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Department of the Treasury
Internal Revenue Service
2022

Instructions for Form 8889

Health Savings Accounts (HSAs)

Section references are to the Internal Revenue Reminders • You acquired an interest in an HSA
Code unless otherwise noted. because of the death of the account
Personal protective equipment. beneficiary. See Death of Account
Future Developments Amounts paid for personal protective Beneficiary, later.
equipment (PPE), such as masks, hand
For the latest information about If you (or your spouse, if filing
sanitizer, and sanitizing wipes, for use
by you, your spouse, or your
developments related to Form 8889 and ! jointly) received HSA
its instructions, such as legislation CAUTION distributions in 2022, you must
dependent(s) to prevent the spread of
enacted after they were published, go to file Form 8889 with Form 1040, Form
COVID-19 are eligible medical
IRS.gov/Form8889. 1040-SR, or Form 1040-NR, even if you
expenses that may be paid or
reimbursed from an HSA. See have no taxable income or any other
What’s New Announcement 2021-7 at IRS.gov/IRB/ reason for filing Form 1040, Form
Telehealth and other remote care ex- 2021-15_IRB#ANN-2021-7. 1040-SR, or Form 1040-NR.
tended. The Consolidated Cost of home testing for COVID-19.
Appropriations Act 2022 extends the The cost to diagnose COVID-19 is an Definitions
availability of telehealth and other eligible medical expense for tax Eligible Individual
remote care for HSAs. In the case of purposes, which means the cost of
months beginning after March 31, 2022, home testing for COVID-19 for you, your To be eligible to have contributions
and before January 1, 2023: spouse, or your dependent(s) may be made to your HSA, you must be
1. An eligible individual may have paid or reimbursed from an HSA. See covered under a high deductible health
separate coverage for telehealth and IRS.gov/Newsroom/IRS-Cost-of-Home- plan (HDHP) and have no other health
other remote care in addition to a high Testing-for-COVID-19-Is-Eligible- coverage except certain disregarded
deductible health plan. Medical-Expense-Reimbursable-Under- coverage. If you are an eligible
2. A high deductible health plan may FSAs-HSAs. individual, anyone can contribute to
your HSA. However, you cannot be
have no deductible (or a deductible enrolled in Medicare or be another
below the minimum annual deductible) General Instructions person's dependent. An individual does
for telehealth and other remote care not fail to be treated as an eligible
services. Purpose of Form individual for any period merely
Use Form 8889 to:
Surprise billing for emergency serv- because the individual receives hospital
ices or air ambulance services. For • Report health savings account (HSA) care or medical services under any law
plan years beginning after 2021: contributions (including those made on administered by the Secretary of
1. An individual who is otherwise your behalf and employer contributions), Veterans Affairs for a service-connected
eligible to contribute to an HSA will not • Figure your HSA deduction, disability. You must be, or be
fail to be considered an eligible • Report distributions from HSAs, and considered, an eligible individual on the
individual because the individual • Figure amounts you must include in first day of a month to take an HSA
receives benefits from a health plan income and additional tax you may owe deduction for that month (see
under anti-“surprise billing” laws. if you fail to be an eligible individual. Last-month rule next).
2. A health plan that is otherwise an Additional information. See Pub. Last-month rule. If you are an eligible
HDHP will not fail to be considered an 969, Health Savings Accounts and individual on the first day of the last
HDHP because it provides benefits Other Tax-Favored Health Plans, for month of your tax year (December 1 for
under anti-“surprise billing” laws without more details on HSAs. Also, see the most taxpayers), you are considered to
satisfaction of the HDHP deductible. Instructions for Form 1040 and the be an eligible individual for the entire
Instructions for Form 1040-NR. year, so long as you remain an eligible
Note. Federal and state individual during the testing period as
anti-“surprise billing” laws generally discussed below.
protect policyholders from “surprise Who Must File
billing” by compelling health plans to You must file Form 8889 if any of the Testing period. You must remain
provide coverage for items like following applies. an eligible individual during the testing
emergency medical services, some • You (or someone on your behalf, period in order to take advantage of the
non-emergency medical services, and including your employer) made last-month rule. The testing period
air ambulance services. See section contributions for 2022 to your HSA. begins with the last month of your tax
223 for details. • You received HSA distributions in year and ends on the last day of the
2022. 12th month following that month (for
Ask your health insurance • You must include certain amounts in example, December 1, 2022 –
! provider(s) whether your HDHP income because you failed to be an December 31, 2023). If you fail to
CAUTION and any disregarded coverage eligible individual during the testing remain an eligible individual during this
meet the requirements of section 223. period. period, other than because of death or

