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Start by identifying the arrangement, not its tax label. Section 105(b) can exclude qualifying reimbursements for incurred medical care, but it does not make every employer payment for health-related costs tax-free or establish that a plan complies with the Affordable Care Act (ACA). Employers should verify eligible expenses, claim substantiation, any applicable nondiscrimination rules, the arrangement’s coverage and notice conditions, and reporting duties against the written plan and current requirements.
First identify what the employer actually offers
“Section 105(b) plan” is not a unique plan design. It refers to a tax exclusion rule that may apply to qualifying medical reimbursements. An employer arrangement using that rule could be an HRA integrated with employer group coverage, an individual coverage HRA (ICHRA), an excepted benefit HRA, a qualified small employer health reimbursement arrangement (QSEHRA), or another kind of medical reimbursement plan. Each design can have different coverage, eligibility, notice, and ACA conditions.
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Before evaluating tax treatment, identify the arrangement in its governing documents and how it operates in practice. A label in a benefits summary or payroll system is not enough. Check who funds it, who can participate, what it reimburses, what other coverage employees must have, and how claims are approved.
- Integrated HRA: Determine which employer group coverage it is integrated with and whether the arrangement satisfies the applicable integration conditions.
- ICHRA: Determine whether it reimburses in connection with individual health insurance coverage or Medicare under the applicable rules, and review its participant notice and coverage-substantiation procedures.
- Excepted benefit HRA: Confirm that the plan fits the limited excepted-benefit category and its distinct conditions; the category name alone does not establish eligibility.
- QSEHRA: Check whether the employer meets the eligibility requirements. An eligible employer generally must not offer a group health plan. A QSEHRA is employer-funded and reimburses eligible medical expenses after proof of coverage, subject to statutory conditions.
- Other reimbursement arrangement: Assess the actual terms and operation rather than assuming that a different design inherits the rules for one of the named HRAs.
The IRS overview of HRAs describes rules allowing specified HRA and account-based plan designs to integrate with individual health insurance coverage or Medicare when conditions are met, and treats excepted benefit HRAs separately. Its employer guidance also describes QSEHRA conditions. Those rules are design-specific: employers should not use one arrangement’s requirements as a shortcut for evaluating another.
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Understand what Section 105(b) does—and does not do
Section 105(b) provides an exclusion for qualifying amounts paid to reimburse incurred medical care expenses as defined by Section 213(d), subject to the statutory terms. The key concepts are reimbursement, an expense that has actually been incurred, and medical care that falls within the relevant definition. The employer must be able to connect the payment to an eligible expense.
A fixed allowance, stipend, or payment an employee can keep regardless of whether they incur an eligible expense does not become an excludable reimbursement simply because the employer calls it a health benefit. The IRS’s Internal Revenue Bulletin 2003-21 explains that claims need substantiation and describes why procedures that do not limit payments to eligible medical expenses fail the requirements of Section 105(b).
Plan terms matter, but they cannot expand the statutory definition. A plan may restrict which otherwise eligible Section 213(d) expenses it will reimburse; listing a nonmedical purchase in the plan does not turn it into medical care. Nor does the fact that a purchase is broadly health-related establish that it qualifies. Employers should have the plan define reimbursable categories clearly and have claims procedures apply those limits consistently.
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Check that each claim is substantiated
Substantiation is not an optional paperwork step after the employer has decided to pay a claim. It is how the employer establishes that the payment reimburses an actual eligible medical expense rather than functioning as unrestricted cash. The IRS states in Internal Revenue Bulletin 2003-21: “Therefore, to ensure that a particular payment is a reimbursement of a medical expense, all claims for expense reimbursements must be substantiated.”
What the claims process should establish
For each claim, the administrator’s process should establish the information needed to show that the expense is eligible and actually incurred, including the service or item, the date incurred, and the amount. The process should also guard against duplicate reimbursement. Employers should be able to explain who reviews claims, what evidence is accepted, how the review is documented, and how the plan’s expense rules are applied.
The IRS discusses procedures that substantiate each claim, including qualifying electronic workflows using reliable transaction data and review or receipts. A payment-card or electronic process should not be treated as automatic proof merely because it is convenient: the employer needs to confirm that the controls actually validate the claim under the applicable guidance.
