Benefits Plans - Flexible Spending Accounts: Health Care -
Health Care Expenses Worksheet

Print the worksheet to help you estimate your annual medical expenses, or use the PayFlex Medical Expense Planning Worksheet or the Savings Calculator.

Health Care Expenses Worksheet

Health Care Expenses You Paid Last Year Estimated Expenses You Expect to Pay
(From your effective date* through March 15 of the following year)
Deductibles and Co-pays    
Routine Physical Exams    
Physician's Office/Clinic Visits    
Dental Care (including co-pays, fluoride treatments, orthodontia)    
Vision Care (exams, glasses, contacts, solutions)    
Hearing Care/Hearing Aids    
Prescription Drugs (including co-pays)    
Over-the-counter medications    
Immunizations/Well Baby Care    
Mental Health Care    
X-rays/Laboratory Tests    
TOTAL    

*Effective Date: If you enroll during Open Enrollment, your effective date is January 1. Otherwise your account becomes effective the first of the month following the date the enrollment form is received by SSC Benefits Transactions, your date of hire, or the date you become newly-eligible, whichever is later. For example, if your date of hire is March 1, and your Flexible Spending Account enrollment form is received March 10, your account becomes effective April 1, and only eligible expenses incurred on or after your April 1 effective date through March 15 of the following year would be eligible for reimbursement from your current FSA. You must re-enroll each year you wish to participate.

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Limitations
The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.