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) |
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| Amount of Current Year HSA Contribution Not Spent (You keep) |
