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Paying a Concierge Fee From an HSA or FSA: What the IRS Has and Hasn’t Said | CMT Research Brief No. 45

Educational content only. Not medical, legal, tax, financial or accounting advice. Read the disclaimer.

Concierge Medicine Today

CMT Research Brief No. 45 · Tax and Policy · October 2026

Research Brief No. 45Tax and PolicyPrimary evidence: Policy and Law

Paying a Concierge Fee From an HSA or FSA: What the IRS Has and Hasn’t Said

Members ask it when the renewal invoice arrives. The honest answer is more careful than most practice websites admit. This brief sorts what the IRS has actually published from what it has left open, and gives you wording for your patient FAQ that does not promise more than the law supports.

By Concierge Medicine Today, Editorial ResearchPublished October 2026Version 1.0External review: pendingReading time: 11 minutes

New in October 2026. A companion to Brief No. 27, which covers the 2025 HSA rule for direct primary care.

Start here: the questions this brief answers

Tap a question for the short answer, then jump to the evidence.

The 30-second answer

CMT found no IRS ruling or regulation that decides whether a concierge membership fee is a qualified medical expense. The one IRS letter that discusses such a fee, written to a U.S. senator in 2011, declined to decide the question and said each reimbursement plan sets its own rules. The tax code defines medical care as amounts paid for the diagnosis, cure, mitigation, treatment or prevention of disease. Parts of a fee tied to identifiable medical services, such as an annual physical, sit on firmer ground than parts that buy access or amenities. A 2025 federal law opened HSAs to certain direct primary care arrangements, a different model, and its terms leave out most concierge practices. Patients on Medicare cannot contribute to an HSA at all. The safe practice answer is “possibly, depending on your plan and your tax situation,” backed by an itemized statement of services and a referral to the patient’s tax adviser. Do not advertise a membership as “HSA-eligible” without written sign-off from a tax professional.

Has the IRS said a concierge fee is a qualified medical expense?

Not in any published ruling, regulation or notice CMT could find. A 2011 IRS information letter described a concierge fee but left the reimbursement decision to the patient’s plan.

Go to the full answer ↓

What do Publications 502 and 969 say about membership fees?

Neither mentions concierge or retainer fees. Publication 502 does allow an annual physical exam and excludes health club dues. Publication 969 ties HSA and FSA spending to the same definition of medical care.

Go to the full answer ↓

Does the 2025 HSA law for direct primary care cover concierge practices?

Generally not. It covers arrangements paid solely by a fixed periodic fee below a monthly cap. A practice that also bills insurance for the care, or charges above the cap, falls outside it. The details sit in the DPC box in Part 2.

Go to the full answer ↓

Why does itemizing the fee matter?

Because the tax question turns on what the money buys. A statement listing dated medical services gives a plan administrator something to evaluate. A single line reading “annual membership” does not.

Go to the full answer ↓

What should our website say?

Cautious wording that fits your structure, reviewed by a tax adviser before it goes live. The FAQ wording builder in Part 5 drafts a starting point.

Go to the full answer ↓

Written for:Concierge physicians and practice ownersPractice administrators and front-desk leadsHybrid practices weighing a DPC tierTax and benefits advisers

Part 1 · The question at the front desk

A simple question without a simple answer

“Can I use my HSA for this?” is a fair question for a member holding a renewal invoice, and front-desk staff usually want to say yes. The tax record does not let them.

Health savings accounts are no longer a niche product. Devenir, which tracks the market through a survey of HSA providers, counted 41.7 million accounts holding nearly $174 billion at the end of 2025.¹ Industry Research Health flexible spending accounts sit alongside them at many employers. Both pay for “medical care” as the tax code defines it, and both leave the account holder to prove it.²

IRS rulings or regulations CMT found that decide whether a concierge membership fee is medical care (CMT search, October 2026)

Practice Insight ³

2011

the year of the only IRS letter CMT found that discusses a concierge fee; it left the decision to the patient’s plan

Policy and Law ⁴

7.5%

of adjusted gross income: the floor that unreimbursed medical costs must pass before an itemizer can deduct any of them

Policy and Law ⁵

20%

additional tax on HSA withdrawals not used for qualified medical expenses, on top of income tax, with narrow exceptions such as after age 65

Policy and Law ²

That 20% figure is why overpromising matters. If a practice tells a 45-year-old member the fee is “HSA-eligible” and it later turns out not to be a qualified expense, the patient pays the tax and the penalty, not the practice.² The patient is also the one who must keep records showing each withdrawal paid a qualified expense.²

Part 2 · The record

What each IRS source says, and what it leaves out

Commentary on this topic often blurs sources of very different weight. An IRS publication explains the law to filers. A private letter ruling binds the IRS only for the taxpayer who asked, and the IRS says it “may not be relied on as precedent by other taxpayers.”⁶ The ruling cited here repeats that limit in its own text.⁷ Here is what the sources say about a concierge fee.

