Expense listing.xls

The University of Tennessee Eligible Expense Listing
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
ACNE TREATMENT
Over-the-counter acne treatment products are eligible for reimbursement as long as the eligible for reimbursement as long as the product’s primary purpose is for the treatment of acne. Cosmetics or other items that merely contain acne-fighting ingredients are not eligible. ACUPUNCTURE
ADAPTIVE EQUIPMENT
Adaptive equipment for a major disability, such as a spinal cord injury, can be reimbursed.
Adaptive equipment to assist you with activities of daily living (ADL) for persons with arthritis, lupus, fibromyalgia, etc., can be reimbursed.
AIR CONDITIONERS/AIR
PURIFIERS
ALCOHOLISM/DRUG/SUBSTANCE
ABUSE TREATMENT
Inpatient treatment, including meals and lodging provided by a licensed addiction center.
Outpatient care ALLERGY PRODUCTS
Eligible expenses include products and home improvements to treat severe allergies. Examples include: HEPA furnace filters and HEPA vacuum cleaner filters (only the difference in cost of the HEPA product minus the standard product can be reimbursed.) Special vacuum cleaners for persons with respiratory problems (only the difference in respiratory problems (only the difference in cost of the special vacuum cleaner minus a standard vacuum can be reimbursed) Special pillow cases, mattress covers, or other bedding barriers that provide protection against allergens to alleviate an allergic condition CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
ALTERNATIVE MEDICINE
Services must be prescribed and rendered by a licensed health care provider to treat a specific illness or disorder.
AMBULANCE
ANALGESICS
ANTACIDS/ACID REDUCERS
ANTI-ARTHRITICS
ANTIBIOTICS, topical
ANTICANDIDAL, yeast infection
ANTICANDIDAL, yeast infection
ANTI-DIARRHEAL
ANTIHISTAMINES
ANTI-ITCH PRODUCTS, lotions or
Please note: This does not include healing ointments/lotions for extremely dry skin, such as Aquaphor, Eucerin or Cerave.
ARTIFICIAL REPRODUCTIVE
Eligible medical expenses include (but are not Eligible medical expenses include (but are not TECHNOLOGIES
Artificial insemination (intracervical, intrauterine, intravaginal)Egg donor and/or sperm donor charges for recipientEmbryo replacement and storage NOTE: Storage fees should not exceed twelve months.
Fertility examsGamete Intrafallopian Transfer Sperm bank storage/fees for artificial insemination may be eligible if there is a diagnosis that requires treatment which may impast fertility (see SPERM STORAGE) ASTHMA MEDICINES
AUTOMOBILE MODIFICATIONS
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
BABY FORMULA
If your baby requires a special formula to treat an illness or disorder, the difference in cost between the special formula and routine baby formula can be reimbursed.
BAND-AIDS/BANDAGES
BEDSIDE COMMODES
BIRTH CONTROL PILLS/DEVICES
BLOOD PRESSURE MONITORS
BLOOD STORAGE
Blood storage is an eligible expense if you are storing blood for use during scheduled elective storing blood for use during scheduled elective surgery. Storage fees should not exceed six months.
BODY SCANS
BRAILLE BOOKS AND MAGAZINES
The cost difference of Braille books and magazines that exceeds the price for regular books and magazines is an eligible expense.
BREAST PUMPS
Routine use of a breast pump is not an eligible If the nursing mother (you or your spouse) or your baby has a medical condition that can be relieved through use of a breast pump, the expense of your breast pump can be reimbursed.
CALCIUM SUPPLEMENTS
CAPITAL EXPENSE
A capital expense (permanent or portable) can be reimbursed if its purpose is to provide medical care for you, your spouse or dependent.
Expenses for improvements or special equipment added to your home can be reimbursed if the main purpose of the item is medical care. How much is reimbursed depends on the extent to which the expense permanently improves the property and whether others benefit.
