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Instruksi Bentuk 8889

Instruksi untuk Pembentukan 8889, Akun Pengelolaan Kesehatan (HSA)

Rev. 2023

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Department of the Treasury  
Internal Revenue Service  
2023  
Instructions for Form 8889  
Health Savings Accounts (HSAs)  
Section references are to the Internal Revenue Code unless  
otherwise noted.  
Ask your health insurance provider(s) whether your  
HDHP and any disregarded coverage meet the  
requirements of section 223.  
!
CAUTION  
Future Developments  
For the latest information about developments related to  
Form 8889 and its instructions, such as legislation enacted  
after they were published, go to IRS.gov/Form8889.  
Reminders  
Personal protective equipment. Amounts paid for  
personal protective equipment (PPE), such as masks, hand  
sanitizer, and sanitizing wipes, for use by you, your spouse,  
or your dependent(s) to prevent the spread of COVID-19 are  
eligible medical expenses that may be paid or reimbursed  
from an HSA. See Announcement 2021-7 at IRS.gov/IRB/  
What’s New  
Notice 2023-37. Due to the end of the COVID-19 national  
emergency, Notice 2023-37, 2023-30 I.R.B. 359, available at  
2020-15 and clarified the definition of preventive care for  
purposes of the safe harbor.  
Cost of home testing for COVID-19. The cost to diagnose  
COVID-19 is an eligible medical expense for tax purposes,  
which means the cost of home testing for COVID-19 for you,  
your spouse, or your dependent(s) may be paid or  
Expiration of special COVID-19 rules in Notice  
2020-15. Notice 2023-37 provides that the special rules  
under Notice 2020-15 for reimbursement of treatment and  
testing for COVID-19 under a high deductible health plan  
(HDHP) apply only for plan years ending on or before  
December 31, 2024. For more information, see the  
discussion of Notice 2020-15 under High Deductible Health  
Plan, later.  
Preventive care safe harbor for COVID-19 testing  
under an HDHP ends. An HDHP may have a zero  
deductible for certain preventive care. Notice 2023-37 ends  
the application of the preventive care safe harbor to  
COVID-19 testing effective as of July 24, 2023. However,  
COVID-19 testing remains a qualified medical expense  
subject to the minimum deductible.  
reimbursed from an HSA. See IRS.gov/Newsroom/IRS-Cost-  
General Instructions  
Purpose of Form  
Use Form 8889 to:  
Report health savings account (HSA) contributions  
(including those made on your behalf and employer  
contributions),  
Figure your HSA deduction,  
Report distributions from HSAs, and  
Telehealth and other remote care extended. The  
Consolidated Appropriations Act 2023 extends the availability  
of telehealth and other remote care for HSAs. In the case of  
plan years beginning in 2023 or 2024:  
Figure amounts you must include in income and additional  
tax you may owe if you fail to be an eligible individual.  
Additional information. See Pub. 969, Health Savings  
Accounts and Other Tax-Favored Health Plans, for more  
details on HSAs. Also, see the Instructions for Form 1040 and  
the Instructions for Form 1040-NR.  
1. An eligible individual may have separate coverage for  
telehealth and other remote care in addition to an HDHP.  
2. An HDHP may have no deductible (or a deductible  
below the minimum annual deductible) for telehealth and  
other remote care services.  
Who Must File  
You must file Form 8889 if any of the following applies.  
You (or someone on your behalf, including your employer)  
Insulin products. The Inflation Reduction Act, enacted  
August 16, 2022, amended section 223 to provide that an  
HDHP may have a zero deductible for selected insulin  
products. The amendment applies to plan years beginning  
after 2022.  
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 HSA at  
health.  
made contributions for 2023 to your HSA.  
You received HSA distributions in 2023.  
You must include certain amounts in income because you  
failed to be an eligible individual during the testing period.  
You acquired an interest in an HSA because of the death  
of the account beneficiary. See Death of Account Beneficiary,  
later.  
If you (or your spouse, if filing jointly) received HSA  
distributions in 2023, you must file Form 8889 with  
!
