Instructions For Form 8853 - 2009


2 0 09
Department of the Treasury
Internal Revenue Service
Instructions for Form 8853
Archer MSAs and Long-Term Care Insurance Contracts
If you (or your spouse, if filing
dental expenses deduction, they do
Section references are to the Internal
jointly) received Archer MSA or
qualify as expenses for MSA purposes.
Revenue Code unless otherwise noted.
Medicare Advantage MSA
Qualified medical expenses are those
General Instructions
distributions in 2009, you must file Form
incurred by the account holder or the
8853 with a Form 1040 even if you have
account holder’s spouse or dependent(s).
no taxable income or any other reason for
See the instructions for line 7 on page 4.
After December 31, 2007,
filing Form 1040.
However, you cannot treat insurance
contributions cannot be made to
premiums as qualified medical expenses
an Archer MSA for you, unless:
unless the premiums are for:
You were an active Archer MSA
participant for any tax year ending before
Specific Instructions
Long-term care (LTC) insurance,
January 1, 2008, or
Health care continuation coverage, or
You became an active Archer MSA
Name and social security number
Health care coverage while receiving
participant for a tax year ending after
(SSN). Enter your name(s) and SSN as
unemployment compensation under
December 31, 2007, because of coverage
shown on your tax return. If filing jointly
federal or state law.
under a high deductible health plan of an
and both you and your spouse each have
Archer MSA participating employer.
an Archer MSA or each have a Medicare
High Deductible Health Plan
Advantage MSA, enter the SSN shown
Purpose of Form
An HDHP is a health plan that meets the
first on your tax return.
following requirements.
Use Form 8853 to:
Section A—Archer MSAs
Report Archer MSA contributions
(including employer contributions),
Figure your Archer MSA deduction,
Eligible Individual
Minimum annual
Report distributions from Archer MSAs
To be eligible for an Archer MSA, you (or
or Medicare Advantage MSAs,
your spouse) must be an employee of a
Report taxable payments from
Maximum annual
small employer or be self-employed. You
long-term care (LTC) insurance contracts,
(or your spouse) must be covered under a
Maximum annual
high deductible health plan (HDHP) and
Report taxable accelerated death
out-of-pocket expenses
have no other health coverage except
benefits from a life insurance policy.
(other than for premiums)
permitted coverage. You must not be
Additional information. See Pub. 969,
enrolled in Medicare and cannot be
Health Savings Accounts and Other
claimed as a dependent on someone
Other Health Coverage
Tax-Favored Health Plans, for more
else’s 2009 tax return. You must be an
If you have an Archer MSA, you (and your
details on MSAs.
eligible individual on the first day of a
spouse, if you have family coverage)
month to take an Archer MSA deduction
cannot have any health coverage other
for that month.
Who Must File
than an HDHP. But your spouse can have
health coverage other than an HDHP if
You must file Form 8853 if any of the
Small Employer
you are not covered by that plan.
following applies.
A small employer is generally an
You (or your employer) made
employer who had an average of 50 or
Exceptions. You can have additional
contributions for 2009 to your Archer
fewer employees during either of the last
insurance that provides benefits only for:
2 calendar years. See Pub. 969 for
Liabilities under workers’ compensation
You are filing a joint return and your
laws, tort liabilities, or liabilities arising
spouse (or his or her employer) made
from the ownership or use of property,
contributions for 2009 to your spouse’s
Archer MSA
A specific disease or illness, or
Archer MSA.
Generally, an Archer MSA is a medical
A fixed amount per day (or other
You (or your spouse, if filing jointly)
savings account set up exclusively for
period) of hospitalization.
acquired an interest in an Archer MSA or
paying the qualified medical expenses of
a Medicare Advantage MSA because of
You can also have coverage (either
the account holder.
the death of the account holder. See
through insurance or otherwise) for
Death of Account Holder on page 2.
accidents, disability, dental care, vision
Qualified Medical Expenses
You (or your spouse, if filing jointly)
care, or long-term care.
were a policyholder who received
Generally, qualified medical expenses for
payments under an LTC insurance
Archer MSA purposes are unreimbursed
contract or received any accelerated
medical expenses that could otherwise be
An individual generally is considered
death benefits from a life insurance policy
deducted on Schedule A (Form 1040).
disabled if he or she is unable to engage
on a per diem or other periodic basis in
See the Instructions for Schedule A and
in any substantial gainful activity due to a
2009. See the instructions for Section C,
Pub. 502, Medical and Dental Expenses
physical or mental impairment which can
that begin on page 5.
(Including the Health Coverage Tax
be expected to result in death or to
You (or your spouse, if filing jointly)
Credit). However, even though
continue indefinitely.
received Archer MSA or Medicare
non-prescription medicines (other than
Advantage MSA distributions in 2009.
insulin) do not qualify for the medical and
Cat. No. 24188L


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