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Retired Members Information: Medical Reimbursement

Non-Medicare Eligible Retiree Members Enrolled in an HMO May Participate in the Medical Reimbursement Plan. Go to the Publications/Forms Section of this Web Site to Download a Medical Reimbursement Claim Form.


Summary

  • Provides payment for eligible out-of-pocket expenses if you are enrolled in the HMO option.
  • Maximum amounts of reimbursement --$240 per family if you are enrolled in an HMO (one-half or more of the plan year).
  • If you are enrolled for less than one-half of the plan year, you are eligible for one-half of the maximum level of reimbursement.

Eligible Medical Expenses

Internal Revenue Service (IRS) regulations designate which expenses are eligible for reimbursement as non-taxable benefits when rendered by licensed providers and legally procured. While the PEBTF believes that the following expenses are properly reimbursable under the Medical Reimbursement Plan, and that they are not taxable to you, it cannot guarantee that this is necessarily the case. Accordingly, it is suggested that you discuss with your accountant or tax advisor whether the particular reimbursement received is excludable from your taxable income.

Eligible expenses include, but are not limited to, the following:

  • Acupuncture performed by a licensed practitioner.
  • Adult vaccinations prescribed by a physician for travel.
  • Alcohol and drug rehabilitation programs in a therapeutic center.
  • Ambulance transfers and transportation expenses primarily for, and essential to, medical care.
  • Cervical pillows prescribed by a physician.
  • Chiropractic services
  • Circumcision.
  • Copayments for emergency room, office visits or mental health visits
  • Cosmetic surgery when necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.
  • Cranial prostheses (wigs) when medically necessary, when purchased for hair loss due to disease or congenital defect.
  • Dental expenses, including orthodontics for handicapping malocclusion, and cosmetic dental services to alleviate a condition or deformity caused by disease or inherited defect.
  • Electrode gel and replacement electrodes.
  • Experimental and investigational procedures provided by a licensed provider.
  • Fertility and erection treatment and drugs prescribed by a physician for fertility and erection treatment.
  • Flu shots.
  • Hearing aid batteries, cords and components.
  • Hearing aid expenses.
  • Hospice care.
  • Hospital services, such as emergency room, nursing, medical, laboratory, surgical and other medical expenses.
  • Inclinators.
  • Massage therapy by a licensed therapist prescribed by a physician for the alleviation of a physical defect or illness.
  • MedicAlert bracelets
  • Mental health outpatient visits provided by a licensed practitioner in excess of 60 with UBH denial.
  • Nursing home care for treatment of illness or injury
  • Nursing Services
  • Nutrition and dietary counseling prescribed by a physician to treat specific illness.
  • Physicals for school, Department of Transportation, camp, travel or for a job.
  • Premarital blood work.
  • Prescription expenses including copayments, brand vs generic cost difference and anorexiant medications.
  • Private room charges if a medical need for a private room can be established.
  • Prosthetic, orthopedic or chiropractic devices including orthotics for heal and foot pain, replacement and repair of orthotics, heel wedges for shoes and neoprene braces.
  • Prosthetic replacements for adults for alleviation of a physical defect.
  • Purchase of service animals for sight or hearing impaired individuals.
  • Radial keratotomy and related services.
  • Sales tax on approved prescription items.
  • Smoking cessation programs to the extent they are not covered by the managed care plans.
  • Social worker expenses for medical care services such as counseling and psychiatric services.
  • Specialty or custom wheelchairs.
  • Speech and physical therapy.
  • Unreimbursed medical expenses including out-of-network services.
  • Vision expenses such as prescription eyeglasses (including prescription sunglasses) and contact lenses, lens options, such as tints, anti-reflective and anti-scratch coatings and varilux coverages, if medically necessary, and sports glasses when used to correct visual acuity (prescription).
  • Warranties on durable medical equipment, such as wheelchairs (if equipment is approved).

Ineligible Medical Expenses

The Medical Reimbursement Plan cannot be used for:

  • Abortion expenses.
  • Air conditioners.
  • Athletic shoes, such as Nike cross-trainers.
  • Athletic mouth guards.
  • Charges in excess of the Medical Reimbursement Plan maximum reimbursement.
  • Clip-on or non-prescription sunglasses, sports glasses when not used to correct visual acuity (non-prescription), contact lens club memberships, saline solutions, enzyme cleaners and contact lens care kits, contact lens insurance and eyeglass warranties.
  • Convenience items (electric razor, shoe horn, sock grip) which are not medically necessary.
  • Cosmetic dental services, such as bleaching of discolored teeth; and orthodontic treatment other than for correction of handicapping malocclusion.
  • Cosmetic surgery which is not medically necessary, for example, hair removal electrolysis, hair transplant, liposuction and face lift surgeries.
  • Counseling, psychological or family, with court order in child custody cases.
  • DUI classes and addiction counseling required by court order.
  • Exercise equipment.
  • Hospital charges for television, telephone, newspapers.
  • Non-prescription medical supplies, such as gauze, adhesive tape, Ace bandages and wrist splints.
  • Non-prescription (over the counter) drugs and medicine.
  • Parking fees.
  • Services incurred prior to the employee/dependent’s effective eligibility date.
  • Services incurred after the employee/dependent’s termination date.
  • Services incurred prior to the plan effective date.
  • Shipping or mailing charges.
  • Swim plugs for nose and ears.

Filing A Medical Reimbursement Plan Claim

All claims for reimbursement under the Medical Reimbursement Plan must be submitted (postmarked) no later than December 31 of the year following the year in which services were provided.

For more information, refer to your REHP Benefits Handbook or contact PEBTF.