CAUTION  
Form 1040, Form 1040-SR, or Form 1040-NR, even if  
you have no taxable income or any other reason for filing  
Form 1040, Form 1040-SR, or Form 1040-NR.  
Ask your HSA trustee whether your HSA and trustee  
meet the requirements of section 223.  
!
CAUTION  
Sep 29, 2023  
Cat. No. 37971Y  
Qualified Medical Expenses  
Definitions  
Generally, qualified medical expenses” for HSA purposes  
are unreimbursed medical expenses that could otherwise be  
deducted on Schedule A (Form 1040). See the Instructions  
for Schedule A and Pub. 502, Medical and Dental Expenses.  
As the HSA account beneficiary, you can pay these expenses  
for medical care for yourself, your spouse, and your  
dependents. Even though nonprescription medicines (other  
than insulin) do not qualify for the medical and dental  
expenses deduction, they do qualify as expenses for HSA  
purposes. The cost of menstrual care products (tampons,  
pads, liners, cups, sponges, or other similar products) are  
also reimbursable for HSA purposes.  
Eligible Individual  
To be eligible to have contributions made to your HSA, you  
must be covered under a high deductible health plan (HDHP)  
and have no other health coverage except certain  
disregarded coverage. If you are an eligible individual,  
anyone can contribute to your HSA. However, you cannot be  
enrolled in Medicare or be another person's dependent. An  
individual does not fail to be treated as an eligible individual  
for any period merely because the individual receives  
hospital care or medical services under any law administered  
by the Secretary of Veterans Affairs for a service-connected  
disability. You will not fail to be considered an eligible  
individual because you receive benefits from a health plan  
under surprise billing laws. You must be, or be considered, an  
eligible individual on the first day of a month to take an HSA  
deduction for that month (see Last-month rule next).  
Last-month rule. If you are an eligible individual on the first  
day of the last month of your tax year (December 1 for most  
taxpayers), you are considered to be an eligible individual for  
the entire year, so long as you remain an eligible individual  
during the testing period as discussed below.  
Testing period. You must remain an eligible individual  
during the testing period in order to take advantage of the  
last-month rule. The testing period begins with the last month  
of your tax year and ends on the last day of the 12th month  
following that month (for example, December 1, 2023 –  
December 31, 2024). If you fail to remain an eligible  
individual during this period, other than because of death or  
becoming disabled, you will have to include in income the  
total contributions made that would not have been made  
except for the last-month rule. You include this amount in  
income in the year in which you fail to be an eligible  
individual. This amount is also subject to a 10% additional  
tax. (See Part III.)  
Amounts you pay for personal protective equipment, such  
as masks, hand sanitizer, and sanitizing wipes for you, your  
spouse, and your dependent(s) for the primary purpose of  
preventing the spread of COVID-19 are treated as medical  
expenses eligible to be reimbursed from an HSA.  
The cost of home testing for COVID-19 for you, your  
spouse, or your dependent(s) is an eligible medical expense  
for tax purposes, which may be paid or reimbursed from an  
HSA.  
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 HSA at  
health.  
Expenses incurred before you establish your HSA are not  
qualified medical expenses. If, under the last-month rule, you  
are considered to be an eligible individual for the entire year  
for determining the contribution amount, only those expenses  
incurred after you actually establish your HSA are qualified  
medical expenses.  
Account Beneficiary  
You cannot treat insurance premiums as qualified medical  
expenses unless the premiums are for:  
The account beneficiary is the individual on whose behalf the  
HSA was established.  
1. Long-term care (LTC) insurance,  
2. Health care continuation coverage (such as coverage  
HSA  
under COBRA),  
3. Health care coverage while receiving unemployment  
compensation under federal or state law, or  
4. Medicare and other health care coverage if you were  
65 or older (other than premiums for a Medicare  
supplemental policy, such as Medigap).  
Generally, an HSA is a health savings account set up  
exclusively for paying the qualified medical expenses of the  
account beneficiary or the account beneficiary's spouse or  
dependents.  
