Instructions For Form 8853 (2015) (Page 4 of 8) in pdf

Part II—Archer MSA

Section B—Medicare

Health

Coverage, earlier) at the time the

expenses were incurred.

Distributions

Advantage MSA

Example. In 2015, you were covered by an

Distributions

Line 6a

HDHP with self-only coverage and your spouse

was covered by a health plan that was not an

Complete Section B if you (or your spouse, if

Enter the total distributions you and your

HDHP. You made contributions to an Archer

filing jointly) received distributions from a

spouse received in 2015 from all Archer MSAs.

MSA for 2015. You cannot include on line 7

Medicare Advantage MSA in 2015. If both you

These amounts should be shown in box 1 of

withdrawals made from the Archer MSA to pay

and your spouse received distributions,

Form 1099-SA.

your spouse's medical expenses incurred in

complete a separate Form 8853, Section B, for

Line 6b

2015 because your spouse was covered by a

each spouse. Enter “statement” across the top

plan that was not an HDHP.

of each Form 8853, fill in the name and SSN,

Include on line 6b any distributions you

and complete Section B. Next, add lines 10, 11,

received in 2015 that were rolled over. See

You cannot take a deduction on

12, and 13b from the two statement Forms

Rollovers, later. Also include any excess

Schedule A (Form 1040) for any

8853 and enter those totals on the respective

contributions (and the earnings on those

amount you include on line 7.

lines of the controlling Form 8853 (the

CAUTION

excess contributions) included on line 6a that

combined Form 8853 for both spouses). If

Lines 9a and 9b

were withdrawn by the due date, including

either spouse checked the box on line 13a of

extensions, of your return. See the instructions

the statement Form 8853, check the box on the

Additional 20% Tax

for line 5, earlier.

controlling Form 8853. Attach the two statement

Archer MSA distributions included in income

Forms 8853 to your paper tax return after the

Rollovers

(line 8) are subject to an additional 20% tax

controlling Form 8853.

unless one of the following exceptions applies.

A rollover is a tax-free distribution (withdrawal)

If you (or your spouse, if filing jointly)

of assets from one Archer MSA that is

received distributions from a Medicare

Exceptions to the Additional 20%

reinvested in another Archer MSA or a health

Advantage MSA in 2015, you must file

CAUTION

savings account (HSA) of the same account

Form 8853 with a Form 1040 even if you have

Tax

holder. Generally, you must complete the

no taxable income or any other reason for filing

The additional 20% tax does not apply to

rollover within 60 days following the distribution.

Form 1040.

distributions made after the date that the

An Archer MSA and an HSA can only receive

account holder—

Medicare Advantage MSA

one rollover contribution during a 1-year period.

Dies,

See Pub. 590-A, Contributions to Individual

A Medicare Advantage MSA is an Archer MSA

Retirement Arrangements (IRAs), for more

Becomes disabled (see Disabled, earlier), or

designated as a Medicare Advantage MSA to

details and additional requirements regarding

Turns age 65.

be used solely to pay the qualified medical

rollovers.

If any of the exceptions applies to any of the

expenses of the account holder. To be eligible

distributions included on line 8, check the box

for a Medicare Advantage MSA, you must be

Note. If you instruct the trustee of your Archer

on line 9a. Enter on line 9b only 20% (.20) of

enrolled in Medicare and have an HDHP that

MSA to transfer funds directly to the trustee of

any amount included on line 8 that does not

meets the Medicare guidelines. Contributions to

another of your Archer MSAs, the transfer is not

meet any of the exceptions.

the account can be made only by Medicare.

considered a rollover. There is no limit on the

The contributions and any earnings, while in the

Example 1. You turned age 66 in 2015 and

number of these transfers. Do not include the

account, are not taxable to the account holder.

had no Archer MSA during 2015. Your spouse

amount transferred in income, deduct it as a

A distribution used exclusively to pay for the

turned age 63 in 2015 and received a

contribution, or include it as a distribution on

qualified medical expenses of the account

distribution from an Archer MSA that is included

line 6a.

holder is not taxable. Distributions that are not

in income. Do not check the box on line 9a

Line 7

used for qualified medical expenses of the

because your spouse (the account holder) did

account holder are included in income and also

not meet the age exception for the distribution.

In general, include on line 7 distributions from

may be subject to a penalty.

Enter 20% of the amount from line 8 on line 9b.

all Archer MSAs in 2015 that were used for the

Death of Account Holder

qualified medical expenses (see

Qualified

Example 2. Both you and your spouse

Medical

Expenses, earlier) of:

received distributions from your Archer MSAs in

If the account holder's surviving spouse is the

1. Yourself and your spouse.

2015 that are included in income. You were age

designated beneficiary, the Medicare

65 at the time you received the distributions and

2. All dependents you claim on your tax

Advantage MSA is treated as a regular Archer

your spouse was age 63 when he or she

return.

MSA (not a Medicare Advantage MSA) of the

received the distributions. Check the box on

surviving spouse for distribution purposes.

3. Any person you could have claimed as

line 9a because the additional 20% tax does not

Follow the instructions in Section A for

Death of

a dependent on your return except that:

apply to the distributions you received (because

Account

Holder, earlier.

a. The person filed a joint return,

you met the age exception). However, the

If the designated beneficiary is not the

additional 20% tax does apply to your spouse's

b. The person had gross income of $4,000

distributions. Enter on line 9b only 20% of the

account holder's surviving spouse, or there is

or more, or

no designated beneficiary, the account ceases

amount of your spouse's distributions included

You, or your spouse if filing jointly, could

in line 8.

to be an MSA as of the date of death. The

be claimed as a dependent on someone else's

beneficiary completes Form 8853 as follows.

return.

Example 3. You turned age 65 in 2015.

Enter “Death of Medicare Advantage MSA

You received distributions that are included in

account holder” across the top of Form 8853.

For this purpose, a child of parents

income both before and after you turned age

Enter the name(s) shown on the beneficiary's

that are divorced, separated, or living

65. Check the box on line 9a because the

TIP

tax return and the beneficiary's SSN in the

apart for the last 6 months of the

additional 20% tax does not apply to the

spaces provided at the top of the form. Skip

calendar year is treated as the dependent of

distributions made after the date you turned age

Section A.

both parents whether or not the custodial parent

65. However, the additional 20% tax does apply

On line 10, enter the fair market value of the

releases the claim to the child's exemption.

to the distributions made on or before the date

Medicare Advantage MSA as of the date of

you turned age 65. Enter on line 9b, 20% of the

death.

However, if a contribution was made to an

amount of these distributions included in line 8.

On line 11, for a beneficiary other than the

Archer MSA in 2015 (by you or your employer),

estate, enter qualified medical expenses

do not include on line 7 withdrawals from an

incurred by the account holder before the date

Archer MSA if the individual for whom the

of death that you paid within 1 year after the

expenses were incurred was not covered by an

date of death.

HDHP or was covered by a plan that was not an

Complete the rest of Section B.

HDHP (other than the exceptions listed in

Other

Instructions for Form 8853 (2015)

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Instructions For Form 8853 (2015) Page 4

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