Flex-Ed: Clearing up the mysteries about vitamins and FSA/HSA eligibility

At first glance, vitamins and supplements seem like natural candidates for FSA- and HSA eligibility. They are designed to fill "gaps" in the average diet, and maybe offset minor nutritional deficiencies along the way -- yes, even those related to larger health problems.

But the IRS -- which governs FSA- and HSA-eligibility -- disagrees, while continuing to cite IRS 213(d), which states all FSA-eligible expenses must conform to the following standard:

"The diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body."

And this is where the arguments start. Arguments such as...

"My vitamins are necessary! Why am I being punished?"

Vitamins are perhaps the most-glaring example of a product that can either be necessary or "dual-purpose." Daily multivitamins are used to promote better health and well-being, but because there's no specific health need or condition that is helped by using multivitamins, they fall outside the accepted qualifications for FSA- and HSA- eligibility.

Is there a medical basis for needing a multivitamin? Sure - it's for your health, after all. But promoting general well-being and treating a specific condition are two very different things in the eyes of the IRS.

In the past, we've used toothbrushes and floss as a good comparison point for the vitamin debate, and it still holds up. Though we all know proper dental cleaning is necessary for all-around health and wellness, using a toothbrush and floss has not been identified as having a direct role in treating or solving the specific medical condition.

"My vitamins are eligible? How did that happen?"

Though multivitamins are likely the most-popular OTC supplement, only a handful of targeted vitamins have achieved FSA- and HSA-eligibility, provided the patients have documentation from their doctors claiming the need.

I think we can all agree prenatal vitamins meet the IRS requirements for eligibility, since they have shown to prevent birth defects and boost fetal development in ways that most modern diets can't quite seem to achieve.

Likewise, glucosamine/chondroitin supplements are extremely popular at FSAstore.com and HSAstore.com because of their proven benefits for treating arthritis.

Because the above exceptions have proven value in treating specific needs and conditions, they can be purchased with tax-free health dollars, and without any written approvals from physicians. However…

"Is there any chance they'll make an exception?"

We obviously can't answer that here. But as many Americans know, working with the IRS is not nearly the nightmare people used to claim. And if a doctor determines your body needs a specific vitamin supplement -- even if it falls outside of regular FSA or HSA parameters -- then a Letter of Medical Necessity might do the trick.

Chances are, the letter will need to be detailed in explaining why these specific products will benefit you, and how long the expected use will be (such as the duration of specific treatment). It's not a guarantee by any means, but a well-presented case made to your benefits administrator can go a long way toward getting the supplements you need, on a tax-free basis.

Glucosamine Chondroitin

Cushion bones and lubricate joints by taking glucosamine chondroitin daily.

Prenatal Vitamins

Keep mom and baby happy and healthy with daily prenatal vitamins for pregnant and nursing mothers.


New to FSAs? Need a refresher course in all things flex spending? Our weekly Flex-Ed column gives you a weekly dose of FSA Living 101, offering tips for making the most of your tax-free funds. Look for it every Thursday, exclusively on the FSAstore.com Learning Center. And for the latest info about your health and financial wellness, be sure to follow us on Facebook, Instagram and Twitter.


Flex-Ed: Shedding light on the letter of medical necessity

Every year, as we approach open enrollment (and it's we receive a lot of the same questions. And discussing the letter of medical necessity (LMN) is always at the top of the list. So, since this a column about the basics of flexible spending account use, we're happy to cover it again. Because it's important, and can impact how you shop for FSA-eligible products and services.

If you've spent some time looking through our Eligibility List, you probably noticed a classification of qualifying medical products and services as "requiring a letter of medical necessity."

In short, an LMN is like a doctor's note. Having an LMN can help any product or service that falls outside the IRS's definition of "medical care" (but can assist the treatment of a condition) get approved for FSA reimbursement.

Defining "medical care"

For a product or service to be FSA-eligible, it must treat, cure, diagnose or prevent a disease or illness. Or it has to affect a function of the body. So a product like a first-aid kit is a no-brainer, as it can be used in a huge variety of medical situations.

