Health Care FSA Calculator Enter your expected health care expenses for 2015 that are eligible for reimbursement under the Health Care Flexible Spending Account. Information about eligible expenses is available in IRS Publication 502. Estimate your expenses carefully. Due to the IRS “use it or lose it” rule, you will forfeit any money remaining in your 2015 Health Care FSA after March 15, 2016, if you have not filed a claim for it by March 31, 2016.Use caution when referring to Publication 502, as it is meant only to help taxpayers determine their tax deductions, not to describe the expenses that are reimbursable under a Health Care FSA. For example, health insurance premiums, long-term care contracts, and long-term care services are listed as deductible expenses in the publication. However, they generally are not reimbursable from your Health Care FSA. In addition, over-the-counter drugs used to treat a medical condition may be reimbursable under a Health Care FSA but are not listed as deductible expenses. Please enter amounts in whole dollars (no decimal points, commas, or dollar signs). *You can use your total out-of-pocket cost of care from the Medical Plan Cost Estimator, excluding payroll deductions. Types of Health Care Expenses Annual Projected Cost of Health Care Expense Medical Plan deductibles, copays, and coinsurance, as well as your cost for expenses that are not covered by the medical plan* $ Over-the-counter medications used to treat a medical condition $ Vision care expenses, including vision plan copays and other 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 the dental plan $ Any other health care expenses not reimbursed that could qualify as a deductible expense on your federal income tax return $ *You can use your total out-of-pocket cost of care from the Medical Plan Cost Estimator, excluding payroll deductions. Income Tax Filing Information (to help estimate your tax savings) Filing status (required field) Number of dependents Do not include yourself or your spouse. Select Your Tax Filing StatusSingleMarried (joint)Married (separate)Head of household Total annual incomeEnter estimated income for 2015 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).”$ Click Calculate/Recalculate to determine the following: Your Results Total projected out-of-pocket costs for medical, dental, and vision care $ Suggested annual Health Care Flexible Spending Account contribution amount based on total projected expenses. (maximum contribution is $2,500) $ Potential federal income tax savings $ Potential FICA tax savings $ Total tax savingsDepending on where you live/work, you may also have state tax savings. $ Use the reset button above to reset form and enter new projected amounts. To modify a current scenario, simply adjust the numbers above and click the Calculate/Recalculate button. Note: This worksheet is an estimating tool only. Estimate your out-of-pocket expenses carefully. You cannot change your Health Care FSA contribution amount after enrollment ends, unless you experience a qualified status change. Using this tool does not enroll you in a Medical Plan or the Health Care FSA.