Form 1099-SA - Distributions From an HSA, Archer MSA, or Medicare Advantage MSA

2021

Department of the Treasury
Internal Revenue Service

Instructions for Forms
1099-SA and 5498-SA

Distributions From an HSA, Archer MSA, or Medicare Advantage MSA, and HSA,
Archer MSA, or Medicare Advantage MSA Information

Future Developments

Advantage MSA (MA MSA). The distribution may have
been paid directly to a medical service provider or to the
account holder. A separate return must be filed for each
plan type.

Reminders

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 transfers.

Section references are to the Internal Revenue Code
unless otherwise noted.
For the latest information about developments related to
Forms 1099-SA and 5498-SA and their instructions, such
as legislation enacted after they were published, go to
IRS.gov/Form1099SA and IRS.gov/Form5498SA.
In addition to these specific instructions, you should also
use the 2021 General Instructions for Certain Information
Returns. Those general instructions include information
about the following topics.
• Who must file.
• When and where to file.
• Electronic reporting.
• Corrected and void returns.
• Statements to recipients.
• Taxpayer identification numbers (TINs).
• Backup withholding.
• Penalties.
• Other general topics.
You can get the general instructions from IRS.gov/
1099GeneralInstructions, IRS.gov/Form1099SA, and
IRS.gov/Form5498SA.
Continuous-use form and instructions. Form 1099-SA
and its instructions are continuous use. Both the form and
instructions will be updated as needed. For the most
recent version, go to IRS.gov/Form1099SA.
Online fillable forms. Due to the very low volume of
paper Forms 1099-SA and 5498-SA received and
processed by the IRS each year, these forms have been
converted to an online fillable format. You may fill out the
forms, found online at IRS.gov/Form1099SA and IRS.gov/
Form5498SA, and send Copy B to the recipient. For filing
with the IRS, follow the applicable procedures if you are
required to file electronically. For Forms 1099-SA and
5498-SA only, if due to a low volume of recipients, you
are filing the form(s) on paper, you can send in the
black-and-white Copy(ies) A with a Form 1096 that you
also printed from the IRS website.

Specific Instructions for Form
1099-SA

File Form 1099-SA, Distributions From an HSA, Archer
MSA, or Medicare Advantage MSA, to report distributions
made from a health savings account (HSA), Archer
medical savings account (Archer MSA), or Medicare
Oct 19, 2020

HSA mistaken distributions. If amounts were
distributed during the year from an HSA because of a
mistake of fact due to reasonable cause, the account
beneficiary may repay the mistaken distribution no later
than April 18 following the first year the account
beneficiary knew or should have known the distribution
was a mistake. For example, the account beneficiary
reasonably, but mistakenly, believed that an expense was
a qualified medical expense and was reimbursed for that
expense from the HSA. The account beneficiary then
repays the mistaken distribution to the HSA.
Under these circumstances, the mistaken distribution is
not included in gross income, is not subject to the
additional 20% tax, and the repayment is not subject to
the excise tax on excess contributions. Do not treat the
repayment as a contribution on Form 5498-SA, HSA,
Archer MSA, or Medicare Advantage MSA Information.
As the trustee or custodian, you do not have to

TIP allow beneficiaries to return a mistaken

distribution to the HSA. However, if you do allow
the return of the mistaken distribution, you may rely on the
account beneficiary's statement that the distribution was
in fact a mistake. See Notice 2004-50, 2004-33 I.R.B.
196, Q/A-76, available at IRS.gov/irb/
2004-33_IRB#NOT-2004-50. Do not report the mistaken
distribution on Form 1099-SA. Correct any filed Form
1099-SA with the IRS and the account beneficiary as soon
as you become aware of the error. See Corrected Returns
on Paper Forms in the current General Instructions for
Certain Information Returns for more information.

HSA Closure Under the USA PATRIOT Act

If an HSA is closed at any time by the HSA trustee or
custodian due to a failure of the participant to satisfy the
Customer Identification Program requirements described
in section 326 of the USA PATRIOT Act, the distribution
from the HSA must be reported.
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

Cat. No. 38470S

Follow the rules and coding above under Distribution in
year of death and Distribution after year of death.

