Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2001 Page 7
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8Filing Requirements for Section C
Go through this chart for each insured person for
whom you received long-term care (LTC) payments.
Start Here
Did you (or your spouse, if
married filing jointly) receive
Were any of those
payments in 2001 made on
payments made
Complete all of
Yes
Yes
Section C
a per diem or other periodic
under a qualified LTC
basis under an LTC
insurance policy?
insurance contract?
No
No
Did you (or your spouse, if
Did you (or your spouse, if
married filing jointly) receive
married filing jointly) receive
any accelerated death
any accelerated death
Complete only lines
benefits in 2001 from a life
benefits in 2001 from a life
No
16a, 16b, and 19 of
insurance policy that were
insurance policy that were
Section C
made on a per diem or
made on a per diem or other
other periodic basis?
periodic basis?
Yes
Were any of the payments
Complete only lines 16a,
paid on behalf of a
16b, 17, 18, 19 (if
No
Yes
No
chronically ill (not terminally
applicable), and 28 of
ill) individual?
Section C
Yes
Do not complete
Complete all of Section C
Section C
Line 24
Generally, do not include on line
persons who received per diem payments
!
26 any reimbursements for
under a qualified LTC insurance contract
Qualified LTC services are necessary
qualified LTC services you
or as accelerated death benefits because
CAUTION
diagnostic, preventive, therapeutic,
received under a contract issued before
the insured was chronically ill. Each
curing, treating, mitigating, and
August 1, 1996. However, you must
person must use the same LTC period. If
rehabilitative services, and maintenance
include reimbursements if the contract
all the recipients of payments do not
or personal care services required to treat
was exchanged or modified after July 31,
agree on which LTC period to use, the
a chronically ill individual under a plan of
1996, to increase per diem payments or
contract period method must be used.
care prescribed by a licensed health care
reimbursements.
After completing the attachment,
practitioner.
determine your share of the per diem
Multiple Payees
Line 26
limitation and any taxable payments. The
If you checked “Yes” on lines 17 and 18
Enter the reimbursements you received or
per diem limitation is allocated first to the
and the only payments you received
expect to receive through insurance or
insured to the extent of the total payments
were accelerated death benefits that were
otherwise for qualified LTC services
the insured received. If the insured is
paid because the insured was terminally
provided for the insured for LTC periods
married and files a joint return and the
ill, skip lines 19 through 27 and enter zero
in 2001. Box 3 of Form 1099-LTC should
insured’s spouse is one of the
on line 28.
indicate whether the payments were
policyholders, the per diem limitation is
made on a reimbursement basis.
In all other cases in which you
allocated first to them to the extent of the
checked “Yes” on line 17, attach a
payments they both received. Any
statement duplicating lines 20 through 28
remaining limitation is allocated among
of the form. This attachment should show
the other policyholders pro rata based on
the aggregate computation for all
the payments they received in 2001.
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