People who pay a doctor a flat monthly membership fee, known as a direct primary care arrangement, can now keep contributing to a health savings account and use the account to pay that fee tax-free. The IRS says the change took effect January 1, 2026, under the 2025 tax law, Public Law 119-21. Before it, enrolling in one of these memberships generally cost a person the right to contribute.
What a direct primary care arrangement is, in the IRS’s terms
Treasury and the IRS laid out the rules in Notice 2026-5, announced December 9, 2025. The notice defines a direct primary care service arrangement as one that provides medical care consisting solely of primary care services from primary care practitioners. The sole payment for that care must be a fixed periodic fee.
Primary care practitioners are physicians whose main specialty is family, internal, geriatric or pediatric medicine, plus nurse practitioners, clinical nurse specialists and physician assistants. Covered services include physical examinations, vaccinations, urgent care, laboratory testing and treatment of some illnesses and injuries.
The December 9 IRS announcement covered three separate HSA changes under the law: telehealth before the deductible, bronze and catastrophic plans, and these memberships. Comments on the notice were due March 6, 2026. The rule applies month by month, to months beginning after December 31, 2025.
Before the change, the notice says, enrollment in such an arrangement generally made a person ineligible to contribute to a health savings account. A membership held in 2026 no longer blocks contributions if it meets the definition.
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The $150 and $300 monthly lines
The decisive number is the fee. An arrangement does not qualify if its total fees run above $150 a month for one person, or $300 a month for an arrangement that covers more than one person. The IRS says those limits are adjusted for inflation for taxable years after 2026.
A membership of $125 a month, or $1,500 over a year, sits under the ceiling for one person. One billed at $175 a month does not qualify, whatever the practice calls it. For a couple on one family arrangement, the line is $300 a month.
Fees can be billed for longer than a month, up to a year, as long as the total is fixed, periodic and within the monthly limit on an annualized basis. For a single person in 2026, the notice gives $1,800 for a year, $900 for six months or $450 for three months as the ceilings.
The test looks at the arrangement’s terms, not at how much care a member actually uses. A patient who rarely visits and one who visits often are judged by the same written terms, and neither can lose eligibility by using more services.
What takes an arrangement outside the rule
Some services cannot be part of the package. The notice excludes procedures requiring general anesthesia, prescription drugs other than vaccines, and laboratory services not typically administered in an ambulatory primary care setting. A membership that bundles those is not a qualifying arrangement.
Billing is the other trap. If an arrangement requires members to bill insurance or anyone else separately for items or services as a condition of membership, it is not a qualifying arrangement. A practice may still bill members and non-members separately for services it offers outside the membership.
A high-deductible health plan cannot offer the membership or its fees as a benefit without a deductible, or before the deductible is met. Fees a person pays for the membership also do not count toward the plan’s deductible or out-of-pocket maximum.
Paying the fee from the account, and what the IRS did not say
On the spending side, the IRS says people in these arrangements can use HSA money tax-free for the periodic fee. Its page on the 2025 tax law provisions, updated October 22, 2026, lists the provision next to the separate bronze and catastrophic plan change that also began January 1, 2026.
The notice says membership fees are qualified medical expenses and carry no specific fee limit for reimbursement. A fee above the monthly ceiling can still be paid from the account, but the member cannot contribute while enrolled in that arrangement. The account may treat the expense as incurred monthly, at the start of the coverage period or on the date paid.
One exclusion matters for workers. Fees an employer pays, including through salary reduction in a cafeteria plan, cannot also be reimbursed from the HSA, because they are already excluded from pay. The IRS summary of the provision does not address Medicare enrollees.
The account rules themselves, including who can contribute at all, sit in Publication 969, the IRS guide to health savings accounts. The new provision lifts only the membership barrier. A person must otherwise be eligible, which is the question to settle before moving a monthly fee into an account.
Can the membership fee already in the budget go through an HSA?
Only the fee limit and the arrangement’s terms decide that.
A flat membership fee that runs even a dollar over the $150 monthly ceiling, or that bills services separately, takes the arrangement outside the rule, and a contribution made while enrolled can then be a problem. The terms are written into the membership agreement, so they can be read before any money moves.
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This article was produced with AI assistance and edited for accuracy against the sources linked above.
