Retirement Plans for Doctors: The 2026 Physician Account Stack by Employment Type

By Craig Wear, CFP® | Last reviewed: October 14, 2026

Retirement plans for doctors depend on employment type first, because who signs the paycheck decides which accounts can be stacked.

The main retirement plans for doctors in 2026 are an employer 401(k) or 403(b) with a $24,500 deferral limit and a $72,000 total cap, a 457(b) with its own separate $24,500 limit at many hospitals, a solo 401(k) or cash balance plan for practice owners and 1099 income, plus a backdoor Roth IRA and an HSA.

What retirement plans can doctors use in 2026?

Doctors can use the same tax-advantaged accounts as other workers, but the combination available depends on whether they are employed by a nonprofit hospital, a public institution, a for-profit group, or their own practice. The table maps each setting to its core plan, common add-ons, and its main trap.

Most attendings also qualify for two personal accounts outside the employer plan: an IRA (the 2026 limit is $7,500, or $8,600 at 50 and older) funded through the backdoor route, and a health savings account if they carry a high-deductible health plan ($4,400 self-only or $8,750 family). Planning for physicians, such as the approach outlined on the Q3 Advisors physician planning page, typically starts by mapping every available account.

How do employed physicians stack a 403(b), 401(k), and 457(b)?

An employed physician can fill the 403(b) or 401(k) and the 457(b) independently, because the 457(b) limit is separate from the shared 401(k) and 403(b) deferral limit. Publication 571 states that 403(b) deferrals are combined with 401(k), other qualified plans, and SIMPLE IRAs, “other than 457 plans.” The combined figures at each age, including the special 457(b) catch-up, are worked out in 457(b) and 401(k) combined limits for 2026, and the plan-level differences between a hospital 403(b) and a corporate 401(k) are covered in 403(b) vs 401(k).

Two physician-specific details change the math. First, employer matches and nonelective contributions are calculated on no more than $360,000 of compensation in 2026, so a surgeon paid $600,000 with a 5% employer contribution receives at most $18,000, not $30,000. Second, catch-up contributions may have to be Roth.

Under section 414(v)(7), a participant whose prior-year wages “from the employer sponsoring the plan” exceed the threshold must designate catch-ups as Roth (26 U.S.C. 414). Notice 2025-67 sets that threshold at $150,000 of 2025 FICA wages for 2026 catch-ups. Most attendings over 50 paid on a W-2 are likely above it, so the catch-up dollars go in after tax even when the base deferral is pre-tax.

Is a non-governmental 457(b) at a hospital worth the risk?

A non-governmental 457(b) can add $24,500 of pre-tax deferral, but it is an unfunded promise, not a trust account, and that trade-off is the central question. The IRS describes these plans as limited to “a select group of management or highly compensated employees,” with assets that stay on the employer’s books (IRS non-governmental 457(b) guidance). A governmental 457(b) at a public hospital works very differently, as the IRS comparison shows.

Source: IRS comparison of tax-exempt and governmental 457(b) plans. Because a non-governmental plan cannot be rolled over, a physician who leaves the hospital typically receives the balance on the schedule elected in advance, sometimes as a lump sum in a single high-income year.

Physicians weighing these plans often look at the health system’s financial strength, the payout options in the plan document, and how likely they are to change employers.

What can practice owners and 1099 physicians add?

Self-employed and practice-owning physicians can add a solo 401(k) or a practice 401(k) with profit sharing, and above that a cash balance plan, which is how owner contributions can climb well past $72,000. The deferral and profit-sharing mechanics are detailed in solo 401(k) contribution limits for 2026, and the actuarial side is explained in how a cash balance plan works.

The rule that trips up physicians with both a W-2 and a side practice is how the two limits interact. The $24,500 elective deferral limit is per person across all 401(k) and 403(b) plans, so moonlighting rarely adds deferral room. The 415(c) total normally applies separately for unrelated employers, but Publication 571 requires a 403(b) participant to combine the 403(b) with plans of “all corporations, partnerships, and sole proprietorships in which you have more than 50% control” (Publication 571, Rev. January 2026).

In practice, a hospital physician with a 403(b) and a wholly owned moonlighting business has one $72,000 ceiling across both, while a physician with a for-profit group 401(k) and the same side business generally has two. For a sole proprietor, the employer contribution works out to 20% of net self-employment earnings after the deduction for half of self-employment tax (IRS Publication 560 rate table).

Cash balance plans are usually the largest lever for owners in their late 40s and 50s, because the funding needed for a benefit of up to $290,000 a year rises with age. They also require staff coverage and multi-year funding, so they tend to fit practices with stable cash flow.

What trips physicians up with the backdoor Roth?

The most common physician mistake is a pre-tax IRA balance on December 31, which makes most of the backdoor conversion taxable under the pro-rata rule. Form 8606 measures the value of all traditional, SEP, and SIMPLE IRAs at year end, not on the conversion date (Form 8606 instructions). The full mechanics are in how a backdoor Roth conversion works.

