Your HSA covers medical expenses you pay out of pocket, not everything health-related

A Health Savings Account holds money you can withdraw tax-free to pay for may have access to medical expenses—the IRS's term for costs that count. The rule is narrow: the expense must be for diagnosis, treatment, or prevention of disease, and it must not be cosmetic. You can use HSA funds for doctor visits, prescriptions, dental work, vision care, and medical equipment. You cannot use them for gym memberships, vitamins, cosmetic procedures, or most over-the-counter items, even if they relate to your health.

The IRS publishes a list of what qualifies, and it changes occasionally. If you are unsure whether a specific expense counts, you can ask the IRS directly using Publication 502, or check with your HSA provider—they usually have a searchable database of approved expenses. Spending money on something that does not may have access to means you owe income tax on that withdrawal plus a 20 percent penalty, so it pays to check first.

Key Takeaways

  • may have access to medical expenses include doctor and dentist visits, prescription medications, medical equipment, and vision care—all paid with HSA funds tax-free.
  • Over-the-counter items like pain relievers, cold medicine, and allergy tablets do not count unless you have a prescription from a doctor.
  • Cosmetic procedures, gym memberships, and general wellness products are never covered, even if they improve your health.
  • You can use HSA money to pay deductibles, copays, and coinsurance on your health insurance plan.
  • Withdrawals for non-may have access to expenses trigger income tax plus a 20 percent penalty, so verify before you spend.

Medical visits, tests, and procedures you can pay for

Doctor office visits, urgent care, emergency room care, and hospital stays all count. So do lab tests, imaging (X-rays, MRIs, ultrasounds), and surgical procedures. Mental health visits—therapy, psychiatry, counseling—are covered. Physical therapy, occupational therapy, and speech therapy are covered. Vaccinations and preventive screenings are covered. You can use HSA funds to pay the full cost if you are uninsured, or to cover your deductible, copay, and coinsurance if you have insurance.

Fertility treatments, including in vitro fertilization (IVF) and related procedures, count as may have access to expenses. Abortion is also a may have access to expense. Childbirth and delivery are covered. Nursing care and home health aide services ordered by a doctor are covered. If a doctor prescribes a treatment or procedure, it almost certainly qualifies—the key is that it must be for diagnosis or treatment of a disease or condition, not general wellness.

Prescription and over-the-counter medications

Prescription medications are always covered. Over-the-counter medications—pain relievers, cold medicine, allergy tablets, antacids, laxatives—are covered only if you have a prescription from a doctor. A prescription does not mean the medication has to be filled at a pharmacy; a doctor's written order counts. Many people ask their doctor to write a prescription for an over-the-counter item specifically so they can pay for it with HSA funds.

Insulin is covered whether it is prescription or over-the-counter. Epinephrine auto-injectors (EpiPens) are covered. Nicotine replacement products—patches, gum, lozenges—are covered only with a prescription. Supplements and vitamins do not count, even if they treat a specific condition, unless a doctor prescribes them for a diagnosed deficiency. The distinction matters: if you buy a multivitamin on your own, it is not covered; if a doctor prescribes a specific vitamin for a documented deficiency, it is.

Dental and vision expenses

Dental cleanings, fillings, root canals, extractions, crowns, and bridges are all covered. Orthodontia (braces) is covered. Dental implants are covered. Dentures are covered. Teeth whitening is not covered because it is cosmetic. Gum disease treatment is covered. You can use HSA funds to pay your dentist directly or to reimburse yourself if you paid out of pocket.

Eye exams are covered. Prescription glasses and contact lenses are covered. Laser eye surgery (LASIK, PRK) is covered. Sunglasses are not covered, even if they have a prescription. Hearing aids are covered, and so are hearing aid batteries and repairs. Cochlear implants and related surgery are covered. If the expense corrects or treats a medical condition of the eye or ear, it counts.

Medical equipment and supplies

Crutches, wheelchairs, walkers, canes, and other mobility aids are covered. Diabetic supplies—test strips, lancets, glucose monitors—are covered. Blood pressure monitors, thermometers, and pulse oximeters are covered. Bandages, gauze, and wound care supplies are covered. Compression stockings are covered. Braces and supports for joints are covered. Heating pads and ice packs are covered if they are used to treat a diagnosed condition.

