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On line 7, for a beneficiary other than the

Contributions to an Archer

MSA, later. Also, if

the excess as income. See

Excess Employer

estate, enter qualified medical expenses

you or your spouse made contributions in

Contributions, later, for details.

incurred by the account holder before the date

addition to any employer contributions, you may

Line 2

of death that you paid within 1 year after the

have to pay an additional tax. See

Excess

date of death.

Contributions You

Make, later.

Include on line 2 contributions you made to your

Complete the rest of Part II.

Archer MSA in 2017. Also include those

You can't deduct any contributions you

contributions made from January 1, 2018,

If the account holder's estate is the

made after you became enrolled in Medicare.

through April 17, 2018, that were for 2017. Don't

beneficiary, the fair market value of the Archer

Also, you can't deduct contributions if you can

include amounts rolled over from another

MSA as of the date of death is included in the

be claimed as a dependent on someone else's

Archer MSA. See Rollovers, later.

account holder's final income tax return.

2017 tax return.

Line 3

Complete Form 8853 as described above,

except you should complete Part I, if applicable.

Go through the chart at the top of the

Line 3

Employer Contributions to an

The transfer isn't subject to the additional

Limitation Chart and Worksheet

for each month

Archer MSA

20% tax. Report any earnings on the account

of 2017. Enter the result on the worksheet next

after the date of death as income on your tax

to the corresponding month. Enter the amount

If an employer made contributions to your

return.

from the last line of the worksheet on line 3.

Archer MSA, you aren't entitled to a deduction.

If you and your spouse are covered under an

If eligibility and coverage for both you

Note. If, during the tax year, you are the

HDHP with family coverage and an employer

and your spouse didn't change from

beneficiary of two or more Archer MSAs or you

TIP

made contributions to either of your Archer

one month to the next, enter the same

are a beneficiary of an Archer MSA and you

MSAs, neither you nor your spouse is allowed

number you entered for the previous month. If

have your own Archer MSA, you must complete

to make deductible contributions to an Archer

eligibility and coverage didn't change during the

a separate Form 8853 for each Medicare

MSA. If you and your spouse both have an

entire year, figure the number for January only,

Advantage MSA. Enter “statement” at the top of

HDHP with self-only coverage and only one of

and enter this amount on Form 8853, line 3.

each Form 8853 and complete the form as

you received employer contributions to an

instructed. Next, complete a controlling Form

Archer MSA, the other spouse is allowed to

More than one HDHP. If you and your spouse

8853, combining the amounts shown on each of

make deductible contributions to an Archer

had more than one HDHP on the first day of the

the statement Forms 8853. Attach the

MSA.

month and one of the plans provides family

statements to your paper tax return after the

coverage, use the Family coverage rules on the

How To Complete Part I

controlling Form 8853.

chart and disregard any plans with self-only

Deemed Distributions From

Complete lines 1 through 5 as instructed on the

coverage. If you and your spouse both have

form unless 1 or 2, next, applies.

HDHPs with family coverage on the first day of

Archer MSAs

the month, you both are treated as having only

1. If employer contributions to an Archer

The following situations result in deemed

the family coverage plan with the lowest annual

MSA prevent you from taking a deduction for

distributions from your Archer MSA.

deductible.

amounts you contributed to your Archer MSA,

You engaged in any transaction prohibited

complete Part I as follows.

Married filing separately. If you have an

by section 4975 with respect to any of your

a. Complete lines 1 and 2.

HDHP with family coverage and are married

Archer MSAs, at any time in 2017. Your

filing separately, enter only 37.5% (0.375)

b. Skip lines 3 and 4.

account ceases to be an Archer MSA as of

(one-half of 75%) of the annual deductible for

January 1, 2017, and you must include the fair

Enter -0- on line 5.

each month on the worksheet; or, if you and

market value of all assets in the account as of

d. If line 2 is more than zero, see

Excess

your spouse agree to divide the 75% of the

January 1, 2017, on line 6a.

Contributions You

Make, later.

annual deductible in a different manner, enter

You used any portion of any of your Archer

your share.

2. If you and your spouse have more than

MSAs as security for a loan at any time in 2017.

one Archer MSA, complete Part I as follows.

You must include the fair market value of the

Line 4

assets used as security for the loan as income

a. If either spouse has an HDHP with

Compensation

on Form 1040, line 21; or Form 1040NR,

family coverage, you both are treated as having

line 21.

only the family coverage plan. Disregard any

Compensation includes wages, salaries,

plans with self-only coverage.

Any deemed distribution won't be treated as

professional fees, and other pay you receive for

used to pay qualified medical expenses.

b. If both spouses have HDHPs with family

services you perform. It also includes sales

Generally, these distributions are subject to the

coverage, you both are treated as having only

commissions, commissions on insurance

additional 20% tax.

the family coverage plan with the lowest annual

premiums, pay based on a percentage of

deductible.

profits, tips, and bonuses. Generally, these

Part I—Archer MSA

amounts are included on the Form(s) W-2 you

If both spouses have HDHPs with

receive from your employer(s). Compensation

Contributions and

self-only coverage, complete a separate Form

also includes net earnings from

8853, Section A, Part I, for each spouse. Enter

Deductions

self-employment, but only for a trade or

“statement” across the top of each Form 8853,

business in which your personal services are a

fill in the name and SSN, and complete Part I.

Use Part I to figure:

material income-producing factor. This is your

Next, add lines 1, 2, and 5 from the two

Your Archer MSA deduction,

income from self-employment minus expenses

statement Forms 8853 and enter those totals on

Any excess contributions you made, and

(including the deductible part of

the respective lines of the controlling Form

Any excess contributions made by an

self-employment tax). Compensation doesn't

8853 (the combined Form 8853 for both

employer (see

Excess Employer

Contributions,

include any amounts received as a pension or

spouses). Don't complete lines 3 and 4 of the

later).

annuity and doesn't include any amount

controlling Form 8853. Attach the two statement

Figuring Your Archer MSA

received as deferred compensation.

Forms 8853 to your paper tax return after the

Deduction

controlling Form 8853.

Line 5

Line 1

The amount you can deduct for Archer MSA

If you (or your employer) contributed more to

your Archer MSA than is allowable, you may

contributions is limited by:

Employer Contributions

The applicable portion of the HDHP's annual

have to pay an additional tax on the excess

contributions. Figure the excess contributions

deductible (line 3), and

Employer contributions include any amount an

Your compensation from the employer

using the following instructions. See Form

employer contributes to any Archer MSA for

maintaining the HDHP (line 4).

5329, Additional Taxes on Qualified Plans

you or your spouse for 2017. These

(Including IRAs) and Other Tax-Favored

contributions should be shown in box 12 of

Any employer contributions made to your

Accounts, to figure the additional tax.

Form W-2 with code R. If your employer made

Archer MSA prevent you from making

excess contributions, you may have to report

deductible contributions. See

Employer

Instructions for Form 8853 (2017)

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Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2017 Page 2

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