HSA qualified medical expenses are the costs you can pay tax-free from a health savings account, defined by federal law as amounts paid for the “diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body” (Source: 26 U.S.C. 213(d)). This 2026 guide gives you the eligible list, the ineligible list, the gray-area items that need a letter of medical necessity, and the tax you owe if you get a withdrawal wrong.
HSA money spent on qualified medical expenses is never included in your gross income (Source: 26 U.S.C. 223(f)(1)). Qualified expenses cover doctor, dental, vision, prescription, mental-health, and medical-equipment costs under IRS Publication 502. Spend HSA dollars on anything else and the amount becomes taxable income, plus a 20% additional tax before age 65 (Source: 26 U.S.C. 223(f)(4)).
What counts as an HSA qualified medical expense
A qualified medical expense meets the Internal Revenue Code Section 213(d) test: a cost for the “diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body” (Source: 26 U.S.C. 213(d)). The IRS lists eligible categories in Publication 502 and applies them to HSAs in Publication 969, the two controlling references (Source: IRS Pub 502; IRS Pub 969).
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Two limits sit on top of that definition. The expense generally must be incurred after the HSA was established, and the same expense cannot also be claimed as an itemized medical deduction on Schedule A (Source: IRS Pub 969). Using both is double-dipping and is not allowed.
The Section 213(d) standard is the single test every item is measured against. If a cost treats or prevents a specific medical condition, it usually qualifies. If it maintains general health, it usually does not. Publication 502 turns that principle into named categories, and the sections below sort common purchases into eligible, ineligible, and conditional.
Eligible HSA expenses by category
Most doctor, dental, vision, mental-health, prescription, and medical-equipment costs are HSA-eligible, along with copays, deductibles, and coinsurance. Since the 2020 CARES Act, over-the-counter medicines qualify without a prescription and menstrual products are treated as medical care (Source: CARES Act of 2020, Pub. L. 116-136 sec. 3702; IRS newsroom). The table below groups the most common eligible items.
This list is not exhaustive. The controlling reference is IRS Publication 502, and any item that meets the Section 213(d) test can qualify even if it is not named here.
| Category | Examples that generally qualify |
|---|---|
| Services | Doctor and specialist visits, hospital care, surgery, acupuncture, chiropractic, physical and speech therapy, mental health and psychiatric care, ambulance transport (Source: IRS Pub 502) |
| Dental | Cleanings, exams, X-rays, fillings, braces and orthodontics, dentures, implants (Source: IRS Pub 502) |
| Vision | Eye exams, prescription glasses, contact lenses and solution, LASIK and laser eye surgery (Source: IRS Pub 502) |
| Equipment and supplies | Wheelchairs, crutches, walkers, hearing aids, CPAP machines, blood pressure monitors, breast pumps and lactation supplies (Source: IRS Pub 502) |
| Medicines | Prescription drugs, insulin, and over-the-counter medicines without a prescription (Source: CARES Act of 2020) |
| Reproductive and preventive | Fertility treatment and in vitro fertilization, vaccines and flu shots, vasectomy (Source: IRS Pub 502) |
| Cost-sharing | Copays, deductibles, and coinsurance under your health plan (Source: IRS Pub 969) |
| Personal care | Menstrual and feminine care products (Source: CARES Act of 2020) |
What is not a qualified medical expense
General-health and personal-hygiene items are not HSA-eligible: toothpaste, deodorant, shampoo, cosmetics, gym memberships, and vitamins or supplements taken for general wellness. Most insurance premiums are also excluded. Cosmetic procedures are ineligible unless they treat a deformity from a congenital abnormality, injury, or disfiguring disease (Source: 26 U.S.C. 213(d)(9); IRS Pub 502).
