Wageworks Retiree Form PDF Details

The Wageworks Retiree Health Reimbursement Arrangement (HRA) represents a critical component of a retiree's health expense management, offering a systematic way to seek reimbursement for various health-related expenses. These range from out-of-pocket costs for medical, dental, vision, and prescription expenses to premiums for Medicare parts B, C, and D not deducted from Social Security checks. The Pay Me Back Claim Form, available both in a downloadable format and for electronic submission on the Wageworks platform, simplifies the reimbursement process, with sections dedicated to capturing structured information about the claimant and the specific expenses incurred. Crucially, the form underscores the necessity of attaching appropriate documentation, such as proof of service and payment, underlining the rigorous verification procedures enacted by Wageworks to ensure compliance with IRS requirements. Additionally, while permitting claims for a copious list of eligible expenses, it also delineates ineligible expenses, guiding retirees in the discernment of valid claims. Moreover, guidelines embedded in the form provide clear instructions on how to properly compile and submit claims, laying emphasis on the need for legibility, accurate and complete information, and the importance of attaching necessary documentation to expedite processing and avoid resubmission. This form, combined with a comprehensive list of eligible expenses on the Wageworks website, not only facilitates the reimbursement process but also helps retirees effectively manage their healthcare finances post-retirement.

QuestionAnswer
Form NameWageworks Retiree Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesretiree pay me back claim form, wageworks hra retiree, wageworks retiree reimbursement claim form, wageworks hra form

Form Preview Example

Health Reimbursement Arrangement (HRA)

www.wageworks.com

RETIREE Pay Me Back Claim Form

**An electronic claim may be submitted at www.wageworks.com.**

TOLL-FREE FAX: (877) 353-9236

Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512

DO NOT USE A FAX COVER SHEET

to ensure speedy processing.

ACCOUNT HOLDER INFORMATION

Last Name

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retiree SSN* (last 4 digits)

Retiree Birth Date

Employer Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM/DD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/Survivor SSN* (last 4 digits) (if applicable)

Email Address (complete only if new)

 

 

 

 

 

 

CERTIFICATION AND AUTHORIZATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Account Holder X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible expenses incurred by myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already received these products and services and I have not/will not seek reimbursement of this expense from any other plan or party because I: 1) am required to pay for the premiums through withholding, 2) have paid for the premiums, 3) have already received these products and services. If I am covered under more than one health care account, reimbursement will be made according to the payment order determined by those plans and as stated on the WageWorks Web site. Use of this service indicates my acceptance of the WageWorks User Agreement at www.wageworks.com (available upon registration; enter user name and password or click on First Time User).

CLAIMS FOR OUT-OF-POCKET EXPENSES

1.One Time Annual Request for Social Security Administration (SSA) Deducted Premiums (Medicare Part B, Medicare Part C – Medicare Advantage, Medicare Part D – Prescriptions)

Relationship to Account Holder

Self

Spouse Dependent

Patient’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Start Date

 

Service End Date

 

 

 

 

 

 

Annual Out-of-Pocket

 

 

(MM/DD/YY)

 

 

 

(MM/DD/YY)

 

 

 

 

 

Cost

2. Health Plan Premiums Not Deducted from Your Social Security Check

Relationship to Account Holder

Self

Spouse Dependent

Patient’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Start Date

 

Service End Date

 

 

 

 

 

 

 

 

Out-of-Pocket Cost

 

 

(MM/DD/YY)

 

 

 

(MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

3.Other Expenses Medical Dental Vision Prescriptions Over-the-counter

Relationship to

 

 

 

 

 

 

 

 

 

 

 

$

Account Holder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

 

Service Date

Total Out-of-Pocket Cost

Spouse

Dependent

(MM/DD/YY)

 

 

Patient’s Name

 

 

 

 

 

 

 

 

 

 

 

*The last 4 digits of the Social Security Number (SSN) is needed to assist us in identifying your account and to process your claim.

YOU MUST ATTACH A COPY OF APPROPRIATE PROOF OF SERVICE AND PAYMENT FOR EACH AMOUNT ABOVE.

