Health Savings Account eligible expenses are defined by IRS rules tied to Section 213(d) of the Internal Revenue Code, which covers costs for the diagnosis, cure, treatment, or prevention of disease. In practice, this means most legitimate medical, dental, and vision expenses qualify, while general wellness products, cosmetic procedures, and everyday toiletries do not. The line between what counts and what doesn’t is sharper than most people expect in some areas and surprisingly blurry in others, and a few legislative changes in recent years have shifted some everyday drugstore items into the eligible column.
The Big Categories That Clearly Qualify
The core of HSA eligibility is straightforward. If a licensed provider charges you for it in a medical, dental, or vision setting, it almost certainly qualifies. That includes doctor visit copays, hospital bills, lab work, imaging, surgical fees, and prescription medications. Dental cleanings, fillings, crowns, orthodontics, and dentures all count. Eye exams, prescription glasses, contact lenses, and prescription sunglasses are eligible too.
Beyond provider visits, a wide range of medical supplies and equipment qualifies when used for a medical purpose. Crutches, wheelchairs, blood pressure monitors, glucose monitors and test strips, hearing aids, and prosthetics are all fair game. Bandages, first aid kits, thermometers, and other basic medical supplies fall on the eligible side as well.
Mental health care is fully eligible. Therapy sessions with a licensed psychologist, psychiatrist, or clinical social worker qualify, as do inpatient psychiatric treatment and substance abuse programs. Prescribed medications for mental health conditions are treated identically to any other prescription.
Over-the-Counter Medications and the CARES Act Shift
Before 2020, most over-the-counter medications required a prescription to be HSA-eligible. The CARES Act permanently changed that rule. Pain relievers like ibuprofen and acetaminophen, allergy medications, acid reducers, cold and flu remedies, and anti-diarrheal drugs are now eligible without a prescription. Menstrual care products, including tampons, pads, cups, and liners, were also added as eligible expenses under the same legislation.
This change caught many account holders off guard because it reversed years of established practice. If you’ve been avoiding the drugstore aisle with your HSA card out of old habit, the rules have shifted in your favor. The key test is whether the product is primarily medicinal in nature. A bottle of ibuprofen qualifies. A bottle of vitamins, with a few exceptions discussed below, generally does not.
What Doesn’t Qualify
The IRS draws a firm line against cosmetic procedures. Teeth whitening, cosmetic surgery (facelifts, liposuction, hair transplants for appearance only), and similar treatments that don’t address a medical condition are ineligible. The same goes for gym memberships, even if your doctor tells you to exercise more. General fitness is considered a lifestyle choice rather than a medical expense under IRS rules.
Everyday personal care items are also excluded. Toothpaste, deodorant, shampoo, moisturizers marketed as skincare, and general-purpose sunscreen (with an important exception below) don’t make the cut. Nutritional supplements and vitamins taken for general health rather than to treat a specific diagnosed condition are ineligible in most cases. The logic is that the IRS considers these items beneficial for overall well-being rather than treatment of a particular medical problem.
Other common exclusions include:
- Health insurance premiums: Generally not eligible, with narrow exceptions for COBRA continuation coverage, coverage while receiving unemployment benefits, and Medicare premiums (Parts A, B, C, and D) once you’re 65 or older.
- Cosmetic dental work: Veneers purely for appearance don’t qualify, though veneers prescribed after dental trauma may.
- Non-prescribed supplements: Protein powder, multivitamins, and herbal supplements taken for general health are out unless a provider writes a letter of medical necessity for a specific diagnosed condition.
- Household items with health claims: Air purifiers, humidifiers, and similar products are only eligible when prescribed to treat a specific condition like asthma or severe allergies, not just because you’d prefer cleaner air.
The Gray Area Items People Ask About Most
Sunscreen is one of the most commonly searched gray-area products. Broad-spectrum sunscreen with an SPF of 15 or higher became HSA-eligible under the CARES Act. This was a meaningful change because sunscreen had previously been treated as a cosmetic or personal care item. The eligibility applies to standalone sunscreen products, not to moisturizers or makeup that happen to contain SPF protection.
Massage therapy falls into a genuinely ambiguous zone. If a doctor prescribes massage to treat a diagnosed condition like chronic back pain or a specific musculoskeletal injury, the expense can qualify. A spa massage for relaxation does not. The practical challenge is documentation: you typically need a letter of medical necessity from your provider, and the massage should be performed by a licensed massage therapist rather than at a resort spa.
Weight loss programs are another source of confusion. If a physician diagnoses you with a specific condition such as obesity, hypertension, or heart disease, and prescribes a weight loss program as treatment, the cost may qualify. A general desire to lose weight, even if your doctor recommends it casually, doesn’t meet the IRS threshold. The distinction hinges on whether a specific disease is being treated rather than whether losing weight would be a good idea in general.
Acupuncture is eligible. Chiropractic care is eligible. Both fall under the IRS definition of medical care when performed by licensed practitioners. You don’t need a separate referral or letter of medical necessity for these, though your HSA administrator may ask for documentation that the provider is licensed.
The Letter of Medical Necessity
A surprising number of items that seem ineligible on their face can become eligible with a letter of medical necessity from a healthcare provider. This is a written statement from a doctor, nurse practitioner, or other qualified provider that a particular item or service is medically necessary to treat a diagnosed condition.
The classic example is a special mattress. An ordinary mattress purchase is never HSA-eligible. But if a doctor prescribes a specific orthopedic mattress to treat a diagnosed back condition, the incremental cost above a standard mattress can qualify. Similarly, an air purifier is a household appliance for most people, but with a letter of medical necessity linking it to a diagnosed respiratory condition, it may become eligible.
Other items that can cross into eligible territory with proper documentation include ergonomic office equipment prescribed for musculoskeletal conditions, certain food items required for medically diagnosed conditions like celiac disease (the incremental cost above comparable regular food), and exercise equipment prescribed for a specific rehabilitation purpose. The letter needs to identify the condition being treated and explain why the specific item is medically necessary. A vague note saying “patient would benefit from exercise” won’t meet the standard.
One important caveat: your HSA administrator and ultimately the IRS make the final call. A letter of medical necessity strengthens your position considerably, but it’s not an absolute guarantee. Keep the letter along with receipts in case of an audit.
Dental and Vision Expenses in Detail
Dental expenses trip people up because the line between medical and cosmetic can be thin in dentistry. Preventive care like cleanings, X-rays, and fluoride treatments is eligible. Restorative work including fillings, root canals, crowns, bridges, and extractions qualifies. Orthodontics, including braces and clear aligners for malocclusion, are eligible. Dentures and dental implants count.
What doesn’t qualify on the dental side is anything done purely for appearance. Professional teeth whitening is the most common exclusion. Veneers are a gray area: if placed to restore a damaged tooth, they can qualify; if placed solely to improve the look of healthy teeth, they likely don’t. In practice, many veneer cases involve some degree of both, and the documentation from your dentist matters.
Vision expenses are more straightforward. Eye exams, prescription eyeglasses, prescription contact lenses and their associated supplies (contact lens solution, cases), and laser eye surgery such as LASIK are all eligible. Reading glasses purchased without a prescription are also eligible under post-CARES Act rules. Non-prescription fashion eyewear is not. Blue-light blocking glasses without a prescription generally don’t qualify unless prescribed for a specific diagnosed condition.
Dependents, Spouses, and Coverage Rules
Your HSA funds can pay for eligible expenses incurred by your spouse and your tax dependents, even if they aren’t covered by your high-deductible health plan. This is a point many account holders miss. If your spouse has their own non-HDHP insurance through their employer, you can still use your HSA to cover their copays, prescriptions, and other qualified medical expenses.
For dependents, the IRS definition aligns with who you claim on your tax return. Children up to age 26 can stay on your health insurance plan under ACA rules, but that’s a different question from whether they’re your tax dependent. If your 24-year-old child is on your insurance but files their own taxes and isn’t your dependent, you can’t use your HSA for their expenses. The health plan rules and the HSA rules don’t always line up, which creates confusion.
Domestic partners who aren’t legal spouses present another wrinkle. Unless your domestic partner qualifies as your tax dependent, their medical expenses aren’t HSA-eligible for you, regardless of how your health insurance plan treats them.
How Spending Patterns Actually Play Out
An interesting pattern emerges in how people with HSAs actually spend on healthcare compared to people without these accounts. Research published in JAMA Health Forum found that families with HSAs spent roughly 44% more on out-of-pocket medical expenses than families without any health savings account, an increase averaging about $697 annually. At the same time, their total healthcare expenditures (combining out-of-pocket and insurer-paid costs) were comparable to families without accounts.1JAMA Health Forum. Health Care–Related Savings Accounts, Health Care Expenditures, and Tax Expenditures
That finding suggests HSA holders are shouldering a bigger share of costs directly, which is by design given that HSAs pair with high-deductible plans. It also means the question of what’s eligible carries real financial weight. The tax advantage of paying with pre-tax HSA dollars is the main lever you have to offset those higher out-of-pocket costs, and missing eligible expenses means leaving that benefit on the table.
