Fillable Reimbursement Request Form Mdea, Dcea & Hra (Rev. 12/2015) (Page 2 of 3) in pdf

A Reminder Regarding Reimbursable Medical/Dental Expenses

Reimbursement is based upon the incurred date not the paid date. You “incur” an expense on the date that the service is

received, not when you pay the bill. You must provide proof that the expenses were incurred by attaching a statement from the

provider indicating the date of service, a description of the service, and the charge for the service.

Examples of acceptable

documentation for healthcare expenses are an itemized statement or an insurance company’s explanation of benefits (EOB). Do Not

send canceled checks, copies of checks, credit card receipts or statements (except for medical co-pays), a predetermination or estimate

of insurance benefits form, balance-forward statements, or balance due statements of expense. Keep a copy of the

documentation for your records. There is a fee for retrieval and copying of previously processed claims. For prescription

medications you must include a copy of the pharmacy drug label or pharmacy statement showing the name of prescription(s). For

over-the-counter medications you must submit a third party receipt with the name of the medicine or drug, the

date purchased, and the amount paid. Reimbursable over-the-counter items must be used to treat a medical condition, not for

personal comfort or general well being.

You can use the Medical/Dental Expense Account (MDEA) for the reimbursement of any eligible expenses not paid in full by another

plan or for any eligible expenses not covered by your health plan. To be eligible, expenses must meet the following requirements:

They must be directed or prescribed by a physician or dentist



They must be directly related to a physical or mental condition



Expenses must be incurred on or after the effective date of the plan and after the date you become a plan participant



Expenses must be incurred by you, your spouse, or other person who qualifies as an eligible dependent for federal income



tax purposes

Examples of eligible expenses:



Deductibles (the part of covered expenses you pay before your health plan pays any benefits)



Co-insurance amounts (the percent of covered expenses you must pay, if any, after the deductible requirement has been

met)

Dental expenses such as exams or other services



Vision care expenses such as eye examinations and eye glasses



Hearing care expenses, including hearing examinations and hearing aids



Routine physical examinations



Prescription and over-the-counter medicines to alleviate or treat a medical condition



Co-pays



A Reminder Regarding Reimbursable Dependent Care (Daycare) Expenses

For your dependent care expenses to qualify for reimbursement from the Dependent Care (Daycare) Expense Account, (DCEA) the

following requirements must be met:

Your spouse must be working for pay, attending school, or seeking employment while you are at work.



Children receiving daycare must be under the age of 13 at the time the daycare services are provided, or the person receiving



care must be physically or mentally incapable of self-care.

The provider cannot be listed as a dependent on your federal income tax form, and if the provider is your own child, your



child must be at least 19 years of age.



An unlicensed care provider must care for no more than six children (excluding full-time residents of the daycare facility).



Expenses must be incurred on or after the effective date of the plan and after the date you become a plan participant.

Under federal law, when you file your income tax return with the IRS you must also report the name, address, and taxpayer



identification number of all providers of dependent care services whose fees were reimbursed to you under this plan during

the year. Failure to do so constitutes tax fraud unless the provider of these services is a 501(c)(3) tax-exempt organization.

If you have questions on how this might affect your tax filing, refer your question to your tax advisor.

If the amount of daycare expense reimbursement you receive for a calendar year exceeds your earnings and you are single or the

earnings of the lower-paid spouse if you are married, the difference must be reported as taxable income for the year. There are special

rules if your spouse is a full-time student or is physically or mentally incapable of self-care. Again, see your tax advisor if you have

questions.

You must provide proof that the expenses were incurred either by having the provider complete the Provider Signature section of the

form or by attaching an itemized statement from the provider. Indicate the actual amount incurred, not the amount you calculate to

be in the account.

If there is not enough money in your DCEA to cover in full the eligible expenses listed on this form, you will be reimbursed up to the

amount of your account balance and the excess expenses will be carried forward and paid from the contributions you make in

subsequent periods. You do not have to re-submit the charges.

Notice Regarding Collection of Private Data

Under provisions of Minnesota Statutes 43A 22-24, 121 Benefits has been authorized to administer the State of Minnesota Pre-tax Benefits

Plan. Information is requested on this form about you, your family members and your expenses to identify you as a participant in the Plan

and to determine your eligibility for expense reimbursements. You are not legally required to provide any information requested. However,

providing all the requested information will help to process your claim accurately and quickly. If you do not provide critical information, we

may be unable to process your reimbursement request. The information requested may be provided to: representatives of the Minnesota

Management & Budget, federal and state tax authorities, professional auditors who audit the State of Minnesota Pre-Tax Benefits Plan, law

enforcement entities with statutory authority to gain access to the data, and any other person or entity authorized by law or court order.

Questions Regarding the Reimbursement Process

Reimbursement Request Form Mdea, Dcea & Hra (Rev. 12/2015) Page 2

Related Articles

Related forms

Related Categories