The amount paid for the improvement is reduced by the increase in the value of your home or property. The difference between the home or property. The difference between the cost of the improvement minus the increased value equals the eligible expense. In addition, the cost should be divided by the number of individuals living in the household to determine the amount that is reimbursable for the person with the medical condition.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
CAPITAL EXPENSE (Cont'd)
If the value of your home or property is not increased by the improvement, the entire cost is and eligible expense.
Widening or otherwise modifying doorways, hallways and stairways Installing railings, support bars, or other modifications to bathrooms Kitchen modifications, including lowering cabinets and other equipment Exterior grading of the property to provide access to your home Removal of carpeting, wall and/or window coverings (this does not include the cost of replacement of these items) IRS regulations require that the cost comparison between a standard item and an item prescribed by a health care provider be submitted from an independent third party. For instance, you may provide a store circular showing the cost of a comparable standard item when submitting a claim for the item when submitting a claim for the reimbursement of the difference on the prescribed item.
This list is not exhaustive. If expenses are similar to those listed above, and are incurred to adapt a personal residence to yours or your spouse’s or dependent’s condition, the expenses are eligible subject to the terms noted above. Expenses must be reasonable, and directly related to the medical condition. Costs that are incurred for architectural or aesthetic reasons are not eligible.
Please refer to IRS Publication 502 for additional information, including operation and upkeep CHAIRS, ergonomic
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
CHAIRS, reclining
Reclining chairs that both elevate the legs and tilt the torso may be considered for reimbursement. The chair must be specifically prescribed by a physician to alleviate a specific medical condition and you must submit a fully completed Letter of Medical Necessity that clearly documents how the chair will alleviate the condition or diagnosis for the expense to be considered. Reimbursement will be limited to a maximum amount of $650 for one chair purchased every 10 years per participant and/or his or her dependents. No other types of chairs are eligible, including massage chairs that have a reclining feature.
CHILDBIRTH CLASSES
Childbirth classes such as Lamaze and Bradley are eligible for reimbursement.
Breastfeeding ClassesNewborn or New Infant Care Classes CHIROPRACTIC
Services performed by a chiropractor such as ultra sounds or therapy are eligible.
CHONDROITIN
CIRCUMCISION
A bris performed in the home by a Rabbi or non-licensed provider is not an eligible expense.
COBRA PREMIUMS
Under IRS rules, insurance premiums cannot be reimbursed under a Health Care FSA.
CO-INSURANCE
Cannot be reimbursed by secondary insurance or any other source.
COLD MEDICINES
COLD SORE MEDICINES
CONTACT LENSES
Contact lenses, cleaning and soaking solutions and lens storage cases are all eligible for reimbursement.
CO-PAYMENTS
Cannot be reimbursed by secondary insurance or any other source.
CORD BLOOD STORAGE
Can be reimbursed if there is a specific medical condition that the cord blood is intended to treat. Indefinite storage “just in case” is not an eligible expense.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
COSMETIC DENTISTRY
Expenses for cosmetic dentistry, such as teeth whitening or bleaching, porcelain veneers, or bonding are not eligible for reimbursement unless the procedure is necessary to improve a deformity arising from a congenital abnormality, personal injury from accident or trauma, or to restore appearance related to treatment for another medical diagnosis or condition.
COSMETIC PROCEDURES
Cosmetic procedures to improve or enhance appearance are not eligible.
COSMETIC PROCEDURES (cont.)
A cosmetic procedure or service necessary to improve a deformity arising from a congenital improve a deformity arising from a congenital abnormality, personal injury from accident or trauma, or to restore appearance related to treatment for another medical diagnosis or condition can be reimbursed.
COUGH MEDICINES
COUNSELING
If counseling is provided to treat a medical or mental diagnosis and is rendered by a licensed mental diagnosis and is rendered by a licensed provider.
Eligible expenses include psychotherapy, bereavement and grief counseling, sex counseling, etc.
COUNSELING (cont.)
Life coaching, career counseling and marriage counseling do not qualify.
CRUTCHES
DEDUCTIBLES
Cannot be reimbursed by secondary insurance or any other source.
