Fillable Form 2.: Capital Expense Worksheet (Cigna Medicare Providers)

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Form 2.: Capital Expense Worksheet (Cigna Medicare Providers)

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963673 Rev. 04/2021
FOR INTERNAL USE ONLY:
CORR TYPE - DC
Capital Expense Worksheet
Pay yourself back for medically necessary special equipment
You may be able to use funds from your health savings account (HSA), flexible spending account (FSA), or
health reimbursement account (HRA) to pay for certain special equipment you put in in your home. The main
purpose of the equipment must be to help with medical care for you, your spouse, or your dependent(s). This
means the equipment must be medically necessary. Examples of special equipment include elevators, chair
lifts, ramps, and hot tubs.
When you put in special equipment for health reasons, it may raise the property value of your home.
To determine whether you can use HSA, FSA, or HRA funds to pay for the equipment, you’ll need to keep detailed receipts of
what you spend. The IRS has strict rules about using money from these accounts to pay for these items.
You’ll also need to know whether the value of your property increases because of the equipment you add. To find this out,
you’ll need to get an official appraisal of your home.
How much can you spend from your HSA, FSA, or HRA?
If the value of your home increases, you’ll need to subtract that amount from what you paid for the equipment. Any balance left
over is then an eligible medical expense that you can pay for with your account funds.
If the value of your home does not increase, the entire cost of the home improvement is an eligible medical expense. The
amount of money you can use from your account to pay for the equipment is then the cost of the expense divided by the
number of people living in the home.
EQUIPMENT INSTALLATION – WHAT TO THINK ABOUT
1.
2.
.
.
1 Enter the amount you paid for the elevator (use your receipts) $10,000.00
Let’s say you have a heart condition. Your doctor suggests adding an elevator in your home so you don’t have to climb stairs. The
elevator costs $10,000. A professional appraisal shows the elevator raises the value of your home by $5,000. There are three other
people living in your home who have no medical conditions, but who also may use the elevator. Here’s how you might calculate
your eligible medical expense:
WORKSHEET EXAMPLE – SAMPLE SCENARIO
2 Enter the value of your home immediately after the improvement* $155,000.00
3 Enter the value of your home immediately before the improvement* $150,000.00
5
Subtract line 4 from line 1.
$5,000.00
6
Divide line 5 by the number of people living in your home. The total is what you may submit on a claim as a
total medical expense ($5,000/4 people).
$1,250.00
4
Subtract line 3 from line 2. This is the increase in the value of your home.
If line 4 is more than, or equal to, line 1, the cost of the home improvement is not an eligible expense.
Stop here.
If line 4 is less than or equal to line 1, go to line 5.
$5,000.00
.
.
*A professional appraisal must beused todeterminethe beforeandaftervalue ofyour home. The cost of the appraisal is not an eligible medical expense.
1 Enter the amount you paid for the special equipment (use your receipts)
YOUR WORKSHEET
2 Enter the value of your home immediately after the improvement*
3 Enter the value of your home immediately before the improvement*
5
Subtract line 4 from line 1.
6
Divide line 5 by the number of people living in your home. The total is what you may submit on a claim as a
total medical expense.
4
Subtract line 3 from line 2. This is the increase in the value of your home.
If line 4 is more than, or equal to, line 1, the cost of the home improvement is not an eligible expense.
Stop here.
If line 4 is less than or equal to line 1, go to line 5.
.
.
*A professional appraisal must beused todeterminethe beforeandaftervalue ofyour home. The cost of the appraisal is not an eligible medical expense.
You may also use funds from your HSA, FSA, or HRA to pay for the operation and maintenance of any special equipment.
You must be using the equipment for a medically necessary reason. You may use your account funds for operation costs
even if you weren’t able to use the funds to pay for the installation of the equipment itself.
For example, the cost of the electricity and maintenance required to operate an elevator are eligible medical expenses as long
as you us e the elevator for a valid medical reason.
Keep receipts for what you spend. We will need to see these receipts if you submit a claim.
The receipts should document what you spend separately from your general household utility or other payments.
OPERATION AND UPKEEP OF EQUIPMENT
.
.
.
Capital Expense Worksheet
PRINT THIS PAGE
If you’d like to submit a claim to use your health care spending account to pay for the installation or operating costs of
special equipment, complete the following steps.
Complete a Health Care Reimbursement Request Form and include receipts for what you spent. Search and download the
form on the Cigna.com website www.Cigna.com. If we approve your claim, you can pay yourself back using funds from your
spending account.
Include a Letter of Medical Necessity from your doctor or other health care provider. The letter should explain why you need
the special equipment and the medical condition you have.
Complete and send us the Worksheet above filled in with your calculations.
Get a professional appraisal from a third party that shows the value of your home before and after you install the equipment.
The cost of the appraisal is not an eligible medical expense.
TO SEND IN A CLAIM
1.
2.
3.
4.
For questions, call us toll-free at 1.800.Cigna24 (1.800.244.6224) or use the number on your Cigna ID card.
FAX OR MAIL YOUR REIMBURSEMENT REQUEST FORM AND OTHER DOCUMENTS TO:
Fax: 1.877.823.8953 or 859.410.2432
Cigna, P.O. Box 182223, Chattanooga, TN 37422-7223, Attention: Claims Department
963673 Rev. 04/2021
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation.
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Form 2.: Capital Expense Worksheet (Cigna Medicare Providers)

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Completed 26 July 2021

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