DPC and HSAs in 2026

General information, not tax advice. This guide summarizes one IRS notice. Your practice, your fee schedule and your patients' situations are specific. Talk to a tax professional before you change your pricing or tell patients anything about their HSA.

Starting in 2026, a patient can belong to a direct primary care practice and still contribute to a health savings account. That was not true before. The change is real, but it comes with conditions, and most of them live in your fee schedule.

Everything below comes from one source: IRS Notice 2026-5, the IRS's guidance on the HSA changes in the 2025 law. Quotes are taken from the notice word for word.

What changed

To contribute to an HSA, a person has to be covered by a high deductible health plan (HDHP) and generally not be covered by any other health plan. Before 2026, the IRS viewed a typical DPC membership as that kind of other plan. In the notice's words, before the new law "an individual generally was not eligible to contribute to an HSA if the individual was enrolled in a DPCSA."

Section 71308 of the One Big Beautiful Bill Act, enacted July 4, 2025, changed that. It amended section 223(c)(1) of the tax code so that a qualifying direct primary care service arrangement (DPCSA) is not treated as a health plan for this purpose. The notice puts it plainly: "enrollment in such a DPCSA will not cause an individual to fail to be an eligible individual for that reason."

The same section also amended section 223(d)(2)(C), so DPCSA fees can be paid from an HSA.

The DPC provisions apply to months beginning after December 31, 2025. In practice, that means January 2026 onward.

Two separate questions

The notice treats these as two different rules, and it helps to keep them apart.

1. Can the member keep contributing to their HSA while enrolled? Only if your arrangement meets the DPCSA definition, including the monthly fee limit.
2. Can the member pay your fees out of their HSA? The notice says there is "no specific limit on the amount of the fixed periodic fee" for this purpose.

So a membership priced over the limit is not useless to an HSA holder. Per the notice, those fees "will be treated as medical expenses reimbursable from an HSA" but "will disqualify the covered individual from eligibility for making HSA contributions while the individual is enrolled." For many patients, losing the ability to contribute is the part that matters.

What counts as a DPCSA

The notice defines it as an arrangement where the person gets medical care "consisting solely of primary care services provided by primary care practitioners," and where "the sole compensation for such care is a fixed periodic fee."

Who counts as a primary care practitioner

• A physician whose primary specialty designation is family medicine, internal medicine, geriatric medicine or pediatric medicine
• A nurse practitioner
• A clinical nurse specialist
• A physician assistant

What is not a primary care service

For this rule, "primary care services" does not include:

1. Procedures that require general anesthesia
2. Prescription drugs other than vaccines (the notice adds that "vaccines are permitted primary care services")
3. Laboratory services not typically administered in an ambulatory primary care setting

The fee limits

An arrangement does not count as a DPCSA if "the aggregate fees for all DPCSAs for the individual for a month exceed $150 (or $300 for any such arrangement that covers more than one individual)."

Three details in that sentence matter:

• $150 a month for an arrangement covering one person.
• $300 a month for an arrangement covering more than one person. It is not $150 times the number of people.
• "All DPCSAs" add together. If one person belongs to two arrangements, both fees count toward the same limit.

The limit "is adjusted annually for inflation for taxable years after 2026." The 2026 numbers are $150 and $300. Check the current figure each year before you repeat it on your site.

Worked examples, 2026

Within the limit is only one test. The arrangement still has to meet the rest of the definition.

Paying by the year or quarter

The notice allows fees billed for periods longer than a month, up to a year, as long as they are fixed, periodic and within the monthly limit on an annualized basis. Its own example for a single person in 2026: "$1,800 for a year; $900 for six months; or $450 for three months."

What the IRS Q&As add

The notice answers a set of DPC questions. These are the ones that touch a practice's day to day.