Dec 2, 2022 Cat. No. 37971Y

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becoming disabled, you will have to hand sanitizer, and sanitizing wipes for * This limit does not apply to deductibles and
include in income the total contributions you, your spouse, and your expenses for out-of-network services if the plan
made that would not have been made dependent(s) for the primary purpose of uses a network of providers. Instead, only
except for the last-month rule. You preventing the spread of COVID-19 are deductibles and out-of-pocket expenses (such
include this amount in income in the treated as medical expenses eligible to as copayments and other amounts, but not
year in which you fail to be an eligible be reimbursed from an HSA. premiums) for services within the network
should be used to figure whether the limit is
individual. This amount is also subject to reached.
a 10% additional tax. (See Part III.) The cost of home testing for
COVID-19 for you, your spouse, or your
Account Beneficiary dependent(s) is an eligible medical
expense for tax purposes, which may be Notice 2020-15, available at
The account beneficiary is the individual paid or reimbursed from an HSA. IRS.gov/irb/
2020-14_IRB#NOT-2020-15, provides
on whose behalf the HSA was Expenses incurred before you that an HDHP may pay for medical care
established. establish your HSA are not qualified services and items purchased related to
medical expenses. If, under the testing for, and treatment of, COVID-19
HSA last-month rule, you are considered to before satisfying the applicable
be an eligible individual for the entire minimum deductible.
Generally, an HSA is a health savings year for determining the contribution
account set up exclusively for paying amount, only those expenses incurred Safe harbor for preventive care. An
the qualified medical expenses of the after you actually establish your HSA HDHP may have a zero deductible for
account beneficiary or the account are qualified medical expenses. preventive care. For more details, see
beneficiary's spouse or dependents. Pub. 969.
You cannot treat insurance premiums Safe harbor for telehealth. An HDHP
Distributions From an HSA as qualified medical expenses unless may have a zero deductible for
the premiums are for: telehealth and other remote care
Distributions from an HSA used 1. Long-term care (LTC) insurance, services for months beginning after
exclusively to pay qualified medical 2. Health care continuation March 31, 2022, and before January 1,
expenses of the account beneficiary, coverage (such as coverage under 2023.
spouse, or dependents are excludable COBRA), Certain coverage disregarded. An
from gross income. (See the Line 15 eligible individual may have:
instructions for information on medical 3. Health care coverage while
expenses of dependents not claimed on receiving unemployment compensation 1. Coverage for any benefit
your return.) You can receive under federal or state law, or provided by permitted insurance, and
distributions from an HSA even if you 4. Medicare and other health care 2. Coverage (whether through
are not currently eligible to have coverage if you were 65 or older (other insurance or otherwise) for accidents,
contributions made to the HSA. than premiums for a Medicare disability, dental care, vision care, or
However, any part of a distribution not supplemental policy, such as Medigap). long-term care, or (in the case of
used to pay qualified medical expenses months beginning after March 31, 2022,
Coverage under (2) and (3) can
is includible in gross income and is and before January 1, 2023) telehealth
TIP be for your spouse or a
subject to an additional 20% tax unless and other remote care.
dependent meeting the
an exception applies.
requirement. For (4), if you, the account
beneficiary, are under age 65, Medicare Permitted insurance. Permitted
Qualified Medical Expenses premiums for your spouse or insurance means:
dependents (who are age 65 or older) A. Insurance if substantially all of the
Generally, “qualified medical expenses” are generally not qualified medical coverage provided relates to:
for HSA purposes are unreimbursed expenses. 1. Liabilities incurred under workers’
medical expenses that could otherwise compensation laws,
be deducted on Schedule A (Form
2. Tort liabilities, and/or,
1040). See the Instructions for High Deductible Health Plan
Schedule A and Pub. 502, Medical and 3. Liabilities relating to ownership or
Dental Expenses. As the HSA account An HDHP is a health plan that meets the use of property;
beneficiary, you can pay these following requirements. B. Insurance for a specified disease or
expenses for medical care for yourself, illness; and
your spouse, and your dependents. Self-only Family C. Insurance paying a fixed amount per
Even though nonprescription medicines coverage coverage day (or other period) of hospitalization.
(other than insulin) do not qualify for the
medical and dental expenses Minimum annual
deductible $1,400 $2,800
deduction, they do qualify as expenses For information on prescription drug
for HSA purposes. The cost of Maximum annual plans, see Pub. 969.
menstrual care products (tampons, out-of-pocket
pads, liners, cups, sponges, or other expenses* $7,050 $14,100 Disabled
similar products) are also reimbursable
for HSA purposes. An individual is generally considered
disabled if he or she is unable to engage
Amounts you pay for personal in any substantial gainful activity due to
protective equipment, such as masks, a physical or mental impairment that

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can be expected to result in death or to Deemed Distributions From HSAs • Any excess contributions made by an
continue indefinitely. employer (see Excess Employer
The following situations result in Contributions, later).
Death of Account Beneficiary deemed distributions from your HSA.
Figuring Your HSA Deduction
• You engaged in any transaction
If the account beneficiary's surviving prohibited by section 4975 with respect The maximum amount that can be
spouse is the designated beneficiary, to any of your HSAs, at any time in contributed to your HSA depends on the
the HSA is treated as if the surviving 2022. Your account ceases to be an type of HDHP coverage you have. If you
spouse were the account beneficiary. HSA as of January 1, 2022, and you have self-only coverage, your maximum
The surviving spouse completes Form must include the fair market value of all contribution is $3,650. If you have family
8889 as though the HSA belonged to assets in the account as of January 1, coverage, your maximum contribution is
him or her. 2022, on line 14a. $7,300.
• You used any portion of any of your
If the designated beneficiary is not HSAs as security for a loan at any time Note. If you are age 55 or older at the
the account beneficiary's surviving in 2022. You must include the fair end of your tax year, you can make an
spouse, or there is no designated market value of the assets used as additional contribution of $1,000.
beneficiary, the account ceases to be security for the loan as income on line 8f Your maximum contribution is
an HSA as of the date of death. The of Schedule 1 (Form 1040). reduced by any employer contributions
beneficiary completes Form 8889 as to your HSA, any contributions made to
follows. Any deemed distribution will not be your Archer MSA, and any qualified
• Enter “Death of HSA account treated as used to pay qualified medical HSA funding distributions.
beneficiary” across the top of Form expenses. Generally, these distributions
8889. are subject to the additional 20% tax. You can make deductible
• Enter the name(s) shown on the contributions to your HSA even if your
beneficiary's tax return and the Rollovers employer made contributions. However,
beneficiary's SSN in the spaces if you (or someone on your behalf)
provided at the top of the form and skip A rollover is a tax-free distribution made contributions in addition to any
Part I. (withdrawal) of assets from one HSA or employer contributions and qualified
• On Part II, line 14a, enter the fair Archer MSA that is reinvested in HSA funding distributions, you may
market value of the HSA as of the date another HSA of the same account have to pay an additional tax. See
of death. beneficiary. Generally, you must Excess Contributions You Make, later.
• On Part II, line 15, for a beneficiary complete the rollover within 60 days You cannot deduct any contributions
other than the estate, enter qualified after you received the distribution. An for any month in which you were
medical expenses incurred by the HSA can only receive one rollover enrolled in Medicare. Also, you cannot
account beneficiary before the date of contribution during a 1-year period. See deduct contributions if you are someone
death that the beneficiary paid within 1 Pub. 590-A, Contributions to Individual else's dependent for 2022.
year after the date of death. Retirement Arrangements (IRAs), for
• Complete the rest of Part II. more details and additional How To Complete Part I
requirements regarding rollovers. If both you and your spouse have HSAs,
If the account beneficiary's estate is
complete lines 1 through 13 as
the beneficiary, the value of the HSA as Note. If you instruct the trustee of your instructed on the form. However, if you,
of the date of death is included on the HSA to transfer funds directly to the and your spouse if filing jointly, are both
account beneficiary's final income tax trustee of another of your HSAs, the eligible individuals and either of you has
return. Complete Form 8889 as transfer is not considered a rollover. an HDHP with family coverage, you
described above, except you should There is no limit on the number of these both are treated as having only the
complete Part I, if applicable. transfers. Do not include the amount family coverage plan. Disregard any
transferred in income, deduct it as a
The distribution is not subject to the plans with self-only coverage.
contribution, or include it as a
additional 20% tax. Report any earnings Complete a separate Form 8889 for
distribution on line 14a.
on the account after the date of death as each spouse. Combine the amounts on
income on your tax return. line 13 of both Forms 8889 and enter
Specific Instructions this amount on Schedule 1 (Form 1040),
Note. If, during the tax year, you are the line 13. Be sure to attach both Forms
beneficiary of two or more HSAs or you Name and social security number
are a beneficiary of an HSA and you (SSN). Enter your name(s) as shown 8889 to your paper tax return.
have your own HSA, you must complete on your tax return and the SSN of the Line 1
a separate Form 8889 for each HSA. HSA account beneficiary. If married
Enter “statement” at the top of each filing jointly and both you and your If you were covered, or considered
Form 8889 and complete the form as spouse have HSAs, complete a covered, by a self-only HDHP and a
instructed. Next, complete a controlling separate Form 8889 for each of you. family HDHP at different times during
the year, check the box for the plan that
Form 8889, combining the amounts was in effect for a longer period. If you
shown on each of the statement Forms Part I—HSA Contributions were covered by both a self-only HDHP
8889. Attach the statements to your and Deductions and a family HDHP at the same time,
paper tax return after the controlling Use Part I to figure: you are treated as having family
Form 8889. • Your HSA deduction, coverage during that period. If, on the
• Any excess contributions you made first day of the last month of your tax
(or those made on your behalf), and year (December 1 for most taxpayers),

Instructions for Form 8889 (2022) -3-

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you had family coverage, check the a. The limitation shown on the last coverage. Neither you nor your spouse
“family” box. line of the Line 3 Limitation Chart and qualify for the additional contribution
Worksheet (in these instructions), or amount. Your spouse has a separate
Line 2 HSA and is an eligible individual from
b. The maximum amount that can
Include on line 2 only those amounts be contributed based on the type of April 1 to December 31, 2022. Because
you, or others on your behalf, HDHP coverage you had on the first day you and your spouse are considered to
contributed to your HSA for 2022. Also, of the last month of your tax year. have family coverage on December 1,
include amounts contributed for 2022 your contribution limit is $7,300 (the
made in 2023 by the unextended If you had family coverage on family coverage maximum). You and
deadline for filing your 2022 federal TIP the first day of the last month, your spouse can divide this amount in
income tax return. Normally, that's the you do not need to use the any allocation to which you agree (such
April 15 after the close of the tax year. worksheet; enter $7,300 on line 3. as allocating nothing to one spouse).
However, for the 2022 income tax • If you are not treated as having family
return, you may file Form 1040 or 5. If you were not an eligible
coverage for each month, use the
1040-SR by April 18, 2023. The due individual on the first day of the last
following steps to determine the amount
date is April 18, instead of April 15, month of your tax year, use the Line 3
to enter on line 6.
because of the Emancipation Day Limitation Chart and Worksheet (in
holiday in the District of these instructions) to determine the Step 1. Refigure the contribution
Columbia—even if you don't live in the amount to enter on line 3. (See (6) in limit that would have been entered on
District of Columbia. If you were serving this list.) line 5 if you had entered on line 3 the
in, or in support of, the U.S. Armed 6. If, at the end of 2022, you were total of the worksheet amounts only for
Forces in a designated combat zone or age 55 or older and unmarried or the months you were treated as having
contingency operation, you may be able married with self-only HDHP coverage family coverage. When refiguring line 5,
to file later. See Pub. 3 for details. Thus, for the entire year, you can increase the use the same amount you previously
you may contribute to your 2022 HSA amount determined in (3) or (4) by entered on line 4.
through April 18, 2023, or a later date if $1,000 (the additional contribution Step 2. Divide the refigured
you served in a designated combat amount). The $1,000 additional contribution limit from Step 1 equally
zone or contingency operation. contribution amount is not allocable between you and your spouse, unless
among spouses, unlike the $7,300 you both agree on a different allocation
Do not include employer family contribution discussed below. For (such as allocating nothing to one
contributions (see line 9) or amounts the Line 3 Limitation Chart and spouse).
rolled over from another HSA or Archer Worksheet, the additional contribution
MSA. See Rollovers, earlier. Also, do amount is included for each month you Step 3. Subtract the part of the
not include any qualified HSA funding are an eligible individual. contribution limit allocated to your
distributions (see line 10). Payroll spouse in Step 2 from the amount
contributions through a salary reduction Note. If you are married and had family determined in Step 1.
agreement elected by an employee (a coverage at any time during the year,
cafeteria plan) are treated as employer the additional contribution amount is Step 4. Determine any other
contributions and are not included on figured on line 7 and is not included on contribution limits that apply for the tax
line 2. line 3. year and add that amount to the result in
Step 3. Enter the total on line 6.
Line 3 See Pub. 969 for more information.
Example. In 2022, you are an
When figuring the amount to enter on If you must complete the Line 3 eligible individual and have family
line 3, apply the following rules. TIP Limitation Chart and Worksheet HDHP coverage. In March, you divorce
1. Use the family coverage amount (in these instructions), and your and change your coverage as of April 1
if you or your spouse had an HDHP with eligibility and coverage did not change to self-only. Neither you nor your
family coverage. Disregard any plan from one month to the next, enter the ex-spouse qualify for the additional
with self-only coverage. same number you entered for the contribution amount. Your ex-spouse
previous month.
2. If the last-month rule (see continued to have family HDHP
Last-month rule, earlier) applies, you coverage and was an eligible individual
are considered an eligible individual for Line 6 for the entire year. The contribution limit
the entire year. You are treated as Spouses who have separate HSAs and for the 3 months you both were
having the same HDHP coverage for had family coverage under an HDHP at considered to have family coverage is
the entire year as you had on the first any time during 2022, use the following $1,825 ($7,300 × 3 ÷ 12). You and your
day of the last month of your tax year. rules to figure the amount on line 6. ex-spouse decide to divide the family
3. If you were, or were considered, • If you are treated as having family coverage contribution in the following
an eligible individual for the entire year coverage for each month, divide the manner: 75% to your ex-spouse and
and you did not change your type of amount on line 5 equally between you 25% to you. Your contribution limit for 9
coverage, enter $3,650 for a self-only and your spouse, unless you both agree months of self-only coverage is
HDHP or $7,300 for a family HDHP on on a different allocation (such as $2,737.50 ($3,650 × 9 ÷ 12). This
line 3. (See (6) in this list.) allocating nothing to one spouse). Enter amount is not divided between you and
your allocable share on line 6. your spouse.
4. If you were, or were considered, Because you are covered under a
an eligible individual for the entire year Example. In 2022, you are an
and you changed your type of coverage eligible individual and have self-only self-only policy on December 1, you will
during the year, enter on line 3 (see (6) HDHP coverage. In March, you marry show $3,650 on line 6 (the greater of
in this list) the greater of: and as of April 1, you have family HDHP either (a) $3,193.75 ($1,825 family

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coverage + $2,737.50 self-only              • Employer contributions for 2021 are                                            or Roth IRA to your HSA in a direct 
coverage – $1,368.75 spousal                included in the amount reported in                                               trustee-to-trustee transfer is called an 
allocation) or (b) the maximum amount       box 12 of Form W-2 with code W.                                                  HSA funding distribution. Note that 
that can be contributed ($3,650 for         • Employer contributions for 2022 are                                            these funds are not being distributed 
self-only coverage)). Your ex-spouse        made in 2023.                                                                    from your HSA, but rather are being 
would show $7,300 on line 6 (the            If your employer made excess                                                     distributed from your IRA and 
greater of either (a) $6,843.75 ($1,825     contributions, you may have to report                                            contributed to your HSA. Enter this 
family coverage for the 3 months prior to   the excess as income. See Excess                                                 amount on line 10.
the divorce + $5,475 family coverage        Employer Contributions, later.                                                       The qualified HSA funding 
maintained after the divorce – $456.25                                                                                       distribution is not included in your 
spousal allocation) or (b) the maximum      Line 10
                                                                                                                             income, is not deductible, and reduces 
amount that can be contributed ($7,300      Qualified HSA funding distribution.                                              the amount that can be contributed to 
for family coverage)).                      A distribution from your traditional IRA                                         your HSA by you and from other 
Line 7
Additional Contribution Amount                          Line 3 Limitation Chart and Worksheet
                                              Before you begin:                                     √ See the instructions for line 3, earlier.
If, at the end of 2022, you were age 55 
or older and married, use the Additional                                                            √ Go through this chart for each month of 2022.
Contribution Amount Worksheet (in                                                                   √ Keep for your records.
these instructions) if both of the 
following apply.                              Start Here
                                                                                                                                                 Yes
1. You or your spouse had family              Were you enrolled in Medicare for the month?
coverage under an HDHP and were, or 
were considered to be, an eligible                          No
individual on the first day of the month.
2. You were not enrolled in 
                                              Were you an eligible individual (see Eligible                                                               Enter -0- on 
Medicare for the month.                                                                                                                          No
                                              Individual, earlier) on the rst day of the month                                                           the line below 
Enter the result on line 7.                   (see the line 3 instructions, earlier)?                                                                     for the month.

      If items (1) and (2) apply to all                     Yes
TIP   months during 2022, enter 
      $1,000 on line 7.
                                              What type of coverage did your HDHP provide on the rst day of the month?
Additional Contribution Amount 
         Worksheet                                 Self-only coverage                                                                     Family coverage
1.  $1,000 × number of months                 Enter $3,650 on the line below                                                  Enter $7,300 on the line below for 
eligible . . . . . . . . . . . . . . . . .    for the month. If you were age                                                  the month. If, at the end of 2022, 
2.  Divide line 1 by 12. Enter                55 or older at the end of 2022,                                                 you were unmarried and age 55 or 
here and on line 7     . . . . . . . .        enter $4,650 for the month.                                                     older, enter $8,300 for the month.

Example. At the end of 2022, you                                                                                                                          Amount from 
were age 55 and married. You had              Month in 2022
                                                                                                                                                          chart above
family coverage under an HDHP from 
January 1 through June 30, 2022 (6            January    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
months). You were not enrolled in             February    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Medicare in 2022. You would enter an 
additional contribution amount of $500        March    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
on line 7 ($1,000 × 6 ÷ 12).                  April    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Line 9                                        May    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
                                              June   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Employer Contributions
                                              July    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
Employer contributions (including             August    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
employee payroll contributions through 
                                              September    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
a cafeteria plan) include any amount an 
employer contributes to any HSA for           October    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
you for 2022. Also, include contributions     November    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
made by a health insurance plan on an 
                                              December    .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
employer's behalf. These contributions 
should be shown in box 12 of Form W-2         Total                            for all months     .   .   .   .   .   .   .   .   .   .   .   .   .  $ 
with code W. If either of the following       Limitation. Divide the total by 12. 
apply, complete the Employer                  Enter                                here and on line 3    .   .   .   .   .   .   .   .   .   .   .   .  $ 
Contribution Worksheet.

Instructions for Form 8889 (2022)                           -5-

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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 2022 for tax year 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         2.  
3. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.  
4. Enter employer contributions made in 2023 for tax year 2022 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                         4.  
5. Employer contributions for 2022. Add lines 3 and 4. Enter here and on Form 8889, line 9 . . . . . . . . . . . . . . . .                                             5.  

sources (including employer                 contributions using the following         • You also withdraw any income 
contributions). This distribution cannot    instructions. See Form 5329, Additional   earned on the withdrawn contributions 
be made from an ongoing SEP IRA or          Taxes on Qualified Plans (Including       and include the earnings in “Other 
SIMPLE IRA. For this purpose, a SEP         IRAs) and Other Tax-Favored Accounts,     income” on your tax return for the year 
IRA or SIMPLE IRA is ongoing if an          to figure the additional tax.             you withdraw the contributions and 
employer contribution is made for the                                                 earnings.
plan year ending with or within your tax    Excess Contributions You Make
year in which the distribution would be                                               Note. If you timely filed your return 
made.                                       To figure your excess contributions       without withdrawing the excess 
The maximum amount that can be              (including those made on your behalf),    contributions, you can still make the 
excluded from income is based on your       subtract your deductible contributions    withdrawal no later than 6 months after 
age at the end of the year and your         (line 13) from your actual contributions  the due date of your tax return, 
HDHP coverage (self-only or family) at      (line 2). However, you can withdraw       excluding extensions. If you do, file an 
the time of the distribution. You can       some or all of your excess contributions  amended return with “Filed pursuant to 
make only one qualified HSA funding         for 2022 and they will be treated as if   section 301.9100-2” written at the top. 
distribution during your lifetime.          they had not been contributed if:         Include an explanation of the 
However, if you make the distribution       • You make the withdrawal by the due      withdrawal. Make all necessary 
during a month when you have self-only      date, including extensions, of your 2022  changes on the amended return (for 
HDHP coverage, you can make another         tax return (but see the Note under        example, if you reported the 
qualified HSA funding distribution in a     Excess Employer Contributions, later);    contributions as excess contributions on 
later month in that tax year if you         • You do not claim a deduction for the    your original return, include an amended 
change to family HDHP coverage.             amount of the withdrawn contributions;    Form 5329 reflecting that the withdrawn 
See the discussions under Line 13           and                                       contributions are no longer treated as 
for the treatment of excess                 • You also withdraw any income            having been contributed).
contributions.                              earned on the withdrawn contributions 
                                            and include the earnings in “Other        Deducting an Excess Contribution 
See Pub. 969 for more information.          income” on your tax return for the year   in a Later Year
Testing period. If you received a           you withdraw the contributions and 
traditional IRA or Roth IRA distribution,   earnings.                                 You may be able to deduct excess 
you must remain an eligible individual                                                contributions for previous years that are 
during the testing period. The testing      Excess Employer Contributions             still in your HSA. The excess 
period begins with the month in which                                                 contributions you can deduct in the 
the traditional IRA or Roth IRA             Excess employer contributions are the     current year is the lesser of the following 
distribution is contributed to the HSA      excess, if any, of your employer's        two amounts.
and ends on the last day of the 12th        contributions over your limitation on     • Your maximum HSA contribution limit 
month following that month. For             line 8. If you made a qualified HSA       for the year minus any amounts 
example, if the distribution is contributed funding distribution (line 10) during the contributed to your HSA for the year.
on June 17, 2022, the testing period        tax year, reduce your limitation (line 8) • The total excess contributions in your 
ends on June 30, 2023. If you fail to       by that distribution before you determine HSA at the beginning of the year.
remain an eligible individual during this   whether you have excess employer 
period, other than because of death or      contributions. If the excess was not        Any excess contribution remaining at 
becoming disabled, you will have to         included in income on Form W-2, you       the end of the tax year is subject to the 
include the qualified HSA funding           must report it as “Other income” on your  additional tax. See Form 5329.
distribution in income in the year in       tax return. However, you can withdraw 
which you fail to be an eligible            some or all of the excess employer        Part II—HSA Distributions
individual. This amount is also subject to  contributions for 2022 and they will be   Line 14a
a 10% additional tax. (See Part III.)       treated as if they had not been 
                                            contributed if:                           Enter the total distributions you received 
Line 13                                                                               in 2022 from all HSAs. Your total 
                                            • You make the withdrawal by the due 
If you or someone on your behalf (or        date, including extensions, of your 2022  distributions include amounts paid with 
your employer) contributed more to your     tax return (but see the following Note);  a debit card that restricts payments to 
HSA than is allowable, you may have to      • You do not claim an exclusion from      health care and amounts withdrawn by 
pay an additional tax on the excess         income for the amount of the withdrawn    other individuals that you have 
contributions. Figure the excess            contributions; and

