How Does a Health Savings Account Work?

An HSA is a good way to save, tax-free, for medical expenses. Image © Grenouille Films/E+/Gettyimages

An HSA, or Health Savings Account, is a special type of tax-advantaged savings account designed to help you pay for out-of-pocket medical expenses when you have a high-deductible health plan, or HDHP. In addition to being a smart way to pay for medical expenses like your deductible, copays, and coinsurance, HSAs are increasingly being used as part of a retirement-planning strategy.

However, because of the tax-advantages, there are lots of rules about who is allowed to start an HSA, who can contribute money to an HSA, and what that money can be used for.

If you don’t follow the rules, you’ll lose the tax advantages and owe additional penalties.

How Does an HSA Lower My Taxes?

If you manage your HSA correctly and follow all of the IRS rules, your HSA money is:

  • Not taxed when you earn it and put it into the HSA.
  • Not taxed as it grows.
  • Not taxed when you take it out of the HSA.

Here’s how it works. The money you put into your HSA is tax-deductible. If your employer contributes to your HSA, that money isn't counted as income so you're not paying taxes on it, either.

Interest and investment earnings in your HSA grow tax-deferred like they do in an IRA. Since you’re not paying income taxes each year on the interest, you keep more of that interest in the account, and the account grows more quickly.

If you take money out of your HSA to pay for qualified medical expenses, you don’t have to pay income taxes on it. However, if you take money out of your HSA but don’t use it for medical expenses, you’ll have to pay income taxes on it plus a 20% penalty.

After you turn 65 years old, the rules are a little different. If you’re on Medicare, you can’t contribute to your HSA anymore. However, you can still use the money you’ve saved in your HSA. Unlike before you turned 65, you can spend your HSA money on anything you want and you won’t have the 20% penalty.

However, you’ll have to pay income taxes on HSA withdrawals not used for medical expenses. If you take money out of your HSA and use it for qualified medical expenses, you don’t pay regular income taxes on it; it’s totally tax-free.

Who’s Eligible for an HSA?

You’re eligible to start and contribute to an HSA if you meet all of these requirements:

  1. You’re covered by a qualified HDHP.
  2. You don’t have additional, more traditional, health insurance coverage.
  3. You aren’t on Medicare.
  4. Nobody else can claim you as a dependent on their tax return.
  5. You don't have a general purpose Flexible Spending Account.

If you already have an HSA and you no longer meet all of the eligibility criteria, in most cases, you may still keep the HSA and use the money in it to pay for eligible medical expenses. However, you can’t contribute any more money into the HSA if you don’t meet all of the eligibility criteria listed above.

How Does Money Get Into the HSA?

You can contribute money into your HSA yourself, your employer may contribute money into your HSA, or another person may contribute money into your HSA.

However, the total yearly contributions to your HSA are limited. The limits change each year and vary based on your age and whether you have self-only HDHP coverage or family coverage.

Yearly HSA Contribution Limits
Self-only coverage under age 55$3,300$3,350
Family coverage under age 55$6,550$6,650
Self-only coverage age 55+$4,300$4,350
Family coverage age 55+$7,550$7,650

If your HDHP health insurance coverage is through your job, you employer might make contributions to your HSA. Additionally, many employers set up payroll deductions so you can easily contribute a portion of each paycheck directly into your HSA.

If your health insurance isn’t through your job, your employer probably won’t be involved. In this case, most people make automatic monthly contributions to their HSA. However, some financial institutions allow you to make a lump-sum contribution to your HSA rather than monthly contributions.

You may be able to fund your HSA with a distribution from your traditional or Roth IRA. The distribution must be made directly by the trustee of the IRA to the trustee of the HSA and is only allowed once in your lifetime. Learn more about this from IRS publication 969 or your financial advisor.

As with your IRA, you may contribute to your HSA through April 15th of the following year. For example, if you had HDHP coverage in 2014 but didn’t max-out your 2014 HSA contributions, you may make an additional 2014 contribution as you’re preparing your taxes on April 15, 2015.

What Can I Spend HSA Money On?

The money in your HSA is yours. You can spend it on whatever you wish. However, if you want to avoid paying income taxes and penalties on it, you’ll only take a distribution from your HSA to pay for eligible medical expenses.

Eligible medical expenses include medical expenses your health insurance doesn’t pay for, but that are eligible to be taken as a deduction on your federal income taxes. See the entire list in IRS Publication 502, but here’s a synopsis:

  • Your health insurance deductible, copayments, and coinsurance.
  • Prescription medications. Over the counter medicine like Tylenol isn’t eligible unless you have a prescription for it. Medical marijuana isn’t eligible even if you have a prescription and are in a state where it’s been legalized.
  • Dental expenses like teeth cleanings, preventive care, and fillings. However, purely cosmetic dentistry like teeth whitening isn’t eligible.
  • Eye exams, vision correction surgery, glasses, contact lenses, and contact lens supplies as long as the glasses or contacts are used for medical reasons like vision correction.
  • Breast feeding supplies.
  • Diabetic supplies.
  • In vitro fertilization expenses.
  • Alternative medical care your health insurance may not cover such as acupuncture treatments, chiropractic care, and medical care provided by a Christian Science practitioner.

Even though your HSA is technically an individual account, you may use it to pay for the eligible medical expenses of your spouse and your tax dependents, also.

In some cases, you can take a tax-free distribution from your HSA to pay your health insurance premiums. However, the rules are strict and it’s only allowed in the following circumstances:

  • The premium is for COBRA continuation of your health insurance, your spouse’s health insurance, or your dependents’ health insurance.
  • The premium is for long-term care insurance (subject to limits.)
  • The premium is for health insurance while you’re receiving government unemployment compensation.
  • The premium is for Medicare or other health coverage if you’re 65 years old or older. However, Medicare supplement insurance like Medigap isn’t an eligible expense.

What Else Do I Need to Know?

You’ll need to file an additional tax form, form 8889, any year you, your employer, or someone else contributes to your HSA. Even if nobody contributed to your HSA, you’ll need to file form 8889 if you withdrew money from your HSA.

The bank that's your HSA administrator  will send you two tax forms each year.  Form 5498-SA will show your HSA contributions for the year. Form 1099-SA will show withdrawals from your HSA for the year.

You'll need to save sufficient documentation that you were spending any HSA withdrawals on eligible medical expenses. If the IRS audits your return, you may have to produce things like doctor's bills, health insurance explanation of benefits forms, and receipts for things like contact lens solution and Band-Aids.

Thinking of gaming the system by hopping into an HDHP for a few months so you can contribute an entire year’s worth of tax-free money into an HSA, only to hop back out of the HDHP a few months later? Don’t bother. The IRS has a testing period that lasts from December of the year you took the deduction through the entire next year. If you don't maintain coverage by a high-deductible health plan during the entire testing period, you’ll lose the tax advantage and could be subject to a penalty. However, if you plan on maintaining HDHP coverage, you needn’t worry about the testing period.


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