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Per the Patient Protection and Affordable Care Act (PPACA),
effective January 1, 2011, reimbursements for over-the-counter (OTC)
medicines and drugs will no longer be eligible for reimbursement under a Health
FSA Plan unless they are prescribed by a physician. The documents below
provide information about this new regulation.
If you have any questions regarding the OTC change,
please contact MedBen Customer Service at (800) 686-8425 or
medben@medben.com. |
FORM
1009: Employee’s Guide to Flexible Spending Accounts (WITH Debit Card)
FORM 1010:Employee’s Guide to Flexible Spending Accounts
(NO Debit Card)
Overviews/FAQs of MedBen FSAs for plan participants.
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If your company does
offer the option of an FSA debit card, use Form 1009.
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If your company
does not offer the option of an FSA debit card, use Form 1010.
FORM
1100: Compensation Redirection Agreement (NO Debit Card)
FORM
1100b: Compensation Redirection Agreement (WITH Debit Card)
Use one of these forms to participate in your company's FSA
plan.
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If your company does
not offer the option of an FSA debit card, use Form 1100.
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If your company
does offer the option of an FSA debit card, use Form 1100b.
If reporting a change in status, Form
1101 must accompany Form 1100/1100b.
FORM
1101: Health and Dependent Care Change Request Form
(8½”x14”)
Use this form to make a change in your flexible
spending account (FSA) election or to change your address.
FORM
1102: Dependent Care Spending Reimbursement Request Form
Use this form to request reimbursement from
the Dependent Care spending account of your FSA.
FORM
1103: Dependent Care Receipt for Services Form
A caregiver or provider of service can use
this form as a receipt for dependent care services provided.
FORM
1104: FSA Mileage Reimbursement Form (For Expenses Incurred from July 2011 to
December 2011)
FORM
1104: FSA Mileage Reimbursement Form (For Expenses Incurred from January 2011 to
June 2011)
Use one of these these form if
you are claiming, under your Health FSA, the mileage used to obtain qualified
medical services from a physician, hospital or facility to prevent or alleviate
a physical disease, defect or illness.
FORM
1105b: Debit
Card Substantiation Form
Use this form to substantiate purchases made with
your MedBen "Benny" Debit Card.
FORM
1106: Health Care Spending Reimbursement Request Form
Use this form to request reimbursement from your
Health FSA account.
FORM
1107: Health Care Spending Reimbursement Request Form
Use this form to request reimbursement from your
Health FSA account.
FORM
1107b: Limited Purpose Health Care Spending Account Reimbursement Request Form
If you have a health savings account (HSA) and a
Limited Purpose Health FSA, use this form to request reimbursement from your
Health FSA account (dental and vision expenses only).
FORM
1109: Orthodontia Services Reimbursement Request Form
An orthodontist (or authorized bookkeeper) can use this form to
request reimbursement for services.
FORM
1114: Request for Debit Card
Use this form to receive a
debit card for your dependent or replace a lost or stolen card.
FORM
1131: Examples of Qualified Medical Expenses
This form provides a useful overview of medical expenses that
typically qualify for reimbursement under a
Health FSA account. You can also find a more detailed list on our
IRS-eligible Expenses
page.
FORM
1132: Sample Letter of Medical Necessity
If a Letter of Medical Necessity is required from your provider
to receive reimbursement from your FSA, this sample letter can be used for that
purpose. Simply print out/save and give to
your doctor.
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