What Can You Spend Your HSA On? A Physician's Complete Guide to HSA-Eligible Expenses (2026)

The IRS-approved expense list is significantly broader than most HSA holders realize, and for physicians who have built a meaningful HSA balance using the stealth IRA strategy, knowing exactly what qualifies determines how effectively that balance can be deployed.

This guide covers every major category of HSA-eligible expenses in 2026, the physician-specific expenses most commonly overlooked, what requires a Letter of Medical Necessity, what is explicitly not covered, and how to document everything so a tax-free withdrawal made years from now holds up if the IRS ever asks.

The Legal Foundation: What Makes an Expense HSA-Eligible

The IRS defines qualified medical expenses as amounts paid for the "diagnosis, cure, mitigation, treatment, or prevention of disease, and for treatments affecting any part or function of the body," as outlined in Section 213(d) of the Internal Revenue Code and detailed in IRS Publication 502.

The critical phrase is primarily for medical care. Expenses that are merely beneficial to general health — a gym membership, vitamins, organic food — do not qualify on their own. The same expense can become eligible when prescribed by a physician to treat a specific, diagnosed medical condition. This distinction is where the Letter of Medical Necessity becomes relevant, covered in detail below.

Qualified HSA expenses can be incurred by you, your spouse, and any dependents you claim on your federal tax return. The dependency definition for HSA purposes is slightly broader than the standard tax definition — the person only needs to have been your dependent either when the medical services were provided or when you paid the bill.

One rule that catches people off guard: expenses must be incurred after your HSA was established. A medical bill from 2023 cannot be reimbursed tax-free from an HSA you opened in 2024. The HSA must exist before the expense is incurred.

What Changed in 2026: The OBBBA Expansion

The One Big Beautiful Bill Act, signed July 4, 2025, made the most significant expansion of HSA-eligible expenses since the accounts were created in 2003. Several categories that were previously excluded or uncertain are now explicitly covered:

• •Direct Primary Care membership fees are now HSA-eligible expenses effective January 1, 2026. A physician paying $100 per month for a DPC membership — for themselves or a family member — can now reimburse that cost tax-free from their HSA. The monthly maximum is $150 per individual or $300 per family. For physicians evaluating DPC membership for their own family's healthcare, this makes the cost significantly more favorable after tax.
• •All ACA Bronze and Catastrophic Marketplace plans now qualify as HDHPs automatically, making them HSA-compatible. Self-employed physicians, locum tenens practitioners, and practice owners purchasing individual coverage now have broader access to HSA-qualified plans on the individual market.
• •Telehealth pre-deductible coverage is now permanently permitted without disqualifying HSA eligibility. Previously extended through temporary legislation repeatedly, this is now a permanent rule. Physicians can use telehealth benefits before meeting their HDHP deductible and still contribute to and use their HSA freely.

The Core Categories: What Your HSA Covers

Medical and Preventive Care

The broadest and most straightforward category. Every physician-billed medical service for the diagnosis, treatment, or prevention of disease qualifies. This includes:

• •Annual physical examinations and preventive screenings.
• •Specialist consultations.
• •Emergency room visits, urgent care, and hospital stays including room and board.
• •Surgical procedures — elective or emergency — performed for medical reasons.
• •Laboratory fees and diagnostic tests including MRI, CT scans, X-rays, and bloodwork.
• •Vaccines and immunizations.
• •Physical therapy and occupational therapy.
• •Chiropractic care.
• •Acupuncture — recognized as an HSA-eligible expense under Publication 502.

Transportation to and from medical appointments qualifies as well. If you drive your own vehicle, the 2026 IRS medical mileage rate is 20.5 cents per mile. Bus, train, and rideshare fares to medical appointments are fully eligible. Lodging while traveling for medical care qualifies up to $50 per night per person — up to $100 per night if a companion must travel with you.

Prescription Medications

All prescription medications dispensed by a licensed pharmacist are HSA-eligible without any additional documentation. This includes maintenance medications for chronic conditions, antibiotics, controlled substances prescribed by a physician, insulin, and any other drug requiring a prescription.

Prescription medications for mental health conditions — antidepressants, anti-anxiety medications, mood stabilizers, ADHD medications, sleep aids — qualify on the same basis as any other prescription drug. There is no distinction between physical and mental health prescriptions for HSA purposes.

