What is the difference between a Medical FSA and an HSA?

Flexible Spending Accounts (FSAs)

• Established by an employer.
• Usually funded by pre-tax payroll deduction, but employers can also contribute.
• Can be used in conjunction with any type of health insurance, although health insurance coverage is not required.
• FSA funds can be used to cover deductibles, copays and coinsurance, as well as qualified medical expenses that are not covered by health insurance, such as LASIK eye surgery. The ACA implemented a rule as of 2011 that prohibited the use of FSA funds to purchase over-the-counter medications, unless a doctor wrote a prescription for them. But Section 4402 of the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act changed that, allowing pre-tax FSA funds to be used for over-the-counter drugs without a prescription. This was retroactive to January 1, 2020, and is a permanent change. Section 4402 of the CARES Act also changed the rules to allow menstrual products to be purchased with FSA funds.
• “Use it or lose it” — money not used by the end of the year (or by March 15th of the following year if the employer offers a grace period) is forfeited, although employers can allow enrollees to carry over up to $500 to the next year instead of allowing FSA funds to be used as late as March 15 of the following year (if the plan doesn’t follow the calendar year, money has to be used up by the end of the plan year; alternatively, the employer can allow up to $500 to be carried over to the next plan year or give employees 2.5 months at the start of the next plan year to use up money remaining in the account). But these rules have been temporarily relaxed due to the COVID pandemic: The Consolidated Appropriations Act, 2021 (enacted in late 2020), allowed employers the option to let employees roll over any unused FSA amounts from 2020 to 2021, and from 2021 to 2022, for use at any time during the year. It also gave employers the option to let employees change their FSA election amount mid-year in 2021, without a qualifying event. As of 2022, a qualifying event is once again necessary in order to make a mid-year FSA election change.
• In the past, employers could set their own FSA contribution limits for their employees. But the ACA limits contributions to no more than $2,850 in 2022 (this is adjusted annually for inflation by the IRS; it started at $2,500 in 2013, but was unchanged from 2020 to 2021). Note that Dependent Care FSAs (DC-FSA) are not the same as medical FSAs, and have different contribution limits.
• Contributions are deducted from each paycheck throughout the year.  However, the full annual contribution amount is available for use immediately (or after the first contribution is made). If the employee uses the full amount and then quits or is terminated prior to the end of the year, FSA funds do not have to be paid back to the employer. But on the flip side of that, if an employee quits with money in their FSA, they forfeit it to the employer. This is also the case under the “use it or lose it” provision, in which leftover funds can be forfeited from one year to the next.

Health Savings Accounts (HSAs)

• Can be established by an employer or by an individual, but only in conjunction with an HSA-qualified high deductible health plan (HDHP). You must be enrolled in an HDHP in order to make contributions to an HSA or receive employer contributions to your HSA. But the HSA administrator (bank, investment firm, etc.) does not have to be in any way affiliated with the insurance company that offers the HDHP. And even people who have an HSA through their employer are free to transfer the money to a different HSA administrator if they choose to do so.
• HDHPs are defined and regulated by the IRS, with minimum deductible and maximum out-of-pocket requirements, as well as a ban on non-preventive services being paid for by the health plan before the deductible has been met (ie, that means the plan will not have copays for office visits, for example, but will instead require the patient to pay the full network-negotiated amount for the visit if they haven’t yet met their deductible). But the IRS has relaxed the rules to allow (but not require) HDHPs to include more services under the preventive care umbrella, and to allow plans to cover COVID testing and treatment pre-deductible.
• Contributions can only be made while the account holder remains covered by an HDHP.  However, the money can be used — without being taxed — for qualified medical expenses at any time in the future, even if the person is no longer covered by an HDHP.
• Can be funded (pre-tax) by employee payroll deductions or employer contributions, or by an individual. Payroll deductions to fund HSA contributions are made before any taxes are calculated, including income tax as well as FICA (Medicare and Social Security) taxes. People who purchase their own individual HDHPs and fund them directly (ie, not with payroll deduction) can deduct the contributions on their tax returns. This makes them pre-tax as far as income tax is concerned, but it does not avoid Medicare and Social Security taxes.
• In 2022, the maximum HSA contribution is $3,650 for a person with individual coverage under an HDHP, and $7,300 for those with family HDHP coverage (“family” means the HDHP covers the primary enrollee plus at least one additional family member; it does not have to cover the whole family). For 2023, the contribution limits will increase to $3,850 and $7,750, respectively.
• If an HSA is established by an employer and the employee quits or is terminated, the HSA balance goes with the employee, regardless of whether contributions were made by the employee or the employer.
• Money in the HSA that is not used for medical expenses remains in the account and simply rolls over from one year to the next. There is no “use it or lose it” rule for HSAs.
• HSA funds can be used for the same qualified medical expenses as FSA funds. And just like FSAs, from 2011 through 2019, a doctor’s prescription was necessary in order to use pre-tax HSA funds to buy over-the-counter medications. But the CARES Act relaxed that rule, allowing over-the-counter medications (and menstrual products) to be purchased with HSA funds.
• If money is withdrawn for qualified medical expenses, it is never taxed.
• If money is withdrawn for other purposes prior to age 65, it is taxed and there is an additional 20% penalty applied. Prior to 2011, the penalty was 10%.
• After age 65, money can be withdrawn without a penalty, but if it is not used for qualified medical expenses, income taxes will be owed.
• Republican health care reform proposals have generally called for an increased focus on HSAs, with higher contribution limits and greater flexibility. But as of 2021, none of those measures had been implemented. HSAs continue to have contribution limits that are indexed annually using the same formula that’s been used in prior years. And access to HSAs continues to be limited to people who have HDHPs, which must comply with IRS regulations.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.