Billing separately for member-only items

If items and services are offered only to members and billed separately, "through insurance or otherwise," the arrangement is not a DPCSA. The notice says "the sole compensation for care provided under a DPCSA must be the fixed periodic fee." (Q-11)

Services you offer to everyone

If your providers offer items and services outside the arrangement "regardless of membership" and bill both members and non-members for them, the arrangement can still qualify. (Q-12)

What a member actually uses does not matter

A member cannot decline the non-qualifying parts and call it a DPCSA. Qualification "depends on the terms of the arrangement, not the services used by an individual." (Q-14)

The HDHP cannot pay for the membership before the deductible

An HDHP cannot offer DPC membership as a benefit "without a deductible or before the deductible has been satisfied." (Q-15)

Fees do not count toward the deductible

Membership fees do not count toward the HDHP's deductible or out-of-pocket maximum. (Q-16)

Employer-paid fees

If an employer pays the fees, including through a cafeteria plan salary reduction, the employee cannot also reimburse those fees from their HSA. (Q-18)

Paying ahead

Generally, an HSA can reimburse fees before the coverage period starts. The notice's example: a substantiated fee for an arrangement starting January 1 can be reimbursed right away, even if it was paid before that date. (Q-19)

What to check on your fee schedule

• Every individual tier is $150 a month or less in 2026, including senior and age-banded tiers.
• Every multi-person arrangement, including your family cap, is $300 a month or less in 2026.
• Annual and quarterly prices are no more than the monthly limit times the months covered.
• Nothing offered only to members is billed on top of the fee, through insurance or otherwise.
• Anything billed separately is offered to non-members too, and billed to both.
• Your membership terms do not include procedures needing general anesthesia, prescription drugs other than vaccines, or labs not typically done in an ambulatory primary care setting.
• Care is delivered by primary care practitioners as the notice defines them.
• You have a date on your calendar to recheck the limit when the inflation adjustment comes out.

Questions to bring to your tax advisor

The notice does not answer everything a DPC practice runs into. Bring these to someone qualified:

• Dispensing medications inside the fee. The statute excludes prescription drugs other than vaccines from primary care services. Ask how that applies to what you dispense and how you price it.
• Medications, labs or supplies sold to members at cost. Ask whether your setup counts as member-only items billed separately.
• One-time enrollment or re-enrollment fees. The notice speaks of a "fixed periodic fee" and does not address one-time fees.
• Per-visit fees, home visit fees, or procedure supply charges. Ask how these fit with "sole compensation."
• Vaccines billed to insurance. Ask how Q-11 applies.
• Add-on tiers (for example, a gynecology or telehealth add-on). Ask whether the add-on and the base membership are judged together.

What to check on your website

Patients read your site before they talk to you. A single word like "eligible" can send them the wrong way.

• Do not say "HSA eligible" or "HSA compatible" unless your tax advisor agrees your arrangement fits, and the specific tier fits the limit.
• If some tiers fit and some do not, say which. A badge on the whole page is not enough.
• Put the fee limit in plain text with the year: "In 2026, the IRS limit is $150 a month for one person, $300 for more than one."
• Keep "contribute to an HSA" and "pay from an HSA" as two separate statements. They are two separate rules.
• Link to the notice so patients can read the source.
• Add a line telling patients to confirm with their own tax professional or HSA administrator.
• Review the wording every January.

What to tell patients

Keep it short, accurate, and pointed at the source. Something like this, adjusted to your situation and reviewed by your advisor:

"Starting in 2026, federal law lets people with an HSA join a qualifying direct primary care practice and keep contributing to their HSA. The IRS limit for 2026 is $150 a month for one person and $300 a month for more than one. Your membership with us is [within / over] that limit. Your situation may differ, so please confirm with your tax professional or HSA administrator. The IRS guidance is Notice 2026-5."

When a patient asks a question you cannot answer from the notice, say so. "Please ask your tax professional" is the right answer, and patients respect it.

Source

Internal Revenue Service, Notice 2026-5, Expanded Availability of Health Savings Accounts under the One, Big, Beautiful Bill Act (OBBBA). See Section II for the law and Section III.C, Q-11 through Q-20, for the DPC questions and answers.

General information, not tax advice. Talk to a tax professional before you change your pricing, your membership terms, or what your site says about HSAs.