HRA eligible expenses: what you can be reimbursed for

What HRAs generally reimburse

The list below is the practical answer to "what are HRA eligible items?" — but every entry on it traces back to one definition. An expense is reimbursable when it is for medical care as defined in Section 213(d) of the Internal Revenue Code: the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting a structure or function of the body, plus transportation primarily for that care and insurance covering it. IRS Publication 502 is the plain-English catalog of that definition, updated each year, and it is the reference an administrator uses when a claim is borderline. If an item is in Publication 502 and your plan document does not exclude it, it is eligible.

• Health insurance premiums (for ICHRA and QSEHRA; many integrated HRAs exclude premiums)
• Doctor visits, copays, coinsurance, and deductibles
• Prescription medications
• Dental care and orthodontia
• Vision care, exams, glasses, and contacts
• Mental health and therapy
• Many over-the-counter items and medical supplies

Premiums vs. medical expenses

The single biggest distinction is whether an HRA reimburses insurance premiums or only out-of-pocket medical expenses. ICHRA and QSEHRA can reimburse individual premiums; integrated (group-coverage) HRAs typically reimburse out-of-pocket costs like deductibles and copays rather than premiums. Always confirm which your specific HRA covers.

The eligible expense list

Eligible medical expenses are defined by IRS Publication 502 — the same list that governs HSAs and FSAs. It's broad, covering most medically necessary care. The employer can choose to cover the full list or narrow it in the plan design. The major categories, per Publication 502:

• Medical care: physician and specialist visits, hospital and inpatient services, lab work, nursing services.
• Prescriptions: medications prescribed by a physician, plus insulin.
• Dental: preventive care and treatment.
• Vision: exams, glasses, contact lenses, and eye surgery.
• Mental health: psychiatric care, psychologist fees, and therapy.
• Medical equipment: hearing aids, wheelchairs, artificial limbs, and diagnostic devices.
• Therapy and rehabilitation: physical therapy and addiction treatment.
• Transportation for medical care, at IRS mileage rates.
• Premiums, where the plan design allows: including Medicare Parts B and D and qualified long-term care insurance.

It depends on the plan design

Within IRS limits, the employer decides what a specific HRA covers. Some HRAs reimburse only premiums; others cover the full range of Publication 502 expenses. So two HRAs can have different eligible-expense lists — always check your plan's specific rules rather than assuming.

What's typically NOT eligible

• Cosmetic procedures aimed at appearance — unless correcting a congenital abnormality, an injury, or a disfiguring disease (Pub 502's own carve-out).
• General wellness items without a medical need: vitamins, nutritional supplements, most gym memberships and health-club dues.
• Federally illegal substances — including marijuana, even where state law allows it.
• Household help and childcare for healthy children, and maternity clothes — everyday costs Pub 502 explicitly excludes.
• Expenses already reimbursed by insurance or another account.
• Life insurance and disability coverage premiums.

Over-the-counter items

Many over-the-counter medications and health products are eligible without a prescription, along with items like menstrual care products and certain medical supplies. The specifics can shift with regulation, so a current eligible-expense list from your administrator is the reliable reference.

The prescription hurdle for over-the-counter medicine is gone. Section 3702 of the CARES Act (2020) amended the tax code so that OTC drugs and medicines — pain relievers, allergy medicine, cold remedies, antacids — count as qualified medical expenses without a doctor's note, and it added menstrual care products to the eligible list for the first time. That change applies to HRAs the same way it applies to HSAs and FSAs. What has not changed: items bought for general health rather than a medical condition, such as vitamins or toiletries, are still out unless a physician recommends them to treat a specific diagnosis, and a plan can still choose to be narrower than the law allows.

How reimbursement and proof work

You pay the expense, submit documentation (a receipt or proof of coverage), and the employer reimburses you tax-free — typically through payroll or an administration platform. Keeping good records is the key to smooth, compliant reimbursement, and substantiation is what preserves the tax-free treatment.

What counts as proof is more specific than people expect. A card receipt alone usually fails, because it shows an amount but not what was bought or for whom. Substantiation needs the provider or merchant, the date of service, a description of the item or service, the amount, and the patient's name — an itemized receipt, an explanation of benefits from an insurer, or an invoice will do it. For premium reimbursement, the plan needs the policy details and an attestation of coverage, and for an ICHRA that attestation is renewed annually and confirmed each time a claim is paid. Administrators review this because the tax-free treatment depends on it: a plan that pays unsubstantiated claims risks the exclusion for everyone.

Section 213(d): the master reference

The universe of eligible medical expenses follows IRS Section 213(d), the same reference used by HSAs and FSAs. It covers a broad range of medical, dental, and vision costs. Whether a given HRA reimburses all of it or just premiums depends on how the plan is written.

The boundaries of Section 213(d) are as useful to know as its contents. Cosmetic procedures are excluded unless they correct a deformity from a congenital abnormality, injury, or disease. Anything for general well-being — gym memberships, health foods, most supplements — is excluded unless prescribed to treat a specific condition. Long-term care insurance premiums are eligible only up to an age-based annual limit the IRS sets each year. Expenses reimbursed by another source, such as an insurance payout, cannot be claimed again. And amounts paid for a year other than the plan year, or before the employee became a participant, fall outside the plan even if the expense itself would qualify. These edges are where most denied claims live.

Reimbursing family members' expenses

Most HRAs can reimburse qualified expenses not just for the employee but for their spouse and tax dependents, when the plan is written to allow it. That makes an HRA a meaningful benefit for employees with families, not just individuals.

How plan design sets the boundaries

The eligible list is ultimately a design choice. A premium-only HRA reimburses just insurance premiums; a full-medical HRA also covers out-of-pocket costs under 213(d). Employers pick the scope when they set up the plan, so always check what your specific HRA is written to cover.