Health Care FSA Participant Toolkit

Follow the steps below to estimate your potential FSA tax savings:

  • A) Determine your expected out-of-pocket expenses for the health care reimbursement account
  • B) Determine your expected out-of-pocket expenses for the dependent care reimbursement account
  • C) Provide information about yourself for determining your tax situation
  • D) Review your estimated tax savings results.
Enter your expected out of pocket health care expenses:
Complete the boxes below. You may want to review receipts from last year for health care expenses you paid out of your own pocket. Using these receipts and the worksheet, you can estimate the amount you want to elect for the Health Care FSA. Only budget for the expenses eligible for reimbursement though the Health Care FSA. Remember, eligible expenses include those for you, your spouse and your dependents.

Deductibles
Medical, dental, vision
$
Copayment / Coinsurance
The amount not paid by your health plan coverage
$
Expenses NOT covered by insurance plans
Prescription drugs $
Vision care $
Dental/orthodontic care $
Medical equipment $
Other eligible expenses (Click here for a list) $
Total Out-Of-Pocket Health Care Expenses
This gives you a good idea of the amount you should elect to place into your Health Care FSA. Consider any other factors that will affect your out-of-pocket health care costs during the upcoming plan year, and adjust the amount above if necessary.
$

 Enter personal information for estimating your tax situation:

Deductibles
Please select your filing status:
Please enter your total number of exemptions. Include yourself and your spouse and all dependents if applicable:
Please enter your annual income before taxes: $
Please enter your spouses annual income before taxes: $
Calculation is based on California state tax rate. (If not in California enter applicable marginal state income tax rate. Enter zero to exclude state income taxes from the calculation.) %
The standard calculation includes social security and Medicare withholding. If you work for an organization that does not withhold Social Security or Medicare amounts, click the box to exclude this from the calculation.