Over-the-Counter Medications and Products

Since the CARES Act took effect in 2020 and permanently changed OTC rules, over-the-counter medications are HSA-eligible without a prescription. This remains in effect for 2026.

OTC medications that qualify include pain relievers such as ibuprofen, acetaminophen, and naproxen. Allergy medications. Cold and flu medications. Antacids and digestive aids. Sleep aids. First aid supplies including bandages, antiseptics, and wound care products.

Products added permanently without prescription requirement also include menstrual care products — tampons, pads, menstrual cups, and similar items. Contraceptives including over-the-counter oral contraceptives, emergency contraceptives, and male condoms are HSA-eligible without a prescription under the 2026 rules. Masks, hand sanitizer, sanitizing wipes, and disposable gloves also remain eligible.

The practical takeaway for physicians: your next trip to CVS or Walgreens for personal OTC medications can be paid with your HSA card or reimbursed from your HSA. Keep the receipt.

Dental Care

Dental care is one of the most underutilized HSA expense categories. The full scope of dental expenses covered includes:

• •Dental exams, X-rays, and cleanings.
• •Fillings, crowns, bridges, and root canals.
• •Tooth extractions.
• •Orthodontic treatment — including adult orthodontics and Invisalign when used to correct a dental condition.
• •Dentures and implants.
• •Periodontal treatment for gum disease.
• •Oral surgery.

Cosmetic dental procedures present a gray area. Teeth whitening and purely aesthetic procedures do not qualify. Porcelain veneers placed for cosmetic reasons are not covered. However, the same procedure performed to address a structural or functional dental problem — replacing a damaged tooth, correcting bite problems causing pain — can qualify depending on documentation of medical necessity.

Vision Care

Vision care is broadly covered and highly relevant for physicians whose professional performance depends directly on visual acuity.

Comprehensive eye examinations. Prescription eyeglasses and frames. Prescription contact lenses and associated supplies including contact lens solution. LASIK laser vision correction surgery — fully eligible as an HSA expense for physicians considering this procedure. PRK, LASEK, and other refractive surgery procedures qualify on the same basis. Prescription sunglasses qualify; non-prescription sunglasses do not. Cataract surgery and other medically necessary eye procedures are covered.

For surgeons, interventional physicians, and any specialist whose precision depends on vision quality, LASIK represents a meaningful HSA opportunity. A LASIK procedure costing $4,000 to $6,000 paid from an HSA saves approximately $1,400 to $2,100 in federal taxes at a 35 percent marginal rate — plus state tax savings on top. The procedure is not deductible or reimbursable any other way once the HSA funds are spent. This is one of the highest-dollar individual HSA expenditures that qualifies cleanly without any additional documentation.

Mental Health Services

Mental health services are fully eligible HSA expenses and an area of particular relevance for physicians given documented burnout rates across virtually every specialty.

Individual therapy and counseling with a licensed psychologist, psychiatrist, licensed clinical social worker, or licensed professional counselor. Group therapy sessions. Inpatient mental health treatment, including meals and lodging during residential treatment. Substance abuse treatment programs. Psychiatric medication management appointments.

The IRS makes no distinction between physical health and mental health in determining HSA eligibility. A therapy session qualifies on exactly the same basis as a cardiology appointment. For physicians who are paying out of pocket for therapy — which many do deliberately to maintain confidentiality outside their employer's insurance network — the HSA reimbursement makes that cost entirely tax-free.

Physicians using the stealth IRA strategy who are paying for therapy out of pocket should be saving the receipts. A year of weekly therapy sessions at $150 to $250 per session represents $7,800 to $13,000 in documented, reimbursable expenses that can be withdrawn tax-free from the HSA at any point in the future.

Fertility and Reproductive Treatments

Fertility-related medical expenses are HSA-eligible in full. This category is more expensive and more commonly needed than most HSA guides acknowledge.

• •In vitro fertilization including all related procedures — egg retrieval, fertilization, embryo transfer, and associated laboratory fees.
• •Fertility medications and injections.
• •Sperm banking and egg freezing for medical reasons — including egg freezing performed in anticipation of medical treatment that may affect fertility, such as chemotherapy or radiation.
• •Fertility evaluations and diagnostic testing.
• •Surrogacy medical costs are partially covered — the medical expenses for the surrogate qualify; legal fees and agency fees do not.

Vasectomy and tubal ligation both qualify as HSA-eligible medical procedures.

For physicians who have pursued fertility treatment — costs that routinely run $15,000 to $30,000 or more per IVF cycle — the ability to retroactively reimburse from an HSA for expenses incurred in prior years (with receipts intact) represents a meaningful tax-free withdrawal opportunity. There is no IRS time limit on when you can reimburse an HSA-eligible expense — a 2022 IVF bill can be reimbursed in 2035, provided the HSA existed when the expense was incurred and the receipt is documented.

Hearing Care

Hearing examinations. Hearing aids and batteries. Cochlear implant surgery. Hearing aid maintenance and repair. Custom earplugs for noise-induced hearing protection when prescribed for medical purposes.

Long-Term Care

Long-term care insurance premiums are HSA-eligible up to an age-based IRS limit. For 2026:

Long-term care services — skilled nursing facility care, home health aide services, assisted living — are also eligible when medically necessary. For physicians approaching retirement age or planning for aging parents, the ability to pay long-term care insurance premiums from an HSA creates a tax-free way to fund one of the largest potential retirement expenses.

COBRA and Certain Insurance Premiums

Health insurance premiums generally do not qualify as HSA expenses. There are three explicit exceptions:

• •COBRA continuation coverage premiums are HSA-eligible. A physician between jobs, on leave, or transitioning between practices who is paying COBRA premiums can reimburse those costs tax-free from their HSA. This can represent $800 to $2,500 per month in eligible expenses during a transition period.
• •Medicare premiums are HSA-eligible after age 65. Medicare Part A, Part B, Part D, and Medicare Advantage plan premiums can all be paid or reimbursed from an HSA tax-free. This is one of the most valuable HSA features for retired physicians — it effectively allows the HSA to cover a significant portion of the healthcare cost structure in retirement tax-free.
• •Long-term care insurance premiums up to the age-based limits above.

Regular employer-sponsored health insurance premiums, ACA Marketplace plan premiums (in most circumstances), and other standard health insurance premiums do not qualify.

Physician-Specific Expenses Worth Knowing

Several HSA-eligible expenses are particularly relevant to physicians that general personal finance guides rarely cover.

• •Ergonomic equipment with a Letter of Medical Necessity. A standing desk, ergonomic chair, lumbar support device, or other workplace equipment prescribed by a physician to treat a specific musculoskeletal condition qualifies with documentation. For physicians experiencing back pain, repetitive strain injuries, or other occupational health conditions common in clinical practice, this can turn necessary workplace equipment into a tax-free HSA expense.
• •Home modifications for medical purposes. Wheelchair ramps, grab bars, widened doorways, and other home modifications made for medical reasons are HSA-eligible. The amount deductible is limited to the cost that exceeds any increase in home value the modification creates — but modifications that add no market value, like grab bars, qualify in full.
• •Weight loss programs with medical necessity. A medically supervised weight loss program prescribed to treat obesity, hypertension, or another diagnosed condition qualifies. General wellness programs and gym memberships do not qualify without an LMN for a specific condition.
• •Stop smoking programs. Prescription cessation medications and physician-supervised stop smoking programs are fully eligible without any additional documentation.
• •Sleep studies and CPAP equipment. Sleep apnea diagnosis, overnight sleep studies, CPAP machines, masks, and associated supplies all qualify. Replacement CPAP supplies — tubing, filters, cushions — qualify as ongoing HSA expenses.
• •Wearable health monitors. Continuous glucose monitors for diagnosed diabetics are HSA-eligible. Wearable devices purchased specifically to diagnose or monitor a medical condition may qualify with appropriate documentation. General fitness trackers and smartwatches purchased for wellness purposes do not qualify.

What Requires a Letter of Medical Necessity

A Letter of Medical Necessity is a written statement from a licensed physician explaining that a specific item or service is medically necessary to treat a diagnosed condition. Without an LMN, certain expenses that could qualify do not qualify — and with one, expenses that would otherwise be ineligible become eligible.

Common physician expenses that may require an LMN to qualify:

• •Fitness and exercise expenses for a specific diagnosed condition. A physician-prescribed exercise program to treat cardiovascular disease, obesity, or a specific musculoskeletal condition can qualify with an LMN. A general gym membership for fitness does not.
• •Nutritional supplements and specialized diets. Vitamins and supplements are generally not eligible. When specifically prescribed to treat a diagnosed deficiency or condition — iron supplementation for documented iron-deficiency anemia, for example — they may qualify with an LMN.
• •Air purifiers and home air quality equipment. Prescribed for a patient with asthma, severe allergies, or other documented respiratory conditions, a HEPA air purifier can qualify as an HSA expense with appropriate documentation.
• •Ergonomic workplace equipment as described above — prescribed for a specific occupational injury or musculoskeletal diagnosis.

The LMN should be written on the prescribing physician's letterhead, include the diagnosis being treated, the specific item or service recommended, and the medical rationale. Keep the LMN with the receipt for the expense permanently — it is your documentation if a withdrawal is ever questioned.

What Is Not Eligible: Common Misconceptions

Several expenses physicians commonly assume are covered are not HSA-eligible without the right documentation — or at all.

• •Cosmetic procedures without a medical purpose do not qualify. Botox for wrinkles, rhinoplasty for aesthetic purposes, and teeth whitening are not eligible. The same procedures performed to treat a documented medical condition — Botox for chronic migraine treatment, rhinoplasty to correct a deviated septum causing breathing obstruction — do qualify.
• •General vitamins and supplements purchased for overall health are not eligible. As noted above, medically prescribed supplements for a documented deficiency may qualify with an LMN.
• •Standard gym memberships and fitness equipment are not eligible without an LMN for a specific condition. The IRS is explicit that expenses beneficial to general health but not treating a specific condition do not qualify.
• •Toothpaste, soap, and general personal hygiene products are not eligible. Medicated shampoos prescribed for scalp conditions and similar medically prescribed personal care products may qualify.
• •Health insurance premiums in most circumstances as described above.
• •Funeral and burial expenses are explicitly excluded.
• •Maternity clothes and nursing supplies — breast pumps and lactation supplies are eligible; maternity clothing is not.

How to Document HSA Expenses Correctly

The IRS requires documentation to substantiate tax-free HSA withdrawals. There is no filing requirement when you use your HSA — you simply report the withdrawal on your tax return. But if the IRS questions a distribution, you must be able to produce records.

What counts as acceptable documentation:

An Explanation of Benefits from your insurance carrier. An itemized receipt from a pharmacy, medical office, or laboratory showing the date, provider, amount, and description of service. A credit card or bank statement showing the payment, paired with a description of the service.

How to store them:

A dedicated folder in cloud storage — Google Drive, Dropbox, iCloud — organized by year is the most reliable long-term system. Photograph paper receipts immediately when you receive them. The IRS does not specify a format, only that records be accessible and legible.

How long to keep them:

Indefinitely. Since there is no time limit on when you can reimburse an HSA-eligible expense from a prior year, a receipt from 2024 might be used to support a withdrawal in 2040. Permanent storage in cloud backup is the appropriate approach.

The Retroactive Reimbursement Strategy: Why Documentation Matters So Much

The most powerful HSA strategy for high-income physicians is to pay every medical expense out of pocket during their working years, save every receipt, and allow the HSA to compound tax-free for decades. When they eventually reimburse themselves — at retirement, or earlier if needed — they withdraw the original expense amount plus all the growth it generated, entirely tax-free.

A physician who paid $5,000 in dental work out of pocket in 2026 and saved the receipt can reimburse themselves from the HSA at any point in the future. If the HSA grew at 7 percent annually, the $5,000 that would have covered that dental bill in 2026 has grown to approximately $9,750 in 2036 — all of it tax-free upon withdrawal for the documented expense.

The documentation is the key that unlocks this strategy. Without the receipt, the $9,750 withdrawal could be challenged as a non-qualified distribution subject to income tax and a 20 percent penalty. With the receipt, it is entirely tax-free regardless of when it is taken.

Maintain a running spreadsheet of unreimbursed HSA-eligible expenses by year. Each row: date, provider, amount, category, receipt file location. This document is your retirement reimbursement log and should be treated as a financial asset.

Use our HSA Contribution Calculator to estimate the tax-free balance you can accumulate over your career based on your contribution amount, investment return, and years until retirement.