Instructions For Form 8889 - Health Savings Accounts (Hsas) - 2004 Page 3
ADVERTISEMENT
1
2
3
4
5HSA or Archer MSA. See Rollovers
Line 3 Limitation Chart and Worksheet
on page 2.
Go through this chart for each month of 2004.
See the instructions for line 3 on this page.
Line 3
(Keep for your records)
If you were under age 55 at the end
of 2004, and on the first day of every
Start Here
month during 2004, you were an
Were you enrolled in Medicare for the
eligible individual with the same
Yes
month?
annual deductible and coverage,
enter the smaller of the following
amounts:
No
•
Your annual deductible, or
•
$2,600 ($5,150 for family
coverage).
Were you an eligible individual (see
Enter -0- on the line
page 1 of the instructions) on the first
No
below for the month.
When figuring the amount to enter
day of the month?
on line 3, apply the following rules:
1. Use the family coverage
Yes
amount if you and your spouse had
more than one HDHP and one of the
plans provided family coverage.
What type of coverage did your HDHP provide on the first day of the
Disregard any plans with self-only
month? If you had more than one HDHP, see the instructions for items (1)
coverage.
through (3) on this page.
2. If you and your spouse had
more than one HDHP with family
coverage, use the plan with the
Self-only coverage
Family coverage
lowest annual deductible.
Enter annual deductible (must
Enter annual deductible (must
3. If you had family coverage with
be at least $1,000 but do not
be at least $2,000 but do not
both an umbrella deductible and an
enter more than $2,600)
enter more than $5,150)
embedded deductible for each
$
$
individual covered by the plan, your
annual deductible is the smaller of
the:
a. Umbrella deductible, or
Enter this amount on the line below
Enter this amount on the line below for
for the month. If you were age 55 or
the month. If, at the end of 2004, you
b. Embedded individual deductible
older at the end of 2004, increase this
were unmarried and age 55 or older,
multiplied by the number of family
amount by $500.
increase this amount by $500.
members covered by the plan.
Example. In 2004, you had family
Amount from
coverage under an HDHP for you and
chart above
Month in 2004
your spouse. Both of you were under
age 55 at the end of 2004. Your
January
HDHP will pay benefits for any family
member whose covered expenses
February
exceed $2,000 (the embedded
individual deductible) and will pay
March
benefits for all family members after
the covered expenses exceed $5,000
April
(the umbrella deductible). Your
May
annual deductible is $4,000 (the
smaller of $5,000 or $4,000 ($2,000 x
June
2)). Your maximum HSA deduction is
$4,000 (the smaller of $4,000 or
July
$5,150).
August
If you did not have the same
coverage on the first day of every
September
month during 2004, or you were age
October
55 or older at the end of 2004, go
through the chart at the top of the
November
Line 3 Limitation Chart and
Worksheet on this page for each
December
month of 2004. Enter the result on
the worksheet next to the
Total for all months
corresponding month.
Limitation. Divide the total by 12. Enter here and on line 3
If eligibility and coverage did
TIP
not change from one month to
the next, enter the same
number you entered for the previous
month.
-3-
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial