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Department of the Treasury
Internal Revenue Service
2023

Instructions for Form 8853

Archer MSAs and Long-Term Care Insurance Contracts

Section references are to the Internal Revenue Code • You (or your spouse, if filing jointly) acquired an interest
unless otherwise noted. in an Archer MSA or a Medicare Advantage MSA because
of the death of the account holder. See Death of Account
Future Developments Holder, later.
• You (or your spouse, if filing jointly) were a policyholder
For the latest information about developments related to who received payments under an LTC insurance contract
Form 8853 and its instructions, such as legislation or received any accelerated death benefits from a life
enacted after they were published, go to IRS.gov/ insurance policy on a per diem or other periodic basis in
Form8853. 2023. See the instructions for Section C, later.
• You (or your spouse, if filing jointly) received Archer
What’s New MSA or Medicare Advantage MSA distributions in 2023.
If you (or your spouse, if filing jointly) received
Q&As on certain qualified medical expenses. You can
Archer MSA or Medicare Advantage MSA
find answers to questions regarding whether certain costs CAUTION!
distributions in 2023, you must file Form 8853 with
related to nutrition, wellness, and general health are
Form 1040, 1040-SR, or 1040-NR even if you have no
medical expenses that may be paid or reimbursed under
taxable income or any other reason for filing Form 1040,
an Archer MSA at IRS.gov/Individuals/Frequently-Asked-
1040-SR, or 1040-NR.
Questions-About-Medical-Expenses-Related-to-Nutrition-
Wellness-and-General-Health.
Specific Instructions
General Instructions
Name and social security number (SSN). Enter your
After December 31, 2007, contributions can't be name(s) and SSN as shown on your tax return. If filing
! made to an Archer Medical Savings Account for jointly and both you and your spouse each have an Archer
CAUTION you, unless:
MSA or each have a Medicare Advantage MSA, enter the
• You were an active Archer MSA participant for any tax SSN shown first on your tax return.
year ending before January 1, 2008, or
• You became an active Archer MSA participant for a tax Section A—Archer MSAs
year ending after December 31, 2007, because of
Eligible Individual
coverage under a high deductible health plan (HDHP) of
an Archer MSA participating employer. To be eligible for an Archer MSA, you (or your spouse)
must be an employee of a small employer or be
self-employed. You (or your spouse) must be covered
Purpose of Form
under an HDHP and have no other health coverage
Use Form 8853 to: except permitted coverage. You must not be enrolled in
• Report Archer MSA contributions (including employer Medicare and can't be another person’s dependent. You
contributions), must be an eligible individual on the first day of a month to
• Figure your Archer MSA deduction, take an Archer MSA deduction for that month.
• Report distributions from Archer MSAs or Medicare
Small Employer
Advantage MSAs,
• Report taxable payments from long-term care (LTC) A small employer is generally an employer who had an
insurance contracts, or average of 50 or fewer employees during either of the last
• Report taxable accelerated death benefits from a life 2 calendar years. See Pub. 969 for details.
insurance policy.
Archer MSA
Additional information. See Pub. 969, Health Savings Generally, an Archer MSA is a medical savings account
Accounts and Other Tax-Favored Health Plans, for more set up exclusively for paying the qualified medical
details on MSAs. expenses of the account holder.

Who Must File Qualified Medical Expenses
You must file Form 8853 if any of the following applies.
Generally, qualified medical expenses for Archer MSA
• You (or your employer) made contributions for 2023 to
purposes are unreimbursed medical expenses that could
your Archer MSA.
otherwise be deducted on Schedule A (Form 1040). See
• You are filing a joint return and your spouse (or their
the Instructions for Schedule A (Form 1040), and Pub.
employer) made contributions for 2023 to your spouse's
502, Medical and Dental Expenses. Qualified medical
Archer MSA.