$

TOTAL THIS FORM

WW-HRA-RT-PMB (Nov 2010)

HEALTH REIMBURSEMENT ARRANGEMENT ‐ ELIGIBLE EXPENSES*

*For a comprehensive list, go to https://www.wageworks.com/employee/health-care/expenses/hra.htm

Services by an M.D. or Licensed Practitioner when medically

necessary, including:

 

• Acupressurist

• Optometrist

• Acupuncturist

• Osteopath

• Anesthesiologist

• Podiatrist

• Chiropractor

• Psychiatrist/Psychologist

• Christian Science Practitioner

• Psychotherapist

• Dermatologist

• Surgeon

• Ophthalmologist

 

Medical/Hospital services or other fees:

Diagnostic services by or under direction of M.D.

Surgical services by or under direction of M.D.

X-rays and radiological services for diagnosis or treatment

Expenses for donating or receiving an organ transplant

Nursing services for specific medical ailments by an RN or LPN who is not related to employees

Services of a physical, speech or an occupational therapist

Ambulance

Laboratory fees

Prescription drugs: including insulin, laetrile and birth control pills

Vitamins and dietary supplements.** Only a quantity of six may be purchased at a time.

Vaccinations and immunizations

Orthotics

Transportation and lodging expenses incurred for medical reasons

Legal fees paid to authorize treatment for mental illness

Deductibles and copayments

Other health-related expenses

Treatment of alcoholism or drug dependency, including expenses for meals and lodging at a treatment center

Lead-based paint removal in the home

Smoking cessation programs and related drugs

Employee plus dependent Medical, Dental, Vision, Rx, Medicare, COBRA or other healthcare insurance premiums.

Dental, vision & hearing

Dental checkups and care (by a DDS or dental hygienist), including dentists’ fees, X-rays, fillings, braces, extractions and dentures

Orthodontics (usually pro-rated cost attributable to this plan year)

Cost of guide dog for blind or deaf

Braille books and magazines (in excess of regular book cost)

LASIK, Laser, RK surgery or PRK surgery, prescription eyeglasses and contact lenses (including solutions)

Special devices for the blind (tape recorder, typewriter)

Hearing aids and care (including batteries)

Cost of note-taker for a deaf person in school

Household visual alert & expenses for special phone equipment for a deaf person

Adapting a television for the deaf

Maintenance & support devices (these require a letter of medical necessity from a licensed physician)

Support hose and orthopedic shoes (in excess of regular shoe cost)

Wheelchairs, crutches and wigs for hair loss due to medical treatment

Oxygen and oxygen equipment

Cost of equipping an auto for the disabled (in excess of regular auto cost)

Prostheses and prosthetic supplies

Colostomy supplies

Capital expenses - the amounts between the cost of improvements or special equipment installed and the increase in the value of the home

Psychiatric care - may include costs of supporting mentally ill dependents at a specially equipped center where a dependent receives medical care

Massage therapy

* If used for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body

**If specifically directed by a licensed practitioner of the healing arts, a written directive is needed

INELIGIBLE EXPENSES (HEALTH CARE)

NEW for 2011 > Over-the-counter (OTC ) drug or medicine

Weight reduction programs for general well-being

 

(unless prescribed by doctor)

Teeth bleaching or whitening

Athletic or health club membership

Marriage counseling

Cosmetic procedures and/or surgeries

Toiletries and sundry items (such as toothpaste, shaving

Household help

 

cream, deodorant, shampoo, makeup

Any illegal treatment

Electric toothbrushes

Prepayment for services

Sunscreen under SPF 3

Cost of remedial reading classes for a non-handicapped

Insect repellent

 

child

 

 

Dancing or ballet, even when recommended by a doctor

 

 

INSTRUCTIONS

(Do NOT FAX these instructions with your1 Claim)

PLEASE READ THIS BEFORE SUBMITTING YOUR RETIREE CLAIM FORM

The IRS requires you to substantiate all your claims with appropriate level of documentation in order to be reimbursed. Documentation in total must show that an eligible health care expense has been incurred by you or your eligible dependent. The documentation must show at a minimum

a)the date of coverage or expense

b)the individual covered by health coverage or the individual that incurred the expense

c)name of the provider, merchant, or insurance carrier

d)type of expense (insurance, or other eligible expense, such as medical service, prescription, over the counter medication, etc)

You will also be required to provide additional documentation for private health care premiums to show evidence of payment such as copy of the front and back of a cleared check along with the provider’s invoice or bill.

