Telehealth Coverage and HSA Eligibility: The 2026 Rules After OBBBA

The One Big Beautiful Bill Act permanently reinstated the HDHP telehealth safe harbor. Here is what changed, what IRS Notice 2026-5 clarified, and what employers should check in their plan design.

Quick Answer (as of 2026): The One Big Beautiful Bill Act permanently reinstated the HDHP telehealth safe harbor, letting high-deductible health plans cover telehealth before the deductible without disqualifying HSA eligibility. The relief applies retroactively to plan years beginning after December 31, 2024. IRS Notice 2026-5 limits qualifying services to Medicare's published telehealth list and adds new HSA rules for direct primary care arrangements starting in 2026.

Telehealth and HSA eligibility have been tangled up in expiration dates and short-term extensions since 2020. That uncertainty ended on July 4, 2025, when the One Big Beautiful Bill Act permanently reinstated the rule letting a high-deductible health plan cover telehealth visits before the deductible without disqualifying employees from contributing to a health savings account. Employers who paused or scaled back free telehealth benefits during the gap year now have a permanent green light, and a new IRS notice spells out exactly which services count.

This matters because the rule had actually lapsed. For employers who suspended pre-deductible telehealth coverage sometime in 2025 waiting for clarity, or who never restarted it after the prior extension expired, this article covers what changed, what still does not qualify, and what to check in plan documents before open enrollment.

What Is the HDHP Telehealth Safe Harbor?

The HDHP telehealth safe harbor is a federal rule that lets a high-deductible health plan pay for telehealth and other remote care visits before the plan's deductible is met, without that first-dollar coverage counting as disqualifying health coverage under IRS HSA eligibility rules. Normally, an HSA-eligible HDHP cannot pay for non-preventive care until the employee has met the statutory minimum deductible, currently $1,700 for self-only coverage and $3,400 for family coverage in 2026. The telehealth safe harbor is a narrow, specific exception written into the tax code just for virtual care visits, letting employees see a doctor by video or phone for free or at low cost while still qualifying to contribute to an HSA.

Did the Telehealth Safe Harbor Expire in 2025?

Yes, for a period of time it did. The prior version of the safe harbor, extended by the Consolidated Appropriations Act of 2023, covered plan years beginning after December 31, 2022, and before January 1, 2025. Congress did not extend it again before that window closed, so calendar-year HDHPs lost the ability to offer pre-deductible telehealth without risking employee HSA eligibility starting January 1, 2025. Employers with non-calendar-year plans kept the relief through the rest of their 2024 plan year, but every plan eventually hit the same gap once its plan year rolled over.

How Did the One Big Beautiful Bill Act Change Telehealth and HSA Rules?

The One Big Beautiful Bill Act, signed into law July 4, 2025, permanently extended the telehealth safe harbor and made the fix retroactive to plan years beginning after December 31, 2024. This closed the 2025 gap entirely rather than leaving it open. Employees enrolled in an HDHP with pre-deductible telehealth coverage in early 2025, before the bill passed, remain HSA-eligible for that period even though the safe harbor had technically lapsed on paper at the time.

Employers who suspended free or low-cost telehealth benefits during the gap can now reinstate that coverage retroactively to January 1, 2025, or choose to apply it prospectively starting with the next plan year. Because the extension is permanent, employers no longer need to track a year-by-year expiration date the way benefits teams had to for the previous three renewal cycles.

Summit Health Benefits helps employers structure HSA-eligible plans correctly. If your HDHP telehealth benefit was paused during the 2025 gap, or you are not sure your plan document reflects the permanent safe harbor, we will check it before your next renewal. Get a free plan review.

What Telehealth Services Qualify Under IRS Notice 2026-5?

