Instructions For Form 8889 - Health Savings Accounts (Hsas) - 2004


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Department of the Treasury
Internal Revenue Service
Instructions for Form 8889
Health Savings Accounts (HSAs)
Section references are to the Internal Revenue Code unless otherwise noted.
Contributions to an HSA
High Deductible Health Plan
General Instructions
Any eligible individual can contribute
An HDHP is a health plan that meets
to an HSA. For an HSA established
the following requirements.
Purpose of Form
by an employee, the employee, the
Use Form 8889 to:
employee’s employer, or both can
contribute to the HSA of the
coverage coverage
Report health savings account
employee. For an HSA established by
(HSA) contributions (including those
a self-employed (or unemployed)
Minimum annual
made on your behalf and employer
individual, the individual can
contribute. A family member or any
Figure your HSA deduction, and
Maximum annual
other person also can make
Report distributions from HSAs.
contributions on behalf of an eligible
$5,000 $10,000
Additional information. See Pub.
969, Health Savings Accounts and
* This limit does not apply to deductibles and
Other Tax-Favored Health Plans, for
expenses for out-of-network services if the plan
Distributions From an HSA
more details on HSAs.
uses a network of providers. Instead, only
Distributions from an HSA used
deductibles and out-of-pocket expenses (such as
copayments and other amounts, but not
Who Must File
exclusively to pay qualified medical
premiums) for services within the network should
expenses of the account beneficiary,
You must file Form 8889 if any of the
be used to figure whether the limit is reached. For
spouse, or dependents are
2004 only, a plan with a deductible that complies
following apply.
excludable from gross income. You
with the maximum limit and that would otherwise
You (or someone on your behalf,
qualify as an HDHP but for the lack of an express
can receive distributions from an HSA
including your employer) made
maximum on payments above the deductible will
even if you are not currently eligible
contributions for 2004 to your HSA.
be treated as an HDHP.
to have contributions made to the
You received HSA distributions in
HSA. However, any part of a
An HDHP can provide preventive
distribution not used to pay qualified
You acquired an interest in an HSA
care and certain other benefits with
medical expenses is includible in
because of the death of the account
no deductible or a deductible below
gross income and is subject to an
beneficiary. See Death of Account
the minimum annual deductible. For
additional 10% tax unless an
Beneficiary on page 2.
more details, see Pub. 969. An HDHP
exception applies.
does not include a plan if
substantially all of the coverage is for
Qualified Medical Expenses
accidents, disability, dental care,
Generally, qualified medical
vision care, or long-term care. An
Eligible Individual
expenses for HSA purposes are
HDHP also cannot be insurance that
To be eligible to have contributions
unreimbursed medical expenses that
you are permitted to have in addition
made to your HSA, you must be
could otherwise be deducted on
to an HDHP. See Other Health
covered under a high deductible
Schedule A (Form 1040). See the
Coverage below.
health plan (HDHP) and have no
Schedule A instructions and Pub.
other health coverage except
502, Medical and Dental Expenses
Other Health Coverage
permitted coverage. You cannot be
(Including the Health Coverage Tax
If you have an HSA, you (and your
enrolled in Medicare or be claimed as
Credit). However, you may not treat
spouse, if you have family coverage)
a dependent on another person’s tax
insurance premiums as qualified
generally cannot have any health
return. You must be an eligible
medical expenses unless the
coverage other than an HDHP. If you
individual on the first day of a month
premiums are for:
have a health flexible spending
to take an HSA deduction for that
arrangement or health reimbursement
Long-term care (LTC) insurance,
arrangement, see Pub. 969.
Health care continuation coverage
Account Beneficiary
(such as coverage under COBRA),
Exceptions. You can have additional
The account beneficiary is the
insurance that provides benefits only
Health care coverage while
individual on whose behalf the HSA
receiving unemployment
was established.
Liabilities under workers’
compensation under federal or state
compensation laws, tort liabilities, or
law, or
liabilities arising from the ownership
Medicare and other health care
An HSA is a health savings account
or use of property,
coverage if you were 65 or older
set up exclusively for paying the
A specific disease or illness, or
(other than premiums for a Medicare
qualified medical expenses of the
supplemental policy, such as
A fixed amount per day (or other
account beneficiary or the account
beneficiary’s spouse or dependents.
period) of hospitalization.
Cat. No. 37971Y


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