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 jointly)
Section references are to the Internal Revenue Code
Health care coverage while receiving
unless otherwise noted.
received Archer MSA or Medicare
unemployment compensation under federal or
Advantage MSA distributions in 2015,
you must file Form 8853 with Form 1040 even if
High Deductible Health Plan
you have no taxable income or any other
For the latest information about developments
reason for filing Form 1040.
An HDHP is a health plan that meets the
related to Form 8853 and its instructions, such
as legislation enacted after they were
published, go to
Name and social security number (SSN).
Enter your name(s) and SSN as shown on your
Minimum annual deductible
tax return. If filing jointly and both you and your
After December 31, 2007,
Maximum annual deductible
spouse each have an Archer MSA or each have
contributions cannot be made to an
a Medicare Advantage MSA, enter the SSN
Archer MSA for you, unless:
shown first on your tax return.
You were an active Archer MSA participant
(other than for premiums)
for any tax year ending before January 1, 2008,
Section A—Archer MSAs
You became an active Archer MSA
Other Health Coverage
participant for a tax year ending after December
31, 2007, because of coverage under a high
If you have an Archer MSA, you (and your
To be eligible for an Archer MSA, you (or your
deductible health plan of an Archer MSA
spouse, if you have family coverage) cannot
spouse) must be an employee of a small
have any health coverage other than an HDHP.
employer or be self-employed. You (or your
But your spouse can have health coverage
spouse) must be covered under a high
other than an HDHP if you are not covered by
Purpose of Form
deductible health plan (HDHP) and have no
other health coverage except permitted
Use Form 8853 to:
coverage. You must not be enrolled in Medicare
Exceptions. You can have additional
and cannot be claimed as a dependent on
insurance that provides benefits only for:
Report Archer MSA contributions (including
someone else's 2015 tax return. You must be
Liabilities under workers' compensation laws,
an eligible individual on the first day of a month
tort liabilities, or liabilities arising from the
Figure your Archer MSA deduction,
to take an Archer MSA deduction for that
ownership or use of property,
Report distributions from Archer MSAs or
A specific disease or illness, or
Medicare Advantage MSAs,
A fixed amount per day (or other period) of
Report taxable payments from long-term
care (LTC) insurance contracts, or
A small employer is generally an employer who
Report taxable accelerated death benefits
You can also have coverage (either through
had an average of 50 or fewer employees
from a life insurance policy.
insurance or otherwise) for accidents, disability,
during either of the last 2 calendar years. See
dental care, vision care, or long-term care.
Pub. 969 for details.
Additional information. See Pub. 969, Health
Savings Accounts and Other Tax-Favored
Health Plans, for more details on MSAs.
An individual generally is considered disabled if
Generally, an Archer MSA is a medical savings
he or she is unable to engage in any substantial
Who Must File
account set up exclusively for paying the
gainful activity due to a physical or mental
qualified medical expenses of the account
You must file Form 8853 if any of the following
impairment which can be expected to result in
death or to continue indefinitely.
Qualified Medical Expenses
You (or your employer) made contributions
Death of Account Holder
for 2015 to your Archer MSA.
Generally, qualified medical expenses for
If the account holder's surviving spouse is the
You are filing a joint return and your spouse
Archer MSA purposes are unreimbursed
(or his or her employer) made contributions for
designated beneficiary, the Archer MSA is
medical expenses that could otherwise be
2015 to your spouse's Archer MSA.
treated as if the surviving spouse were the
deducted on Schedule A (Form 1040). See the
account holder. The surviving spouse
You (or your spouse, if filing jointly) acquired
Instructions for Schedule A (Form 1040),
completes Form 8853 as though the Archer
an interest in an Archer MSA or a Medicare
Itemized Deductions and Pub. 502, Medical
MSA belonged to him or her.
Advantage MSA because of the death of the
and Dental Expenses. Qualified medical
account holder. See
Death of Account
expenses are those incurred by the account
If the designated beneficiary is not the
holder or the account holder's spouse or
account holder's surviving spouse, or there is
You (or your spouse, if filing jointly) were a
dependent(s). Only prescribed medicines or
no designated beneficiary, the account ceases
policyholder who received payments under an
drugs (including over-the-counter medicines
to be an Archer MSA as of the date of death.
LTC insurance contract or received any
and drugs that are prescribed) and insulin (even
The beneficiary completes Form 8853 as
accelerated death benefits from a life insurance
if purchased without a prescription) for the
policy on a per diem or other periodic basis in
account holder or the account holder's spouse
Enter “Death of Archer MSA account holder”
2015. See the instructions for Section C, later.
or dependent(s), are qualified medical
across the top of Form 8853.
You (or your spouse, if filing jointly) received
expenses. See the instructions for line 7, later.
Enter the name(s) shown on the beneficiary's
Archer MSA or Medicare Advantage MSA
You cannot treat insurance premiums as
tax return and the beneficiary's SSN in the
distributions in 2015.
qualified medical expenses unless the
spaces provided at the top of the form and skip
premiums are for:
Long-term care (LTC) insurance,
On lines 6a and 6c, enter the fair market
Health care continuation coverage, or
value of the Archer MSA as of the date of death.
Oct 23, 2015
Cat. No. 24188L