Health Care Spending Account Estimator

Use this worksheet to estimate how much you and your dependents will spend during the upcoming plan year on eligible, out-of-pocket medical, dental, vision, and other eligible health care expenses. Then when you enroll for benefits, enter the total amount when you make your Health Care Spending Account choice. Check your employer's plan information to verify the maximum annual contribution amount.

After you are finished, you can estimate your income tax savings if you contribute to the Health Care Spending Account. Note: If you have an eligible same-sex domestic partner, do not list expenses for your partner or your partner’s children in this tool.¹ Also, please note that if you want to enroll in a plan offering an HSA, you may not be eligible to contribute to the Health Care Spending Account, or it could be Limited use. Check with your employer's plan information to understand for what expenses a Health Care Spending Account may be used.

About This Tool
A Health Care Spending Account can help you save money by giving you a tax break. You set aside money from each paycheck on a before-tax basis to pay for a variety of eligible health care expenses. As the money you contribute is deducted from your paychecks, your taxable income is reduced.

Enter Annual Amounts for

Health Care Expense You Your Spouse Your Children

Medical

Deductible $ $ $

Copayments or coinsurance $ $ $

Prescription Drugs

Expenses $ $ $

Dental

Deductible $ $ $

Copayments or coinsurance $ $ $

Exams, fillings, etc., if you're not covered by a dental plan $ $ $

Vision

Exams, glasses, contacts $ $ $

Hearing Expenses

Exams, hearing aids $ $ $

Other Unreimbursed Eligible Health Care Expenses $ $ $

Add It Up! * Annual Total $

* Your estimated annual total may be higher than your employer’s maximum annual contribution. Check your employer’s plan information to verify the maximum amount.

You should carefully estimate the expenses you expect to claim through the Health Care Spending Account for the year. Some employer plans allow you to carryover a portion of unused balances. If your employer plan does not allow the carry-over of unused balances, you must spend all of your funds either by the end of the plan year or within the grace period. No matter estimate your income tax savings as you consider your needs.

¹Federal tax law does not permit you to claim expenses for your domestic partner or your domestic partner’s children, unless they qualify as dependents on your federal income tax return for the year.

If you enroll in a plan with an HSA you may not be allowed to enroll in a Health Care Spending Account, or it could be Limited use. You do not have to contribute additional personal funds to the HSA, but the company may make contributions.