The IRS decides what counts, and the list is longer than most people think
A health savings account lets you spend money on medical expenses without paying income tax on that money. The IRS publishes a list of what qualifies, and it includes far more than doctor visits and prescriptions. You can buy insulin, physical therapy, dental work, vision care, hearing aids, crutches, and dozens of other things. You cannot buy cosmetic procedures, vitamins (unless prescribed for a specific condition), or most over-the-counter medicines without a prescription.
The rule is straightforward: if a medical professional diagnoses a condition and the item treats or prevents that condition, it usually qualifies. The tricky part is that "medical professional" does not always mean a doctor. A dentist, optometrist, audiologist, or chiropractor can all sign off on expenses that count. What matters is whether the IRS considers the item a treatment for a diagnosed medical condition, not whether your insurance covers it.
Key Takeaways
- Prescription medications, medical equipment, and treatments ordered by any licensed medical professional count toward HSA spending, even if insurance does not cover them.
- Over-the-counter medicines require a prescription from a doctor to may have access to, with the exception of insulin, which qualifies without one.
- Dental, vision, and hearing care all count, as do mental health services, physical therapy, and chiropractic care.
- Cosmetic procedures, gym memberships, and general wellness products do not count, even if they improve your health.
- You can spend HSA money on family members' medical expenses, not just your own, if they are your dependents.
Prescription medications and insulin
Any prescription medication counts, regardless of what it treats. Diabetes medication, blood pressure pills, antibiotics, antidepressants, birth control, and inhalers all may have access to. You can buy them at a pharmacy, through mail order, or from an online pharmacy, as long as a licensed doctor prescribed them.
Insulin is the single exception to the prescription rule. You can buy insulin with HSA money without a prescription. This matters because some people buy insulin over the counter in states where it is available that way, and the IRS treats it as a may have access to expense either way.
Over-the-counter medicines like ibuprofen, acetaminophen, antihistamines, and cough syrup do not count unless a doctor writes a prescription for them. This is a common source of confusion because you can walk into a pharmacy and buy these items without a prescription, but the IRS does not consider them HSA-may be able to access unless a doctor has specifically ordered them for you.
Medical equipment and supplies
If a doctor orders it to treat a medical condition, it counts. This includes crutches, wheelchairs, walkers, blood pressure monitors, glucose meters, test strips, lancets, bandages, compression stockings, and heating pads. You can buy these at a pharmacy, medical supply store, or online retailer.
Eyeglasses and contact lenses count, along with the solution and cases you need to maintain them. Hearing aids and hearing aid batteries count. Orthopedic shoes count if a doctor prescribes them for a foot condition, but regular shoes do not, even if they are supportive.
The line between medical equipment and general wellness is where confusion often starts. A mattress does not count, even if a doctor says better sleep would help your back pain. A standing desk does not count. A humidifier does not count. But a CPAP machine for sleep apnea does, because it is a device that treats a diagnosed condition.
Dental, vision, and hearing care
Dental work counts in full: cleanings, fillings, root canals, crowns, extractions, braces, and dentures all may have access to. You do not need a referral from your primary care doctor. A dentist's recommendation is enough. Dental X-rays and exams count too.
Vision care includes eye exams, glasses, contact lenses, and surgery like LASIK or cataract removal. You can use HSA money at an optometrist or ophthalmologist. Sunglasses do not count, even if they have a prescription in them.
Hearing aids and the cost of fitting them count. Hearing tests count. Cochlear implants count. Batteries for hearing aids count. But earbuds and headphones do not, even if you use them to manage tinnitus.
Mental health and therapy services
Therapy, counseling, and psychiatric care all count. You can use HSA money to pay a therapist, psychologist, psychiatrist, or counselor for sessions. Inpatient mental health treatment counts. Outpatient programs count. Medication for mental health conditions counts.
This includes therapy for conditions like depression, anxiety, PTSD, eating disorders, and substance use. It also includes therapy for adjustment issues, grief, or relationship problems if a mental health professional is providing it. The key is that a licensed mental health professional is delivering the service.
Physical therapy, chiropractic care, and other treatments
Physical therapy ordered by a doctor counts. Chiropractic care counts if a doctor refers you or if a chiropractor diagnoses a condition and treats it. Acupuncture counts if a doctor orders it. Massage therapy counts if a doctor prescribes it for a medical condition, but not if you are paying for it as general wellness.
The pattern here is consistent: if a licensed medical professional diagnoses a condition and orders the treatment, it counts. If you are paying for it because it feels good or you think it will help you stay healthy, it does not.
What does not count
Cosmetic procedures do not count, even if they are performed by a doctor. Botox, fillers, teeth whitening, and hair removal do not may have access to. Cosmetic surgery does not may have access to unless it is reconstructive—for example, surgery to repair a scar from an accident or injury counts, but surgery to change the shape of your nose for appearance does not.
Gym memberships, fitness classes, and general wellness products do not count. Vitamins and supplements do not count unless a doctor prescribes them for a specific diagnosed deficiency. Sunscreen does not count. Toothpaste does not count. Deodorant does not count.
Long-term care insurance premiums do not count. Health insurance premiums do not count (with narrow exceptions for COBRA, Medicare, and military health coverage). Cosmetic dentistry like veneers or whitening does not count.
Spending HSA money on family members
You can spend your HSA on medical expenses for your spouse and any dependent children, even if they are not covered by your health plan. You cannot spend it on an adult child who is no longer your dependent, even if you help pay their medical bills. You cannot spend it on a parent unless that parent is your dependent for tax purposes.
This matters because it means a family HSA can cover multiple people's medical costs. If your spouse has a dental procedure or your child needs glasses, you can pay for those with your HSA money.
How to know if something qualifies
The IRS publishes a full list of may have access to medical expenses in Publication 502. If you are unsure whether something counts, you can check that list or ask your HSA provider. Many HSA administrators have a searchable database on their website where you can look up specific items.
When in doubt, the safest approach is to keep the receipt and the doctor's order or prescription. If the IRS ever questions the expense, you will have documentation that a medical professional ordered it. You are not required to submit receipts when you spend HSA money, but keeping them protects you if there is ever a question about whether an expense was legitimate.
Frequently Asked Questions
Can I buy over-the-counter pain relievers with my HSA?
Not without a prescription. Ibuprofen, acetaminophen, and other over-the-counter pain relievers do not count as HSA-may be able to access expenses unless a doctor writes a prescription for them. Insulin is the only over-the-counter medicine that counts without a prescription.
Does my HSA cover dental work?
Yes. All dental care counts: cleanings, fillings, root canals, crowns, braces, and extractions. You do not need a referral from your primary care doctor. A dentist's recommendation is sufficient.
Can I use my HSA for my adult child's medical expenses?
Only if that child is still your dependent for tax purposes. Once they are independent, you cannot use your HSA to pay their medical bills, even if you help support them.
What if my doctor prescribes something that my insurance does not cover?
You can still use your HSA to pay for it. HSA may be able to access is based on whether a medical professional ordered it, not on whether your insurance covers it. Keep the prescription and receipt in case you need to document the expense later.
Does my HSA cover cosmetic procedures?
Not unless they are reconstructive. Cosmetic procedures like teeth whitening, Botox, or elective nose surgery do not count. Reconstructive surgery—for example, to repair a scar from an accident—does count.