HSA qualified medical expenses are the costs that can be paid with health savings account dollars tax-free, 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 guide sets out a 2026 eligible-versus-ineligible list, the tax rules on non-qualified withdrawals, and the documentation used to defend an expense.
HSA money spent on qualified medical expenses is not included in gross income (Source: 26 U.S.C. 223(f)(1)). Money spent on anything else is taxable, plus a 20% additional tax before age 65 (Source: 26 U.S.C. 223(f)(4); IRS Form 8889 instructions, 2025). The 2026 contribution limit is $4,400 self-only and $8,750 family (Source: IRS Rev. Proc. 2025-19).
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 (Source: IRS Pub 502, 2025; IRS Pub 969, 2025).
Talk With Craig Wear's Team
Craig has helped IRA millionaires save over $1 million each in unnecessary taxes. Find out if a Roth conversion strategy fits your retirement, with no sales pressure and no product pitch.
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, 2025). Using both would be double-dipping and is not allowed.
Whose expenses qualify is broader than the account itself. HSA funds can cover qualified medical expenses for the account holder, a spouse, and tax dependents, even when only one person owns the account (Source: IRS Pub 969, 2025).
Eligible 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, “IRS outlines changes to health care spending available under CARES Act”).
The table below groups common eligible items. It is not exhaustive; the controlling reference is IRS Publication 502 (Source: IRS Pub 502, 2025).
| 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, 2025) |
| Dental | Cleanings, exams, X-rays, fillings, braces and orthodontics, dentures, implants (Source: IRS Pub 502, 2025) |
| Vision | Eye exams, prescription glasses, contact lenses and solution, LASIK and laser eye surgery (Source: IRS Pub 502, 2025) |
| Equipment and supplies | Wheelchairs, crutches, walkers, hearing aids, CPAP machines, blood pressure monitors, breast pumps and lactation supplies (Source: IRS Pub 502, 2025) |
| 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, 2025) |
| Cost-sharing | Copays, deductibles, and coinsurance under your health plan (Source: IRS Pub 969, 2025) |
| 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. 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, 2025).
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: 26 U.S.C. 213(d); IRS Pub 502, 2025).
Common ineligible items include toothpaste, mouthwash, deodorant, shampoo and conditioner, cosmetics and most skincare, gym and health-club memberships, and vitamins or dietary supplements taken for general health. Cosmetic surgery is ineligible unless it treats a deformity arising from a congenital abnormality, a personal injury from an accident or trauma, or a disfiguring disease (Source: 26 U.S.C. 213(d)(9); IRS Pub 502, 2025).
Frequently confused items, adjudicated
Borderline items generate conflicting answers online. The table below sorts frequently disputed items by whether they generally qualify, with the trigger that changes the answer. Where eligibility depends on medical necessity, a provider’s written statement tying the item to a diagnosed condition is often what moves it into the eligible column (Source: IRS Pub 502, 2025).
| Item | Status | Key condition |
|---|---|---|
| Over-the-counter 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 | Eligibility depends on medical purpose; confirm with IRS guidance or a tax professional |
| Toothpaste | Ineligible | General personal hygiene (Source: IRS Pub 502, 2025) |
| Vitamins and supplements | Ineligible for general health | May qualify when a provider documents a diagnosed condition (Source: IRS Pub 502, 2025) |
| Gym membership | Ineligible by default | May qualify when a provider documents a diagnosed condition (Source: IRS Pub 502, 2025) |
| Weight-loss program | Conditional | Eligible if to treat a specific disease diagnosed by a physician (Source: IRS Pub 502, 2025) |
| Massage therapy | Conditional | May qualify when tied to a diagnosis by a provider (Source: IRS Pub 502, 2025) |
| Cosmetic procedures | Ineligible | Eligible only if medically necessary under the statute (Source: 26 U.S.C. 213(d)(9)) |
| Fertility treatment and IVF | Eligible | Treated as medical care (Source: IRS Pub 502, 2025) |
Wellness devices such as red light therapy panels, saunas, cold plunges, and wearables sit in the gray zone. They are not automatically eligible; treatment as a qualified medical expense generally depends on documentation linking the item to a diagnosed condition, and items that also serve general wellness carry more scrutiny (Source: IRS Pub 502, 2025).
