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Instruksi Bentuk 8853

Instruksi untuk Form 8853, Archer MSAs dan Kontrak Asuransi Perawatan Panjang Term

Rev. 2023

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  • Formulir 8853 - Pemanah Archer MSAs dan Kontrak Asuransi Keperawatan Panjang Term
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Department of the Treasury  
Internal Revenue Service  
2023  
Instructions for Form 8853  
Archer MSAs and Long-Term Care Insurance Contracts  
Section references are to the Internal Revenue Code  
unless otherwise noted.  
You (or your spouse, if filing jointly) acquired an interest  
in an Archer MSA or a Medicare Advantage MSA because  
of the death of the account holder. See Death of Account  
Holder, later.  
Future Developments  
For the latest information about developments related to  
Form 8853 and its instructions, such as legislation  
enacted after they were published, go to IRS.gov/  
You (or your spouse, if filing jointly) were a policyholder  
who received payments under an LTC insurance contract  
or received any accelerated death benefits from a life  
insurance policy on a per diem or other periodic basis in  
2023. See the instructions for Section C, later.  
You (or your spouse, if filing jointly) received Archer  
MSA or Medicare Advantage MSA distributions in 2023.  
What’s New  
If you (or your spouse, if filing jointly) received  
Q&As on certain qualified medical expenses. You can  
find answers to questions regarding whether certain costs  
related to nutrition, wellness, and general health are  
medical expenses that may be paid or reimbursed under  
Archer MSA or Medicare Advantage MSA  
!
CAUTION  
distributions in 2023, you must file Form 8853 with  
Form 1040, 1040-SR, or 1040-NR even if you have no  
taxable income or any other reason for filing Form 1040,  
1040-SR, or 1040-NR.  
Specific Instructions  
General Instructions  
Name and social security number (SSN). Enter your  
name(s) and SSN as shown on your tax return. If filing  
jointly and both you and your spouse each have an Archer  
MSA or each have a Medicare Advantage MSA, enter the  
SSN shown first on your tax return.  
After December 31, 2007, contributions can't be  
made to an Archer Medical Savings Account for  
!
CAUTION  
you, unless:  
You were an active Archer MSA participant for any tax  
year ending before January 1, 2008, or  
Section A—Archer MSAs  
Eligible Individual  
To be eligible for an Archer MSA, you (or your spouse)  
must be an employee of a small employer or be  
You became an active Archer MSA participant for a tax  
year ending after December 31, 2007, because of  
coverage under a high deductible health plan (HDHP) of  
an Archer MSA participating employer.  
self-employed. You (or your spouse) must be covered  
under an HDHP and have no other health coverage  
except permitted coverage. You must not be enrolled in  
Medicare and can't be another person’s dependent. You  
must be an eligible individual on the first day of a month to  
take an Archer MSA deduction for that month.  
Purpose of Form  
Use Form 8853 to:  
Report Archer MSA contributions (including employer  
contributions),  
Figure your Archer MSA deduction,  
Report distributions from Archer MSAs or Medicare  
Small Employer  
A small employer is generally an employer who had an  
average of 50 or fewer employees during either of the last  
2 calendar years. See Pub. 969 for details.  
Advantage MSAs,  
Report taxable payments from long-term care (LTC)  
insurance contracts, or  
Report taxable accelerated death benefits from a life  
insurance policy.  
Archer MSA  
Generally, an Archer MSA is a medical savings account  
set up exclusively for paying the qualified medical  
expenses of the account holder.  
Additional information. See Pub. 969, Health Savings  
Accounts and Other Tax-Favored Health Plans, for more  
details on MSAs.  
Who Must File  
Qualified Medical Expenses  
You must file Form 8853 if any of the following applies.  
Generally, qualified medical expenses for Archer MSA  
purposes are unreimbursed medical expenses that could  
otherwise be deducted on Schedule A (Form 1040). See  
the Instructions for Schedule A (Form 1040), and Pub.  
502, Medical and Dental Expenses. Qualified medical  
You (or your employer) made contributions for 2023 to  
your Archer MSA.  
You are filing a joint return and your spouse (or their  
employer) made contributions for 2023 to your spouse's  
Archer MSA.  
Jul 12, 2023  
Cat. No. 24188L  
 
expenses are those incurred by the account holder or the  
account holder's spouse or dependent(s). Amounts paid  
for menstrual care products shall be treated as paid for  
medical care. See the instructions for Line 7, later. You  
can't treat insurance premiums as qualified medical  
expenses unless the premiums are for:  
If the designated beneficiary isn't the account holder's  
surviving spouse, or there is no designated beneficiary,  
the account ceases to be an Archer MSA as of the date of  
death. The beneficiary completes Form 8853 as follows.  
Enter “Death of Archer MSA account holder” across the  
top of Form 8853.  
LTC insurance,  
Enter the name(s) shown on the beneficiary's tax return  
Health care continuation coverage, or  
Health care coverage while receiving unemployment  
and the beneficiary's SSN in the spaces provided at the  
top of the form and skip Part I.  
compensation under federal or state law.  
On lines 6a and 6c, enter the fair market value of the  
Archer MSA as of the date of death.  
You can find answers regarding whether certain costs  
related to nutrition, wellness, and general health are  
medical expenses that may be paid or reimbursed under  
On line 7, for a beneficiary other than the estate, enter  
qualified medical expenses incurred by the account holder  
before the date of death that you paid within 1 year after  
the date of death.  
