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Form 1099-SA
Cat. No. 38471D
Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Copy A For Internal Revenue Service Center
Department of the Treasury - Internal Revenue Service
File with Form 1096.
OMB No. 1545-
For Privacy Act and Paperwork Reduction Act Notice, see the 2019 General Instructions for Certain Information Returns.
9494 VOID CORRECTED
TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number
PAYER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross distribution $
2 Earnings on excess cont. $ 3 Distribution code 4 FMV on date of death
$ 5 HSA Archer MSA MA MSA
Form 1099-SA (^) www.irs.gov/Form1099SA
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-SA
Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Copy B For Recipient
Department of the Treasury - Internal Revenue Service
This information is being furnished to the IRS.
OMB No. 1545-
CORRECTED (if checked) TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number
PAYER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross distribution $
2 Earnings on excess cont. $ 3 Distribution code 4 FMV on date of death
$ 5 HSA Archer MSA MA MSA
Form 1099-SA (keep for your records) (^) www.irs.gov/Form1099SA
Form 1099-SA
Distributions From an HSA, Archer MSA, or Medicare Advantage MSA
Copy C For Trustee/Payer
Department of the Treasury - Internal Revenue Service
OMB No. 1545-
For Privacy Act and Paperwork Reduction Act Notice, see the 2019 General Instructions for Certain Information Returns.
VOID CORRECTED
TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number
PAYER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross distribution $
2 Earnings on excess cont. $ 3 Distribution code 4 FMV on date of death
$ 5 HSA Archer MSA MA MSA
Form 1099-SA (^) www.irs.gov/Form1099SA
Instructions for Trustee/Payer
To complete Form 1099-SA, use:
- The 2019 General Instructions for Certain Information Returns, and
- The 2019 Instructions for Forms 1099-SA and 5498-SA.
To get or to order these instructions, go to www.irs.gov/Form1099SA.
Due dates. Furnish Copy B of this form to the recipient by January 31, 2020.
File Copy A of this form with the IRS by February 28, 2020. If you file electronically, the due date is March 31, 2020. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. Need help? If you have questions about reporting on Form 1099-SA, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).
If a regular contribution is made to the HSA that is closed, and a distribution is made to the participant, enter the gross distribution in box 1. If no earnings are distributed, enter zero in box 2. If earnings are distributed, enter the amount of earnings in box 2. Enter code 2 in box 3. See the instructions for boxes 1 through 3, later.
In addition, Form 5498-SA must be filed to report any rollover (qualified HSA funding distributions (trustee-to-trustee transfers from an IRA to an HSA under section 408(d)(9))) contributions to the HSA subsequently closed by the trustee or custodian. See the Specific Instructions for Form 5498-SA, later.
Death of Account Holder
Archer MSAs and MA MSAs. When the account holder dies and the designated beneficiary is the surviving spouse, the following apply.
- The spouse becomes the account holder of the Archer MSA.
- An MA MSA is treated as an Archer MSA of the spouse for distribution purposes.
- Distributions from these accounts are subject to the rules that apply to Archer MSAs.
If the designated beneficiary is not the spouse or there is no named beneficiary, the account ceases to be an MSA as of the date of death and the fair market value (FMV) on that date is reported.
If there is more than one recipient, the FMV should be allocated among them, as appropriate.
If the beneficiary is the estate, enter the estate's name and TIN in place of the recipient's on the form. Distribution in year of death. If you learn of the account holder's death and make a distribution to the beneficiary in the year of death, issue a Form 1099-SA and enter in:
- Box 1, the gross distribution;
- Box 3, code 4 (see Box 3. Distribution Code , later); and
- Box 4, the FMV of the account on the date of death. Distribution after year of death. If you learn of the death of the account holder and make a distribution after the year of death, issue a Form 1099-SA in the year you learned of the death of the account holder. Enter in:
- Box 1, the gross distribution;
- Box 3, one of the following codes (see^ Box 3. Distribution Code , later):
1—If the beneficiary is the spouse, 4—If the beneficiary is the estate, or 6—If the beneficiary is not the spouse or estate;
- Box 4, the FMV of the account on the date of death, reduced by any payments from the HSA made for the decedent's qualified medical expenses, if paid within 1 year after death.
HSAs. When the account holder dies, the following applies.
- If the designated beneficiary is the surviving spouse, the spouse becomes the account holder of the HSA.
- If the designated beneficiary is not the surviving spouse, the account ceases to be an HSA on the date of
the account holder's death. The FMV of the account as of the date of death is required to be reported in box 4. Follow the rules and coding above under Distribution in year of death and Distribution after year of death.
Statements to Recipients
If you are required to file Form 1099-SA, you must provide a statement to the recipient. For more information about the requirement to furnish a Form 1099-SA or acceptable substitute statement to recipients, see part M in the current General Instructions for Certain Information Returns.
Truncating Recipient's TIN on Payee Statements
Pursuant to Regulations section 301.6109-4, all filers of this form may truncate a recipient’s TIN (social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN)) on payee statements. Truncation is not allowed on any documents the filer files with the IRS. A trustee's/payer's TIN may not be truncated on any form. See part J in the current General Instructions for Certain Information Returns.
