Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2001
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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
following requirements.
Specific Instructions
Purpose of Form
Name and Social Security Number
Self-only
Family
Use Form 8853 to:
(SSN). Enter your name(s) and SSN as
coverage
coverage
shown on your tax return. If married filing
•
jointly and both you and your spouse
Minimum annual
Report Archer MSA contributions
each have an Archer MSA or each have a
deductible
$1,600
$3,200
(including employer contributions);
Medicare+Choice MSA, enter the SSN
•
Maximum annual
Figure your Archer MSA deduction;
shown first on your tax return.
deductible
$2,400
$4,800
•
Report distributions from Archer MSAs
Section A—Archer MSAs
Maximum annual
or Medicare+Choice MSAs;
out-of-pocket expenses
$3,200
$5,850
•
Report taxable payments from
Eligible Individual
Other Health Insurance
long-term care (LTC) insurance contracts;
To be eligible for an Archer MSA, you
or
If you have an Archer MSA, you (and your
must be an employee of a small employer
•
spouse, if you have family coverage) may
or be self-employed. You also must have
Report taxable accelerated death
not have any health insurance coverage
a high deductible health plan (HDHP) and
benefits from a life insurance policy.
other than an HDHP.
have no other health insurance coverage
except permitted coverage. You must be
Exception. You may have additional
Additional information. See Pub. 969,
an eligible individual on the first day of a
insurance that provides benefits only for:
Medical Savings Accounts (MSAs), for
•
month to take an Archer MSA deduction
Accidents,
more details on MSAs.
•
for that month.
Disability,
•
Dental care,
Who Must File
Small Employer
•
Vision care,
•
A small employer is generally an
You must file Form 8853 if any of the
Long-term care,
•
employer who had an average of 50 or
following apply.
Liabilities under workers’ compensation
fewer employees during either of the last
•
laws, tort liabilities, or liabilities arising
You (or your employer) made
2 calendar years. See Pub. 969 for
from the ownership or use of property,
contributions for 2001 to your Archer
•
details.
A specific disease or illness, or
MSA.
•
A fixed amount per day (or other
Archer MSA
•
You are filing a joint return and your
period) of hospitalization.
An Archer MSA is a medical savings
spouse (or his or her employer) made
account set up exclusively for paying the
Disabled
contributions for 2001 to your spouse’s
qualified medical expenses of the account
An individual generally is considered
Archer MSA.
holder or the account holder’s spouse or
disabled if he or she is unable to engage
•
dependent(s) in conjunction with an
You (or your spouse, if married filing
in any substantial gainful activity due to a
HDHP.
jointly) received Archer MSA or
physical or mental impairment which can
Medicare+Choice MSA distributions in
be expected to result in death or to
Qualified Medical Expenses
2001.
continue indefinitely.
Generally, qualified medical expenses for
•
You acquired an interest in an Archer
Archer MSA purposes are unreimbursed
Part I—General
medical expenses that could otherwise be
MSA or a Medicare+Choice MSA
deducted on Schedule A (Form 1040).
Information
because of the death of the account
See the Schedule A (Form 1040)
holder. See Death of Account Holder on
Complete this part if contributions were
instructions and Pub. 502, Medical and
page 4 for details.
made for 2001 by:
Dental Expenses. However, you may not
•
•
You (or your employer) to your Archer
You (or your spouse, if married filing
treat insurance premiums as qualified
MSA or
jointly) were a policyholder who received
medical expenses unless the premiums
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Your spouse (or his or her employer) to
payments under an LTC insurance
are for:
your spouse’s Archer MSA (if you are
contract or received any accelerated
•
Long-term care (LTC) insurance,
filing a joint return).
•
death benefits from a life insurance policy
Health care continuation coverage, or
•
Lines 1a and 2a
on a per diem or other periodic basis in
Health care coverage while receiving
2001. See the instructions for Section C,
unemployment compensation under
Check the “Yes” box on line 1a if you or
beginning on page 6.
Federal or state law.
your employer made contributions to your
Cat. No. 24188L
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