What Is Covered by an HSA: Eligible Expenses and Exclusions

An HSA covers expenses that diagnose, treat, or prevent a physical or mental condition, or that affect a structure or function of the body.¹ In practice, the list of HSA eligible expenses runs from doctor visits, hospital stays, and prescriptions to dental work, eyeglasses, medically necessary home modifications, and travel to get care. Spend the money on something outside that definition and the withdrawal becomes taxable income plus a 20% additional tax if you’re under 65.²

Medical Care and Treatment

Professional medical services form the core of what an HSA pays for. Primary care visits, specialist appointments, surgeries, hospital stays, nursing care, lab work, X-rays, and ambulance transport all qualify.³ Physical therapy, mental health counseling, and substance abuse treatment qualify when recommended by a healthcare provider. Long-term care services are eligible too.

Preventive screenings sit inside the eligible category, including screenings for cancer, heart disease, infectious diseases, mental health conditions, and vision and hearing disorders.⁴ Under guidance tied to the One, Big, Beautiful Bill Act, periodic fees paid for a direct primary care arrangement are also HSA eligible starting in 2026.⁵

Dental and Vision

Dental and vision expenses are fully eligible, which matters because standard health plans often cover little of either. Cleanings, fluoride treatments, dental X-rays, fillings, crowns, bridges, extractions, and dentures all qualify.⁶ Orthodontic treatment, braces included, qualifies at any age as long as it addresses a dental condition rather than pure appearance.

On the vision side, eye exams, prescription eyeglasses, contact lenses, and the cleaning supplies and saline solution used with contacts are all covered. LASIK and radial keratotomy qualify because they treat defective vision.⁶

Prescription and Over-the-Counter Drugs

Prescription medications, including insulin and other maintenance drugs, are straightforward HSA expenses. Over-the-counter products no longer need a prescription to qualify: since the CARES Act took effect in 2020, pain relievers, cold medicine, allergy treatments, and similar non-prescription drugs can be bought with HSA funds directly.⁷

The same law added menstrual care products as permanently qualified. Tampons, pads, liners, and cups all count.⁷

Vitamins and supplements taken for general health do not qualify. They become eligible only when a physician prescribes them to treat a specific diagnosed condition, and you’ll want a letter of medical necessity from the prescribing doctor identifying the condition, stating that the item is medically necessary rather than cosmetic or general wellness, and noting the expected duration of treatment.

Health Insurance Premiums

Regular monthly premiums for your HDHP are not qualified expenses. Federal law carves out a short list of premium types you can pay with HSA dollars:²

COBRA continuation premiums
Health coverage premiums while you’re receiving unemployment benefits
Qualified long-term care insurance
Once you turn 65, any health insurance premiums other than Medigap policies

Travel and Lodging for Medical Care

Getting to your provider is itself an eligible expense. For 2026, you can claim mileage at the IRS medical rate of 20.5 cents per mile, along with parking fees and tolls.⁸ Bus, taxi, and ambulance fares for medical trips count too.

Lodging while traveling for treatment qualifies up to $50 per night per person, provided the trip is primarily for medical care at a licensed hospital or equivalent facility. If a parent travels with a sick child, that’s up to $100 per night for both. Meals during the trip are not included, the lodging can’t be lavish, and the trip can’t have a significant vacation element mixed in.⁹

Home Modifications for Medical Needs

Changes to your home to accommodate a disability or medical condition can qualify. The rule turns on property value: if the modification doesn’t increase your home’s value, the whole cost is eligible. If it does increase the value, only the portion above the value increase counts.⁹

Certain modifications are presumed not to add value and typically qualify in full:

Ramps, widened doorways, and graded ground for wheelchair access
Grab bars, support bars, and accessible bathroom fixtures
Widened hallways, modified stairways, and lowered kitchen cabinets
Modified fire alarms, smoke detectors, and warning systems
Porch lifts and similar devices (elevators generally do add value, so only part of that cost qualifies)

