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Paragon Benefits FSA Savings Calculator for Individuals You may want to review receipts from last year for health care expenses you paid out of your own pocket. Using these receipts and the worksheet, you can estimate the amount you want to elect for the Health Care FSA. Only budget for the expenses eligible for reimbursement through the Health Care FSA. Remember, eligible expenses include those for you, your spouse and your dependents. How much do you spend per year on the following Health Care Items: 1. Medical, Dental, Vision Deductibles: $ - 2. Insurance Copayments: $ - 3. Prescriptions and Over-the-Counter Medications not covered by insurance: $ - 4. Vision Care (glasses, contacts, solutions and cleaners, exams): $ - 5. Dental/orthodontic care (cleanings, braces, crowns): $ - 6. Medical Equipment and other non-reimbursed medical expenses: $ - A. Total Out-of-Pocket Medical Expenses: $ - How much do you spend per year on the following Dependent Care Items: 7. Day Care Center, Au Pair and In-Home Care Expenses: $ - 8. Nursery, Pre-school and After School Care: $ - 9. Summer Day Camps: $ - 10. Elder Care Center and In-Home Care Expenses for Adult Dependents: $ - B. Total Out-of-Pocket Dependent Care Expenses: $ - 11. How much do you contribute per pay check towards your employer's insurance plans? $ - 12. How many times do you get paid per year? 13. Multiply number 11 by number 12 for total amount per year: $ - 14. Enter your estimated federal tax rate (see rate table below): 0% Not Enrolled in FSA Enrolled in FSA GROSS ANNUAL PAY $ - $ - Pre-Tax Contributions minus 0.00 minus total of A, B & 13 above $ - Taxable Income equals $ - equals $ - PAYROLL DEDUCTIONS (Base taxes on Taxable Income above.) Social Security $ - $ - Federal Income Tax $ - $ - State Income Tax $ - $ - Group Insurance Amount from 13 above $ - 0.00 TAKE HOME PAY $ - $ - (Taxable Income minus Payroll Deductions) Out of Pocket Medical Costs From A. above $ - From A. above $ - Dependent Care Expenses From B. above $ - From B. above $ - Tax Free Reimbursement 0.00 Total of above two amounts $ - NET SPENDABLE INCOME $ - $ - Take Home Pay MINUS Medical Costs and Dependent Care Expenses, PLUS Tax Free Reimbursement. TAX RATE TABLE (Federal): Single - up to $23,350 15% Married - up to $46,700 household 15% Single - $23,351 - $56,425 27% Married - $46,701 - $112,850 27% Single - $56,426 - $85,975 30% Married - $112,851 - $171,950 30% Single - $85,976 - $153,525 35% Married - $171,951 - $307,050 35% Single - $153,526 and up 39% Married - $307,050 and up 39% A comprehensive FSA Savings Calculator is available on the web-site www.FSAandYou.com. The calculations are done automatically for you based on the information you provide. Determining Your Payroll Deduction Flexible Spending Account Unreimbursed Medical/Dental Expenses Use this worksheet to decide how much to set aside each pay period for health and dependent care expenses. Refer to the list of eligible health care expenses. However, this list doesnot completely cover all of the IRS guidelines. Therefore,if you are unsure if an expense is eligible, please refer to IRS Publication 502 or call the toll free number 800-277-9218 ext. 1381for assistance. Expenses can be for the whole family whether or not covered by your health insurance. Conservatively estimate your expenses, based on previous year's experience. Funds not used by the end of the plan year are forfeited. Once you designate a contribution amount, you cannot change it or stop making contributions until the next year's enrollment, except as specified in your plan. UNREIMBURSED MEDICAL---(this is an example, all you will need to do is key in your figures and this form calculates for you) Deductibles $500.00 Coinsurance $450.00 Drug copays $900.00 Over the counter drugs $150.00 PPO/HMO copays $120.00 Birth Control pills $__________ Chiropractor fees $__________ Contact Lenses/Eyeglasses $__________ Dental Expenses $200.00 Hospital Services $__________ Orthodontics $__________ Other $__________ TOTAL $2,320.00 24 = $96.67 Pay period Deductions per pay period (The total divided by the number of paychecks you receive will be deducted from your pay before taxes are calculated) **This amount will be deducted from your pay and deposited into accounts from which you will request reimbursement fro eligible expenses. A comprehensive FSA Savings Calculator is available on the web-site www.FSAandYou.com. The calculations are done automatically for you based on the information you provide.
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