Instructions For Form 8889 - Health Savings Accounts (Hsas)

account beneficiary, the account

On Part II, line 15, for a beneficiary

Other Health Coverage

beneficiary's spouse or dependent(s),

other than the estate, enter qualified

If you have an HSA, you (and your

are qualified medical expenses.

medical expenses incurred by the

spouse, if you have family coverage)

account beneficiary before the date of

generally cannot have any health

You cannot treat insurance premiums

death that the beneficiary paid within 1

coverage other than an HDHP. Your

as qualified medical expenses unless

year after the date of death.

spouse can have health coverage that is

the premiums are for:

Complete the rest of Part II.

non-HDHP provided you are not

1. Long-term care (LTC) insurance,

covered by that plan. If you have a

If the account beneficiary's estate is

2. Health care continuation

health flexible spending arrangement or

the beneficiary, the value of the HSA as

coverage (such as coverage under

health reimbursement arrangement, see

of the date of death is included on the

COBRA),

Pub. 969.

account beneficiary's final income tax

3. Health care coverage while

return. Complete Form 8889 as

Exceptions. You can have additional

receiving unemployment compensation

described above, except you should

insurance that provides benefits only

under federal or state law, or

complete Part I, if applicable.

for:

4. Medicare and other health care

Liabilities under workers'

The distribution is not subject to the

coverage if you were 65 or older (other

compensation laws, tort liabilities, or

additional 20% tax. Report any earnings

than premiums for a Medicare

liabilities arising from the ownership or

on the account after the date of death as

supplemental policy, such as Medigap).

use of property;

income on your tax return.

A specific disease or illness; or

Coverage under (2) and (3) can

A fixed amount per day (or other

be for your spouse or a

Note. If, during the tax year, you are the

TIP

period) of hospitalization.

dependent meeting the

beneficiary of two or more HSAs or you

You can also have coverage (either

requirement. For (4), if you, the account

are a beneficiary of an HSA and you

through insurance or otherwise) for

beneficiary, are under age 65, Medicare

have your own HSA, you must complete

accidents, disability, dental care, vision

premiums for your spouse or

a separate Form 8889 for each HSA.

care, or long-term care.

dependents (who are age 65 or older)

Enter “statement” at the top of each

generally are not qualified medical

For information on prescription drug

Form 8889 and complete the form as

expenses.

plans, see Pub. 969.

instructed. Next, complete a controlling

Form 8889, combining the amounts

shown on each of the statement Forms

Disabled

High Deductible Health Plan

8889. Attach the statements to your

An individual generally is considered

An HDHP is a health plan that meets the

paper tax return after the controlling

disabled if he or she is unable to engage

following requirements.

Form 8889.

in any substantial gainful activity due to

a physical or mental impairment which

Deemed Distributions From HSAs

Self-only

Family

can be expected to result in death or to

coverage

continue indefinitely.

The following situations result in

deemed distributions from your HSA.

Minimum annual

Death of Account Beneficiary

You engaged in any transaction

deductible

$1,300

$2,600

prohibited by section 4975 with respect

If the account beneficiary's surviving

Maximum annual

to any of your HSAs, at any time in

out-of-pocket

spouse is the designated beneficiary,

2017. Your account ceases to be an

expenses*

$6,550

$13,100

the HSA is treated as if the surviving

HSA as of January 1, 2017, and you

spouse were the account beneficiary.

must include the fair market value of all

The surviving spouse completes Form

assets in the account as of January 1,

8889 as though the HSA belonged to

2017, on line 14a.

* This limit does not apply to deductibles and

him or her.

You used any portion of any of your

expenses for out-of-network services if the plan

uses a network of providers. Instead, only

HSAs as security for a loan at any time

If the designated beneficiary is not

deductibles and out-of-pocket expenses (such

in 2017. You must include the fair

the account beneficiary's surviving

as copayments and other amounts, but not

market value of the assets used as

spouse, or there is no designated

premiums) for services within the network

security for the loan as income on

beneficiary, the account ceases to be

should be used to figure whether the limit is

line 21 of Form 1040 or Form 1040NR.

an HSA as of the date of death. The

reached.

beneficiary completes Form 8889 as

Any deemed distribution will not be

follows.

treated as used to pay qualified medical

Enter “Death of HSA account

An HDHP can provide preventive

expenses. Generally, these distributions

beneficiary” across the top of Form

care and certain other benefits with no

are subject to the additional 20% tax.

8889.

deductible or a deductible below the

Enter the name(s) shown on the

minimum annual deductible. For more

Rollovers

beneficiary's tax return and the

details, see Pub. 969. An HDHP does

beneficiary's SSN in the spaces

not include a plan if substantially all of

A rollover is a tax-free distribution

provided at the top of the form and skip

the coverage is for accidents, disability,

(withdrawal) of assets from one HSA or

Part I.

dental care, vision care, or long-term

Archer MSA that is reinvested in

On Part II, line 14a, enter the fair

care. See

Other Health Coverage

next.

another HSA of the same account

market value of the HSA as of the date

beneficiary. Generally, you must

of death.

complete the rollover within 60 days

after you received the distribution. An

-2-

Form 8889 (2017)

Instructions For Form 8889 - Health Savings Accounts (Hsas) - 2017 Page 2

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