Page 21 - Open Enrollment Guide Sample
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Estimate Your Out-of-Pocket Healthcare Expenses Dependent Care FSA
Using your expenses from previous years, complete the section below You may contribute up to $5,000 each
to estimate the out-of-pocket healthcare expenses you (and your eligible year ($2,500 if married and iling
dependents) expect to incur during the plan year. These expenses may separate tax returns). This account
not be reimbursed from another source (e.g., insurance). The total reimburses day care expenses for
you calculate here is the total amount you may want to deposit in your dependent children under age 13 and
disabled or elderly dependents that
Healthcare FSA for the plan year. rely on your income. Eligible expenses
include charges for licensed nursery
Medical schools, day care centers, baby-sitting,
Medical Deductibles $__________ and disabled dependent day care (in
Coinsurance Payments $__________ or out of your home).
Routine Exams (e.g., OB-GYN, physicals, etc.) $__________ The healthcare and dependent care
Medical Ofice Copayments (e.g., $20 per visit) $__________ accounts are completely separate—
Prescription Drugs (including allergy shots and insulin) $__________ you cannot transfer money between
Hearing Aids and Exams $__________ the two or use funds from one to
Vision Care (e.g., eye exams, contact lenses, prescription pay claims against the other. Refer
eyewear) $__________ to IRS publications 502 and 503 at
Medically Required Equipment (e.g., wheelchair, prosthetic www.irs.gov for a complete listing of
devices) $__________ eligible expenses.
Chiropractor $__________
Emergency Room Charges $__________
Dental
Dental Deductibles $__________
Coinsurance Payments $__________
Orthodontia (e.g., braces, retainers) $__________
Other (Non-Cosmetic) Dental Expenses Not Covered by
Insurance $__________
Other Expenses $__________
Total Healthcare Expenses $__________
To determine the amount of money you may want to contribute to your FSA each
paycheck, divide your Total Healthcare Expenses by the number of pay periods in
the plan year.
$__________ /26 $__________
Total Healthcare Expenses Number of pay periods in Per paycheck contributed
listed above plan year to your HSA
2016 Open Enrollment
Estimate Your Out-of-Pocket Healthcare Expenses Dependent Care FSA
Using your expenses from previous years, complete the section below You may contribute up to $5,000 each
to estimate the out-of-pocket healthcare expenses you (and your eligible year ($2,500 if married and iling
dependents) expect to incur during the plan year. These expenses may separate tax returns). This account
not be reimbursed from another source (e.g., insurance). The total reimburses day care expenses for
you calculate here is the total amount you may want to deposit in your dependent children under age 13 and
disabled or elderly dependents that
Healthcare FSA for the plan year. rely on your income. Eligible expenses
include charges for licensed nursery
Medical schools, day care centers, baby-sitting,
Medical Deductibles $__________ and disabled dependent day care (in
Coinsurance Payments $__________ or out of your home).
Routine Exams (e.g., OB-GYN, physicals, etc.) $__________ The healthcare and dependent care
Medical Ofice Copayments (e.g., $20 per visit) $__________ accounts are completely separate—
Prescription Drugs (including allergy shots and insulin) $__________ you cannot transfer money between
Hearing Aids and Exams $__________ the two or use funds from one to
Vision Care (e.g., eye exams, contact lenses, prescription pay claims against the other. Refer
eyewear) $__________ to IRS publications 502 and 503 at
Medically Required Equipment (e.g., wheelchair, prosthetic www.irs.gov for a complete listing of
devices) $__________ eligible expenses.
Chiropractor $__________
Emergency Room Charges $__________
Dental
Dental Deductibles $__________
Coinsurance Payments $__________
Orthodontia (e.g., braces, retainers) $__________
Other (Non-Cosmetic) Dental Expenses Not Covered by
Insurance $__________
Other Expenses $__________
Total Healthcare Expenses $__________
To determine the amount of money you may want to contribute to your FSA each
paycheck, divide your Total Healthcare Expenses by the number of pay periods in
the plan year.
$__________ /26 $__________
Total Healthcare Expenses Number of pay periods in Per paycheck contributed
listed above plan year to your HSA
2016 Open Enrollment
