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Evaluate the arrangement—not just its label. Confirm that it reimburses only eligible, incurred medical-care expenses; that every claim is substantiated; that Section 105(h) nondiscrimination rules are addressed when applicable; and that the HRA or other design satisfies its own coverage, notice, ACA, and reporting requirements. Section 105(b) is a federal tax-exclusion rule, not a complete plan design or a guarantee that an employer reimbursement program is lawful.
What Section 105(b) actually does
Section 105(b) can exclude from an employee’s gross income amounts paid by an employer to reimburse medical-care expenses. The medical-care definition comes from Section 213(d), subject to the statutory conditions. In practical terms, the employee must incur an expense that qualifies as medical care, and the plan must reimburse that expense under its written terms.
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The provision does not create a universal “Section 105(b) plan.” Employers may use the tax rule within several different arrangements, including health reimbursement arrangements (HRAs), self-insured medical reimbursement plans, or other account-based designs. Each design has separate eligibility, coverage, notice, nondiscrimination, and Affordable Care Act (ACA) requirements.
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A payment that an employee can keep regardless of whether a medical expense was incurred is generally not transformed into tax-free medical reimbursement merely because payroll or plan documents call it a health benefit. The plan must limit payments to eligible care and connect each payment to an actual expense.
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The Internal Revenue Service has stated that claims must be substantiated so the employer can establish both the nature of the care and the amount incurred. A written list of approved items cannot make a nonmedical purchase eligible, and a broad wellness or cash stipend should not be assumed to qualify.
First identify what arrangement the employer offers
Ask for the plan document, summary materials, claim procedures, and payroll description. “HRA” can refer to materially different arrangements. The correct compliance analysis depends on the arrangement’s coverage structure, eligible employees, reimbursable expenses, and relationship to other employer coverage.
| Arrangement | Coverage structure | Important conditions to verify | Primary evaluation risk |
|---|---|---|---|
| HRA integrated with employer group coverage | Employer group health plan, with the HRA coordinated under applicable integration rules | Eligibility, coordination with the group plan, claim substantiation, and ACA market-reform compliance | Assuming the HRA can stand alone or reimburse expenses in a way the integration rules do not permit |
| Individual coverage HRA (ICHRA) | Individual health insurance coverage or Medicare, rather than a traditional employer group plan for the covered class | Initial and ongoing proof of required individual coverage or Medicare, participant notices, class rules, and premium-tax-credit consequences | Reimbursing a month without verifying required coverage or giving the required notice |
| Excepted benefit HRA | A limited HRA that operates alongside other coverage and is restricted to the regulatory excepted-benefit framework | Limited benefit scope, annual amount rules, eligibility, and interaction with other employer coverage | Treating it like a full medical HRA and reimbursing expenses outside its permitted scope |
| Qualified small employer HRA (QSEHRA) | Employer-funded reimbursement for eligible medical expenses, generally for an eligible small employer that does not offer a group health plan | Employer-size and group-plan conditions, proof of coverage, statutory employee-class rules, notices, and annual limits | Offering a QSEHRA while maintaining disqualifying group coverage or overlooking current statutory limits |
| Stand-alone employer payment plan | Employer payment or reimbursement of individual-policy premiums outside an expressly permitted HRA design | ACA market-reform analysis and whether the arrangement is actually an ICHRA or another authorized design | Assuming a premium reimbursement is integrated with individual policies simply because it is called an HRA |
| Other self-insured reimbursement plan | Employer-funded reimbursement of specified medical expenses under a self-insured plan | Section 105(b) substantiation, Section 105(h) nondiscrimination, plan terms, ERISA and state-law review | Applying a generic HRA checklist to a different plan category |
Federal IRS materials describe final rules under which specified HRAs and account-based plans can integrate with individual coverage or Medicare when detailed conditions are met. They also describe the narrower excepted-benefit HRA category. A QSEHRA generally requires an eligible employer not to offer a group health plan and requires proof of coverage before reimbursement. Verify the current rules rather than relying on historical summaries.
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Use the Section 213(d) definition and the written plan
Build an expense matrix that maps every reimbursable category to Section 213(d) and to the plan document. Depending on the design, the plan might cover individual-policy premiums, other insurance premiums, deductibles, copayments, prescription drugs, or other qualified medical expenses. A plan may choose to reimburse fewer categories than the statute permits, but it cannot make a nonmedical expense qualify by listing it.
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Review exclusions as carefully as inclusions. Ask whether the plan excludes cosmetic services, general health items, ordinary personal expenses, or costs paid by another source. Check whether the same expense can be reimbursed under a spouse’s plan, a flexible spending arrangement, or another employer benefit; duplicate tax-free reimbursement is not allowed.
Separate premiums from broader medical expenses
Premium-only arrangements can receive different treatment from plans that reimburse a broader range of medical expenses, particularly for Section 105(h) analysis. Do not infer that rules for a premium reimbursement arrangement automatically apply to a plan paying claims for deductibles, services, and supplies.
Require an incurred expense
The employee must generally have incurred the expense before reimbursement. Advance cash, an unrestricted debit balance, or a payment available without evidence of an incurred expense can undermine the Section 105(b) exclusion. The plan’s timing rules should explain when an expense is incurred, when a claim may be submitted, and how unused amounts are handled.
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Test substantiation before money is paid
Substantiation is the operational core of a compliant reimbursement plan. The IRS has said: “Therefore, to ensure that a particular payment is a reimbursement of a medical expense, all claims for expense reimbursements must be substantiated.”
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Sampling a portion of claims is not enough when the remaining claims are paid without verification. IRS guidance describes procedures that validate each claim, including reliable electronic workflows that use transaction data together with appropriate review or receipts. The control must establish the item or service, the date it was incurred, the amount, and its eligibility under the plan.
Use a claim-level control checklist
- Identify the claimant and covered person. Confirm that the employee, spouse, or dependent is eligible under the written plan.
- Capture the service or item. Require an itemized receipt, explanation of benefits, invoice, or dependable electronic transaction record showing what was purchased.
- Verify the incurred date. Distinguish the date of service or purchase from the date a claim was submitted or paid.
- Verify the amount. Confirm the employee’s actual out-of-pocket cost and deduct any insurance payment, discount, refund, or prior reimbursement.
- Apply the plan’s expense rules. Check the Section 213(d) category, plan exclusions, annual limits, and any required medical-purpose documentation.
- Prevent duplicates. Match claim identifiers and amounts against prior reimbursements and other benefit accounts.
- Approve, deny, or request evidence. Record the decision and retain the supporting documentation under the plan’s retention policy.
Controls should operate before payment or within a narrowly defined correction process. A platform can organize documents and workflow, but software alone does not establish that the plan or its claims process complies with federal law.
Apply the additional ICHRA coverage check
For an ICHRA, medical-expense substantiation is only part of the process. The plan must also substantiate that the participant has the required individual health insurance coverage or Medicare for the month being reimbursed. IRS final-rule materials describe initial and ongoing substantiation; an expense cannot be reimbursed for a month in which the required coverage has not been verified. Build a monthly attestation or documentation process and stop or correct payments when coverage ends.
Analyze Section 105(h) nondiscrimination
Self-insured medical reimbursement plans may be subject to Section 105(h). The analysis has two broad parts: whether the plan benefits an appropriate classification of employees and whether the benefits provided to highly compensated individuals (HCIs) are discriminatory compared with benefits available to other participants.
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Review eligibility and benefits separately
Document the employee classes that may participate, waiting periods, service requirements, employment status rules, and any exclusions. Then compare the actual benefits: reimbursement percentages, deductibles, maximums, covered expenses, and access to richer options. A plan can have a facially neutral eligibility rule yet provide materially better benefits to HCIs.
If the applicable tests fail, excess reimbursements to HCIs can lose the Section 105(b) exclusion and become taxable to those individuals. That consequence is not the same as saying every employee must receive identical dollar amounts. The result depends on the plan category, statutory tests, regulations, and facts.
Do not import a rule from the wrong plan
Premium-only arrangements may be treated differently from plans reimbursing other medical expenses. Classify the plan first, then apply the relevant Section 105(h) rules. Have benefits counsel or a tax adviser test the plan at adoption and after changes in workforce composition, contribution levels, or covered expenses.
Screen ACA integration and employer-payment-plan risk
An employer that reimburses employees for individual-policy premiums through a stand-alone payment arrangement may be operating a group health plan subject to ACA market reforms. IRS guidance states that such a plan cannot be integrated with individual policies merely to satisfy those reforms. Calling the arrangement an “HRA” does not cure the problem.
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Compare the actual terms with the requirements for an ICHRA or another expressly permitted design. Examine whether the employer offers group coverage to the same employee class, whether employees must enroll in individual coverage, how affordability and premium-tax-credit rules affect participants, and whether the plan meets applicable nondiscrimination and notice requirements. The answer can differ by employee class, so analyze each class rather than the workforce as one group.
Check notices, reporting, and records
Plan documents and employee communications
The written plan should state eligibility, effective dates, reimbursable expenses, substantiation standards, claim deadlines, correction procedures, carryover or forfeiture rules, and coordination with other coverage. Employee materials should explain what participants must prove and when reimbursement can be denied.
