Department of Management Services

Limited Purpose FSA Estimator (for Active Employees)

Enter your expected healthcare expenses for the plan year that are eligible for reimbursement under the Limited Purpose FSA. Information about eligible expenses is available at in IRS Publication 502 (Adobe PDF Document). Keep in mind that the Limited Purpose FSA is available for dental, vision and over-the-counter medication expenses if you enroll in a High Deductible Health Plan. If you're considering the Standard PPO or a Standard HMO, you should use the Health Care FSA Estimator.

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

Types of Healthcare Expenses Projected Healthcare Expenses for Calendar Year
Over-the-counter medications used to treat a medical condition (only covered with doctor's prescription): $
Vision care expenses, including qualified expenses not covered by a vision or medical 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 including medical expenses for services the High Deductible Health Plan covers) not reimbursed by a plan 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 calendar 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 Limited Purpose FSA contribution mount if you enroll in a Health Investor medical plan based on your total estimated expenses (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.

Note: This Limited Purpose FSA Estimator is an estimating tool only. Estimate your out-of-pocket expenses carefully. You cannot change your contribution amount after enrollment ends, unless you experience a qualified status change, and you forfeit any money you have not claimed by the claim filing deadline for the plan year.

Using this estimator does not enroll you in a Health Plan, the Health Savings Account or the Limited Purpose FSA.