The dividing line is medical necessity. An item bought to maintain general health, rather than to treat or prevent a specific condition, falls outside the Section 213(d) definition (Source: IRS Pub 502). The comparison table below shows the two sides side by side.
| Generally eligible | Generally ineligible |
|---|---|
| Prescription and OTC medicines | Toothpaste, mouthwash, deodorant, shampoo |
| Dental, vision, and hearing care | Cosmetics and most skincare |
| Doctor, hospital, and surgery costs | Gym and health-club memberships (general fitness) |
| Mental health and therapy | Vitamins and supplements for general health |
| Medical equipment and supplies | Cosmetic procedures without a medical reason |
| Menstrual and lactation products | Most insurance premiums (see exceptions below) |
Gray-area items and the letter of medical necessity
When an otherwise-ineligible item is prescribed to treat a specific diagnosed condition, a written statement from a licensed provider, often called a letter of medical necessity, is what supports HSA eligibility. This path can apply to supplements, a gym membership, a weight-loss program, or massage therapy when each is tied to a diagnosis (Source: IRS Pub 502). The diagnosis, not the receipt, carries the eligibility.
Effective documentation identifies the patient, names the diagnosed condition, states the specific item or service, and explains how it treats or mitigates that condition. The stronger the link between the diagnosis and the item, the better it holds up if the IRS examines the distribution (Source: IRS Pub 502).
| Item | Status | Key condition |
|---|---|---|
| OTC pain relievers | Eligible | No prescription needed since 2020 (Source: CARES Act of 2020) |
| Menstrual products | Eligible | Treated as medical care (Source: CARES Act of 2020) |
| Sunscreen | Conditional | Depends on medical purpose; confirm with a tax professional |
| Vitamins and supplements | Conditional | Qualify only when a provider documents a diagnosed condition (Source: IRS Pub 502) |
| Gym membership | Conditional | Qualifies only with a provider letter tying it to a diagnosis (Source: IRS Pub 502) |
| Weight-loss program | Conditional | Eligible to treat a specific disease diagnosed by a physician (Source: IRS Pub 502) |
| Massage therapy | Conditional | May qualify when tied to a diagnosis by a provider (Source: IRS Pub 502) |
| Cosmetic procedures | Ineligible | Eligible only if medically necessary under the statute (Source: 26 U.S.C. 213(d)(9)) |
Wellness devices such as red light panels, saunas, cold plunges, and wearables sit in the same gray zone. They are not automatically eligible, and items that also serve general fitness carry more scrutiny, so treatment as a qualified medical expense depends on documentation linking the device to a diagnosed condition (Source: IRS Pub 502).
Insurance premiums HSA can and cannot pay
Insurance premiums are generally not HSA-eligible, with four exceptions: COBRA continuation coverage, qualified long-term care insurance up to the age-based statutory limits, coverage while receiving unemployment, and, at age 65 or older, Medicare premiums other than Medigap (Source: IRS Pub 969; 26 U.S.C. 213(d)(10)). Medicare Part A, Part B, and Part D premiums qualify; Medigap does not.
Publication 969 states an HSA can pay for “Medicare and other health care coverage if you were 65 or older (other than premiums for a Medicare supplemental policy, such as Medigap)” (Source: IRS Pub 969). Publication 502 confirms Medicare Part A, Part B, and Part D premiums are includible while Medigap premiums are not (Source: IRS Pub 502). Medicare Advantage (Part C) is not named explicitly, so confirm that case with a tax professional.
The other three exceptions apply at any age: qualified long-term care insurance up to the age-based dollar limits under Section 213(d)(10), COBRA-type continuation coverage, and health coverage bought while receiving unemployment compensation (Source: IRS Pub 969; 26 U.S.C. 213(d)(10)).
New for 2026: OBBBA and IRS Notice 2026-05
Guidance under the One Big Beautiful Bill Act (P.L. 119-21) expanded HSA access. IRS Notice 2026-05, issued December 9, 2025, made pre-deductible telehealth coverage permanent, treated bronze and catastrophic Exchange plans as HSA-compatible starting January 1, 2026, and let people in qualifying direct primary care arrangements keep an HSA and pay periodic DPC fees tax-free from January 1, 2026 (Source: IRS Notice 2026-05).
Three changes matter for 2026. First, telehealth and remote-care services can be covered before you meet the deductible without disqualifying HSA contributions, and that relief is now permanent rather than year-by-year. Second, bronze and catastrophic plans sold on an Affordable Care Act Exchange now count as high-deductible health plans for HSA purposes beginning January 1, 2026 (Source: IRS Notice 2026-05).
Third, a monthly direct primary care membership no longer blocks HSA eligibility. Qualifying DPC fees are treated as a medical expense, so members can both contribute to an HSA and pay those fees tax-free from January 1, 2026 (Source: IRS Notice 2026-05). Most competing eligibility pages have not yet reflected this notice, so verify any older list against it.
Whose expenses qualify: spouse, dependents, and no double-dipping
HSA funds can pay qualified medical expenses for the account holder, a spouse, and tax dependents, even when only the account holder is covered by the high-deductible health plan and even when the spouse or dependent is not (Source: IRS Pub 969). The same expense cannot be both reimbursed from an HSA and deducted on Schedule A, which is the no-double-dipping rule.
This reach is wider than many account holders assume. A spouse on separate coverage and an adult child claimed as a tax dependent can both have their qualified costs paid from one person’s HSA (Source: IRS Pub 969). What matters is the tax relationship, not whose name is on the health plan.
The offset is the no-double-dipping rule. If you pay a bill from your HSA tax-free, you cannot also count that same bill toward the itemized medical deduction on Schedule A (Source: IRS Pub 969). Choosing which bucket to use for each expense is one of several coordination questions to weigh with a qualified professional.
The tax on non-qualified HSA withdrawals
An HSA withdrawal not used for qualified medical expenses is included in gross income and taxed (Source: 26 U.S.C. 223(f)(2)). Before age 65, it also carries a 20% additional tax reported on Form 8889 and Schedule 2 (Source: 26 U.S.C. 223(f)(4)(A)). Three events remove that 20%: death, disability, or reaching age 65.
The statute is direct. Amounts not used exclusively for qualified medical expenses “shall be included in the gross income” of the account beneficiary, and the tax “shall be increased by 20 percent of the amount which is so includible” (Source: 26 U.S.C. 223(f)(2), (f)(4)(A)). The 20% sits on top of ordinary income tax, not instead of it.
After age 65, a non-medical withdrawal is still taxable income but escapes the 20% penalty (Source: IRS Pub 969). At that point an HSA behaves much like a traditional IRA for non-medical spending, so drawdowns add to the modified adjusted gross income that sets Medicare Part B and Part D premiums. Since Medicare uses a two-year income lookback, timing an HSA withdrawal alongside a Roth conversion can stack income into one year and lift a premium tier. Larger withdrawals can also interact with the 3.8% net investment income tax thresholds, and the deciding how much to convert question often depends on the same income tiers.
Pay now, reimburse yourself later
Publication 969 sets no stated deadline to reimburse yourself for a qualified medical expense, as long as the expense was incurred after the HSA was established and was not otherwise reimbursed or deducted (Source: IRS Pub 969). One approach the rules allow is paying medical bills out of pocket, keeping the HSA invested, then withdrawing tax-free years later against saved receipts.
Because the only conditions are that the expense came after the account opened and was not reimbursed or deducted elsewhere, there is no stated time limit between paying a bill and taking a matching tax-free distribution (Source: IRS Pub 969). This lets the account work as a long-horizon, invested medical reserve rather than a checking account, a use that pairs with sequencing decisions around required minimum distributions later in retirement.
The trade-off is recordkeeping. To support a delayed reimbursement, keep the itemized receipt, proof the cost was a qualified medical expense, and evidence it was not reimbursed by insurance or deducted elsewhere (Source: IRS Pub 969). The account holder, not the custodian, must prove an expense qualified if the IRS asks. Custodians report total distributions on Form 1099-SA but do not certify that any of them were qualified; you reconcile that on Form 8889.
2025 and 2026 HSA contribution limits
For 2026, the HSA contribution limit is $4,400 self-only and $8,750 family, the age-55 catch-up is $1,000, and the high-deductible health plan minimum deductibles are $1,700 self-only and $3,400 family (Source: IRS Rev. Proc. 2025-19). These amounts are adjusted for inflation each year except the catch-up, which is fixed by statute at $1,000.
| Figure | 2025 | 2026 |
|---|---|---|
| Contribution limit, self-only | $4,300 | $4,400 |
| Contribution limit, family | $8,550 | $8,750 |
| Catch-up (age 55+) | $1,000 | $1,000 |
| HDHP minimum deductible, self-only / family | $1,650 / $3,300 | $1,700 / $3,400 |
| HDHP out-of-pocket max, self-only / family | $8,300 / $16,600 | $8,500 / $17,000 |
The 2025 amounts come from IRS Publication 969; the 2026 amounts come from IRS Rev. Proc. 2025-19 (Source: IRS Pub 969; IRS Rev. Proc. 2025-19). The catch-up is set by statute and is not inflation-indexed (Source: 26 U.S.C. 223(b)(3)).
