Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2003
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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.
High Deductible Health Plan
General Instructions
An HDHP is a health plan that meets the
Specific Instructions
following requirements.
Purpose of Form
Name and Social Security Number
Use Form 8853 to:
Self-only
Family
•
(SSN). Enter your name(s) and SSN as
coverage
coverage
Report Archer MSA contributions
shown on your tax return. If filing jointly
(including employer contributions);
•
and both you and your spouse each have
Figure your Archer MSA deduction;
Minimum annual
•
an Archer MSA or each have a
deductible
$1,700
$3,350
Report distributions from Archer MSAs
Medicare+Choice MSA, enter the SSN
or Medicare+Choice MSAs;
Maximum annual
•
shown first on your tax return.
Report taxable payments from
deductible
$2,500
$5,050
long-term care (LTC) insurance contracts;
Section A—Archer MSAs
Maximum annual
or
•
out-of-pocket expenses
Report taxable accelerated death
(other than for premiums)
$3,350
$6,150
benefits from a life insurance policy.
Eligible Individual
Additional information. See Pub. 969,
Other Health Insurance
To be eligible for an Archer MSA, you
Medical Savings Accounts (MSAs), for
must be an employee of a small employer
If you have an Archer MSA, you (and your
more details on MSAs.
or be self-employed. You also must have
spouse, if you have family coverage) may
a high deductible health plan (HDHP) and
not have any health insurance coverage
Who Must File
have no other health insurance coverage
other than an HDHP.
You must file Form 8853 if any of the
except permitted coverage. You must be
Exception. You may have additional
following apply.
an eligible individual on the first day of a
•
insurance that provides benefits only for:
You (or your employer) made
•
month to take an Archer MSA deduction
Accidents,
contributions for 2003 to your Archer
•
for that month.
Disability,
MSA.
•
Dental care,
•
Small Employer
You are filing a joint return and your
•
Vision care,
spouse (or his or her employer) made
A small employer is generally an
•
Long-term care,
contributions for 2003 to your spouse’s
employer who had an average of 50 or
•
Liabilities under workers’ compensation
Archer MSA.
fewer employees during either of the last
laws, tort liabilities, or liabilities arising
•
You (or your spouse, if filing jointly)
2 calendar years. See Pub. 969 for
from the ownership or use of property,
received Archer MSA or
details.
•
A specific disease or illness, or
Medicare+Choice MSA distributions in
•
A fixed amount per day (or other
Archer MSA
2003.
•
period) of hospitalization.
You acquired an interest in an Archer
An Archer MSA is a medical savings
MSA or a Medicare+Choice MSA
Disabled
account set up exclusively for paying the
because of the death of the account
qualified medical expenses of the account
An individual generally is considered
holder. See Death of Account Holder on
holder or the account holder’s spouse or
disabled if he or she is unable to engage
this page.
dependent(s) in conjunction with an
in any substantial gainful activity due to a
•
You (or your spouse, if filing jointly)
HDHP.
physical or mental impairment which can
were a policyholder who received
be expected to result in death or to
Qualified Medical Expenses
payments under an LTC insurance
continue indefinitely.
contract or received any accelerated
Generally, qualified medical expenses for
Death of Account Holder
Archer MSA purposes are unreimbursed
death benefits from a life insurance policy
medical expenses that could otherwise be
on a per diem or other periodic basis in
If the account holder’s surviving spouse is
2003. See the instructions for Section C,
deducted on Schedule A (Form 1040).
the designated beneficiary, the Archer
beginning on page 5.
See the Schedule A instructions and Pub.
MSA is treated as if the surviving spouse
502, Medical and Dental Expenses
were the account holder. The surviving
(Including the Health Coverage Tax
spouse completes Form 8853 as though
Credit). However, you may not treat
the Archer MSA belonged to him or her.
insurance premiums as qualified medical
If the designated beneficiary is not the
expenses unless the premiums are for:
account holder’s surviving spouse, the
•
Long-term care (LTC) insurance,
account ceases to be an Archer MSA as
•
Health care continuation coverage, or
of the date of death. The beneficiary
•
Health care coverage while receiving
completes Form 8853 as follows.
•
unemployment compensation under
Write “Death of Archer MSA account
Federal or state law.
holder” across the top of Form 8853.
Cat. No. 24188L
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