Health Care Flexible Spending Account Estimator

Enter your expected health care expenses for 2012 (January 1 - December 31) that are eligible for reimbursement under the Health Care Flexible Spending Account. Information about eligible expenses is available at www.irs.gov in IRS Publication 502. The Choice® POS II HSA option has a Limited Purpose Health Care Flexible Spending Account that limits the expenses reimbursed before you reach the plan deductible. After you reach your deductible, the Limited Purpose Health Care FSA works like a Standard Health Care FSA. Until it becomes a Standard Health Care FSA, you can use the account for dental and vision costs only until your deductible is met then it will become a Standard Health Care FSA.

Please enter amounts in whole dollars (no decimal point, comma or dollar sign).

Types of Health Care Expenses 2012 Projected Health Care Expenses
HRA Option Health Care FSA HSA Option Limited Purpose
Health Care FSA
Medical deductibles, copayments and coinsurance, as well as your cost for expenses that are not covered by a TECO medical plan (your total cost of care from the Medical Cost Estimator other than annual deductions from paychecks) or another medical plan in which you are enrolled: $  
Vision care expenses, including vision care costs and other qualified expenses not covered by a vision or medical benefit: $ $
Dental Plan deductibles and coinsurance (your share of the total cost for covered services including orthodontics, after the deductible is met): $ $
Other qualified dental expenses not covered by the Dental Plan: $ $
Any other health care expenses not reimbursed by a health plan that could qualify as a deductible expense on your federal income tax return: $  

Income Tax Filing Information (to help estimate your tax savings)
Level of coverage
Salary Band
Filing status (required field): Number of dependents:
Do not include yourself or your spouse.
Your total annual income:
Enter estimated income for 2012 from all sources you would include on your tax form, including wages, bonus, investment income, etc.

Look at Employee Self Service (ESS) https://selfservice.tecoenergy.com to obtain your most current salary information. Do not include a decimal point, comma or dollar sign when entering income.

$
Your spouse's total annual income:
Enter estimated income for 2012 from all sources your spouse would include on your tax form, including wages, bonus, investment income, etc.

$

to determine the following: