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The $150 Line: HSAs, Direct Primary Care and the 2025 Tax Law
Since January 2026, patients with health savings accounts can keep contributing while paying for direct primary care, and can pay the fee from the HSA. The rule is narrow. Most concierge practices will not qualify as written, and many of their patients could not use it anyway.
Updated October 2026: evidence grades replaced with evidence types; funding disclosed on every source.
Start here: the questions this brief answers
Tap a question for the short answer, then jump to the evidence.
The 2025 tax law lets HSA-eligible patients pay for qualifying direct primary care arrangements, up to $150 a month for an individual or $300 for a family, without losing HSA eligibility. IRS guidance defines a qualifying arrangement narrowly: primary care only, from primary care clinicians, paid only by a fixed periodic fee. A concierge practice that bills insurance for visits, or charges more than $150 a month, appears not to qualify. Patients on Medicare cannot contribute to HSAs at all. Confirm your structure with tax counsel before marketing HSA eligibility.
“The $150 line is a gift to direct primary care and a test for concierge medicine. If your value only makes sense at a lower price, you have a pricing problem. If it makes sense at a higher one, you'd better be able to explain it in one sentence.”
What changed, and when?
The One Big Beautiful Bill Act, enacted July 4, 2025, made qualifying direct primary care arrangements compatible with HSAs starting January 1, 2026. The IRS explained the rules in Notice 2026-5 in December 2025.
Go to the full answer ↓What is the $150 line?
Total qualifying fees cannot exceed $150 a month for one person or $300 for an arrangement covering more than one person. The 2027 limits remain $150 and $300.
Go to the full answer ↓Does my concierge practice qualify?
Probably not if you bill insurance or Medicare for visits, charge over $150 a month, or include non-primary care services in the fee. The test is "sole compensation" through a fixed periodic fee. Part 3 lists the questions to take to a tax adviser.
Go to the full answer ↓Can my Medicare patients use their HSA for my fee?
Generally they cannot contribute to an HSA once enrolled in Medicare. Some may still have older HSA balances; how those can be spent is a question for their tax adviser.
Go to the full answer ↓Should I restructure to qualify?
Only after modeling it. A sub-$150 fee changes panel size, staffing and revenue. For some practices, a separate qualifying tier may make sense. For many, it will not.
Go to the full answer ↓What the law and the IRS actually say
Before 2026, a patient in a direct primary care arrangement could lose eligibility to contribute to a health savings account, because the IRS could treat the membership as disqualifying health coverage. Section 71308 of the One Big Beautiful Bill Act changed that.1 Policy and Law
One Big Beautiful Bill Act enacted. Qualifying direct primary care service arrangements are disregarded for HSA eligibility, and HSA funds may pay the fees.
IRS issues Notice 2026-5 with definitions, limits and examples. Comments invited through March 6, 2026.2,
Provision takes effect for months beginning after December 31, 2025.
Commenters, including the Direct Primary Care Coalition and UnitedHealthcare, argue the IRS reading is narrower than Congress intended.4
Rev. Proc. 2026-24 sets the 2027 limits, which remain $150 and $300 per month.5
The definition, in plain language
| Element | What qualifies | Source |
|---|---|---|
| Who provides care | Primary care practitioners: physicians whose primary specialty is family, internal, geriatric or pediatric medicine; nurse practitioners; clinical nurse specialists; physician assistants | 6, |
| What care | Primary care services. Excludes procedures requiring general anesthesia, prescription drugs other than vaccines, and lab services not typically done in ambulatory primary care | 6 |
| How it is paid | The sole compensation for the care is a fixed periodic fee. A practice may not bill members separately for services included in the package | 6, |
| How much | Aggregate fees no more than $150 per month (individual) or $300 (more than one person). 2027 limits unchanged | 2, |
| Over the limit | The arrangement is disqualifying coverage, so the patient cannot contribute to an HSA while enrolled | 1 |
| Employer-paid fees | Excludable from the employee's income, but cannot also be reimbursed from the HSA. Fees do not count toward the deductible | 1 |
Who the rule helps, and who it misses
The provision was written with direct primary care in mind. The fee data confirm the fit.
These figures describe direct primary care (DPC), not concierge medicine. DPC usually operates outside insurance billing at lower monthly fees. They are shown here, separately, for context only and should not be read as concierge data.
