The IRS decides what counts, and the list is narrower than you think
A health savings account lets you spend money on medical expenses without paying federal income tax on that money. But not every health-related purchase qualifies. The IRS publishes a specific list of what you can buy, and it includes some things you might expect and excludes others that sound medical but aren't covered.
The core rule: you can pay for diagnosis, treatment, or prevention of a disease or condition. That covers doctor visits, prescriptions, dental work, and vision care. It does not cover cosmetic procedures, general wellness products, or most over-the-counter items—though some over-the-counter drugs and medical supplies do may have access to if you have a prescription or meet specific conditions.
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. The IRS does not forgive this retroactively, so knowing the rules before you spend matters.
Key Takeaways
- Doctor visits, prescription medications, dental work, and vision care are always covered by HSA funds.
- Most over-the-counter medicines and medical supplies require a prescription to be HSA-may be able to access, even if you can buy them without one at a pharmacy.
- Cosmetic procedures, gym memberships, and general wellness products are never covered, even if they improve your health.
- You can use HSA funds to pay insurance premiums in specific situations: COBRA, Medicare, or long-term care insurance, but not regular health insurance premiums while employed.
- Keeping receipts and documentation is essential because the IRS can audit HSA spending years after the purchase.
Medical services and provider visits that HSA covers
Any visit to a doctor, dentist, optometrist, or other licensed healthcare provider for diagnosis or treatment is covered. This includes office visits, urgent care, emergency room visits, and hospital stays. You pay with your HSA debit card or reimburse yourself from the account after you pay out of pocket.
Mental health and addiction treatment also may have access to. Therapy sessions, psychiatric visits, and inpatient or outpatient rehab programs are all covered expenses. You can use HSA funds to pay a therapist directly or to cover your portion of the cost after insurance.
Preventive care is covered too: annual physicals, vaccinations, cancer screenings, and cholesterol tests. Some preventive services are free under your health plan, but if you pay anything out of pocket, HSA funds can cover it.
Prescription and over-the-counter medications
Any prescription medication your doctor writes is covered. This includes birth control, psychiatric medications, antibiotics, and chronic disease management drugs. You can use your HSA debit card at the pharmacy or pay cash and reimburse yourself later.
Over-the-counter medications are trickier. Aspirin, cold medicine, allergy pills, and antacids are not HSA-may be able to access unless you have a prescription from a doctor. A prescription for ibuprofen, for example, makes it may be able to access; buying the same dose over the counter does not. Some employers or HSA administrators allow you to self-certify that a purchase is for a may have access to expense, but the safest route is to get a prescription if you plan to use HSA funds.
Insulin is the one major exception: you can buy insulin over the counter with HSA funds without a prescription, even though it is sold without one in most states.
Dental, vision, and hearing care
Dental work is fully covered: cleanings, fillings, root canals, crowns, extractions, and orthodontia. You can use HSA funds to pay a dentist directly or to cover your deductible and coinsurance after insurance pays its share. Cosmetic dental work—like teeth whitening or veneers for appearance only—is not covered, but the same procedure done for medical reasons (like a crown to restore a broken tooth) is.
Vision care includes eye exams, glasses, contact lenses, and lens solution. Laser eye surgery (LASIK) is covered. Sunglasses are not, even if you have a prescription for them, because they are not primarily corrective.
Hearing aids and related services are covered. Hearing tests, fitting, repairs, and batteries all may have access to. Cochlear implants and other hearing devices are covered too.
Medical equipment and supplies you can buy
Crutches, wheelchairs, walkers, and other mobility aids are covered. Blood pressure monitors, glucose meters, and test strips are covered. Bandages, braces, compression socks, and heating pads are covered. The rule is simple: if it is a medical device or supply used to treat or manage a condition, it qualifies.
Some items require a prescription to be HSA-may be able to access even though you can buy them without one. Elastic bandages, knee braces, and back braces fall into this category at some HSA administrators. Check with your plan before you buy, or get a prescription from your doctor to be safe.