Source	What it says that matters here	What it does not say	Evidence type
Publication 502 (2025), Medical and Dental Expenses	Medical expenses are “the costs of diagnosis, cure, mitigation, treatment, or prevention of disease.” An annual physical exam counts, even if you are not ill. Amounts paid for the right to receive care from an HMO are treated as insurance premiums. Health club dues do not count. Payments for care to be provided substantially beyond the end of the year generally do not count.⁵	The words concierge and retainer do not appear. Nothing addresses a fee paid to a medical practice for access.	Policy and Law
Publication 969 (2025), HSAs and other tax-favored plans	HSA money may pay medical care as defined in section 213(d), to the extent insurance does not cover it, and may not pay most insurance premiums. FSAs may not reimburse health insurance premiums and need a third-party statement that the expense was incurred and its amount. HSA contributions require an HDHP, no other disqualifying coverage, no Medicare enrollment, and not being claimed as someone else’s dependent.²	No mention of concierge fees. The 2025 edition was written for 2025 returns and does not yet describe the 2026 DPC rule.	Policy and Law
Information Letter INFO 2011-0027	Answering a senator about a constituent whose medical reimbursement account refused her practice’s annual fee, which bought physician access, an annual physical, half-hour visits and dietitian access. The IRS restated the medical care definition and said a plan “can disallow an expense even if it otherwise fits the definition.”⁴	It does not decide whether the fee, or any part of it, was medical care. Information letters are general and advisory.³	Policy and Law
Private letter rulings	CMT searched and found no published ruling on a concierge or retainer fee.	Even if one existed, it could not be cited as precedent for another practice’s patients.^6,7	Policy and Law
IRS questions on wellness and general health (updated September 2026)	Expenses “merely beneficial to general health” are not medical care. Nutrition counseling counts only when it treats a specific diagnosed disease, and a gym membership only in narrow cases.⁸	Concierge fees are not mentioned. The page matters for wellness and lifestyle extras bundled into a membership.	Policy and Law

Legal commentary reaches the same place. An American Bar Association Health Law Section article states that the IRS “has not issued interpretive guidance on the eligibility of concierge fees as medical expenses.”³ Practice Insight CMT’s own search of IRS rulings and letters, current to October 2026, found nothing that changes that.

Direct primary care · a different model · The 2025 HSA rule and the 2020 proposal

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.

Congress settled the HSA question for one model only. Since January 1, 2026, a qualifying direct primary care service arrangement no longer counts as a health plan that blocks HSA contributions, and its fees are treated as medical expenses an HSA may reimburse.⁹ Policy and Law

$150 / $300

aggregate monthly fee limit for one person, or for an arrangement covering more than one; indexed for inflation after 2026

Policy and Law ⁹

Sole fee

the fixed periodic fee must be the only compensation; billing separately for covered care, through insurance or otherwise, disqualifies the arrangement

Policy and Law ⁹

Notice 2026-5 says that before the law changed, such an arrangement “generally would constitute a health plan” providing coverage before the deductible.⁹ Six years earlier, Treasury and the IRS had proposed rules treating DPC fees as medical care under section 213(d), possibly deductible, while warning that DPC membership would generally end HSA eligibility.¹⁰ The proposal defined DPC as a fee paid to primary care physicians “without billing a third party” and never mentioned concierge practices. CMT found no final version. Brief No. 27 covers the DPC rule in detail.

CMT reading: why the DPC rule rarely reaches a concierge fee

The rule describes an arrangement paid only by a fixed fee, with no third-party billing for the included care. A concierge practice that keeps billing insurance or Medicare for visits appears to fall outside the definition on that ground alone, before the fee level is even considered. This is CMT’s reading of the published terms, not a determination for any practice.

Part 3 · What the money buys

Access fees and itemized medical services

Because there is no concierge-specific rule, the analysis falls back on the general one: is the money paying for medical care as the code defines it, or for something else?⁵ A membership usually buys a mix.

The ABA article works through a hypothetical. A patient named George pays $1,200 a year. The author allocates $400 to an annual physical and $600 to three follow-up consultations, and treats the remaining $200, for access and amenities, as ineligible.³ Practice Insight The split is the author’s illustration, not an IRS method. It shows the logic a plan administrator or adviser may apply.

One author’s split of a $1,200 membership

Hypothetical from ABA Health eSource legal commentary. Teal: services the author treats as medical care. Brick: access and amenities the author treats as ineligible.

Treated as medical care in the exampleTreated as ineligible in the example

Analysis and chart: Concierge Medicine TodaySource: Petrova, ABA Health eSource.³ Illustration only. The IRS has not endorsed any allocation method for concierge fees, and real memberships rarely price components this neatly.

