Does the Letter of Medical Necessity expire?

Yes, a Letter of Medical Necessity typically expires after 1 year. You need a new one annually, which requires an annual visit to re-evaluate the underlying condition.

Can I use my HSA for the Fishtown Medicine membership fee?

Yes, you can use your HSA for the Fishtown Medicine membership fee. Under the Primary Care Enhancement Act, effective 2025, Direct Primary Care (DPC) membership fees are recognized as qualified medical expenses under Section 213(d). Use your HSA or FSA card directly. Download your itemized receipt from the Billing Portal for your records.

What if I get audited by the IRS?

If you get audited by the IRS, keep the LMN and the receipt. As long as a licensed physician signed the LMN based on a real diagnosis and you used the funds for that treatment, you are following the rules.

What is the difference between an HSA and an FSA?

The difference between an HSA and an FSA is in eligibility, rollover, and ownership. An HSA requires a high-deductible health plan (HDHP), the funds roll over forever, and the account is yours for life. An FSA does not require an HDHP, but most funds expire at year-end (use it or lose it).

Are vitamins covered by HSA?

Most general vitamins are not covered by HSA without a Letter of Medical Necessity. Specific vitamins prescribed to correct a documented deficiency (low vitamin D, low vitamin B12) generally do qualify with an LMN.

Can I use my HSA for therapy?

Yes, you can use your HSA for therapy. Mental health visits with a licensed therapist or psychiatrist are qualified medical expenses. Couples or marriage counseling is generally not eligible.

Is dental work HSA eligible?

Dental work is HSA eligible. Cleanings, fillings, crowns, root canals, and orthodontia are all qualified expenses. Cosmetic dentistry (like cosmetic veneers or whitening) is not.

Are over-the-counter medications HSA eligible?

Over-the-counter medications are HSA eligible without a prescription as of 2020. The CARES Act made common items like ibuprofen, allergy medication, and menstrual products eligible without an LMN.

Why is the HSA called triple tax-advantaged?

The HSA is called triple tax-advantaged because contributions are pre-tax, growth and investment gains are tax-free, and qualified withdrawals are tax-free. No other account in the U.S. tax code offers all three. Used well, it can outperform a 401(k) for medical expenses in retirement.

How does the Primary Care Enhancement Act change DPC eligibility?

The Primary Care Enhancement Act lets HSA holders pay DPC (Direct Primary Care) membership fees with pre-tax dollars without losing HSA eligibility. Before the act, paying for DPC could disqualify you from contributing to an HSA. The change makes DPC structurally easier for HSA holders to use.

Should I invest my HSA balance?

You should consider investing your HSA balance once you cover an emergency baseline. Most HSA custodians let you invest balances above a minimum threshold (often $1,000 to $2,000) in mutual funds or ETFs. Long-term growth is where the triple-tax advantage really compounds.

Can I use my HSA in retirement?

Yes, you can use your HSA in retirement. After age 65, you can withdraw HSA funds for any reason, paying ordinary income tax on non-medical use (the same treatment as a traditional 401k). Medical use remains tax-free at any age.

How much should I contribute to my HSA each year?

Most patients should contribute the full annual maximum if they can afford it ($4,300 individual or $8,550 family for 2025). Even partial contributions create immediate tax savings, since contributions are pre-tax.

What happens to my HSA if I leave my employer?

Your HSA stays with you if you leave your employer. Unlike an FSA, the HSA is yours. You can keep contributing as long as you maintain a qualifying high-deductible health plan, or you can stop contributing and let the balance grow.

Are Peloton subscriptions HSA eligible?

Peloton subscriptions can be HSA eligible with a Letter of Medical Necessity tied to a relevant condition. The hardware and the subscription can both be eligible if the LMN ties the at-home program to a treatment plan for obesity, depression, or other qualifying diagnoses.

Can I reimburse myself years later?

Yes, you can reimburse yourself years later for qualified medical expenses, as long as the expense occurred after you opened the HSA. Save receipts. Some patients let the balance grow tax-free for decades and reimburse old expenses in retirement to pull tax-free cash.

What counts as a high-deductible health plan?

A high-deductible health plan (HDHP) for HSA eligibility in 2025 means a plan with a minimum deductible of $1,650 individual or $3,300 family, and an out-of-pocket maximum no higher than $8,300 individual or $16,600 family. The IRS updates these figures annually.

Is a CGM HSA eligible without diabetes?