Likely to benefit
- Cash-only DPC practices under $150 a month
- Younger, working-age members with HSA-qualified plans, including exchange bronze and catastrophic plans, which became HSA-compatible in 20263
- Small employers pairing DPC with a high-deductible plan
Likely to miss out
- Concierge practices that bill insurance or Medicare for visits
- Practices with fees above $150 a month
- Medicare enrollees, who generally cannot contribute to an HSA once enrolled9
Many concierge members are 65 or older and on Medicare. For them, HSA compatibility is largely irrelevant. The provision's real competitive effect is on working-age, younger members, where a sub-$150, HSA-payable DPC membership now carries a tax advantage that a typical concierge fee does not. That is CMT's inference from the rule's structure.
Discussion guide: questions to take to your tax adviser
Answer five questions. This is an educational screen based on the published definition, not a tax determination. Confirm with a qualified tax adviser before telling patients a membership is HSA-eligible.
Five questions from the published definition
Should a concierge or hybrid practice restructure?
From first principles: a fee under $150 a month is $1,800 a year or less. Sustaining a physician on that fee requires a larger panel than most concierge models are built around. The question is not "can we qualify?" but "what practice would we become if we did?"
Option A: Stay as you are
Fits practices with mostly Medicare-age members or fees well above $150. HSA status matters little to your members.
Option B: Add a qualifying tier
A separate, cash-only, primary-care-only tier for working-age members. Requires clean separation of services and billing. Ask counsel how the IRS views mixed structures; the guidance does not clearly address it.
Option C: Convert to DPC pricing
A full model change: bigger panel, different staffing, different economics. Only after detailed modeling.
Fees and billing: what published data show
On both counts the new rule tests, concierge practices often fall outside it: at CMT's estimate of about $3,000 a year, a typical concierge fee is well above $150 a month, and many concierge practices keep billing insurance. MDVIP, the largest national network, states that its affiliated physicians “continue to participate in Medicare and most commercial insurance plans.”13 Industry Research Medicare enrollment also ends HSA contribution eligibility, which matters for practices with older members.9 The CMT polls are open online polls with unverified respondents; read them as direction, not national rates.
These figures describe direct primary care (DPC), not concierge medicine. DPC usually operates outside insurance billing at lower monthly fees. They are shown here, separately, for context only and should not be read as concierge data.
Direct primary care is the model the rule was written for. In a 2024 survey of 465 DPC practices, the average fee was $98.46 a month8, and employer-sponsored DPC rates on Hint Health's platform stayed between $55 and $65 per member per month for five years14. Practice Insight Industry Research
CMT could not verify a methodology-disclosed survey of concierge fee levels or of the share of concierge members under 65. Whether a specific arrangement qualifies is a question for a tax adviser.
Know the definition
Sole compensation, primary care only, $150 per person per month.
Model before you market
Run panel, staffing and revenue scenarios before offering an HSA tier.
Say it precisely
Never advertise "HSA-eligible" without counsel's sign-off. Overstating it can create tax problems for members.
How this brief was built
CMT reviewed IRS Notice 2026-5, Revenue Procedure 2026-24 (as reported), and analyses by tax and benefits publications and the American Academy of Family Physicians. Quotations of the definition are drawn from those sources. CMT is not a tax adviser; this brief explains the rule's structure and its implications for practice models, not how it applies to any individual practice or patient. Treasury and the IRS invited comments through March 6, 2026; readers should check for later guidance. Concierge figures come from MDVIP's website, a CMT editorial estimate and CMT open online polls (unverified respondents). DPC fee data, from the Direct Primary Care Alliance survey and Hint Health (company-reported), appear only in separate, labeled DPC boxes because DPC is a different model.
How to read the evidence types
Every key finding is labeled by evidence type. Labels describe the type of evidence, not its value. Each type answers different questions. Funding is disclosed on every source.
Randomized trials and systematic reviews.Best for cause and effect.
Large observational studies and government data.Best for trends at scale.
Surveys, smaller studies and expert consensus.Best for real-world experience.
Company-sponsored or company-reported data that is not peer-reviewed.Best for early signals and operating data.
Statutes, regulation and official guidance.Best for what is required.
What we don't know
- Whether Treasury will revise the definition of "primary care services" in response to public comments, which several commenters asked for.
