Fifteen categories, three tests each, and a note on every row explaining why the three tests disagree. Where a row is backed by industry convention rather than an IRS document, it says so — because that difference is the one that matters if a claim is ever questioned.
| Expense category | Medical care §213(d) | Card / claim desk practice | Schedule A deduction | Basis |
|---|---|---|---|---|
| 💊 Dietary supplements & vitamins | Letter needed | Letter needed | Letter needed | IRS |
| 🤰 Prenatal vitamins | Letter needed | Yes | Letter needed | Practice |
| 🦴 Glucosamine / chondroitin | Letter needed | Yes | Letter needed | Practice |
| 🌾 Fiber supplement / psyllium | Partly | Partly | No | IRS |
| 🩹 OTC drugs (aspirin, antacids, allergy) | Yes | Yes | No | IRS |
| 🩸 Menstrual care products | Yes | Yes | No | IRS |
| 🧴 Sunscreen (SPF 15+, broad spectrum) | Yes | Yes | No | IRS |
| 🥤 Food, groceries, protein powder, shakes | No | No | No | IRS |
| 🏋️ Gym membership / health club dues | No | No | No | IRS |
| 🚴 Fitness / exercise equipment | Letter needed | Letter needed | Letter needed | Practice |
| 🥗 Nutritional counseling / dietitian | Letter needed | Letter needed | Letter needed | IRS |
| 🧬 Lab panels / biomarker testing | Partly | Yes | Partly | IRS |
| 📈 Monitors & devices (CGM, BP cuff, glucose) | Yes | Yes | Yes | IRS |
| 🩺 Doctor visits, copays, prescriptions | Yes | Yes | Yes | IRS |
| 📦 Something else | Letter needed | Letter needed | Letter needed | Practice |
Yes Reimbursable without a letter.
Letter needed Only if a practitioner recommends it as treatment for a specific condition a physician has diagnosed.
No Not medical care — no letter changes this.
Partly Only part of the cost, or only in a narrow case.
The three columns are not three opinions about one question. They are three different questions, decided by three different bodies, and a row is interesting exactly when they disagree.
Medical care asks whether the expense is §213(d) medical care at all — that is the law, and it is the only column that would survive an argument. Card / claim desk asks whether a custodian will let the transaction through without a letter — that is industry convention, and it is the column that governs your afternoon. Schedule A asks whether the same purchase is deductible as an itemised medical expense on your return, which is a separate rule that reaches its own answer.
The Basis column is the one to read last and remember longest. IRS means there is a published document behind the row. Practice means there is not — that the answer comes from how custodians have decided to code the category, which is a real constraint on your claim and no help at all if the claim is ever questioned.
These are the rows that a single yes-or-no eligibility list has to lie about. In each case at least two of the three questions reach different answers about the same purchase.
| Category | Care | Card | Sch. A | The disagreement |
|---|---|---|---|---|
| 🤰 Prenatal vitamins | Letter needed | Yes | Letter needed | Custodians auto-approve these; no IRS document names them. Practice runs ahead of the text. |
| 🦴 Glucosamine / chondroitin | Letter needed | Yes | Letter needed | The card clears on convention alone — no statute, notice, publication or FAQ mentions these compounds. |
| 🌾 Fiber supplement / psyllium | Partly | Partly | No | Two different rules apply to the same molecule, depending on which label panel the manufacturer printed. |
| 🩹 OTC drugs (aspirin, antacids, allergy) | Yes | Yes | No | Reimbursable from the account, not deductible on the return: the CARES Act amended §223, not §213(d). |
| 🩸 Menstrual care products | Yes | Yes | No | The same split — §223 now treats these as paid for medical care; §213(d) was left alone. |
| 🧴 Sunscreen (SPF 15+, broad spectrum) | Yes | Yes | No | Rides the OTC-drug rule for reimbursement, and the Schedule A answer is unchanged by it. |
| 🧬 Lab panels / biomarker testing | Partly | Yes | Partly | Diagnostic testing qualifies; a bundled consumer kit puts an allocation question inside the price. |
These categories are classified the way they are because custodians code them that way, not because any statute, regulation, notice, publication or IRS FAQ addresses them. That distinction costs nothing while a claim is clearing and everything if it is ever examined.
Custodians almost always auto-approve these, but no IRS document names prenatal vitamins. Under Pub. 502’s literal text they are…
The clearest case of industry convention outrunning the law. No statute, reg, notice, publication or IRS FAQ mentions…
No IRS authority lists exercise equipment. Custodians code it letter-required, applying the same "sole purpose / specific…
Unclassified — check it against Pub. 502 and your plan administrator before you reimburse.
Two categories answer no to all three questions, and the reason matters: it is not that the evidence is weak or the paperwork is missing. It is that the expense is not medical care in the first place, so there is nothing for a letter to document.
Pub. 502: diet food and beverages are excluded because they substitute for what is normally consumed to satisfy nutritional…
Pub. 502 excludes health club dues and amounts paid to improve general health. The FAQ leaves a needle-thin window — bought for…
The full reasoning and citations for every category live on the deep pages linked below — this page is the map, not the territory.
Three parts of this catalogue have no row of their own, and pretending otherwise would be worse than saying so. Home environment equipment — air purifiers, reverse-osmosis systems, white-noise machines, light therapy lamps in Air, Water & Sleep Systems — is not addressed in this reference set and falls to the catch-all: check it against Pub. 502 and your plan administrator. Cosmetic skincare beyond sunscreen — the serums and acids in Skin & Topical Longevity — runs into the attestation on most administrator forms that the item is not cosmetic. Consumer wearables in Biometric Wearables & Sensors are not the same object as a diagnostic device, even when they sit on an adjacent shelf.
In all three cases the answer is the same and it is not satisfying: ask your plan administrator, before you buy.
Most supplements are not HSA- or FSA-eligible. The Pub. 502 exception has two halves people collapse into one — here…
OTC drugs, menstrual products and sunscreen became HSA/FSA-reimbursable under the CARES Act. The catch: that law…
Diagnostic devices are the cleanest yes in the framework — eligible regardless of prescription status. Where consumer…
Diagnostic testing is squarely medical care. The wrinkle is bundled consumer kits, where a 2019 private ruling…
Health club dues are excluded by Pub. 502 and custodians decline outright. Exercise equipment is letter-required with…
Food is excluded because it substitutes for normal nutrition, and no letter changes that. Nutrition counselling can…
What the IRS documents say, what custodians actually do, and the three questions hiding inside "is it eligible?"
A dated, printable spend-down plan — and the trap the internet tells you to walk into every December.
Twenty-two questions with the citation attached to each answer.
What one is, the six fields administrators look for, and the three things a letter cannot do.
Open the HSA / FSA ledger in the Magellan app →