ICHRA notices require specific information, including plan terms, the available amount, coverage requirements, and the possible effect on eligibility for premium tax credits. Confirm the current notice content and delivery timing against the governing rules and the actual plan.
Federal reporting
An HRA is generally self-insured group health-plan coverage and minimum essential coverage for reporting purposes. IRS employer reporting guidance describes exceptions when the same reporting entity also reports other minimum essential coverage. Determine which entity reports, which individuals and months are covered, and whether the HRA must appear on applicable Forms 1094-C, 1095-C, 1094-B, or 1095-B. Use the instructions for the relevant tax year; the 2025 Forms 1094-B and 1095-B instructions concern coverage in 2025 and filing in 2026.
Keep an auditable record
- The executed plan document and amendments.
- Employee-class and eligibility analyses.
- Claim evidence, approval decisions, and duplicate-payment checks.
- Coverage attestations or enrollment evidence for ICHRA or QSEHRA participants.
- Section 105(h) testing and corrective actions.
- Participant notices, delivery records, and annual reporting workpapers.
A practical employer evaluation sequence
- Inventory the promise. Collect the plan document, enrollment materials, payroll codes, vendor procedures, and any informal promises made to employees.
- Name the legal design. Decide whether the arrangement is an integrated HRA, ICHRA, excepted benefit HRA, QSEHRA, stand-alone employer payment plan, or another self-insured plan.
- Map the covered population. List employee classes, waiting periods, part-time and seasonal rules, related employers, and existing group coverage.
- Map expenses. For each category, document the Section 213(d) basis, plan authorization, required evidence, and coordination with other benefits.
- Test claims operations. Walk through several claim types from submission to payment, confirming that every claim—not merely a sample—is substantiated.
- Run nondiscrimination testing. Apply Section 105(h) eligibility and benefits tests where relevant, with special attention to HCI access and reimbursement levels.
- Perform the ACA screen. Identify any stand-alone premium reimbursement and verify that the chosen HRA design satisfies its integration and coverage conditions.
- Confirm notices and reporting. Calendar ICHRA, QSEHRA, and other required notices and identify the correct tax forms for each covered person and month.
- Document corrections. Establish how to recover an improper payment, amend a claim, correct payroll treatment, and notify affected participants.
- Schedule a recurring review. Revisit the arrangement when regulations, annual limits, workforce classes, carrier coverage, or reimbursement categories change.
How to compare alternative designs
There is no universally best HRA. Compare alternatives against the employer’s workforce and existing benefits using the following questions:
| Decision factor | Questions to answer |
|---|---|
| Coverage structure | Will employees use an employer group plan, individual-market coverage, or Medicare? Must the HRA coordinate with another plan? |
| Employer eligibility | Can the employer satisfy the conditions for a QSEHRA, including the general restriction on offering a group health plan? |
| Reimbursable expenses | Is the goal premium-only reimbursement, broader Section 213(d) expenses, or a limited excepted benefit? |
| Workforce rules | Which employee classes participate, and how could eligibility or richer benefits affect Section 105(h) testing? |
| Administration | Can the employer substantiate every claim, retain evidence, prevent duplicates, and correct errors promptly? |
| Employee impact | What coverage choices, proof requirements, notices, and premium-tax-credit consequences will participants face? |
| Compliance operations | What plan documents, ACA reviews, tax reporting, and annual updates are required? |
Common warning signs and corrective actions
- “Everyone receives the same monthly cash.” Reclassify the benefit and determine whether payments are taxable; a fixed allowance is not automatically a Section 105(b) reimbursement.
- Claims are paid from a card with no receipt or transaction controls. Add claim-level substantiation and retain evidence for each payment.
- The administrator samples claims after payment. Replace sampling that leaves claims unverified with a process that validates every claim.
- An employee’s individual-policy premium is reimbursed without monthly coverage proof. Apply the ICHRA or applicable design’s initial and ongoing coverage substantiation.
- The employer reimburses individual premiums outside a permitted HRA structure. Obtain an ACA market-reform analysis before continuing the arrangement.
- Highly compensated employees receive richer reimbursement terms. Run Section 105(h) eligibility and benefits tests and correct taxable excess reimbursements when required.
- Historical QSEHRA limits appear in current materials. Replace them with the limits and instructions applicable to the current year.
When to obtain professional review
Have qualified benefits, tax, and legal advisers review the written plan and operations before launch and whenever the design changes. Federal IRS materials explain the core tax and reporting principles, but they do not replace analysis of ERISA duties, state insurance rules, employment classifications, privacy obligations, or the employer’s particular facts. The final answer depends on the actual plan terms, workforce, existing coverage, intended expenses, and the rules in effect for the relevant year.
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