IRS Notice 2026-5, released by the Treasury Department and the IRS in December 2025, clarified that a qualifying telehealth service is one that appears on the Medicare telehealth services list, which the Centers for Medicare and Medicaid Services publishes and updates every year. This ties the HSA safe harbor to an existing federal list instead of leaving "telehealth" as an undefined term, which gives employers and plan administrators a specific reference point to check services against.

The notice also confirmed what does not qualify. The safe harbor covers the virtual visit itself. It does not extend to in-person services, medical equipment, or prescription drugs that happen to be furnished in connection with a telehealth visit. An HDHP that pays pre-deductible for a video consultation but also waives cost-sharing on a prescription ordered during that visit is applying the safe harbor too broadly, since the drug itself falls outside the exception.

What Is a Direct Primary Care Service Arrangement, and Does It Affect HSA Eligibility?

A Direct Primary Care Service Arrangement, or DPCSA, is a subscription-style arrangement where a patient pays a fixed periodic fee directly to a primary care practice instead of billing insurance for each visit. Starting in 2026, the One Big Beautiful Bill Act and IRS Notice 2026-5 confirm that enrolling in a qualifying DPCSA no longer disqualifies a person from HSA eligibility, a change from the prior rule that treated most DPCSA fees as separate health coverage that blocked HSA contributions.

To qualify, the arrangement can only cover primary care services delivered by primary care practitioners, family medicine, internal medicine, geriatric medicine, or pediatric medicine physicians, plus nurse practitioners, clinical nurse specialists, and physician assistants. It cannot include procedures requiring general anesthesia, prescription drugs other than vaccines, or lab services outside a typical ambulatory primary care setting. The monthly fee is also capped, at $150 for individual coverage or $300 for coverage of more than one person, with inflation adjustments starting in 2027.

One detail catches employers off guard here. An HDHP cannot pay a DPCSA fee before the deductible, and the fee does not count toward the deductible or out-of-pocket maximum. However, once an employee has an eligible HSA, that HSA can reimburse DPCSA fees as a qualified medical expense, as long as the employer did not pay the fee directly or through salary reduction.

Do Bronze and Catastrophic Marketplace Plans Count as HDHPs Now?

For months beginning after December 31, 2025, the One Big Beautiful Bill Act treats ACA Marketplace bronze and catastrophic plans as HDHPs for HSA eligibility purposes, even when those plans do not meet the traditional HDHP deductible or out-of-pocket limits. This provision mainly affects individuals buying coverage on the ACA exchange rather than employer-sponsored group plans, so most employers will not see a direct effect on their own HDHP design from this specific change.

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What Should Employers Do With Their HDHP Plan Design in 2026?

Employers offering an HSA-eligible HDHP should review their plan documents now to confirm pre-deductible telehealth coverage matches the permanent safe harbor rather than an outdated 2024 expiration date some plan documents may still reference. Confirm that any telehealth benefit is limited to services on the current Medicare telehealth list, since the IRS notice ties eligibility to that specific reference point rather than a general definition of virtual care. If the workforce includes anyone considering a Direct Primary Care arrangement, check that the arrangement meets the fixed-fee, primary-care-only, and monthly cap requirements before assuming it will not interfere with HSA contributions.

Employers who paused telehealth cost-sharing waivers sometime in 2025 have a choice to make. Reinstating the benefit retroactively to January 1, 2025 requires coordinating with the plan's third-party administrator on claims already processed during the gap. Applying it prospectively for the next plan year is simpler administratively but means employees who paid full telehealth cost-sharing during 2025 do not get that money back. Either path is permitted under the law. The employer decides which approach fits its payroll and claims administration capacity.

Summit Health Benefits pairs HSA-eligible plan design with a Section 125 cafeteria plan. Pre-tax HSA contributions and a properly structured telehealth benefit work together to lower payroll taxes and keep coverage affordable for employees. Talk to a specialist.

