HSA Savings Calculation Worksheet

  Expenses Without HSA Savings Without HSA Expenses With HSA Savings With HSA
Plan Specifications Deductible: $
Coinsurance:
Deductible: $
Coinsurance:
Estimated Annual Medical Expenses
Annual Premiums (A)
HSA Contribution (B) + +
Tax Savings on Premium:
Premium:
Tax Rate:
Allowable Deduction: (C)


x



-


x



-
Tax Savings on HSA:
HSA Contribution:
Tax Rate: (D)


x


-


x


-
Out of Pocket to Cover Deductible: (E) + +
Out of Pocket to Cover Coinsurance: (F) + +
Total Out of Pocket Costs
=(A+B) - (C+D) + (E+F)
Amount of Current Year HSA Contribution Not Spent (You keep)

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