Health Care Spending Account Calculator

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

Type of Expense NOT Covered by Insurance (including deductibles, coinsurance and co-payments)	Projected Amount of Expense
Medical:
Dental:
Orthodontia:
Vision care:
Prescriptions:
Other expenses not covered by insurance including eligible over-the-counter medications:


Tax filing status (required field): Single Married filing jointly Married filing separately Head of household	Number of dependents: Do not include yourself or your spouse.

Total annual income:
Enter income amount from all sources including wages, salary, income from a business/profession, rents/royalties, lottery winnings, investment income, etc. Please include all income sources for your spouse if your filing status above is "Married filing jointly."

to determine the following:

Total projected expenses:
Suggested contribution amount based on total projected expenses: Maximum is $5000.
Total available for reimbursement: Equals your contribution amount.
Total potential tax savings: This amount represents potential federal and FICA tax savings only. You may also realize additional state tax savings.

Note: This worksheet is an estimating tool only and does not constitute an enrollment.

form and enter new projection amounts.