Download Health Care FSA- Qualified Expense Information

Flexible Spending Accounts
Health Care FSA- Qualified Expense Information
The health care FSA pays medical, dental, vision and prescription drug expenses with pre-tax income. Significant tax savings are available
to help pay for out-of-pocket health care expenses when:
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The product or service is primarily for health care to diagnose, alleviate or treat injuries, illness or sickness
You receive the service or purchase the product for use during your Coverage Period
The cost will not be waived, paid by another source or claimed as a medical tax deduction on your income tax return
The service or product is not received or purchased for cosmetic or general well-being
Eligible Health Care Expenses
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Acne treatments*
Acupuncture
Alcoholism/Drug treatment
Allergy treatments (in office)
Alternative providers (must be legal & qualify as
medical care)
Ambulance
Artificial limbs
Band aids/bandages/tape
Birth control spermicides*
Braille books/magazines (cost exceeding regular
editions)
Breast pump & lactation supplies
CPAP kit & supplies
Car modifications for handicapped
Chiropractic care
Coinsurance
Condoms (non-spermicidal)
Contact lenses & supplies
Copays & deductibles
Dental care/bridges/crowns/implants
Dentures & denture care products
Dermatologist fees
Diagnostic/screening test products
Doctor’s fees
Emergency equipment
Eye exams
Eyeglasses/sunglasses (prescription)
Experimental treatments (must be legal & qualify
as medical care)
Fertility/infertility treatment
First aid kits
Foot care (corn/callus/bunion removal)
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Guide & service dogs
Head lice supplies (combs)
Head lice treatments (shampoos, etc.)*
Hearing aid/batteries/exams/treatment
Home health care products (grab
bars/commode/bath bench, etc.)
Hospital services
Hot/cold therapy products
Incontinence products for adult/juvenile
Insulin & diabetic supplies
Joint care products (liquid & tabs)
Lab fees
Lamaze (for mother only)
Mammograms
Medical alert ID bracelet/necklace
Medical conference admission
& transportation to/from
Medical records
Midwife/Doula
Mileage to/from medical services (primary purpose
must be medical)
Monitoring devices (blood pressure, stethoscope,
etc.)
Motion sickness bands
Nursing services
Occlusal guards to prevent teeth grinding
Optometrist fee
Organ transplant
Orthopedic braces/supports/aids
Orthodontia expenses for on-going services
(treatment plan required)
Orthopedic custom/prescription made shoes (cost
difference)
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Orthotics
Ostomy pouches & products
Over-the-counter medicine/drug*
Oxygen
Periodontal fees
Physical examinations
Pill counter/dispenser/cutter
Pregnancy aids (support hosiery/support belts
Prenatal vitamins
Prescription drugs – FDA approved
Psychiatric/Psychoanalysis
Reading glasses (OTC)
Rental of medical equipment
Respiratory therapy (mask/nebulizer)
Sales tax for eligible expense
Saline products for sinus/nasal
Scooter (disability aid)
Shipping & handling
Shoe inserts/supports
Sleep deprivation testing & treatment
Smoking cessation programs
Smoking cessation patch, gum, etc.*
Surgery
Telephone for hearing- impaired
Therapy for health/mental disorders
Thermometer
Vaccinations/flu shots
Vasectomy
Vision surgeries
Walking aids (cane/walker/crutches)
Wheelchairs/ramps
X-rays
*Requires a valid prescription (electronic or written order for a medicine or drug that meets the legal requirements of a prescription in the state in which the medical
expense is incurred and that is issued by an individual authorized to issue a prescription in that state).
Important note: The information presented is not an all-inclusive list, nor a guarantee of eligibility or payment. Eligibility will be
based upon the applicable provisions of your plan as stated in your company’s plan document. Contact BMO Benefit Services for
additional information.
Mailing address: BMO Benefit Services, PO Box 2517, Appleton, WI 54912-2517
Phone: 800-236-3539| Fax: 888-244-2759 | Email: [email protected] | Website: bmoflex.com
BMO Benefit Services is a part of BMO Global Asset Management and a division of the BMO Harris Bank N.A., offering products and services through various
affiliates of BMO Financial Group.
