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Department of the Treasury
Internal Revenue Service
2023

Instructions for Form 8889

Health Savings Accounts (HSAs)

Section references are to the Internal Revenue Code unless Ask your health insurance provider(s) whether your
otherwise noted. ! HDHP and any disregarded coverage meet the
CAUTION requirements of section 223.
Future Developments
Reminders
For the latest information about developments related to
Form 8889 and its instructions, such as legislation enacted Personal protective equipment. Amounts paid for
after they were published, go to IRS.gov/Form8889. personal protective equipment (PPE), such as masks, hand
sanitizer, and sanitizing wipes, for use by you, your spouse,
What’s New or your dependent(s) to prevent the spread of COVID-19 are
eligible medical expenses that may be paid or reimbursed
Notice 2023-37. Due to the end of the COVID-19 national from an HSA. See Announcement 2021-7 at IRS.gov/IRB/
emergency, Notice 2023-37, 2023-30 I.R.B. 359, available at 2021-15_IRB#ANN-2021-7.
IRS.gov/irb/2023-30_IRB#NOT-2023-37, modified Notice
2020-15 and clarified the definition of preventive care for Cost of home testing for COVID-19. The cost to diagnose
purposes of the safe harbor. COVID-19 is an eligible medical expense for tax purposes,
Expiration of special COVID-19 rules in Notice which means the cost of home testing for COVID-19 for you,
2020-15. Notice 2023-37 provides that the special rules your spouse, or your dependent(s) may be paid or
under Notice 2020-15 for reimbursement of treatment and reimbursed from an HSA. See IRS.gov/Newsroom/IRS-Cost-
testing for COVID-19 under a high deductible health plan of-Home-Testing-for-COVID-19-Is-Eligible-Medical-Expense-
(HDHP) apply only for plan years ending on or before Reimbursable-Under-FSAs-HSAs.
December 31, 2024. For more information, see the
discussion of Notice 2020-15 under High Deductible Health General Instructions
Plan, later.
Preventive care safe harbor for COVID-19 testing Purpose of Form
under an HDHP ends. An HDHP may have a zero Use Form 8889 to:
deductible for certain preventive care. Notice 2023-37 ends
the application of the preventive care safe harbor to • Report health savings account (HSA) contributions
COVID-19 testing effective as of July 24, 2023. However, (including those made on your behalf and employer
COVID-19 testing remains a qualified medical expense contributions),
subject to the minimum deductible. • Figure your HSA deduction,
• Report distributions from HSAs, and
Telehealth and other remote care extended. The Figure amounts you must include in income and additional
•
Consolidated Appropriations Act 2023 extends the availability tax you may owe if you fail to be an eligible individual.
of telehealth and other remote care for HSAs. In the case of
plan years beginning in 2023 or 2024: Additional information. See Pub. 969, Health Savings
1. An eligible individual may have separate coverage for Accounts and Other Tax-Favored Health Plans, for more
telehealth and other remote care in addition to an HDHP. details on HSAs. Also, see the Instructions for Form 1040 and
the Instructions for Form 1040-NR.
2. An HDHP may have no deductible (or a deductible
below the minimum annual deductible) for telehealth and Who Must File
other remote care services. You must file Form 8889 if any of the following applies.
Insulin products. The Inflation Reduction Act, enacted • You (or someone on your behalf, including your employer)
made contributions for 2023 to your HSA.
August 16, 2022, amended section 223 to provide that an
HDHP may have a zero deductible for selected insulin • You received HSA distributions in 2023.
products. The amendment applies to plan years beginning • You must include certain amounts in income because you
failed to be an eligible individual during the testing period.
after 2022.
• You acquired an interest in an HSA because of the death
Q&As on certain qualified medical expenses. You can of the account beneficiary. See Death of Account Beneficiary,
find answers to questions regarding whether certain costs later.
related to nutrition, wellness, and general health are medical
expenses that may be paid or reimbursed under an HSA at If you (or your spouse, if filing jointly) received HSA
IRS.gov/Individuals/Frequently-asked-questions-about- ! distributions in 2023, you must file Form 8889 with
medical-expenses-related-to-nutrition-wellness-and-general- CAUTION Form 1040, Form 1040-SR, or Form 1040-NR, even if
health. you have no taxable income or any other reason for filing
Form 1040, Form 1040-SR, or Form 1040-NR.
Ask your HSA trustee whether your HSA and trustee
! meet the requirements of section 223.
CAUTION

Sep 29, 2023 Cat. No. 37971Y

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Definitions Qualified Medical Expenses

Eligible Individual Generally, “qualified medical expenses” for HSA purposes
are unreimbursed medical expenses that could otherwise be
To be eligible to have contributions made to your HSA, you deducted on Schedule A (Form 1040). See the Instructions
must be covered under a high deductible health plan (HDHP) for Schedule A and Pub. 502, Medical and Dental Expenses.
and have no other health coverage except certain As the HSA account beneficiary, you can pay these expenses
disregarded coverage. If you are an eligible individual, for medical care for yourself, your spouse, and your
anyone can contribute to your HSA. However, you cannot be dependents. Even though nonprescription medicines (other
enrolled in Medicare or be another person's dependent. An than insulin) do not qualify for the medical and dental
individual does not fail to be treated as an eligible individual expenses deduction, they do qualify as expenses for HSA
for any period merely because the individual receives purposes. The cost of menstrual care products (tampons,
hospital care or medical services under any law administered pads, liners, cups, sponges, or other similar products) are
by the Secretary of Veterans Affairs for a service-connected also reimbursable for HSA purposes.
disability. You will not fail to be considered an eligible
individual because you receive benefits from a health plan Amounts you pay for personal protective equipment, such
under surprise billing laws. You must be, or be considered, an as masks, hand sanitizer, and sanitizing wipes for you, your
eligible individual on the first day of a month to take an HSA spouse, and your dependent(s) for the primary purpose of
deduction for that month (see Last-month rule next). preventing the spread of COVID-19 are treated as medical
Last-month rule. If you are an eligible individual on the first expenses eligible to be reimbursed from an HSA.
day of the last month of your tax year (December 1 for most
The cost of home testing for COVID-19 for you, your
taxpayers), you are considered to be an eligible individual for
spouse, or your dependent(s) is an eligible medical expense
the entire year, so long as you remain an eligible individual
for tax purposes, which may be paid or reimbursed from an
during the testing period as discussed below.
HSA.
Testing period. You must remain an eligible individual
during the testing period in order to take advantage of the You can find answers regarding whether certain costs
last-month rule. The testing period begins with the last month related to nutrition, wellness, and general health are medical
of your tax year and ends on the last day of the 12th month expenses that may be paid or reimbursed under an HSA at
following that month (for example, December 1, 2023 – IRS.gov/Individuals/Frequently-asked-questions-about-
December 31, 2024). If you fail to remain an eligible medical-expenses-related-to-nutrition-wellness-and-general-
individual during this period, other than because of death or health.
becoming disabled, you will have to include in income the
total contributions made that would not have been made Expenses incurred before you establish your HSA are not
except for the last-month rule. You include this amount in qualified medical expenses. If, under the last-month rule, you
income in the year in which you fail to be an eligible are considered to be an eligible individual for the entire year
individual. This amount is also subject to a 10% additional for determining the contribution amount, only those expenses
tax. (See Part III.) incurred after you actually establish your HSA are qualified
medical expenses.
Account Beneficiary
You cannot treat insurance premiums as qualified medical
The account beneficiary is the individual on whose behalf the expenses unless the premiums are for:
HSA was established. 1. Long-term care (LTC) insurance,
2. Health care continuation coverage (such as coverage
HSA under COBRA),
3. Health care coverage while receiving unemployment
Generally, an HSA is a health savings account set up compensation under federal or state law, or
exclusively for paying the qualified medical expenses of the
account beneficiary or the account beneficiary's spouse or 4. Medicare and other health care coverage if you were
dependents. 65 or older (other than premiums for a Medicare
supplemental policy, such as Medigap).
Distributions From an HSA Coverage under (2) and (3) can be for your spouse or
TIP a dependent meeting the requirement. For (4), if you,
Distributions from an HSA used exclusively to pay qualified the account beneficiary, are under age 65, Medicare
medical expenses of the account beneficiary, spouse, or premiums for your spouse or dependents (who are age 65 or
dependents are excludable from gross income. (See the older) are generally not qualified medical expenses.
Line 15 instructions for information on medical expenses of
dependents not claimed on your return.) You can receive
distributions from an HSA even if you are not currently eligible High Deductible Health Plan
to have contributions made to the HSA. However, any part of
a distribution not used to pay qualified medical expenses is An HDHP is a health plan that meets the following
includible in gross income and is subject to an additional requirements.
20% tax unless an exception applies.

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Self-only Disabled
coverage Family coverage
An individual is generally considered disabled if the individual
Minimum annual deductible $1,500 $3,000
is unable to engage in any substantial gainful activity due to a
Maximum annual physical or mental impairment that can be expected to result
out-of-pocket expenses* $7,500 $15,000 in death or to continue indefinitely.

Death of Account Beneficiary
* This limit does not apply to deductibles and expenses for out-of-network
services if the plan uses a network of providers. Instead, only deductibles If the account beneficiary's surviving spouse is the
and out-of-pocket expenses (such as copayments and other amounts, but designated beneficiary, the HSA is treated as if the surviving
not premiums) for services within the network should be used to figure spouse were the account beneficiary. The surviving spouse
whether the limit is reached. completes Form 8889 as though the HSA belonged to the
surviving spouse.

Notice 2020-15, available at IRS.gov/irb/ If the designated beneficiary is not the account
2020-14_IRB#NOT-2020-15, provides that an HDHP may beneficiary's surviving spouse, or there is no designated
pay for medical care services and items purchased related to beneficiary, the account ceases to be an HSA as of the date
testing for, and treatment of, COVID-19 before satisfying the of death. The beneficiary completes Form 8889 as follows.
applicable minimum deductible. Notice 2023-37, 2023-30 • Enter “Death of HSA account beneficiary” across the top of
I.R.B. 359, provides that these special rules under Notice Form 8889.
2020-15 apply only for plan years ending on or before • Enter the name(s) shown on the beneficiary's tax return
December 31, 2024. For more information, see Notice and the beneficiary's SSN in the spaces provided at the top
2023-37 at IRS.gov/irb/2023-30_IRB#NOT-2023-37. of the form and skip Part I.
• On Part II, line 14a, enter the fair market value of the HSA
A health plan that is otherwise an HDHP will not fail to be as of the date of death.
considered an HDHP because it provides benefits under • On Part II, line 15, for a beneficiary other than the estate,
surprise billing laws before satisfaction of the HDHP enter qualified medical expenses incurred by the account
deductible. beneficiary before the date of death that the beneficiary paid
within 1 year after the date of death.
Safe harbor for insulin. An HDHP may have a zero • Complete the rest of Part II.
deductible for selected insulin products. For more details, see
Pub. 969. If the account beneficiary's estate is the beneficiary, the
Safe harbor for preventive care. An HDHP may have a value of the HSA as of the date of death is included on the
zero deductible for preventive care. For more details, see account beneficiary's final income tax return. Complete Form
Pub. 969. Testing for COVID-19 is no longer considered 8889 as described above, except you should complete Part I,
preventive care under this safe harbor effective as of July 24, if applicable.
2023. See Notice 2023-37, 2023-30 I.R.B. 359, at
IRS.gov/irb/2023-30_IRB#NOT-2023-37. The distribution is not subject to the additional 20% tax.
Safe harbor for telehealth. An HDHP may have a zero Report any earnings on the account after the date of death as
deductible for telehealth and other remote care services for income on your tax return.
plan years beginning in 2023 or 2024. Note. If, during the tax year, you are the beneficiary of two or
Certain coverage disregarded. An eligible individual may more HSAs or you are a beneficiary of an HSA and you have
have: your own HSA, you must complete a separate Form 8889 for
1. Coverage for any benefit provided by permitted each HSA. Enter “statement” at the top of each Form 8889
insurance, and and complete the form as instructed. Next, complete a
controlling Form 8889, combining the amounts shown on
2. Coverage (whether through insurance or otherwise) for each of the statement Forms 8889. Attach the statements to
accidents, disability, dental care, vision care, or long-term your paper tax return after the controlling Form 8889.
care, or (in the case of plan years beginning in 2023 or 2024)
telehealth and other remote care.
Deemed Distributions From HSAs
Permitted insurance. Permitted insurance means:
A. Insurance if substantially all of the coverage provided The following situations result in deemed distributions from
relates to: your HSA.
1. Liabilities incurred under workers’ compensation laws, • You engaged in any transaction prohibited by section 4975
2. Tort liabilities, and/or, with respect to any of your HSAs, at any time in 2023. Your
account ceases to be an HSA as of January 1, 2023, and you
3. Liabilities relating to ownership or use of property; must include the fair market value of all assets in the account
B. Insurance for a specified disease or illness; and as of January 1, 2023, on line 14a.
C. Insurance paying a fixed amount per day (or other period) • You used any portion of any of your HSAs as security for a
of hospitalization. loan at any time in 2023. You must include the fair market
value of the assets used as security for the loan as income on
Schedule 1 (Form 1040), line 8f.
For information on prescription drug plans, see Pub. 969.

Instructions for Form 8889 (2023) -3-

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Any deemed distribution will not be treated as used to pay How To Complete Part I
qualified medical expenses. Generally, these distributions are If both you and your spouse have HSAs, complete lines 1
subject to the additional 20% tax. through 13 as instructed on the form. However, if you, and
your spouse if filing jointly, are both eligible individuals and
Rollovers either of you has an HDHP with family coverage, you both are
treated as having only the family coverage plan. Disregard
A rollover is a tax-free distribution (withdrawal) of assets from any plans with self-only coverage.
one HSA or Archer MSA that is reinvested in another HSA of
the same account beneficiary. Generally, you must complete Complete a separate Form 8889 for each spouse.
the rollover within 60 days after you received the distribution. Combine the amounts on line 13 of both Forms 8889 and
An HSA can only receive one rollover contribution during a enter this amount on Schedule 1 (Form 1040), line 13. Be
1-year period. See Pub. 590-A, Contributions to Individual sure to attach both Forms 8889 to your paper tax return.
Retirement Arrangements (IRAs), for more details and
additional requirements regarding rollovers. Line 1
If you were covered, or considered covered, by a self-only
Note. If you instruct the trustee of your HSA to transfer funds HDHP and a family HDHP at different times during the year,
directly to the trustee of another of your HSAs, the transfer is check the box for the plan that was in effect for a longer
not considered a rollover. There is no limit on the number of period. If you were covered by both a self-only HDHP and a
these transfers. Do not include the amount transferred in family HDHP at the same time, you are treated as having
income, deduct it as a contribution, or include it as a family coverage during that period. If, on the first day of the
distribution on line 14a. last month of your tax year (December 1 for most taxpayers),
you had family coverage, check the “family” box.

Specific Instructions Line 2
Name and social security number (SSN). Enter your Include on line 2 only those amounts you, or others on your
name(s) as shown on your tax return and the SSN of the HSA behalf, contributed to your HSA for 2023. Also, include
account beneficiary. If married filing jointly and both you and amounts contributed for 2023 made in 2024 by the
your spouse have HSAs, complete a separate Form 8889 for unextended deadline for filing your 2023 federal income tax
each of you. return, April 15, 2024. If you were serving in, or in support of,
the U.S. Armed Forces in a designated combat zone or
Part I—HSA Contributions and contingency operation, you may be able to file later. See Pub.
3 for details. Thus, you may contribute to your 2023 HSA
Deductions through April 15, 2024, or a later date if you served in a
Use Part I to figure: designated combat zone or contingency operation.
• Your HSA deduction,
• Any excess contributions you made (or those made on Do not include employer contributions (see line 9) or
your behalf), and amounts rolled over from another HSA or Archer MSA. See
• Any excess contributions made by an employer (see Rollovers, earlier. Also, do not include any qualified HSA
Excess Employer Contributions, later). funding distributions (see line 10). Payroll contributions
through a salary reduction agreement elected by an
Figuring Your HSA Deduction employee (a cafeteria plan) are treated as employer
The maximum amount that can be contributed to your HSA contributions and are not included on line 2.
depends on the type of HDHP coverage you have. If you have
self-only coverage, your maximum contribution is $3,850. If Line 3
you have family coverage, your maximum contribution is When figuring the amount to enter on line 3, apply the
$7,750. following rules.
1. Use the family coverage amount if you or your spouse
Note. If you are age 55 or older at the end of your tax year, had an HDHP with family coverage. Disregard any plan with
you can make an additional contribution of $1,000. self-only coverage.
Your maximum contribution is reduced by any employer 2. If the last-month rule (see Last-month rule, earlier)
contributions to your HSA, any contributions made to your applies, you are considered an eligible individual for the
Archer MSA, and any qualified HSA funding distributions. entire year. You are treated as having the same HDHP
coverage for the entire year as you had on the first day of the
You can make deductible contributions to your HSA even if last month of your tax year.
your employer made contributions. However, if you (or
someone on your behalf) made contributions in addition to 3. If you were, or were considered, an eligible individual
any employer contributions and qualified HSA funding for the entire year and you did not change your type of
distributions, you may have to pay an additional tax. See coverage, enter $3,850 for a self-only HDHP or $7,750 for a
Excess Contributions You Make, later. family HDHP on line 3. (See (6) in this list.)
4. If you were, or were considered, an eligible individual
You cannot deduct any contributions for any month in for the entire year and you changed your type of coverage
which you were enrolled in Medicare. Also, you cannot during the year, enter on line 3 (see (6) in this list) the greater
deduct contributions if you are someone else's dependent for of:
2023.
a. The limitation shown on the last line of the Line 3
Limitation Chart and Worksheet (in these instructions), or

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b. The maximum amount that can be contributed based spouses, unlike the $7,750 family contribution discussed
on the type of HDHP coverage you had on the first day of the below. For the Line 3 Limitation Chart and Worksheet, the
last month of your tax year. additional contribution amount is included for each month
you are an eligible individual.
If you had family coverage on the first day of the last
TIP month, you do not need to use the worksheet; enter Note. If you are married and had family coverage at any time
$7,750 on line 3. during the year, the additional contribution amount is figured
5. If you were not an eligible individual on the first day of on line 7 and is not included on line 3.
the last month of your tax year, use the Line 3 Limitation See Pub. 969 for more information.
Chart and Worksheet (in these instructions) to determine the
amount to enter on line 3. (See (6) in this list.) If you must complete the Line 3 Limitation Chart and
TIP Worksheet (in these instructions), and your eligibility
6. If, at the end of 2023, you were age 55 or older and and coverage did not change from one month to the
unmarried or married with self-only HDHP coverage for the next, enter the same number you entered for the previous
entire year, you can increase the amount determined in (3) or month.
(4) by $1,000 (the additional contribution amount). The
$1,000 additional contribution amount is not allocable among

Instructions for Form 8889 (2023) -5-

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                                                      Line 3 Limitation Chart and Worksheet

Before you begin:                                     √ See the instructions for line 3, earlier.
                                                      √ Go through this chart for each month of 2023.
                                                      √ Keep for your records.

Start Here
                                                                                                   Yes
Were you enrolled in Medicare for the month?

              No

Were you an eligible individual (see Eligible                                                               Enter -0- on 
                                                                                                   No
Individual, earlier) on the rst day of the month                                                           the line below 
(see the line 3 instructions, earlier)?                                                                     for the month.

              Yes

What type of coverage did your HDHP provide on the rst day of the month?

     Self-only coverage                                                                     Family coverage
Enter $3,850 on the line below                                                  Enter $7,750 on the line below for 
for the month. If you were age                                                  the month. If, at the end of 2023, 
55 or older at the end of 2023,                                                 you were unmarried and age 55 or 
enter $4,850 for the month.                                                     older, enter $8,750 for the month.

                                                                                                            Amount from 
Month in 2023                                                                                               chart above

January    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
February    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
March    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
April    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
May    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
June   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
July    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
August    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
September    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
October    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
November    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
December    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Total                            for all months     .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Limitation. Divide the total by 12. 
Enter                                here and on line 3    .   .   .   .   .   .   .   .   .   .   .   .  $ 

                                                                                       -6-                  Instructions for Form 8889 (2023)

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Line 6 Line 7
Spouses who have separate HSAs and had family coverage Additional Contribution Amount
under an HDHP at any time during 2023, use the following
rules to figure the amount on line 6. If, at the end of 2023, you were age 55 or older and married,
• If you are treated as having family coverage for each use the Additional Contribution Amount Worksheet (in these
month, divide the amount on line 5 equally between you and instructions) if both of the following apply.
your spouse, unless you both agree on a different allocation
1. You or your spouse had family coverage under an
(such as allocating nothing to one spouse). Enter your
HDHP and were, or were considered to be, an eligible
allocable share on line 6.
individual on the first day of the month.
Example. In 2023, you are an eligible individual and have 2. You were not enrolled in Medicare for the month.
self-only HDHP coverage. In March, you marry and as of
April 1, you have family HDHP coverage. Neither you nor your Enter the result on line 7.
spouse qualify for the additional contribution amount. Your
spouse has a separate HSA and is an eligible individual from If items (1) and (2) apply to all months during 2023,
April 1 to December 31, 2023. Because you and your spouse TIP enter $1,000 on line 7.
are considered to have family coverage on December 1, your
contribution limit is $7,750 (the family coverage maximum). Additional Contribution Amount Worksheet
You and your spouse can divide this amount in any allocation
to which you agree (such as allocating nothing to one 1. $1,000 × number of months eligible . . . . . . . . .
spouse). 2. Divide line 1 by 12. Enter here and on
• If you are not treated as having family coverage for each line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
month, use the following steps to determine the amount to
enter on line 6.
Step 1. Refigure the contribution limit that would have Example. At the end of 2023, you were age 55 and
been entered on line 5 if you had entered on line 3 the total of married. You had family coverage under an HDHP from
the worksheet amounts only for the months you were treated January 1 through June 30, 2023 (6 months). You were not
as having family coverage. When refiguring line 5, use the enrolled in Medicare in 2023. You would enter an additional
same amount you previously entered on line 4. contribution amount of $500 on line 7 ($1,000 × 6 ÷ 12).

Step 2. Divide the refigured contribution limit from Step 1 Line 9
equally between you and your spouse, unless you both agree
on a different allocation (such as allocating nothing to one Employer Contributions
spouse).
Step 3. Subtract the part of the contribution limit allocated Employer contributions (including employee payroll
to your spouse in Step 2 from the amount determined in Step contributions through a cafeteria plan) include any amount an
1. employer contributes to any HSA for you for 2023. Also,
Step 4. Determine any other contribution limits that apply include contributions made by a health insurance plan on an
for the tax year and add that amount to the result in Step 3. employer's behalf. These contributions should be shown in
Enter the total on line 6. box 12 of Form W-2 with code W. If either of the following
Example. In 2023, you are an eligible individual and have apply, complete the Employer Contribution Worksheet.
family HDHP coverage. In March, you divorce and change • Employer contributions for 2022 are included in the
your coverage as of April 1 to self-only. Neither you nor your amount reported in box 12 of Form W-2 with code W.
ex-spouse qualify for the additional contribution amount. Your • Employer contributions for 2023 are made in 2024.
ex-spouse continued to have family HDHP coverage and was If your employer made excess contributions, you may have to
an eligible individual for the entire year. The contribution limit report the excess as income. See Excess Employer
for the 3 months you both were considered to have family Contributions, later.
coverage is $1,937.50 ($7,750 × 3 ÷ 12). You and your
Line 10
ex-spouse decide to divide the family coverage contribution
in the following manner: 75% to your ex-spouse and 25% to Qualified HSA funding distribution. A distribution from
you. Your contribution limit for 9 months of self-only coverage your traditional IRA or Roth IRA to your HSA in a direct
is $2,887.50 ($3,850 × 9 ÷ 12). This amount is not divided trustee-to-trustee transfer is called an HSA funding
between you and your spouse. distribution. Note that these funds are not being distributed
Because you are covered under a self-only policy on from your HSA, but rather are being distributed from your IRA
December 1, you will show $3,850 on line 6 (the greater of and contributed to your HSA. Enter this amount on line 10.
either (a) $3,371.87 ($1,937.50 family coverage + $2,887.50 The qualified HSA funding distribution is not included in
self-only coverage – $1,453.13 spousal allocation) or (b) the your income, is not deductible, and reduces the amount that
maximum amount that can be contributed ($3,850 for can be contributed to your HSA by you and from other
self-only coverage)). Your ex-spouse would show $7,750 on sources (including employer contributions). This distribution
line 6 (the greater of either (a) $7,265.62 ($1,937.50 family cannot be made from an ongoing SEP IRA or SIMPLE IRA.
coverage for the 3 months prior to the divorce + $5,812.50 For this purpose, a SEP IRA or SIMPLE IRA is ongoing if an
family coverage maintained after the divorce – $484.38 employer contribution is made for the plan year ending with
spousal allocation) or (b) the maximum amount that can be or within your tax year in which the distribution would be
contributed ($7,750 for family coverage)). made.
The maximum amount that can be excluded from income
is based on your age at the end of the year and your HDHP
coverage (self-only or family) at the time of the distribution.

Instructions for Form 8889 (2023) -7-

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Employer Contribution Worksheet                                                            Keep for Your Records
1. Enter the employer contributions reported in box 12 of Form W-2, with code W . . . . . . . . . . . . . . . . . . . . . . . . . .                                    1.  
2. Enter employer contributions made in 2023 for tax year 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         2.  
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.  
4. Enter employer contributions made in 2024 for tax year 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         4.  
5. Employer contributions for 2023. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .                                             5.  

You can make only one qualified HSA funding distribution             made a qualified HSA funding distribution (line 10) during the 
during your lifetime. However, if you make the distribution          tax year, reduce your limitation (line 8) by that distribution 
during a month when you have self-only HDHP coverage, you            before you determine whether you have excess employer 
can make another qualified HSA funding distribution in a later       contributions. If the excess was not included in income on 
month in that tax year if you change to family HDHP                  Form W-2, you must report it as “Other income” on your tax 
coverage.                                                            return. However, you can withdraw some or all of the excess 
  See the discussions under Line 13 for the treatment of             employer contributions for 2023 and they will be treated as if 
excess contributions.                                                they had not been contributed if:
                                                                     • You make the withdrawal by the due date, including 
  See Pub. 969 for more information.                                 extensions, of your 2023 tax return (but see the following 
  Testing period. If you received a traditional IRA or Roth          Note);
IRA distribution, you must remain an eligible individual during      • You do not claim an exclusion from income for the amount 
the testing period. The testing period begins with the month         of the withdrawn contributions; and
in which the traditional IRA or Roth IRA distribution is             • You also withdraw any income earned on the withdrawn 
contributed to the HSA and ends on the last day of the 12th          contributions and include the earnings in “Other income” on 
month following that month. For example, if the distribution is      your tax return for the year you withdraw the contributions 
contributed on June 17, 2023, the testing period ends on             and earnings.
June 30, 2024. If you fail to remain an eligible individual 
during this period, other than because of death or becoming          Note. If you timely filed your return without withdrawing the 
disabled, you will have to include the qualified HSA funding         excess contributions, you can still make the withdrawal no 
distribution in income in the year in which you fail to be an        later than 6 months after the due date of your tax return, 
eligible individual. This amount is also subject to a 10%            excluding extensions. If you do, file an amended return with 
additional tax. (See Part III.)                                      “Filed pursuant to section 301.9100-2” written at the top. 
                                                                     Include an explanation of the withdrawal. Make all necessary 
Line 13                                                              changes on the amended return (for example, if you reported 
If you or someone on your behalf (or your employer)                  the contributions as excess contributions on your original 
contributed more to your HSA than is allowable, you may              return, include an amended Form 5329 reflecting that the 
have to pay an additional tax on the excess contributions.           withdrawn contributions are no longer treated as having been 
Figure the excess contributions using the following                  contributed).
instructions. See Form 5329, Additional Taxes on Qualified 
Plans (Including IRAs) and Other Tax-Favored Accounts, to            Deducting an Excess Contribution in a Later Year
figure the additional tax.
                                                                     You may be able to deduct excess contributions for previous 
Excess Contributions You Make                                        years that are still in your HSA. The excess contributions you 
                                                                     can deduct in the current year is the lesser of the following 
To figure your excess contributions (including those made on         two amounts.
your behalf), subtract your deductible contributions (line 13)       • Your maximum HSA contribution limit for the year minus 
from your actual contributions (line 2). However, you can            any amounts contributed to your HSA for the year.
withdraw some or all of your excess contributions for 2023           • The total excess contributions in your HSA at the 
and they will be treated as if they had not been contributed if:     beginning of the year.
• You make the withdrawal by the due date, including 
extensions, of your 2023 tax return (but see the Note under            Any excess contribution remaining at the end of the tax 
Excess Employer Contributions, later);                               year is subject to the additional tax. See Form 5329.
• You do not claim a deduction for the amount of the 
withdrawn contributions; and                                         Part II—HSA Distributions
• You also withdraw any income earned on the withdrawn 
contributions and include the earnings in “Other income” on          Line 14a
your tax return for the year you withdraw the contributions          Enter the total distributions you received in 2023 from all 
and earnings.                                                        HSAs. Your total distributions include amounts paid with a 
                                                                     debit card that restricts payments to health care and amounts 
Excess Employer Contributions                                        withdrawn by other individuals that you have designated. 
                                                                     These amounts should be shown in box 1 of Form 1099-SA.
Excess employer contributions are the excess, if any, of your 
employer's contributions over your limitation on line 8. If you 

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Line 14b If any of the exceptions apply to any of the distributions
Include on line 14b any distributions you received in 2023 included on line 16, check the box on line 17a. Enter on
that qualified as a rollover contribution to another HSA. See line 17b only 20% (0.20) of any amount included on line 16
Rollovers, earlier. Also include any excess contributions (and that does not meet any of the exceptions.
the earnings on those excess contributions) included on Example 1. You turned age 63 in 2023 and received a
line 14a that were withdrawn by the due date, including distribution from an HSA that is included in income. Do not
extensions, of your return. See the instructions for line 13, check the box on line 17a because you (the account
earlier. beneficiary) did not meet the age exception for the
distribution. Enter 20% of the amount from line 16 on
Line 15 line 17b.
Only include on line 15 distributions from your HSA Example 2. You turned age 65 in 2023. You received
distributions that are included in income both before and after
! that were used to pay you for qualified medical
CAUTION expenses (see Qualified Medical Expenses, earlier) you turned age 65. Check the box on line 17a because the
not reimbursed by insurance or other coverage and that you additional 20% tax does not apply to the distributions made
incurred after the HSA was established. Do not include the after the date you turned age 65. However, the additional
distribution of an excess contribution taken out after the due 20% tax does apply to the distributions made on or before the
date, including extensions, of your return even if used for date you turned age 65. Enter on line 17b, 20% of the amount
qualified medical expenses. of these distributions included on line 16.
In general, include on line 15 distributions from all HSAs in Note. There may be very limited and unusual circumstances
2023 that were used for the qualified medical expenses (see in which you may be able to return mistaken distributions
Qualified Medical Expenses, earlier) of: such that the amount will not be subject to the additional tax.
1. You and your spouse. For more information, see Notice 2004-50, Q/A 37 and 76, at
IRS.gov/IRB/2004-33_IRB#NOT-2004-50.
2. All your dependents.
3. Any person who would be a dependent except that: Part III—Income and Additional Tax
a. The person filed a joint return. for Failure To Maintain HDHP
b. The person had gross income.
Coverage
c. You, or your spouse if filing jointly, are dependents of
Use Part III to figure any additional income and adjustments
someone else.
to income that must be reported on Schedule 1 (Form 1040)
For this purpose, a child of parents who are divorced, and additional taxes that must be reported on Schedule 2
TIP separated, or living apart for the last 6 months of the (Form 1040) for failure to be an eligible individual during the
calendar year is treated as the dependent of both testing period for:
parents whether or not the custodial parent releases claim to • Last-month rule (see Last-month rule, earlier), or
the child as the custodial parent’s dependent. • A qualified HSA funding distribution (see the Instructions
for line 10, earlier).
You cannot take a deduction on Schedule A (Form
! 1040) for any amount you include on line 15. See the discussion, earlier, on determining the testing period
CAUTION for both the last-month rule and a qualified HSA funding
distribution. Include the amount in income in the year in
Lines 17a and 17b which you fail to be an eligible individual.
Additional 20% Tax
Line 18
HSA distributions included in income (line 16) are subject to You can use the Line 3 Limitation Chart and Worksheet (in
an additional 20% tax unless one of the following exceptions these instructions) for the year the contribution was made to
applies. determine the contribution you could have made if the
last-month rule did not apply. Enter on line 18 the excess of
Exceptions to the Additional 20% Tax the amount contributed over the redetermined amount.
Examples of this computation are in Pub. 969.
The additional 20% tax does not apply to distributions made
after the account beneficiary: Line 19
• Dies, Enter the total of any qualified HSA funding distribution (see
• Becomes disabled (see Disabled, earlier), or line 10).
• Turns age 65.

Instructions for Form 8889 (2023) -9-

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