8853 Archer MSAa and Long-Term Care Insurance Contracts

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Form

8853

Department of the Treasury
Internal Revenue Service (99)
Name(s) shown on return

Archer MSAs and
Long-Term Care Insurance Contracts

▶

OMB No. 1545-0074

2021

Go to www.irs.gov/Form8853 for instructions and the latest information.
▶ Attach to Form 1040, 1040-SR, or 1040-NR.

Attachment
Sequence No. 39

Social security number of MSA
account holder. If both spouses
have MSAs, see instructions ▶

Section A. Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
Part I
Archer MSA Contributions and Deductions. See instructions before completing this part. If you are filing
jointly and both you and your spouse have high deductible health plans with self-only coverage, complete a
separate Part I for each spouse.
1
2

DRAFT AS OF
August 20, 2021
DO NOT FILE

Total employer contributions to your Archer MSA(s) for 2021 . . . . . .
1
Archer MSA contributions you made for 2021, including those made from January 1, 2022, through
April 18, 2022, that were for 2021. Don’t include rollovers. See instructions . . . . . . . . .
Limitation from the Line 3 Limitation Chart and Worksheet in the instructions . . . . . . . .
Compensation (see instructions) from the employer maintaining the high deductible health plan. (If
self-employed, enter your earned income from the trade or business under which the high deductible
health plan was established.) . . . . . . . . . . . . . . . . . . . . . . . .
Archer MSA deduction. Enter the smallest of line 2, 3, or 4 here. Also include this amount on
Schedule 1 (Form 1040), line 23 . . . . . . . . . . . . . . . . . . . . . . .
Caution: If line 2 is more than line 5, you may have to pay an additional tax. See instructions.

3
4

5

Part II
6a

2
3

4

5

Archer MSA Distributions

Total distributions you and your spouse received in 2021 from all Archer MSAs (see instructions) .

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b Distributions included on line 6a that you rolled over to another Archer MSA or a health savings
account. Also include any excess contributions (and the earnings on those excess contributions)
included on line 6a that were withdrawn by the due date of your return. See instructions . . . . .
c Subtract line 6b from line 6a
. . . . . . . . . . . . . . . . . . . . . . . .
7
Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . . .
8
Taxable Archer MSA distributions. Subtract line 7 from line 6c. If zero or less, enter -0-. Also include
this amount in the total on Schedule 1 (Form 1040), line 8z. On the dotted line next to Schedule 1
(Form 1040), line 8z, enter “MSA” and the amount . . . . . . . . . . . . . . . . .
If any of the distributions included on line 8 meet any of the Exceptions to the Additional 20% Tax
(see instructions), check here . . . . . . . . . . . . . . . . . . . . . . ▶
b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 8 that are
subject to the additional 20% tax. Also include this amount in the total on Schedule 2 (Form 1040),
line 17e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6a

6b
6c
7

8

9a

9b

Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2021 from a Medicare Advantage MSA, complete a separate Section B for each spouse.
See instructions.
10
11
12

Total distributions you received in 2021 from all Medicare Advantage MSAs (see instructions) . . .
Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . . .
Taxable Medicare Advantage MSA distributions. Subtract line 11 from line 10. If zero or less, enter
-0-. Also include this amount in the total on Schedule 1 (Form 1040), line 8z. On the dotted line next to
Schedule 1 (Form 1040), line 8z, enter “Med MSA” and the amount . . . . . . . . . . . .
If any of the distributions included on line 12 meet any of the Exceptions to the Additional 50% Tax
(see instructions), check here . . . . . . . . . . . . . . . . . . . . . . ▶
b Additional 50% tax. Enter 50% (0.50) of the distributions included on line 12 that are subject to the
additional 50% tax. See instructions for the amount to enter if you had a Medicare Advantage MSA
at the end of 2020. Also include this amount in the total on Schedule 2 (Form 1040), line 17f . . .

10
11

12

13a

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 24091H

13b
Form 8853 (2021)

Form 8853 (2021)

Attachment Sequence No.

Name of policyholder (as shown on return)

39

Page 2

Social security number of
policyholder ▶

Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C in the instructions
before completing this section.
If more than one Section C is attached, check here .

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Name of insured

15

In 2021, did anyone other than you receive payments on a per diem or other periodic basis under a
qualified LTC insurance contract covering the insured or receive accelerated death benefits under a life
insurance policy covering the insured? . . . . . . . . . . . . . . . . . . . . . . .
Was the insured a terminally ill individual? . . . . . . . . . . . . . . . . . . . . . .
Note: If “Yes” and the only payments you received in 2021 were accelerated death benefits that were
paid to you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.

17

18
19
20

21
22
23
24

25
26

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DRAFT AS OF
August 20, 2021
DO NOT FILE

14a

16

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▶

b Social security number of insured

Gross LTC payments received on a per diem or other periodic basis. Enter the total of the amounts
from box 1 of all Forms 1099-LTC you received with respect to the insured on which the “Per diem”
box in box 3 is checked . . . . . . . . . . . . . . . . . . . . . . . . . .
Caution: Don’t use lines 18 through 26 to figure the taxable amount of benefits paid under an LTC
insurance contract that isn’t a qualified LTC insurance contract. Instead, if the benefits aren’t
excludable from your income (for example, if the benefits aren’t paid for personal injuries or sickness
through accident or health insurance), report the amount not excludable as income on Schedule 1
(Form 1040), line 8z or, for taxpayers filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12.
Enter the part of the amount on line 17 that is from qualified LTC insurance contracts . . . . .
Accelerated death benefits received on a per diem or other periodic basis. Don’t include any amounts
you received because the insured was terminally ill. See instructions . . . . . . . . . . .
Add lines 18 and 19 . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: If you checked “Yes” on line 15 above, see Multiple Payees in the
instructions before completing lines 21 through 25.
Multiply $400 by the number of days in the LTC period . . . . . . . .
21
Costs incurred for qualified LTC services provided for the insured during the
LTC period (see instructions) . . . . . . . . . . . . . . . .
22
Enter the larger of line 21 or line 22 . . . . . . . . . . . . . .
23
Reimbursements for qualified LTC services provided for the insured during the
LTC period . . . . . . . . . . . . . . . . . . . . . .
24
Caution: If you received any reimbursements from LTC contracts issued
before August 1, 1996, see instructions.
Per diem limitation. Subtract line 24 from line 23 . . . . . . . . . . . . . . . . . .

Taxable payments. Subtract line 25 from line 20. If zero or less, enter -0-. Also include this amount in
the total on Schedule 1 (Form 1040), line 8z or, for taxpayers filing Form 1040-NR, on Form 1040-NR,
Schedule NEC, line 12. On the dotted line next to Schedule 1 (Form 1040), line 8z or, for taxpayers
filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12, enter “LTC” and the amount . . .

.

▶

▶

Yes
Yes

No
No

17

18

19
20

25

26
Form 8853 (2021)