Jul 12, 2023 Cat. No. 24188L

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expenses are those incurred by the account holder or the If the designated beneficiary isn't the account holder's
account holder's spouse or dependent(s). Amounts paid surviving spouse, or there is no designated beneficiary,
for menstrual care products shall be treated as paid for the account ceases to be an Archer MSA as of the date of
medical care. See the instructions for Line 7, later. You death. The beneficiary completes Form 8853 as follows.
can't treat insurance premiums as qualified medical • Enter “Death of Archer MSA account holder” across the
expenses unless the premiums are for: top of Form 8853.
• LTC insurance, • Enter the name(s) shown on the beneficiary's tax return
• Health care continuation coverage, or and the beneficiary's SSN in the spaces provided at the
• Health care coverage while receiving unemployment top of the form and skip Part I.
compensation under federal or state law. • On lines 6a and 6c, enter the fair market value of the
You can find answers regarding whether certain costs Archer MSA as of the date of death.
related to nutrition, wellness, and general health are • On line 7, for a beneficiary other than the estate, enter
medical expenses that may be paid or reimbursed under qualified medical expenses incurred by the account holder
an Archer MSA at IRS.gov/Individuals/Frequently-Asked- before the date of death that you paid within 1 year after
Questions-About-Medical-Expenses-Related-to-Nutrition- the date of death.
Wellness-and-General-Health. • Complete the rest of Part II.
If the account holder's estate is the beneficiary, the fair
High Deductible Health Plan market value of the Archer MSA as of the date of death is
An HDHP is a health plan that meets the following included in the account holder's final income tax return.
requirements. Complete Form 8853 as described above, except you
should complete Part I, if applicable.
Self-only Family
coverage coverage The transfer isn't subject to the additional 20% tax.
Report any earnings on the account after the date of death
Minimum annual deductible $2,650 $5,300
as income on your tax return.
Maximum annual deductible $3,950 $7,900
Note. If, during the tax year, you are the beneficiary of two
Maximum annual out-of-pocket
expenses (other than for premiums) $5,300 $9,650 or more Archer MSAs or you are a beneficiary of an
Archer MSA and you have your own Archer MSA, you
must complete a separate Form 8853 for each Medicare
Advantage MSA. Enter “statement” at the top of each
Other Health Coverage Form 8853 and complete the form as instructed. Next,
If you have an Archer MSA, you (and your spouse, if you complete a controlling Form 8853, combining the amounts
have family coverage) can't have any health coverage shown on each of the statement Forms 8853. Attach the
other than an HDHP. However, your spouse can have statements to your paper tax return after the controlling
health coverage other than an HDHP if you aren't covered Form 8853.
by that plan.
Deemed Distributions From Archer MSAs
Exceptions. You can have additional insurance that
The following situations result in deemed distributions
provides benefits only for:
from your Archer MSA.
• Liabilities under workers' compensation laws, tort
• You engaged in any transaction prohibited by section
liabilities, or liabilities arising from the ownership or use of
4975 with respect to any of your Archer MSAs at any time
property;
in 2023. Your account ceases to be an Archer MSA as of
• A specific disease or illness; or
January 1, 2023, and you must include the fair market
• A fixed amount per day (or other period) of
value of all assets in the account as of January 1, 2023,
hospitalization.
on line 6a.
You can also have coverage (either through insurance • You used any portion of any of your Archer MSAs as
or otherwise) for accidents, disability, dental care, vision security for a loan at any time in 2023. You must include
care, or long-term care. See Other health coverage in Pub. the fair market value of the assets used as security for the
969, Health Savings Accounts and Other Tax-Favored loan as income on Schedule 1 (Form 1040), line 8e.
Health Plans, for additional information about exceptions.
Any deemed distribution won't be treated as used to
Disabled pay qualified medical expenses. Generally, these
An individual is generally considered disabled if they are distributions are subject to the additional 20% tax.
unable to engage in any substantial gainful activity due to
Part I—Archer MSA Contributions and
a physical or mental impairment that can be expected to
result in death or to continue indefinitely. Deductions
Use Part I to figure:
Death of Account Holder • Your Archer MSA deduction,
If the account holder's surviving spouse is the designated • Any excess contributions you made, and
beneficiary, the Archer MSA is treated as if the surviving • Any excess contributions made by an employer (see
spouse were the account holder. The surviving spouse Excess Employer Contributions, later).
completes Form 8853 as though the Archer MSA
belonged to them.

-2- Instructions for Form 8853 (2023)