A continuous glucose monitor can be HSA eligible without a diabetes diagnosis if a physician prescribes it for a related diagnosis like pre-diabetes, polycystic ovary syndrome (PCOS), or insulin resistance. Some plans require a more specific code.

Are saunas and cold plunges really eligible?

Saunas and cold plunges can be eligible with a strong LMN tied to a chronic condition like fibromyalgia, autoimmune disease, or chronic pain. Pure wellness use does not qualify. The diagnosis and treatment plan need to match.

Can I use HSA for travel to medical appointments?

Yes, you can use HSA funds for travel to qualifying medical appointments. The IRS allows mileage at a fixed medical rate (24 cents per mile in 2025), parking, and tolls. For longer trips, lodging up to $50 per night per person can qualify.

What is the Family HSA contribution rule for couples?

The family HSA contribution rule for couples allows splitting the family limit between two HSAs. If both spouses have qualifying HDHPs, they can split contributions however they want. People age 55 and older can each add a $1,000 catch-up contribution to their own HSAs.

How do I document HSA expenses correctly?

You document HSA expenses correctly by keeping the LMN, receipt, and a brief note on what condition the expense treats. A simple folder (digital is fine) with these three items per expense is enough for most audits.

Can I use HSA for genetic testing?

Yes, you can typically use HSA funds for genetic testing when ordered by a physician for clinical reasons. Tests like ApoE for Alzheimer's risk or BRCA for cancer risk usually qualify. Direct-to-consumer genealogy kits do not.

What is the rule for HSA after a Medicare enrollment?

The rule for HSA after Medicare enrollment is that you can no longer contribute new funds once you are enrolled in any part of Medicare. You can still spend the existing balance tax-free on qualified medical expenses, including Medicare premiums and out-of-pocket costs.

Does the Letter of Medical Necessity expire?

Yes, a Letter of Medical Necessity typically expires after 1 year. You need a new one annually, which requires an annual visit to re-evaluate the underlying condition.

Can I use my HSA for the Fishtown Medicine membership fee?

Yes, you can use your HSA for the Fishtown Medicine membership fee. Under the Primary Care Enhancement Act, effective 2025, Direct Primary Care (DPC) membership fees are recognized as qualified medical expenses under Section 213(d). Use your HSA or FSA card directly. Download your itemized receipt from the Billing Portal for your records.

What if I get audited by the IRS?

If you get audited by the IRS, keep the LMN and the receipt. As long as a licensed physician signed the LMN based on a real diagnosis and you used the funds for that treatment, you are following the rules.

What is the difference between an HSA and an FSA?

The difference between an HSA and an FSA is in eligibility, rollover, and ownership. An HSA requires a high-deductible health plan (HDHP), the funds roll over forever, and the account is yours for life. An FSA does not require an HDHP, but most funds expire at year-end (use it or lose it).

Are vitamins covered by HSA?

Most general vitamins are not covered by HSA without a Letter of Medical Necessity. Specific vitamins prescribed to correct a documented deficiency (low vitamin D, low vitamin B12) generally do qualify with an LMN.

Can I use my HSA for therapy?

Yes, you can use your HSA for therapy. Mental health visits with a licensed therapist or psychiatrist are qualified medical expenses. Couples or marriage counseling is generally not eligible.

Is dental work HSA eligible?

Dental work is HSA eligible. Cleanings, fillings, crowns, root canals, and orthodontia are all qualified expenses. Cosmetic dentistry (like cosmetic veneers or whitening) is not.

Are over-the-counter medications HSA eligible?

Over-the-counter medications are HSA eligible without a prescription as of 2020. The CARES Act made common items like ibuprofen, allergy medication, and menstrual products eligible without an LMN.

Why is the HSA called triple tax-advantaged?

The HSA is called triple tax-advantaged because contributions are pre-tax, growth and investment gains are tax-free, and qualified withdrawals are tax-free. No other account in the U.S. tax code offers all three. Used well, it can outperform a 401(k) for medical expenses in retirement.

How does the Primary Care Enhancement Act change DPC eligibility?

The Primary Care Enhancement Act lets HSA holders pay DPC (Direct Primary Care) membership fees with pre-tax dollars without losing HSA eligibility. Before the act, paying for DPC could disqualify you from contributing to an HSA. The change makes DPC structurally easier for HSA holders to use.

Should I invest my HSA balance?

You should consider investing your HSA balance once you cover an emergency baseline. Most HSA custodians let you invest balances above a minimum threshold (often $1,000 to $2,000) in mutual funds or ETFs. Long-term growth is where the triple-tax advantage really compounds.

