Page 120 - 2022 MLB Benefit Guide 08.2022

04 Estimate your FSA Expenses and Tax Savings

MEDICAL ESTIMATE
Estimate out-of-pocket medical services for you, your spouse, and your eligible dependents.

GENERAL EXPENSES SPECIAL TY EXPENSES
Office visits/doctor’s fees Emergency room/hospital bills $ _____________
(actual cost if deductible applies $ _____________
or total copayments) Hearing aids $ _____________
Immunizations/vaccines $ _____________ Specialists or alternative medicine
(Acupuncture, chiropractor, physical $ _____________
Laboratory fees/X-rays $ _____________ therapy, specialists fees, etc.)
Surgery $ _____________
Over-the-counter drugs and medicines $ _____________
Other expenses $ _____________
Prescription drugs $ _____________
SUBTOTAL $ _____________
SUBTOTAL $ _____________

VISION DENTAL
Cleanings, exams, fillings,
Corrective eye surgery $ _____________ and procedures $ _____________
and eye wear
Orthodontia $ _____________
Eye exams $ _____________
X-rays $ _____________
Prescription glasses $ _____________
SUBTOTAL $ _____________
Contact lenses $ _____________
SUBTOTAL $ _____________ T OTAL ESTIMATE: $ _____________

DEPENDENT CARE ESTIMATE TAX SAVINGS ESTIMATE

Estimate out-of-pocket expenses related to non- Estimate your total annual tax savings.
medical care for your dependents.

A. Total medical estimate (see plan $ _____________
highlights for the maximum limits that may apply)
DEPENDENT CARE EXPENSES
Adult day care $ _____________ B. Total dependent care estimate (see plan $ _____________
highlights for the maximum limits that may apply)
Child day care or in-home $ _____________
dependent care C. Total expenses (line A + line B) $ _____________
Nursery school $ _____________ D. Tax rate (enter what you pay in total for
Federal, State, and Local taxes. If uncertain, $ _____________
use 30% of your gross salary)
T OTAL ESTIMATE: $ _____________ E. FICA (includes Social Security and Medicare) $ _____________

F. Total tax rate (line D + line E) $ _____________

Use our free FSA calculator to help estimate your ESTIMATED ANNUAL

expenses: BenefitResource.com/estimate. TAX SAVINGS (line C x line F) $ _____________