Request For Reimbursement Form (Page 2 of 2) in pdf

A REMINDER ABOUT REIMBURSABLE

HEALTH CARE EXPENSES

DAY CARE EXPENSES

See your Summary Plan Description for additional information.

1. In order for your day care expenses to qualify for reimbursement from

1. You can use a Medical Reimbursement Account to get reimbursed for

the Day Care Expense Account, the following requirements must be met:

any eligible expenses not paid in full by another plan, or for any eligible

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expenses not covered by your health plan. An eligible expense must

If you are married, your spouse must be working for pay, attending

meet the following requirements:

school or seeking employment while you are at work.

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Must be directed or prescribed by a physician, except for eligible

The children receiving day care must be under the age of 13 at the

over-the-counter products.

time the day care services are provided, or the person receiving care

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must be physically or mentally incapable of self care.

Must be directly related to a physical or mental condition.

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The provider cannot be listed as a dependent on your federal income

Expenses must be incurred on or after the effective date of the plan

tax form, and, if the provider is your own child, must be at least 19

and while you are a participating employee.

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years of age.

Expenses must be incurred for you, your spouse, or other person

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Expenses must be incurred on or after the effective date of the plan

who qualifies as an eligible dependent for federal income tax

and after the date you become a plan participant.

purposes.

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Under federal law, when you file your income tax return with the IRS

2. Examples of eligible expenses include:

you must also report the name, address, and taxpayer identification

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Deductibles (the part of covered expenses you pay before your

number of all providers of dependent day care services whose fees

health plan pays any benefits).

were reimbursed to you under this plan during the year. Failure to

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do so constitutes tax fraud unless the provider of these services is a

Coinsurance amounts (the percent of covered expenses you must

501(c) (3) tax-exempt organization. If you have questions on how

pay, if any, after the deductible requirement has been met).

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this might affect your tax filing, refer them to your tax advisor.

Dental expenses, such as, exams or other accepted services.

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Vision care expenses, such as, eye examinations and eyeglasses.

2. If the amount of day care expense reimbursement you receive for a

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Hearing care expenses, including hearing examinations and hearing

calendar year exceeds your earnings if you are single, or the earnings of

aids.

the lower paid spouse if you are married, the difference must be reported

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Routine physical examinations

as taxable income for the year. There are special rules if your spouse is

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Prescription medications

a full time student or is physically or mentally incapable of self care.

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Certain over-the-counter products

Again, see your tax or legal advisor.

3. You must furnish proof the expenses were incurred by attaching an

3. You must furnish proof that the expenses were incurred either by having

itemized statement from the provider. If a statement is attached, please

the provider complete the Certification of Provider Section of the form or

write the corresponding line number which the expense is listed (taken

by attaching an itemized statement from the provider. If a statement is

from column (1) on the front of the form).

attached, please write on that statement the line number (taken from

column (1) from the front of the form) corresponding to that item of

4. HRA/VEBA Eligible Expenses (if applicable):

expense.

Eligible expenses are subject to your employer’s HRA/VEBA Plan

4. If there is not enough money in your Day Care Expense account to cover

Document. See the HRA/VEBA plan document for a list of eligible

in full the eligible expenses listed on this form, you will be reimbursed up

expenses as they may differ from those listed above.

to the amount of your account balance. Additional reimbursements due

you will be temporarily suspended. Suspended amounts will

automatically be processed each time reimbursements are paid.

Request For Reimbursement Form Page 2

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