Can I use my HSA in retirement?

Yes, you can use your HSA in retirement. After age 65, you can withdraw HSA funds for any reason, paying ordinary income tax on non-medical use (the same treatment as a traditional 401k). Medical use remains tax-free at any age.

How much should I contribute to my HSA each year?

Most patients should contribute the full annual maximum if they can afford it ($4,300 individual or $8,550 family for 2025). Even partial contributions create immediate tax savings, since contributions are pre-tax.

What happens to my HSA if I leave my employer?

Your HSA stays with you if you leave your employer. Unlike an FSA, the HSA is yours. You can keep contributing as long as you maintain a qualifying high-deductible health plan, or you can stop contributing and let the balance grow.

Are Peloton subscriptions HSA eligible?

Peloton subscriptions can be HSA eligible with a Letter of Medical Necessity tied to a relevant condition. The hardware and the subscription can both be eligible if the LMN ties the at-home program to a treatment plan for obesity, depression, or other qualifying diagnoses.

Can I reimburse myself years later?

Yes, you can reimburse yourself years later for qualified medical expenses, as long as the expense occurred after you opened the HSA. Save receipts. Some patients let the balance grow tax-free for decades and reimburse old expenses in retirement to pull tax-free cash.

What counts as a high-deductible health plan?

A high-deductible health plan (HDHP) for HSA eligibility in 2025 means a plan with a minimum deductible of $1,650 individual or $3,300 family, and an out-of-pocket maximum no higher than $8,300 individual or $16,600 family. The IRS updates these figures annually.

Is a CGM HSA eligible without diabetes?

A continuous glucose monitor can be HSA eligible without a diabetes diagnosis if a physician prescribes it for a related diagnosis like pre-diabetes, polycystic ovary syndrome (PCOS), or insulin resistance. Some plans require a more specific code.

Are saunas and cold plunges really eligible?

Saunas and cold plunges can be eligible with a strong LMN tied to a chronic condition like fibromyalgia, autoimmune disease, or chronic pain. Pure wellness use does not qualify. The diagnosis and treatment plan need to match.

Can I use HSA for travel to medical appointments?

Yes, you can use HSA funds for travel to qualifying medical appointments. The IRS allows mileage at a fixed medical rate (24 cents per mile in 2025), parking, and tolls. For longer trips, lodging up to $50 per night per person can qualify.

What is the Family HSA contribution rule for couples?

The family HSA contribution rule for couples allows splitting the family limit between two HSAs. If both spouses have qualifying HDHPs, they can split contributions however they want. People age 55 and older can each add a $1,000 catch-up contribution to their own HSAs.

How do I document HSA expenses correctly?

You document HSA expenses correctly by keeping the LMN, receipt, and a brief note on what condition the expense treats. A simple folder (digital is fine) with these three items per expense is enough for most audits.

Can I use HSA for genetic testing?

Yes, you can typically use HSA funds for genetic testing when ordered by a physician for clinical reasons. Tests like ApoE for Alzheimer's risk or BRCA for cancer risk usually qualify. Direct-to-consumer genealogy kits do not.

What is the rule for HSA after a Medicare enrollment?

The rule for HSA after Medicare enrollment is that you can no longer contribute new funds once you are enrolled in any part of Medicare. You can still spend the existing balance tax-free on qualified medical expenses, including Medicare premiums and out-of-pocket costs.

HSA/FSA for Longevity: The 2025 Playbook

TL;DR30-second take

An HSA (Health Savings Account) is triple tax-advantaged money you can use for prevention, not just sick visits. With a Letter of Medical Necessity (LMN) from your doctor, gym memberships, supplements, CGMs, and even DPC membership fees can be eligible. The 2025 limits are $4,300 for individuals and $8,550 for families.

Investing pre-tax dollars in your biological future

Most people use their Health Savings Account (HSA) for sick visits and bandaids. The smart play is to use it for prevention. Here is how to legally fund your gym membership, supplements, and longevity tools through an HSA in 2025.

You have a quiet financial advantage called an HSA (or FSA). It is triple tax-advantaged money. The contributions are pre-tax, the growth is tax-free, and qualified withdrawals are tax-free. Yet millions of dollars go unused or get spent on drugstore items in December panic-shopping. In Medicine 3.0, we treat the HSA as a longevity investment fund.

Disclaimer: I am a doctor, not an accountant. This is educational. Always verify with your plan administrator and tax advisor.