DENTAL CARE
Covered services include, but are not limited to: BridgesCleaningsCrownsDental implantsDenturesEndodontic care (root canal)ExtractionsFillingsOrthodontiaPeriodontal servicesRoutine prophylaxisSealantsX-rays DIABETIC SUPPLIES
DIAPER RASH CREAMS
DIAPERS, DIAPER SERVICE
DIAPERS, DIAPER SERVICE
Not for routine care of a healthy newborn.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
DIETARY SUPPLEMENTS
DOCTOR FEES
In addition to all expenses for care not reimbursed by any other source, eligible expenses include fees for: Charges by your physician for letters of medical necessity to schools, etc.
Physician tele-advice, including email communication If the doula is a licensed health care professional who renders medical care, his or her fees can be reimbursed.
DRUG ADDICTION, treatment of
Inpatient treatment, including meals and lodging provided by a licensed addiction center.
Outpatient care Transportation expenses associated with attending outpatient meetings, including AA groups, if attending on a doctor’s advice.
EAR PLUGS
Must be prescribed to treat a specific medical condition, such as the presence of middle/inner ear tubes.
ELECTROLYSIS
ELECTROLYTE REPLACEMENTS
EYEGLASSES/EYE EXAMS
Includes prescription sunglasses and reading glasses (even those purchased over-the-counter).
EXERCISE EQUIPMENT
EXERCISE PROGRAMS
FEMININE HYGIENE PRODUCTS
Feminine hygiene products used post-surgery or after childbirth may be reimbursed. FERTILITY ENHANCEMENT
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
FIBER SUPPLEMENTS
FINANCE CHARGES
FIRST AID KIT/SUPPLIES
FITNESS PROGRAMS
Fees paid for a fitness program may be an Fees paid for a fitness program may be an
eligible expense if prescribed by a physician
and substantiated by his or her statement that
treatment is necessary to alleviate a medical
problem. You cannot be reimbursed for
expenses that will be incurred in the
future, even if the provider requires payment
in advance for the entire period. You can
provide a receipt for the entire period and
several receipts incrementally that detail the
dates of service, provider name and cost after
the date of service that corresponds to each
time increment.
FLU SHOTS
Food may be eligible if prescribed by a medical practitioner to treat a specific illness or ailment and if the food does not substitute for normal nutritional requirements that may qualify for reimbursement is limited to the amount by which the cost of the food exceeds the cost of commonly available versions of the same product.
Sugar-free and gluten-free foods are not eligible.
FOOT CARE
FUNERAL EXPENSES
GLUCOSAMINE
GUIDE DOGS
GYM MEMBERSHIP
Fees paid for a gym membership may be an
eligible expense if prescribed by a physician
and substantiated by his or her statement that
treatment is necessary to alleviate a medical
problem. You cannot be reimbursed for
ex
e penses that will be incurred in the
future, even if the provider requires payment
in advance for the entire period. You can
provide a receipt for the entire period and
several receipts incrementally that detail the
dates of service, provider name and cost after
the date of service that corresponds to each
time increment.
HAIR LOSS TREATMENT
May be eligible when used to treat hair loss due to a specific medical condition.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
HAIR TRANSPLANT
HEALTH SCREENINGS
HEARING AIDS
HEMORRHOIDAL TREATMENTS
HERBAL MEDICINES
HOME DIAGNOSTIC KITS/TESTS
HOME MEDICAL EQUIPMENT
Home medical equipment may require a letter of medical necessity (LMN) for reimbursement.
HOMEOPATHIC CARE
Homeopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a HCFSA.
HOMEOPATHIC MEDICINES
Homeopathic medicines used for treatment of a specific illness or disorder may be reimbursed.
HORMONE SUPPLEMENTS OTC
Supplements used for relief of perimenopausal Supplements used for relief of perimenopausal or menopausal symptoms may be reimbursed.
HYDROTHERAPY
HYPNOSIS
IMMUNIZATIONS
Includes those recommended for overseas travel INCONTINENCE PRODUCTS
Incontinence products used for a diagnosed medical condition may be reimbursed.
