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Health Care Expense Calculator

Worksheet to Determine Eligible Expenses

Use this worksheet to help you decide how much to put into your health care spending account. Follow these steps:
  1. Enter the annual health care plan deductibles and copayments (where they apply) for you and your family.
  2. Review your out-of-pocket expenses for the past year to help estimate upcoming expenses. Keep in mind:
    • If the expenses are covered by a medical or dental plan, enter your share of the costs. For example, if the expense is $200 and your coinsurance is 20%, you would enter $40.
    • If the expense is not covered by a medical or dental plan, enter the whole amount.
    • View list of ELIGIBLE HEALTH CARE EXPENSES
  3. The estimated expenses will then be added up at the bottom. Be sure to consider the out-of-pocket limit.

Description

Estimated Annual Out-of-Pocket Expenses

Deductibles
Doctor Visits
Surgical Expenses
Prescription Drugs
Routine Physical Exam
Well-baby Care
Mental Health/Substance Abuse Aid
Other Medical Expenses
Dental Care
Orthodontics
Vision Care
Hearing Care
Other Eligible Expenses
Total