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2017

Department of the Treasury

Internal Revenue Service

Instructions for Form 8853

Archer MSAs and Long-Term Care Insurance Contracts

If you (or your spouse, if filing jointly)

Health care coverage while receiving

Section references are to the Internal Revenue Code

unless otherwise noted.

received Archer MSA or Medicare

unemployment compensation under federal or

Advantage MSA distributions in 2017,

state law.

Future Developments

CAUTION

you must file Form 8853 with Form 1040 or

High Deductible Health Plan

1040NR even if you have no taxable income or

For the latest information about developments

any other reason for filing Form 1040 or

An HDHP is a health plan that meets the

related to Form 8853 and its instructions, such

1040NR.

following requirements.

as legislation enacted after they were

published, go to IRS.gov/Form8853.

Self-only

Family

Specific Instructions

coverage

General Instructions

Minimum annual deductible

$2,250

$4,500

Name and social security number (SSN).

Enter your name(s) and SSN as shown on your

After December 31, 2007, contributions

Maximum annual deductible

$3,350

$6,750

tax return. If filing jointly and both you and your

can't be made to an Archer Medical

Maximum annual

spouse each have an Archer MSA or each have

Savings Account for you, unless:

out-of-pocket expenses

CAUTION

a Medicare Advantage MSA, enter the SSN

(other than for premiums)

$4,500

$8,250

You were an active Archer MSA participant

shown first on your tax return.

for any tax year ending before January 1, 2008,

Section A—Archer MSAs

Other Health Coverage

You became an active Archer MSA

participant for a tax year ending after December

Eligible Individual

If you have an Archer MSA, you (and your

31, 2007, because of coverage under a high

spouse, if you have family coverage) can't have

To be eligible for an Archer MSA, you (or your

deductible health plan (HDHP) of an Archer

any health coverage other than an HDHP.

spouse) must be an employee of a small

MSA participating employer.

However, your spouse can have health

employer or be self-employed. You (or your

coverage other than an HDHP if you aren't

spouse) must be covered under an HDHP and

Purpose of Form

covered by that plan.

have no other health coverage except permitted

coverage. You must not be enrolled in Medicare

Use Form 8853 to:

Exceptions. You can have additional

and can't be claimed as a dependent on

insurance that provides benefits only for:

Report Archer MSA contributions (including

someone else's 2017 tax return. You must be

Liabilities under workers' compensation

employer contributions),

an eligible individual on the first day of a month

laws, tort liabilities, or liabilities arising from the

Figure your Archer MSA deduction,

to take an Archer MSA deduction for that

ownership or use of property,

Report distributions from Archer MSAs or

month.

A specific disease or illness, or

Medicare Advantage MSAs,

Small Employer

A fixed amount per day (or other period) of

Report taxable payments from long-term

hospitalization.

care (LTC) insurance contracts, or

A small employer is generally an employer who

You can also have coverage (either through

Report taxable accelerated death benefits

had an average of 50 or fewer employees

insurance or otherwise) for accidents, disability,

from a life insurance policy.

during either of the last 2 calendar years. See

dental care, vision care, or long-term care.

Pub. 969 for details.

Additional information. See Pub. 969, Health

Disabled

Savings Accounts and Other Tax-Favored

Archer MSA

Health Plans, for more details on MSAs.

An individual generally is considered disabled if

Generally, an Archer MSA is a medical savings

he or she is unable to engage in any substantial

Who Must File

account set up exclusively for paying the

gainful activity due to a physical or mental

qualified medical expenses of the account

impairment which can be expected to result in

You must file Form 8853 if any of the following

holder.

death or to continue indefinitely.

applies.

Qualified Medical Expenses

You (or your employer) made contributions

Death of Account Holder

for 2017 to your Archer MSA.

Generally, qualified medical expenses for

If the account holder's surviving spouse is the

You are filing a joint return and your spouse

Archer MSA purposes are unreimbursed

designated beneficiary, the Archer MSA is

(or his or her employer) made contributions for

medical expenses that could otherwise be

treated as if the surviving spouse were the

2017 to your spouse's Archer MSA.

deducted on Schedule A (Form 1040). See the

account holder. The surviving spouse

You (or your spouse, if filing jointly) acquired

Instructions for Schedule A (Form 1040),

completes Form 8853 as though the Archer

an interest in an Archer MSA or a Medicare

Itemized Deductions and Pub. 502, Medical

MSA belonged to him or her.

Advantage MSA because of the death of the

and Dental Expenses. Qualified medical

account holder. See

Death of Account

Holder,

expenses are those incurred by the account

If the designated beneficiary isn't the

later.

holder or the account holder's spouse or

account holder's surviving spouse, or there is

You (or your spouse, if filing jointly) were a

dependent(s). Only prescribed medicines or

no designated beneficiary, the account ceases

policyholder who received payments under an

drugs (including over-the-counter medicines

to be an Archer MSA as of the date of death.

LTC insurance contract or received any

and drugs that are prescribed) and insulin (even

The beneficiary completes Form 8853 as

accelerated death benefits from a life insurance

if purchased without a prescription) for the

follows.

policy on a per diem or other periodic basis in

account holder or the account holder's spouse

Enter “Death of Archer MSA account holder”

2017. See the instructions for Section C, later.

or dependent(s), are qualified medical

across the top of Form 8853.

You (or your spouse, if filing jointly) received

expenses. See the instructions for

Line

7, later.

Enter the name(s) shown on the

Archer MSA or Medicare Advantage MSA

You can't treat insurance premiums as qualified

beneficiary's tax return and the beneficiary's

distributions in 2017.

medical expenses unless the premiums are for:

SSN in the spaces provided at the top of the

LTC insurance,

form and skip Part I.

Health care continuation coverage, or

On lines 6a and 6c, enter the fair market

value of the Archer MSA as of the date of death.

Sep 14, 2017

Cat. No. 24188L

Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2017

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