HSA qualified medical expenses are the costs the IRS lets you pay from a Health Savings Account tax-free. The governing definition sits in Section 213(d) of the Internal Revenue Code: amounts paid to diagnose, treat, cure, mitigate, or prevent disease, or to affect a structure or function of the body, plus transportation essential to that care and a short list of insurance premiums. Doctor visits, prescriptions, dental work, vision care, and most over-the-counter medicines fit. Cosmetic procedures, general wellness spending, and ordinary health insurance premiums do not. Spend HSA money on something outside the definition and you owe income tax on the withdrawal plus a 20% penalty if you’re under 65.
The 213(d) Test
Every eligibility question comes back to the same standard. If the expense diagnoses, treats, or prevents a specific medical condition, or affects a bodily structure or function, it generally qualifies. If it’s for personal comfort, appearance, or general health, it generally doesn’t.
Some purchases sit on the line. A special diet, a nutritional supplement, a weight-loss program, or a gym membership might be medical for one person and lifestyle for another. The IRS resolves that with medical necessity: if a physician diagnoses a specific condition and recommends the expense as treatment for it, the cost can qualify. Without that documented connection — a letter of medical necessity in the file — the same purchase doesn’t. General fitness or overall wellness, however sincerely recommended, isn’t enough.
Medical Services and Transportation
Professional care is the core of what an HSA is for. Visits to doctors, surgeons, specialists, and licensed mental health professionals qualify, in person or by telehealth. Physical therapy, chiropractic care, and psychological counseling are eligible when they address a medical condition. Nursing services from a licensed nurse for a patient’s specific medical needs are covered. So are laboratory fees, diagnostic imaging, and blood work.
Transportation to get care counts too. Ambulance services are eligible. So are mileage on your own car, parking at the hospital, and bus or taxi fares when the trip is essential to receiving medical care.
Dental and Vision
Dental and vision expenses qualify whether or not your health insurance covers them. On the dental side: cleanings, fluoride treatments, fillings, extractions, root canals, dentures, and orthodontic treatment for structural problems, including braces and aligners.
On the vision side: eye exams, prescription eyeglasses, contact lenses, and corrective eye surgery such as LASIK. Non-prescription sunglasses don’t qualify, because they serve no medical purpose.
Over-the-Counter Medicines and Supplies
The rules here changed in 2020. Before the CARES Act, most over-the-counter drugs needed a prescription to be HSA-eligible. That requirement is gone permanently. Pain relievers, cold and flu remedies, allergy medicine, and antacids can now be bought with an HSA card without a prescription.
Medical supplies and devices are eligible on the same terms: bandages, thermometers, blood pressure monitors, first-aid kits. The same legislation added menstrual care products — tampons, pads, liners, and cups — to the list of qualified expenses.
The Four Insurance Premiums That Qualify
HSA funds generally cannot pay for health insurance premiums. This surprises a lot of account holders. There are exactly four exceptions:
- COBRA continuation coverage after you leave a job.
- Health insurance premiums paid while you’re collecting unemployment compensation under federal or state law.
- Medicare premiums once you turn 65 — Part A, Part B, Part D, and Medicare Advantage. Medigap (Medicare supplement) premiums are specifically excluded.
- Long-term care insurance premiums, up to an age-based annual limit. For 2026, the cap ranges from $500 if you’re 40 or younger to $6,200 if you’re 71 or older.
Any other premium paid from an HSA is a non-qualified distribution and triggers tax and the penalty.
What Doesn’t Qualify
Cosmetic surgery is the biggest exclusion. Any procedure aimed at improving appearance that doesn’t meaningfully treat disease or restore function after injury is out. Face lifts, hair transplants, electrolysis, and liposuction all fail the test. The exception is surgery that corrects a deformity from a congenital abnormality, an accident, or a disfiguring disease, such as breast reconstruction after cancer treatment.
General wellness is the other big exclusion zone. Gym memberships and fitness classes don’t qualify unless a physician prescribes them to treat a specific diagnosed condition like obesity or heart disease, and even then the purpose must be treating that condition rather than general fitness. Exercise recommended for “improvement of general health” doesn’t qualify no matter how sound the advice.
Everyday personal care never qualifies. Toothpaste, deodorant, shaving cream, and similar toiletries are personal items. Standard multivitamins and supplements taken for general wellness are also excluded unless a doctor recommends a specific supplement to treat a diagnosed condition. The question to ask about any borderline purchase is whether it treats a medical problem or maintains general health.
What Happens If You Get It Wrong
A non-qualified withdrawal is added to your taxable income for the year, and you owe an additional 20% tax on top. For someone in the 22% federal bracket, a $1,000 mistaken withdrawal costs about $420 in combined tax and penalty. After age 65, the 20% penalty disappears, though the withdrawal is still taxed as ordinary income. The penalty also doesn’t apply after disability or death.
Genuine mistakes can sometimes be reversed. If you take a distribution in error, you can repay it to your HSA by the due date of your tax return for the year you discovered the error, not counting extensions. If your custodian accepts the repayment, the distribution isn’t included in income and no penalty applies. Not every custodian is required to allow this, so confirm before assuming you can unwind a bad withdrawal.
Keeping Records — Including for Expenses You Pay Now and Reimburse Later
Your HSA custodian doesn’t check whether each purchase is qualified. That job is yours. If the IRS audits the return, you’ll need to prove every distribution went to an eligible expense. Keep itemized receipts showing the date, provider, and specific service or product. Explanation of Benefits statements are useful for documenting what you actually paid after insurance. All HSA distributions get reported on IRS Form 8889 with your federal return, and filing it is mandatory in any year you take a distribution, even if every dollar was qualified.
Records matter for another reason. There’s no deadline for reimbursing yourself. IRS Notice 2004-50 confirmed that you can pay a medical bill out of pocket today and withdraw the same amount from your HSA years or decades later, as long as the expense was incurred after your HSA was established. Some account holders use this deliberately, paying current expenses out of pocket and letting the HSA balance grow tax-free. To do it, you need records proving four things: the expense was incurred after your HSA existed, the distribution covers only qualified expenses, the expense wasn’t reimbursed from another source, and you didn’t claim it as an itemized deduction in a prior year.
The front-end cutoff is strict. Medical expenses incurred before your HSA was established never qualify, even if you had HDHP coverage at the time. State law determines the exact establishment date, so confirm the account is formally open before incurring expenses you plan to reimburse from it later.