However, there are many treatment methods and products available that fall outside IRS guidelines that could be made eligible with some additional documentation from your doctor.

Here's an example: If your doctor suggests massage therapy to treat an injury, it's not FSA-eligible on its own. However, if you get an LMN from your doctor that outlines how the treatment method is essential to your recovery, your benefits administrator may accept it as an FSA-eligible expense.

How to submit a letter of medical necessity

If you and your doctor have identified a medical product or service that can aid the treatment of an injury or medical condition and it falls outside FSA eligibility, here's what you need to do:

  • Check with your benefits administrator to see if there is an official form to fill out for the expense to be approved.
  • If your doctor is writing a letter on his/her own, the letter must outline: what medical condition is being treated, a description of the treatment (frequency, dosage), and how long the expense will be needed to treat the condition.
  • A receipt or invoice must be submitted with the LMN for the full price to be reimbursed.

In some cases, benefits administrators may ask for additional information from your doctor, most likely for products/services that also have non-medical uses.

Beyond its direct medical use, most expenses are non-reimbursable if the individual would have purchased it anyway. In other words, this product can't be something you would purchase even if you didn't have the condition. It needs to be directly related to this course of treatment, and the specific use needs to be confirmed by a doctor.

One example is yoga. If you're already paying for yoga classes unrelated to a medical condition, your payments are not FSA-eligible, and these costs won't be covered retroactively. But if a physician recommends yoga to help a specific condition, they might submit an LMN on your behalf, to allow you to use tax-free funds to cover the costs of classes for a set period of time, until the doctor determines your treatment is complete.

With any luck, you shouldn't have any difficulties getting reimbursed for your expense as long as you keep an open line of communication with your benefits administrator and ensure that your physician is as detailed as possible.


New to FSAs? Need a refresher course in all things flex spending? Our weekly Flex-Ed column gives you a weekly dose of FSA Living 101, offering tips for making the most of your tax-free funds. Look for it every Thursday, exclusively on the FSAstore.com Learning Center.


Flex-Ed: Understanding hormone replacement therapy and your FSA

If you're just starting out with an FSA, or even if you've had one for a while, it can be challenging to understand all the healthcare services eligible to use with your account.

One way to keep this clear is to remember that the IRS only allows you to use your FSA for the costs of diagnosis, cure, mitigation, treatment, or prevention of disease, and the costs for treatments affecting any part or function of the body .

But that still leaves some room for discussion. For example, what about something like hormone replacement therapy (HRT)? Would that be covered under an FSA? In this week's Flex-Ed, let's take a look at the conditions under which HRT would be considered eligible.

When is HRT covered by an FSA?

One purpose of HRT is to help patients deal with several symptoms of menopause. Because menopause is a recognized medical diagnosis, any treatments doctors use to help women deal with its symptoms and complications are covered under an FSA.

Women that are menopausal have a higher risk of bone fractures, heart disease and stroke, so treating menopause is an important part of an overall health maintenance program.

There are many types of HRT treatments, depending on a patient's symptoms. For example, doctors can prescribe medication as well as gels, creams, and patches for patients that experience symptoms like hot flashes.

To be eligible for coverage under your FSA, your FSA administrator may require that your HRT treatment include a prescription and/or a Letter of Medical Necessity (LMN) to detail the diagnosis and overall need for the treatment.

Also for FSA coverage, medication you use to treat your menopause will require a prescription, even if that medication is available over the counter.

HRT expenses that aren't covered

The expenses for any non-prescription medication you take for menopause will likely not be eligible for reimbursement under your FSA.

It's also important to remember that HRT not specifically used to treat menopause or osteoporosis is likely not eligible for reimbursement with FSA funds.

For example, if you're a healthy woman that wants to use HRT to maintain a good level of estrogen, that wouldn't be a qualified expense, and wouldn't be eligible for coverage with your FSA.