Complete the rest of Part II.  
If the account holder's estate is the beneficiary, the fair  
High Deductible Health Plan  
An HDHP is a health plan that meets the following  
requirements.  
market value of the Archer MSA as of the date of death is  
included in the account holder's final income tax return.  
Complete Form 8853 as described above, except you  
should complete Part I, if applicable.  
Self-only  
coverage  
Family  
coverage  
The transfer isn't subject to the additional 20% tax.  
Report any earnings on the account after the date of death  
as income on your tax return.  
Minimum annual deductible  
Maximum annual deductible  
$2,650  
$5,300  
$3,950  
$7,900  
Note. If, during the tax year, you are the beneficiary of two  
or more Archer MSAs or you are a beneficiary of an  
Archer MSA and you have your own Archer MSA, you  
must complete a separate Form 8853 for each Medicare  
Advantage MSA. Enter “statement” at the top of each  
Form 8853 and complete the form as instructed. Next,  
complete a controlling Form 8853, combining the amounts  
shown on each of the statement Forms 8853. Attach the  
statements to your paper tax return after the controlling  
Form 8853.  
Maximum annual out-of-pocket  
expenses (other than for premiums)  
$5,300  
$9,650  
Other Health Coverage  
If you have an Archer MSA, you (and your spouse, if you  
have family coverage) can't have any health coverage  
other than an HDHP. However, your spouse can have  
health coverage other than an HDHP if you aren't covered  
by that plan.  
Deemed Distributions From Archer MSAs  
The following situations result in deemed distributions  
from your Archer MSA.  
Exceptions. You can have additional insurance that  
provides benefits only for:  
Liabilities under workers' compensation laws, tort  
You engaged in any transaction prohibited by section  
liabilities, or liabilities arising from the ownership or use of  
property;  
4975 with respect to any of your Archer MSAs at any time  
in 2023. Your account ceases to be an Archer MSA as of  
January 1, 2023, and you must include the fair market  
value of all assets in the account as of January 1, 2023,  
on line 6a.  
A specific disease or illness; or  
A fixed amount per day (or other period) of  
hospitalization.  
You can also have coverage (either through insurance  
or otherwise) for accidents, disability, dental care, vision  
care, or long-term care. See Other health coverage in Pub.  
969, Health Savings Accounts and Other Tax-Favored  
Health Plans, for additional information about exceptions.  
You used any portion of any of your Archer MSAs as  
security for a loan at any time in 2023. You must include  
the fair market value of the assets used as security for the  
loan as income on Schedule 1 (Form 1040), line 8e.  
Any deemed distribution won't be treated as used to  
pay qualified medical expenses. Generally, these  
distributions are subject to the additional 20% tax.  
Disabled  
An individual is generally considered disabled if they are  
unable to engage in any substantial gainful activity due to  
a physical or mental impairment that can be expected to  
result in death or to continue indefinitely.  
Part I—Archer MSA Contributions and  
Deductions  
Use Part I to figure:  
Death of Account Holder  
Your Archer MSA deduction,  
If the account holder's surviving spouse is the designated  
beneficiary, the Archer MSA is treated as if the surviving  
spouse were the account holder. The surviving spouse  
completes Form 8853 as though the Archer MSA  
belonged to them.  
Any excess contributions you made, and  
Any excess contributions made by an employer (see  
-2-  
Instructions for Form 8853 (2023)  
     
c. If both spouses have HDHPs with self-only  
coverage, complete a separate Form 8853, Section A,  
Part I, for each spouse. Enter “statement” across the top  
of each Form 8853, fill in the name and SSN, and  
complete Part I. Next, add lines 1, 2, and 5 from the two  
statement Forms 8853 and enter those totals on the  
respective lines of the controlling Form 8853 (the  
combined Form 8853 for both spouses). Don't complete  
lines 3 and 4 of the controlling Form 8853. Attach the two  
statement Forms 8853 to your paper tax return after the  
controlling Form 8853.  
Figuring Your Archer MSA Deduction  
The amount you can deduct for Archer MSA contributions  
is limited by:  
The applicable portion of the HDHP's annual deductible  
(line 3), and  
Your compensation from the employer maintaining the  
HDHP (line 4).  
Any employer contributions made to your Archer MSA  
prevent you from making deductible contributions. See  
you or your spouse made contributions in addition to any  
employer contributions, you may have to pay an additional  
tax. See Excess Contributions You Make, later.  
You can't deduct any contributions you made after you  
became enrolled in Medicare. Also, you can't deduct  
contributions if you are someone else’s dependent.  
Line 1  
Employer Contributions  
Employer contributions include any amount an employer  
contributes to any Archer MSA for you or your spouse for  
2023. These contributions should be shown in box 12 of  
Form W-2 with code R. If your employer made excess  
contributions, you may have to report the excess as  
income. See Excess Employer Contributions, later, for  
details.  
Employer Contributions to an Archer MSA  
If an employer made contributions to your Archer MSA,  
you aren't entitled to a deduction. If you and your spouse  
are covered under an HDHP with family coverage and an  
employer made contributions to either of your Archer  
MSAs, neither you nor your spouse is allowed to make  
deductible contributions to an Archer MSA. If you and your  
spouse both have an HDHP with self-only coverage and  
only one of you received employer contributions to an  
Archer MSA, the other spouse is allowed to make  
deductible contributions to an Archer MSA.  