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Figuring Your Archer MSA Deduction c. If both spouses have HDHPs with self-only
The amount you can deduct for Archer MSA contributions coverage, complete a separate Form 8853, Section A,
is limited by: Part I, for each spouse. Enter “statement” across the top
• The applicable portion of the HDHP's annual deductible of each Form 8853, fill in the name and SSN, and
(line 3), and complete Part I. Next, add lines 1, 2, and 5 from the two
• Your compensation from the employer maintaining the statement Forms 8853 and enter those totals on the
HDHP (line 4). respective lines of the controlling Form 8853 (the
combined Form 8853 for both spouses). Don't complete
Any employer contributions made to your Archer MSA lines 3 and 4 of the controlling Form 8853. Attach the two
prevent you from making deductible contributions. See statement Forms 8853 to your paper tax return after the
Employer Contributions to an Archer MSA, later. Also, if controlling Form 8853.
you or your spouse made contributions in addition to any
employer contributions, you may have to pay an additional Line 1
tax. See Excess Contributions You Make, later.
Employer Contributions
You can't deduct any contributions you made after you
became enrolled in Medicare. Also, you can't deduct Employer contributions include any amount an employer
contributions if you are someone else’s dependent. contributes to any Archer MSA for you or your spouse for
2023. These contributions should be shown in box 12 of
Employer Contributions to an Archer MSA Form W-2 with code R. If your employer made excess
contributions, you may have to report the excess as
If an employer made contributions to your Archer MSA, income. See Excess Employer Contributions, later, for
you aren't entitled to a deduction. If you and your spouse details.
are covered under an HDHP with family coverage and an
employer made contributions to either of your Archer Line 2
MSAs, neither you nor your spouse is allowed to make Include on line 2 contributions you made to your Archer
deductible contributions to an Archer MSA. If you and your MSA in 2023. Also include those contributions made from
spouse both have an HDHP with self-only coverage and January 1, 2024, through April 15, 2024, that were for
only one of you received employer contributions to an 2023. Don't include amounts rolled over from another
Archer MSA, the other spouse is allowed to make Archer MSA. See Rollovers, later.
deductible contributions to an Archer MSA.
Line 3
How To Complete Part I Go through the chart at the top of the Line 3 Limitation
Complete lines 1 through 5 as instructed on the form Chart and Worksheet for each month of 2023. Enter the
unless (1) or (2), next, applies. result on the worksheet next to the corresponding month.
1. If employer contributions to an Archer MSA prevent Enter the amount from the last line of the worksheet on
you from taking a deduction for amounts you contributed line 3.
to your Archer MSA, complete Part I as follows. If eligibility and coverage for both you and your
a. Complete lines 1 and 2. TIP spouse didn't change from one month to the next,
b. Skip lines 3 and 4. enter the same number you entered for the
previous month. If eligibility and coverage didn't change
c. Enter -0- on line 5.
during the entire year, figure the number for January only,
d. If line 2 is more than zero, see Excess Contributions and enter this amount on Form 8853, line 3.
You Make, later.
2. If you and your spouse have more than one Archer More than one HDHP. If you and your spouse had more
MSA, complete Part I as follows. than one HDHP on the first day of the month and one of
a. If either spouse has an HDHP with family coverage, the plans provides family coverage, use the Family
you both are treated as having only the family coverage coverage rules on the chart and disregard any plans with
plan. Disregard any plans with self-only coverage. self-only coverage. If you and your spouse both have
HDHPs with family coverage on the first day of the month,
b. If both spouses have HDHPs with family coverage, you both are treated as having only the family coverage
you both are treated as having only the family coverage plan with the lowest annual deductible.
plan with the lowest annual deductible.

Instructions for Form 8853 (2023) -3-

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                                                           Line 3 Limitation Chart and Worksheet

Before you begin:                                     √ See the instructions for line 3.
                                                      √ 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                                                                 the line below 
month?                                                                                                      for the month.

              Yes

What type of coverage did your HDHP provide on the rst day of the month? 
If you had more than one HDHP, see More than one HDHP, earlier. 

     Self-only coverage                                                                        Family coverage
     Enter annual deductible                                                               Enter annual deductible 
(must be at least $2,650 but                                                           (must be at least $5,300 but 
     not more than $3,950).                                                                not more than $7,900).
       $                                                                                      $

Enter 65% (0.65) of the annual                                                      Enter 75% (0.75) of the annual 
deductible on the line below                                                        deductible on the line below 
for the month.                                                                      for the month. If married ling 
                                                                                    separately, see Married ﬁling 
                                                                                    separately.

                                                                                                            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    .   .   .   .   .   .   .   .   .   .   .   .  $ 
                                                                                                       -4-                 Instructions for Form 8853 (2023)

