Search This Site:

Health Care Spending Account What Is The Health Care Spending Account? Who Is Eligible To Enroll? How Do I Enroll? Eligible Expenses Ineligible Expenses Changes In Status HCSAccount Claims Process Payroll Changes Saving With The HCSAccount Health Care Spending Account Worksheet Health Care Spending Account Forms         Message From The Director Overview Health Care Spending Account Dependent Care Advantage Account Frequently Asked Questions NYS Flexspend Home   Health Care Spending Account Worksheet To help you plan the amount of your Health Care Spending Account contribution, use this worksheet. You may want to look at what you spent on health care last year before making your decision. Include annual estimated expenses for health care services rendered in the upcoming Plan Year that will not be reimbursed by your medical, dental or other benefit plans. Type of Expense Amount per Year MEDICAL EXPENSES, SUCH AS: Health Plan Deductible: Office Visit and Hospital Copayments: Prescription Drug Copayments: Routine Physicals: Non-covered Prescriptions: Hearing Aids: Planned, Non-covered Medical Procedures: Other Eligible Expenses: DENTAL EXPENSES, SUCH AS: Deductibles and Copayments: Routine Check-ups, Cleaning and X-rays: Orthodontia (braces, etc.): Planned dental work (crowns, dentures, dental implants, etc.): VISION CARE EXPENSES, SUCH AS: Exams: Eyeglasses: Corrective contact lenses & contact lens solutions: Total Estimated Out-Of-Pocket Health Care Expenses: Back to Table of Contents

This Page Last Updated: Thursday, September 20, 2001 at 11:00:58 AM

Flex Spending Account Home | Contact Flex Spending Staff | Our Accuracy Statement Message From The Director | Overview Health Care Spending Account | Dependent Care Advantage Account Forms | Request 2002 Enrollment Kit | Tax Savings Calculators Frequently Asked Questions | Online Account Information | Privacy Policy