the provider at the point of care. It is not necessary to pay the provider until you have received an Explanation of Benefits (EOB) and/or the bill with the patient balance-due after it had been submitted to your insurance. You can then write your card number on the invoice and return for payment. However, if a doctor or dentist insists that you pay at the point of service, use another form of payment and then submit a manual claim.
- Only use your debit card for dependents covered under your health plan.
- Only use your debit card at pharmacies that can separate eligible items from non-eligible items. To find out which merchants are participating, visit the web site or call the number on the back of the Card.
You WON’T receive a letter:
- If you have a benefit plan with co-payments.
- When prepaid card transactions are verified electronically.
If you are asked to provide a receipt, it must include: merchant or provider name, service received or item purchased, date of service, and amount of the expense. Cancelled checks, handwritten receipts, your debit card transaction receipts or previous balance receipts cannot be used to verify an expense. If you don’t have the receipt, you can contact the provider who can usually supply the receipt from their files.
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