Fertility-related supplies and treatments are covered: ovulation kits, fertility drugs, and in vitro fertilization (IVF) procedures. Contraception is covered. Pregnancy tests and prenatal vitamins are covered.
Insurance premiums and long-term care you can pay with HSA
You cannot use HSA funds to pay your regular health insurance premium while you are employed—that defeats the tax advantage. But you can use HSA funds to pay premiums in three specific situations: COBRA continuation coverage after you leave a job, Medicare premiums (Part A, Part B, Part D, or supplemental coverage), and long-term care insurance premiums.
If you are unemployed, you can use HSA funds to pay your health insurance premium while you are receiving unemployment benefits. Once you are employed again, you cannot use HSA funds for that premium anymore.
What is not covered, even if it sounds medical
Cosmetic procedures are never covered, even if they improve your appearance and confidence. Botox, facelifts, hair transplants, and teeth whitening for cosmetic reasons do not may have access to. The exception: if a procedure is medically necessary (like reconstructive surgery after an accident), it is covered.
Gym memberships, fitness classes, and general wellness programs are not covered, even if your doctor recommends exercise. Weight loss programs are not covered unless they treat a specific disease like obesity-related diabetes, and even then, only the medical treatment portion qualifies, not the general program fee.
Vitamins and supplements are not covered unless they treat a specific deficiency and you have a prescription. A multivitamin you take for general health does not may have access to. Herbal remedies, essential oils, and alternative medicine treatments are generally not covered unless they are prescribed by a licensed provider for a specific condition.
Cosmetic dental work, like veneers or whitening, is not covered. Orthodontia for cosmetic reasons only is not covered, though orthodontia to correct a bite problem or other medical issue is. Ask your orthodontist whether the treatment is medically necessary or cosmetic; they can help you get a prescription if it qualifies.
How to document and keep records of HSA purchases
Keep every receipt for every HSA purchase. The IRS can audit HSA spending up to seven years after you make a withdrawal. If you cannot produce a receipt showing the expense was medical, you owe income tax plus the 20 percent penalty on that amount, even if you genuinely spent the money on a may have access to expense.
If you use your HSA debit card, the transaction shows up on your statement, but the statement alone is not enough proof. You need the receipt showing what you bought. If you pay out of pocket and reimburse yourself from the HSA later, keep both the receipt and documentation of the reimbursement.
Some HSA administrators offer online portals where you can upload receipts and track expenses. Use this if your plan offers it. For expenses that are borderline or unusual, write a note on the receipt explaining why it qualifies (for example, "prescription for ibuprofen" or "LASIK surgery for vision correction").
Frequently Asked Questions
Can I use HSA money to pay for my spouse's medical expenses?
Yes, as long as your spouse is a dependent on your tax return. You can use HSA funds to pay for your spouse's doctor visits, prescriptions, dental work, and other may have access to medical expenses. If your spouse is not a dependent, you cannot use your HSA to pay their expenses.
Is a prescription required for all over-the-counter items?
Not all. Insulin does not require a prescription. Most other over-the-counter medications and medical supplies do require one to be HSA-may be able to access. Some HSA administrators are more flexible and allow self-certification, but getting a prescription is the safest approach if you plan to use HSA funds.
Can I use HSA funds for my Medicare premiums?
Yes. Medicare Part A, Part B, Part D, and supplemental insurance premiums are all HSA-may be able to access. This is one of the few insurance premiums you can pay with HSA funds. You cannot use HSA funds for regular health insurance premiums while you are employed.
What happens if I spend HSA money on something that does not may have access to?
You owe federal income tax on that amount plus a 20 percent penalty. The IRS does not forgive this retroactively. If you are unsure whether an expense qualifies, check with your HSA administrator or get a prescription from your doctor before you spend the money.
Do I need to report HSA purchases to the IRS?
You do not report individual purchases on your tax return. But the IRS can audit your HSA spending, and you must be able to prove that withdrawals were for may have access to expenses. Keep receipts for at least seven years in case of an audit.