In other words, HRT is a treatment that needs the supervision of a medical professional. At least if you want it to qualify for flex spending. This is likely because studies have associated HRT with an increased risk of conditions that include stroke, heart disease, blood clots and even breast cancer.

These risks vary and depend on the kind of treatment plan your doctor orders for your menopause, including the dosage of estrogen you receive, and the length of time you take the medication.

Of course, we're not doctors, and you should always speak with your FSA administrator if you're unsure about any expenses you may incur and whether or not they will qualify under your plan. But if your physician determines HRT can provide you with relief from menopause symptoms and increase your quality of life, using your FSA may be able to help give you some additional peace of mind.

New to FSAs? Need a refresher course in all things flex spending? Our weekly Flex-Ed column gives you a weekly dose of FSA Living 101, offering tips for making the most of your tax-free funds. Look for it every Thursday, exclusively on the FSAstore.com Learning Center.


Why Do I Need a Letter of Medical Necessity?

by Donna Crisalli, FSAstore.com Technical Advisor

To be reimbursable from an FSA or HSA, an expense must be for medical care. Some items or services may be for medical care or may be for personal use. To tell the difference, plan administrators often request a “letter of medical necessity," or LMN.

An expense is for medical care if the primary purpose for the expense is to treat, cure, mitigate, diagnose, or prevent a disease or illness, or to affect a structure or function of the body. Items and services that usually are personal, such as air conditioners, may be used for medical purposes, for example to reduce the symptoms of asthma. Other items and services, such as vitamins and exercise equipment, usually are used to maintain general good health, which is not medical care eligible for reimbursement, but may be used to treat or mitigate a disease, such as high blood pressure, osteoporosis, or obesity.

An item or service is reimbursable as medical care only if an individual's primary purpose for the expense fits within the definition of medical care. Because a plan administrator is unable to look into someone's mind, the plan administrator will look at certain objective facts and circumstances to determine an individual's purpose. These include:

(1) Has a doctor or other medical professional determined that the individual (or a qualifying family member) has a disease or illness?

(2) Has a medical professional recommended the item or service to treat, mitigate, etc., the medical condition?

(3) Is the item or service medically effective?

(4) How soon did the individual purchase the item or service after the diagnosis of the medical condition?

(5) Are there less expensive treatments?

These questions don't need to be asked if the item or service has no use other than medical care (for example, x-rays and other diagnostic tests, supplies and equipment such as bandages and wheelchairs). These facts are relevant only when an item has a non-medical use. They are guidelines for a plan administrator to determine if a personal use item is medical care, based on all the facts and circumstances of a particular case.

There is no set requirement that every one of the facts and circumstances is present in every case. However, it always will be necessary to determine that a medical condition is present and that the item or service is for the treatment or improvement of the medical condition. The letter of medical necessity provides the plan administrator with at least this information. (The term “letter of medical necessity" is misleading because there is no requirement that the treatment is necessary if it is for medical care. It is the shorthand plan administrators use for a letter from a health provider providing this basic information.)

However, a letter from a doctor or other health care practitioner stating that there is a medical condition and prescribing the item or service may not provide all the information a plan administrator may need. First, the medical use has to be the primary purpose for the expense. Second, the expense is not reimbursable if the individual would have purchased it anyway (would not have purchased it without the medical condition, a requirement called the “but for" test). The plan administrator may ask for information relating to some or all of the other facts and circumstances to determine if the medical use is the primary purpose for the expense and whether the “but for" test is satisfied.

Let's apply these rules to some concrete examples.

Jack's doctor diagnoses Jack with a heart condition. The doctor recommends light exercise, such as brisk walking, to lessen the symptoms and reduce the risk of a heart attack. The next day Jack buys a $500 pair of athletic shoes and begins walking a mile every day. Jack has never walked for exercise or owned athletic shoes. Jack has a medical condition that the shoes will help, he buys the shoes right away, and he has never owned this type of shoes before. Jack did not buy the cheapest shoes available, but the rest of the facts and circumstances show that his primary purpose in buying the shoes is to help his heart condition and he would not have bought them “but for" the medical condition. Jack may be reimbursed for the athletic shoes from his FSA.

