What an HSA covers: the basics

A Health Savings Account covers medical, dental, and vision expenses that you would otherwise pay out of pocket. The IRS publishes a list of what counts as a may have access to medical expense, and if it's on that list, you can withdraw HSA money tax-free to pay for it. If it's not on the list, you can still withdraw the money, but you'll owe income tax plus a 20% penalty on the withdrawal amount.

The key word is "medical"—meaning treatment, diagnosis, or prevention of disease or injury. Gym memberships don't count. Cosmetic surgery doesn't count. But the range of what does count is wider than most people realize, and it includes things you might not think of as medical at all.

Key Takeaways

  • may have access to medical expenses include doctor visits, prescriptions, dental work, vision care, mental health treatment, and medical equipment like wheelchairs or hearing aids.
  • Over-the-counter medications and supplies—from pain relievers to bandages to pregnancy tests—count as may have access to expenses if you have a prescription or a doctor's written recommendation.
  • Expenses that improve general health but aren't treating a specific condition—like vitamins, gym memberships, or cosmetic procedures—do not count.
  • You can use HSA money to pay insurance premiums in specific situations: COBRA coverage, long-term care insurance, and health insurance while unemployed.
  • Keeping receipts and records is your responsibility; the IRS does not require you to submit them when you withdraw, but you must be able to prove the expense was may have access to if audited.

Doctor visits, prescriptions, and hospital care

The straightforward expenses are covered: doctor office visits, urgent care, emergency room visits, hospital stays, surgery, anesthesia, and X-rays. Prescription medications are covered. Mental health treatment—therapy, psychiatry, inpatient psychiatric care—is covered. Substance abuse treatment is covered.

Telehealth visits count the same way as in-person visits. If you pay a copay or coinsurance to a provider, that payment is a may have access to expense. If you pay the full cost of a visit because you haven't met your deductible, that's may have access to too.

Dental and vision care

Dental work is covered: cleanings, fillings, root canals, extractions, crowns, braces, and dentures. Dental implants are covered. Orthodontia is covered. Teeth whitening is not covered because it's considered cosmetic, not treatment of disease.

Vision care includes eye exams, glasses, contact lenses, and contact lens solution. LASIK and other corrective eye surgery is covered. Sunglasses are not covered, even if you need them for a medical condition, because they're not specifically prescribed to treat disease.

Over-the-counter medications and supplies

This is where HSA rules diverge from what people expect. You cannot use HSA money for over-the-counter medications without a prescription or a doctor's written recommendation—that rule changed in 2011. But if your doctor writes a prescription for ibuprofen, acetaminophen, or any OTC drug, or writes a note saying you need it, then it becomes a may have access to expense.

Medical supplies are different. You do not need a prescription for bandages, gauze, thermometers, blood pressure monitors, glucose monitors, test strips, lancets, or pregnancy tests. These count as may have access to expenses on their own. The same applies to crutches, elastic bandages, heating pads, and ice packs.

The distinction is this: if it's a supply that treats or monitors a condition, it's covered. If it's a medication, you need documentation from a doctor.

Medical equipment and devices

Durable medical equipment is covered: wheelchairs, walkers, canes, hospital beds, oxygen equipment, CPAP machines, and hearing aids. Prosthetics and orthotics are covered. Insulin pumps and continuous glucose monitors are covered. Crutches, braces, and back supports are covered.

The equipment must be prescribed or recommended by a doctor and must treat a specific medical condition. A general fitness tracker is not covered. A fitness tracker prescribed by a cardiologist to monitor heart rhythm after an arrhythmia diagnosis may be covered, depending on how the prescription is written.

Insurance premiums you can pay with HSA money

You cannot use HSA money to pay your regular health insurance premium—that would defeat the purpose of the account. But there are three exceptions where you can:

  • COBRA continuation coverage (the temporary health insurance you can buy if you lose employer coverage)
  • Long-term care insurance premiums (with limits based on your age)
  • Health insurance premiums while you are unemployed and receiving unemployment benefits

Medicare premiums are also allowed, but only for the Part B and Part D premiums themselves, not for supplemental or Medigap policies. If you're over 65 and still working, you can use HSA money for Medicare premiums.

What is not covered

General health and wellness expenses that don't treat a disease are not covered: vitamins and supplements (unless prescribed for a deficiency), gym memberships, fitness classes, weight loss programs, and cosmetic procedures. Hairpieces are not covered. Maternity clothes are not covered. Travel to receive medical care is not covered, even if the care itself is.

Cosmetic surgery is not covered unless it's reconstructive—meaning it repairs damage from injury, disease, or birth defect. Teeth whitening, Botox, and elective facelifts are not covered. Reconstructive surgery after a car accident or cancer treatment is covered.

How to track what you spend and keep records

You are responsible for keeping receipts and records of what you spend HSA money on. The IRS does not require you to submit receipts when you make a withdrawal, but you must keep them in case you're audited. If you cannot prove an expense was may have access to, the IRS will tax it as income plus assess the 20% penalty.

Many HSA providers offer a debit card that you can use at pharmacies and medical providers. Some will match the transaction to a category (pharmacy, doctor, dental) automatically. This is helpful but not a substitute for your own records. Keep the receipt anyway.

If you're unsure whether an expense is may have access to, ask your HSA provider or check the IRS Publication 502, which lists may have access to medical expenses in detail. Your provider's customer service line can also tell you whether a specific item or service counts.

Frequently Asked Questions

Can I use my HSA debit card at any store?

The debit card is designed to work at pharmacies, doctor offices, dental offices, and medical supply stores. It may decline at general retailers even if you're buying a may have access to item like bandages, because the merchant category doesn't match. In that case, pay out of pocket and withdraw the money from your HSA later, or ask the pharmacy or medical supply store if they can process the transaction differently.

What happens if I use HSA money for something that's not may have access to?

You owe income tax on the amount you withdrew, plus a 20% penalty. If you withdrew $100 for a non-may have access to expense and you're in the 22% tax bracket, you'd owe $22 in income tax plus $20 in penalty, for a total of $42. Keep receipts so you can prove the expense was may have access to if the IRS asks.

Can I use HSA money to pay for my spouse's medical expenses?

Yes, if your spouse is covered under your health plan or if you file taxes jointly. You do not need to be on the same insurance plan. The expense itself must still be may have access to—your spouse's doctor visit, prescription, or dental work counts.

Are fertility treatments and birth control covered?

Yes. Prescription birth control, IUDs, fertility testing, and fertility treatments like IVF are all may have access to medical expenses. Condoms and other over-the-counter contraceptives are not covered unless prescribed by a doctor for a specific medical reason.

Can I use HSA money for my adult child's medical expenses?

Only if you claim them as a dependent on your tax return. If they're independent, their medical expenses don't count as may have access to for your HSA, even if you pay for them.