Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2004
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Department of the Treasury
Internal Revenue Service
Instructions for Form 8853
Archer MSAs and Long-Term Care Insurance Contracts
Section references are to the Internal Revenue Code unless otherwise noted.
•
2004. See the instructions for Section C,
Long-term care (LTC) insurance,
General Instructions
•
beginning on page 6.
Health care continuation coverage, or
•
Health care coverage while receiving
What’s New
unemployment compensation under
federal or state law.
Specific Instructions
Rollover distributions. You can make a
tax-free distribution from your Archer
High Deductible Health Plan
Name and social security number
MSA into a health savings account. For
An HDHP is a health plan that meets the
(SSN). Enter your name(s) and SSN as
more details, see Rollovers on page 4.
following requirements.
shown on your tax return. If filing jointly
For more information on health savings
and both you and your spouse each have
accounts, see Pub. 969.
Self-only
Family
an Archer MSA or each have a Medicare
Medicare medical savings accounts.
coverage
coverage
Advantage MSA, enter the SSN shown
Medicare+Choice MSAs are now called
first on your tax return.
Medicare Advantage MSAs.
Minimum annual
deductible
$1,700
$3,450
Section A—Archer MSAs
Purpose of Form
Maximum annual
Use Form 8853 to:
deductible
$2,600
$5,150
•
Eligible Individual
Report Archer MSA contributions
Maximum annual
To be eligible for an Archer MSA, you (or
(including employer contributions),
out-of-pocket expenses
•
your spouse) must be an employee of a
Figure your Archer MSA deduction,
(other than for premiums)
$3,450
$6,300
•
small employer or be self-employed. You
Report distributions from Archer MSAs
(or your spouse) must be covered under a
or Medicare Advantage MSAs,
Other Health Coverage
•
high deductible health plan (HDHP) and
Report taxable payments from
If you have an Archer MSA, you (and your
have no other health coverage except
long-term care (LTC) insurance contracts,
spouse, if you have family coverage)
permitted coverage. You must not be
or
cannot have any health coverage other
•
enrolled in Medicare and may not be
Report taxable accelerated death
than an HDHP.
claimed as a dependent on another
benefits from a life insurance policy.
Exceptions. You can have additional
person’s tax return. You must be an
Additional information. See Pub. 969,
insurance that provides benefits only for:
eligible individual on the first day of a
•
Health Savings Accounts and Other
Liabilities under workers’ compensation
month to take an Archer MSA deduction
Tax-Favored Health Plans, for more
laws, tort liabilities, or liabilities arising
for that month.
details on MSAs.
from the ownership or use of property,
•
Small Employer
A specific disease or illness, or
Who Must File
•
A fixed amount per day (or other
A small employer is generally an
You must file Form 8853 if any of the
period) of hospitalization.
employer who had an average of 50 or
following apply.
fewer employees during either of the last
You can also have coverage (whether
•
You (or your employer) made
2 calendar years. See Pub. 969 for
provided through insurance or otherwise)
contributions for 2004 to your Archer
details.
for:
•
MSA.
Accidents,
•
Archer MSA
•
You are filing a joint return and your
Disability,
•
spouse (or his or her employer) made
An Archer MSA is a medical savings
Dental care,
•
contributions for 2004 to your spouse’s
account set up exclusively for paying the
Vision care, or
•
Archer MSA.
qualified medical expenses of the account
Long-term care.
•
You (or your spouse, if filing jointly)
holder or the account holder’s spouse or
Disabled
received Archer MSA or Medicare
dependent(s).
Advantage MSA distributions in 2004.
An individual generally is considered
•
Qualified Medical Expenses
You acquired an interest in an Archer
disabled if he or she is unable to engage
MSA or a Medicare Advantage MSA
Generally, qualified medical expenses for
in any substantial gainful activity due to a
because of the death of the account
Archer MSA purposes are unreimbursed
physical or mental impairment which can
holder. See Death of Account Holder that
medical expenses that could otherwise be
be expected to result in death or to
begins on this page.
deducted on Schedule A (Form 1040).
continue indefinitely.
•
You (or your spouse, if filing jointly)
See the Schedule A instructions and Pub.
Death of Account Holder
were a policyholder who received
502, Medical and Dental Expenses
payments under an LTC insurance
(Including the Health Coverage Tax
If the account holder’s surviving spouse is
contract or received any accelerated
Credit). However, you may not treat
the designated beneficiary, the Archer
death benefits from a life insurance policy
insurance premiums as qualified medical
MSA is treated as if the surviving spouse
on a per diem or other periodic basis in
expenses unless the premiums are for:
were the account holder. The surviving
Cat. No. 24188L
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