Costs have to be reasonable for the medical purpose. Premium materials or architectural upgrades beyond what the condition requires are personal expenses.⁹

Expenses for a Spouse or Dependent

You can use your HSA tax-free for medical costs of your spouse and your tax dependents, not just your own. The family member does not need to be covered by your HDHP or by any insurance at all.⁴

Dependents generally include children under 19, or under 24 if they’re full-time students, who receive more than half their support from you. Other relatives who depend on you for more than half their support can also qualify.¹⁰ One timing point matters: the person must meet the dependent definition when the expense is incurred, not when you pay or reimburse it from the HSA.

What an HSA Does Not Cover

Expenses that are merely good for your health but don’t treat or prevent a specific condition are out.¹¹ The common non-qualifying categories:

Gym memberships and fitness classes, unless prescribed by a physician for a diagnosed condition such as obesity or heart disease
Cosmetic procedures such as face lifts, hair transplants, teeth whitening, and liposuction, where the aim is appearance rather than function¹²
General-use vitamins and supplements
Swimming lessons, dance classes, and other activities for overall fitness, even if a doctor recommends them¹¹
Regular HDHP monthly premiums, outside the COBRA, unemployment, and long-term care exceptions listed earlier

The gym rule catches a lot of people. A physician’s prescription for a gym-based treatment plan tied to a specific disease can make the membership qualify. A general “exercise more” recommendation does not.¹¹

What Happens If You Spend on Something That Doesn’t Qualify

A non-qualified withdrawal is added to your gross income for the year and hit with an additional 20% tax on top of regular income tax.² On a $1,000 non-qualified purchase, that’s $200 in penalty alone before income tax.

The 20% penalty drops away after you turn 65, or if you become disabled, or upon death. After 65 you can withdraw for any purpose and only owe regular income tax on non-medical amounts.²

If you swipe your HSA debit card by mistake for something non-medical, you can repay the distribution. The deadline is April 15 following the first year you knew or should have known the distribution was a mistake.¹³

Records You Should Keep

Your HSA custodian will not verify whether a purchase is eligible. That burden falls on you if the IRS ever asks. Keep records showing that each distribution paid for a qualified medical expense, that the expense wasn’t reimbursed by insurance or another source, and that you didn’t also claim it as an itemized deduction.¹⁴

Save itemized receipts, invoices, and Explanation of Benefits forms showing the date of service, provider name, and description of treatment. You don’t submit these with your return, but hold onto them as long as the tax year stays open for audit. If you relied on a letter of medical necessity for a dual-purpose item, file that letter with the receipt.

1
Office of the Law Revision Counsel. 26 USC 213 – Medical, Dental, Etc., Expenses
2
Office of the Law Revision Counsel. 26 US Code 223 – Health Savings Accounts
3
eCFR. 26 CFR 1.213-1 – Medical, Dental, Etc., Expenses
4
Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans
5
Internal Revenue Service. Treasury, IRS Provide Guidance on New Tax Benefits for Health Savings Account Participants Under the One, Big, Beautiful Bill
6
Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses – Section: What Medical Expenses Are Includible?
7
Internal Revenue Service. IRS Outlines Changes to Health Care Spending Available Under CARES Act
8
Internal Revenue Service. IRS Sets 2026 Business Standard Mileage Rate at 72.5 Cents Per Mile, Up 2.5 Cents
9
Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses
10
Internal Revenue Service. Distributions From an HSA
11
Internal Revenue Service. Frequently Asked Questions About Medical Expenses Related to Nutrition, Wellness and General Health
12
Internal Revenue Service. Publication 502 (2025), Medical and Dental Expenses – Section: What Expenses Aren’t Includible?
13
Internal Revenue Service. Distributions From an HSA – Mistaken Distributions
14
Internal Revenue Service. Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans – Section: Recordkeeping