Distributions From an HSA  
Coverage under (2) and (3) can be for your spouse or  
a dependent meeting the requirement. For (4), if you,  
the account beneficiary, are under age 65, Medicare  
TIP  
Distributions from an HSA used exclusively to pay qualified  
medical expenses of the account beneficiary, spouse, or  
dependents are excludable from gross income. (See the  
Line 15 instructions for information on medical expenses of  
dependents not claimed on your return.) You can receive  
distributions from an HSA even if you are not currently eligible  
to have contributions made to the HSA. However, any part of  
a distribution not used to pay qualified medical expenses is  
includible in gross income and is subject to an additional  
20% tax unless an exception applies.  
premiums for your spouse or dependents (who are age 65 or  
older) are generally not qualified medical expenses.  
High Deductible Health Plan  
An HDHP is a health plan that meets the following  
requirements.  
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Instructions for Form 8889 (2023)  
     
Disabled  
Self-only  
coverage  
Family coverage  
$3,000  
An individual is generally considered disabled if the individual  
is 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.  
Minimum annual deductible  
$1,500  
$7,500  
Maximum annual  
out-of-pocket expenses*  
$15,000  
Death of Account Beneficiary  
* This limit does not apply to deductibles and expenses for out-of-network  
services if the plan uses a network of providers. Instead, only deductibles  
and out-of-pocket expenses (such as copayments and other amounts, but  
not premiums) for services within the network should be used to figure  
whether the limit is reached.  
If the account beneficiary's surviving spouse is the  
designated beneficiary, the HSA is treated as if the surviving  
spouse were the account beneficiary. The surviving spouse  
completes Form 8889 as though the HSA belonged to the  
surviving spouse.  
If the designated beneficiary is not the account  
Notice 2020-15, available at IRS.gov/irb/  
beneficiary's surviving spouse, or there is no designated  
beneficiary, the account ceases to be an HSA as of the date  
of death. The beneficiary completes Form 8889 as follows.  
2020-14_IRB#NOT-2020-15, provides that an HDHP may  
pay for medical care services and items purchased related to  
testing for, and treatment of, COVID-19 before satisfying the  
applicable minimum deductible. Notice 2023-37, 2023-30  
I.R.B. 359, provides that these special rules under Notice  
2020-15 apply only for plan years ending on or before  
December 31, 2024. For more information, see Notice  
Enter “Death of HSA account beneficiary” across the top of  
Form 8889.  
Enter the name(s) shown on the beneficiary's tax return  
and the beneficiary's SSN in the spaces provided at the top  
of the form and skip Part I.  
On Part II, line 14a, enter the fair market value of the HSA  
as of the date of death.  
A health plan that is otherwise an HDHP will not fail to be  
considered an HDHP because it provides benefits under  
surprise billing laws before satisfaction of the HDHP  
deductible.  
Safe harbor for insulin. An HDHP may have a zero  
deductible for selected insulin products. For more details, see  
Pub. 969.  
Safe harbor for preventive care. An HDHP may have a  
zero deductible for preventive care. For more details, see  
Pub. 969. Testing for COVID-19 is no longer considered  
preventive care under this safe harbor effective as of July 24,  
2023. See Notice 2023-37, 2023-30 I.R.B. 359, at  
Safe harbor for telehealth. An HDHP may have a zero  
deductible for telehealth and other remote care services for  
plan years beginning in 2023 or 2024.  
On Part II, line 15, for a beneficiary other than the estate,  
enter qualified medical expenses incurred by the account  
beneficiary before the date of death that the beneficiary paid  
within 1 year after the date of death.  
Complete the rest of Part II.  
If the account beneficiary's estate is the beneficiary, the  
value of the HSA as of the date of death is included on the  
account beneficiary's final income tax return. Complete Form  
8889 as described above, except you should complete Part I,  
if applicable.  
The distribution is not subject to the additional 20% tax.  
Report any earnings on the account after the date of death as  
income on your tax return.  
Note. If, during the tax year, you are the beneficiary of two or  
more HSAs or you are a beneficiary of an HSA and you have  
your own HSA, you must complete a separate Form 8889 for  
each HSA. Enter “statement” at the top of each Form 8889  
and complete the form as instructed. Next, complete a  
controlling Form 8889, combining the amounts shown on  
each of the statement Forms 8889. Attach the statements to  
your paper tax return after the controlling Form 8889.  
Certain coverage disregarded. An eligible individual may  
have:  
1. Coverage for any benefit provided by permitted  
insurance, and  
2. Coverage (whether through insurance or otherwise) for  
accidents, disability, dental care, vision care, or long-term  
care, or (in the case of plan years beginning in 2023 or 2024)  
telehealth and other remote care.  
Deemed Distributions From HSAs  
Permitted insurance. Permitted insurance means:  
A. Insurance if substantially all of the coverage provided  
relates to:  
The following situations result in deemed distributions from  
your HSA.  
You engaged in any transaction prohibited by section 4975  
1. Liabilities incurred under workers’ compensation laws,  
2. Tort liabilities, and/or,  
3. Liabilities relating to ownership or use of property;  
with respect to any of your HSAs, at any time in 2023. Your  
account ceases to be an HSA 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 14a.  
B. Insurance for a specified disease or illness; and  
C. Insurance paying a fixed amount per day (or other period)  
of hospitalization.  
You used any portion of any of your HSAs 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 8f.  
For information on prescription drug plans, see Pub. 969.  
-3-  
Instructions for Form 8889 (2023)  
   
Any deemed distribution will not be treated as used to pay  
qualified medical expenses. Generally, these distributions are  
subject to the additional 20% tax.  
How To Complete Part I  
If both you and your spouse have HSAs, complete lines 1  
through 13 as instructed on the form. However, if you, and  
your spouse if filing jointly, are both eligible individuals and  
either of you has an HDHP with family coverage, you both are  
treated as having only the family coverage plan. Disregard  
any plans with self-only coverage.  
Rollovers  
A rollover is a tax-free distribution (withdrawal) of assets from  
one HSA or Archer MSA that is reinvested in another HSA of  
the same account beneficiary. Generally, you must complete  
the rollover within 60 days after you received the distribution.  
An HSA can only receive one rollover contribution during a  
1-year period. See Pub. 590-A, Contributions to Individual  
Retirement Arrangements (IRAs), for more details and  
additional requirements regarding rollovers.  
Complete a separate Form 8889 for each spouse.  
Combine the amounts on line 13 of both Forms 8889 and  
enter this amount on Schedule 1 (Form 1040), line 13. Be  
sure to attach both Forms 8889 to your paper tax return.  
Line 1  
If you were covered, or considered covered, by a self-only  
HDHP and a family HDHP at different times during the year,  
check the box for the plan that was in effect for a longer  
period. If you were covered by both a self-only HDHP and a  
family HDHP at the same time, you are treated as having  
family coverage during that period. If, on the first day of the  
last month of your tax year (December 1 for most taxpayers),  
you had family coverage, check the “family” box.  
Note. If you instruct the trustee of your HSA to transfer funds  
directly to the trustee of another of your HSAs, the transfer is  
not considered a rollover. There is no limit on the number of  
these transfers. Do not include the amount transferred in  
income, deduct it as a contribution, or include it as a  
distribution on line 14a.  
Specific Instructions  
Line 2  
Include on line 2 only those amounts you, or others on your  
behalf, contributed to your HSA for 2023. Also, include  
amounts contributed for 2023 made in 2024 by the  
Name and social security number (SSN). Enter your  
name(s) as shown on your tax return and the SSN of the HSA  
account beneficiary. If married filing jointly and both you and  
your spouse have HSAs, complete a separate Form 8889 for  
each of you.  
unextended deadline for filing your 2023 federal income tax  
return, April 15, 2024. If you were serving in, or in support of,  
the U.S. Armed Forces in a designated combat zone or  
contingency operation, you may be able to file later. See Pub.  
3 for details. Thus, you may contribute to your 2023 HSA  
through April 15, 2024, or a later date if you served in a  
designated combat zone or contingency operation.  
