Fillable Veba Trust - Claim Form (Page 2 of 2) in pdf

instructions for submitting claims

Use this form to request reimbursement of qualified healthcare expenses and/or insurance premiums you have incurred on behalf of yourself, your

spouse, and/or your eligible dependents (fillable version available at ). Qualified expenses and premiums submitted for reimbursement must

have been incurred after you became a participant eligible to file claims. Want to see your claims in progress and claims history? Go to and

VEBA Plan

click

to login to your account.

online

To expedite your claim:

1. Fully complete all requested information. Missing information may delay the processing of your claim and could result in your claim being

denied. Don’t forget to sign and date the form.

2. You must attach itemized verification for each expense or service. Generally, verification should contain (1) patient (covered individual)

name; (2) date item was purchased or service was provided; (3) description of expense or service; and (4) out-of-pocket amount. Acceptable

forms of verification include (1) an explanation of benefits (EOB); (2) an itemized billing or statement from your provider; or (3) a detailed

receipt for prescription or over-the-counter (OTC) medications. Cancelled checks and balance forward statements are not acceptable.

3. For qualified insurance premium reimbursement, you must attach documentation which includes the following: (1) name(s) of covered

individual(s); (2) premium amount(s); (3) policy period; and (4) insurance provider name and address. This information is typically contained

on your premium billing notice. NOTE: Premiums paid by an employer, or premiums that are or could be deducted pre-tax through your or

your spouse’s employer, are not eligible for reimbursement.

VEBA Plan

online

To set up systematic reimbursement of monthly insurance premiums, go to and click

VEBA Plan

to login to your account. Or,

online

submit a completed Systematic Premium Reimbursement Form.

Questions? Contact the third-party administrator, Meritain Health, at or 1-888-828-4953.

qualified exPenses and Premiums

Internal Revenue Code § 213(d) defines qualified expenses and premiums, in part, as “medical care” amounts paid for insurance or “for the diagnosis,

cure, mitigation, treatment, or prevention of disease…” Expenses solely for cosmetic reasons generally are not eligible (e.g. facelifts, hair transplants,

hair removal, etc.).

Common expenses include co-pays, coinsurance, deductibles, and prescriptions. Common insurance premiums include medical, dental, vision, tax-

qualified long-term care (subject to IRS limits), Medicare Part B, Medicare Part D, and Medicare supplement plans. Go to to view a more

extensive list.

Please note the following:

1. Insurance premiums paid by an employer, or premiums that are or could be deducted pre-tax through your or your spouse’s section 125

cafeteria plan, are not eligible for reimbursement.

2. If you or your spouse have a section 125 healthcare flexible spending account (FSA), you must exhaust the FSA benefits before submitting

claims.

3. Claims for over-the-counter (OTC) medicines and drugs should be for reasonable quantities expected to be consumed within a reasonable

period of time. Sales tax can be included.

qualified dePendents

Generally, dependents must satisfy the IRS definition of Qualifying Child or Qualifying Relative as of the end of the calendar year in which expenses

were incurred to be eligible for benefits. These requirements are defined by Internal Revenue Code § 152 and described in IRS Publication 502. These

definitions supersede and may differ from state definitions. Go to for more information.

Qualifying Child. A qualifying child is a child who: (1) is your son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, or a descen-

dant of any of them (for example, your grandchild, niece, or nephew); and (2) at the end of the calendar year in which expenses were incurred will be (a)

under age 19, or (b) under age 24 and a full-time student, or (c) permanently and totally disabled; and (3) is younger than you; and (4) is unmarried; and

(5) lives with you for more than half the year; and (6) does not provide more than half of his or her own support; and (7) is a citizen, national, or resident

of the U.S. or a resident of Canada or Mexico.

Qualifying Relative. A qualifying relative is a person who: (1) is your (a) son, daughter, stepchild, foster child, or a descendant of any of them (e.g.

your grandchild); or (b) brother, sister, or a son or daughter of either of them; or (c) father, mother, or an ancestor or sibling of either of them (for ex-

ample, your grandmother, grandfather, aunt, or uncle); or (d) stepbrother, stepsister, stepfather, stepmother, son-in-law, daughter-in-law, father-in-law,

mother-in-law, brother-in-law, or sister-in-law; or (e) any other person (other than your spouse) who lived with you all year as a member of your house-

hold; and (2) will not be a qualifying child of any other person as of the last day of the calendar year in which expenses were incurred; and (3) does not

provide more than half of his or her own support; and (4) is a citizen, national, or resident of the U.S. or a resident of Canada or Mexico.