Line 2  
Include on line 2 contributions you made to your Archer  
MSA in 2023. Also include those contributions made from  
January 1, 2024, through April 15, 2024, that were for  
2023. Don't include amounts rolled over from another  
Archer MSA. See Rollovers, later.  
Line 3  
How To Complete Part I  
Go through the chart at the top of the Line 3 Limitation  
Chart and Worksheet for each month of 2023. Enter the  
result on the worksheet next to the corresponding month.  
Enter the amount from the last line of the worksheet on  
line 3.  
Complete lines 1 through 5 as instructed on the form  
unless (1) or (2), next, applies.  
1. If employer contributions to an Archer MSA prevent  
you from taking a deduction for amounts you contributed  
to your Archer MSA, complete Part I as follows.  
If eligibility and coverage for both you and your  
a. Complete lines 1 and 2.  
b. Skip lines 3 and 4.  
c. Enter -0- on line 5.  
spouse didn't change from one month to the next,  
enter the same number you entered for the  
TIP  
previous month. If eligibility and coverage didn't change  
during the entire year, figure the number for January only,  
and enter this amount on Form 8853, line 3.  
d. If line 2 is more than zero, see Excess Contributions  
You Make, later.  
More than one HDHP. If you and your spouse had more  
than one HDHP on the first day of the month and one of  
the plans provides family coverage, use the Family  
coverage rules on the chart and disregard any plans with  
self-only coverage. If you and your spouse both have  
HDHPs with family coverage on the first day of the month,  
you both are treated as having only the family coverage  
plan with the lowest annual deductible.  
2. If you and your spouse have more than one Archer  
MSA, complete Part I as follows.  
a. If either spouse has an HDHP with family coverage,  
you both are treated as having only the family coverage  
plan. Disregard any plans with self-only coverage.  
b. If both spouses have HDHPs with family coverage,  
you both are treated as having only the family coverage  
plan with the lowest annual deductible.  
Instructions for Form 8853 (2023)  
-3-  
 
Line 3 Limitation Chart and Worksheet  
Before you begin: √ See the instructions for line 3.  
√ Go through this chart for each month of 2023.  
√ Keep for your records.  
Start Here  
Yes  
Were you enrolled in Medicare for the month?  
No  
Were you an eligible individual (see Eligible  
Individual, earlier) on the ꢀrst day of the  
month?  
Enter -0- on  
the line below  
for the month.  
No  
Yes  
What type of coverage did your HDHP provide on the ꢀrst day of the month?  
If you had more than one HDHP, see More than one HDHP, earlier.  
Self-only coverage  
Family coverage  
Enter annual deductible  
(must be at least $2,650 but  
not more than $3,950).  
$
Enter annual deductible  
(must be at least $5,300 but  
not more than $7,900).  
$
Enter 65% (0.65) of the annual  
deductible on the line below  
for the month.  
Enter 75% (0.75) of the annual  
deductible on the line below  
for the month. If married ꢀling  
separately, see Married filing  
separately.  
Amount from  
chart above  
Month in 2023  
January  
. . . . . . . . . . . . . . . . . $  
February . . . . . . . . . . . . . . . . . $  
March . . . . . . . . . . . . . . . . . . $  
April . . . . . . . . . . . . . . . . . . . $  
May . . . . . . . . . . . . . . . . . . . $  
June . . . . . . . . . . . . . . . . . . . $  
July . . . . . . . . . . . . . . . . . . . $  
August . . . . . . . . . . . . . . . . . . $  
September . . . . . . . . . . . . . . . . $  
October  
. . . . . . . . . . . . . . . . . $  
. . . . . . . . . . . . . . . . $  
. . . . . . . . . . . . . . . . $  
November  
December  
Total for all months . . . . . . . . . . . . . $  
Limitation. Divide the total by 12.  
Enter here and on line 3  
. . . . . . . . . . . . $  
-4-  
Instructions for Form 8853 (2023)  
 
You make the withdrawal by the due date, including  
Married filing separately. If you have an HDHP with  
family coverage and are married filing separately, enter  
only 37.5% (0.375) (one-half of 75%) of the annual  
deductible for each month on the worksheet; or, if you and  
your spouse agree to divide the 75% of the annual  
deductible in a different manner, enter your share.  
extensions, of your 2023 tax return (but see the Note  
below);  
You don't claim an exclusion from income for the  
amount of the withdrawn contributions; and  
You also withdraw any income earned on the withdrawn  
contributions and include the earnings in “Other income”  
on your tax return for the year you withdraw the  
contributions and earnings.  
Line 4  
Compensation  
Note. If you timely filed your return without withdrawing  
the excess contributions, you can still make the withdrawal  
no later than 6 months after the due date of your tax  
return, excluding extensions. If you do, file an amended  
return with “Filed pursuant to section 301.9100-2” written  
at the top. Include an explanation of the withdrawal. Make  
all necessary changes on the amended return (for  
example, if you reported the contributions as excess  
contributions on your original return, include an amended  
Form 5329 reflecting that the withdrawn contributions are  
no longer treated as having been contributed).  
Compensation includes wages, salaries, professional  
fees, and other pay you receive for services you perform.  
