Wells Fargo

Wells Fargo HSA plan comparison

Use this worksheet to compare the cost of health plans from which you can choose. The worksheet allows you to compare your healthcare premium (or contribution) for a traditional healthcare plan and an HSA-eligible plan. It also allows you to compare the deductible of your plan options. The deductible is the amount you will need to pay out of pocket before your health plan benefits begin.

Note: complete the fields in gray. If you have more than one plan to compare, enter the details of each plan separately.

   

Health plan option #1

 

HSA-eligible
health plan option

Your monthly or bi-weekly cost for healthcare plan

 

$

 

$

Number of annual payments for health plan (12, 24, or 26)

x


x


Total annual cost of health plan for you

 

$1,872

 

$768

         

Cost savings of HSA plan over other plan options

 

NA

 

$1,104

Enter amount your employer contributes to your HSA

+

NA


+

$


HSA contribution with no change to your take-home pay

 

NA

 

$1,854

         

Enter the deductible amount for each health plan option

 

$

 

$

HSA contribution with no change to your take-home pay

-

NA


-

$1,854


Effective deductible for plan options (for HSA-eligible plan the HSA contribution offsets the actual deductible)

 

$350

 

$(354)

 

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More information about this worksheet

For this worksheet, we assume that you will fund your HSA with the savings you get from the difference in cost between your traditional health plan option and that of the HSA-eligible option. You can also enter the amount of any HSA contribution your employer offers. When you offset the deductible with the savings you get from the funds in your HSA that were placed there with no direct cost to you (savings from other plans plus employer HSA contributions), it's called the effective deductible. This is the amount you are responsible for paying.

You may find that the effective deductible for your HSA-eligible plan is less than that of your traditional plan options, which means your out of pocket costs could be lower with the HSA-eligible plan. The funds in your HSA are also yours to keep, so if you don't spend them you can carry them over, year after year, even if you leave your employer or change health plans.

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  1. All tax references are at the federal level. State taxes vary. Please consult with your tax advisor.
  2. INVESTMENT PRODUCTS: NOT FDIC INSURED • NO BANK GUARANTEE • MAY LOSE VALUE

© 2012 Wells Fargo Health Benefit Services, a Division of Wells Fargo Bank, N.A.