Part I—HSA Contributions and  
Deductions  
Use Part I to figure:  
Your HSA deduction,  
Do not include employer contributions (see line 9) or  
amounts rolled over from another HSA or Archer MSA. See  
Rollovers, earlier. Also, do not include any qualified HSA  
funding distributions (see line 10). Payroll contributions  
through a salary reduction agreement elected by an  
employee (a cafeteria plan) are treated as employer  
contributions and are not included on line 2.  
Any excess contributions you made (or those made on  
your behalf), and  
Any excess contributions made by an employer (see  
Figuring Your HSA Deduction  
The maximum amount that can be contributed to your HSA  
depends on the type of HDHP coverage you have. If you have  
self-only coverage, your maximum contribution is $3,850. If  
you have family coverage, your maximum contribution is  
$7,750.  
Line 3  
When figuring the amount to enter on line 3, apply the  
following rules.  
1. Use the family coverage amount if you or your spouse  
had an HDHP with family coverage. Disregard any plan with  
self-only coverage.  
Note. If you are age 55 or older at the end of your tax year,  
you can make an additional contribution of $1,000.  
2. If the last-month rule (see Last-month rule, earlier)  
applies, you are considered an eligible individual for the  
entire year. You are treated as having the same HDHP  
coverage for the entire year as you had on the first day of the  
last month of your tax year.  
3. If you were, or were considered, an eligible individual  
for the entire year and you did not change your type of  
coverage, enter $3,850 for a self-only HDHP or $7,750 for a  
family HDHP on line 3. (See (6) in this list.)  
4. If you were, or were considered, an eligible individual  
for the entire year and you changed your type of coverage  
during the year, enter on line 3 (see (6) in this list) the greater  
of:  
Your maximum contribution is reduced by any employer  
contributions to your HSA, any contributions made to your  
Archer MSA, and any qualified HSA funding distributions.  
You can make deductible contributions to your HSA even if  
your employer made contributions. However, if you (or  
someone on your behalf) made contributions in addition to  
any employer contributions and qualified HSA funding  
distributions, you may have to pay an additional tax. See  
You cannot deduct any contributions for any month in  
which you were enrolled in Medicare. Also, you cannot  
deduct contributions if you are someone else's dependent for  
2023.  
a. The limitation shown on the last line of the Line 3  
Limitation Chart and Worksheet (in these instructions), or  
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Instructions for Form 8889 (2023)  
 
b. The maximum amount that can be contributed based  
on the type of HDHP coverage you had on the first day of the  
last month of your tax year.  
spouses, unlike the $7,750 family contribution discussed  
below. For the Line 3 Limitation Chart and Worksheet, the  
additional contribution amount is included for each month  
you are an eligible individual.  
If you had family coverage on the first day of the last  
month, you do not need to use the worksheet; enter  
$7,750 on line 3.  
TIP  
Note. If you are married and had family coverage at any time  
during the year, the additional contribution amount is figured  
on line 7 and is not included on line 3.  
5. If you were not an eligible individual on the first day of  
the last month of your tax year, use the Line 3 Limitation  
Chart and Worksheet (in these instructions) to determine the  
amount to enter on line 3. (See (6) in this list.)  
6. If, at the end of 2023, you were age 55 or older and  
unmarried or married with self-only HDHP coverage for the  
entire year, you can increase the amount determined in (3) or  
(4) by $1,000 (the additional contribution amount). The  
$1,000 additional contribution amount is not allocable among  
See Pub. 969 for more information.  
If you must complete the Line 3 Limitation Chart and  
Worksheet (in these instructions), and your eligibility  
and coverage did not change from one month to the  
TIP  
next, enter the same number you entered for the previous  
month.  
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Instructions for Form 8889 (2023)  
Line 3 Limitation Chart and Worksheet  
Before you begin: √ See the instructions for line 3, earlier.  
√ 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  
(see the line 3 instructions, earlier)?  
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?  
Self-only coverage  
Family coverage  
Enter $3,850 on the line below  
for the month. If you were age  
55 or older at the end of 2023,  
enter $4,850 for the month.  
Enter $7,750 on the line below for  
the month. If, at the end of 2023,  
you were unmarried and age 55 or  
older, enter $8,750 for the month.  
