You can use your HSA card to pay for a broad list of medical costs with pre-tax dollars: doctor and specialist visits, hospital care, prescriptions, over-the-counter medicine, dental and vision care, mental health treatment, medical equipment, and certain insurance premiums in specific situations. The IRS ties eligibility to spending on the diagnosis, treatment, or prevention of disease, or on something that affects a structure or function of the body.1Office of the Law Revision Counsel. 26 USC 213 – Medical, Dental, Etc., Expenses – Section: Definitions Cosmetic procedures and general-wellness purchases are out. Distributions that go to qualified expenses come out tax-free; anything else can trigger income tax and a 20% additional tax.2Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans
Doctor Visits, Hospital Care, and Prescriptions
Standard office visits with any licensed medical practitioner qualify, along with diagnostic testing like X-rays and blood panels, and surgical procedures. Hospital stays, laboratory fees, ambulance services, and nursing care during recovery all count when they address a medical need rather than general well-being. Coverage runs across the full range of medical professionals, from primary care to specialists like cardiologists or neurologists. Annual physicals and immunizations qualify as preventive care.3Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses
All prescription drugs and insulin are eligible at the point of sale. Since the CARES Act, over-the-counter medications — pain relievers, cold medicine, allergy treatments, and similar products — are eligible without a prescription. The same expansion made menstrual care products — pads, tampons, liners, cups, and sponges — qualified medical expenses.4Internal Revenue Service. IRS Outlines Changes to Health Care Spending Available Under CARES Act
Dental and Vision Care
Dental and vision spending qualifies even though many standard health plans limit or exclude this coverage. On the dental side, you can pay for routine cleanings, fillings, extractions, dentures, braces, root canals, and X-rays.5Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses – Section: Dental Treatment Teeth whitening is specifically excluded as cosmetic.
Vision expenses include eye exams, prescription eyeglasses, and contact lenses. LASIK and other laser eye surgery qualify because they restore the function of the eyes.
Mental Health, Therapy, and Addiction Treatment
Psychiatric care from licensed professionals is eligible, along with physical therapy. Addiction treatment programs qualify, including inpatient facility stays.
Medical Equipment and Monitoring Devices
Physical devices qualify when they are needed for mobility or sensory improvement: crutches, wheelchairs, and hearing aids are all covered. Monitoring equipment such as blood sugar meters and blood pressure cuffs is also eligible for direct payment or reimbursement.
Home Modifications for a Disability
If you, your spouse, or a dependent living with you has a disability, you can use HSA funds for home modifications whose main purpose is medical care. Improvements that typically do not increase your home’s value qualify in full, and they include:
- Constructing entrance ramps, grading the ground for access, and modifying areas in front of doorways
- Widening doorways and hallways, modifying stairways, and installing handrails or grab bars
- Installing support bars in bathrooms and kitchens, lowering cabinets, and modifying fixtures
- Modifying fire alarms, smoke detectors, and other warning systems
- Installing porch lifts and similar devices (elevators generally add home value and may only partially qualify)
If an improvement does raise your property value, only the portion of the cost above that increase counts as a medical expense. Purely aesthetic or architectural upgrades don’t qualify.6Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses – Section: Capital Expenses
Service Animals
The cost of buying, training, and maintaining a guide dog or other service animal qualifies when the animal assists a person with a physical disability. Ongoing food, grooming, and veterinary costs are eligible because they keep the animal able to perform its duties.7Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses – Section: Guide Dog or Other Service Animal
Insurance Premiums the HSA Can Cover
Health insurance premiums are generally not qualified HSA expenses. The exceptions are narrow but useful. You can pay tax-free from your HSA for:8Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans – Section: Insurance Premiums
- COBRA continuation coverage after leaving a job
- Health coverage during any period you are collecting federal or state unemployment benefits
- Qualified long-term care insurance, up to age-based annual limits
- Medicare premiums after age 65, including Part A, Part B, Part D, and Medicare Advantage, but not Medigap supplemental policies
The 2026 age-based caps for long-term care insurance are $500 at age 40 or younger, $930 from age 41 to 50, $1,860 from age 51 to 60, $4,960 from age 61 to 70, and $6,200 over age 70. You cannot use HSA funds for premiums on your regular HDHP, another employer-sponsored plan (unless you are 65 or older), or a Medigap policy.9Internal Revenue Service. Notice 2004-2 – Health Savings Accounts
Whose Expenses You Can Pay
Your HSA card can pay for qualified medical expenses for your spouse or anyone who qualifies as your dependent under the federal tax code, even if that person isn’t enrolled in your high-deductible health plan.10Office of the Law Revision Counsel. 26 U.S. Code 223 – Health Savings Accounts A dependent generally means a qualifying child or qualifying relative for whom you provide more than half of their financial support and whom you claim on your return.
Eligibility tracks tax-dependent status, not age. An adult child who is not your tax dependent doesn’t qualify, and paying their expenses from your HSA would trigger income tax plus the 20% additional tax on the amount. If your domestic partner is not your legal spouse, their expenses only qualify when they meet the IRS definition of your tax dependent.
What You Can’t Use Your HSA Card For
The IRS excludes spending that is cosmetic or aimed at general well-being rather than treating or preventing disease. Common ineligible purchases include:
- Cosmetic surgery that doesn’t treat a deformity from disease, injury, or congenital abnormality
- Teeth whitening
- Gym memberships and general fitness programs, even when a doctor recommends exercise
- Non-prescription vitamins and supplements taken for general health
Some items in the gray zone can become eligible with a Letter of Medical Necessity from your doctor stating your diagnosis, the specific treatment or product needed, and the expected duration. Weight-loss programs, certain supplements, and some accessibility-related home modifications may qualify with that letter on file.
If you use HSA funds for a non-qualified expense before age 65, the amount is added to your taxable income and hit with an additional 20% tax.11Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans – Section: Additional Tax That 20% goes away after you turn 65, become disabled, or die, though ordinary income tax still applies to non-medical withdrawals after 65.
What Changes After Age 65
At 65, the account gets more flexible. Qualified medical spending remains completely tax-free, including Medicare premiums (Medigap still excluded). The 20% additional tax on non-medical withdrawals disappears, so a withdrawal for a vacation or home repair costs you ordinary income tax but no penalty. Once you enroll in Medicare, you can’t make new HSA contributions, but you can keep spending your balance.
Keeping Records the IRS Will Accept
You don’t send receipts with your tax return, but you do need records showing that each distribution paid for a qualified medical expense, that the expense wasn’t already paid or reimbursed from another source, and that you didn’t also claim it as an itemized deduction.12Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans – Section: Recordkeeping Keep receipts, explanation-of-benefits statements, and any Letters of Medical Necessity with your tax files. The general IRS audit window is three years from filing, so three years is a safe minimum. If you can’t substantiate an expense during an audit, the IRS treats the distribution as non-qualified, meaning income tax and potentially the 20% additional tax on the unsubstantiated amount.