What an HSA covers: the IRS list and what it means in practice

Your HSA can pay for any medical expense the IRS considers may have access to. That means doctor visits, prescriptions, dental work, vision care, mental health treatment, and medical equipment like crutches or blood pressure monitors. It also covers some things that feel less medical: copays and coinsurance on your health plan, deductibles, and premiums for certain types of insurance. The IRS publishes a full list, but the basic rule is simple—if it treats, diagnoses, or prevents a medical condition, it probably qualifies.

What does not may have access to is anything that improves general health or wellness without treating a specific condition. Vitamins and supplements are out unless a doctor prescribes them for a diagnosed deficiency. Gym memberships don't count, even if your doctor recommends exercise. Cosmetic procedures—including teeth whitening or Botox—are not covered, though reconstructive surgery after an injury or illness is. Sunscreen is not covered as a preventive, but it is if a dermatologist prescribes it for a skin condition.

The line between may have access to and not may have access to is sometimes blurry, and your HSA administrator may reject a purchase you thought was allowed. If that happens, you can appeal or ask your doctor to write a letter explaining the medical necessity. Keep receipts for everything—the IRS can audit HSA spending years later, and you need proof that each purchase was actually may have access to.

Key Takeaways

  • HSA funds cover doctor visits, prescriptions, dental, vision, mental health care, and medical equipment—anything the IRS classifies as treating or preventing a medical condition.
  • Copays, coinsurance, deductibles, and some insurance premiums count as may have access to expenses and can be paid from your HSA.
  • Wellness items like vitamins, gym memberships, and cosmetic procedures do not may have access to unless a doctor prescribes them for a diagnosed medical condition.
  • Your HSA administrator may reject a purchase; keep all receipts and ask your doctor for documentation if you need to appeal.
  • Spending HSA money on non-may have access to expenses triggers income tax plus a 20 percent penalty, so verify before you pay.

Medical services and supplies you can pay for

Doctor visits, lab work, X-rays, and imaging (CT scans, MRIs, ultrasounds) all may have access to. So do prescriptions filled at a pharmacy, insulin, inhalers, and other medications. If you need physical therapy, occupational therapy, or chiropractic care, those are covered. Mental health counseling and psychiatric medication are covered. Dental cleanings, fillings, root canals, and orthodontia (braces) may have access to. Eye exams, glasses, contact lenses, and laser eye surgery (LASIK) are all covered.

Medical equipment and supplies include crutches, wheelchairs, hearing aids, blood pressure monitors, glucose meters, and test strips. Bandages, gauze, and first-aid supplies count. If you need a hospital bed, oxygen equipment, or a CPAP machine for sleep apnea, those are covered. Pregnancy tests and contraceptives are covered. Acupuncture is covered if performed by a licensed practitioner. Fertility treatments, including IVF, are covered expenses.

Some services that feel routine still may have access to: annual physicals, vaccinations, and preventive screenings (mammograms, colonoscopies, blood pressure checks). Nursing care and home health aide services are covered if medically necessary. If you are hospitalized, your HSA can cover the hospital bill, surgery, and anesthesia.

Insurance premiums and cost-sharing you can pay from your HSA

You can use HSA funds to pay the deductible on your health plan—the amount you have to pay out of pocket before insurance kicks in. You can also pay copays (the flat fee you pay at a doctor visit) and coinsurance (your percentage of the cost after insurance pays its share). These are among the most common HSA uses because they come up every time you see a doctor.

You can pay premiums for certain types of insurance: health insurance if you are unemployed and receiving unemployment benefits, Medicare premiums (Part A, Part B, Part D, and Medigap), and long-term care insurance premiums. You cannot use HSA funds to pay premiums for your employer's health plan while you are still employed, but you can pay them if you are retired and on Medicare.

COBRA premiums (the temporary health coverage you can keep after leaving a job) can be paid from your HSA. So can premiums for health coverage through the marketplace if you are self-employed or between jobs. The key distinction: you can pay premiums only when you are not actively covered by an employer plan, with the exception of Medicare and long-term care.

What does not may have access to and why the penalty matters

Vitamins and supplements do not may have access to unless a doctor prescribes them for a specific deficiency and documents that diagnosis in writing. Over-the-counter pain relievers, cold medicine, and allergy medication do not may have access to—even though you can buy them without a prescription, the IRS does not consider them medical treatment. Toothpaste, mouthwash, and floss do not may have access to, but dental work (fillings, cleanings, extractions) does. Shampoo and conditioner do not may have access to, even medicated ones, unless a dermatologist prescribes them for a diagnosed scalp condition.

