Instruksi Bentuk 8889
Instruksi untuk Pembentukan 8889, Akun Pengelolaan Kesehatan (HSA)
Rev. 2023
Borang Berkaitan
- Formulir 8889 - Rekening Simpanan Kesehatan (HSA)
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
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
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
•
later.
If you (or your spouse, if filing jointly) received HSA
distributions in 2023, you must file Form 8889 with
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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.
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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
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
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
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.
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
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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
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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,
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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
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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.
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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,
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•
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
•
Excess Employer Contributions, later).
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.
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.
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
. . . . . . . . . . . . $
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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
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:
excess contributions.
You make the withdrawal by the due date, including
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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%
Note);
You do not claim an exclusion from income for the amount
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of the withdrawn contributions; and
You also withdraw any income earned on the withdrawn
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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
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any amounts contributed to your HSA for the year.
The total excess contributions in your HSA at the
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beginning of the year.
You make the withdrawal by the due date, including
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Any excess contribution remaining at the end of the tax
year is subject to the additional tax. See Form 5329.
Excess Employer Contributions, later);
You do not claim a deduction for the amount of the
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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
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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
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CAUTION
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
Qualified Medical Expenses, earlier) of:
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
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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
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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,
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Turns age 65.
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Instructions for Form 8889 (2023)