INSURANCE PREMIUMS
Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA.
IN VITRO FERTILIZATION
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
LACTOSE INTOLERANCE
SUPPLEMENTS
Please note: Lactose-free milk and/or food products are not eligible for reimbursement.
LAMAZE CLASSES
LASER EYE SURGERY
LATE PAYMENT FEES
LEAD-BASED PAINT REMOVAL
Expenses for removing lead-based paints from surfaces in your home to prevent a child who has, has had, or is in danger of lead poisoning from eating the paint can be reimbursed. These surfaces must be in poor repair and within a child’s reach.
The cost of repainting the affected area(s) is not an eligible expense.
expense. If you cover the area with wallboard or paneling instead of removing the lead paint, these items will be treated as Capital Expenses.
LEARNING DISABILITIES
The portion of tuition/tutoring fees covering services rendered specifically for your child's severe learning disabilities caused by mental or physical impairments (such as nervous system disorders, or closed head injuries) and paid to a special school or to a specially-trained teacher may be reimbursed under a HCFSA if prescribed by a physician. Examples of eligible expenses include: Remedial reading for your child or dependent with dyslexia LEGAL FEES
Legal fees paid to authorize treatment for mental illness are eligible expenses.
LICE TREATMENT
LIFETIME CARE
Fees or advance payments made to a retirement home or continuing care facility are not eligible expenses.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
Up to $50 per night is eligible if the following conditions are met: The lodging is primarily for, and essential to, medical care The medical care is provided by a doctor in a licensed hospital or medical care facility related to/equivalent to a licensed hospital There is no significant element of personal pleasure or leisure in the travel.
Expenses for food and beverages are not LODGING, for companion
Your companion’s lodging can be reimbursed if he or she is accompanying the patient (you or your eligible dependents) for medical reasons and it meets the criteria listed above. Meals are not eligible for reimbursement.
Example: Parents traveling with a sick child Example: Parents traveling with a sick child, up to $100 per night ($50 per person) may be reimbursed, as well as lodging and pre and post-hospitalization for bone marrow transplants.
LODGING, special
The cost of a special home or step-down facility for your mentally handicapped dependent, recommended by a psychiatrist to help your dependent adjust after inpatient help your dependent adjust after inpatient mental health care to community living, can be reimbursed.
LONG-TERM CARE INSURANCE
Under IRS rules, insurance premiums cannot PREMIUMS
LONG-TERM CARE SERVICES
Refer to Section 106(c) of the IRS Code for more information.
MASSAGE THERAPY
To reduce stress or improve general health.
MASSAGE THERAPY (cont.)
If prescribed by a physician for a specific illness, injury, trauma or condition. Must include frequency and duration of therapy.
MATERNITY AIDS
MATERNITY CLOTHES
MEDICAL ALERT
Watches with medical alert identifications are BRACELET/NECKLACE
MEDICAL INFORMATION
Amounts paid to a plan that maintains electronic medical information for you, your spouse or dependents are eligible for reimbursement under an HCFSA.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
MEDICAL RECORDS
Costs associated with copying or transferring medical records to a new provider are eligible for reimbursement.
MEDICAL SAVINGS ACCOUNTS
MEDICAL SERVICES
Expenses for medical services prescribed by Expenses for medical services prescribed by physicians or other health care providers acting within their scope of licensure can be reimbursed under a HCFSA.
MEDICINES
Prescribed; over‐the‐counter medicines and drugs to alleviate or treat injury or sickness are reimbursable, whether or not prescribed by a physician.
MENSTRUAL RELIEF
MIGRAINE RELIEF
The mileage rate for 2009 24 cents per mile, for medical care received during the 2008 calendar year.
Beginning January 1, 2010 the mileage rate will be 24 cents per mile.
Be sure to provide a statement indicating the reason for travel, the date(s) of service and number of miles traveled for reimbursement.