Gym memberships, yoga classes, and fitness equipment do not may have access to, even if your doctor recommends exercise. Weight loss programs and diet plans do not may have access to unless they are prescribed by a doctor for a diagnosed condition like obesity or diabetes, and even then the documentation has to be very specific. Cosmetic procedures—teeth whitening, hair removal, anti-wrinkle treatments—do not may have access to. Maternity clothes, baby formula, and diapers do not may have access to (though pregnancy-related medical care does).

If you spend HSA money on something that does not may have access to, you owe income tax on that amount plus a 20 percent penalty. That penalty is in addition to the tax, not instead of it. So if you withdraw $500 for a non-may have access to expense and you are in the 22 percent tax bracket, you owe $110 in tax plus $100 in penalty—$210 total. The IRS does not forgive this penalty easily, so it is worth double-checking before you spend.

How to pay for may have access to expenses: direct payment, reimbursement, and HSA debit cards

Most HSA administrators give you a debit card linked to your account. You can use it at pharmacies, doctor offices, and hospitals just like a regular debit card. The transaction is deducted from your HSA balance. This is the fastest method, but keep your receipt—the IRS wants proof that the expense was actually may have access to, and your HSA administrator may ask for documentation later.

You can also pay out of pocket and then reimburse yourself from your HSA. Write a check from your HSA account or transfer money electronically to your personal bank account, then use that money to pay the medical provider. This method works well if you want to let your HSA grow and invest the money—you can pay medical expenses now and reimburse yourself years later, as long as you keep the original receipts. There is no time limit on reimbursement, but you must have documentation that the expense was incurred.

Some providers (large hospitals, pharmacy chains, insurance companies) let you pay directly from your HSA through their billing system. You provide your HSA account number, and they bill your HSA account directly. This is common for large bills like surgery or ongoing prescriptions. Ask your provider whether they accept HSA payments before you go in.

Keeping records and what happens if the IRS audits your HSA

Save every receipt, explanation of benefits (EOB), and invoice for every HSA purchase. The IRS can audit your HSA spending up to three years after you file your tax return, and in some cases longer. If you cannot produce a receipt showing that an expense was may have access to, the IRS will treat it as a non-may have access to withdrawal, which means you owe income tax plus the 20 percent penalty on that amount.

Your HSA administrator may also ask for documentation when you make a purchase. If you use the debit card and the transaction looks unusual (a large amount, a vendor that does not obviously sell medical items), they may request a receipt before processing it. If you do not provide one, they may freeze your account or deny the transaction. This is their way of protecting themselves from IRS scrutiny.

Keep a simple spreadsheet or folder with the date, amount, provider name, and what the expense was for. If you are reimbursing yourself from your HSA years after the original expense, you will need to show that the expense was incurred in the year you are claiming it. A receipt dated 2022 proves the expense happened in 2022, even if you reimburse yourself in 2025.

Frequently Asked Questions

Can I use my HSA to pay for my spouse's or child's medical expenses?

Yes. Your HSA can pay for may have access to medical expenses for you, your spouse, and any dependent you claim on your tax return—even if they are not covered by your health plan. You do not need to be on the same insurance. Keep receipts showing who the expense was for, in case the IRS asks.

What if my doctor prescribes something but my insurance does not cover it?

Your HSA can still pay for it, as long as it is a may have access to medical expense. The fact that your insurance denied it does not change whether your HSA can cover it. You will pay the full cost out of pocket or from your HSA, not just your copay or coinsurance. Get a receipt and keep it.

Can I use my HSA to pay for therapy or counseling?

Yes. Mental health counseling, therapy, and psychiatric care are covered. You can pay for sessions with a therapist, psychologist, or psychiatrist. Medication prescribed by a psychiatrist is also covered. Keep receipts showing the provider's name and the date of service.

Are over-the-counter medications like ibuprofen or allergy pills covered?

No. Over-the-counter medications do not may have access to, even though you can buy them without a prescription. The only exception is if a doctor prescribes them specifically for you and documents the medical reason. In that case, you need a written prescription (not just a recommendation) to use your HSA.

What happens if I use my HSA for something that turns out not to be may have access to?

You owe income tax on that amount plus a 20 percent penalty. If you catch the mistake, some HSA administrators let you correct it by returning the money within a certain window, but this varies. It is better to ask before you spend than to deal with the penalty later.