With a health savings account (HSA), you can set aside pretax income to pay for current or future health care, including deductibles, copayments, and any qualified medical expenses such as dental bills and prescription drugs. Any withdrawals you make from the HSA to cover these costs are tax free.
While an HSA resembles a flexible spending account (FSA), which your employer may offer as part of your benefits package, there are some major differences as well. For example, the money in your HSA can be rolled over from year to year, which isn't the case with an FSA. If you change jobs, you can take an HSA, but not an FSA, with you. And if you don't have access to an HSA through your job, you can open one with a bank or other financial services company on your own and deduct your contribution when you file your tax return for the year in which you contributed. That's not possible with an FSA.
So why doesn't everybody have an HSA? A primary reason is that you must be enrolled in a high deductible health plan (HDHP) to be eligible.
Federal law defines an HDHP as one having a minimum upfront deductible — $1,400 for individual coverage and $2,800 for family coverage in 2021 — that participants must pay out-of-pocket before the insurer begins to cover any health care costs. Your employer may offer such a plan, though the deductible may be higher than the federal floor. Or, if you aren't offered health insurance where you work, you may choose an HDHP on your own rather than traditional health insurance because traditional health insurance is likely to have lower or no deductibles but higher premiums.
The same federal law that sets the minimum upfront deductible puts a cap on your annual out-of-pocket medical expenses for 2021 at $7,000 for individual coverage and $14,000 for family coverage. Those are the expenses the savings in an HSA are designed to cover.
Because of the HDHP-HSA link, the first thing you must decide is whether an HDHP is right for you. You'll also want to consider whether you'll contribute to a linked HSA up to the annual cap. In 2021, that's $3,600 if you have individual coverage and $7,200 if you have family coverage. If the HDHP is an employer plan, your employer may contribute part of that amount as an incentive to encourage you to choose the HDHP. That's because the typically lower HDHP premiums reduce employers' cost of providing health insurance.
In addition to the lower premiums and tax advantages, HDHP-HSAs give you the flexibility to comparison shop among health care providers and more control over the prices you pay for health care — at least in theory. But that's not always the case. In fact, if you're part of an employer plan, you may have to use the insurance company's network of doctors if you want your out-of-pocket expenditures to count toward meeting your deductible.
And if you purchase an HDHP on your own, you may find it's not easy to compare costs, as doctors tend not to provide a schedule of prices. You may also have difficulty negotiating a lower price for services as an individual than a group plan might be able to achieve.
If you have an employer-provided HDHP, your employer probably has selected a financial services company to act as custodian for participants' HSAs. This just means that they administer the HSA plan. You can use a different custodian if you wish.
The advantage of using the designated custodian is that your employer will pay the administrative costs. It's also typically easy to arrange the direct deposit of your pretax money, which may not be the case if you use an outside custodian. The default account may be a money market or savings account that you can readily tap to pay your qualifying medical bills, either by submitting them for reimbursement or by using a designated debit card. However, the interest rate you'll earn on the account will probably be modest.
If you can afford to fully fund your HSA and pay your out-of-pocket health expenses from your ordinary income rather than withdrawing from the HSA account, you can take advantage of an additional way to accumulate tax-free savings. That may be especially attractive if your modified adjusted gross income is too high to allow you to contribute to a Roth IRA. This way, you can draw on the funds in your HSA to cover your health needs when you're retired and likely spending more on health care than you have in the past.
In order to make this most effective, it's wise to contribute as much as you can in order to fully fund your HSA. When you turn 55, you can contribute an additional $1,000 in catch-up contributions annually for the next ten years, further boosting your account value. But you can no longer make contributions after you turn 65. Be aware that you can't make any more contributions after you turn 65. You should also keep in mind that if you use the money for anything other than health care expenses before you turn 65, you'll owe tax on the amount you take out of the account, plus a 10% tax penalty.
On the other hand, if you're trying to manage your current health care costs, HSAs can be a useful tool for accumulating tax-free money to pay your out-of-pocket expenses. You'll owe less tax because what you contribute to an HSA isn't taxed, your earnings aren't taxed, and neither are your qualified withdrawals. So you're saving on taxes in three ways.
While there are many potential advantages to HSAs for meeting both immediate and long-term health care costs, you do have to determine whether you are willing to enroll in an HDHP to have access to this opportunity to save and whether you'll actually contribute enough to cover your costs.
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