Firmer ground

An annual physical exam, which Publication 502 names directly⁵
Dated office visits, consultations and tests for diagnosis or treatment
Nutrition or exercise counseling that treats a specific, diagnosed disease⁸
Services delivered in the same year the claim covers

Weaker ground

Same-day scheduling or a direct phone line, standing alone
Wellness programs or fitness coaching aimed at general health⁸
Non-medical amenities
Fees paid now for care to be provided well beyond the end of the year⁵
Any portion an insurer or other plan already paid

An open question for HSA holders under 65

HSA contributions require that the account holder have no disqualifying health coverage besides the high-deductible plan.² The IRS said a DPC arrangement “generally would” have been such coverage before Congress changed the law.⁹ CMT found no IRS guidance applying that reasoning, for or against, to a concierge membership that includes medical care without a separate charge. In CMT’s reading, that makes it a question for the patient’s tax adviser, not one a practice should answer on its website.

Members on Medicare

From the first month a person is enrolled in Medicare, the HSA contribution limit is zero.² Many concierge members are 65 or older, so for them the live question is usually whether an existing HSA balance or the itemized deduction can help. The deduction helps only to the extent total unreimbursed medical costs pass 7.5% of adjusted gross income.⁵

Part 4 · Operations

How to document the fee so patients can make their own case

The practice cannot decide a patient’s tax treatment. It can make the paperwork honest and useful. MDVIP, a national concierge network, tells patients the fee “may” be reimbursable after services are received and offers a statement of services on request. It does not accept FSA debit or credit cards for the fee.¹¹ Industry Research The same wording appears on Optum Colorado’s MDVIP page.¹² That is one company’s approach, not a legal standard, but it reflects the record above.

Describe each component

Write the membership agreement and fee schedule so medical services and access or amenity features are listed separately. The AMA asks retainer practices to separate retainer charges for special services or amenities from care billed to insurance.¹³

Offer an itemized statement

On request, give a statement listing medical services actually provided, with dates. FSAs require a third-party statement that an expense was incurred and its amount.²

Date it to the care

FSAs reimburse expenses incurred during the coverage period, and Publication 502 generally excludes payments for care far beyond year end.^2,5 A statement tied to service dates is more useful than a receipt for an annual prepayment.

Let the patient file the claim

Plans set their own rules and may refuse an expense that fits the definition of medical care.⁴ HSA holders keep their own records.² The practice supplies documents and stays out of the eligibility call.

Use one script at the desk

Give staff the same approved wording that appears on your website. Part 5 drafts it.

Review once a year

Have a tax adviser review your wording before each renewal season and check for new IRS guidance.

CMT data slot · HSA and FSA questions in concierge practices

CMT does not yet have survey data on this topic. Useful data would come from a survey of concierge practice administrators (concierge only, reported separately from DPC) asking what share of members ask about HSA or FSA payment each year, whether the practice provides itemized statements, and how often members report a plan approving or denying the fee. Sample size, dates and recruitment method must be reported.

Editor: replace this box with CMT survey results (with sample size, dates and recruitment method) before publishing, or delete it.

Part 5 · Build

Draft your patient FAQ answer

Answer five questions about your practice to draft cautious wording for a website FAQ or front-desk script. The output is educational starting language, not tax advice. Have a tax adviser and your healthcare attorney review it before you publish.

Interactive tool

Patient FAQ wording builder

Does the practice bill insurance or Medicare for visits? Will you provide an itemized statement of services on request? Do you accept HSA or FSA debit cards for the membership fee? Are many of your members on Medicare? Length

The practice’s job is to describe the fee accurately and document the care. Whether it qualifies is a call for the patient’s plan and tax adviser.

Tax disclaimer

This brief and the wording it generates are general education about published IRS materials. They are not tax or legal advice, and they do not say whether any fee, patient, account or plan qualifies for tax-free payment or a deduction. Tax rules change and individual facts control the answer. A practice should have a CPA or tax attorney review any statement about tax treatment before it reaches patients, and patients should consult their own tax adviser and plan administrator.

Learn

Know what was said

One IRS letter and no ruling on concierge fees. Start every conversation from that record.

Build

Build the paperwork

Separate the fee components on paper and offer dated statements of services.

Lead

Lead with candor

Patients trust a practice that says “it depends, and here is what you need” over one that says “HSA-eligible” and turns out wrong.

Methods, limitations and evidence types

How this brief was built

CMT read the 2025 editions of IRS Publications 502 and 969, IRS Notice 2026-5, the 2020 proposed regulations on medical care arrangements, an IRS information letter that discusses a concierge fee, an IRS primer on the weight of different kinds of guidance, and an IRS page of medical expense questions on wellness. It searched for IRS private letter rulings on concierge or retainer fees and found none; one unrelated ruling is cited only for its standard statement that such rulings are not precedent. It also read one piece of legal commentary from the American Bar Association Health Law Section and the patient FAQ of one national concierge network, labeled Industry Research. Every source was opened and checked in October 2026.