BMO Global Asset Management is the brand name for various affiliated entities of BMO Financial Group that provide investment management, retirement, and
trust and custody services. Certain of the products and services offered under the brand name BMO Global Asset Management are designed specifically for
various categories of investors in a number of different countries and regions and may not be available to all investors. Those products and services are only
offered to such investors in those countries and regions in accordance with applicable laws and regulations. BMO Financial Group is a service mark of Bank of
Montreal (BMO). Investment products are: NOT FDIC INSURED — NO BANK GUARANTEE — MAY LOSE VALUE.
©2014 BMO Financial Corp.
Flexible Spending Accounts
Health Care FSA- Dual Purpose and Ineligible Qualified Expense Information
The health care FSA pays medical, dental, vision and prescription drug expenses with pre-tax income. Significant tax savings are
available to help pay for out-of-pocket health care expenses when:




The product or service is primarily for health care to diagnose, alleviate or treat injuries, illness or sickness
You receive the service or purchase the product for use during your Coverage Period
The cost will not be waived, paid by another source or claimed as a medical tax deduction on your income tax return
The service or product is not received or purchased for cosmetic or general well-being
Dual-Purpose and Ineligible Health Care Expenses
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Capital Expenditures (call for
clarification)**
COBRA premiums
Cosmetic treatments/drugs**
Dehydration products (pedialyte,
etc.)**
Dental products (mouthwash,
toothpaste, electric toothbrush, etc.)
Elective counseling (dietary,
marriage, etc.)**
Electrolysis
Employment related expenses
Estimates/pre-payments
Exercise classes (fees pro-rated) &
equipment**
Expenses claimed on tax return
Expenses paid by another source
Fees for long-term storage of sperm
or embryo
Fiber supplements**
Finance charges
Food/beverages or meal
replacements as part of a weight loss
program – Not eligible
Genetic testing**
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Hair loss/replacement treatment or
prescriptions
Health club memberships (fees prorated)**
Illegal treatments, operations or
drugs
Insurance policies/premiums
Language training for a child with
dyslexia or disability**
Learning disability tuition**
Liposuction
Massage therapy for medical
condition**
Meals
Medicare premiums
No show fees for missed
appointments
Nutritionist**
Over-the-counter medicine/drug
without a valid prescription
Personal use items
Physician retainer fees
Plastic surgery**
PPO provider discounts
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Prescription drugs imported from
another country (not FDA approved)
Qualified Long-Term Care Services
Service contracts (dental/vision)
Special schools/education for
relieving a disability**
Stockpiling (excessive purchases)
Student health fee
Supplements (herbs, minerals,
vitamins)**
Support/compression hosiery**
Teeth whitening**
Toiletries
Travel allowance/lodging for out-oftown medical care**
Veneers/bonding for cosmetic
reasons
Warranties/protection plans
Weight loss programs (fees prorated)**
Wigs for hair loss due to medical
condition**
**Expenses may be eligible if accompanied by a doctor’s written statement indicating the medical condition and that this is the treatment
needed to cure, mitigate, treat or prevent a specific medical condition. A doctor’s recommendation does not automatically make the expense
eligible. In some cases, additional documentation may also be required to validate the expense for reimbursement.
Important note: The information presented is not an all-inclusive list, nor a guarantee of eligibility or payment. Eligibility will be
based upon the applicable provisions of your plan as stated in your company’s plan document. Contact BMO Benefit Services for
additional information.
Mailing address: BMO Benefit Services, PO Box 2517, Appleton, WI 54912-2517
Phone: 800-236-3539| Fax: 888-244-2759 | Email: [email protected] | Website: bmoflex.com
BMO Benefit Services is a part of BMO Global Asset Management and a division of the BMO Harris Bank N.A., offering products and services through
various affiliates of BMO Financial Group.
BMO Global Asset Management is the brand name for various affiliated entities of BMO Financial Group that provide investment management, retirement,
and trust and custody services. Certain of the products and services offered under the brand name BMO Global Asset Management are designed
specifically for various categories of investors in a number of different countries and regions and may not be available to all investors. Those products and
services are only offered to such investors in those countries and regions in accordance with applicable laws and regulations. BMO Financial Group is a
service mark of Bank of Montreal (BMO). Investment products are: NOT FDIC INSURED — NO BANK GUARANTEE — MAY LOSE VALUE.
©2014 BMO Financial Corp.