Employers running a <a href="/blog/section-125-cafeteria-plan-2026-guide">Section 125 cafeteria plan</a> alongside their HDHP can let employees elect HSA contributions pre-tax, on top of whatever the permanent telehealth safe harbor already saves them. For a full breakdown of where the 2026 HSA numbers landed, see our <a href="/blog/hsa-contribution-limits">HSA contribution limits guide</a>, and for the difference between an HSA and a Flexible Spending Account, see our <a href="/blog/hsa-vs-fsa-2026">HSA vs. FSA comparison</a>. Employers who over-fund an HSA through payroll should also review our guide to the <a href="/blog/hsa-excess-contribution-excise-tax">HSA excess contribution excise tax</a>, since a mistimed telehealth or DPCSA reimbursement is one of several ways an account can end up over the limit.

Frequently Asked Questions

Does telehealth coverage before the deductible disqualify someone from HSA contributions in 2026?
No. The One Big Beautiful Bill Act permanently reinstated the HDHP telehealth safe harbor, so a high-deductible health plan can pay for telehealth visits before the deductible is met without disqualifying an employee from contributing to a health savings account. This applies to plan years beginning after December 31, 2024.
Was the telehealth HSA safe harbor ever actually gone?
Yes, for part of 2025. The prior extension under the Consolidated Appropriations Act of 2023 covered plan years through December 31, 2024, and Congress did not extend it again before that date. The gap closed retroactively when the One Big Beautiful Bill Act passed on July 4, 2025, so no calendar-year HDHP participant actually lost HSA eligibility once the retroactive fix applied.
What telehealth services qualify for the pre-deductible safe harbor?
IRS Notice 2026-5 limits qualifying services to those on the Medicare telehealth services list, which the Centers for Medicare and Medicaid Services publishes and updates annually. The safe harbor covers the virtual visit itself and does not extend to in-person care, medical equipment, or prescription drugs furnished in connection with a telehealth appointment.
Can an employee join a direct primary care arrangement and still contribute to an HSA?
Starting in 2026, yes, if the arrangement meets specific requirements. It must provide only primary care services from qualifying practitioners for a fixed periodic fee capped at $150 a month for individual coverage or $300 for coverage of more than one person, with no procedures requiring general anesthesia, no prescription drugs other than vaccines, and no lab services outside a typical primary care setting.
Can an HSA reimburse direct primary care membership fees?
Yes, an HSA can reimburse a qualifying direct primary care fee as a qualified medical expense once the person is HSA-eligible. However, an HDHP cannot pay the fee before the deductible, and the fee does not count toward the deductible or out-of-pocket maximum. Employer-paid fees, including payment through salary reduction, are not eligible for HSA reimbursement.
Do employers need to update their plan documents for the permanent telehealth safe harbor?
Employers should review plan documents and summary plan descriptions that may still reference the prior expiration date under the Consolidated Appropriations Act of 2023. Confirming the telehealth benefit language reflects the permanent extension, and that covered services match the current Medicare telehealth list, avoids a mismatch between what the plan document says and what the IRS notice actually allows.
Does the telehealth safe harbor apply to bronze and catastrophic Marketplace plans too?
The bronze and catastrophic plan provision is a separate part of the same law. For months beginning after December 31, 2025, those ACA Marketplace plans are treated as HDHPs for HSA eligibility purposes even if they do not meet standard HDHP deductible requirements. This mainly affects individual Marketplace enrollees rather than employer-sponsored group plans.
Can employers reinstate a paused telehealth benefit retroactively to January 1, 2025?
Yes, the law permits reinstating pre-deductible telehealth coverage retroactively to the start of the 2025 plan year, since the fix itself is retroactive. Employers choosing this route need to coordinate with their third-party administrator on any telehealth claims already processed with cost-sharing applied during the gap period.

Sources

This article cites the One Big Beautiful Bill Act (Public Law 119-21), IRS Notice 2026-5, the Consolidated Appropriations Act of 2023, and guidance from the Centers for Medicare and Medicaid Services on its annually published Medicare telehealth services list.

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