Concierge medicine and direct primary care were kept apart throughout. The 2025 HSA rule and the 2020 proposal concern DPC, so their terms and dollar limits appear only inside the walled-off DPC box. CMT is not a tax adviser. Nothing here says whether any particular fee, patient or account qualifies, and the FAQ builder in Part 5 produces draft language for review, not tax advice. Because this is a tax topic, CMT recommends review by a CPA or tax attorney before any practice relies on it.

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.

Clinical Trial Evidence
Randomized trials and systematic reviews.Best for cause and effect.

Population Data
Large observational studies and government data.Best for trends at scale.

Practice Insight
Surveys, smaller studies and expert consensus.Best for real-world experience.

Industry Research
Company-sponsored or company-reported data that is not peer-reviewed.Best for early signals and operating data.

Policy and Law
Statutes, regulation and official guidance.Best for what is required.

What we don't know

Whether the IRS will ever address concierge or retainer fees directly. CMT found no project or request for comment on the question.
How often plan administrators approve or deny concierge fee claims. No public data exist, and administrators’ internal rules vary.
Whether a concierge membership that includes medical care without a separate charge could count as other health coverage that interferes with HSA contributions. CMT found no IRS guidance on concierge memberships and treats this as an open question.
Whether the 2020 proposed regulations on DPC arrangements will be finalized, withdrawn or replaced now that Congress has acted. CMT found no final rule.

How to cite this brief

Concierge Medicine Today. “Paying a Concierge Fee From an HSA or FSA: What the IRS Has and Hasn’t Said.” CMT Research Brief No. 45. October 2026. https://conciergemedicinetoday.net/concierge-fees-hsa-fsa

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.

Keep reading

Related CMT Research Briefs

Sources

References

Devenir. HSA assets reach nearly $174 billion at year-end 2025 as investment assets rise to $85 billion (2025 Year-End Devenir HSA Research Report). April 23, 2026. www.devenir.comFunding: not stated (survey conducted and published by Devenir; data self-reported by HSA providers)
Internal Revenue Service. Publication 969 (2025): Health Savings Accounts and Other Tax-Favored Health Plans. For use in preparing 2025 returns. Accessed October 2026. www.irs.govFunding: federal (Internal Revenue Service publication)
Petrova G. Are concierge physician fees payable tax-free from health savings accounts and reimbursable health flexible spending accounts? ABA Health eSource, American Bar Association Health Law Section (archived in the 2016 to 2017 volume, July 2017 issue). Legal commentary. www.americanbar.orgFunding: not stated (legal commentary published by the American Bar Association Health Law Section)
Internal Revenue Service, Office of Associate Chief Counsel. Information Letter INFO 2011-0027 (UIL 213.00-00), letter to the Honorable Mark R. Warner, United States Senator, on reimbursement of a medical practice's annual fee from a medical reimbursement account. March 11, 2011; released March 25, 2011. www.irs.govFunding: federal (Internal Revenue Service information letter)
Internal Revenue Service. Publication 502 (2025): Medical and Dental Expenses. For use in preparing 2025 returns. Accessed October 2026. www.irs.govFunding: federal (Internal Revenue Service publication)
Internal Revenue Service. Understanding IRS guidance: a brief primer. Page last reviewed February 28, 2026. www.irs.govFunding: federal (Internal Revenue Service publication)
Internal Revenue Service. Private Letter Ruling 202505002 (PLR-107243-24, index 213.00-00), on section 213 medical expenses for fertility and surrogacy costs. Dated October 11, 2024; released January 31, 2025. Cited here only for its standard statement on precedent. www.irs.govFunding: federal (Internal Revenue Service private letter ruling)
Internal Revenue Service. Frequently asked questions about medical expenses related to nutrition, wellness and general health. Page last reviewed September 23, 2026. www.irs.govFunding: federal (Internal Revenue Service publication)
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)
Department of the Treasury, Internal Revenue Service. Certain Medical Care Arrangements (proposed regulations, REG-109755-19, RIN 1545-BP31). Federal Register. 85 FR 35398. June 10, 2020. www.govinfo.govFunding: federal (Department of the Treasury and Internal Revenue Service proposed rule)
MDVIP. FAQs for Patients (membership fee reimbursement and tax questions). Company website. Accessed October 2026. www.mdvip.comFunding: not stated (company website, MDVIP)
Optum Colorado. Concierge Medicine with MDVIP (service page). Company website. Accessed October 2026. www.optum.comFunding: not stated (company website, Optum)
American Medical Association. Code of Medical Ethics Opinion 11.2.5: Retainer Practices. code-medical-ethics.ama-assn.orgFunding: not stated (American Medical Association ethics policy)

Disclaimer

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.