The worksheet below is designed to assist you in determining your eligible expenses, pre-tax paycheck withholdings, and estimated overall savings. Plug in your anticipated annual expenses in each of the categories below and select the number of pay periods you have per year. The worksheet will automatically calculate the rest.
Not sure if all your healthcare expenses qualify? Double check the list of eligible items on our Eligible Expenses page.
|
|
Calculating Your FSA
Election
|
Healthcare Expense Sheet
|
|
Co-payments
/ Coinsurance / Deductibles
|
|
|
|
Dental
Expenses
(Braces, exams, preventive, crowns, bridges)
|
|
|
|
Vision Expenses
(Eye exams, glasses, contacts and supplies, and prescription
sunglasses). |
|
|
|
|
Hearing Expenses
(Exams, hearing aids, batteries) |
|
|
|
Therapy
(Physical Therapy, Chiropractic, Speech, etc.)
|
|
|
|
|
Medically Necessary Expenses
|
|
|
|
|
|
|
|
Total Anticipated Medical
Expenses |
|
|
|
|
Number of Pay
Periods
|
|
|
|
|
|
|
|
Per Pay
Contribution (pre-tax)
|
|
|
|
| |
|
| |
|
|
Dependent Care
Expense Worksheet
|
|
| First Quarter
(January -March)
|
|
|
|
|
Second Quarter
(April - June)
|
|
|
|
|
Third Quarter (July
- September)
|
|
|
|
|
Fourth Quarter
(October - December)
|
|
|
|
|
|
|
|
Total Dependent
Care Expense*
|
|
|
|
|
Other Qualified
Dependent Care Expenses
|
|
|
|
|
|
|
|
Total Anticipated
Dependent Care Expenses
|
|
|
|
|
Number of Pay
Periods
|
|
|
|
|
|
|
|
Per Pay Contribution
(pre-tax)
|
|
|
|
| |
|
|
*Limits apply. Maximum allowable dependent care deduction is
$2500 for one child or $5000 for more than one child. If your expenses are
greater than the allowed maximum, please enter your maximum allowable rate on
this line.
|
|
Calculating Your
Flexible Spending Account Benefit
|
|
|
without FSA program |
|
with FSA program |
|
Annual Income |
|
|
|
|
|
Pre-tax Healthcare FSA
contribution |
0 |
|
|
|
|
Pre-tax Dependent Care
contribution |
0 |
|
|
|
|
Taxable Income |
|
|
|
|
|
Taxes (Federal,
State, and FICA)* |
|
|
|
|
|
Taxes |
|
|
|
|
|
After Tax Income |
|
|
|
|
|
After Tax 0ut of
Pocket Medical Expenses |
|
|
$0.00 |
|
|
After Tax Dependent
Care Expenses |
|
|
$0.00 |
|
|
Take Home Pay |
|
|
|
|
|
Savings through a FSA
Participation |
|
|
|
|
|
|
| |
|
*
This tool is designed to provide an estimate of the savings you might receive
based upon your inputs. Final results may vary. Several factors will
determine your actual savings including your tax rate. If you are unsure of
your associated tax rate assume 20% as a conservative planning figure. |
|
| |
| |