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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) 59 EXHIBIT A Eligible Medical Care Expenses Health FSA. Medical and dental expenses that qualify as expenses for medical care under I nternal Revenue Service rules generally qualify as Eligible Expenses for reimbursement under the Health FSA. Those may take the form of co-pays, deductibles, and medical expenses not covered by other insurance. Often expenses that qualify for deductions under IRS rules are Eligible Expenses, but in some instances expenses that are deductible will not be reimbursable and expenses that are not deductible will be reimbursable. Some specific examples are identified below. The following is not an exhaustive list and there are other expenses that are eligible if they satisfy the IRS rules. Limited Scope Health FSA. Only a limited number of the following expenses are Eligible Expenses for reimbursement under the Limited Scope Health FSA. The expenses must be for dental and vision care. Dental care expenses are primarily listed under the “Dental & Orthodontic Care” section. Vision care expenses are primarily listed under the “Vision Care” section. Dental & Orthodontic Care Allowable expenses: • Dental treatment • Artificial teeth/dentures • Braces, orthodontic devices Expenses specifically disallowed by the IRS or courts: • Teeth whitening • Toothbrushes and toothpaste, even if special type is recommended by dentist Therapy Treatments Allowable expenses: • X-ray treatments • Treatment for alcoholism or drug dependency • Legal sterilization • Acupuncture • Vaccinations • Hair transplant to treat specific medical conditions • Physical therapy (as a medical treatment) • Fee to use swimming pool for exercises prescribed by physician to alleviate specific medical condition such as rheumatoid arthritis • Speech therapy • Smoking cessation programs and drugs to alleviate nicotine withdrawal Expenses specifically disallowed by the IRS or courts: • Physical treatments unrelated to a specific health problem (e.g., massage for general well being) • Any illegal treatment • Cosmetic surgery • Treatment for baldness (unless it is for a specific medical condition and not for cosmetic purposes) • Electrolysis (unless it is for a specific medical condition and not for cosmetic purposes) Fees/Services Allowable expenses: • Physician’s fees and hospital services • Nursing services for care of a specific medical ailment • Cost of a nurse’s room and board if paid by the taxpayer where nurse’s services qualify • Social Security tax paid with respect to wages of a nurse where nurse’s services qualify • Services of chiropractors • Christian Science practitioner fees • Diagnostic tests Expenses specifically disallowed by the IRS or courts: • Payments to domestic help, companion, babysitter, chauffeur, etc. who primarily render services of a non-medical nature • Nursemaids or practical nurses who render general care for healthy infants • Fees for exercise, athletic, or health club membership when there is no specific health reason for needing membership • Marriage counseling provided by clergyman Hearing Expenses Allowable expenses: • Hearing aids and hearing aid batteries • Hearing aid repair • Special telephone equipment