Jill has high blood pressure. Her doctor suggests she buy a blood pressure monitor. Jill buys a smart watch, which has a blood pressure monitoring function. Jill owns a smart watch but was thinking about upgrading it. After buying the new watch, she does not have to buy another blood pressure monitor. Jill has been using a smart watch, planned to buy one before the doctor made the recommendation, and chose an expensive device with many other functions besides monitoring blood pressure. Although Jill may use the watch for a medical purpose, the facts and circumstances show that the medical function is not Jill's primary purpose in buying the watch and she would have bought it or a similar watch even if she did not have the medical condition. The smart watch is not eligible for reimbursement.

James has emphysema. His doctor recommends light exercise, but James also has severe arthritis and is unable to walk for exercise. He builds a simple lap pool in his yard and uses it only to swim laps, which he does most days. His family members also sometimes swim laps in the pool. James works long hours and lives in a remote area, and it is not convenient for him to go to a gym or other facility with a pool on a regular basis. James uses the pool for medical purposes, he built it only after receiving the doctor's advice, and he built the most basic pool for the purpose. There are reasons why he does not engage in another kind of exercise. Although his family members also sometimes use the pool, the facts and circumstances indicate that James's primary purpose in building the pool is to treat his emphysema and he would not have built the pool otherwise. James may use his HSA for the cost of the pool.

Jane has not had a medical condition and has been getting massage therapy once a month to reduce stress and improve her general good health. Jane's chiropractor diagnoses Jane with muscle strain from lifting a heavy object and suggests massage therapy might help the condition. At her next massage therapy appointment, Jane asks the therapist to focus on the strained muscles. Jane may have a medical purpose for this particular massage therapy appointment, but the facts and circumstances indicate that the medical purpose is not her primary purpose and she would have had the massage therapy even without the medical issue. Jane is not entitled to reimbursement for the massage therapy.

In each of these situations, a LMN would tell the plan administrator that there is a medical purpose for the athletic shoes, the smart watch, the swimming pool, and the massage therapy, which usually are personal and not medical expenses. The plan administrator would need to know more of the facts and circumstances, however, to determine whether the medical purpose is the primary purpose and if the “but for" test is satisfied. This additional information may be included in what the plan administrator calls a “letter of medical necessity" or the plan administrator may request it separately.

These rules may seem very complicated, but when the answer to the question “is this an expense for medical care" depends on the facts and circumstances, there is no simple answer that applies in every case.


What is LMN eligible?

There are specific products and services that may be what is considered dual-purpose (can serve a medical purpose an an alternative purpose), at which point, FSA users may be able to cover the cost with a Letter of Medical Necessity (LMN) from a physician. This letter must outline how a product/service is necessary to treat a legitimate medical condition and how long it will last. LMNs are approved on a case-by-case basis by benefits administrators, so be sure to inquire with them first before seeking out an LMN from a doctor. Some administrators may have other requirements besides an LMN as well. The LMN designation is there to let you know to inquire with your benefits administrator, as the specific expense may or may not be considered eligible.


Can I use my FSA to improve my air quality?

One of the most common product eligibility questions we receive from our customers relates to products that affect air quality, such as air purifiers, filters and air conditioning units. After all, the quality of the air we breathe has an inordinate effect on our overall health, so why wouldn't this be covered under an FSA? So are they FSA-eligible or not? The answer is: possibly. Let's explore the eligibility requirements around the most common products that can affect your home's air quality.

  1. Air Conditioners

Air conditioning regulates temperature in an indoor space, which is especially helpful during the summer months when excessive heat could become a health hazard. While air conditioners are not designed exclusively to treat a specific medical condition, the IRS will allow individuals and families to cover the cost of an air conditioner if it can be proven that the unit is needed for medical reasons. The primary purpose of the air conditioner must be to treat or alleviate a medical condition.