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Married filing separately.  If you have an HDHP with           • You make the withdrawal by the due date, including 
family coverage and are married filing separately, enter       extensions, of your 2023 tax return (but see the Note 
only 37.5% (0.375) (one-half of 75%) of the annual             below);
deductible for each month on the worksheet; or, if you and     • You don't claim an exclusion from income for the 
your spouse agree to divide the 75% of the annual              amount of the withdrawn contributions; and
deductible in a different manner, enter your share.            • You also withdraw any income earned on the withdrawn 
                                                               contributions and include the earnings in “Other income” 
Line 4                                                         on your tax return for the year you withdraw the 
                                                               contributions and earnings.
Compensation
                                                               Note. If you timely filed your return without withdrawing 
Compensation includes wages, salaries, professional            the excess contributions, you can still make the withdrawal 
fees, and other pay you receive for services you perform.      no later than 6 months after the due date of your tax 
It also includes sales commissions, commissions on             return, excluding extensions. If you do, file an amended 
insurance premiums, pay based on a percentage of               return with “Filed pursuant to section 301.9100-2” written 
profits, tips, and bonuses. Generally, these amounts are       at the top. Include an explanation of the withdrawal. Make 
included on the Form(s) W-2 you receive from your              all necessary changes on the amended return (for 
employer(s). Compensation also includes net earnings           example, if you reported the contributions as excess 
from self-employment, but only for a trade or business in      contributions on your original return, include an amended 
which your personal services are a material                    Form 5329 reflecting that the withdrawn contributions are 
income-producing factor. This is your income from              no longer treated as having been contributed).
self-employment minus expenses (including the 
deductible part of self-employment tax). Compensation 
                                                               Deducting an Excess Contribution in a Later Year
doesn't include any amounts received as a pension or 
annuity and doesn't include any amount received as 
deferred compensation.                                         You may be able to deduct excess contributions for 
                                                               previous years that are still in your Archer MSA. The 
Line 5                                                         excess contribution you can deduct in the current year is 
If you (or your employer) contributed more to your Archer      the lesser of the following two amounts.
MSA than is allowable, you may have to pay an additional       • Your maximum Archer MSA contribution limit for the 
tax on the excess contributions. Figure the excess             year minus any amounts contributed to your Archer MSA 
contributions using the following instructions. See Form       for the year.
5329, Additional Taxes on Qualified Plans (Including IRAs)     • The total excess contributions in your Archer MSA at 
and Other Tax-Favored Accounts, to figure the additional       the beginning of the year.
tax.
                                                                 Any excess contribution remaining at the end of a tax 
                                                               year is subject to the additional tax. See Form 5329.
Excess Contributions You Make
                                                               Part II—Archer MSA Distributions
To figure your excess contributions, subtract your 
deductible contributions (line 5) from your actual             Line 6a
contributions (line 2). However, you can withdraw some or      Enter the total distributions you and your spouse received 
all of your excess contributions for 2023, and they will be    in 2023 from all Archer MSAs. These amounts should be 
treated as if they hadn't been contributed if:                 shown in box 1 of Form 1099-SA.
• You make the withdrawal by the due date, including 
extensions, of your 2023 tax return (but see the Note          Line 6b
under Excess Employer Contributions below);
                                                               Include on line 6b any distributions you received in 2023 
• You don't claim a deduction for the amount of the 
                                                               that were rolled over. See Rollovers below. Also include 
withdrawn contributions; and
                                                               any excess contributions (and the earnings on those 
• You also withdraw any income earned on the withdrawn 
                                                               excess contributions) included on line 6a that were 
contributions and include the earnings in “Other income” 
                                                               withdrawn by the due date, including extensions, of your 
on your tax return for the year you withdraw the 
                                                               return. See the instructions for line 5, earlier.
contributions and earnings.
                                                               Rollovers
Excess Employer Contributions
Excess employer contributions are the excess, if any, of       A rollover is a tax-free distribution (withdrawal) of assets 
your employer's contributions over the smaller of (a) your     from one Archer MSA that is reinvested in another Archer 
limitation on line 3, or (b) your compensation from the        MSA or a health savings account (HSA) of the same 
employer(s) who maintained your HDHP (line 4). If the          account holder. Generally, you must complete the rollover 
excess wasn't included in income on Form W-2, you must         within 60 days following the distribution. An Archer MSA 
report it as “Other income” on your tax return. However,       and an HSA can receive only one rollover contribution in a 
you can withdraw some or all of the excess employer            1-year period. See Pub. 590-A, Contribution to Individual 
contributions for 2023, and they will be treated as if they    Retirement Arrangements (IRAs), for more details and 
hadn't been contributed if:                                    additional requirements regarding rollovers.

