HSA/FSA

Download PDF — HSA Quick Reference Guide

Using HSA Funds for Your RH Band

Quick Reference Guide to eligibility, documentation, and recordkeeping

Your RH Band may qualify for tax-free HSA payment or reimbursement when it is purchased primarily to help diagnose, treat, mitigate, or prevent a specific medical condition. It is not automatically eligible when purchased only for general fitness, wellness, or weight-management goals.

When might the purchase qualify?

IRS rules focus on why you purchased the product. A wellness or weight-management expense may qualify when it is part of care for a specific condition diagnosed by a medical professional, such as obesity, hypertension, heart disease, or another qualifying condition. Eligibility depends on your individual facts and applicable plan rules.

A Letter of Medical Necessity can help

If you plan to use HSA funds, consider asking your physician or other licensed healthcare provider for a Letter of Medical Necessity. The letter should identify your diagnosed medical condition and explain how using the RH Band supports your treatment plan. For your convenience, we have provided a form that your healthcare provider may complete. Your provider is not required to use our form and may instead provide a letter in their own format. A Letter of Medical Necessity can help document the medical purpose of your purchase, but it does not guarantee HSA eligibility or reimbursement.

What to keep

  • Keep your completed Letter of Medical Necessity. Keep it with your personal tax and HSA records. You do not need to send it to us.
  • Keep your receipt and product information. Retain proof of the amount paid and the date of purchase.
  • Keep any other records requested by your HSA administrator. Requirements can vary, so check with your administrator if you have questions before purchasing.

Why documentation matters

You are responsible for determining whether an HSA distribution is used for a qualified medical expense and for keeping supporting records. If an HSA distribution is later determined not to qualify, the amount generally must be included in taxable income and may also be subject to an additional 20% tax. For example, a nonqualified $200 distribution could result in a $40 additional tax, plus ordinary income tax, unless an exception applies. While audits of HSA accounts are reportedly rare, it is better to be prepared than to pay an unnecessary tax penalty.

We do not provide tax, accounting, or medical advice and cannot determine whether your purchase qualifies. Tax rules and HSA plan practices can change. Please consult your HSA administrator, tax adviser, or healthcare provider about your circumstances.

Learn more: IRS Publication 969 (Health Savings Accounts) and IRS Publication 502 (Medical and Dental Expenses), available at IRS.gov.

Letter of Medical Necessity

RH Band — optional provider form

This optional form may be completed by the patient's physician or other licensed healthcare provider. The provider may instead supply a letter containing substantially similar information.

Patient information

Patient name: _______________________________

Date of birth: _______________________________

Date of recommendation: _____________________

Medical determination

I am a licensed healthcare provider treating the patient identified above. The patient has been diagnosed with the following medical condition or conditions:

 

As part of the patient's treatment plan, I recommend the patient's use of:

  • ☐ RH Band and associated program

The recommended product will assist the patient in monitoring activity and available biometric or wellness data, supporting adherence, and tracking progress in connection with the diagnosed condition or conditions. In my professional judgment, the product is being recommended primarily to support the diagnosis, treatment, mitigation, or prevention of the condition or conditions identified above, and not merely to promote general health, fitness, or well-being.

Please briefly explain how the product relates to the patient's diagnosed condition and treatment plan:

 

 

Recommended period of use

  • ☐ ______ months
  • ☐ ______ years
  • ☐ Ongoing, subject to medical review

Healthcare provider certification

I certify that the information provided above is accurate to the best of my professional knowledge and reflects my medical judgment. This recommendation is not a determination of federal tax eligibility or a guarantee of payment or reimbursement by an HSA, health plan, or account administrator.

Provider name and credentials: _______________

Practice name: _____________________________

Address: __________________________________

Phone: ____________________________________

Provider signature: _________________________

Date: _____________________________________

Patient note: Keep the completed form with your receipt and other personal tax and HSA records. You do not need to send it to Reverse Health.