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      .33

 

 

 

 

-         

 

 

 

x     .33

 

 

 

 

-          

Tax Savings on HSA:

HSA Contribution:

Tax Rate: (D)

 

0

x     .33

 

 

-         

 

 

x     .33

 

 

-          

Out of Pocket to Cover Deductible: (E)

 

+         

 

 

 

+         

 

Out of Pocket to Cover Coinsurance: (F)

 

+         

 

 

+       0

 

Total Out of Pocket Costs

=(A+B) - (C+D) + (E+F)

 

 

 

 

 

 

 

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

 

 

 

0

 

The tax rate shown here is 33%. Change this number if your tax bracket is different.

 

Currently, the IRS allows a 70% deduction on health insurance premiums for self employed individuals.