MINERALS
MISSED APPOINTMENT FEES
MOTION SICKNESS MEDICINES
NASAL STRIPS
Nasal strips or sprays that are used to alleviate snoring or reduce nasal congestion are eligible for reimbursement from your HCFSA. NATUROPATHIC CARE
Naturopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a HCFSA NON-COVERED SERVICES
Medical care or services that are not covered under your FEHB plan may be reimbursed under an HCFSA.
NEWBORN NURSING CARE
Nursing services for a normal, healthy newborn are not an eligible expense.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
NURSING CARE AND SERVICES
Nursing services are an eligible expense, (private duty nursing)
whether provided in your home or another facility. The nurse need not be an R.N. or L.P.N., so long as the services rendered are of a kind generally performed by a nurse. These include services directly related to caring for and monitoring your, your spouse’s or dependent’s condition, including: Changing dressings and providing wound care Assessing responses to prescribed treatments, and documenting those assessments in written notes If the individual providing nursing services also provides household and personal services, only those charges related to actual nursing care are eligible expenses.
NURSING HOME
Expenses for medical care in a nursing home f for you, your spouse and dependent(s), including meals and lodging may be reimbursed if the main purpose of the stay is to receive medical care.
If the primary reason for confinement is personal (i.e., you or your spouse or dependent needs assistance with activities of daily living safety issues portion of the cost that is directly related to medical care or nursing services may be reimbursed.
NUTRITIONAL SUPPLEMENTS
Dietary, nutritional, and herbal supplements, vitamins, and natural medicines are not reimbursable if they are merely beneficial for general health. However, they may be reimbursable if recommended by a medical practitioner to treat a specific medical condition.
NUTRITIONIST
Nutritional services related to the treatment and guidance of a specific diagnosis or medical condition can be reimbursed.
OCCUPATIONAL THERAPY
OPTOMETRIST
ORAL CARE
ORTHODONTIA
See Orthondontia Quick Reference Guide for more information CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
ORTHOPEDIC SHOES
Only shoes custom-fitted to the wearer’s feet are eligible. Only the cost difference between the custom-made shoe and a regular comparable shoe is reimbursable. Mass produced shoes are not eligible.
ORTHOTIC INSERTS
Custom-made and over-the-counter inserts are eligible for reimbursement.
OSTEOPATH
OVER-THE-COUNTER MEDICINES
AND SUPPLIES
OVER-THE-COUNTER MEDICINES
Eligible dental or vision over-the-counter AND SUPPLIES (cont.)
expenses, such as denture care products, and contact lens cleaning, soaking solutions and OVULATION MONITOR
PAIN RELIEVERS
PARENTAL FEES
Fees or premiums paid to participate in a state-funded assistance program for the medical care of disabled dependents are not eligible for reimbursement from your HCFSA.
PATTERNING EXERCISES
While these exercises are often done by family members, the expense to hire someone to perform patterning exercises is an eligible expense.
PENILE IMPLANTS
Amounts paid for implants may be eligible if the diagnosis of impotence is due to organic causes, such as diabetes, post-prostatectomy complications, or spinal cord injury.
PERMANENT CONTACT LENSES
PERSONAL ITEMS
not to treat a specific medical condition are not eligible for reimbursement.
PHYSICAL THERAPY
PHYSICIAN FEES Pre
Pre paid physician fees that cover the cost of services such as exams, physicals, screenings, check-ups and immunizations, are not eligible for reimbursement. A common example is an annual pre-paid fee to access the services of an on-staff physician. Also see Boutique Practice/Concierge/Pre-Paid Physician Fees CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
PILLOWS, lumbar support
Pillows or cushions that provide lumbar support may be eligible for reimbursement if prescribed by a licensed health care provider to alleviate a specific medical condition.
POST-MASTECTOMY CLOTHING
POST MASTECTOMY CLOTHING
Prosthetic bras and related clothing purchased Prosthetic bras and related clothing purchased after any surgical procedure related to breast cancer (lumpectomy, mastectomy, etc.) are eligible for expenses. Prosthetic bras and inserts are reimbursable at 100%. Tank tops or swimwear with built-in prosthetic bras are reimbursed up to 50% of the total cost not to exceed $75.
