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An IRC Section 105(b) medical expense reimbursement plan is an employer-sponsored accident or health plan that can reimburse qualifying medical-care expenses without including those reimbursements in an employee’s gross income. The exclusion depends on the written plan, eligible expenses, timely substantiation, enrollment and payment rules, and how unused amounts are handled; the label “105(b)” alone does not make an arrangement tax-free.
What Section 105(b) does
Section 105(b) addresses the federal income-tax treatment of benefits paid through an employer’s accident or health plan. When the arrangement reimburses medical care that qualifies under Internal Revenue Code Section 213(d), and the plan’s operational requirements are met, the reimbursement generally is excluded from the employee’s gross income.
This is a tax rule for benefits paid under an accident or health arrangement. It is not a universal authorization for an employer to repay any personal expense. The plan document, the nature of the expense, the evidence supplied before payment, and the treatment of unused balances all affect the result.
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1Fix the driver behind crashes, sound loss and screen glitches2Clear out junk files and repair common Windows errors3Scan for outdated or missing drivers - takes under a minuteIRS Publication 15-B (2026), Employer’s Tax Guide to Fringe Benefits, explains the general tax treatment of employer-provided accident and health benefits. Revenue Ruling 2005-24 addresses reimbursement-plan designs and is especially important for substantiation and for arrangements that offer cash or other benefits instead of medical reimbursement.
Who and what the plan may cover
Covered people
The written plan determines who can submit claims. Revenue Ruling 2005-24 describes a plan that reimburses “the medical care expenses of both current and former employees (including retired employees), their spouses and dependents.” That sentence describes the facts of that ruling; it is not a blanket rule requiring every employer plan to cover all of those groups. Eligibility, waiting periods, termination provisions and dependent definitions must be read from the particular plan.
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Covered expenses
Reimbursements must be limited to qualifying medical care under Section 213(d) and any narrower definition in the plan. A claim should identify the person who received care, the provider, the date and nature of the service, and the amount that remains eligible after insurance or other reimbursements. A payment that merely benefits an employee financially, without being tied to qualifying medical care, does not become excludable because an employer calls it a “medical allowance.”
When an expense is incurred
IRS guidance for health reimbursement arrangements generally requires an expense to be incurred on or after the date the individual is enrolled. A receipt dated before enrollment may therefore be ineligible even if the employee submits it after enrollment. The plan can contain additional restrictions, so employees should check its effective-date and claim-period language before obtaining reimbursement.
How a compliant reimbursement claim works
- Confirm eligibility. Verify that the claimant is covered on the date the expense was incurred and that the person receiving care is an eligible employee, spouse or dependent under the plan.
- Check the expense definition. Compare the bill with the plan’s list of reimbursable Section 213(d) medical-care expenses. Determine whether another source, such as insurance, has already paid part of the bill.
- Collect substantiation. Obtain an itemized statement or other independent documentation showing the provider, patient, service or product, date and amount. A credit-card slip or an employee’s unsupported assertion normally does not establish what care was received.
- Submit before payment. Revenue Ruling 2005-24 describes substantiation before reimbursement. The administrator should review the documentation and confirm that the expense is eligible rather than paying first and asking for proof later.
- Record the reimbursement. Keep the claim, approval, payment date and amount, along with evidence of any insurance reduction. Records should be retained under the employer’s document-retention policy and any applicable tax or benefits rules.
- Apply the unused-balance rule. After a claim is paid, the remaining account balance must be handled exactly as the plan states—for example, carried forward or forfeited—not converted informally into a cash bonus.
These controls are not cosmetic administration. If the arrangement pays claims without adequate evidence, reimburses expenses from before enrollment, or treats ineligible purchases as medical care, the employer may not be able to support the intended exclusion.
What happens to unused amounts
A plan can state that an unused amount carries forward, is forfeited at the end of a period, or is handled when coverage ends. The critical distinction is whether the employee can elect cash or an unrelated benefit instead of medical reimbursement.
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Revenue Ruling 2005-24 specifically considers arrangements that pay unused reimbursement amounts in cash or other benefits. Do not describe an unused balance as freely cashable while also promising Section 105(b) exclusion. The tax result depends on the plan’s exact terms and facts, including whether a cash option is available before the medical expense is incurred and whether the payment is connected to qualifying care.
Employers should document the balance rule in the plan and apply it consistently. Employees should ask what happens at year-end, at termination, during retirement and when a dependent loses eligibility; those events can have different consequences under the plan.
Section 105(b) compared with HRA and QSEHRA arrangements
“Section 105(b) plan,” “HRA” and “QSEHRA” are not interchangeable labels. Section 105(b) describes an income-tax exclusion for qualifying reimbursements. An HRA is a type of employer-funded health reimbursement arrangement with its own plan and administration rules. A QSEHRA is a narrower statutory arrangement for eligible small employers with specific eligibility and annual-limit rules.