Insurance premiums: the exceptions that matter
Insurance premiums are generally not HSA-eligible, with narrow exceptions: COBRA continuation coverage, qualified long-term care insurance up to the age-based limits set by statute, coverage while receiving unemployment, and, at age 65 or older, Medicare premiums other than Medigap (Source: IRS Pub 969, 2025; 26 U.S.C. 213(d)(10)).
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, 2025). Publication 502 confirms Medicare Part A, Part B, and Part D premiums are includible medical expenses while Medigap premiums are not (Source: IRS Pub 502, 2025). Medicare Advantage (Part C) premium treatment is not named explicitly in these publications, so confirm your specific situation with the IRS guidance or a tax professional.
The other three exceptions apply regardless of age: qualified long-term care insurance up to the age-based dollar limits set under Section 213(d)(10), health-care continuation coverage such as COBRA, and health coverage purchased while receiving unemployment compensation (Source: IRS Pub 969, 2025; 26 U.S.C. 213(d)(10)). For those coordinating Medicare timing, the interaction between income and premiums is one factor to weigh with a qualified professional; background is in the Medicare IRMAA brackets overview.
How non-qualified distributions are taxed
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); IRS Form 8889 instructions, 2025). Three exceptions remove that additional tax: 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% is on top of ordinary income tax, not instead of it.
Three exceptions remove the 20% additional tax: the account beneficiary dies, becomes disabled within the meaning of Section 72(m)(7), or reaches age 65 (Source: 26 U.S.C. 223(f)(4)(C); IRS Pub 969, 2025). After 65, a non-medical withdrawal still counts as taxable income but is not subject to the additional tax (Source: IRS Pub 969, 2025). Because non-qualified HSA withdrawals add to income, they can affect Medicare premium tiers and other income-linked thresholds. How an HSA fits within a drawdown order, including alongside a Roth conversion, is one of several factors to weigh with a qualified professional given each person’s circumstances.
The reimburse-yourself-later approach
Publication 969 sets no stated deadline to reimburse yourself for a qualified medical expense, provided the expense was incurred after the HSA was established and not otherwise reimbursed or deducted. 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 (Source: IRS Pub 969, 2025).
Because Publication 969 requires only that the expense be incurred after the HSA was established and not otherwise reimbursed or deducted, there is no stated time limit between paying a bill and taking a matching tax-free distribution (Source: IRS Pub 969, 2025). This lets the account function as a long-horizon, invested medical reserve.
The trade-off is recordkeeping. To support a delayed reimbursement, an account holder generally keeps the itemized receipt, proof it was a qualified medical expense, and evidence it was not reimbursed by insurance or deducted elsewhere (Source: IRS Pub 969, 2025). The account holder, not the HSA custodian, bears responsibility to prove an expense qualified if the IRS asks. This retirement-drawdown angle connects to broader sequencing questions covered in the HSA as a retirement account discussion.
Documenting medical necessity for gray-area items
When an otherwise-ineligible item is prescribed to treat a specific diagnosed condition, documentation from a licensed provider is generally what supports HSA eligibility. This can apply to supplements, a gym membership, a weight-loss program, or massage when tied to a diagnosis (Source: IRS Pub 502, 2025). The underlying diagnosis and treatment purpose determine eligibility.
Effective documentation generally identifies the patient, names the diagnosed medical condition, states the specific item or service, and explains how it treats or mitigates that condition. The stronger the link between diagnosis and item, the better it supports the expense if the IRS examines the distribution (Source: IRS Pub 502, 2025).
Documentation does not convert general-wellness spending into medical care by itself; the underlying diagnosis and treatment rationale do the work (Source: IRS Pub 502, 2025). Items like saunas, cold plunges, and wearables carry higher scrutiny because they also serve general fitness.
