(for you, your spouse, your eligible dependents)

You may want to review receipts from last year for health care expenses you paid out of your own pocket. Using your receipts will assist you in estimating how much you may want to elect to contribute to your Health Flexible Spending Account during your open enrollment period. Remember to only budget for the expenses that are eligible for reimbursement through a Health Flexible Spending Account, and also to budget only for eligible expenses that you will incur in the new plan year. For additional information on eligible expenses, please review the following link: Eligible Expenses for Health Care FSA

Enter the following information Please use whole numbers only # Visits per Year Average Miles per Visit* Cost per Visit Est. Annual Cost Office Visits: Primary Care, Pediatrician, OB/GYN, Dermatologist Chiropractor Visits Hospitalization or Surgery Emergency Room Visits Speech, Physical, or Occupational Therapy Counseling or Therapy Sessions   Monthly Cost Est. Annual Cost In Store Prescriptions Over the Counter Medications: allergy, cold and pain relief, diabetic treatment, smoking cessation, antacid, etc. Other Over the Counter Items: wart treatment, wound or injury care, etc.   Annual Cost Est. Annual Cost Other anticipated health care expenses; one-time prescriptions, for example.   Total Estimated Health Costs: $  Total Estimated Mileage Costs: $    * Average Miles per visit is defined as the average number of miles to and from a medical provider for one visit. This mileage is an eligible expense for reimbursement through a health care flexible spending account.

                                           

(for you, your spouse, your eligible dependents)

Vision expenses that are eligible for reimbursement through a Health Care Flexible Spending Account include items such as prescription glasses, prescription and over the counter reading glasses, contacts, Lasik surgery, radial keratotomy, and vision exams. For additional information on eligible expenses, please review the following link: Eligible Expenses for Health Care FSA

Enter the following information Please use whole numbers only # Visits per Year Average Miles per Visit* Cost per Visit Est. Annual Cost Eye Exams   Monthly Cost Est. Annual Cost Over the Counter Eye Care Items: Saline Solution, Contact Cleaning Supplies, Eye Drops   Annual Cost Est. Annual Cost Prescription Glasses Prescription Contacts Eye Surgery   Total Estimated Vision Costs: $  Total Estimated Mileage Costs: $    * Average Miles per visit is defined as the average number of miles to and from a medical provider for one visit. This mileage is an eligible expense for reimbursement through a health care flexible spending account.

             

(for you, your spouse, your eligible dependents)

You may want to review receipts from last year for dental expenses you paid out of your own pocket. Procedures that are deemed cosmetic, such as bleaching or whitening, and veneers, are not eligible for reimbursement through a Flexible Spending Account, and therefore should not be included below when estimating your expenses. For additional information on eligible expenses, please review the following link: Eligible Expenses for Health Care FSA

Enter the following information Please use whole numbers only # Visits per Year Average Miles per Visit* Cost per Visit Est. Annual Cost Orthodontia Annual Cleanings Dental Office Visits   # Visits for Proc Average Miles per Visit* Total Cost for Proc Est. Annual Cost Procedures: Root Canals Filings, Crowns, Extractions   Total Estimated Dental Costs: $  Total Estimated Mileage Costs: $    * Average Miles per visit is defined as the average number of miles to and from a medical provider for one visit. This mileage is an eligible expense for reimbursement through a health care flexible spending account.

                       

(for your eligible dependents)

The Dependent Care Flexible Spending Account helps you pay for child care services that make it possible for you and your spouse (if applicable) to work. Under certain circumstances it also may be used to help pay for the care of elderly parents or a disabled spouse or dependent. To be an eligible expense, you must be at work during the time your eligible dependent receives care. For more information go to: Dependent Care FSA Information

Enter the following information Please use whole numbers only # of Weeks Cost per Week Est. Annual Cost Child Care Center Nursery / Pre-School Before / After-School Care In-Home Care Summer Camp Au Pair Service Elder Care Center or In-Home Care for Adult Dependents   Total Estimated Dependent Costs: $

                           

Federal Marginal Tax Rate % You may overwrite the default with your projected marginal tax rate using the Federal Tax Rate Schedule (Tax Rate Schedule) State Tax Rate % If applicable, and if health care and dependent care flexible spending account contributions are exempt from state tax in your state of residence. City Tax Rate % If applicable, and if health care and dependent care flexible spending account contributions are exempt from city or local tax in your area of residence. Social Security Tax % If your taxable wage income exceeds $90,000, enter 0% in this field. Income in excess of $90,000 is not subject to Social Security Tax. Medicare Tax % # of Pay Periods Per Year Estimated Total Health Care Flexible Spending Account Contributions If your employer's plan maximum is less than your estimated total contributions overwrite the above number with the plan maximum. Show Summary * Tax savings examples are based on the numbers that you enter. Payroll and income tax laws vary from state to state. Savings may be more or less depending on your individual tax bracket, state income tax rates and the accuracy of the information that you supplied.

         

Your Results Estimated Total Health Care Flexible Spending Account Contributions: $0 Estimated Total Dependent Care Flexible Spending Account Contributions: $0 TOTAL PROJECTED TAX SAVINGS: $0 Print results Common Questions What if I don't use all of the money that I contribute? Federal law governing flexible benefit plans specifies that any money remaining in your account at the end of the plan year will be forfeited. However, based on your estimated tax savings, you would only need to incur $ 0 to break-even! If you spend all of your FSA contributions, your rate of return is equivalent to your combined tax rate of 0 % What does this mean to my paycheck? The deduction per pay period if you elect to contribute the above amounts would be $ 15, and this amount is available to cover your Health and/or Dependent Care expenses with pre-tax dollars. Since taxes are not withheld on FSA contributions, the taxes on your paycheck will decrease by $ 15 The result? It's like getting $0 worth of Health and/or Dependent Care services for only $ 0 For more answers to frequently asked questions, click on the following link: FSA Frequently Asked Questions Reset Calculator * Per Federal Regulations, the maximum amount that can be contributed to a Dependent Care Flexible Spending Account is $5000. ** Tax savings examples are based on the numbers that you enter. Payroll and income tax laws vary from state to state. Savings may be more or less depending on individual tax bracket, state income tax rates and the accuracy of the information that you supplied.