Flexible Spending Account Calculator

FSA Accounts allow you to pay for eligible Medical Care and Dependent Care expenses on a pre-tax basis. This means that the money is deposited into your account before federal, state, local and Social Security taxes are withheld from your pay. New Jersey residents continue to pay state income tax on gross pay. This worksheet will help you in calculating how much to deposit for medical care and dependent care expenses for you and your family. It is important to plan how much to deposit because if you have money left in the account at the end of the plan year, you will forfeit your unused balance in accordance with IRS regulations.

Medical Care FSA

Medical and dental expenses not covered or partially covered under any group insurance plan.

	List the amount you spend for: Prior year actual expenses Projected expenses Medical Deductibles  $  $ Co-insurance payments  $  $ Prescription drugs not covered or co-pays  $  $ Office visit, ER, hospital co-pays  $  $ Child immunization/Well baby care  $  $ Vision care (exams, glasses, contact lenses)  $  $ Lab fees/co-pays  $  $ Dental Deductibles  $  $ Co-insurance payments  $  $ Orthodontic services  $  $ Other expenses:  $  $    Total medical, dental, and other expenses: $       $

Dependent Care FSA

	List the amount you spend for: Prior year actual expenses Projected expenses In-home daycare  $  $ Day care center  $  $ Nursery school  $  $ Summer day camp  $  $ After-school care  $  $ Disabled adult care (over 13 who is your dependent)  $  $    Total dependent care expenses: $       $       Total Projected Expenses:$

Consult IRS Publication 502 and 503 for a more detailed description of covered medical and day care expenses. When you calculate your FSA deposits, consider the following questions:

• Do you, your spouse or dependent expect to have medical or dental expenses that are not fully covered by insurance?
• Do you, your spouse or dependent have a chronic illness that requires expensive medication or frequent visits to a physician?
• Do you, your spouse or dependent need new glasses or an eye exam?
• Do you, your spouse or dependent need dental or orthodontic services?