Can You Buy a Mattress With HSA? Rules, Letter, and Excess Cost

Buying a mattress with an HSA is allowed, but only under specific conditions: a licensed medical provider must prescribe it to treat or prevent a diagnosed condition, and only the portion of the price that exceeds what a comparable regular mattress would cost counts as a qualified medical expense. A mattress bought for comfort, better sleep in general, or wellness does not qualify, no matter the price tag.

When a Mattress Counts as a Medical Expense

The IRS defines medical expenses as costs paid for the diagnosis, cure, treatment, or prevention of disease, or for affecting any structure or function of the body.¹ Anything “merely beneficial to general health” is excluded.² A mattress falls on the qualifying side of that line only when it’s a direct response to a diagnosed physical or mental condition.

Conditions that may support a medically necessary mattress include chronic back pain, degenerative disc disease, scoliosis, severe allergies to dust mites or mold in standard bedding, sleep apnea (where an adjustable bed elevates the upper body), and gastroesophageal reflux disease. The practical test: would you have bought this particular mattress if you didn’t have the condition? If the answer is no, and your doctor agrees in writing, you have a case.

Only the Excess Over a Regular Mattress Qualifies

This is the rule most people miss. When you buy a personal-use item in a special form to accommodate a medical condition, only the difference between the special version and a regular version is a medical expense.³ The IRS treats mattresses the way it treats Braille books: you can count only the amount that exceeds the cost of the standard edition.

So if your doctor prescribes a specialized pressure-relieving mattress that costs $2,500 and a comparable standard mattress would run $800, the qualified expense is $1,700, not $2,500. The full price qualifies only when the mattress has no general-use equivalent, such as a hospital-grade therapeutic surface no healthy person would buy. Save documentation of comparable standard mattress prices at the time of purchase so you can support the amount you claim.

Get a Letter of Medical Necessity First

Before you spend HSA funds, get a Letter of Medical Necessity (LMN) from a licensed provider. Without it, your HSA administrator will likely deny the expense, and the IRS can treat the withdrawal as non-qualified. The letter should include:

The specific diagnosis requiring a specialized mattress
How the mattress treats the condition (for example, pressure redistribution for chronic lumbar pain, or elevation capability for reflux)
The features your condition requires, such as adjustable positioning, memory foam density, or hypoallergenic materials
How long the mattress is expected to be medically necessary
The provider’s name, credentials, and signature

Your primary care doctor, orthopedic specialist, sleep medicine physician, or another licensed practitioner treating the condition can write it. Contact your HSA administrator before you buy. Many have their own pre-approval forms that mirror these requirements, and submitting them in advance reduces the risk of a denial after the money is already spent.

How to Pay With Your HSA

Once documentation is in order, you have two options. The simplest is to use your HSA debit card at the retailer; the purchase records as a distribution and creates an electronic trail. If the retailer doesn’t accept the card, pay out of pocket and submit a reimbursement request through your administrator’s portal.⁴

For reimbursement, you’ll typically upload an itemized receipt showing the purchase date, vendor, and amount. There’s no IRS deadline for reimbursing yourself. You can pay out of pocket now and reimburse from your HSA months or years later, as long as the expense was incurred after the HSA was established.

Sales Tax and Delivery Fees

Sales tax on the mattress is generally treated as part of the eligible expense, since it’s inseparable from the purchase price. Publication 502 includes medical equipment and supplies as qualified expenses and allows transportation costs essential to medical care, but it doesn’t specifically address delivery fees for medical equipment.³ If delivery is the only way to obtain the prescribed mattress, the fee may be defensible, but this is a gray area. Ask your HSA administrator how they handle it before assuming it’s covered.

Reporting the Distribution and the Cost of Getting It Wrong

Every HSA distribution goes on IRS Form 8889, filed with your annual return. The form tracks total withdrawals and identifies which were used for qualified medical expenses. You must file Form 8889 if you took any HSA distributions during the year, even if you otherwise wouldn’t need to file.⁵

If a mattress distribution isn’t properly supported, the IRS can reclassify it as non-qualified. The withdrawn amount then gets added to your gross income and hit with an additional 20% tax.⁵ On a $2,000 mattress, that’s roughly $400 in penalties on top of your regular income tax, a cost that proper documentation entirely prevents.

The 20% penalty stops applying once you turn 65 or become disabled, though you’d still owe regular income tax on any distribution not used for a qualified medical expense.⁴

If You Return the Mattress

Return the mattress and get a refund, and that money needs to go back into your HSA. The IRS treats it as a mistaken distribution: you withdrew funds for a medical expense that ultimately didn’t occur. Repay it to your HSA no later than the tax filing deadline (typically April 15) following the first year you learned the expense was invalid.⁶

Repay within that window and the distribution stays out of your gross income and avoids the 20% penalty. Your HSA trustee isn’t required to accept the returned funds, though, so contact your administrator quickly to confirm they allow mistaken distribution repayments and to understand their process. Miss the deadline or get turned down by the trustee, and you’ll owe income tax on the refunded amount plus the 20% additional tax.

Spouse and Dependents

Your HSA can pay for qualified medical expenses of your spouse, any dependent you claim on your tax return, and certain people you could have claimed as dependents.⁴ The same rules apply: you need a Letter of Medical Necessity in that person’s name, and only the excess over a regular mattress qualifies. For children of divorced or separated parents, the IRS treats the child as a dependent of both parents for medical expense purposes, so either parent with an HSA can cover a medically necessary mattress for the child.¹

Records to Keep and for How Long

Hold on to the Letter of Medical Necessity, the itemized receipt, your evidence of comparable standard mattress pricing, and any correspondence with your HSA administrator for at least three years after filing the return that reports the distribution. Three years is the standard IRS window for assessing additional tax.⁷ If you underreport income by more than 25%, the IRS has six years to audit, so six years of records gives you an extra margin.

Digital copies are usually the safer choice. Thermal paper receipts fade within a few years, sometimes sooner. Scan or photograph everything shortly after the purchase and store the files somewhere you can pull them up fast if the IRS ever questions the distribution.

1
Office of the Law Revision Counsel. 26 U.S. Code 213 – Medical, Dental, Etc., Expenses
2
Internal Revenue Service. Frequently Asked Questions About Medical Expenses Related to Nutrition, Wellness and General Health
3
Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses
4
Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans
5
Internal Revenue Service. Instructions for Form 8889 (2025)
6
Internal Revenue Service. Instructions for Forms 1099-SA and 5498-SA
7
Internal Revenue Service. How Long Should I Keep Records?