- How the IRS will treat hybrid practices that run a qualifying tier alongside an insurance-billing tier.
- How many patients and employers will actually use the provision in 2026 and 2027.
How to cite this brief
External review: this brief has not yet been reviewed by an outside expert. When review is complete, the reviewer is credited by name above with any conflicts of interest, and the version number is updated. Reviewers check accuracy and fairness; CMT is responsible for the final content.
Corrections policy: when an error is identified, CMT corrects it in the open and updates the version number above. Send corrections to the editor through conciergemedicinetoday.net.
Related CMT Research Briefs
References
- Current Federal Tax Developments. Notice 2026-5: Expansion of HSA availability and eligibility under the OBBBA (analysis). December 10, 2025. www.currentfederaltaxdevelopments.comFunding: not stated (tax commentary)
- Internal Revenue Service. Notice 2026-5: Expansion of health savings account availability and eligibility under the One, Big, Beautiful Bill Act. December 9, 2025. www.irs.govFunding: federal (Internal Revenue Service publication)
- PlanAdviser. IRS posts rules for HSAs in ACA bronze, catastrophic plans. December 2025. www.planadviser.comFunding: not stated (news report)
- BenefitsPRO. IRS guidance could cripple new HSA direct primary care access law, commenters say. March 12, 2026. www.benefitspro.comFunding: not stated (news report)
- Current Federal Tax Developments. 2027 inflation adjustments for HSAs, HRAs, and the new DPCSA limits (Rev. Proc. 2026-24). May 29, 2026. www.currentfederaltaxdevelopments.comFunding: not stated (tax commentary)
- Louisiana Academy of Family Physicians (source: American Academy of Family Physicians). Guidance released on allowing HSA funds to be used for DPC arrangements. December 17, 2025. lafp.orgFunding: not stated (association news item)
- BenefitsPRO. How will HSA-compatible direct primary care work? The IRS explains. December 10, 2025. www.benefitspro.comFunding: not stated (news report)
- Direct Primary Care Alliance. State of Direct Primary Care report (2024 survey, 465 respondents), as reported by Medical Economics, July 29, 2026. www.medicaleconomics.comFunding: not stated (conducted and published by the Direct Primary Care Alliance)
- Internal Revenue Service. Publication 969: Health Savings Accounts and Other Tax-Favored Health Plans (Medicare enrollment and HSA contributions). www.irs.govFunding: federal (Internal Revenue Service publication)
- Concierge Medicine Today. Media Desk: quotes from the Editor-in-Chief, FAQs and data. Accessed October 2026. conciergemedicinetoday.netFunding: Concierge Medicine Today (self-published; no outside funder) CMT original
- Concierge Medicine Today, LLC. Poll: Does your concierge medicine office accept and/or bill insurance and/or Medicare? 97 votes, through February 2020. Open online poll (CrowdSignal). Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- Concierge Medicine Today, LLC. Poll: How many of your private membership medicine patients are Medicare participants? 50 votes, approximately 2015 to 2018. Open online poll (CrowdSignal). Not representative; respondents not verified.Funding: Concierge Medicine Today (self-conducted; no outside funder) CMT original
- MDVIP. How MDVIP is different from other concierge medicine (company website). Accessed October 2026. www.mdvip.comFunding: industry (MDVIP company website)
- Hint Health. Hint Health releases 2026 Direct Primary Care Trends Report (platform data from 2,700+ DPC clinicians and 1.4 million members). Press release via Cision. April 23, 2026. digital-release.nwahomepage.comFunding: industry (Hint Health; company-reported platform data)
Educational and informational only. This CMT Research Brief does not constitute medical, legal, tax, financial, accounting or other professional advice, and it does not create a professional relationship of any kind. Statements about laws, regulations, tax rules and payer policies are general, may not reflect the rules in your state, and can change after publication. Consult a qualified attorney, accountant, tax adviser, compliance professional or licensed clinician before acting on anything here.
Independence. Concierge Medicine Today is an independent publication. It does not accept payment for favorable coverage, and it does not favor one practice model over another. Company names and products are mentioned for context only and are not endorsements. Funding is disclosed for every source in the reference list.
Accuracy. CMT verifies figures against their original or best available sources at the time of publication. Where a figure is an estimate, an inference or a company-reported number, the brief says so. This content is not without possible error or omission.
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