Prosthetics and artificial limbs are covered. Wigs required for medical reasons (such as hair loss from chemotherapy) are covered. Mattresses and pillows are not covered unless a doctor prescribes them specifically for a medical condition like sleep apnea. CPAP machines and supplies are covered. Oxygen equipment and supplies are covered. The rule is that the item must be primarily medical in purpose, not something that happens to have a health benefit.

Insurance costs and long-term care

You can use HSA funds to pay premiums for long-term care insurance. You can also use them to pay for actual long-term care services—nursing home care, assisted living, or in-home care—if the care is medically necessary. The rules for long-term care are strict: the person must be chronically ill or unable to perform at least two activities of daily living (bathing, dressing, eating, toileting, continence, or mobility). Custodial care that is not medically necessary does not count.

You cannot use HSA funds to pay premiums for health insurance while you are employed, with one exception: if you are receiving unemployment benefits, you can use HSA funds to pay for COBRA continuation coverage or other health insurance. You also cannot use HSA funds to pay Medicare premiums while you are still working, but once you are retired and enrolled in Medicare, you can use HSA funds to pay Medicare premiums (Part B, Part D, and supplemental insurance), and you can use them to pay for Medicare copays and deductibles.

What does not count, even if it seems health-related

Gym memberships and fitness classes do not count, even if your doctor recommends exercise. Sports equipment does not count. Nutritional supplements and vitamins do not count unless prescribed for a diagnosed deficiency. Weight loss programs do not count unless they are prescribed by a doctor for a specific medical condition like obesity-related diabetes. Cosmetic procedures—Botox, fillers, hair transplants, liposuction, breast augmentation—do not count even if they improve your appearance and confidence.

Maternity clothes, baby formula, diapers, and other pregnancy-related items do not count. Toiletries and personal hygiene products do not count. Sunscreen does not count. Cosmetics do not count. Over-the-counter pain relievers and cold medicine do not count without a prescription. Marijuana, even in states where it is legal, is not covered by HSA funds because it remains illegal under federal law. If you are uncertain, check with your HSA provider or the IRS before you spend.

How to document and reimburse yourself

You can withdraw HSA funds and use them to pay a provider directly, or you can pay out of pocket and reimburse yourself from your HSA later. There is no time limit on reimbursement—you can pay for an expense in 2024 and reimburse yourself in 2030 if you want. Keep receipts and documentation for every may have access to expense. If the IRS audits your HSA, you will need to show proof that the money went to a may have access to expense.

Your HSA provider will send you a debit card or checkbook, or you can request a check or transfer. Some providers let you upload receipts directly to their app. Keep your own records too—a spreadsheet or folder with receipts—because your provider's records may not be detailed enough if you need to prove the expense later. If you withdraw money for a non-may have access to expense, report it on your tax return and pay the income tax and 20 percent penalty.

Frequently Asked Questions

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

Yes, if your spouse is a dependent on your tax return. You can also use HSA funds to pay for any dependent's medical expenses, including children and parents you claim as dependents. The expense must still be may have access to—a dependent's gym membership does not count, but their doctor visit does.

What happens if I use HSA money for something that is not may have access to?

You owe income tax on that withdrawal at your ordinary tax rate, plus a 20 percent penalty. If you withdraw $100 for a non-may have access to expense and you are in the 22 percent tax bracket, you owe $22 in tax plus $20 in penalty, for a total of $42. Report the non-may have access to withdrawal on your tax return using Form 8889.

Can I use my HSA to pay for my pet's medical care?

No. Veterinary expenses are not covered by HSA funds because the IRS defines may have access to medical expenses as those for human diagnosis, treatment, or prevention of disease. Pet health care does not count, even if your pet is a service animal.

Do I need a prescription for over-the-counter pain relievers to use my HSA?

Yes. As of 2020, over-the-counter medications require a prescription to be covered by HSA funds. Ask your doctor to write a prescription for the specific over-the-counter item you need, and keep that prescription with your receipt.

Can I use my HSA to pay for a medical expense that happened before I opened the account?

No. You can only use HSA funds for may have access to expenses incurred after the account is open. If you paid for a doctor visit in January and opened your HSA in March, you cannot reimburse yourself for the January expense.