FSA Worksheet

Estimate the medical expenses you anticipate to pay out of your own pocket (not covered by insurance) during the year.

Annual Expense Amounts:

$
$
$
$
$
$
$
$
=
#
=
=

*Beginning January 1, 2015, the maximum employee contribution permitted by tax law to a Health FSA is $2,600 per calendar year. Reminder, whatever amount you contribute to your Health FSA and do not receive as reimbursement for qualified medical expenses will be lost at the end of the plan year (or grace period if applicable). Therefore, it is important to be conservative when determining your annual contribution. Your annual contribution cannot exceed the maximum amount permitted in your plan by your employer. A Health FSA Account is only for expenses incurred by qualified individuals during the plan year and grace period.