By contrast, the same study found that families with Flexible Spending Accounts spent about 20% more on healthcare overall, largely driven by higher insurer-paid expenses rather than out-of-pocket costs.1JAMA Health Forum. Health Care–Related Savings Accounts, Health Care Expenditures, and Tax Expenditures The contrast matters because people often conflate HSA and FSA rules. FSAs have a “use it or lose it” structure that encourages spending down the account each year, while HSAs roll over indefinitely and can be invested. That difference in design shapes not just how much people spend, but how carefully they track which expenses qualify.
Common Mistakes That Trigger Tax Problems
The most frequent HSA mistake is using funds for an ineligible expense and not catching it. If you swipe your HSA debit card for something that doesn’t qualify, the IRS treats that withdrawal as a non-qualified distribution. You’ll owe income tax on the amount, plus a 20% penalty if you’re under age 65. After 65, the penalty disappears but the income tax still applies, which effectively turns your HSA into a regular retirement account for non-medical spending.
A second common mistake is double-dipping: paying for something with HSA funds and also claiming it as an itemized medical expense deduction on your tax return. You can’t do both. The expense is either paid with pre-tax HSA money or deducted on Schedule A, not both.
People also stumble on timing. You can only use HSA funds for expenses incurred after your HSA was established. If you opened your account in March and had a dental bill in January, that January bill isn’t eligible for HSA reimbursement even though it was a qualified medical expense. There’s no deadline for when you actually reimburse yourself, however. Some people deliberately pay out of pocket and let their HSA grow tax-free for years before reimbursing themselves for old expenses, as long as the expense occurred after the account was established and they keep receipts.
Items That Became Eligible Recently
Beyond the CARES Act changes already mentioned, a few developments have expanded the eligible list in recent years. COVID-19 home testing kits are eligible. Personal protective equipment purchased for the primary purpose of preventing the spread of COVID-19, including masks and hand sanitizer, was clarified as eligible by the IRS. Whether these rulings extend indefinitely or get revisited as pandemic-era guidance is updated remains somewhat uncertain, but for now they stand.
Telehealth visits are eligible just like in-person visits. The underlying service determines eligibility, not whether the appointment happened over video or in a clinic. This seems obvious in hindsight, but early in the telehealth expansion there was some confusion about platform fees versus medical service fees. The medical service component is what qualifies.
Continuous glucose monitors for people with diabetes have become an increasingly significant HSA-eligible purchase as the devices have grown in popularity. The sensors, transmitters, and reader devices all qualify as medical equipment. The same applies to insulin pumps and their associated supplies.
Fertility, Pregnancy, and Childbirth Expenses
Pregnancy and childbirth expenses are broadly eligible, covering prenatal visits, labor and delivery, hospital stays, and postpartum care. Fertility treatments including in vitro fertilization are also eligible, which surprises people who assume IRS rules might treat fertility care differently from other medical procedures. Egg storage fees when tied to a medical condition, ovulation monitors, and pregnancy test kits all qualify.
Breast pumps and lactation supplies are eligible, including replacement parts and storage bags. Lactation consultant fees qualify when the consultant is a licensed healthcare provider. Formula prescribed for a medical condition may qualify with proper documentation, though standard infant formula purchased for routine feeding does not.
Where fertility and family-planning expenses get complicated is surrogacy. The IRS has taken the position that intended parents generally cannot deduct a surrogate’s medical expenses, and the same logic limits HSA use for those costs. This area of tax law is genuinely unsettled and has been challenged in tax court, so if you’re navigating surrogacy expenses, it’s worth getting professional tax advice rather than assuming one way or another.
Travel and Lodging for Medical Care
When you need to travel to receive medical care, some of those costs are HSA-eligible. Mileage driven to and from medical appointments qualifies at the IRS standard medical mileage rate. Parking fees and tolls at medical facilities count. Public transportation costs to reach a medical provider are eligible.
Lodging is trickier. If you need to stay near a medical facility for treatment, up to $50 per night per person is potentially eligible under IRS rules. The lodging can’t be lavish or extravagant, and the trip must be primarily for medical care. Meals during medical travel generally don’t qualify. If a companion’s presence is medically necessary (for instance, a parent accompanying a child for surgery), the companion’s lodging can also qualify at the same nightly limit.
Flights or long-distance travel to see a specialist can qualify if the care isn’t available locally. The expense needs to be primarily for and essential to the medical care. Flying across the country to combine a vacation with a routine checkup wouldn’t meet that standard, even if you do squeeze in a doctor visit.