2023 Form 8853

Form 8853

2023

Archer MSAs and

Long-Term Care Insurance Contracts

Department of the Treasury

Internal Revenue Service

Go to www.irs.gov/Form8853 for instructions and the latest information.

Attach to Form 1040, 1040-SR, or 1040-NR.

OMB No. 1545-0074

Attachment

Sequence No.

Name(s) shown on return

Social security number of MSA

account holder. If both spouses

have MSAs, see instructions

Section A. Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.

Part I

Archer MSA Contributions and Deductions. See instructions before completing this part. If you are filing

jointly and both you and your spouse have high deductible health plans with self-only coverage, complete a

separate Part I for each spouse.

1 Total employer contributions to your Archer MSA(s) for 2023 . . . . . . 1

2 Archer MSA contributions you made for 2023, including those made in 2024 by the unextended due

date of your return that were for 2023. Don’t include rollovers. See instructions . . . . . . . .

3 Limitation from the Line 3 Limitation Chart and Worksheet in the instructions . . . . . . . . 3

Compensation (see instructions) from the employer maintaining the high deductible health plan. (If

self-employed, enter your earned income from the trade or business under which the high deductible

health plan was established.)

. . . . . . . . . . . . . . . . . . . . . . . .

5 Archer MSA deduction. Enter the smallest of line 2, 3, or 4 here. Also include this amount on

Schedule 1 (Form 1040), line 23 . . . . . . . . . . . . . . . . . . . . . . .

Caution: If line 2 is more than line 5, you may have to pay an additional tax. See instructions.

Part II Archer MSA Distributions

6a Total distributions you and your spouse received in 2023 from all Archer MSAs (see instructions) . . 6a

Distributions included on line 6a that you rolled over to another Archer MSA or a health savings

account. Also include any excess contributions (and the earnings on those excess contributions)

included on line 6a that were withdrawn by the unextended due date of your return. See instructions

c Subtract line 6b from line 6a . . . . . . . . . . . . . . . . . . . . . . . . 6c

7 Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . . . 7

Taxable Archer MSA distributions. Subtract line 7 from line 6c. If zero or less, enter -0-. Also include

this amount in the total on Schedule 1 (Form 1040), line 8e . . . . . . . . . . . . . .

9 a If any of the distributions included on line 8 meet any of the Exceptions to the Additional 20% Tax

(see instructions), check here . . . . . . . . . . . . . . . . . . . . . . .

Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 8 that are

subject to the additional 20% tax. Also include this amount in the total on Schedule 2 (Form 1040),

line 17e

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received

distributions in 2023 from a Medicare Advantage MSA, complete a separate Section B for each spouse. See

instructions.

10 Total distributions you received in 2023 from all Medicare Advantage MSAs (see instructions) . . . 10

11 Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . . . 11

12 Taxable Medicare Advantage MSA distributions. Subtract line 11 from line 10. If zero or less, enter

-0-. Also include this amount in the total on Schedule 1 (Form 1040), line 8e . . . . . . . . .

13 a If any of the distributions included on line 12 meet any of the Exceptions to the Additional 50% Tax

(see instructions), check here . . . . . . . . . . . . . . . . . . . . . . .

Additional 50% tax. Enter 50% (0.50) of the distributions included on line 12 that are subject to the

additional 50% tax. See instructions for the amount to enter if you had a Medicare Advantage MSA

at the end of 2022. Also include this amount in the total on Schedule 2 (Form 1040), line 17f

. . .

13b

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

Cat. No. 24091H

Form 8853 (2023)

Attachment Sequence No. 39 Page 2

Name of policyholder (as shown on return)

Social security number

of policyholder

Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C in the instructions

before completing this section.

If more than one Section C is attached, check here . . . . . . . . . . . . . . . . . . . . . . .

14a

Name of insured

Social security number of insured

In 2023, did anyone other than you receive payments on a per diem or other periodic basis under a qualified

LTC insurance contract covering the insured or receive accelerated death benefits under a life insurance

policy covering the insured? . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

16 Was the insured a terminally ill individual? . . . . . . . . . . . . . . . . . . . . . .

Yes No

Note: If “Yes” and the only payments you received in 2023 were accelerated death benefits that were paid to

you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.

Gross LTC payments received on a per diem or other periodic basis. Enter the total of the amounts

from box 1 of all Forms 1099-LTC you received with respect to the insured on which the “Per diem”

box in box 3 is checked . . . . . . . . . . . . . . . . . . . . . . . . . .

Caution: Don’t use lines 18 through 26 to figure the taxable amount of benefits paid under an LTC

insurance contract that isn’t a qualified LTC insurance contract. Instead, if the benefits aren’t

excludable from your income (for example, if the benefits aren’t paid for personal injuries or sickness

through accident or health insurance), report the amount not excludable as income on Schedule 1

(Form 1040), line 8e, or, for taxpayers filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12.

18 Enter the part of the amount on line 17 that is from qualified LTC insurance contracts . . . . . 18

19 Accelerated death benefits received on a per diem or other periodic basis. Don’t include any amounts

you received because the insured was terminally ill. See instructions . . . . . . . . . . .

20 Add lines 18 and 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Note: If you checked “Yes” on line 15 above, see Multiple Payees in the

instructions before completing lines 21 through 25.

21 Multiply $420 by the number of days in the LTC period . . . . . . . . 21

22 Costs incurred for qualified LTC services provided for the insured during the

LTC period (see instructions) . . . . . . . . . . . . . . . .

23 Enter the larger of line 21 or line 22 . . . . . . . . . . . . . . 23

24 Reimbursements for qualified LTC services provided for the insured during the

LTC period . . . . . . . . . . . . . . . . . . . . . .

Caution: If you received any reimbursements from LTC contracts issued before August 1, 1996, see

instructions.

25 Per diem limitation. Subtract line 24 from line 23 . . . . . . . . . . . . . . . . . . 25

Taxable payments. Subtract line 25 from line 20. If zero or less, enter -0-. Also include this amount in

the total on Schedule 1 (Form 1040), line 8e, or, for taxpayers filing Form 1040-NR, on Form 1040-NR,

Schedule NEC, line 12. For taxpayers filing Form 1040-NR, on Schedule NEC (Form 1040-NR), line 12,

enter “LTC” and the amount . . . . . . . . . . . . . . . . . . . . . . . .

Form 8853 (2023)