It also includes sales commissions, commissions on  
insurance premiums, pay based on a percentage of  
profits, tips, and bonuses. Generally, these amounts are  
included on the Form(s) W-2 you receive from your  
employer(s). Compensation also includes net earnings  
from self-employment, but only for a trade or business in  
which your personal services are a material  
income-producing factor. This is your income from  
self-employment minus expenses (including the  
deductible part of self-employment tax). Compensation  
doesn't include any amounts received as a pension or  
annuity and doesn't include any amount received as  
deferred compensation.  
Deducting an Excess Contribution in a Later Year  
You may be able to deduct excess contributions for  
previous years that are still in your Archer MSA. The  
excess contribution you can deduct in the current year is  
the lesser of the following two amounts.  
Line 5  
If you (or your employer) contributed more to your Archer  
MSA than is allowable, you may have to pay an additional  
tax on the excess contributions. Figure the excess  
contributions using the following instructions. See Form  
5329, Additional Taxes on Qualified Plans (Including IRAs)  
and Other Tax-Favored Accounts, to figure the additional  
tax.  
Your maximum Archer MSA contribution limit for the  
year minus any amounts contributed to your Archer MSA  
for the year.  
The total excess contributions in your Archer MSA at  
the beginning of the year.  
Any excess contribution remaining at the end of a tax  
year is subject to the additional tax. See Form 5329.  
Excess Contributions You Make  
Part II—Archer MSA Distributions  
Line 6a  
Enter the total distributions you and your spouse received  
in 2023 from all Archer MSAs. These amounts should be  
shown in box 1 of Form 1099-SA.  
To figure your excess contributions, subtract your  
deductible contributions (line 5) from your actual  
contributions (line 2). However, you can withdraw some or  
all of your excess contributions for 2023, and they will be  
treated as if they hadn't been contributed if:  
You make the withdrawal by the due date, including  
extensions, of your 2023 tax return (but see the Note  
under Excess Employer Contributions below);  
Line 6b  
Include on line 6b any distributions you received in 2023  
that were rolled over. See Rollovers below. Also include  
any excess contributions (and the earnings on those  
excess contributions) included on line 6a that were  
withdrawn by the due date, including extensions, of your  
return. See the instructions for line 5, earlier.  
You don't claim a deduction for the amount of the  
withdrawn contributions; and  
You also withdraw any income earned on the withdrawn  
contributions and include the earnings in “Other income”  
on your tax return for the year you withdraw the  
contributions and earnings.  
Rollovers  
Excess Employer Contributions  
A rollover is a tax-free distribution (withdrawal) of assets  
from one Archer MSA that is reinvested in another Archer  
MSA or a health savings account (HSA) of the same  
account holder. Generally, you must complete the rollover  
within 60 days following the distribution. An Archer MSA  
and an HSA can receive only one rollover contribution in a  
1-year period. See Pub. 590-A, Contribution to Individual  
Retirement Arrangements (IRAs), for more details and  
additional requirements regarding rollovers.  
Excess employer contributions are the excess, if any, of  
your employer's contributions over the smaller of (a) your  
limitation on line 3, or (b) your compensation from the  
employer(s) who maintained your HDHP (line 4). If the  
excess wasn't included in income on Form W-2, you must  
report it as “Other income” on your tax return. However,  
you can withdraw some or all of the excess employer  
contributions for 2023, and they will be treated as if they  
hadn't been contributed if:  
Instructions for Form 8853 (2023)  
-5-  
       
Note. If you instruct the trustee of your Archer MSA to  
transfer funds directly to the trustee of another of your  
Archer MSAs, the transfer isn't considered a rollover.  
There is no limit on the number of these transfers. Don't  
include the amount transferred in income, deduct it as a  
contribution, or include it as a distribution on line 6a.  
line 9b only 20% (0.20) of any amount included on line 8  
that doesn't meet any of the exceptions.  
Example 1. You turned age 66 in 2023 and had no  
Archer MSA during 2023. Your spouse turned age 63 in  
2023 and received a distribution from an Archer MSA that  
is included in income. Don't check the box on line 9a  
because your spouse (the account holder) didn't meet the  
age exception for the distribution. Enter 20% of the  
amount from line 8 on line 9b.  
Line 7  
In general, include on line 7 distributions from all Archer  
MSAs in 2023 that were used for the qualified medical  
expenses (see Qualified Medical Expenses, earlier) of:  
Example 2. Both you and your spouse received  
distributions from your Archer MSAs in 2023 that are  
included in income. You were age 65 at the time you  
received the distributions and your spouse was age 63  
when they received the distributions. Check the box on  
line 9a because the additional 20% tax doesn't apply to  
the distributions you received (because you met the age  
exception). However, the additional 20% tax does apply to  
your spouse's distributions. Enter on line 9b only 20% of  
the amount of your spouse's distributions included on  
line 8.  
Example 3. You turned age 65 in 2023. You received  
distributions that are included in income both before and  
after you turned age 65. Check the box on line 9a because  
the additional 20% tax doesn't apply to the distributions  
made after the date you turned age 65. However, the  
additional 20% tax does apply to the distributions made  
on or before the date you turned age 65. Enter on line 9b,  
20% of the amount of these distributions included on  
line 8.  
