Plan Information
📋 Complete This Section First
Enter your plan details below. These values will automatically populate throughout the Plan Document and Summary Plan Description.
⚠️ QSEHRA Limits for 2025
If using QSEHRA, the IRS maximum annual limits are:
- Self-only coverage: $6,350
- Family coverage: $12,800
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HEALTH REIMBURSEMENT ARRANGEMENT
Plan Document
Effective Date: [Effective Date]
[Employer Name] (hereinafter referred to as the "Employer") hereby establishes a Health Reimbursement Arrangement (hereinafter referred to as the "Plan") for the exclusive benefit of eligible employees and their eligible dependents, effective as of [Effective Date].
The purpose of this Plan is to provide reimbursement to eligible employees for qualified medical expenses as defined under Internal Revenue Code Section 213(d), to the extent such expenses are not covered by any other health plan or insurance. This Plan is intended to qualify as an employer-provided accident and health plan under Internal Revenue Code Sections 105 and 106.
This Plan is intended to be an unfunded welfare benefit plan maintained primarily for the purpose of providing health benefits to employees. The Plan is not intended to be subject to the Employee Retirement Income Security Act of 1974 (ERISA) to the extent the Employer qualifies for any applicable exemption, including the exemption for plans covering only owners and their spouses.
Means an individual who qualifies as a dependent of the Participant under Internal Revenue Code Section 152, or a child of the Participant who has not attained age 27 as of the end of the Plan Year.
Means any individual who is employed by the Employer and receives compensation that is reported on Form W-2. For purposes of this Plan, the term specifically includes owner-employees and their spouses who are bona fide employees of the Employer receiving W-2 compensation for services actually performed.
Means [Employer Name], EIN: [EIN], located at [Address], or any successor thereto.
Means expenses incurred by a Participant or Dependent for medical care as defined in Internal Revenue Code Section 213(d), including but not limited to 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. A complete list of eligible expenses is attached as Exhibit A to this Plan Document.
Means an Eligible Employee who has satisfied the eligibility requirements of Article III and has been enrolled in the Plan.
Means [Administrator Name], [Title], or such other person or entity as may be designated by the Employer from time to time.
Means the twelve-month period beginning on [Start Date] and ending on [End Date]. The initial Plan Year shall begin on the Effective Date and end on [Initial Year End].
An employee shall be eligible to participate in the Plan if such employee:
(a) Is an Eligible Employee as defined in Section 2.2;
(b) Has completed any applicable waiting period established by the Employer (currently: No waiting period); and
(c) Is not covered by another employer's group health plan that provides similar benefits (if applicable).
An Eligible Employee shall become a Participant upon completion of the eligibility requirements and submission of the required enrollment form to the Plan Administrator. Participation shall be effective as of the first day of the month following satisfaction of eligibility requirements, or such other date as determined by the Plan Administrator.
A Participant's participation in the Plan shall terminate upon the earliest of:
(a) The date the Participant ceases to be an Eligible Employee;
(b) The date the Participant fails to meet any continuing eligibility requirement;
(c) The date the Plan is terminated; or
(d) The date of the Participant's death.
Subject to the terms and conditions of this Plan, the Employer shall reimburse each Participant for Eligible Medical Expenses incurred by the Participant or the Participant's Dependents during the Plan Year, up to the Maximum Annual Benefit amount.
The maximum amount that may be reimbursed to a Participant during any Plan Year shall be:
(a) Employee Only Coverage: [Amount] per Plan Year
(b) Employee + Family Coverage: [Amount] per Plan Year
The Employer reserves the right to modify these amounts for future Plan Years upon written notice to Participants.
Unless otherwise specified by the Employer, unused benefit amounts shall NOT be carried over to subsequent Plan Years. Any unused amounts at the end of the Plan Year shall be forfeited.
Benefits under this Plan are secondary to any other health insurance or health plan covering the Participant or Dependent. Reimbursement shall only be made for expenses that have not been reimbursed by any other source and that are not reimbursable under any other health plan or insurance.