To show that the expense is primarily for medical care, a note from the medical practitioner recommending the item to treat a specific medical condition is normally required. If it is attached to a home (such as central air conditioning), only a portion of the cost to install the device will qualify. If you have a medical condition in which an air conditioner is needed for treatment, your FSA third party administrator can provide you with more details on exactly what will be needed in order for it to qualify for reimbursement.

  1. Air Filters

Air filters, such as high-efficiency particle air (HEPA) filters, are used to remove a wide variety of irritants from an indoor space, such as allergens, mold and other particles that could affect a person's overall state of health. In particular, these devices are extremely useful for individuals with asthma or allergies whose symptoms can be worsened by allergens being present in the environment. For an air filter to be eligible for reimbursement, the primary purpose of the device must be to treat or alleviate a medical condition. To show that the expense is primarily for medical care, a note from a medical practitioner (Letter of Medical Necessity) recommending the item to treat a specific medical condition is normally required.

  1. Air Purifier

Air purifiers go one step further from a traditional air filter by actively sanitizing rather than simply removing particles from the air. According to the Los Angeles Times, one of the most common air purifiers on the market is the ionizing air purifier, which releases a steady stream of negatively charged ions that electrify the bits of dust, dander or other particles. The airborne particles pick up the negative charge and become strongly attracted to positively charged collection plates inside the machine. Once again, air purifiers are not eligible, but they could be covered with an LMN from a physician that outlines how the product will be used to treat a legitimate medical condition.

For everything you need to keep you and your loved ones healthy, rely on FSAstore.com! We have the web's largest selection of FSA eligible products to help you maximize the potential of your healthcare benefits.

Steam Inhalers

Start breathing easier in minutes by inhaling the warm, soothing mist from steam inhalers.


What vitamins are FSA/HSA eligible?

One of the most common questions we receive in our FSA Learning Center from our customers is related to the eligibility of daily multivitamins and supplements. Traditionally, multivitamins are used to fill in the nutritional gaps that a person is lacking in his/her diet, but certain supplements can also help to alleviate a nutritional deficiency that may be caused by an underlying health problem. When it comes to FSA/HSA eligibility, vitamins seem to fall into a gray area, but we hope to clear up the confusion!

What determines vitamin eligibility?

A product/service's FSA eligibility is dictated by the Internal Revenue Service (IRS), which adheres to IRS 213(d). This regulation states that all FSA eligible expenses must conform to the IRS's definition of medical care:

"The term “medical care" means amounts paid— for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body."

While this seems straightforward, vitamins are a prime example of a product that can be considered necessary for "general health" or is considered "dual purpose." This means that while the product/service may have a medical basis, they are used primarily to promote one's general health and do not have a direct role in treating a specific medical condition. For instance, a toothbrush or dental floss are considered dual purpose items as they have both a medical and non-medical purpose.

What vitamins are FSA/HSA eligible?

With this IRS definition in mind, while daily multivitamins are not FSA/HSA eligible, there are some types of vitamins that are eligible with consumer-directed healthcare accounts and others that may be eligible with proper documentation from a physician. For instance, prenatal vitamins are FSA/HSA eligible, as they help prevent birth defects and support fetal development, while glucosamine/chondroitin supplements are also eligible when used to treat arthritis.

However, in some cases, doctors may prescribe a specific vitamin supplement to treat a medical condition that falls outside of FSA regulations. In this case, your benefits administrator may require a Letter of Medical Necessity (LMN) to show that these vitamins are necessary for the treatment of a medical condition. The letter will typically need to outline how these products will be used to aid the treatment process, and how long the treatment will last. If you are considering a specific vitamin for treatment of a medical condition, talk to your FSA/HSA benefits administrator to determine what types of documentation may be required.

Glucosamine Chondroitin

Lubricate joints and cushion bones with FSA-eligible glucosamine chondroitin.

Prenatal Vitamins

Keep mommy and baby happy and healthy with prenatal vitamins.