What Actually Counts as an HSA-Eligible Expense?

The IRS defines "qualified medical expenses" for HSA purposes in Publication 502, and the list is longer — and sometimes more surprising — than most people assume. Here's a practical breakdown, organized by category. As always, when in doubt about a specific expense, check current IRS guidance or ask a tax professional; this is a general guide, not tax advice.

Clearly eligible, almost always

• Doctor, specialist, and dental visits (copays, coinsurance, and costs before you hit your deductible)
• Prescription medications
• Vision care: eye exams, glasses, contact lenses and solution, and vision correction surgery like LASIK
• Dental care: cleanings, fillings, crowns, orthodontia
• Mental health: therapy, psychiatric care, and counseling
• Physical therapy and chiropractic care
• Hearing aids and batteries
• Durable medical equipment: crutches, wheelchairs, blood pressure monitors, CPAP machines

Over-the-counter items (broader than people expect)

Since 2020, OTC medications no longer require a prescription to be HSA-eligible. This includes things like pain relievers, allergy medication, cold and flu remedies, and similar OTC drugs. Menstrual care products are also explicitly eligible. Many people miss this and pay for these items with a regular debit card out of habit, leaving eligible expenses unclaimed.

Categories people get wrong

Cosmetic procedures are generally not eligible — a nose job for appearance reasons, teeth whitening, and similar purely cosmetic work don't qualify, even though they're performed by a licensed provider. The exception is when a procedure corrects a deformity from an accident, illness, or congenital condition — that shifts it from cosmetic to medical.

General health and wellness items are usually not eligible just because they're "good for you." Vitamins and supplements typically don't qualify unless prescribed for a specific diagnosed condition. Gym memberships are generally not eligible either, though there are narrow exceptions if a doctor prescribes exercise to treat a specific diagnosed condition — the bar for that is high and needs documentation.

Health insurance premiums are usually not eligible, with a few specific exceptions: COBRA premiums, premiums while collecting federal or state unemployment, and Medicare premiums (excluding Medigap) for those 65+.

Categories that surprise people (in a good way)

• Travel for medical care: mileage, and in some cases lodging, when you travel primarily for medical treatment
• Breast pumps and lactation supplies
• Acupuncture
• Smoking cessation programs and prescribed medications
• Weight-loss programs, but only when prescribed by a doctor to treat a specific diagnosed disease (not general weight loss)
• Long-term care insurance premiums, up to age-based IRS limits

When it's genuinely unclear

Plenty of expenses sit in a gray area — a specific supplement, a specialized mattress recommended for a back condition, a service that's partly medical and partly personal. When something is ambiguous, the safest approach is a letter of medical necessity from your provider explaining why the expense treats a specific diagnosed condition, kept alongside the receipt. That documentation is what protects you if the IRS ever asks about a distribution.

Why this matters for record-keeping

Because the eligible list is broad and includes a lot of small, easy-to-forget purchases — OTC allergy medication, a mileage log for a specialist visit two states away — it's easy to either miss legitimate reimbursements or, worse, lose track of what you've already claimed. Every receipt you save is a future tax-free reimbursement, or evidence you need if a distribution is ever questioned. That's the entire premise behind SaveMyHSA: capture the receipt once, tag it correctly, and never have to reconstruct three years of medical spending from memory.