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  
. . . . . . . . . . . . $  
-6-  
Instructions for Form 8889 (2023)  
 
Line 6  
Line 7  
Spouses who have separate HSAs and had family coverage  
under an HDHP at any time during 2023, use the following  
rules to figure the amount on line 6.  
Additional Contribution Amount  
If, at the end of 2023, you were age 55 or older and married,  
instructions) if both of the following apply.  
1. You or your spouse had family coverage under an  
HDHP and were, or were considered to be, an eligible  
individual on the first day of the month.  
If you are treated as having family coverage for each  
month, divide the amount on line 5 equally between you and  
your spouse, unless you both agree on a different allocation  
(such as allocating nothing to one spouse). Enter your  
allocable share on line 6.  
Example. In 2023, you are an eligible individual and have  
self-only HDHP coverage. In March, you marry and as of  
April 1, you have family HDHP coverage. Neither you nor your  
spouse qualify for the additional contribution amount. Your  
spouse has a separate HSA and is an eligible individual from  
April 1 to December 31, 2023. Because you and your spouse  
are considered to have family coverage on December 1, your  
contribution limit is $7,750 (the family coverage maximum).  
You and your spouse can divide this amount in any allocation  
to which you agree (such as allocating nothing to one  
spouse).  
2. You were not enrolled in Medicare for the month.  
Enter the result on line 7.  
If items (1) and (2) apply to all months during 2023,  
enter $1,000 on line 7.  
TIP  
Additional Contribution Amount Worksheet  
1. $1,000 × number of months eligible . . . . . . . . .  
2. Divide line 1 by 12. Enter here and on  
line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
If you are not treated as having family coverage for each  
month, use the following steps to determine the amount to  
enter on line 6.  
Example. At the end of 2023, you were age 55 and  
married. You had family coverage under an HDHP from  
January 1 through June 30, 2023 (6 months). You were not  
enrolled in Medicare in 2023. You would enter an additional  
contribution amount of $500 on line 7 ($1,000 × 6 ÷ 12).  
Step 1. Refigure the contribution limit that would have  
been entered on line 5 if you had entered on line 3 the total of  
the worksheet amounts only for the months you were treated  
as having family coverage. When refiguring line 5, use the  
same amount you previously entered on line 4.  
Step 2. Divide the refigured contribution limit from Step 1  
equally between you and your spouse, unless you both agree  
on a different allocation (such as allocating nothing to one  
spouse).  
Line 9  
Employer Contributions  
Employer contributions (including employee payroll  
Step 3. Subtract the part of the contribution limit allocated  
to your spouse in Step 2 from the amount determined in Step  
1.  
Step 4. Determine any other contribution limits that apply  
for the tax year and add that amount to the result in Step 3.  
Enter the total on line 6.  
contributions through a cafeteria plan) include any amount an  
employer contributes to any HSA for you for 2023. Also,  
include contributions made by a health insurance plan on an  
employer's behalf. These contributions should be shown in  
box 12 of Form W-2 with code W. If either of the following  
apply, complete the Employer Contribution Worksheet.  
Example. In 2023, you are an eligible individual and have  
family HDHP coverage. In March, you divorce and change  
your coverage as of April 1 to self-only. Neither you nor your  
ex-spouse qualify for the additional contribution amount. Your  
ex-spouse continued to have family HDHP coverage and was  
an eligible individual for the entire year. The contribution limit  
for the 3 months you both were considered to have family  
coverage is $1,937.50 ($7,750 × 3 ÷ 12). You and your  
ex-spouse decide to divide the family coverage contribution  
in the following manner: 75% to your ex-spouse and 25% to  
you. Your contribution limit for 9 months of self-only coverage  
is $2,887.50 ($3,850 × 9 ÷ 12). This amount is not divided  
between you and your spouse.  