Two physician patterns cause most of the problems. A doctor who opened a SEP IRA for locums income has created a pre-tax IRA balance that counts in the formula, as explained in whether SEP and SIMPLE IRAs count for the pro-rata rule. And a doctor who rolled a residency 403(b) into an IRA has done the same thing; many physicians instead consider rolling pre-tax IRA money into a current employer plan or solo 401(k) that accepts it.

Some hospital and group 401(k) plans also permit after-tax contributions with in-plan conversion, which can add Roth dollars above the deferral limit up to the $72,000 total. That route, and how it differs from the IRA version, is covered in the mega backdoor Roth for high earners.

When do Roth contributions make sense for a high-earning physician?

For most attendings in the 32% to 37% brackets, pre-tax contributions remove income at a high rate today, while Roth dollars tend to make more sense in years when income is temporarily low. The 2026 brackets put the 35% rate at $256,225 for single filers and $512,450 for joint filers, and the 37% rate at $640,600 and $768,700 (IRS 2026 inflation adjustments).

The answer flips in low-income years that are common in medicine: residency and fellowship, a gap between training and the first attending job, a sabbatical, part-time years, and the stretch between retiring and claiming Social Security or starting required minimum distributions at 73 or 75. A resident at the AAMC median stipend of $65,100 has about $49,000 of taxable income after the $16,100 standard deduction, which sits in the 12% bracket.

Those windows are also where Roth conversions of earlier pre-tax savings are usually modeled, since large pre-tax balances drive larger required distributions later. High-earner trade-offs are covered in Roth conversion strategies for high income earners.

A worked 2026 example: one hospitalist with moonlighting income

Hypothetical illustration: a 45-year-old hospitalist at a nonprofit hospital earns $400,000 in W-2 pay, files jointly with a non-earning spouse, and nets $60,000 from locums work billed as a sole proprietor. The hospital offers a 403(b) with a 5% nonelective contribution and a non-governmental 457(b), and the family has HDHP coverage. Hospital nurses weighing a 403(b) and a 457(b) can see retirement planning for nurses.

Three details are easy to miss. Self-employment tax on the locums income is only the 2.9% Medicare portion (about $1,607), because $400,000 of W-2 wages already exceeds the $184,500 Social Security wage base. The solo 401(k) adds no employee deferral, since the 403(b) used the full $24,500. And because the hospitalist controls the side business, the 403(b) additions ($42,500) and the solo 401(k) ($11,839) share one $72,000 limit, leaving room to spare at $54,339.

Before these contributions, taxable income after the $32,200 standard deduction would be about $426,997, partly in the 32% bracket. After the pre-tax deferrals, profit sharing, and HSA, it falls to about $357,408, inside the 24% bracket that tops out at $403,550 for joint filers. State tax, itemized deductions, and the 0.9% Additional Medicare Tax are ignored for simplicity.

How can a doctor who started saving late catch up?

A doctor who began saving in their mid-30s can use age-based catch-ups, the 457(b) special catch-up, and, for owners, a cash balance plan to compress savings into fewer years. From age 50 the 401(k), 403(b), and governmental 457(b) catch-up is $8,000, rising to $11,250 in the years a participant turns 60 to 63; the age details are in catch-up contributions for 2026.

The 457(b) special catch-up lets a participant in the three years before the plan’s normal retirement age contribute up to another full deferral limit, but only for unused deferrals from earlier years. It is the only catch-up a non-governmental 457(b) permits.

The 403(b) 15-year catch-up looks tailor-made, since hospitals are a qualifying organization, but it requires 15 years of service with the same employer and is reduced by deferrals above $5,000 a year on average. Physicians who deferred heavily from the start usually find it unavailable.

How protected are physician retirement accounts from malpractice judgments?

Employer plans covered by ERISA generally offer the strongest protection, IRAs are protected in bankruptcy up to a cap, and a non-governmental 457(b) offers little protection from the employer’s own creditors. ERISA requires qualified plans to bar assignment of benefits, and in Patterson v. Shumate (1992) the Supreme Court held that ERISA-qualified plan interests are excluded from a bankruptcy estate.

For IRAs, 11 U.S.C. 522(n) caps the bankruptcy exemption, adjusted to $1,711,975 for cases filed on or after April 1, 2025, and amounts rolled over from employer plans do not count toward the cap (Judicial Conference adjustment, 90 FR). Outside bankruptcy, whether a judgment creditor can reach an IRA depends on state law, and states differ widely.

A solo 401(k) that covers only an owner and spouse is generally outside ERISA Title I, so its protection outside bankruptcy can also rest on state law. Malpractice insurance remains the first line of defense, and an asset-protection attorney can review state-specific rules.

Frequently asked questions

This article is for educational purposes only and is not individualized investment, tax, or legal advice. Consult a qualified professional about your specific situation.