The following worksheet can help you estimate your health care expenses for the year:
Last Year’s Estimate
This Year’s Estimate
Medical
• Medical plan deductible • Medical plan copayments (portion of covered expenses that you pay, such as copayments for physician office visits and prescription drugs) • Expenses not paid or only partially paid by medical plan, such as -physical exam costs -hearing exams and hearing aids -doctor and hospital costs above the covered amount(such as extra charges for private rooms or fees above R&C limits) -family planning costs not covered • Other
$_______ $_______ $_______ $_______
$_______ $_______ $_______ $_______
Vision Care
• Fee for eye examination not covered • Cost of eyeglasses or contact lenses not covered • Contact lens solution • Other
$_______ $_______ $_______ $_______
$_______ $_______ $_______ $_______
Dental
• Dental plan deductibles • Copayments on major services such as crowns, bridges, and dentures • Expenses exceeding plan maximums or fees exceeding R&C limits • Expenses not paid or only partially paid by the plan, including orthodontia • Other
$_______ $_______ $_______ $_______ $_______
$_______ $_______ $_______ $_______ $_______
Total:
$_______
$_______*
*This is the maximum amount you would want to contribute to your Health Care Reimbursement Account. You may want to contribute less if you’re not sure of all your expenses. Remember, the use it or lose it rule, any money remaining at year end for which you have no eligible expenses will be forfeited back to the employer.