Because you are covered under a self-only policy on  
December 1, you will show $3,850 on line 6 (the greater of  
either (a) $3,371.87 ($1,937.50 family coverage + $2,887.50  
self-only coverage – $1,453.13 spousal allocation) or (b) the  
maximum amount that can be contributed ($3,850 for  
self-only coverage)). Your ex-spouse would show $7,750 on  
line 6 (the greater of either (a) $7,265.62 ($1,937.50 family  
coverage for the 3 months prior to the divorce + $5,812.50  
family coverage maintained after the divorce – $484.38  
spousal allocation) or (b) the maximum amount that can be  
contributed ($7,750 for family coverage)).  
Employer contributions for 2022 are included in the  
amount reported in box 12 of Form W-2 with code W.  
Employer contributions for 2023 are made in 2024.  
If your employer made excess contributions, you may have to  
report the excess as income. See Excess Employer  
Contributions, later.  
Line 10  
Qualified HSA funding distribution. A distribution from  
your traditional IRA or Roth IRA to your HSA in a direct  
trustee-to-trustee transfer is called an HSA funding  
distribution. Note that these funds are not being distributed  
from your HSA, but rather are being distributed from your IRA  
and contributed to your HSA. Enter this amount on line 10.  
The qualified HSA funding distribution is not included in  
your income, is not deductible, and reduces the amount that  
can be contributed to your HSA by you and from other  
sources (including employer contributions). This distribution  
cannot be made from an ongoing SEP IRA or SIMPLE IRA.  
For this purpose, a SEP IRA or SIMPLE IRA is ongoing if an  
employer contribution is made for the plan year ending with  
or within your tax year in which the distribution would be  
made.  
The maximum amount that can be excluded from income  
is based on your age at the end of the year and your HDHP  
coverage (self-only or family) at the time of the distribution.  
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Instructions for Form 8889 (2023)  
   
Keep for Your Records  
Employer Contribution Worksheet  
1. Enter the employer contributions reported in box 12 of Form W-2, with code W . . . . . . . . . . . . . . . . . . . . . . . . . .  
2. Enter employer contributions made in 2023 for tax year 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
4. Enter employer contributions made in 2024 for tax year 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
5. Employer contributions for 2023. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .  
1.  
2.  
3.  
4.  
5.  
You can make only one qualified HSA funding distribution  
during your lifetime. However, if you make the distribution  
during a month when you have self-only HDHP coverage, you  
can make another qualified HSA funding distribution in a later  
month in that tax year if you change to family HDHP  
coverage.  
made a qualified HSA funding distribution (line 10) during the  
tax year, reduce your limitation (line 8) by that distribution  
before you determine whether you have excess employer  
contributions. If the excess was not 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 had not been contributed if:  
See the discussions under Line 13 for the treatment of  
excess contributions.  
You make the withdrawal by the due date, including  
See Pub. 969 for more information.  
extensions, of your 2023 tax return (but see the following  
Testing period. If you received a traditional IRA or Roth  
IRA distribution, you must remain an eligible individual during  
the testing period. The testing period begins with the month  
in which the traditional IRA or Roth IRA distribution is  
contributed to the HSA and ends on the last day of the 12th  
month following that month. For example, if the distribution is  
contributed on June 17, 2023, the testing period ends on  
June 30, 2024. If you fail to remain an eligible individual  
during this period, other than because of death or becoming  
disabled, you will have to include the qualified HSA funding  
distribution in income in the year in which you fail to be an  
eligible individual. This amount is also subject to a 10%  
additional tax. (See Part III.)  
Note);  
You do not 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.  
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).  
Line 13  
If you or someone on your behalf (or your employer)  
contributed more to your HSA 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.  
Deducting an Excess Contribution in a Later Year  
You may be able to deduct excess contributions for previous  
years that are still in your HSA. The excess contributions you  
can deduct in the current year is the lesser of the following  
two amounts.  
Excess Contributions You Make  
To figure your excess contributions (including those made on  
your behalf), subtract your deductible contributions (line 13)  
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 had not been contributed if:  
Your maximum HSA contribution limit for the year minus  
any amounts contributed to your HSA for the year.  
The total excess contributions in your HSA at the  
beginning of the year.  