To receive reimbursement, a Participant must submit a written claim to the Plan Administrator that includes:
(a) A completed claim form (see Exhibit B);
(b) Documentation of the expense, including receipts, invoices, or Explanation of Benefits (EOB) statements;
(c) A statement that the expense has not been reimbursed and is not reimbursable from any other source; and
(d) Such other information as the Plan Administrator may reasonably require.
Claims for reimbursement must be submitted within 90 days after the end of the Plan Year in which the expense was incurred. Claims submitted after this deadline may be denied at the discretion of the Plan Administrator.
The Plan Administrator shall review and process claims within a reasonable time, generally not to exceed 30 days from receipt of a complete claim. If additional information is required, the Plan Administrator shall notify the Participant within 15 days of receipt of the claim.
Approved reimbursements shall be paid to the Participant by check or direct deposit within 30 days of claim approval. Reimbursements shall be paid from the general assets of the Employer.
If a claim is denied in whole or in part, the Plan Administrator shall provide written notice to the Participant stating the specific reason for the denial and referencing the Plan provision upon which the denial is based. The Participant may appeal any denial by submitting a written request for review within 60 days of receiving the denial notice.
The Employer shall serve as the Plan Administrator, or may designate another person or entity to serve in this capacity. The Plan Administrator shall have full authority and discretion to interpret the Plan, determine eligibility, and decide all questions arising under the Plan.
The Plan Administrator shall maintain records of all claims, payments, and relevant Plan information for at least seven (7) years. The Plan Administrator shall provide such reports as may be required by applicable law.
All claims for reimbursement must be substantiated with appropriate documentation as required by Internal Revenue Code Section 105(b) and applicable Treasury Regulations. The Plan Administrator shall not approve any claim that is not properly substantiated.
The Employer reserves the right to amend this Plan at any time by written instrument. Any amendment shall be prospective only and shall not affect the right of Participants to reimbursement for expenses incurred prior to the effective date of the amendment.
The Employer reserves the right to terminate this Plan at any time. Upon termination, Participants shall be entitled to reimbursement for eligible expenses incurred prior to the termination date, subject to the claims deadline in Section 5.2.
Benefits under this Plan may not be assigned, transferred, pledged, or encumbered by any Participant or beneficiary.
Nothing in this Plan shall be construed to create any right to continued employment or to limit the right of the Employer to terminate the employment of any employee at any time.
The Plan shall comply with all applicable requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), including privacy and security requirements. Protected health information obtained by the Plan shall be used and disclosed only as permitted by HIPAA and applicable state law.
This Plan shall be construed and governed in accordance with applicable federal law and, to the extent not preempted by federal law, the laws of the state in which the Employer is located.
If any provision of this Plan is held invalid or unenforceable, such invalidity or unenforceability shall not affect any other provisions, and this Plan shall be construed as if such invalid or unenforceable provision had never been contained herein.
IN WITNESS WHEREOF, the Employer has caused this Plan to be executed by its duly authorized representative as of the date indicated below.
EMPLOYER
[Employer Name]
PARTICIPANT ACKNOWLEDGMENT
I acknowledge receipt of this Plan Document and the Summary Plan Description.
SUMMARY PLAN DESCRIPTION
Health Reimbursement Arrangement
📄 What is This Document?
