Instructions For Form 8889 - Health Savings Accounts

Example. In 2005, you had family

coverage under an HDHP for you and

Line 3 Limitation Chart and Worksheet

your spouse. Both of you were under

Go through this chart for each month of 2005.

age 55 at the end of 2005. Your

See the instructions for line 3 that begin on page 2.

HDHP will pay benefits for any family

(Keep for your records)

member whose covered expenses

exceed $2,000 (the embedded

Start Here

individual deductible) and will pay

benefits for all family members after

Were you enrolled in Medicare for the

Yes

the covered expenses exceed $5,000

month?

(the umbrella deductible). Your

annual deductible is $4,000 (the

smaller of $5,000 or $4,000 ($2,000 ×

2)). Your maximum HSA deduction is

$4,000 (the smaller of $4,000 or

Were you an eligible individual (see

$5,250).

Enter -0- on the line

page 1 of the instructions) on the first

below for the month.

If you did not have the same

day of the month?

coverage on the first day of every

month during 2005, or you were age

Yes

55 or older at the end of 2005, go

through the chart at the top of the

Line 3 Limitation Chart and

What type of coverage did your HDHP provide on the first day of the

Worksheet on this page for each

month (see items (1) through (3) in the instructions for line 3, on page 2)?

month of 2005. Enter the result on

the worksheet next to the

corresponding month.

If eligibility and coverage did

Self-only coverage

Family coverage

TIP

not change from one month to

Enter your annual deductible (must be at

the next, enter the same

least $2,000 but not more than $5,250)

least $1,000 but not more than $2,650)

number you entered for the previous

on the line below for the month. If, at the

on the line below for the month. If you

month.

were age 55 or older at the end of 2005,

end of 2005, you were unmarried and

increase this amount by $600.

age 55 or older, increase this amount by

Line 6

$600.

Spouses that have separate HSAs

and had family coverage under an

HDHP at any time during 2005, use

Amount from

the following rules to figure the

chart above

Month in 2005

amount on line 6.

•

If you were treated as having family

coverage for each month you were an

January

eligible individual, divide the amount

on line 5 equally between you and

February

your spouse, unless you both agree

March

on a different allocation (such as

allocating nothing to one spouse).

April

Enter your allocable share on line 6.

•

If you were not treated as having

May

family coverage for each month you

were an eligible individual, use the

June

following steps to determine the

July

amount to enter on line 6.

Step 1. Refigure the contribution

August

limit that would have been entered on

line 5 if you had entered on line 3 the

September

total of the worksheet amounts only

for the months you were treated as

October

having family coverage. When

November

refiguring line 5, use the same

amount you previously entered on

December

line 4.

Step 2. Divide the refigured

Total for all months

contribution limit from Step 1 equally

Limit. Divide the total by 12. Enter here and on line 3

between you and your spouse, unless

you both agree on a different

allocation (such as allocating nothing

to one spouse).

Step 3. Subtract the part of the

contribution limit allocated to your

spouse in Step 2 from the amount

-3-

Instructions For Form 8889 - Health Savings Accounts - 2005 Page 3

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