You make the withdrawal by the due date, including  
Any excess contribution remaining at the end of the tax  
year is subject to the additional tax. See Form 5329.  
extensions, of your 2023 tax return (but see the Note under  
Excess Employer Contributions, later);  
You do not claim a deduction for the amount of the  
Part II—HSA Distributions  
Line 14a  
Enter the total distributions you received in 2023 from all  
HSAs. Your total distributions include amounts paid with a  
debit card that restricts payments to health care and amounts  
withdrawn by other individuals that you have designated.  
These amounts should be shown in box 1 of Form 1099-SA.  
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.  
Excess Employer Contributions  
Excess employer contributions are the excess, if any, of your  
employer's contributions over your limitation on line 8. If you  
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Instructions for Form 8889 (2023)  
         
If any of the exceptions apply to any of the distributions  
included on line 16, check the box on line 17a. Enter on  
line 17b only 20% (0.20) of any amount included on line 16  
that does not meet any of the exceptions.  
Example 1. You turned age 63 in 2023 and received a  
distribution from an HSA that is included in income. Do not  
check the box on line 17a because you (the account  
beneficiary) did not meet the age exception for the  
distribution. Enter 20% of the amount from line 16 on  
line 17b.  
Line 14b  
Include on line 14b any distributions you received in 2023  
that qualified as a rollover contribution to another HSA. See  
Rollovers, earlier. Also include any excess contributions (and  
the earnings on those excess contributions) included on  
line 14a that were withdrawn by the due date, including  
extensions, of your return. See the instructions for line 13,  
earlier.  
Line 15  
Example 2. 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 17a because the  
additional 20% tax does not 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 17b, 20% of the amount  
of these distributions included on line 16.  
Only include on line 15 distributions from your HSA  
that were used to pay you for qualified medical  
!
CAUTION  
expenses (see Qualified Medical Expenses, earlier)  
not reimbursed by insurance or other coverage and that you  
incurred after the HSA was established. Do not include the  
distribution of an excess contribution taken out after the due  
date, including extensions, of your return even if used for  
qualified medical expenses.  
Note. There may be very limited and unusual circumstances  
in which you may be able to return mistaken distributions  
such that the amount will not be subject to the additional tax.  
For more information, see Notice 2004-50, Q/A 37 and 76, at  
In general, include on line 15 distributions from all HSAs in  
2023 that were used for the qualified medical expenses (see  
1. You and your spouse.  
2. All your dependents.  
Part III—Income and Additional Tax  
for Failure To Maintain HDHP  
Coverage  
3. Any person who would be a dependent except that:  
a. The person filed a joint return.  
b. The person had gross income.  
c. You, or your spouse if filing jointly, are dependents of  
Use Part III to figure any additional income and adjustments  
to income that must be reported on Schedule 1 (Form 1040)  
and additional taxes that must be reported on Schedule 2  
(Form 1040) for failure to be an eligible individual during the  
testing period for:  
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 dependent of both  
TIP  
Last-month rule (see Last-month rule, earlier), or  
parents whether or not the custodial parent releases claim to  
the child as the custodial parent’s dependent.  
A qualified HSA funding distribution (see the Instructions  
for line 10, earlier).  
You cannot take a deduction on Schedule A (Form  
1040) for any amount you include on line 15.  
See the discussion, earlier, on determining the testing period  
for both the last-month rule and a qualified HSA funding  
distribution. Include the amount in income in the year in  
which you fail to be an eligible individual.  
!
CAUTION  
Lines 17a and 17b  
Additional 20% Tax  
Line 18  
these instructions) for the year the contribution was made to  
determine the contribution you could have made if the  
last-month rule did not apply. Enter on line 18 the excess of  
the amount contributed over the redetermined amount.  
Examples of this computation are in Pub. 969.  
HSA distributions included in income (line 16) are subject to  
an additional 20% tax unless one of the following exceptions  
applies.  
Exceptions to the Additional 20% Tax  
The additional 20% tax does not apply to distributions made  
after the account beneficiary:  
Line 19  
Enter the total of any qualified HSA funding distribution (see  
line 10).  
Dies,  
Becomes disabled (see Disabled, earlier), or  
Turns age 65.  
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Instructions for Form 8889 (2023)