The IRS recognizes that orthodontia treatment is different from any other type of healthcare expense. To get reimbursed for orthodontia expenses you are required to submit one of the following:
Orthodontia Example: Full payment is made on the first orthodontist visit
- Coupon Payment Option – You can submit an itemized statement of your orthodontia expenses as the service is provided. Submit this documentation with a completed claim form for reimbursement.
- Monthly Payment Option (Auto Pay) – To set up Auto Pay, download a claim form via My HealthHub Resources, complete all required fields and make sure to check the box for Automatic Monthly Reimbursement for Orthodontia expenses. You must also include a copy of your ortho contract/agreement* with your first claim. Once the claim has been processed, PayFlex® will automatically reimburse you each month, according to the agreement. This eliminates the need for you to submit a claim form for each visit and allows expenses to be paid monthly for the length of the contract, as long as you are enrolled in an FSA and have funds available in your account.
*You can obtain a contract/payment agreement from the orthodontist with the following information:
- Patient name
- Date the service begins
- Length of service
- Charges for the initial banding work
- Dollar amount charged each month
- If you enroll in AutoPay, the PayFlex Card® cannot be used to pay for orthodontia expenses.
- Reimbursements will be issued on a monthly basis near the due date stated on your orthodontia contract agreement.
- Total Payment Option – If you paid the full amount when the orthodontia treatment began, you can get reimbursed for the amount you paid for the treatment, minus the amount covered by your dental insurance. PayFlex® will reimburse you, up to your FSA election amount, minus any previous FSA reimbursements. If you have already submitted other claims, make sure to check your FSA balance online to confirm the amount you have available to cover your orthodontia treatment.
To get reimbursed, simply send a copy of your paid receipt and completed claim form to PayFlex®, along with an itemized statement with the following information:
Note: If you choose the total payment option, please remember a paid receipt must be submitted to PayFlex® and can only be submitted once for reimbursement.
- Provider name
- Patient name
- Date treatment started
- Amount of expense
- Amount insurance will pay
Let’s say you participate in a healthcare Flexible Spending Account (FSA) in 2011 and 2012. In October 2011, you sign an agreement with an orthodontist for your son. During the first visit (November 2011), your son is X-rayed and fitted for braces. On the second visit (December 2011), the braces are installed. During 15 more monthly visits, the braces will be adjusted. Eventually in 18 months, (if everything goes as planned), the braces will be removed. For these services, the orthodontist charges $3,000 on the date of the first visit, which you pay in 2011.Can I be reimbursed the full $3,000 from my 2011 healthcare FSA?
Yes, provided you have at least $3,000 available in your FSA. Although your son did not receive all of the care in 2011, the IRS regulations allow the healthcare FSA to reimburse you for the entire $3,000 as a 2011 expense.What if I do not have the full $3,000 remaining in my 2011 healthcare FSA?
If you paid the entire orthodontia bill of $3,000 in a lump sum, and your FSA balance is only $2,000, PayFlex® can only reimburse you for the amount available in your account (e.g., $2,000).What if my plan includes the grace period, how will my lump sum orthodontia payment be processed?
It depends on when you paid the lump sum orthodontia expense. Let’s say your orthodontia treatment started in October 2011 and the orthodontist is charging you $3,000. On January 15, 2012, you decided to pay the lump sum amount. Since you paid for the expense during the grace period, you would be reimbursed from the 2011 FSA balance first (if money is still available) and then from the 2012 FSA balance. (Note: the amount you are reimbursed cannot exceed the amount paid to the orthodontist or the total amount of your 2011 and 2012 FSA balances.) Orthodontia Example: Orthodontia treatments provided over two plan years
When treatment is spread over two plan years and you do not pay for the full expense up front, you have two options:
I am currently set up with PayFlex’s monthly payment option (Auto Pay) for my orthodontia treatment. If I choose not to enroll in an FSA for the following plan year, will the Auto Pay process continue during my grace period (e.g., January 1 – March 15)?
- You can pay the monthly payment amount based on the orthodontia agreement by submitting a claim each month with your payment coupon.
- You can set up an automatic payment (Auto Pay) with PayFlex® based on the amount set by the orthodontia agreement. To set up Auto Pay, you will need to complete a claim form with the monthly payment amount listed under the Amount Requested column and Ortho – Auto Pay under the Type of Service column. When completing the form, make sure to check the box for Automatic Monthly Reimbursement for Orthodontia expenses. In addition, a copy of the ortho contract/agreement must be sent in with the claim form. Once PayFlex® processes this claim, you will be reimbursed on a monthly basis near the due date stated on your orthodontia contract agreement.
If you choose not to enroll in an FSA for the following plan year and you have money left in your FSA, the Auto Pay process will automatically continue for the first 2 months of the grace period. The grace period, if offered by your employer, generally covers expenses incurred between January 1 and March 15. With Auto Pay, the orthodontia payments are scheduled based on an amount for an entire month. Therefore, in this situation, the Auto Pay for your January and February payments will be processed. However, the Auto Pay for your March payment will be denied, since coverage ends on March 15 and does not continue for the entire month of March.