Instructions for Form 8853 (2023)                           -5-

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Note. If you instruct the trustee of your Archer MSA to line 9b only 20% (0.20) of any amount included on line 8
transfer funds directly to the trustee of another of your that doesn't meet any of the exceptions.
Archer MSAs, the transfer isn't considered a rollover. Example 1. You turned age 66 in 2023 and had no
There is no limit on the number of these transfers. Don't Archer MSA during 2023. Your spouse turned age 63 in
include the amount transferred in income, deduct it as a 2023 and received a distribution from an Archer MSA that
contribution, or include it as a distribution on line 6a. is included in income. Don't check the box on line 9a
because your spouse (the account holder) didn't meet the
Line 7 age exception for the distribution. Enter 20% of the
In general, include on line 7 distributions from all Archer amount from line 8 on line 9b.
MSAs in 2023 that were used for the qualified medical Example 2. Both you and your spouse received
expenses (see Qualified Medical Expenses, earlier) of: distributions from your Archer MSAs in 2023 that are
1. Yourself and your spouse; included in income. You were age 65 at the time you
2. All your dependents; and received the distributions and your spouse was age 63
when they received the distributions. Check the box on
3. Any person who would be your dependent except line 9a because the additional 20% tax doesn't apply to
that: the distributions you received (because you met the age
a. The person filed a joint return; exception). However, the additional 20% tax does apply to
b. The person had gross income of $4,700 or more; or your spouse's distributions. Enter on line 9b only 20% of
the amount of your spouse's distributions included on
c. You, or your spouse if filing jointly, are dependents
line 8.
of someone else.
Example 3. You turned age 65 in 2023. You received
For this purpose, a child of parents who are distributions that are included in income both before and
TIP divorced, separated, or living apart for the last 6 after you turned age 65. Check the box on line 9a because
months of the calendar year is treated as the the additional 20% tax doesn't apply to the distributions
dependent of both parents whether or not the custodial made after the date you turned age 65. However, the
parent releases the claim to the child as their dependent. additional 20% tax does apply to the distributions made
on or before the date you turned age 65. Enter on line 9b,
However, if you or your employer made a contribution to 20% of the amount of these distributions included on
your Archer MSA in 2023 and you used withdrawals to pay line 8.
expenses for an individual who wasn't covered by an
HDHP or was covered by a plan that wasn't an HDHP Section B—Medicare Advantage MSA
(other than the exceptions listed under Other Health Distributions
Coverage, earlier) at the time the expenses were incurred, Complete Section B if you (or your spouse, if filing jointly)
then you shouldn't include those withdrawals on line 7. received distributions from a Medicare Advantage MSA in
Example. In 2023, you were covered by an HDHP with 2023. If both you and your spouse received distributions,
self-only coverage and your spouse was covered by a complete a separate Form 8853, Section B, for each
health plan that wasn't an HDHP. You made contributions spouse. Enter “statement” across the top of each Form
to an Archer MSA for 2023. You can't include on line 7 8853, fill in the name and SSN, and complete Section B.
withdrawals made from the Archer MSA to pay your Next, add lines 10, 11, 12, and 13b from the two
spouse's medical expenses incurred in 2023 because statement Forms 8853 and enter those totals on the
your spouse was covered by a plan that wasn't an HDHP. respective lines of the controlling Form 8853 (the
You can't take a deduction on Schedule A (Form combined Form 8853 for both spouses). If either spouse
checked the box on line 13a of the statement Form 8853,
CAUTION amount you include on line 7.
! 1040) or Schedule A (Form 1040-NR) for any check the box on the controlling Form 8853. Attach the
two statement Forms 8853 to your paper tax return after
the controlling Form 8853.
Lines 9a and 9b
If you (or your spouse, if filing jointly) received
Additional 20% Tax
! distributions from a Medicare Advantage MSA in
CAUTION 2023, you must file Form 8853 with a Form 1040,
Archer MSA distributions included in income (line 8) are 1040-SR, or 1040-NR even if you have no taxable income
subject to an additional 20% tax unless one of the or any other reason for filing Form 1040, 1040-SR, or
following exceptions applies. 1040-NR.
Exceptions to the Additional 20% Tax
Medicare Advantage MSA
The additional 20% tax doesn't apply to distributions A Medicare Advantage MSA is an Archer MSA designated
made after the date that the account holder: as a Medicare Advantage MSA to be used solely to pay
• Dies, the qualified medical expenses of the account holder. To
• Becomes disabled (see Disabled, earlier), or be eligible for a Medicare Advantage MSA, you must be
• Turns age 65. enrolled in Medicare and have an HDHP that meets the
If any of the exceptions applies to any of the distributions Medicare guidelines. Contributions to the account can be
included on line 8, check the box on line 9a. Enter on made only by Medicare. The contributions and any
earnings, while in the account, aren't taxable to the

-6- Instructions for Form 8853 (2023)

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Additional 50% Tax Worksheet—Line 13b                                                                                                    Keep for Your Records
1. Enter the total distributions included on Form 8853, line 12, that don't meet either of the exceptions to the additional 
   50% tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.  
2. Did you have a Medicare Advantage MSA on December 31, 2022?
         STOP
          No. Enter one-half of line 1 above on Form 8853, line 13b.
                                                                                                                                     2.  
          Yes. Enter the value of your Medicare Advantage MSA on December 31, 2022 . . . . . . . . .
3. Enter the amount of the annual deductible for your HDHP policy on 
   January 1, 2023 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   3.  
4. Multiply line 3 by 60% (0.60) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.  
5. Subtract line 4 from line 2. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               5.  
6. Subtract line 5 from line 1. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               6.  
7. Enter one-half of line 6 here and on Form 8853, line 13b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        7.  

