MEDICAL REIMBURSEMENT ACCOUNT

(Unreimbursed Medical)

Reimbursement Account

Qualified expenses under this category allow employees to have those expenses taken out of their paycheck on a tax-free basis. This allows you to be reimbursed from the first dollar you spend for medically related expenses. This includes expenses for you and your dependents. Several examples include reimbursements for co-pays, co-insurance, and deductibles covering medical, dental, vision, as well as costs for prescription drugs, and many other non-covered medical expenses.

Certain over the counter (OTC) drugs can be included in this section (e.g. allergy, cold, flu and pain medications). However, vitamins and other dietary supplements are specifically excluded. Drugs and medical procedures for cosmetic purposes are also excluded under this section.

Unused medical reimbursement dollars cannot be carried into the next plan year, thus any unused portion will be forfeited at the end of the current plan year.

In order to be reimbursed, you need to copy billing statements or receipts and submit them with the completed voucher that you receive each month. The monthly voucher also provides you with the up-to-date balance of your account

The example above is only for illustration purposes. Your individual savings could be higher or lower.

Terms and Conditions

To be eligible for reimbursement medical expenses must: Be incurred by you or an eligible dependent during the plan year, not to be reimbursable from any other source, must be claimed on your monthly reimbursement voucher and submitted along with proper “third-party verification” (i.e., copies of receipts, cancelled checks, EOB’s)

My signature on my monthly reimbursement voucher certifies that the expenses submitted are deductible medical expenses and cannot be reimbursed from any other source or used as a deduction on my personal income taxes. Any dollar amounts that are not used during the plan year to provide benefits will be forfeited and may not be paid to me in case or used to provide benefits specifically for me in a later plan year.

The expenses may not be paid or payable to any of your children who are under the age of 19 at the end of the year in which the expenses are incurred or to an individual who is declared as a dependent on your tax return.

These health related expenses are reimbursable if they are considered “medical care” under Section 213© of the Internal Revenue Code.

Some of these eligible expenses for reimbursement include but are not limited to the following:

Acupuncture	Glasses	Oral Surgery
Alcoholism and Drug Abuse	Guide Dogs	Orthodontia
Ambulance	Gynecologists	Over the Counter Items (for specific ailments)
Anesthetist	Halfway House Residency	Physiotherapist
Artificial Limbs	Hearing Devices	Practical Nurse
Birth Control	Hospital Bills	Psychiatrist or Psychoanalysis
Blood Donor	Insulin	Psychologist
Braille Books or Magazines	Iron Lung Operating Costs	RX – Prescription Drugs
Childbirth Classes	Laboratory Fees	Rental of Medical Equipment
Chiropractor	Lip Reading Lessons	Sanitarium
Christian Science Practitioners	Marriage Counseling	Sex Therapist
Crutches	Midwife	Support or Corrective Devices
Dental	Nurse	Telephones for the Hearing Impaired
Diathermy	Nursing Home	Therapy
Examinations (Physicals)	Obstetrician	Transplants
Eye Examinations	Oculist	Vasectomy
Family Counseling	Operations (Surgeries)	Vitamins (for specific ailments)
Food and Beverages	Ophthalmology	Wheel Chairs
(for specific ailments)	Optician or Optometrist	X-Rays

To enroll in the Medical Reimbursement Account click on the Election Form and:

   •Print your name, address, social security number
   •Print your company name
   •Enter the monthly medical reimbursement amount to the left of Unreimbursed Medical expense and initial
    to the right of the monthly amount.
   •Print the form
   •Sign the original and remit to:
    Provess
    4050 Katella Avenue, Suite 213
    Los Alamitos, CA 90720

** Please complete only one CLICK HERE for all benefit choices.