The IRS decides what counts, and the list is narrower than you think

You can use your HSA to pay for medical care that a doctor prescribes or that you need to treat a diagnosed condition. The IRS publishes a list of may have access to medical expenses, and if an expense is not on it, you cannot use HSA money without paying income tax plus a 20% penalty on that withdrawal. The list includes doctor visits, prescription drugs, dental work, vision care, mental health treatment, and medical equipment like wheelchairs or hearing aids. It does not include gym memberships, vitamins, cosmetic procedures, or over-the-counter medications unless a doctor writes a prescription for them.

The key word is prescribed or medically necessary. If you buy something at a pharmacy or medical supply store without a doctor's order, you need to know whether the IRS considers it a may have access to expense before you swipe your HSA card. Many people assume they can buy anything health-related; they cannot. The penalty for guessing wrong is steep enough that it is worth checking first.

Key Takeaways

  • Doctor visits, prescription medications, dental care, vision care, and mental health treatment are all may have access to HSA expenses with no income tax or penalty.
  • Over-the-counter medications like cold medicine or pain relievers are not may have access to unless a doctor writes a prescription for them specifically.
  • Gym memberships, weight loss programs, cosmetic procedures, and general wellness products are never may have access to, even if they improve your health.
  • You can use your HSA to pay for medical equipment, supplies, and devices your doctor says you need, including wheelchairs, hearing aids, and diabetic testing supplies.
  • If you withdraw money for a non-may have access to expense, you owe income tax on that amount plus a 20% penalty, so verify before you spend.

Doctor visits, prescriptions, and mental health care

Any visit to a doctor, specialist, or mental health provider is a may have access to expense. This includes the copay, the full cost if you are uninsured, and the out-of-pocket amount after insurance pays its share. Prescription medications are may have access to. Over-the-counter medications are not may have access to unless a doctor writes a prescription for them—meaning you take the prescription to the pharmacy, not that you buy them on your own and claim they were prescribed.

Mental health treatment, including therapy and psychiatric care, is may have access to. Substance abuse treatment is also may have access to. If you see a therapist, psychiatrist, or counselor and pay out of pocket, you can use your HSA. If your insurance covers part of it and you pay a copay or coinsurance, that out-of-pocket amount is may have access to.

Dental and vision expenses

Dental work is a may have access to expense: cleanings, fillings, root canals, extractions, crowns, and orthodontia all count. You can use your HSA to pay a dentist directly or to cover the out-of-pocket cost after dental insurance pays. Dental insurance premiums themselves are not may have access to, but the care they do not fully cover is.

Vision care is also may have access to. Eye exams, glasses, contact lenses, and contact lens solution are all may have access to expenses. Laser eye surgery (LASIK) is may have access to. If you have vision insurance, you can use your HSA for the copay or the portion your insurance does not cover.

Medical equipment, supplies, and devices

If a doctor says you need medical equipment or supplies to treat a condition, it is usually may have access to. This includes wheelchairs, crutches, hearing aids, glucose monitors, insulin pumps, continuous positive airway pressure (CPAP) machines, and diabetic testing supplies. Bandages, braces, and compression stockings are may have access to. Canes, walkers, and grab bars are may have access to.

The rule is that the item must be primarily medical—used to treat or manage a diagnosed condition—and not something that would be useful even if you were healthy. A blood pressure monitor is may have access to because it treats hypertension. A general fitness tracker is not may have access to, even if you use it to monitor your heart rate, because it is not primarily a medical device.

What is not may have access to, even though people often think it is

Gym memberships and fitness classes are never may have access to, even if your doctor recommends exercise. Weight loss programs are not may have access to. Cosmetic procedures are not may have access to, even if they make you feel better. Vitamins and supplements are not may have access to unless a doctor prescribes them for a specific deficiency. Sunscreen is not may have access to. Toothpaste and mouthwash are not may have access to.

Over-the-counter pain relievers, cold medicine, allergy medicine, and antacids are not may have access to unless you have a prescription. Many people buy these at the pharmacy and assume they can use their HSA; they cannot. If you want to use HSA money for an over-the-counter medication, ask your doctor to write a prescription for it, then fill that prescription at the pharmacy.

Long-term care insurance premiums are not may have access to. Life insurance is not may have access to. Health insurance premiums are generally not may have access to, with narrow exceptions for COBRA continuation coverage and Medicare premiums if you are retired.

How to know before you spend

The IRS maintains a list of may have access to medical expenses in Publication 502. Your HSA provider (the bank or financial company that holds your account) usually has a searchable database on their website where you can look up whether a specific item or service is may have access to. If you are unsure, email your provider or call them before you make the purchase.

Keep receipts for everything you buy with your HSA, even if you pay the expense out of pocket and reimburse yourself later. The IRS can audit your HSA, and you need documentation to prove that the expense was may have access to. Write down what the expense was for—not just "pharmacy" but "prescription antibiotics" or "diabetic test strips."

What happens if you use HSA money for a non-may have access to expense

If you withdraw money from your HSA and use it for something that is not a may have access to medical expense, you owe income tax on that amount at your regular tax rate, plus a 20% penalty. If you withdraw $500 for a non-may have access to expense and you are in the 22% tax bracket, you owe $110 in income tax plus $100 in penalty—a total of $210 on top of the $500 you already spent.

You report non-may have access to withdrawals on your tax return. Your HSA provider sends you a Form 1099-SA at the end of the year showing all your withdrawals. If some of those withdrawals were non-may have access to, you have to report them and calculate the tax and penalty yourself. There is no way to hide it or correct it after the fact without paying.

Frequently Asked Questions

Can I use my HSA to buy over-the-counter pain relievers or cold medicine?

Not without a prescription. Ibuprofen, acetaminophen, cold medicine, and allergy medicine are not may have access to expenses unless a doctor writes a prescription for them. If you want to use HSA money for these, ask your doctor to prescribe them, then fill that prescription at the pharmacy.

Is a gym membership or fitness class a may have access to HSA expense?

No, never. Even if your doctor recommends exercise or you use the gym to manage a health condition, the IRS does not consider gym memberships or fitness classes may have access to medical expenses. Weight loss programs are also not may have access to.

Can I use my HSA for dental work or vision care?

Yes. Dental care (cleanings, fillings, crowns, braces) and vision care (eye exams, glasses, contacts, LASIK) are all may have access to expenses. You can use your HSA to pay the dentist or eye doctor directly, or to cover the out-of-pocket cost after insurance pays.

What if I buy something with my HSA and later find out it was not may have access to?

You owe income tax plus a 20% penalty on that withdrawal. If you spent $300 on a non-may have access to expense and are in the 24% tax bracket, you owe $72 in tax plus $60 in penalty. Report it on your tax return when you file.

Can I use my HSA to pay for vitamins or supplements?

Only if a doctor prescribes them for a specific medical condition or deficiency. General vitamins and supplements you buy on your own are not may have access to. If your doctor diagnoses a vitamin D deficiency and prescribes a supplement, that prescription is may have access to.