Yes — many telehealth services are HSA-eligible right now, and IRS Notice 2026-5 makes that clearer than it has ever been. The notice ties qualifying telehealth services to the annual Medicare telehealth services list published by HHS under Section 1834(m)(4)(F), giving patients and employers a concrete reference point instead of vague guidance. Before you pay for a virtual visit with your HSA card, run through these three checks:
Keep every receipt. Ask your provider for the CPT or HCPCS code tied to the visit — that code is what connects your expense to the Medicare telehealth list and protects you in an audit.
The path from pandemic workaround to permanent law took five years and several near misses. Here is the condensed version.
| Year / Period | What Changed |
|---|---|
| 2020 (CARES Act) | First-dollar telehealth coverage allowed under HDHPs without disqualifying HSA eligibility — a temporary COVID-era fix. |
| 2026 (LATEST NOTICE) | Congress extended the relief through plan years beginning in 2024 via the Consolidated Appropriations Acts. |
| End of 2024 | The extension expired. A brief gap reopened where the old pre-CARES rules technically applied again, creating transitional uncertainty for some 2025 plan years. |
| — | The One Big Beautiful Bill Act made the pre-deductible telehealth safe harbor permanent for plan years beginning after December 31, 2024. |
| 2026 (IRS Notice 2026-5) | IRS issued technical guidance tying eligibility to the HHS Medicare telehealth services list and clarifying grandfathering rules for employers who maintained continuous coverage since the CARES Act. |
A few things worth noting about that 2024 gap. Employers who adopted telehealth-first coverage continuously since the COVID relief began are generally protected from HSA-eligibility challenges for the affected plan years. The IRS clarified grandfathering rules so that a plan sponsor who never dropped the benefit does not face retroactive exposure. If your employer paused and restarted telehealth pre-deductible coverage during that window, it is worth asking HR whether your plan year was affected.
The OBBBA’s permanent reinstatement is described by policy experts as a rare bipartisan outcome, designed to let employers offer virtual primary care, urgent care, and behavioral health without the deterrent of a high deductible. The practical effect: you no longer need to track congressional extension deadlines to know whether your telehealth visit is pre-deductible.
The governing rule comes directly from IRS Notice 2026-5: a telehealth service qualifies for the safe harbor when it appears on the annual Medicare telehealth services list published by HHS under §1834(m)(4)(F), or when it aligns with §1834(m) principles and 42 CFR 410.78. That list is updated annually and publicly available at CMS.gov — you can search it by service type before your appointment.
| Service Type | Notes |
|---|---|
| Live video visits | Standard virtual appointments with real-time audio and video — the clearest qualifying category. |
| Audio-only phone consultations | Permitted where the provider’s state and payer rules allow audio-only telehealth. |
| Asynchronous exchanges | Secure messaging or store-and-forward data when they meet the telehealth definitions under HHS guidance. |
| Behavioral health and substance use disorder visits | High-frequency beneficiaries of the safe harbor; mental health care saw the largest practical benefit from pre-deductible flexibility. |
Mental health telehealth deserves particular attention. Practitioners report that early access to mental health care increased meaningfully once pre-deductible coverage removed the cost barrier at the front of the deductible. If you use telehealth for therapy, psychiatry, or substance use treatment, those visits are among the most clearly supported by the safe harbor. For more on how telehealth reduces mental health barriers, the distinction between remote and in-person delivery matters both clinically and for HSA purposes.
Pro Tip: Before your appointment, ask the provider’s billing team which CPT or HCPCS code will appear on your receipt. Cross-reference it against the Medicare telehealth services list to confirm the service qualifies before you pay.
Paying with an HSA is straightforward when you have the right documentation lined up first. Here is the sequence that keeps you audit-ready.
A receipt that will hold up in an audit includes these fields at minimum:
If your receipt shows only a generic “telehealth visit” with no code, call the billing department and request an itemized statement. Most providers can generate one within a few business days.
Pro Tip: Paying out of pocket and reimbursing yourself later gives you better document control — you receive the full itemized EOB before any HSA funds move, so you can confirm the service code matches the Medicare telehealth list before submitting the reimbursement.
Bundled digital care subscriptions are a specific trap. If a platform charges a flat monthly fee covering unlimited messaging, video visits, and wellness content, only the portion attributable to qualifying telehealth visits is HSA-eligible. You need an itemized breakdown from the provider to separate eligible from ineligible costs. Without it, the entire subscription fee is at risk of disqualification.
The safe harbor only protects your HSA eligibility when your employer’s plan is designed correctly. A plan that covers telehealth pre-deductible but is not structured as a qualifying HDHP can disqualify your contributions entirely. Ask HR these specific questions at open enrollment:
Employers that need to audit telehealth benefit design for compliance should map their vendor’s service offerings against the Medicare telehealth list — some digital health vendors expanded their service scope during COVID-era relief and have not yet retooled to match the enumerated codes.
