Instruksi Bentuk 8853
Instruksi untuk Form 8853, Archer MSAs dan Kontrak Asuransi Perawatan Panjang Term
Rev. 2023
Borang Berkaitan
- Formulir 8853 - Pemanah Archer MSAs dan Kontrak Asuransi Keperawatan Panjang Term
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
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
an Archer MSA at IRS.gov/Individuals/Frequently-Asked-
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
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
an Archer MSA at IRS.gov/Individuals/Frequently-Asked-
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
Excess Employer Contributions, later).
-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
Employer Contributions to an Archer MSA, later. Also, if
you or your spouse made contributions in addition to any
employer contributions, you may have to pay an additional
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
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
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.
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
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
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,
•
•
•
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
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
•
•
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.
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-
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
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
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.
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,
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
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-