Download NGS American, Inc

NGS American, Inc.
P.O. Box 7680
St. Clair Shores, MI 48080-7680
(800) 521-1555
Fax: (586) 416-2362
FLEXIBLE
COMPENSATION
Planning Worksheet
FLEXIBLE COMPENSATION PLANNING WORKSHEET
ELIGIBLE HEALTH RELATED EXPENSES
There are many health related expenses you pay for out-of-pocket, even though you have insurance, such as deductibles, copays and coinsurance. You can pay for many of these expenses with pre-tax dollars by putting part of your paycheck into a
flexible spending account. This means that you do not pay federal, state or FICA taxes on that portion of your paycheck which
you put aside for those expenses for the plan year. With a flexible spending account, you pay for health related expenses as
usual, then you submit a request for reimbursement for these expenses from your pre-tax flexible spending account or you use
a flex spending account debit card and send in verification of expenses when requested.
Use this planning worksheet to determine your estimated eligible annual medical/dental/vision expenses. Begin by reviewing
medical, dental and vision expenses you paid last year. Then, plan your estimated expenses for the coming plan year.
Remember to be conservative, since unused money will be forfeited in accordance with IRS regulations. Also, be certain to read
your summary plan description and other available material for information on eligible expenses and requirements for
submitting claims for reimbursement. See your HR representative with questions.
ELIGIBLE HEALTH RELATED EXPENSES
LAST YEAR’S
EXPENSES
NEXT YEAR’S
ESTIMATED EXPENSES
Deductibles
Co-payments
Co-insurance
Office Visits
Lab Fees
Prescriptions
Routine Exams
Immunizations
Dental Care
Orthodontic Care (subject to certain
requirements-call NGS)
Vision Care
Eyeglasses, Contacts & Corrective Surgery
Hearing Care
Other eligible expenses not covered by ins.
TOTAL ANNUAL ELIGIBLE EXPENSES
Examples of I neligible Health Care Expenses:
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Any over-the-counter drugs, vitamins or supplements without a letter of medical necessity for your physician
Any illegal treatment or controlled substance dispensed in violation of federal law
Household allergy treatments & improvements (filters, pillows, special vacuums)
Cosmetic procedures, surgeries, medicines, products
Weight reduction programs for general well-being
Athletic or health club membership
Insurance premiums of any type
Teeth bleaching or whitening
Fitness programs
Maternity clothes
Household help
Safety glasses
Revised 01/11