                                                              -6-                       Instructions for Form 8889 (2022)

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designated. These amounts should be parent releases claim to the child as his before the date you turned age 65.
shown in box 1 of Form 1099-SA. or her dependent. Enter on line 17b, 20% of the amount of
these distributions included on line 16.
Line 14b You cannot take a deduction on
Note. There may be very limited and
Include on line 14b any distributions you ! Schedule A (Form 1040) for any unusual circumstances in which you
received in 2022 that qualified as a CAUTION amount you include on line 15.
rollover contribution to another HSA. may be able to return mistaken
distributions such that the amount will
See Rollovers, earlier. Also include any Lines 17a and 17b
excess contributions (and the earnings not be subject to the additional tax. For
on those excess contributions) included Additional 20% Tax more information, see Notice 2004-50,
on line 14a that were withdrawn by the Q/A 37 and 76, at IRS.gov/IRB/
due date, including extensions, of your HSA distributions included in income 2004-33_IRB#NOT-2004-50.
return. See the instructions for line 13, (line 16) are subject to an additional
earlier. 20% tax unless one of the following Part III—Income and
exceptions applies. Additional Tax for Failure
Line 15
To Maintain HDHP
Only include on line 15 Exceptions to the Additional 20%
! distributions from your HSA that Tax Coverage
CAUTION were used to pay you for Use Part III to figure any additional
income and adjustments to income that
qualified medical expenses (see The additional 20% tax does not apply
must be reported on Schedule 1 (Form
Qualified Medical Expenses, earlier) not to distributions made after the account
1040) and additional taxes that must be
reimbursed by insurance or other beneficiary:
reported on Schedule 2 (Form 1040) for
coverage and that you incurred after the • Dies,
failure to be an eligible individual during
HSA was established. Do not include • Becomes disabled (see Disabled,
the testing period for:
the distribution of an excess contribution earlier), or
taken out after the due date, including • Turns age 65. • Last-month rule (see Last-month rule,
extensions, of your return even if used earlier), or
for qualified medical expenses. If any of the exceptions apply to any • A qualified HSA funding distribution
(see the Instructions for line 10, earlier).
In general, include on line 15 of the distributions included on line 16,

distributions from all HSAs in 2022 that check the box on line 17a. Enter on
See the discussion, earlier, on
were used for the qualified medical line 17b only 20% (0.20) of any amount
determining the testing period for both
expenses (see Qualified Medical included on line 16 that does not meet
the last-month rule and a qualified HSA
Expenses, earlier) of: any of the exceptions.
funding distribution. Include the amount
1. You and your spouse. Example 1. You turned age 63 in in income in the year in which you fail to
2022 and received a distribution from an be an eligible individual.
2. All your dependents. HSA that is included in income. Do not
3. Any person who would be a check the box on line 17a because you Line 18
dependent except that: (the account beneficiary) did not meet You can use the Line 3 Limitation Chart
a. The person filed a joint return. the age exception for the distribution. and Worksheet (in these instructions)
Enter 20% of the amount from line 16 on for the year the contribution was made
b. The person had gross income.
line 17b. to determine the contribution you could
c. You, or your spouse if filing have made if the last-month rule did not
jointly, are dependents of someone Example 2. You turned age 65 in
else. 2022. You received distributions that are apply. Enter on line 18 the excess of the
included in income both before and after amount contributed over the
For this purpose, a child of you turned age 65. Check the box on redetermined amount. Examples of this
TIP parents who are divorced, line 17a because the additional 20% tax computation are in Pub. 969.
separated, or living apart for the does not apply to the distributions made Line 19
last 6 months of the calendar year is after the date you turned age 65. Enter the total of any qualified HSA
treated as the dependent of both However, the additional 20% tax does funding distribution (see line 10).
parents whether or not the custodial apply to the distributions made on or

Instructions for Form 8889 (2022) -7-

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