| Issue | Section 105(b) tax question | HRA or QSEHRA design question |
|---|---|---|
| Funding | Whether an employer-paid accident or health benefit can be excluded when it reimburses qualifying medical care. | Whether the arrangement is employer-funded, and for a particular design whether employee salary-reduction contributions are permitted. |
| Expenses | Claims must involve qualifying Section 213(d) medical care. | The plan defines eligible expenses and may impose additional categories or limits. |
| Substantiation | Evidence must support the medical expense before payment. | The administrator needs procedures, documentation and records that implement the plan. |
| Timing | The payment must correspond to an eligible expense under the plan. | HRA guidance generally looks to expenses incurred on or after enrollment. |
| Unused amounts | Cash or unrelated benefits can create a separate tax problem. | The document may allow carryforward or forfeiture, subject to the arrangement’s rules. |
| Annual limits | There is no universal Section 105(b) dollar cap established merely by using the label. | QSEHRAs have statutory annual limits; other HRAs follow their plan terms and applicable law. |
| Health-plan compliance | Income-tax exclusion is only one analysis. | The arrangement may also be a group health plan subject to Affordable Care Act market reforms and other requirements. |
Do not apply QSEHRA limits to every 105(b) plan
IRS Publication 15-B (2026) lists 2026 QSEHRA limits of $6,450 for employee-only coverage and $13,100 for family coverage. Those are QSEHRA limits for 2026; they are not automatic limits for every employer medical-reimbursement arrangement that relies on Section 105(b).
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IRS Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans, states that there is no general limit on employer contributions to an HRA. That statement does not eliminate plan-specific limits, eligibility conditions, substantiation requirements or other compliance obligations. An employer must identify the actual plan category before applying a contribution limit.
Tax exclusion is separate from ACA compliance
An arrangement can appear to satisfy the income-tax conditions of Section 105(b) and still raise a separate health-plan compliance issue. IRS guidance on employer health-care arrangements explains that some reimbursement arrangements are group health plans subject to Affordable Care Act market reforms. The guidance also distinguishes HRAs from QSEHRAs and other arrangements.
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Employer implementation checklist
- Adopt a written plan. State eligibility, effective dates, covered family members, eligible expenses, claim deadlines, annual amounts, carryforward or forfeiture rules, termination treatment and amendment procedures.
- Define the expense standard. Tie reimbursement to qualifying medical care and explain how insurance, health savings accounts or other reimbursements affect the amount payable.
- Build pre-payment substantiation. Require itemized documentation and a review process before funds are released. Keep an audit trail of approvals and denials.
- Control timing. Configure the system to reject expenses incurred before the claimant’s enrollment date when the applicable HRA rules require that result.
- Prevent cash conversion. Do not allow employees to exchange unused amounts for cash or unrelated benefits unless the arrangement has been analyzed for the resulting tax treatment.
- Review the regulatory category. Determine whether the plan is a general HRA, QSEHRA or another group health plan and perform a separate ACA market-reform review.
- Coordinate payroll and records. Reimbursements intended to be excluded should be handled consistently in payroll, while records supporting the exclusion are retained.
- Explain the rules to employees. Provide claim instructions, examples of acceptable documentation, enrollment dates and the treatment of unused amounts.
Common mistakes and how to correct them
Calling any stipend a 105(b) plan
A taxable wellness stipend, fixed cash allowance or unrestricted medical bonus is not transformed into a Section 105(b) reimbursement plan by its name. Replace the informal payment with a documented accident or health arrangement and analyze the actual terms before promising tax-free treatment.
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Paying first and substantiating later
Requiring employees to certify that a purchase was medical care, without itemized evidence, leaves the employer unable to show what was reimbursed. Pause payment until the administrator has documentation that identifies the expense and confirms eligibility.
Reimbursing pre-enrollment bills
Configure claim procedures around the coverage effective date. If an expense predates enrollment, deny it or handle it under another legally available benefit rather than overriding the date rule informally.
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Offering a year-end cash-out
A cash-out election can undermine the intended treatment of unused amounts. Remove the election or obtain a specific tax analysis of the arrangement before implementing it.
Using QSEHRA numbers for a different plan
First classify the arrangement. Apply the 2026 QSEHRA limits only when the employer and plan actually qualify as a QSEHRA; do not use $6,450 or $13,100 as a generic Section 105(b) ceiling.
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Ignoring the ACA analysis
Passing a tax review does not establish compliance with market reforms. Conduct the separate group-health-plan review and retain the analysis with the plan records.
How employee medical deductions interact with reimbursements
Whether an employer reimbursement is excluded from wages is different from whether an individual may claim a medical-expense deduction. IRS Publication 502 (2025), Medical and Dental Expenses, explains that reimbursements generally reduce the expenses a taxpayer can use for an individual deduction. An employee should not claim a personal deduction for an amount already reimbursed tax-free, because that would seek two tax benefits for the same expense.
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Publication 502 is therefore useful for the employee’s personal return, but it is not the authority for deciding whether the employer’s plan qualifies under Section 105(b). That decision turns on the plan and its administration.
Questions to ask before relying on a plan
- What document establishes the arrangement, and who is eligible?
- Does the plan limit claims to Section 213(d) medical care?
- Are expenses incurred before enrollment excluded?
- What documentation must be supplied before payment?
- Can unused amounts carry forward, be forfeited or be paid in another form?
- Is the arrangement a general HRA, a QSEHRA or another type of group health plan?
- Has the employer separately reviewed ACA market reforms and other benefit-plan requirements?
- How are reimbursements and supporting records handled in payroll and at tax time?
If the written plan, the claim records and the payment practice do not match, the employer should pause new claims and obtain benefits-tax advice. IRS materials do not determine the result for an individual arrangement without its documents and facts.
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