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The FSA Calculator will help you determine an appropriate Annual Health Care
FSA Contribution Amount. And, it will automatically calculate estimated tax
savings based on your Annual FSA Contributions.
Annual FSA expenses consist of all qualified expenses incurred by you, your
spouse and your eligible dependents. FSA expenses are out-of-pocket expenses
that are not covered by your benefit plan. Check out the IRS web site for a
full list of all qualified expenses.
To Begin, please enter your Annual Household Income, Marital Status, Number of
Exemptions, and select your number of annual Pay Periods. Then, enter the
amount of out-of-pocket expenses you typically incur on a yearly basis for each
of the qualified categories.
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| Enter amounts in whole dollars - no decimal points, or dollar signs (For
example: 500). |
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>Please enter your annual FSA eligible medical expenses into the fields
below(Example: 500).
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| 1. Medical - Deductibles, Copayments, Coinsurance, Routine Exams. |
| Physician/Doctor:
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$ |
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| Osteopathic Physician:
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$ |
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| Chiropractor:
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$ |
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| Podiatrist: |
$ |
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| Other Health
Practitioner: |
$ |
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| 2. Prescription - Prescription Drugs(Covered &
Non-Covered), Copayments, Coinsurance.
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| Pharmacy: |
$ |
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| 3. Hospital - Deductibles, Copayments, Coinsurance. |
| Hospitals: |
$ |
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| 4. Dental/Orthodontist - Deductibles, Copayments,
Coinsurance, Routine Exams. |
| Dentist/Orthodontist:
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$ |
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| 5. Vision - Prescription Eyeglasses & Contacts
Lenses, Deductibles, Copayments, Coinsurance. |
| Optometrist: |
$ |
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| Ophthalmologist:
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$ |
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| 6. Supplies - Contact Lens Supplies, Medical and Dental
supplies |
| Medical/Dental/Vision:
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$ |
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| Orthopedic Goods:
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$ |
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| Hearing Aids:
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$ |
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| 7. Laboratory - X-Ray/ Lab Fees |
| Medical/Dental
laboratory: |
$ |
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The tax savings computation is based on 2004 Tax Tables, assumes various tax
deductibles, and does not consider state and local taxes. Actual savings will
vary based on your individual tax situation. Please consult a tax professional
for more information on tax implications of an FSA. |
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