Most states follow federal HSA tax treatment. California and New Jersey do not. State tax treatment can differ significantly: California does not adopt the federal exclusion for employer-provided HSA contributions, and New Jersey limits the cafeteria plan exclusion for HSAs. In practical terms, if you live or work in either state, your HSA contributions may be taxable at the state level even when they are fully excluded federally.
What that means for your paycheck: employer HSA contributions may appear as taxable wages on your California or New Jersey state return. Your W-2 will reflect federal treatment, but your state wages may differ. A tax professional familiar with your state’s rules can clarify the exact impact for your filing situation.
The IRS does not require you to submit receipts when you file your taxes, but it can request them in an audit. An audit-ready file for each HSA-funded telehealth visit should contain:
| Document | What It Proves | Where to Get It |
|---|---|---|
| Itemized receipt / EOB | Service was a qualifying telehealth visit | Provider billing department or insurer portal |
| CPT/HCPCS code confirmation | Service maps to Medicare telehealth list | Provider billing team (request in writing) |
| HDHP enrollment proof | You were HSA-eligible on the date of service | HR / insurer enrollment confirmation |
| HSA distribution record | Funds were used for a qualified expense | HSA administrator account statement |
Subscriptions and bundled digital health memberships require an extra step. Ask the platform for a year-end statement that itemizes each qualifying visit separately, with dates and service codes. If the platform cannot produce that, you should not use HSA funds for the full subscription cost. Claim only what you can document at the individual-visit level.
Most HSA disqualification problems are preventable. These are the errors that come up most often, and what to do about each.
Understanding telehealth vs. in-person care distinctions is not just clinical — it directly affects which expenses you can legitimately reimburse from your HSA.
The core IRS position in Notice 2026-5 is precise: telehealth services qualify for the pre-deductible safe harbor when they appear on the HHS Medicare telehealth services list under §1834(m)(4)(F), or when they align with §1834(m) principles and 42 CFR 410.78. That is the standard employers and patients should apply.
“Qualifying ‘telehealth and other remote care services’ are generally restricted to services on the annual Medicare telehealth services list published by HHS under Section 1834(m)(4)(F); services not listed must align with §1834(m) principles and 42 CFR 410.78 to qualify for the safe harbor.” — IRS Notice 2026-5
Benefits professionals also recommend auditing telehealth vendor offerings against the Medicare telehealth list because some digital services expanded beyond enumerated codes during COVID-era relief and have not been retooled since.
The permanent telehealth safe harbor under the OBBBA, clarified by IRS Notice 2026-5, means qualifying telehealth services can be paid pre-deductible from an HSA without jeopardizing eligibility, provided the service appears on the HHS Medicare telehealth services list and your plan is a compliant HDHP.
| Point | Details |
|---|---|
| Confirm HDHP status first | Your plan must meet the 2026 minimum deductible thresholds before any HSA benefit applies. |
| Always request a service code | Ask providers for the CPT or HCPCS code that maps to the Medicare telehealth list before paying. |
| Keep itemized receipts | Date, provider, service code, and amount paid are the four fields an audit-ready receipt must show. |
| Watch state taxes in CA and NJ | California and New Jersey do not follow federal HSA tax exclusions — contributions may be taxable at the state level. |
| AM Rx documents visits for HSA reimbursement | AM Rx issues itemized receipts and provides telehealth video consultations designed to support HSA reimbursement claims. |
The shift from a temporary, extension-dependent relief to a permanent statutory safe harbor is not a technicality. When patients had to wonder each year whether their telehealth visits would count pre-deductible, many simply waited. They delayed a mental health appointment, skipped a follow-up, or paid out of pocket rather than risk an HSA compliance problem. Permanent clarity removes that hesitation.
Mental health care is where this plays out most visibly. The pre-deductible barrier was a real deterrent for people enrolled in HDHPs who needed therapy or psychiatric care but faced hundreds of dollars in out-of-pocket costs before their deductible kicked in. Removing that barrier through the safe harbor has a direct effect on whether someone books an appointment or postpones it indefinitely.
The practical recommendation is simple: audit your plan now, not at tax time. Confirm your HDHP status, ask your telehealth provider for service codes, and keep receipts organized by visit date. The rules are finally stable enough to build a reliable system around.
If you want a telehealth provider that takes the documentation burden seriously, AM Rx is worth a direct look. The platform covers primary care, mental health, weight management, and other services through video consultations with experienced providers, and it issues itemized receipts designed to support HSA reimbursement claims. That means you get the visit code, the provider name, the date, and the amount on a single document — exactly what the IRS expects.
Before booking with any telehealth provider, ask three questions: Will you provide the CPT or HCPCS code for my visit? Can you issue an itemized receipt showing the service code? How do you bill membership or subscription fees separately from individual visits? AM Rx is built to answer yes to all three. Disclosure: this publication is operated by AM Rx.
Ready to use your HSA for a documented telehealth visit? Start with AM Rx and confirm your visit code before the appointment ends.
This article is general information, not tax or legal advice. Confirm current rules with the IRS, your state tax authority, or a qualified benefits professional for your specific situation.