1. Yourself and your spouse;  
2. All your dependents; and  
3. Any person who would be your dependent except  
that:  
a. The person filed a joint return;  
b. The person had gross income of $4,700 or more; or  
c. You, or your spouse if filing jointly, are dependents  
of someone else.  
For this purpose, a child of parents who are  
divorced, separated, or living apart for the last 6  
months of the calendar year is treated as the  
TIP  
dependent of both parents whether or not the custodial  
parent releases the claim to the child as their dependent.  
However, if you or your employer made a contribution to  
your Archer MSA in 2023 and you used withdrawals to pay  
expenses for an individual who wasn't covered by an  
HDHP or was covered by a plan that wasn't an HDHP  
(other than the exceptions listed under Other Health  
Coverage, earlier) at the time the expenses were incurred,  
then you shouldn't include those withdrawals on line 7.  
Example. In 2023, you were covered by an HDHP with  
self-only coverage and your spouse was covered by a  
health plan that wasn't an HDHP. You made contributions  
to an Archer MSA for 2023. You can't include on line 7  
withdrawals made from the Archer MSA to pay your  
spouse's medical expenses incurred in 2023 because  
your spouse was covered by a plan that wasn't an HDHP.  
Section B—Medicare Advantage MSA  
Distributions  
Complete Section B if you (or your spouse, if filing jointly)  
received distributions from a Medicare Advantage MSA in  
2023. If both you and your spouse received distributions,  
complete a separate Form 8853, Section B, for each  
spouse. Enter “statement” across the top of each Form  
8853, fill in the name and SSN, and complete Section B.  
Next, add lines 10, 11, 12, and 13b from the two  
statement Forms 8853 and enter those totals on the  
respective lines of the controlling Form 8853 (the  
combined Form 8853 for both spouses). If either spouse  
checked the box on line 13a of the statement Form 8853,  
check the box on the controlling Form 8853. Attach the  
two statement Forms 8853 to your paper tax return after  
the controlling Form 8853.  
You can't take a deduction on Schedule A (Form  
1040) or Schedule A (Form 1040-NR) for any  
!
CAUTION  
amount you include on line 7.  
Lines 9a and 9b  
Additional 20% Tax  
If you (or your spouse, if filing jointly) received  
distributions from a Medicare Advantage MSA in  
!
CAUTION  
2023, you must file Form 8853 with a Form 1040,  
Archer MSA distributions included in income (line 8) are  
subject to an additional 20% tax unless one of the  
following exceptions applies.  
1040-SR, or 1040-NR even if you have no taxable income  
or any other reason for filing Form 1040, 1040-SR, or  
1040-NR.  
Exceptions to the Additional 20% Tax  
Medicare Advantage MSA  
A Medicare Advantage MSA is an Archer MSA designated  
as a Medicare Advantage MSA to be used solely to pay  
the qualified medical expenses of the account holder. To  
be eligible for a Medicare Advantage MSA, you must be  
enrolled in Medicare and have an HDHP that meets the  
Medicare guidelines. Contributions to the account can be  
made only by Medicare. The contributions and any  
earnings, while in the account, aren't taxable to the  
The additional 20% tax doesn't apply to distributions  
made after the date that the account holder:  
Dies,  
Becomes disabled (see Disabled, earlier), or  
Turns age 65.  
If any of the exceptions applies to any of the distributions  
included on line 8, check the box on line 9a. Enter on  
-6-  
Instructions for Form 8853 (2023)  
 
Keep for Your Records  
Additional 50% Tax Worksheet—Line 13b  
1. Enter the total distributions included on Form 8853, line 12, that don't meet either of the exceptions to the additional  
50% tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
1.  
2. Did you have a Medicare Advantage MSA on December 31, 2022?  
STOP  
No.  
Enter one-half of line 1 above on Form 8853, line 13b.  
2.  
4.  
Yes. Enter the value of your Medicare Advantage MSA on December 31, 2022 . . . . . . . . .  
3. Enter the amount of the annual deductible for your HDHP policy on  
January 1, 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3.  
4. Multiply line 3 by 60% (0.60) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Subtract line 4 from line 2. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
6. Subtract line 5 from line 1. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
7. Enter one-half of line 6 here and on Form 8853, line 13b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5.  
6.  
7.  
account holder. A distribution used exclusively to pay for  
the qualified medical expenses of the account holder isn't  
taxable. Distributions that aren't used for qualified medical  
expenses of the account holder are included in income  
and also may be subject to a penalty.  
instructed. Next, complete a controlling Form 8853,  
combining the amounts shown on each of the statement  
Forms 8853. Attach the statements to your paper tax  
return after the controlling Form 8853.  
Line 10  
Death of Account Holder  
Enter the total distributions you received in 2023 from all  
Medicare Advantage MSAs. These amounts should be  
shown in box 1 of Form 1099-SA. This amount shouldn't  
include any erroneous contributions made by Medicare (or  
any earnings on the erroneous contributions) or any  
amounts from a trustee-to-trustee transfer from one  
Medicare Advantage MSA to another Medicare  
If the account holder's surviving spouse is the designated  
beneficiary, the Medicare Advantage MSA is treated as a  
regular Archer MSA (not a Medicare Advantage MSA) of  
the surviving spouse for distribution purposes. Follow the  
instructions in Section A for Death of Account Holder,  
earlier.  