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Frequently asked questions
What are qualified medical expenses for an HSA?
Qualified medical expenses are costs for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for affecting a structure or function of the body (Source: 26 U.S.C. 213(d)). They include doctor visits, hospital care, dental and vision care, prescriptions, mental-health care, and many medical supplies, all listed in IRS Publication 502.
What is not a qualified medical expense for HSA?
General-health and personal-care items are not qualified: toothpaste, deodorant, shampoo, cosmetics, gym memberships, and vitamins or supplements for general wellness (Source: IRS Pub 502). Cosmetic procedures are ineligible unless medically necessary, and most insurance premiums are excluded except for a few named categories (Source: IRS Pub 969).
Can I use my HSA for gym membership?
A gym membership is generally not HSA-eligible because it serves general health (Source: IRS Pub 502). It may become eligible when a licensed provider documents in a letter of medical necessity that the membership treats a specific diagnosed condition. The documentation and diagnosis carry the eligibility, not the membership alone. Confirm any gray-area item with a tax professional.
Are vitamins HSA eligible?
Vitamins and dietary supplements taken for general health are not HSA-eligible (Source: IRS Pub 502). They may qualify when a licensed provider prescribes a specific supplement to treat a diagnosed condition and documents that purpose in writing. Without that link to a diagnosis, they remain ineligible, so keep the documentation with your records.
Can I use my HSA to pay insurance premiums?
Premiums are generally not HSA-eligible, with four exceptions: COBRA continuation coverage, qualified long-term care insurance up to the statutory age-based limits, coverage while receiving unemployment, and, at age 65 or older, Medicare premiums other than Medigap (Source: IRS Pub 969). Medicare Part A, Part B, and Part D premiums qualify; Medigap does not (Source: IRS Pub 502).
What happens if I use my HSA for non-qualified expenses?
A non-qualified distribution is included in gross income and taxed (Source: 26 U.S.C. 223(f)(2)). Before age 65, it also carries a 20% additional tax reported on Form 8889 and Schedule 2 (Source: 26 U.S.C. 223(f)(4)(A)). After age 65, death, or disability, the 20% is not applied, but the amount is still taxable income (Source: IRS Pub 969).
Can I use my HSA for my spouse or dependents?
Yes. HSA funds can pay qualified medical expenses for your spouse and tax dependents, even when they are not covered by your high-deductible health plan and even if only you own the account (Source: IRS Pub 969). What matters is the tax relationship, not whose name is on the health plan or the HSA.
Is there a time limit to reimburse yourself from an HSA?
No, Publication 969 sets no stated deadline. You can pay a qualified medical expense out of pocket and reimburse yourself tax-free years later, provided the expense was incurred after the HSA was established and was not otherwise reimbursed or deducted (Source: IRS Pub 969). Keep the receipts, because you must prove the expense qualified.
Sources
26 U.S.C. 223 (HSA distributions and taxation), law.cornell.edu/uscode/text/26/223. 26 U.S.C. 213(d) (definition of medical care, cosmetic-surgery exception, long-term care insurance limits), law.cornell.edu/uscode/text/26/213. IRS Publication 969, Health Savings Accounts, irs.gov/publications/p969. IRS Publication 502, Medical and Dental Expenses, irs.gov/publications/p502. IRS Form 8889 instructions, irs.gov/instructions/i8889. IRS Rev. Proc. 2025-19 (2026 HSA/HDHP amounts), irs.gov/pub/irs-drop/rp-25-19.pdf. IRS Notice 2026-05 (OBBBA HSA guidance), irs.gov/pub/irs-drop/n-26-05.pdf. IRS newsroom, “IRS outlines changes to health care spending available under CARES Act.” CARES Act of 2020, Pub. L. 116-136. One Big Beautiful Bill Act, P.L. 119-21.
