Department of Management Services

Health Care FSA Estimator (for Active Employees)

Enter your expected healthcare expenses for the plan year that are eligible for reimbursement under the Healthcare FSA. Information about eligible expenses is available at www.irs.gov in IRS Publication 502 (Adobe PDF Document). Keep in mind that if you enroll in a High Deductible Health Plan and HSA, you may use only the Limited Purpose FSA.

Please enter amounts in whole dollars (no decimal point, comma, or dollar sign). 

Types of Healthcare Expenses Projected Annual Healthcare Expenses
Enter your cost for Health Plan deductibles, copayments and coinsurance, as well as your cost for expenses that are not covered by the Health Plan (your total cost of care from the Health Plan Cost Estimator): $
Over-the-counter medications used to treat a health condition (only covered with doctor's prescription): $
Vision care expenses, including qualified expenses not covered by a vision or health benefit: $
Dental Plan deductibles and coinsurance (your share of the total cost for covered services including orthodontics, after the deductible is met): $
Other qualified dental expenses not covered by your Dental Plan: $
Any other healthcare expenses not reimbursed that could qualify as a deductible expense on your federal income tax return: $

Income Tax Filing Information (to help estimate your tax savings)
Filing status (required field): Number of dependents:
Do not include yourself or your spouse.
Total annual income:
Enter estimated income for the year from all sources you would include on your tax form, including wages, bonus, investment income, etc. Include income for your spouse if your filing status is "Married (joint)".
$

to determine the following:

Your Results
Total estimated out-of-pocket costs for medical, dental and vision care: $
Suggested annual Medical Reimbursement Account contribution amount based on your total estimated expenses if you enroll in the Standard PPO or a Standard HMO (Maximum contribution for the calendar year is $2,500): $
Potential federal income tax savings: $
Potential FICA tax savings: $
Total estimated federal and FICA tax savings: $

form and enter new projection amounts. To modify a current scenario, simply adjust the numbers above and click the Calculate/Recalculate button.