Account Number
The account number is required if you have multiple accounts for a recipient for whom you are filing more than one Form 1099-SA. Additionally, the IRS encourages you to designate an account number for all Forms 1099-SA that you file. See part L in the current General Instructions for Certain Information Returns.
Box 1. Gross Distribution
Enter the total amount of the distribution. Include any earnings separately reported in box 2. You are not required to determine the taxable amount of a distribution. Do not report a negative amount in box 1. Do not report the withdrawal of excess employer contributions (and the earnings on them) returned to an employer as a distribution from an employee's HSA. Do not report excess MA MSA contributions returned to the Secretary of Health and Human Services or his or her representative.
Box 2. Earnings on Excess Contributions
Enter the total earnings distributed with any excess HSA or Archer MSA contributions returned by the due date of the account holder's tax return. Include this amount in box 1. Report earnings on other distributions only in box 1.
For HSAs and Archer MSAs, if you are reporting earnings on a distribution of excess contributions, use the method under Regulations section 1.408-11 for calculating the net income attributable to IRA contributions that are distributed as a returned contribution. If the amount in box 2 includes earnings on excess contributions, enter distribution code 2 in box 3.
Box 3. Distribution Code
Enter the appropriate distribution code from the following list that shows the type of distribution.
TIP
-2- Instructions for Forms 1099-SA and 5498-SA (2022)
Distribution Codes for Distributions from HSAs, Archer MSAs, and Medicare Advantage MSAs
1—Normal distributions
Use this code for normal distributions to the account holder and any direct payments to a medical service provider. Use this code if no other code applies. Also, see Distribution after year of death , earlier.
2—Excess contributions
Use this code for distributions of excess HSA or Archer MSA contributions to the account holder.
3—Disability
Use this code if you made distributions after the account holder was disabled (see section 72(m)(7)).
4—Death distribution other than code 6
Use this code for payments to a decedent's estate in the year of death. Also use this code for payments to an estate after the year of death. Do not use with code 6. See Death of Account Holder , earlier.
5—Prohibited transaction See sections 220(e)(2) and 223(e)(2).
6—Death distribution after year of death to a nonspouse beneficiary
Use this code for payments to a decedent's nonspouse beneficiary, other than an estate, after the year of death. Do not use with code 4.
Box 4. FMV on Date of Death
Enter the FMV of the account on the date of death. See Death of Account Holder , earlier.
Box 5. Checkbox
Check the box to indicate if this distribution was from an HSA, Archer MSA, or MA MSA.
Specific Instructions for Form
5498-SA
File Form 5498-SA, HSA, Archer MSA, or Medicare Advantage MSA Information, with the IRS on or before May 31, 2023, for each person for whom you maintained a health savings account (HSA), Archer medical savings account (Archer MSA), or Medicare Advantage MSA (MA MSA) during 2022. You are required to file if you are the trustee or custodian of an HSA, Archer MSA, or MA MSA. A separate form is required for each type of plan.
For HSA or Archer MSA contributions made between January 1, 2023, and April 18, 2023, you should obtain the participant's designation of the year for which the contributions are made.
For repayment of a mistaken distribution amount, see HSA Mistaken Distributions , earlier. Do not treat the repayment as a contribution on Form 5498-SA.
Rollovers
You must report the receipt of a rollover from one Archer MSA to another Archer MSA, and receipt of a rollover from an Archer MSA or an HSA to an HSA in box 4.
Transfers
Do not report a trustee-to-trustee transfer from one Archer MSA or MA MSA to another Archer MSA or MA MSA, from an Archer MSA to an HSA, or from one HSA to another HSA. For reporting purposes, contributions and rollovers do not include these transfers. However, see Box 2 , later, for the reporting of a trustee-to-trustee transfer from an IRA to an HSA.
Total Distribution, No Contributions
Generally, if a total distribution was made from an HSA or Archer MSA during the year and no contributions were made for that year, you need not file Form 5498-SA nor furnish a statement to the participant to reflect that the fair market value (FMV) on December 31 was zero.
Death of Account Holder
In the year an HSA, Archer MSA, or MA MSA owner dies, you must generally file a Form 5498-SA and furnish a statement for the decedent. If the designated beneficiary is the surviving spouse, the following apply.
- The spouse becomes the account holder of the HSA or Archer MSA.
- An MA MSA is treated as an Archer MSA of the spouse for distribution purposes, but no new contributions may be made to the account.
If the designated beneficiary is not the spouse or there is no designated beneficiary, the account ceases to be an HSA, Archer MSA, or MA MSA.
Statements to Participants
If you are required to file Form 5498-SA, you must provide a statement to the participant (generally Copy B) by May 31, 2023. You may, but you are not required to, provide the participant with a statement of the December 31, 2022, FMV of the participant's account by January 31,
- For more information about statements to participants, see part M in the 2022 General Instructions for Certain Information Returns.
If you furnished a statement of the FMV of the account to the participant by January 31, 2023, and no reportable contributions, including rollovers, were made for 2022, you need not furnish another statement (or Form 5498-SA) to the participant to report zero contributions. However, you must file Form 5498-SA with the IRS by May 31, 2023, to report the December 31, 2022, FMV of the account.
Instructions for Forms 1099-SA and 5498-SA (2022) (^) -3-
