Page 79 - 2021-2022 New Hire Benefits

Health FSA Worksheet Dependent Care

Keep these things in mind: Account Worksheet

• Use the money in this account to pay for the Keep these things in mind:
diagnosis, cure, prevention or treatment of a
disease. • $5,000 annual maximum per household .
• Expenses cannot be reimbursed by insurance or • Record expenses for dependent children under
any other source. age 13 who you claim on your taxes, or a disabled
• Plan ahead. If you don’t use the money in spouse or dependent of any age.
your account within the plan year, you could • To qualify, you and your spouse must be
potentially lose it. employed, or your spouse must be a full-time
student or looking for work.
• You cannot change, midyear, the amount you set
aside unless there is an IRS-approved status • Plan ahead. If you don’t use the money in your
change event. account within the plan year, you lose it.
• For a Limited Health FSA, only record expenses • Once the plan year has started, you cannot
for vision, dental and preventive care. (You change your election unless there is an IRS-
can use your HSA for other eligible medical approved status change event.
expenses, if offered by your employer.)
January $ ______________________
Insurance deductibles $ ______________________ February $ ______________________
Co-pays/coinsurance $ ______________________ March $ ______________________
Exams $ ______________________ April $ ______________________
Prescription drugs $ ______________________ May $ ______________________
Diabetic supplies $ ______________________ June $ ______________________
Chiropractic $ ______________________ July $ ______________________
*Over-the-counter medicines $ ______________________ August $ ______________________
Hearing exams $ ______________________ September $ ______________________
Hearing aid $ ______________________ October $ ______________________

Hearing aid battery $ ______________________ November $ ______________________
Dental fillings, bridges, crowns $ ______________________ December $ ______________________
Dentures $ ______________________
Orthodontia $ ______________________ Total: Amount to set aside $
Vision exams $ ______________________ Divide by # of paychecks/year $
Glasses (lenses and frames) $ ______________________
Contact lenses $ ______________________
Contact lens solution $ ______________________
Corrective eye surgery $ ______________________

Total: Amount to set aside $

Divide by # of paychecks/year $

FSA: Over-the-Counter (OTC) Purchases
As a result of Health Care Reform, the IRS will require a prescription for OTC medication to be eligible for reimbursement.
Go to www.DiscoveryBenefits.com for other reform updates.

4