Advantage MSA of the same account holder.  
If the designated beneficiary isn't the account holder's  
surviving spouse, or there is no designated beneficiary,  
the account ceases to be an MSA as of the date of death.  
The beneficiary completes Form 8853 as follows.  
Line 11  
Enter the total distributions from all Medicare Advantage  
MSAs in 2023 that were used only for the account holder's  
qualified medical expenses (see Qualified Medical  
Expenses, earlier).  
Enter “Death of Medicare Advantage MSA account  
holder” across the top of Form 8853.  
Enter the name(s) shown on the beneficiary's tax return  
You can't take a deduction on Schedule A (Form  
and the beneficiary's SSN in the spaces provided at the  
top of the form. Skip Section A.  
1040) or Schedule A (Form 1040-NR) for any  
!
CAUTION  
amount you include on line 11.  
On line 10, enter the fair market value of the Medicare  
Advantage MSA as of the date of death.  
On line 11, for a beneficiary other than the estate, enter  
Lines 13a and 13b  
Additional 50% Tax  
qualified medical expenses incurred by the account holder  
before the date of death that you paid within 1 year after  
the date of death.  
Medicare Advantage MSA distributions included in  
income (line 12) may be subject to an additional 50% tax  
unless one of the following exceptions applies.  
Complete the rest of Section B.  
If the account holder's estate is the beneficiary, the fair  
market value of the Medicare Advantage MSA as of the  
date of death is included in the account holder's final  
income tax return.  
Exceptions to the Additional 50% Tax  
The additional 50% tax doesn't apply to distributions  
made on or after the date that the account holder:  
The transfer isn't subject to the additional 50% tax. The  
beneficiary should report any earnings on the account  
after the date of death as income on the beneficiary's tax  
return.  
Dies, or  
Becomes disabled (see Disabled, earlier).  
If either of the exceptions applies to any of the  
distributions included on line 12, check the box on  
line 13a. Next, if either of the exceptions applies to all the  
distributions included on line 12, enter -0- on line 13b.  
Otherwise, complete the Additional 50% Tax  
Worksheet—Line 13b to figure the amount of the  
additional 50% tax to enter on line 13b.  
Note. If, during the tax year, you are the beneficiary of two  
or more Medicare Advantage MSAs or you are a  
beneficiary of a Medicare Advantage MSA and you have  
your own Medicare Advantage MSA, you must complete a  
separate Form 8853 for each MSA. Enter “statement” at  
the top of each Form 8853 and complete the form as  
Instructions for Form 8853 (2023)  
-7-  
 
income if the insured is a Terminally Ill Individual (defined  
below). Accelerated death benefits paid with respect to an  
insured individual who is chronically ill are generally  
excludable from your gross income to the same extent as  
they would be under a qualified LTC insurance contract.  
Section C—Long-Term Care (LTC)  
Insurance Contracts  
See Filing Requirements for Section C, later. Also, for  
more information, see Pub. 502.  
Definitions  
Policyholder  
Terminally Ill Individual  
A terminally ill individual is any individual who has been  
certified by a physician as having an illness or physical  
condition that can reasonably be expected to result in  
death within 24 months of the date of certification.  
The policyholder is the person who owns the proceeds of  
the LTC insurance contract, life insurance contract, or  
viatical settlement, and also can be the insured individual.  
The policyholder is required to report the income, even if  
payment is assigned to a third party or parties. In the case  
of a group contract, the certificate holder is considered to  
be the policyholder.  
Line 15  
Special rules apply in determining the taxable payments if  
other individuals received per diem payments under a  
qualified LTC insurance contract or as accelerated death  
benefits with respect to the insured listed on line 14a. See  
Multiple Payees, later, for details.  
Qualified LTC Insurance Contract  
A qualified LTC insurance contract is a contract issued:  
Line 18  
After December 31, 1996, that meets the requirements  
If you have more than one LTC period, you must  
of section 7702B, including the requirement that the  
separately calculate the taxable amount of the  
insured must be a chronically ill individual (defined later);  
or  
!
CAUTION  
payments received during each LTC period. To do  
this, complete lines 18 through 26 on separate Sections C  
for each LTC period. Enter the total on line 26 from each  
separate Section C on the Form 8853 that you attach to  
your tax return. See the instructions for line 21 for the LTC  
period.  
Before January 1, 1997, that met state law  
requirements for LTC insurance contracts at the time when  
and in the state where the contract was issued and hasn't  
been changed materially.  
In general, amounts paid under a qualified LTC  
insurance contract are excluded from your income.  
However, if you receive Per Diem Payments (defined  
next), the amount you can exclude is limited.  
Line 19  
Enter the total accelerated death benefits you received  
with respect to the insured listed on line 14a. These  
amounts are generally shown in box 2 of Form 1099-LTC.  
Include only amounts you received while the insured was  
a chronically ill individual. Don't include amounts you  
received while the insured was a terminally ill individual. If  
the insured was redesignated from chronically ill to  
terminally ill in 2023, only include on line 19 payments  
received before the insured was certified as terminally ill.  
Per Diem Payments  
Per diem payments are payments of a fixed amount made  
on a periodic basis without regard to actual expenses  
incurred. Box 3 of Form 1099-LTC should indicate whether  
payments were per diem payments.  