PREGNANCY AIDS
Items that relieve or reduce the discomfort of pregnancy may be reimbursed under a HCFSA. Examples include: PREGNANCY TESTS
PRESCRIPTION DRUG DISCOUNT
Fees paid to get access to drugs at a reduced cost are not eligible for reimbursement under a HCFSA. Actual costs paid for prescription drugs are an eligible expense.
PRESCRIPTION DRUGS
Eligible expenses include deductibles, co-payments or co-insurance as well as the costs for prescription drugs that may not be covered under FEHB, such as drugs that treat erectile dysfunction. Your claim documentation must include either the name of the drug or a receipt indicating the item is a prescription along with the provider's name and the date of service.
PREVENTIVE CARE SCREENINGS
If the tests are designed to assess symptoms of a medical diagnosis, they are eligible for of a medical diagnosis, they are eligible for reimbursement. Examples include clinic and home testing kits for blood pressure, glaucoma, cataracts, hearing, cholesterol, etc.
PROSTHETICS
PSYCHIATRIC SERVICES AND CARE
PSYCHOANALYSIS
PSYCHOLOGIST
READING GLASSES
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
SERVICE ANIMALS
Expenses to train or procure any guide dog, signal dog, or other animal individually trained to provide assistance to you, your spouse or dependent with a disability can be reimbursed under a HCFSA. Expenses such as food, medications, vet visits, and dental care products needed for the care or maintenance of service animals are eligible expenses.
Please note, you must provide documentation to support the expense is for an actual service animal.
SHAMPOO, medicated
May be eligible when used to treat a specific medical condition.
A Letter of Medical Necessity from your physician must be signed by your health care practitioner, state your medical diagnosis, practitioner, state your medical diagnosis, the name of the medicated shampoo that will treat the medical diagnosis and specify the length of time the medicated shampoo is required Please note, this does not include cosmetic-type shampoos, such as Rogaine or Nioxin.
SHIPPING AND HANDLING
Shipping and handling charges for medical needs, such as mail SHOWER CHAIRS
SLEEP AIDS
SMOKING CESSATION MEDICINES
SMOKING CESSATION PROGRAMS
SPECIAL FOODS
If prescribed by a physician to treat a special If prescribed by a physician to treat a special illness or ailment, and not merely as a substitute for normal nutritional requirements.
The amount that can be reimbursed is limited to the amount that the special food exceeds the cost of commonly available versions of the same product.
SPEECH THERAPY
SPEECH THERAPY
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
SPERM STORAGE
Storage fees can be reimbursed if you, your spouse or dependent has a cancer or blood dyscrasia diagnosis that requires chemotherapy or whole body radiation which may affect future ability to conceive children. NOTE: Storage fees should not exceed twelve STERILIZATION PROCEDURES
STERILIZATION REVERSAL
STUDENT HEALTH FEE
SUBSTANCE ABUSE
SUNBURN/BURN RELIEF
SUN-PROTECTIVE CLOTHING
Clothing that offers at least 30+ UVA and UVB sun protection for individuals with melanoma or other skin cancer, systemic lupus erythematosus (SLE), acute cutaneous lupus (ACLE) or other significant dermatologic conditions may be eligible with a letter of medical necessity from your doctor. The clothing is reimbursed for the difference between “normal” apparel and this specially-constructed clothing up to 33% of the total cost. The receipt must show the purchase was from an accredited sun-protective company such as Solumbra® or Coolibar®.
SUNSCREEN
Sunscreen products with an SPF 30 or higher are eligible. Lotions or cosmetics that contain ingredients to protect you from the sun and/or list a SPF are not eligible. TANNING SALON OR EQUIPMENT
May be reimbursed under a HCFSA for treatment of certain skin disorders, such as eczema and psoriasis. The cost of the equipment must be divided by the number of individuals living in the household and is only reimbursable for the individual with the medical condition.
Expenses to improve general health and/or appearance are not eligible.