account holder. A distribution used exclusively to pay for              instructed. Next, complete a controlling Form 8853, 
the qualified medical expenses of the account holder isn't              combining the amounts shown on each of the statement 
taxable. Distributions that aren't used for qualified medical           Forms 8853. Attach the statements to your paper tax 
expenses of the account holder are included in income                   return after the controlling Form 8853.
and also may be subject to a penalty.
                                                                        Line 10
Death of Account Holder                                                 Enter the total distributions you received in 2023 from all 
If the account holder's surviving spouse is the designated              Medicare Advantage MSAs. These amounts should be 
beneficiary, the Medicare Advantage MSA is treated as a                 shown in box 1 of Form 1099-SA. This amount shouldn't 
regular Archer MSA (not a Medicare Advantage MSA) of                    include any erroneous contributions made by Medicare (or 
the surviving spouse for distribution purposes. Follow the              any earnings on the erroneous contributions) or any 
instructions in Section A for Death of Account Holder,                  amounts from a trustee-to-trustee transfer from one 
earlier.                                                                Medicare Advantage MSA to another Medicare 
                                                                        Advantage MSA of the same account holder.
  If the designated beneficiary isn't the account holder's 
surviving spouse, or there is no designated beneficiary,                Line 11
the account ceases to be an MSA as of the date of death. 
                                                                        Enter the total distributions from all Medicare Advantage 
The beneficiary completes Form 8853 as follows.
                                                                        MSAs in 2023 that were used only for the account holder's 
• Enter “Death of Medicare Advantage MSA account 
                                                                        qualified medical expenses (see Qualified Medical 
holder” across the top of Form 8853.
                                                                        Expenses, earlier).
• Enter the name(s) shown on the beneficiary's tax return 
and the beneficiary's SSN in the spaces provided at the                                                       You can't take a deduction on Schedule A (Form 
top of the form. Skip Section A.                                                                         !    1040) or Schedule A (Form 1040-NR) for any 
• On line 10, enter the fair market value of the Medicare               CAUTION                               amount you include on line 11.
Advantage MSA as of the date of death.
• On line 11, for a beneficiary other than the estate, enter            Lines 13a and 13b
qualified medical expenses incurred by the account holder 
before the date of death that you paid within 1 year after              Additional 50% Tax
the date of death.
• Complete the rest of Section B.                                       Medicare Advantage MSA distributions included in 
                                                                        income (line 12) may be subject to an additional 50% tax 
  If the account holder's estate is the beneficiary, the fair           unless one of the following exceptions applies.
market value of the Medicare Advantage MSA as of the 
date of death is included in the account holder's final                 Exceptions to the Additional 50% Tax
income tax return.
  The transfer isn't subject to the additional 50% tax. The             The additional 50% tax doesn't apply to distributions 
beneficiary should report any earnings on the account                   made on or after the date that the account holder:
after the date of death as income on the beneficiary's tax              •                                Dies, or
return.                                                                 •                                Becomes disabled (see Disabled, earlier).
                                                                        If either of the exceptions applies to any of the 
Note. If, during the tax year, you are the beneficiary of two           distributions included on line 12, check the box on 
or more Medicare Advantage MSAs or you are a                            line 13a. Next, if either of the exceptions applies to all the 
beneficiary of a Medicare Advantage MSA and you have                    distributions included on line 12, enter -0- on line 13b. 
your own Medicare Advantage MSA, you must complete a                    Otherwise, complete the Additional 50% Tax 
separate Form 8853 for each MSA. Enter “statement” at                   Worksheet—Line 13b to figure the amount of the 
the top of each Form 8853 and complete the form as                      additional 50% tax to enter on line 13b.

Instructions for Form 8853 (2023)                                    -7-

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Section C—Long-Term Care (LTC) income if the insured is a Terminally Ill Individual (defined
below). Accelerated death benefits paid with respect to an
Insurance Contracts insured individual who is chronically ill are generally
See Filing Requirements for Section C, later. Also, for excludable from your gross income to the same extent as
more information, see Pub. 502. they would be under a qualified LTC insurance contract.

Definitions Terminally Ill Individual
Policyholder
A terminally ill individual is any individual who has been
The policyholder is the person who owns the proceeds of certified by a physician as having an illness or physical
the LTC insurance contract, life insurance contract, or condition that can reasonably be expected to result in
viatical settlement, and also can be the insured individual. death within 24 months of the date of certification.
The policyholder is required to report the income, even if
Line 15
payment is assigned to a third party or parties. In the case
of a group contract, the certificate holder is considered to Special rules apply in determining the taxable payments if
be the policyholder. other individuals received per diem payments under a
qualified LTC insurance contract or as accelerated death
Qualified LTC Insurance Contract benefits with respect to the insured listed on line 14a. See
Multiple Payees, later, for details.

A qualified LTC insurance contract is a contract issued: Line 18
• After December 31, 1996, that meets the requirements
of section 7702B, including the requirement that the If you have more than one LTC period, you must
insured must be a chronically ill individual (defined later); ! separately calculate the taxable amount of the
or CAUTION payments received during each LTC period. To do
• Before January 1, 1997, that met state law this, complete lines 18 through 26 on separate Sections C
requirements for LTC insurance contracts at the time when for each LTC period. Enter the total on line 26 from each
and in the state where the contract was issued and hasn't separate Section C on the Form 8853 that you attach to
been changed materially. your tax return. See the instructions for line 21 for the LTC
period.
In general, amounts paid under a qualified LTC
insurance contract are excluded from your income. Line 19
However, if you receive Per Diem Payments (defined
Enter the total accelerated death benefits you received
next), the amount you can exclude is limited.
with respect to the insured listed on line 14a. These
amounts are generally shown in box 2 of Form 1099-LTC.
Per Diem Payments Include only amounts you received while the insured was
a chronically ill individual. Don't include amounts you
Per diem payments are payments of a fixed amount made received while the insured was a terminally ill individual. If
on a periodic basis without regard to actual expenses the insured was redesignated from chronically ill to
incurred. Box 3 of Form 1099-LTC should indicate whether terminally ill in 2023, only include on line 19 payments
payments were per diem payments. received before the insured was certified as terminally ill.