What is a Letter of Medical Necessity (LMN)?

A Letter of Medical Necessity (LMN) is a physicians note that turns "general wellness" purchases into eligible medical expenses by tying them to a specific diagnosis.

The IRS rules state that HSA-eligible expenses must treat a specific medical condition. General wellness does not count. If a doctor certifies that a gym membership or supplement is necessary to treat a diagnosis (for example, hypertension, obesity, or sarcopenia), it can become eligible.

A physician (like us) can write an LMN stating:

"Patient X has a diagnosis of pre-diabetes (R73.03)."
"Treatment plan: exercise program (gym membership) and omega-3 supplementation."
"Duration: 12 months."

With this letter, your gym dues and supplements may become reimbursable through your HSA or FSA.

What is HSA-eligible in 2025?

HSA-eligible items in 2025 fall into two groups: items that are automatically eligible and items that need a Letter of Medical Necessity.

Automatically eligible (no letter needed)

You can buy these directly through HSAstore or Amazons FSA/HSA filter:

Sunscreen: Zinc-based options are best.
Blood pressure monitors: Essential for tracking.
Continuous glucose monitor (CGM): With a prescription, which we provide when clinically appropriate.
Oura Ring and other wearables: Sometimes eligible directly. Check your specific plan.

LMN required (the longevity stack)

These items typically require a doctors letter:

Gym memberships: To treat obesity, hypertension, or depression.
Cold plunge or sauna: When prescribed for chronic pain or autoimmune conditions.
Supplements: Vitamin D, omega-3, magnesium when treating a documented deficiency.
Personal training: To treat sarcopenia or chronic back pain.
Massage therapy: For chronic back pain.

How does the HSA strategy fit into longevity care?

Longevity Medicine

A personalized longevity strategy starts with knowing your real baselines.

Start Your Longevity Assessment

The HSA strategy fits longevity care by funding the diagnostics, devices, and interventions that help reduce disease risk earlier, not just treat disease once it appears. For our proactive tier members, we routinely review diagnostics to identify HSA-eligible interventions.

Exercise (gym): Prescribed to treat metabolic dysfunction.
Nutraceuticals (supplements): Prescribed to correct specific deficiencies.
Data (CGM): Prescribed to monitor insulin resistance and glucose variability.

What longevity gear is worth buying with an HSA?

The longevity gear worth buying with an HSA is gear that generates data or directly treats a diagnosis. Use HSA dollars on tools that change your biology, not just your comfort.

Item	HSA Status	Fishtown Verdict
Oura Ring	Complex (often requires LMN)	Buy. Sleep tracking is a key longevity input.
Theragun	Eligible (often automated)	Maybe. Good for pain. Does not change biology the way exercise does.
Sauna blanket	LMN required	Yes, particularly if you cannot join a gym sauna.
Supplements	LMN required	Yes, but only clinical-grade brands with third-party testing.

Guidance from the Clinic

"Dont leave money on the table. The government is offering you roughly a 30% discount on your health."

We have your back: At Fishtown Medicine, the goal is not just to order tests and hand you a result. We interpret, explain, and advocate. You should feel like you have a Chief Medical Officer in your corner, one who fights for clarity and access, not just checkboxes.

"Dr. Ash, can I buy a Peloton with my HSA?"

Yes, if we can justify it medically. If you are under-conditioned or meet diagnostic criteria for a relevant condition, a Peloton is a valid medical device for treating that condition, and we can write the LMN. You do have to actually use it. The IRS audits, and effectiveness matters.

Actionable Steps in Philly

Maximize the 2025 limits ($4,300 for individuals, $8,550 for families).

Get a diagnosis: Come in for your annual physical. We will find the biomarkers that justify the interventions (low vitamin D, high cholesterol, pre-diabetes, etc.).
Request LMNs: Ask us for letters for your gym, supplements, and devices.
Shop smart: Use HSAstore.com or filter Amazon by FSA/HSA Eligible to avoid paperwork headaches.

Tax-free longevity.

Book Your Warm Invitation Call Here

Scientific References

Internal Revenue Service. "Publication 502: Medical and Dental Expenses."
Internal Revenue Service. "Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans."
U.S. Congress. "Primary Care Enhancement Act." Congressional Record.
Fidelity Investments. "2025 HSA Contribution Limits and Rules."
CARES Act. "Coronavirus Aid, Relief, and Economic Security Act, Section 3702."

Fishtown Medicine | Longevity

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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