Chronically Ill Individual  
Line 21  
The number of days in your LTC period depends on which  
method you choose to define the LTC period. Generally,  
you can choose either the Contract Period method or the  
Equal Payment Rate method. However, special rules  
apply if other persons also received per diem payments in  
2023 under a qualified LTC insurance contract or as  
accelerated death benefits with respect to the insured  
listed on line 14a. See Multiple Payees, later, for details.  
A chronically ill individual is someone who has been  
certified (at least annually) by a licensed health care  
practitioner as:  
Being unable to perform at least two activities of daily  
living (eating, toileting, transferring, bathing, dressing, and  
continence), without substantial assistance from another  
individual, for at least 90 days, due to a loss of functional  
capacity; or  
Requiring substantial supervision to protect the  
Method 1—Contract Period  
individual from threats to health and safety due to severe  
cognitive impairment. An individual must have been  
certified within the past 12 months as meeting this  
condition.  
Under this method, your LTC period is the same period as  
that used by the insurance company under the contract to  
compute the benefits it pays you. For example, if the  
insurance company computes your benefits on a daily  
basis, your LTC period is 1 day.  
Accelerated Death Benefits  
Generally, amounts paid as accelerated death benefits  
under a life insurance contract or for the sale or  
assignment of any portion of the death benefit as part of a  
viatical settlement are fully excludable from your gross  
-8-  
Instructions for Form 8853 (2023)  
         
Filing Requirements for Section C  
Go through this chart for each insured person for whom you received  
long-term care (LTC) payments. See Definitions, earlier.  
Start Here  
Did you (or your spouse, if ꢀling  
jointly) receive payments in  
2023 made on a per diem or  
other periodic basis under an  
LTC insurance contract?  
Were any of those payments  
made under a qualiꢀed LTC  
insurance contract?  
Yes  
Yes  
Complete all  
of Section C.  
No  
No  
Did you (or your spouse, if  
ꢀling jointly) receive any  
accelerated death beneꢀts in  
2023 from a life insurance  
policy that were made on a per  
diem or other periodic basis?  
Did you (or your spouse, if  
ꢀling jointly) receive any  
accelerated death beneꢀts in  
2023 from a life insurance  
policy that were made on a per  
diem or other periodic basis?  
Complete only  
lines 14a, 14b, and 17  
of Section C.  
No  
No  
Yes  
No  
Complete only  
lines 14a, 14b, 15, 16,  
17 (if applicable), and 26  
of Section C.  
Were any of the payments paid  
on behalf of a chronically ill  
(not terminally ill) individual?  
Yes  
Don’t complete  
Section C.  
Yes  
Complete all of Section C.  
If you choose this method for defining the LTC  
period(s) and different LTC insurance contracts for  
the same insured use different contract periods,  
insurance contract didn't begin making payments until  
May 1, 2023. The first LTC period is 61 days (March 1  
through April 30) and the second LTC period is 245 days  
(May 1 through December 31).  
!
CAUTION  
then all such LTC contracts must be treated as computing  
benefits on a daily basis.  
Line 22  
Qualified LTC services are necessary diagnostic,  
preventive, therapeutic, curing, treating, mitigating, and  
rehabilitative services, and maintenance or personal care  
services required to treat a chronically ill individual under  
a plan of care prescribed by a licensed health care  
practitioner.  
Method 2—Equal Payment Rate  
Under this method, your LTC period is the period during  
which the insurance company uses the same payment  
rate to compute your benefits. For example, you have two  
LTC periods if the insurance contract computes payments  
at a rate of $175 per day from March 1, 2023, through May  
31, 2023, and then at a rate of $195 per day from June 1,  
2023, through December 31, 2023. The first LTC period is  
92 days (from March 1 through May 31) and the second  
LTC period is 214 days (from June 1 through December  
31).  
Line 24  
Enter the reimbursements you received or expect to  
receive through insurance or otherwise for qualified LTC  
services provided for the insured for LTC periods in 2023.  
Box 3 of Form 1099-LTC should indicate if payments were  
made on a reimbursement basis.  
Generally, don't include on line 24  
You can choose this method even if you have more than  
one qualified LTC insurance contract covering the same  
period. For example, you have one insurance contract that  
pays $100 per day from March 1, 2023, through  
reimbursements for qualified LTC services you  
!
CAUTION  
received under a contract issued before August 1,  
1996. However, you must include reimbursements if the  
contract was exchanged or modified after July 31, 1996,  
to increase per diem payments or reimbursements.  
December 31, 2023, and a second contract that pays  
$1,500 per month from March 1, 2023, through December  
31, 2023. You have one LTC period because each  
payment rate doesn't vary during the LTC period of March  
1 through December 31. However, you have two LTC  
periods if the facts are the same except that the second  
Multiple Payees  
If you checked “Yes” on lines 15 and 16 and the only  
payments you received were accelerated death benefits  
Instructions for Form 8853 (2023)  
-9-  
     
that were paid because the insured was terminally ill, skip  
lines 17 through 25 and enter -0- on line 26.  
LTC insurance contract under which Anna is the insured.  
Neither Ben nor Cleo incurred any costs for qualified LTC  
services for Anna in 2023. From July 1, 2023, through  
December 31, 2023, Ben received per diem payments of  
$5,000 per month ($30,000 total) and Cleo received per  
diem payments of $3,000 per month ($18,000 total).  
