Page 16 - 2020FCSBenefitsGuide
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Flexible Spending Worksheet
Follow these steps to put the lexible spending accounts to work for you.
Estimate Your Medical Expenses
When calculating expenses for 2020, estimate carefully! The IRS allows a maximum rollover of unused funds of
$500; any remaining balance above $500 is not refundable.
Estimated Monthly Healthcare Expenses × 12
Deductibles (medical, dental, Rx) $ $
Coinsurance $ $
Prescriptions $ $
Total $ $
Decide on Your Contribution
Annual total $______ divided by 26 pay periods $______
Once you begin contributing, you may not change or stop your contribution during the year unless you have a
qualifying family status/life event change.
Estimate Your Dependent Care Expenses
When calculating expenses for 2020, estimate carefully! The IRS does not allow rollover or refund of unused
dependent care funds.
Estimated Monthly Dependent Care Expenses × 12
Monthly Day Care Expenses $ $
Total $ $
Annual total $______ divided by 26 pay periods $______
Remember if you are enrolling mid-year, the FSA accounts cannot be used for expenses incurred before
you are eligible for beneits. You will want to consider this in your total dollar elections.
16 2020 Benefits Guide
Follow these steps to put the lexible spending accounts to work for you.
Estimate Your Medical Expenses
When calculating expenses for 2020, estimate carefully! The IRS allows a maximum rollover of unused funds of
$500; any remaining balance above $500 is not refundable.
Estimated Monthly Healthcare Expenses × 12
Deductibles (medical, dental, Rx) $ $
Coinsurance $ $
Prescriptions $ $
Total $ $
Decide on Your Contribution
Annual total $______ divided by 26 pay periods $______
Once you begin contributing, you may not change or stop your contribution during the year unless you have a
qualifying family status/life event change.
Estimate Your Dependent Care Expenses
When calculating expenses for 2020, estimate carefully! The IRS does not allow rollover or refund of unused
dependent care funds.
Estimated Monthly Dependent Care Expenses × 12
Monthly Day Care Expenses $ $
Total $ $
Annual total $______ divided by 26 pay periods $______
Remember if you are enrolling mid-year, the FSA accounts cannot be used for expenses incurred before
you are eligible for beneits. You will want to consider this in your total dollar elections.
16 2020 Benefits Guide
