Page 16 - KIPP NYC 2022 Benfits Summary

Healthcare FSA Expense Worksheet
Check Out Your Savings!
Your out-of-pocket expenses for the following services for you and your family may be eligible for reimbursement from your Healthcare FSA (including copay and deductible amounts). You will save money on what you spend if this money is drawn from a tax-free FSA. Estimate your Plan Year out-of-pocket expenses below. The IRS has set the annual maximum of $2,750. Visit www.irs.gov for the current mileage reimbursement rate.
Medical
_______ Acupuncture
_______ Alcohol/drug treatment _______ Allergy treatments
_______ Ambulance
_______ Anesthesia
_______ Artificial limbs
_______ Birth control pills
_______ Braille books and magazines _______ Chiropractor fees
_______ Crutches, wheelchairs _______ Diabetic supplies
_______ Emergency room visits _______ Healthcare equipment _______ Hospital bills
_______ Immunizations
_______ Infertility treatments
_______ Laboratory fees
_______ Mileage to/from provider _______ OB/GYN exams
_______ Office visits
_______ Osteopath fees
_______ Oxygen
_______ Pap smears
_______ Parking/tolls
_______ Physical therapy
_______ Physician fees
_______ Prescription drugs
_______ Private hospital room _______ Private nurses
_______ Psychiatric Care
_______ Psychological Care
_______ Routine checkups
_______ Smoking cessation programs _______ Special school, handicapped _______ Surgery
_______ Vaccinations
_______ Well baby care
_______ X-rays
$ _________ SUBTOTAL (a)
16 KIPP NYC PUBLIC SCHOOLS
Dental
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Anesthesia Bondings Cleanings Crowns, bridges Dental exams Dentures Extractions Fillings
Fluoride treatments Mileage to/from provider Occlusal guards
Oral surgery Orthodontia (braces) Parking/tolls
Root canal/therapy X-rays
Vision
_______ Prescription contact lenses _______ Contact lens supplies _______ Eye exams
_______ Corrective eye wear _______ Corrective eye surgery _______ Mileage to/from provider _______ Parking/tolls
_______ Prescription sunglasses $_________ SUBTOTAL (c)
Hearing
_______ Hearing aids
_______ Hearing exams
_______ Mileage to/from provider _______ Telephones for hearing
impaired $_________ SUBTOTAL (d)
$___________
$___________
$_________ SUBTOTAL (b)
Total Plan Year Estimate
(e) = a + b + c + d
Total Plan Year Tax Savings
(e x 35%)