This Summary Plan Description (SPD) provides a plain-language summary of your Health Reimbursement Arrangement benefits. If there is any conflict between this SPD and the formal Plan Document, the Plan Document will govern.
| Plan Name | [Plan Name] |
| Plan Sponsor / Employer | [Employer Name] |
| Employer EIN | [EIN] |
| Employer Address | [Address] |
| Employer Phone | [Phone] |
| Plan Administrator | [Administrator Name] |
| Plan Effective Date | [Effective Date] |
| Plan Year | [Plan Year] |
| Type of Plan | Health Reimbursement Arrangement (HRA) under IRC §105 |
You are eligible to participate in this Plan if you are:
- An employee of [Employer Name]
- Receiving W-2 wages for services performed
- Have completed any applicable waiting period
Your eligible dependents include:
- Your spouse
- Your children under age 27
- Other dependents as defined under IRC §152
The Plan reimburses you for eligible medical expenses that you or your dependents incur during the Plan Year. The maximum amount available for reimbursement is:
| Employee Only Coverage | [Amount] per year |
| Employee + Family Coverage | [Amount] per year |
💡 Tax-Free Benefits
Reimbursements you receive under this Plan are generally tax-free. They are not included in your taxable income and are not subject to federal income tax, Social Security tax, or Medicare tax.
The Plan covers "eligible medical expenses" as defined under Internal Revenue Code Section 213(d). Common examples include:
- Health insurance premiums
- Doctor and specialist visits
- Hospital charges
- Prescription medications
- Dental care
- Vision care (exams, glasses, contacts)
- Mental health services
- Chiropractic care
- Physical therapy
- Medical equipment
- Lab tests and X-rays
- Hearing aids
See the attached Eligible Expenses List (Exhibit A) for a complete list of covered expenses.
⚠️ Not Covered
Expenses that are NOT eligible for reimbursement include:
- Cosmetic procedures (unless medically necessary)
- Expenses reimbursed by insurance or another plan
- Non-prescription items (with some exceptions)
- General health items (gym memberships, vitamins without prescription)
Pay for medical expenses for yourself or your eligible dependents. Keep all receipts, invoices, and Explanation of Benefits (EOB) statements.
Fill out the HRA Claim Form (see Exhibit B) with details about the expense, including the date, description, provider, and amount.
Submit the completed claim form along with supporting documentation to the Plan Administrator. Required documentation includes:
- Itemized receipt or invoice showing the date, description, and amount
- Explanation of Benefits (EOB) if you have other insurance
- Your certification that the expense has not been reimbursed elsewhere
Once your claim is approved, you will receive reimbursement within 30 days by check or direct deposit.
📅 Claim Deadline
Claims must be submitted within 90 days after the end of the Plan Year in which the expense was incurred.
Unless otherwise specified, unused benefits at the end of the Plan Year do not carry over to the next year. Any unused amount is forfeited. Plan your healthcare expenses accordingly to maximize your benefit.
Your coverage under this Plan ends when:
- Your employment terminates
- You no longer meet the eligibility requirements
- The Plan is terminated by the Employer
You may still submit claims for expenses incurred before your coverage ended, subject to the claim deadline.
As a Participant in this Plan, you have the right to:
- Receive this Summary Plan Description
- Examine the Plan Document and related records
- Receive an explanation of any denied claim
- Appeal any denied claim within 60 days
- Privacy of your protected health information under HIPAA
If you have questions about the Plan, contact the Plan Administrator:
[Administrator Name]
[Employer Name]
[Address]
[Phone]
PARTICIPANT ACKNOWLEDGMENT
I acknowledge that I have received and read this Summary Plan Description.
EXHIBIT A
Eligible Medical Expenses
The following is a list of expenses that are generally eligible for reimbursement under this Health Reimbursement Arrangement. This list is based on IRS Publication 502 and IRC Section 213(d). The Plan Administrator has final authority to determine whether any expense qualifies for reimbursement.
