The list of HSA-eligible expenses is broader than most people think — and more nuanced than any summary can fully capture. The IRS defines qualified medical expenses under IRC §213(d) as costs for the “diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.”

That definition covers hundreds of specific items and services. It also creates a large gray zone where eligibility depends on the circumstances, a physician's recommendation, or both.

This guide covers the major categories, the most commonly misunderstood items, and the 2026 changes you need to know about. It is not a substitute for IRS Publication 502, which is the authoritative reference — but it is a more practical starting point.

Key takeaways

HSA-eligible expenses are defined by IRC §213(d) and cover hundreds of items across medical, dental, vision, mental health, and more.
Many expenses -- like gym memberships and supplements -- can qualify, but only with a Letter of Medical Necessity (LMN) from a licensed provider.
The OBBBA (signed July 2025) made Direct Primary Care fees a qualified expense and permanently extended the telehealth safe harbor.
Non-qualified distributions carry a 20% penalty plus income tax -- getting eligibility right matters.
When in doubt, check IRS Publication 502 and get an LMN before making the purchase.

How eligibility works

Every HSA expense falls into one of three categories:

Eligible. The expense qualifies under §213(d) without additional documentation. Doctor visits, prescription drugs, surgery, lab work, dental care, vision care, mental health services — these are straightforward.

Eligible with a Letter of Medical Necessity (LMN). The expense can qualify, but only if a licensed healthcare provider documents that it is medically necessary to treat a specific diagnosed condition. Gym memberships, weight-loss programs, vitamins, massage therapy, and many other items fall here. Without an LMN, they are personal expenses. With one, they become qualified medical expenses.

Not eligible. The expense does not qualify regardless of circumstances. Cosmetic surgery (unless it corrects a deformity from disease, injury, or birth defect), general health club dues without a medical prescription, teeth whitening, and health insurance premiums (with specific exceptions) are in this category.

The 20% penalty is real

If the IRS determines that an HSA distribution was not for a qualified medical expense, the funds are taxable as ordinary income plus a 20% penalty. The penalty is waived after age 65 or upon disability, but the income tax still applies. When in doubt, get an LMN before making a purchase.

Major eligible categories

Medical care and services

Doctor visits, specialist consultations, hospital stays, surgery, ambulance services, lab work, diagnostic imaging (X-rays, MRIs, CT scans), physical therapy, occupational therapy, speech therapy, chiropractic care, mental health counseling, psychiatric care, substance abuse treatment, fertility treatments, and preventive care including annual physicals, screenings, and immunizations.

Prescription drugs and medications

All prescription medications are eligible. Since the CARES Act of 2020, over-the-counter medications are also eligible without a prescription — including pain relievers, allergy medicine, cold and flu remedies, antacids, and similar products. Insulin has always been eligible without a prescription.

Menstrual products

Also added by the CARES Act. Tampons, pads, menstrual cups, and similar products are eligible without any prescription or LMN.

Dental care

Cleanings, fillings, crowns, bridges, dentures, orthodontics (braces), root canals, extractions, dental X-rays, and periodontal treatment. Teeth whitening is not eligible.

Vision care

Eye exams, prescription eyeglasses, prescription sunglasses, contact lenses, contact lens solution and supplies, and laser eye surgery (LASIK, PRK). Non-prescription sunglasses are not eligible.

Hearing

Hearing exams, hearing aids, hearing aid batteries and repairs, cochlear implants.

Mental health

Therapy and counseling sessions, psychiatric care, psychological testing, inpatient mental health treatment, and substance abuse treatment including inpatient rehabilitation.

Long-term care

Qualified long-term care services and long-term care insurance premiums (up to age-based limits set annually by the IRS under §213(d)(10)).

Medical equipment and supplies

Crutches, wheelchairs, walkers, blood pressure monitors, glucose monitors and test strips, thermometers, bandages, first aid kits, and other durable medical equipment prescribed by a physician.

Items that require a Letter of Medical Necessity

These items are only eligible when a licensed healthcare provider documents that they are treating, mitigating, or preventing a specific diagnosed medical condition. Without an LMN, the IRS considers them personal expenses.

What makes a valid LMN

A Letter of Medical Necessity should come from a licensed healthcare provider and must identify the specific diagnosed condition being treated, explain why the item or service is medically necessary, and be dated before or at the time of purchase. Keep the LMN with the receipt as part of your documentation.

Exercise and fitness

Gym memberships, personal training, fitness equipment (treadmills, exercise bikes, resistance bands). Eligible only when prescribed to treat a specific condition such as obesity, cardiovascular disease, diabetes, or hypertension.

Weight-loss programs

Programs like Weight Watchers, Noom, or medically supervised weight loss. Eligible when prescribed to treat a diagnosed condition like obesity. Weight loss for general health or appearance does not qualify.

Vitamins and supplements

Only eligible when prescribed to treat a specific diagnosed deficiency or medical condition. A daily multivitamin taken for general wellness does not qualify.

Massage therapy

Eligible when prescribed to treat a diagnosed condition such as chronic pain, injury recovery, or a musculoskeletal disorder. Massage for relaxation or stress relief does not qualify.

