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Flex

Health Flexible Spending Account (FSA) Worksheet

This worksheet can help you decide an appropriate election for a Health FSA and estimate the amount of your tax savings. List medical expenses you regularly experience and any additional expected medical expenses that will be incurred during the plan year. Medical bills, bank records, and Explanation of Benefits statements (EOBs) can be helpful in projecting future expenses. For detailed tax rate information, consult your tax advisor.


BE CONSERVATIVE!
Include in your estimate only amounts that you are confident will be incurred by you and your family during the plan year.
Estimate Your Monthly Out-Of-Pocket Health Expenses
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