In March of 2004, the Treasury Department issued four rulings regarding HSAs. The most important of these rulings has to do with prescription drug coverage. From IRS.gov:
Under section 223, an eligible individual cannot be covered by a health plan that is not an HDHP [High Deductible Health Plan] unless that health plan provides coverage for permitted insurance or permitted coverage. A plan that provides benefits for prescription drugs is a health plan. Prescription drug benefits are not in the list of permitted insurance or permitted coverage. Consequently, an individual who is covered by both an HDHP and by a prescription drug plan is not an eligible individual for the purpose of contributing to an HSA unless the prescription drug coverage is also an HDHP (i.e., the prescription drug plan does not provide benefits unless the required minimum annual deductible under section 223(c)(2)(A) for an HDHP has been satisfied).
In layman's terms, what this means is to be eligible for tax exempt status under an HSA, you have to give up any prescription drug coverage in which you are now enrolled unless that coverage is also an HDHP, which would not make financial sense unless you have really, really expensive drug costs. In other words you will now be paying the first $1,000 of your drug costs out of pocket, or $2,000 for a family.
Typically, if you now have prescription drug coverage today, you get your prescription, go to the pharmacy and pay a co-pay, or perhaps a small deductible. Under HSAs, this all goes away. You pay full price for your medication. The question is, who sets the price of this medication? I don't know yet. If it is like Medicare Part D, the private insurer sets the price and from the prices I've seen while reviewing Medicare Part D, they set them higher than you can buy prescriptions on the open market.
To make a long story short, if Medicare Part D is the Springtime prescription drug plan, HSAs are the Autumn prescription drug plan.
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