Anna, Ben, and Cleo agree to use the equal payment rate  
method to determine their LTC periods.  
There are two LTC periods. The first is 181 days  
(January 1–June 30) during which the per diem payments  
were $2,000 per month. The second is 184 days (July 1–  
December 31) during which the aggregate per diem  
payments were $10,000 per month ($2,000 under Anna's  
contract + $5,000 under Ben's contract + $3,000 under  
Cleo's contract).  
In all other cases in which you checked “Yes” on  
line 15, attach a statement duplicating lines 18 through 26  
of the form. This statement should show the aggregate  
computation for all persons who received per diem  
payments under a qualified LTC insurance contract or as  
accelerated death benefits because the insured was  
chronically ill. Each person must use the same LTC  
period. If all the recipients of payments don't agree on  
which LTC period to use, the contract period method must  
be used.  
After completing the statement, determine your share  
of the per diem limitation and any taxable payments. The  
per diem limitation is allocated first to the insured to the  
extent of the total payments the insured received. If the  
insured files a joint return and the insured's spouse is one  
of the policyholders, the per diem limitation is allocated  
first to them to the extent of the payments they both  
received. Any remaining limitation is allocated among the  
other policyholders pro rata based on the payments they  
received in 2023. The statement showing the aggregate  
computation must be attached to the Form 8853 for each  
person who received a payment.  
An aggregate statement must be completed for the  
second LTC period and attached to Anna’s, Ben's, and  
Cleo's forms.  
Step 1. They complete a statement for Anna for the first  
LTC period as follows.  
Line  
Amount  
20  
21  
22  
23  
24  
25  
26  
$12,000 ($2,000 x 6 months)  
$76,020 ($420 x 181 days)  
$27,150 ($150 x 181 days)  
$76,020  
Enter your share of the per diem limitation and the  
taxable payments on lines 25 and 26 of your individual  
Form 8853. Leave lines 21 through 24 blank.  
Example 1  
Anna was chronically ill in 2023 and received 12 monthly  
payments on a per diem basis from a qualified LTC  
insurance contract. She was paid $2,000 per month  
($24,000 total). Anna incurred expenses for qualified LTC  
services of $150 per day ($54,750) and was reimbursed  
for one-half of those expenses ($27,375). She uses the  
equal payment rate method and thus has a single benefit  
period for 2023 (January 1–December 31). Anna  
$13,575 ($75 x 181 days)  
$62,445  
$ -0-  
completes Form 8853, lines 20 through 26, as follows.  
Step 2. They complete the aggregate statement for the  
second LTC period as follows.  
Line  
Amount  
Line  
Amount  
20  
21  
22  
23  
24  
25  
26  
$24,000 ($2,000 x 12 months)  
$153,300 ($420* x 365 days)  
$54,750 ($150 x 365 days)  
$153,300  
20  
21  
22  
23  
24  
25  
26  
$60,000 ($10,000 x 6 months)  
$77,280 ($420 x 184 days)  
$27,600 ($150 x 184 days)  
$77,280  
$27,375 ($75 x 365 days)  
$125,925  
$13,800 ($75 x 184 days)  
$63,480  
$ -0-  
*$420 is the 2023 per diem limit for periodic  
payments received under a qualified LTC  
insurance contract. See Rev. Proc. 2022-38,  
section 3.61.  
$ -0-  
Step 3. They allocate the aggregate per diem limitation of  
$63,480 on line 25 among Anna, Ben, and Cleo. Because  
Anna is the insured, the per diem limitation is allocated  
first to her to the extent of the per diem payments she  
received during the second LTC period ($12,000). The  
remaining per diem limitation of $51,480 is allocated  
between Ben and Cleo.  
Example 2  
The facts are the same as in Example 1, except Anna's  
adult children, Ben and Cleo, each also own a qualified  
-10-  
Instructions for Form 8853 (2023)  
Allocation ratio to Ben: 62.5% of the remaining  
limitation ($32,175) is allocated to Ben because the  
$30,000 he received during the second LTC period is  
62.5% of the $48,000 received by both Ben and Cleo  
during the second LTC period.  
Allocation ratio to Cleo: 37.5% of the remaining  
limitation ($19,305) is allocated to Cleo because the  
$18,000 she received during the second LTC period is  
37.5% of the $48,000 received by both Ben and Cleo  
during the second LTC period.  
Ben's Form 8853:  
1st LTC  
Period  
2nd LTC  
Period  
Line  
Form 8853  
20  
25  
26  
$ -0-  
$30,000  
$32,175  
$ -0-  
$30,000  
$32,175  
$ -0-  
$ -0-  
$ -0-  
Step 4. Anna, Ben, and Cleo each complete Form 8853  
Cleo’s Form 8853:  
as follows.  
1st LTC  
Period  
2nd LTC  
Period  
Anna's Form 8853:  
Line  
Form 8853  
1st LTC  
Period  
2nd LTC  
Period  
Line  
Form 8853  
20  
25  
26  
$ -0-  
$18,000  
$19,305  
$ -0-  
$18,000  
$19,305  
$ -0-  
20  
25  
26  
$12,000  
$62,445  
$ -0-  
$12,000  
$12,000  
$ -0-  
$24,000  
$74,445  
$ -0-  
$ -0-  
$ -0-  
Instructions for Form 8853 (2023)  
-11-