Microsoft word - 2011 som mdea worksheet-draft2.doc

The Medical/Dental Expense Account (MDEA) al ows an employee to set aside pre-tax dol ars to pay for medical, dental, and vision expenses that are not paid by insurance. You can include out-of-pocket expenses incurred by you, your spouse, and your qualified dependents. The fol owing is a partial list of eligible expenses. These include expenses related to the diagnosis, care, treatment, or prevention of disease. Eligible expenses are general y those permit ed by Section 213 of the Internal Revenue Code. Laser eye surgery, radial keratotomy, LASIK, corneal ring segments Acupuncture – to treat a specific medical condition Lead-based paint removal – to prevent a child, who has or has had Adoption – medical expenses incurred before adoption is finalized lead poisoning from eating the paint, excl Alcoholism or drug dependency treatment and treatment centers Legal fees – to authorize treatment for mental il ness Lodging for medical care – $50 per night for outpatient, essential Automobile modifications for physical y handicapped person medical care, up to $100 if companion required Medical conference admission and transportation to/from – Brail e books and magazines – only amount paid ABOVE the cost expenses for admission and transportation to medical conference relating to chronic disease of participant or dependent, includes Breast pumps – (not for personal preference or convenience) transportation to city where conference is held and local Childbirth preparation classes for mother, ex transportation to conference. Cost of meals and lodging is not Medical information plan – expenses charged for storing and Christian Science practitioners for specific medical care retrieving medical records from a computer data bank Contact lenses and contact lens solutions Medical monitoring and testing devices (ex: blood pressure Counseling – to treat a specific medical condition, exclude Medical supplies – (ex: bandages, gauze, carpel tunnel wrist Deductible, coinsurance, and co-pay amounts if underlying expense Mental institution or special home-care for mental y il or mental y disabled person who is unsafe when left alone Dental treatment, including dentures, orthodontia (braces and retainers), and occlusal guards to prevent teeth grinding Diabetic insulin, syringes and glucose monitoring equipment Nursing services – nurse expenses, board and care for a specific c udes nursing services for a healthy baby Nursing home – if for specific medical condition Eyeglasses, prescription sunglasses, reading glasses, and eyeglass Nutritionist’s professional expenses – if to treat a specific medical Fertility treatments – if treatment impacts the participant or dependent of participant, includes shots, treatment, surgery, IVF, GIFT, ovulation monitor, fees for storage of sperm or embryo Orthopedic shoes, only the cost over what normal shoes would cost Guide dog or other animal aide – purchase, training, and Pat erning exercises for a mental y disabled child Physical exams – excluding employment related physicals Pregnancy test (includes over-the-counter tests) Home modifications to accommodate handicapped person Psychiatric care – includes cost of supporting mental y il dependent at a special center which provides medical care Language training for child with dyslexia or disabled child Psychologist – medical care if to treat a specific medical condition Reconstructive surgery fol owing mastectomy Rev. 02/2011 Pre-Tax Benefits • Eide Bail y Employee Benefits • 5601 Green Val ey Drive, Suite 710 • Minneapolis, Minnesota 55437-1145 952-944-6633 1- 800-300-1672• Fax 952-918-3622• www.eidebail ybenefits.com/som Screening tests (e.g. hearing, vision, cholesterol) Telephone – purchase and repair for special telephone Smoking cessation program – includes programs and prescription Television for hearing-impaired person – equipment which displays the audio part of TV programs (costs of special y equipped Special schooling for physical y or mental y handicapped – main television that exceed the cost of regular models only) reason for using school is its resources for relieving the disability Transportation – expenses for essential medical care (.19 per mile, rate subject to IRS changes), parking and tol s Transportation for conference relating to a chronic disease of Support or corrective devices (such as orthopedic shoes) Surgery to improve deformity from congenital abnormality, personal injury from accident or trauma, or disfiguring disease Wheelchair – purchase, operation, and upkeep Taxes imposed on reimbursable medical care or products, along c tes an expense that requires a p c iption. Please include, with claim, a p prescription indicating the specific m c l condition requiring the item or service Effective 1/1/2011, Al over-the-counter medications require a physician’s prescription to be eligible for reimbursement (excluding Massage therapy – for specific injury or trauma, excl to relieve stress or depression. (Prescription must include medical condition, length of time treatment wil be needed, and number of sessions during stated time. Prescript Genetic testing - (if done to determine possible defects) Vitamins (excludes multi or one a day vitamins) Holistic or naturopathic treatment/remedies Weight loss program or drugs prescribed to induce weight loss Learning disability (amount paid to special school or special y Wigs – for a patient who has lost al of their hair trained teacher) (for severe learning disability caused by mental Al ergy treatment products and household improvements to treat al ergies – examples – filters, pil ows, and special vacuums – products that would be owned even without al ergies Laser hair removal, even when prescribed by a physician Any charges incurred outside the plan year, even if paid for during Baby-sit ing, child care and nursing services for a healthy baby Over the counter medications or vitamins for general wel being – Cosmetic surgery, electrolysis, and/or hair transplants Cost of remedial classes for non-handicapped child Propecia and/or Rogaine – prescription drugs to stimulate hair Dance or bal et lessons for improvement of general health Diapers or diaper service unless for specific medical condition Sperm or embryo storage fees for future conception Swimming lessons for improvement of general health Fees/dues for exercise, fitness programs, athletic, or health club membership, even if prescribed by physician Weight reduction program for general wel being Total estimated reimbursable health care expenses Rev. 02/2011 Pre-Tax Benefits • Eide Bail y Employee Benefits • 5601 Green Val ey Drive, Suite 710 • Minneapolis, Minnesota 55437-1145 952-944-6633 1- 800-300-1672• Fax 952-918-3622• www.eidebail ybenefits.com/som

Source: ftp://ftp2.dot.state.mn.us/pub/outbound/MetroSurveys/th55exrw/2011/EideBailly/2011%20mdea%20worksheet.pdf