2025 and 2026 HSA figures
Contribution limits and high-deductible health plan thresholds are adjusted annually. For 2026, the HSA contribution limit is $4,400 self-only and $8,750 family, the age-55 catch-up is $1,000, and HDHP minimum deductibles are $1,700 self-only and $3,400 family (Source: IRS Rev. Proc. 2025-19). The table below shows verified 2025 and 2026 figures.
| 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 (2025); the 2026 amounts come from IRS Rev. Proc. 2025-19 (Source: IRS Pub 969, 2025; IRS Rev. Proc. 2025-19). The catch-up figure is set by statute at $1,000 and is not inflation-indexed (Source: 26 U.S.C. 223(b)(3)). For a wider view of annual limits, see the 2026 retirement contribution limits.
Guidance issued under the One Big Beautiful Bill Act added flexibility: Notice 2026-05 (issued December 9, 2025) made pre-deductible telehealth coverage permanent for plan years beginning on or after January 1, 2025, treated bronze and catastrophic Exchange plans as HSA-compatible beginning January 1, 2026, and allowed eligible individuals in qualifying direct primary care arrangements to contribute to an HSA and pay periodic DPC fees tax-free beginning January 1, 2026 (Source: IRS Notice 2026-05).
Recordkeeping and the audit burden
The account holder must be able to prove each HSA distribution paid a qualified medical expense. The IRS does not vet withdrawals in advance; the account holder keeps receipts and documentation and reports distributions on Form 8889 (Source: IRS Pub 969, 2025; IRS Form 8889 instructions, 2025). Non-qualified amounts flow to income and, if applicable, the 20% additional tax.
Custodians report total distributions on Form 1099-SA but do not certify that they were qualified (Source: IRS Form 8889 instructions, 2025). The account holder reconciles qualified versus non-qualified amounts on Form 8889, and any non-qualified amount flows to income and, if applicable, the 20% additional tax on Schedule 2 (Source: IRS Form 8889 instructions, 2025).
Practical documentation generally includes the itemized receipt or explanation of benefits, the date the expense was incurred, and, for gray-area items, the provider statement supporting medical necessity. Keeping these for as long as the distribution could be examined supports both current-year withdrawals and the pay-now, reimburse-later approach (Source: IRS Pub 969, 2025).
Work with Q3 Advisors
Q3 Advisors is a registered investment adviser focused on retirement tax planning. This article is educational and is not advice; for guidance on your own circumstances, consult a qualified tax or financial professional.
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, and many medical supplies, listed in IRS Publication 502 (Source: IRS Pub 502, 2025).
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 taken for general wellness (Source: IRS Pub 502, 2025). Cosmetic procedures are ineligible unless medically necessary. Insurance premiums are generally excluded except for a few named categories (Source: IRS Pub 969, 2025).
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, 2025). It may become eligible when a licensed provider documents that the membership treats a specific diagnosed condition. The documentation and the 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, 2025). They may qualify when a licensed provider prescribes a specific supplement to treat a diagnosed condition and documents that purpose. Without that link to a diagnosis, they remain ineligible. Keep the documentation with your records.
Is toothpaste HSA eligible?
Toothpaste is not HSA-eligible because it is general personal hygiene rather than treatment of a disease (Source: IRS Pub 502, 2025). The same reasoning excludes mouthwash, deodorant, and shampoo. Dental treatment such as cleanings, fillings, and orthodontics is eligible, but daily hygiene products are not (Source: IRS Pub 502, 2025).
Can I use 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, 2025). Medicare Part A, B, and D premiums qualify; Medigap does not (Source: IRS Pub 502, 2025).
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, 2025).
Are over-the-counter medications HSA eligible?
Yes. Since the CARES Act of 2020, over-the-counter medicines are HSA-eligible without a prescription, and menstrual care products are treated as qualified medical care (Source: CARES Act of 2020; IRS newsroom). Keep the receipt as documentation in case the IRS examines the distribution. This provision has no listed expiration date.
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 (2025), Health Savings Accounts, irs.gov/publications/p969. IRS Publication 502 (2025), Medical and Dental Expenses, irs.gov/publications/p502. IRS Form 8889 instructions (2025), 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,” irs.gov/newsroom. CARES Act of 2020, Pub. L. 116-136 (OTC medicines and menstrual products).