✓ Customization
Check the boxes next to expenses that are covered under YOUR plan. Unchecked items are not eligible for reimbursement.
| ✓ | Expense Type | Notes |
|---|---|---|
| Doctor visits (primary care, specialists) | Includes copays and deductibles | |
| Hospital services | Inpatient and outpatient | |
| Emergency room services | ||
| Urgent care visits | ||
| Laboratory fees and tests | Blood work, diagnostic tests | |
| X-rays and imaging | MRI, CT scan, ultrasound | |
| Surgery and surgical fees | ||
| Ambulance services |
| ✓ | Expense Type | Notes |
|---|---|---|
| Prescription drugs | Requires valid prescription | |
| Insulin | No prescription required | |
| Over-the-counter medications | With prescription (post-CARES Act: without) | |
| Menstrual care products | No prescription required (post-CARES Act) |
| ✓ | Expense Type | Notes |
|---|---|---|
| Dental exams and cleanings | ||
| Fillings and extractions | ||
| Crowns, bridges, dentures | ||
| Root canals | ||
| Orthodontia (braces) | ||
| Dental X-rays | ||
| Teeth whitening | Generally NOT eligible (cosmetic) |
| ✓ | Expense Type | Notes |
|---|---|---|
| Eye exams | ||
| Prescription eyeglasses | Includes frames and lenses | |
| Contact lenses and supplies | ||
| LASIK and vision correction surgery | ||
| Reading glasses | Prescription not required |
| ✓ | Expense Type | Notes |
|---|---|---|
| Psychiatrist visits | ||
| Psychologist/therapist visits | Must be licensed provider | |
| Substance abuse treatment | Inpatient or outpatient | |
| Smoking cessation programs |
| ✓ | Expense Type | Notes |
|---|---|---|
| Physical therapy | ||
| Occupational therapy | ||
| Speech therapy | ||
| Chiropractic care | ||
| Acupuncture | For medical treatment |
| ✓ | Expense Type | Notes |
|---|---|---|
| Blood pressure monitors | ||
| Glucose monitors and supplies | For diabetes management | |
| Hearing aids and batteries | ||
| Crutches, wheelchairs, walkers | ||
| CPAP machine and supplies | For sleep apnea | |
| First aid supplies | Bandages, antiseptics |
| ✓ | Expense Type | Notes |
|---|---|---|
| Health insurance premiums | Not pre-tax payroll | |
| Dental insurance premiums | ||
| Vision insurance premiums | ||
| Medicare premiums (Parts B and D) | ||
| Long-term care insurance premiums | Subject to age limits | |
| COBRA premiums |
The following expenses are NOT eligible:
- Cosmetic surgery or procedures (unless medically necessary)
- Expenses reimbursed by insurance or any other source
- Gym memberships or health club dues (without medical necessity letter)
- Nutritional supplements and vitamins (without prescription)
- Personal care items (toothpaste, deodorant, etc.)
- Household help or childcare
- Funeral expenses
- Maternity clothes
EXHIBIT B
HRA Reimbursement Claim Form
📝 Instructions
- Complete all sections of this form
- Attach itemized receipts or EOB statements for each expense
- Submit to the Plan Administrator within 90 days after the end of the Plan Year
- Keep copies of all submitted documentation for your records
List each expense for which you are requesting reimbursement:
| Date of Service | Description of Expense | Provider Name | Patient Name | Amount |
|---|---|---|---|---|
| TOTAL REQUESTED: | ||||
Please attach the following documentation for EACH expense listed above:
- ☐ Itemized receipt or invoice showing date, description, and amount
- ☐ Explanation of Benefits (EOB) if you have other health insurance
- ☐ Prescription (if required for the expense type)
⚠️ Important
Credit card statements and cancelled checks are NOT acceptable documentation. You must provide itemized receipts or EOB statements.
By signing below, I certify that:
- All expenses listed above were incurred by me or my eligible dependents for medical care as defined under IRC §213(d);
- None of these expenses have been reimbursed from any other source, nor will I seek reimbursement from any other source;
- These expenses are not being claimed as a deduction on my personal income tax return;
- I have attached proper documentation to support each expense claimed;
- I understand that providing false information may result in termination from the Plan and may be considered tax fraud.
PARTICIPANT SIGNATURE
FOR ADMINISTRATOR USE ONLY
[Administrator Name]
[Employer Name]
[Address]
[Phone]