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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
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
1105b: Debit
Card Substantiation Form
Use this form to substantiate purchases made with
your MedBen "Benny" Debit Card.
FORM
1107: Health Care Spending Reimbursement Request Form
Use this form to request reimbursement from your
Health FSA account.
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.
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