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Use the tables below to help estimate your annual needs and tax savings for a health care FSA . Please note that the examples given are only a guide for completing the worksheet. Your FSA election amounts* should be based on an estimate of your own expenses. To see a list of qualified medical expenses visit www.healthequity.com/qme.
Enter in your annual FSA expenses
| Eligible expenses | Example estimate | Your estimated amount |
|---|---|---|
| Annual dental plan deductible | $100 | $ |
| Dental fillings and crowns | $150 | $ |
| Orthodontics | $1,500 | $ |
| Annual health plan deductible | $300 | $ |
| Chiropractor visits | $ | |
| Counselor or therapist visits | $ | |
| Doctor’s office visits | $60 | $ |
| Contact lenses and solutions | $30 | $ |
| Corrective eye surgery | $ | |
| Prescription sunglasses/glasses | $ | |
| Other | $ | |
| Estimated expense total | $2,140 | $ |
| Your effective tax rate | 20%** | % |
Based off the total expenses you entered:
Suggested FSA election amount*
Total tax savings**
$ 0*The IRS has set the limit for health care FSA contributions to $2,750 per household (see publication 969). However, employers may decide to decrease this limit.
**Estimated savings are based on an assumed combined federal and state income tax bracket of 20%. Actual savings will depend on your taxable income and tax status. This information is intended to be used for FSA education purposes only. You should consult your tax advisor or account consultant regarding you own personal situation and as to whether participating in an FSA is right for you.
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