HSA and HDHP Safe Harbors for Telehealth and Preventive Care

Under federal law, a High Deductible Health Plan can pay for a narrow set of services before you meet the deductible without costing you the right to contribute to a Health Savings Account. The HSA and HDHP safe harbors for telehealth and preventive care cover four things: telehealth and other remote care (now a permanent safe harbor as of July 2025), a list of standard preventive services, specific medications and devices for certain chronic conditions, and certain contraceptive products. Anything outside those categories triggers the default rule: if your HDHP pays for care before you hit the deductible, your HSA eligibility disappears.¹

The Preventive Care Safe Harbor

Preventive care is the oldest and broadest exception to the no-first-dollar-coverage rule. Your HDHP may cover qualifying preventive services before you reach the deductible, and your HSA eligibility stays intact.¹ The IRS has expanded what counts as preventive several times, most notably in 2019 and 2024.

Standard Preventive Services

IRS Notice 2004-23 set the original list. It includes routine physicals and periodic health evaluations, prenatal and well-child care, childhood and adult immunizations, and screening services for cancer and other diseases.² The common thread is early detection or prevention. Treatment of an existing condition does not qualify.

There is one useful wrinkle. If a screening turns up a problem and the doctor treats it during the same visit because a separate procedure would be impractical, that incidental treatment stays within the safe harbor.³ A colonoscopy that removes a polyp during the screening is the standard example.

Chronic Condition Medications and Services

IRS Notice 2019-45 added specific items for a defined list of chronic conditions, on the theory that managing these conditions early prevents costlier crises later. The covered items include:

Diabetes: insulin and other glucose-lowering agents, glucometers, retinopathy screenings, and hemoglobin A1c testing
Heart disease: statins, blood pressure monitors, and low-dose aspirin
Asthma: inhaled corticosteroids and peak flow meters
Depression: selective serotonin reuptake inhibitors (SSRIs)

The list is specific. Only the exact medications and services named in the IRS appendix qualify.⁴ If your doctor prescribes a drug for a chronic condition that is not on the list, your HDHP still has to apply the deductible before covering it.

Contraceptive Products

IRS Notice 2024-75 broadened the safe harbor to include over-the-counter oral contraceptives for individuals who could become pregnant, including emergency contraception, along with male condoms. Plans can cover these items before the deductible whether they are bought with a prescription or not. The IRS specifically excluded other male contraceptive methods, including vasectomies, from the safe harbor.⁵

The Telehealth and Remote Care Safe Harbor

The telehealth safe harbor works differently. It covers a delivery method rather than a medical reason, so it reaches sick visits, mental health counseling, follow-ups, and any other care given remotely. The medical purpose does not have to be preventive.

How the Rule Got Here

The CARES Act of 2020 first allowed HDHPs to cover telehealth and other remote care before the deductible without disturbing HSA eligibility.⁶ That provision was temporary. Congress extended it through the Consolidated Appropriations Act of 2023, keeping the safe harbor alive for plan years beginning before January 1, 2025.

Permanent Extension in 2025

The safe harbor is now permanent. Section 71306 of H.R. 1, signed into law on July 4, 2025, extended it indefinitely and applied that extension retroactively to plan years beginning after December 31, 2024, closing the gap that would otherwise have opened between the prior expiration and the new law. IRS Notice 2026-05 confirms that HDHPs may offer telehealth and other remote care as a first-dollar benefit while preserving participants’ HSA eligibility.⁷

The practical effect is that you no longer have to track expiration dates or watch how your plan year lines up with a covered window. If your HDHP offers telehealth before the deductible, that alone will not affect your HSA eligibility.

Where the Safe Harbors End

Most confusion sits on the line between preventive and treatment. IRS Notice 2004-50 is direct: any service intended to treat an existing illness, injury, or condition falls outside the preventive care safe harbor.³ A routine mammogram qualifies; the surgery after a cancer diagnosis does not. A diabetes screening qualifies; hospitalization for diabetic ketoacidosis does not.

The same limit holds for chronic conditions on the Notice 2019-45 list. The safe harbor covers the exact medications and services named in the appendix. A different drug for the same condition, or emergency treatment tied to that condition, is subject to the deductible.⁴ The IRS gave plans room to cover chronic condition management, not a blank check for all care tied to those conditions.

Emergency room visits, acute illness treatment, and surgeries are the categories that most reliably fall outside the safe harbor. If your plan pays for these before the deductible, it loses its HDHP status and your HSA contributions for that period become a problem.

Other Coverage That Can Still Disqualify You

A compliant HDHP is necessary for HSA eligibility, not sufficient. You also cannot be covered by other health insurance that is not an HDHP, enrolled in Medicare, or covered by a general-purpose Flexible Spending Account or Health Reimbursement Arrangement.⁸

A Spouse’s FSA or HRA

This one catches people. If your spouse has a general-purpose FSA through their employer and it covers you, that counts as disqualifying coverage even though you have your own HDHP. A limited-purpose FSA or HRA covering only dental and vision expenses does not interfere with HSA eligibility, and neither does a post-deductible FSA or HRA that does not kick in until after the HDHP deductible is met.⁸

Medicare

Once you enroll in Medicare Part A or Part B, HSA contributions must stop. You can still spend existing HSA funds on qualified medical expenses. For most people who claim Social Security at 65, Part A enrollment is automatic and cannot be declined without giving up Social Security benefits.

What Happens if the Rules Are Broken

The tax consequences are steep. If you take HSA money out for anything other than qualified medical expenses, the withdrawn amount is added to your taxable income and hit with an additional 20% penalty tax.¹ On a $1,000 non-qualified withdrawal in the 22% tax bracket, that is $220 in income tax plus $200 in penalty.

The 20% penalty has three exceptions: it does not apply after you become disabled, after you die (for distributions to a beneficiary), or after you reach the Medicare eligibility age of 65.¹ After 65, non-qualified withdrawals are still taxed as income but avoid the penalty.

If your plan loses HDHP status because it covered non-preventive care before the deductible, the IRS can disqualify contributions for the affected period. Excess contributions carry a separate 6% excise tax for every year they remain in the account. Withdrawing excess contributions before your tax filing deadline stops the ongoing excise tax, though you will owe income tax on any earnings those excess contributions generated.

1
Office of the Law Revision Counsel. 26 USC 223 – Health Savings Accounts
2
Internal Revenue Service. IRS Notice 2004-23 – Preventive Care Safe Harbor
3
Internal Revenue Service. IRS Notice 2004-50 – Additional Guidance on HDHPs and HSAs
4
Internal Revenue Service. IRS Notice 2019-45 – Additional Preventive Care Benefits for HDHPs
5
Internal Revenue Service. IRS Notice 2024-75 – Preventive Care for HDHPs Under Section 223
6
Internal Revenue Service. IRS Outlines Changes to Health Care Spending Available Under CARES Act
7
Internal Revenue Service. Notice 2026-05 – HSA and HDHP Limits for 2026
8
Internal Revenue Service. Publication 969 – Health Savings Accounts and Other Tax-Favored Health Plans