Why sampling alone is not enough
Sampling that leaves some claims unverified does not establish that all reimbursements were for eligible medical expenses. A process that routinely pays first and checks only a portion later therefore creates a basic tax-compliance risk. Establish a claim-level control before reimbursement, or use another procedure that the applicable guidance permits to substantiate each claim.
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Separate expense substantiation from coverage substantiation
Some designs require proof of qualifying coverage as well as proof of an expense. The IRS’s 2019 final-rule materials describe initial and ongoing substantiation of required individual coverage or Medicare enrollment for ICHRA purposes. Under those materials, the arrangement may not reimburse an expense for a month unless the required coverage has been substantiated for that month. A receipt for an expense does not, by itself, prove required coverage; keep the two checks distinct in the administration process.
Determine whether Section 105(h) nondiscrimination rules apply
For a self-insured medical reimbursement plan within Section 105(h), evaluate both eligibility and benefits under the applicable rules. This is a separate analysis from whether an individual claim is a substantiated Section 213(d) expense. An individually valid claim does not resolve whether the plan’s eligibility or benefit design satisfies nondiscrimination requirements.
The IRS’s 2019 discussion of Section 105(h) explains that highly compensated individuals may lose the Section 105(b) exclusion for excess reimbursements when a covered plan fails the applicable nondiscrimination requirements. Employers should identify the relevant highly compensated individuals, review who is eligible and how benefits are made available, and assess the consequences under the governing rules if a test is failed.
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Do not reduce this review to a slogan such as “everyone must get the same dollar amount.” The statutory and regulatory analysis depends on the plan category and its terms. The IRS discussion also indicates that premium-only arrangements may be treated differently from plans reimbursing other medical expenses. Classify the arrangement first, then have a qualified benefits or tax adviser apply the rules to its actual eligibility and benefit structure.
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Screen for ACA integration and employer-payment-plan problems
A major risk is treating a stand-alone employer payment plan as if it were an HRA design expressly permitted to work with individual coverage. The IRS guidance on employer health care arrangements describes a stand-alone employer payment plan that reimburses individual policy premiums as a group health plan subject to ACA market reforms; it states that this type of plan cannot be integrated with individual policies to satisfy those reforms.
That warning does not mean all arrangements involving individual-market coverage are prohibited. The IRS describes specified HRA designs, including ICHRAs, that can integrate with individual coverage or Medicare when their conditions are met. The distinction is the arrangement’s actual design and compliance with the relevant conditions—not simply whether the reimbursement concerns an individual policy.
Before reimbursing individual premiums, determine whether the employer has adopted an ICHRA or another permitted design, or instead operates a stand-alone payment arrangement. Then verify the current requirements for that design, including coverage, employee-class, notice, and other applicable conditions. A Section 105(b) label does not cure an ACA integration problem.
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There is no universal best HRA or reimbursement plan. The right evaluation depends on existing benefits, workforce, intended expenses, and operational capacity. Use the following questions to compare genuine alternatives rather than choosing a design based on its name.
| Decision area | What to evaluate |
|---|---|
| Coverage structure | Whether the employer has group coverage, intends to use individual-market coverage or Medicare, or is considering an arrangement that must integrate with other coverage. |
| Employer eligibility | Whether the employer can use the proposed design. For a QSEHRA, generally check that the employer does not offer a group health plan and confirm the other statutory conditions. |
| Expense scope | Whether the design is premium-only or covers broader Section 213(d) expenses, and whether its terms fit an excepted-benefit arrangement if that category is being considered. |
| Workforce rules | Who may participate, how eligible employee classes are handled, and whether Section 105(h) nondiscrimination rules apply to the arrangement. |
| Claims operations | Whether every claim can be substantiated, documentation can be retained, errors can be corrected, and duplicate reimbursement can be prevented. |
| Employee impact | What coverage choices participants must make, what notices they need, and whether an ICHRA affects premium tax credit eligibility. |
| Ongoing compliance | Whether the employer can maintain the plan documents, administer applicable ACA conditions, complete reporting, and revisit the design when workforce facts or law change. |
These questions are connected. For example, the desired expense scope may affect which design is suitable, while the coverage structure can change which proof and notice processes are required. A proposed design that works for one workforce or employer’s existing coverage should not be assumed to work for another.