Chronically Ill Individual Line 21
The number of days in your LTC period depends on which
A chronically ill individual is someone who has been method you choose to define the LTC period. Generally,
certified (at least annually) by a licensed health care you can choose either the Contract Period method or the
practitioner as: Equal Payment Rate method. However, special rules
• Being unable to perform at least two activities of daily apply if other persons also received per diem payments in
living (eating, toileting, transferring, bathing, dressing, and 2023 under a qualified LTC insurance contract or as
continence), without substantial assistance from another accelerated death benefits with respect to the insured
individual, for at least 90 days, due to a loss of functional listed on line 14a. See Multiple Payees, later, for details.
capacity; or
• Requiring substantial supervision to protect the Method 1—Contract Period
individual from threats to health and safety due to severe
cognitive impairment. An individual must have been Under this method, your LTC period is the same period as
certified within the past 12 months as meeting this that used by the insurance company under the contract to
condition. compute the benefits it pays you. For example, if the
insurance company computes your benefits on a daily
Accelerated Death Benefits basis, your LTC period is 1 day.

Generally, amounts paid as accelerated death benefits
under a life insurance contract or for the sale or
assignment of any portion of the death benefit as part of a
viatical settlement are fully excludable from your gross

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Filing Requirements for Section C

Go through this chart for each insured person for whom you received
long-term care (LTC) payments. See Deﬁnitions, earlier.
Start Here
Did you (or your spouse, if ling
jointly) receive payments in Were any of those payments
2023 made on a per diem or Yes made under a qualied LTC Yes Complete all
other periodic basis under an insurance contract? of Section C.
LTC insurance contract?

No
No

Did you (or your spouse, if Did you (or your spouse, if
ling jointly) receive any ling jointly) receive any
accelerated death benets in accelerated death benets in No Complete only
2023 from a life insurance 2023 from a life insurance lines 14a, 14b, and 17
policy that were made on a per policy that were made on a per of Section C.
diem or other periodic basis? diem or other periodic basis?

Yes
No
Complete only
Yes Were any of the payments paid No lines 14a, 14b, 15, 16,
Don’t complete on behalf of a chronically ill 17 (if applicable), and 26
Section C. (not terminally ill) individual? of Section C.
Yes

Complete all of Section C.

If you choose this method for defining the LTC insurance contract didn't begin making payments until
! period(s) and different LTC insurance contracts for May 1, 2023. The first LTC period is 61 days (March 1
CAUTION the same insured use different contract periods, through April 30) and the second LTC period is 245 days
then all such LTC contracts must be treated as computing (May 1 through December 31).
benefits on a daily basis.
Line 22
Qualified LTC services are necessary diagnostic,
Method 2—Equal Payment Rate preventive, therapeutic, curing, treating, mitigating, and
rehabilitative services, and maintenance or personal care
Under this method, your LTC period is the period during services required to treat a chronically ill individual under
which the insurance company uses the same payment a plan of care prescribed by a licensed health care
rate to compute your benefits. For example, you have two practitioner.
LTC periods if the insurance contract computes payments
at a rate of $175 per day from March 1, 2023, through May Line 24
31, 2023, and then at a rate of $195 per day from June 1, Enter the reimbursements you received or expect to
2023, through December 31, 2023. The first LTC period is receive through insurance or otherwise for qualified LTC
92 days (from March 1 through May 31) and the second services provided for the insured for LTC periods in 2023.
LTC period is 214 days (from June 1 through December Box 3 of Form 1099-LTC should indicate if payments were
31). made on a reimbursement basis.
You can choose this method even if you have more than Generally, don't include on line 24
one qualified LTC insurance contract covering the same ! reimbursements for qualified LTC services you
period. For example, you have one insurance contract that CAUTION received under a contract issued before August 1,
pays $100 per day from March 1, 2023, through 1996. However, you must include reimbursements if the
December 31, 2023, and a second contract that pays contract was exchanged or modified after July 31, 1996,
$1,500 per month from March 1, 2023, through December to increase per diem payments or reimbursements.
31, 2023. You have one LTC period because each
payment rate doesn't vary during the LTC period of March Multiple Payees
1 through December 31. However, you have two LTC If you checked “Yes” on lines 15 and 16 and the only
periods if the facts are the same except that the second payments you received were accelerated death benefits