Tips for Completing the HRA Retiree Pay Me Back Claim Form

Print, or write legibly.

Complete a separate form for your Dependent or Spouse.

Make sure you sign the form. If a person holding a Power of Attorney for the Retiree is signing, please make sure he or she signs the form in the following format “John Smith, Attorney in Fact for Jane Smith” [Make sure the Power of Attorney is either on file or submitted with the first claim.]

The account holder Name section should be completed with the Retiree’s First and Last Name UNLESS you are a surviving spouse of a Retiree. In that case, the surviving spouse should complete his or her name in the name field.

If you have a spouse, put the last four digits of your spouse’s Social Security Number (SSN) on the claim form to better expedite the claim.

Keep your original receipts. Submit copies of your receipts with your claim form. If your claim is incomplete, you will be required to resubmit the claim form and receipts. Send legible copies of your receipts.

1[As used on this form, “you,” “your” or “yours” refer to the Retiree.]

WW-HRA-RT-PMB-INST (Jun 2008)

Page 1

HRA Retiree Pay Me Back Claim Form Instructions

Section 1 – One Time Annual Request for Social Security Administration (SSA) Deduct Premiums (Medicare Part B, Medicare Part C – Medicare Advantage, Medicare Part D – Prescriptions)

Complete this section if you are requesting reimbursement for a premium that is deducted from your Social Security Check.

In the “Service Start Date” boxes, enter the first of the month in which you are eligible for Medicare Part B, C or D for this year. In the “Service End Date” boxes, enter the last day of the year. (If eligible for Medicare Part B, C or D on January 1, this will be January 1 to December 31.)

Enter the annual amount of your Medicare Part B, C or D expense (the monthly amount multiplied by the number of months of coverage.)

Include a copy of your Social Security “Cost of Living Statement” as proof of your expense (typically mailed starting in November the year before it becomes effective) or any other Medicare statement that clearly indicates your Medicare B, C or D premiums. If the cost is not deducted from your Social Security Check, please fill out Section 2 (Health Care Premiums Not Deducted from Your Social Security Check) on the claim form in order to be reimbursed.

You will be reimbursed on a pro-rated monthly basis based on your annual premiums. The amount of your monthly reimbursement will not exceed the current balance in your account.

Section 2 – Health Care Premiums Not Deducted from Your Social Security Check

Complete this section if you are requesting a lump sum reimbursement for Health Care premiums that:

-were not deducted from your Social Security Check, and

-you have paid to your health plan on an after-tax basis.

Make sure to provide documentation such as a statement from your insurance carrier, or a copy of the front and back of a cleared check that shows the premiums you have paid.

The Service Start and End Dates should represent the period of coverage you have paid for and are seeking reimbursement for. These dates should match the statement from your health plan indicating the coverage period you have paid for.

Keep your original receipts and make copies to fax or mail to WageWorks.

Note: Pre-tax deductions for premiums from your payroll or your pension plan are not eligible for reimbursement.

WW-HRA-RT-PMB-INST (Jun 2008)

Page 2

HRA Retiree Pay Me Back Claim Form Instructions

Section 3 – Other Expenses

If you are requesting reimbursement for other out-of-pocket expenses that you have paid for such as co-pays, dental services, eligible over-the-counter items or other eligible expenses, please complete this section.

Acceptable forms of documentation to show the item was an eligible expense include a receipt or an explanation of benefits from your health plan.

Documentation should show the date of service, amount of the expense, and a description of the expense.

When completing the claim form indicate who the expense was for.

You may add up more than one receipt or expenses incurred for several small eligible expenses and enter that amount on the claim form. When submitting several receipts or pieces of documentation please circle the expense amounts, date of service and description on each receipt or supporting documentation. Print the earliest service start date on the claim form if requesting reimbursement for several expenses. You will also need to indicate on the claim form who the expenses were for. (Dependent)

WW-HRA-RT-PMB-INST (Jun 2008)

Page 3

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hra retiree claim form writing process shown (part 1)

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Service Start Date, Self Spouse, and CLAIMS FOR OUTOFPOCKET EXPENSES in hra retiree claim form

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