Review notices, employee communication, and reporting
Give participants accurate, design-specific information
Employees need to know what the plan reimburses, what evidence they must provide, and any coverage conditions that apply. For an ICHRA, the IRS’s 2019 final-rule materials describe notice content that includes plan terms, available amounts, coverage requirements, and premium tax credit consequences. Employers should confirm the current notice form and timing against governing rules and their actual plan, rather than reusing a notice written for a different design.
Communication should distinguish an amount the plan makes available from a reimbursement that qualifies for the tax exclusion. It should also explain the practical steps for submitting proof and the coverage or timing requirements that affect a claim. Avoid promising that every employee’s premium or health-related purchase will be reimbursed unless the plan terms and applicable rules support that statement.
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The IRS describes an HRA as generally self-insured group health plan coverage and minimum essential coverage for reporting purposes, while noting exceptions where the same reporting entity also reports other minimum essential coverage. This means the employer should not assume that a small reimbursement arrangement has no reporting consequence.
Determine which reporting rules apply to the actual arrangement, reporting entity, individuals, and months involved. The IRS employer Form 1094-C/1095-C Q&As and the Instructions for Forms 1094-B and 1095-B for 2025 (coverage in 2025, filing in 2026) are relevant references for the reporting questions they address. Use the instructions for the applicable tax year and confirm whether the HRA must be reported in the employer’s circumstances.
Use a practical review sequence
- Collect the governing documents. Obtain the written plan, amendments, employee materials, claims procedures, and any agreement describing how the arrangement is administered.
- Name the design accurately. Decide whether it is an integrated HRA, ICHRA, excepted benefit HRA, QSEHRA, or another reimbursement arrangement. Resolve any difference between the document label and how payments actually work.
- Map the expense rules. Identify reimbursable categories, confirm they fit the plan terms and Section 213(d), and check that payments are tied to incurred expenses rather than available as unconditional cash.
- Walk through a claim from submission to payment. Verify how the administrator confirms the item or service, incurred date, amount, eligibility, coverage where required, and duplicate-payment controls. Confirm that each claim is substantiated.
- Test the workforce design. Identify eligible classes and participation rules, then determine whether Section 105(h) applies and whether eligibility and benefits meet its requirements.
- Check ACA fit and participant notices. In particular, distinguish a stand-alone individual-premium employer payment plan from an ICHRA or other permitted design, and confirm the conditions and notices for the arrangement actually offered.
- Assign reporting responsibility. Identify the reporting entity, applicable forms and tax year, relevant people and months, and any exception that may apply.
- Document the review and revisit it when facts change. Changes to coverage, employee classes, expense categories, administration, or governing rules can alter the analysis. Set an owner for periodic review with qualified benefits, tax, and legal advisers.
Common evaluation mistakes to avoid
- Relying on the name. Calling a payment a “Section 105(b) benefit” does not establish that it is a reimbursement or that the underlying arrangement meets other rules.
- Paying before adequate substantiation. Sampling claims or accepting a general employee attestation without controls that substantiate each claim can leave payments unsupported.
- Conflating proof of expense with proof of coverage. A design may require separate evidence of qualifying coverage for the month in which an expense is reimbursed.
- Assuming all premium reimbursement is alike. A stand-alone payment plan and a properly designed ICHRA are not interchangeable for ACA purposes.
- Applying a one-size-fits-all nondiscrimination rule. Section 105(h) analysis depends on the plan category and detailed rules; assess the actual design rather than relying on a simplified uniform-dollar test.
- Using an outdated annual limit or filing instruction. QSEHRA limits and tax-year reporting materials can change. Do not carry forward historical figures; verify the current year’s rules before setting or communicating amounts.
- Treating software as compliance by itself. An administrative platform can support claim controls, but the employer remains responsible for having compliant written terms and procedures that operate as intended.
What an employer can conclude from the review
A sound evaluation should leave the employer able to explain, in writing, what plan design it has, what expenses and coverage it permits, how every payment is substantiated, whether Section 105(h) applies, how the design fits ACA rules, what participants must be told, and who handles reporting. If any answer depends on facts not reflected in the documents or administration, resolve that mismatch before relying on the intended tax treatment.
The governing analysis is federal, and the IRS materials cited here do not answer every question involving state law, ERISA, insurance rules, or other agency guidance. Plan-specific conclusions depend on written terms, workforce facts, existing coverage, and intended expenses. Have qualified benefits, tax, and legal advisers review the actual arrangement and confirm current requirements.
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