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.

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.

Death of Account Holder

Truncating Recipient's TIN on Payee Statements

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.

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

TIP 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.

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.

Box 3. Distribution Code

Enter the appropriate distribution code from the following
list that shows the type of distribution.

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Instructions for Forms 1099-SA and 5498-SA (2021)

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

Total Distribution, No Contributions

Enter the FMV of the account on the date of death. See
Death of Account Holder, earlier.

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.

Box 5. Checkbox

Check the box to indicate if this distribution was from an
HSA, Archer MSA, or MA MSA.

Death of Account Holder

Specific Instructions for Form
5498-SA

In the year an HSA, Archer MSA, or MA MSA owner dies,
generally you must 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.

File Form 5498-SA, HSA, Archer MSA, or Medicare
Advantage MSA Information, with the IRS on or before
May 31, 2022, 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 2021. 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.

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.

For HSA or Archer MSA contributions made between
January 1, 2022, and April 18, 2022, you should obtain
the participant's designation of the year for which the
contributions are made.

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, 2022. You may, but you are not required to, provide
the participant with a statement of the December 31,
2021, FMV of the participant's account by January 31,
2022. For more information about statements to
participants, see part M in the 2021 General Instructions
for Certain Information Returns.

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.

If you furnished a statement of the FMV of the account
to the participant by January 31, 2022, and no reportable
contributions, including rollovers, were made for 2021,
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, 2022, to report the December 31, 2021, FMV of
the account.

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.
Instructions for Forms 1099-SA and 5498-SA (2021)

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Box 2. Total Contributions Made in 2021

If you do not furnish another statement to the
participant because no reportable contributions
CAUTION were made for the year, the statement of the FMV
of the account must contain a legend designating which
information is being furnished to the IRS.

!

Enter the total HSA or Archer MSA contributions made in
2021. Include any contribution made in 2021 for 2020.
Also include qualified HSA funding distributions
(trustee-to-trustee transfers from an IRA to an HSA under
section 408(d)(9)) received by you during 2021. Any
excess employer contributions (and the earnings on them)
withdrawn by the employer pursuant to Notice 2008-59,
Q/A 24, available at IRS.gov/irb/
2008-29_IRB#NOT-2008-59, should not be reported as a
contribution. You may, but you are not required to, report
the total MA MSA contributions made in 2021 by the
Secretary of Health and Human Services or his or her
representative. Do not include amounts reported in box 4.

Truncating Participant's TIN on Payee
Statements

Pursuant to Regulations section 301.6109-4, all filers of
this form may truncate a participant'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 TIN may not be
truncated on any form. See part J in the 2021 General
Instructions for Certain Information Returns.

Box 3. Total HSA or Archer MSA Contributions
Made in 2022 for 2021

Enter the total HSA or Archer MSA contributions made in
2022 for 2021.

Account Number

The account number is required if you have multiple
accounts for a recipient for whom you are filing more than
one Form 5498-SA. Additionally, the IRS encourages you
to designate an account number for all Forms 5498-SA
that you file. See part L in the 2021 General Instructions
for Certain Information Returns.

Box 4. Rollover Contributions

Enter rollover contributions to the HSA or Archer MSA
received by you during 2021. These amounts are not to
be included in box 2.

Box 5. Fair Market Value of HSA, Archer MSA, or
MA MSA

Box 1. Employee or Self-Employed Person's
Archer MSA Contributions Made in 2021 and
2022 for 2021

Enter the FMV of the account on December 31, 2021.

Box 6. Checkbox

Enter the employee's or self-employed person's regular
contributions to the Archer MSA made in 2021 and
through April 18, 2022, for 2021. Report gross
contributions, including any excess contributions, even if
the excess contributions were withdrawn. No HSA
information is to be reported in box 1.

Check the box to indicate if this account is an HSA, Archer
MSA, or MA MSA.

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Instructions for Forms 1099-SA and 5498-SA (2021)