Instructions for Form 8853 (2023) -9-

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that were paid because the insured was terminally ill, skip LTC insurance contract under which Anna is the insured.
lines 17 through 25 and enter -0- on line 26. Neither Ben nor Cleo incurred any costs for qualified LTC
In all other cases in which you checked “Yes” on services for Anna in 2023. From July 1, 2023, through
line 15, attach a statement duplicating lines 18 through 26 December 31, 2023, Ben received per diem payments of
of the form. This statement should show the aggregate $5,000 per month ($30,000 total) and Cleo received per
computation for all persons who received per diem diem payments of $3,000 per month ($18,000 total).
payments under a qualified LTC insurance contract or as Anna, Ben, and Cleo agree to use the equal payment rate
accelerated death benefits because the insured was method to determine their LTC periods.
chronically ill. Each person must use the same LTC There are two LTC periods. The first is 181 days
period. If all the recipients of payments don't agree on (January 1–June 30) during which the per diem payments
which LTC period to use, the contract period method must were $2,000 per month. The second is 184 days (July 1–
be used. December 31) during which the aggregate per diem
After completing the statement, determine your share payments were $10,000 per month ($2,000 under Anna's
of the per diem limitation and any taxable payments. The contract + $5,000 under Ben's contract + $3,000 under
per diem limitation is allocated first to the insured to the Cleo's contract).
extent of the total payments the insured received. If the An aggregate statement must be completed for the
insured files a joint return and the insured's spouse is one second LTC period and attached to Anna’s, Ben's, and
of the policyholders, the per diem limitation is allocated Cleo's forms.
first to them to the extent of the payments they both
Step 1. They complete a statement for Anna for the first
received. Any remaining limitation is allocated among the
LTC period as follows.
other policyholders pro rata based on the payments they
received in 2023. The statement showing the aggregate
computation must be attached to the Form 8853 for each Line Amount
person who received a payment.
Enter your share of the per diem limitation and the 20 $12,000 ($2,000 x 6 months)
taxable payments on lines 25 and 26 of your individual
21 $76,020 ($420 x 181 days)
Form 8853. Leave lines 21 through 24 blank.
22 $27,150 ($150 x 181 days)
Example 1
Anna was chronically ill in 2023 and received 12 monthly 23 $76,020
payments on a per diem basis from a qualified LTC
24 $13,575 ($75 x 181 days)
insurance contract. She was paid $2,000 per month
($24,000 total). Anna incurred expenses for qualified LTC 25 $62,445
services of $150 per day ($54,750) and was reimbursed
for one-half of those expenses ($27,375). She uses the 26 $ -0-
equal payment rate method and thus has a single benefit
period for 2023 (January 1–December 31). Anna
completes Form 8853, lines 20 through 26, as follows. Step 2. They complete the aggregate statement for the
Line Amount second LTC period as follows.

20 $24,000 ($2,000 x 12 months) Line Amount

21 $153,300 ($420* x 365 days) 20 $60,000 ($10,000 x 6 months)
22 $54,750 ($150 x 365 days) 21 $77,280 ($420 x 184 days)
23 $153,300 22 $27,600 ($150 x 184 days)
24 $27,375 ($75 x 365 days) 23 $77,280
25 $125,925 24 $13,800 ($75 x 184 days)
26 $ -0- 25 $63,480
*$420 is the 2023 per diem limit for periodic 26 $ -0-
payments received under a qualified LTC
insurance contract. See Rev. Proc. 2022-38,
section 3.61. Step 3. They allocate the aggregate per diem limitation of
$63,480 on line 25 among Anna, Ben, and Cleo. Because
Anna is the insured, the per diem limitation is allocated
first to her to the extent of the per diem payments she
Example 2 received during the second LTC period ($12,000). The
The facts are the same as in Example 1, except Anna's remaining per diem limitation of $51,480 is allocated
adult children, Ben and Cleo, each also own a qualified between Ben and Cleo.

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Allocation ratio to Ben: 62.5% of the remaining           Ben's Form 8853: 
limitation ($32,175) is allocated to Ben because the 
                                                                   1st LTC  2nd LTC 
$30,000 he received during the second LTC period is 
62.5% of the $48,000 received by both Ben and Cleo        Line     Period   Period  Form 8853
during the second LTC period.
Allocation ratio to Cleo: 37.5% of the remaining          20       $ -0-    $30,000 $30,000
limitation ($19,305) is allocated to Cleo because the     25       $ -0-    $32,175 $32,175
$18,000 she received during the second LTC period is 
37.5% of the $48,000 received by both Ben and Cleo        26       $ -0-    $ -0-   $ -0-
during the second LTC period.
Step 4. Anna, Ben, and Cleo each complete Form 8853 
                                                          Cleo’s Form 8853: 
as follows.
Anna's Form 8853:                                                  1st LTC  2nd LTC 
                                                          Line     Period   Period  Form 8853
           1st LTC       2nd LTC 
Line       Period         Period  Form 8853               20       $ -0-    $18,000 $18,000
20      $12,000    $12,000        $24,000                 25       $ -0-    $19,305 $19,305
25      $62,445    $12,000        $74,445                 26       $ -0-    $ -0-   $ -0-
26      $ -0-      $ -0-          $ -0-

Instructions for Form 8853 (2023)                     -11-

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