Acupuncture

Generally eligible as a medical treatment, though some plan administrators may request an LMN depending on the condition being treated.

Air purifiers, humidifiers, and air conditioners

Eligible when prescribed to treat respiratory conditions like asthma or severe allergies.

Special mattresses and ergonomic equipment

Eligible when prescribed for a diagnosed condition like chronic back pain, sleep apnea, or a specific orthopedic issue.

Sunscreen

SPF 15+ sunscreen is eligible without an LMN as a preventive care item. This is one of the most commonly overlooked eligible expenses.

Commonly overlooked eligible expenses

Sunscreen (SPF 15+), OTC medications (since the CARES Act), menstrual products, contact lens solution, first aid kits, and bandages are all eligible without a prescription or LMN. Many people pay for these out-of-pocket without realizing they could be using HSA funds or building their unreimbursed balance.

What is NOT eligible

Cosmetic procedures

Facelifts, liposuction, teeth whitening, hair transplants, and similar procedures are not eligible unless they correct a deformity arising from disease, accidental injury, or a congenital abnormality.

General health and wellness

Nutritional supplements for general health, gym memberships without a medical prescription, spa treatments, personal care products, and general fitness programs.

Health insurance premiums

With specific exceptions: COBRA continuation coverage, coverage while receiving unemployment compensation, Medicare premiums (Parts A, B, D, and Medicare Advantage) for individuals age 65+, and qualified long-term care insurance premiums. Regular health insurance premiums, including HDHP premiums, are generally not eligible.

Non-medical services

Childcare, elder care (unless it qualifies as long-term care), household help, and personal convenience items.

Funeral and burial expenses

Not eligible.

Non-prescription items that are not OTC drugs or menstrual products

Toiletries, cosmetics, and personal hygiene products (other than those specifically eligible like sunscreen and first aid supplies) do not qualify.

What changed in 2026: the OBBBA

The One Big Beautiful Bill Act (OBBBA), signed into law in July 2025, made several changes that affect HSA-eligible expenses and eligibility starting in 2026. IRS Notice 2026-5 provides the implementing guidance.

Direct Primary Care fees are now qualified medical expenses

Starting January 1, 2026, periodic fees paid to a direct primary care arrangement can be reimbursed from your HSA tax-free. DPC arrangements are subscription-based models where you pay a fixed monthly fee directly to a primary care provider for routine medical services, outside of insurance. The monthly fee cap is $150 for individual coverage and $300 for family coverage. Fees above these caps are still qualified medical expenses for HSA reimbursement, but the arrangement itself becomes disqualifying coverage for HSA contributions. DPC fees paid by an employer (including through a cafeteria plan) cannot be reimbursed from the employee's HSA.

DPC fee caps matter for HSA eligibility

If your DPC monthly fee exceeds $150 (individual) or $300 (family), you can still reimburse the fee from your HSA -- but the arrangement itself becomes disqualifying coverage, meaning you can no longer contribute to your HSA while enrolled. Stay under the caps if you want to keep contributing.

Telehealth safe harbor is now permanent

HDHPs can cover telehealth and other remote care services before the deductible is met without disqualifying the enrollee from HSA contributions. This had been a temporary provision since the CARES Act, renewed twice by Congress. It is now permanent for plan years beginning after December 31, 2024.

Bronze and Catastrophic ACA plans now qualify as HDHPs

Effective January 1, 2026, Bronze and Catastrophic plans purchased through an ACA Exchange are treated as HSA-compatible high-deductible health plans, even if they do not meet the traditional HDHP deductible and out-of-pocket maximum requirements. This opens HSA eligibility to millions of people who were previously excluded.

2026 contribution limits

For reference, the 2026 annual contribution limits are $4,400 for self-only coverage and $8,750 for family coverage (Rev. Proc. 2025-19). The catch-up contribution for individuals age 55 and older remains $1,000 (this amount is statutory and not indexed for inflation).

The gray zone: when in doubt

The eligible expense list runs to hundreds of items, and the boundaries are not always clear. A hot tub is not eligible for general use, but it may be eligible with an LMN if prescribed to treat a specific condition like severe arthritis. A standing desk is not eligible as a work preference, but it may be eligible if prescribed for a diagnosed back condition.

When you are unsure, the safest approach is:

Check IRS Publication 502 for the specific item or category
If the item is not clearly listed, ask whether its primary purpose is to treat, mitigate, or prevent a diagnosed medical condition
If it falls in the gray zone, get an LMN from your healthcare provider before making the purchase
Keep the LMN with the receipt as part of your documentation

And always remember: if the IRS determines that a distribution was not for a qualified medical expense, the funds are taxable as ordinary income plus a 20% penalty (waived after age 65 or upon disability). The stakes for getting this wrong are not trivial.

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This article is for informational purposes only and does not constitute tax advice. The eligible expense categories listed here are summaries, not exhaustive legal definitions. Consult IRS Publication 502 for the authoritative list and a qualified tax professional before making HSA decisions. IRS guidance referenced: IRC §213(d); IRS Publication 502; IRS Notice 2026-5; OBBBA (Pub. L. 119-21).