Instructions For Form 8889 - 2016 (Page 2 of 6) in pdf

For information on prescription drug

paper tax return after the controlling

dependents (who are age 65 or older)

plans, see Pub. 969.

Form 8889.

generally are not qualified medical

expenses.

Disabled

Deemed Distributions From HSAs

An individual generally is considered

The following situations result in

High Deductible Health Plan

disabled if he or she is unable to engage

deemed distributions from your HSA.

An HDHP is a health plan that meets the

in any substantial gainful activity due to

You engaged in any transaction

following requirements.

a physical or mental impairment which

prohibited by section 4975 with respect

can be expected to result in death or to

to any of your HSAs, at any time in

continue indefinitely.

2016. Your account ceases to be an

Self-only

Family

HSA as of January 1, 2016, and you

coverage

must include the fair market value of all

Death of Account Beneficiary

assets in the account as of January 1,

Minimum annual

If the account beneficiary's surviving

2016, on line 14a.

deductible

$1,300

$2,600

spouse is the designated beneficiary,

You used any portion of any of your

Maximum annual

the HSA is treated as if the surviving

HSAs as security for a loan at any time

out-of-pocket

spouse were the account beneficiary.

in 2016. You must include the fair

expenses*

$6,550

$13,100

The surviving spouse completes Form

market value of the assets used as

8889 as though the HSA belonged to

security for the loan as income on

him or her.

line 21 of Form 1040 or Form 1040NR.

* This limit does not apply to deductibles and

If the designated beneficiary is not

Any deemed distribution will not be

expenses for out-of-network services if the plan

the account beneficiary's surviving

treated as used to pay qualified medical

uses a network of providers. Instead, only

spouse, or there is no designated

expenses. Generally, these distributions

deductibles and out-of-pocket expenses (such

beneficiary, the account ceases to be

are subject to the additional 20% tax.

as copayments and other amounts, but not

an HSA as of the date of death. The

premiums) for services within the network

beneficiary completes Form 8889 as

should be used to figure whether the limit is

Rollovers

follows.

reached.

A rollover is a tax-free distribution

Enter “Death of HSA account

(withdrawal) of assets from one HSA or

beneficiary” across the top of Form

Archer MSA that is reinvested in

8889.

An HDHP can provide preventive

another HSA of the same account

Enter the name(s) shown on the

care and certain other benefits with no

beneficiary. Generally, you must

beneficiary's tax return and the

deductible or a deductible below the

complete the rollover within 60 days

beneficiary's SSN in the spaces

minimum annual deductible. For more

after you received the distribution. An

provided at the top of the form and skip

details, see Pub. 969. An HDHP does

HSA can only receive one rollover

Part I.

not include a plan if substantially all of

contribution during a 1-year period. See

On line 14a, enter the fair market

the coverage is for accidents, disability,

Pub. 590−A, Contributions to Individual

value of the HSA as of the date of death.

dental care, vision care, or long-term

Retirement Arrangements (IRAs), for

On line 15, for a beneficiary other

care. An HDHP also cannot be

more details and additional

than the estate, enter qualified medical

insurance that you are permitted to have

requirements regarding rollovers.

expenses incurred by the account

in addition to an HDHP. See

Other

beneficiary before the date of death that

Health Coverage

next.

Note. If you instruct the trustee of your

the beneficiary paid within 1 year after

HSA to transfer funds directly to the

the date of death.

Other Health Coverage

trustee of another of your HSAs, the

Complete the rest of Part II.

transfer is not considered a rollover.

If you have an HSA, you (and your

There is no limit on the number of these

If the account beneficiary's estate is

spouse, if you have family coverage)

transfers. Do not include the amount

the beneficiary, the value of the HSA as

generally cannot have any health

transferred in income, deduct it as a

of the date of death is included on the

coverage other than an HDHP. But your

contribution, or include it as a

account beneficiary's final income tax

spouse can have health coverage other

distribution on line 14a.

return. Complete Form 8889 as

than an HDHP if you are not covered by

described above, except you should

that plan. If you have a health flexible

Specific Instructions

complete Part I, if applicable.

spending arrangement or health

reimbursement arrangement, see Pub.

Name and social security number

The distribution is not subject to the

969.

(SSN). Enter your name(s) as shown

additional 20% tax. Report any earnings

Exceptions. You can have additional

on your tax return and the SSN of the

on the account after the date of death as

insurance that provides benefits only

HSA account beneficiary. If married

income on your tax return.

for:

filing jointly and both you and your

Liabilities under workers'

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

spouse have HSAs, complete a

compensation laws, tort liabilities, or

beneficiary of two or more HSAs or you

separate Form 8889 for each of you.

liabilities arising from the ownership or

are a beneficiary of an HSA and you

use of property;

Part I—HSA Contributions

have your own HSA, you must complete

A specific disease or illness; or

a separate Form 8889 for each HSA.

and Deductions

A fixed amount per day (or other

Enter “statement” at the top of each

Use Part I to figure:

period) of hospitalization.

Form 8889 and complete the form as

Your HSA deduction,

You can also have coverage (either

instructed. Next, complete a controlling

Any excess contributions you made

through insurance or otherwise) for

Form 8889, combining the amounts

(or those made on your behalf), and

accidents, disability, dental care, vision

shown on each of the statement Forms

care, or long-term care.

8889. Attach the statements to your

-2-

Form 8889 (2016)

Instructions For Form 8889 - 2016 Page 2

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