Taxes on medical services and products may be reimbursed under a HCFSA. This includes local, state, service and other taxes.
TEETH WHITENING
Teeth whitening products or services to enhance the brightness of your teeth are cosmetic and cannot be reimbursed.
TEETH WHITENING (cont.)
Teeth whitening performed to restore function after an injury or trauma or to correct a congenital disease can be reimbursed.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
TELEPHONE FOR HEARING
The cost difference associated with purchasing IMPAIRED
or repairing special telephone equipment versus a standard telephone for you, your spouse or dependent with a hearing impairment are eligible for reimbursement under a HCFSA.
TELEVISION FOR HEARING
Expenses for equipment that displays the IMPAIRED
audio of television programming as subtitles for hearing impaired persons are eligible for reimbursement under a HCFSA.
The eligible expense is limited to the cost that exceeds the cost of a non-adapted set.
TEMPORARY CONTINUATION OF
Under IRS rules, insurance premiums cannot COVERAGE (TCC) PREMIUMS
be reimbursed under a health care FSA.
TOILET SEAT EXTENDERS
TOOTHBRUSHES
Toothbrushes, including electric or battery-powered, are personal care items and not eligible for reimbursment.
TRANSPORTATION
Costs of transportation to/from locations of Costs of transportation to/from locations of medical care/service are potentially eligible for reimbursement, but not guaranteed. There must be a medical reason why the care was obtained from a location that necessitated the travel. You cannot simply choose to receive medical services at a location you were going to travel to anyway and then receive reimbursement for it. The purpose of the trip must be purely medical in nature. You must submit the following: 1. the need for travel to a place outside of your mormal home or work location 2. an Explanation of Benefits or other dated receipt that clearly shows when and where the services were received, and 3. a dated receipt for the travel (plane fare, t i f taxi fare etc) that corresponds to the date(s) of the medical services.
TRICARE PREMIUMS
Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA.
Excursions taken for a change in environment, general health improvement etc., even those taken on the advice of your health care provider are not an eligible expense.
UCR, CHARGES ABOVE
Medical expenses in excess of your plan’s usual, customary and reasonable (UCR) charges may be reimbursed under a HCFSA if the underlying expense is eligible.
CONDITION / TYPE OF
ELIGIBLE
POTENTIALLY
ADDITIONAL INFORMATION
SERVICE / EXPENSE
ELIGIBLE
ELIGIBLE
EXPENSE*
ULTRASOUND, PRE-NATAL
An ultrasound ordered by your physician to monitor fetal growth, and/or to diagnose, treat or monitor a pregnancy-related condition is a covered expense under your HCFSA, even if your health plan does not provide reimbursement. An ultrasound not ordered or performed by a physician or other licensed professional, and/or not intended to diagnose, treat or monitor a pregnancy-related condition is not an eligible expense.
VASECTOMY
VASECTOMY REVERSAL
VISION CARE
Expenses such as eye exams, vision correction procedures, vision therapy and glasses or contact lenses are eligible.
VISION DISCOUNT PROGRAMS
Fees paid to gain access to a vision network, or to a reduced fee structure are not an eligible expense under a HCFSA.
VITAMIN B-12 INJECTIONS
VITAMINS
WARRANTIES
Warranties that cover the replacement of items such as eyeglasses, hearing aids, or adaptive equipment are not eligible for reimbursement.
WART REMOVAL
WATER FLUORIDATION
WEIGHT LOSS DRUGS
Drugs prescribed by a health care provider for weight loss are eligible. However OTC drugs, such as Alli, are only potentially eligible. See the OTC Quick Reference Guide.
WEIGHT LOSS PROGRAMS
Food is not eligible, even if it is part of the wieght loss program.
WELL-BABY/WELL-CHILD CARE
WHIRLPOOL BATHS
WHEELCHAIRS
The full cost of a wig purchased because the patient has lost all of his or her hair from disease or treatment.
Eligible expenses listed here are subject to change without notice.

Source: http://flexiblebenefits.tennessee.edu/Medical%20Expense%20Listing.pdf