Self reimbursement from HSA

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Self reimbursement from HSA

Postby Walleye12 » Sat Dec 15, 2012 5:01 pm

I have an HDHP through Cigna with a HSA account that is managed by Chase Bank. I've gotten a few prescriptions, paid out of pocket, and wanted to reimburse myself from the HSA. I called Cigna to try and determine which form I need to fill out to receive a reimbursement check for the cost of these prescriptions and the person on the phone said that I can just go to a Chase ATM and withdraw the funds to reimburse myself.

I thought this sounded strange and pressed her on it, but she insisted that is correct. Has anyone done anything like this? I expected that I'd have to prove at some point that the withdrawn funds went toward a medical expense... Or should I be safe just taking the money out? And then there is the issue that I'll only be able to withdraw in $20 increments; how should I handle that?

As always, thank you for your help!
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Re: Self reimbursement from HSA

Postby Rainier » Sat Dec 15, 2012 5:23 pm

Yes, it is that easy. It is entirely up to you to prove your expenses are eligible for reimbursement.

I put everything on personal credit cards to earn the points and pay myself back from the hsa when I need the cash.
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Re: Self reimbursement from HSA

Postby Rainier » Sat Dec 15, 2012 5:25 pm

Ours is chase too. Use their bill pay to send yourself a check for exact dollar amount. My chase has a new ach feature to transfer directly to your bank.
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Re: Self reimbursement from HSA

Postby Walleye12 » Sat Dec 15, 2012 5:31 pm

Thanks!
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Re: Self reimbursement from HSA

Postby texasdiver » Sat Dec 15, 2012 7:37 pm

Put every medical related receipt in a big folder and let them accumulate over the years. Then any time you want to tap into your HSA for any reason you can spend it without penalty up to the amount of receipts you have saved. Even if it's 10 years from now and you are spending the HSA for a Caribbean cruise.
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Re: Self reimbursement from HSA

Postby Spirit Rider » Sun Dec 16, 2012 12:18 am

TJ2012

I think the HSA can be confusing for previous users of FSAs. In the case of a FSA you must provide proof and get authorization for each disbursement/reimbursement. With a HSA, the HSA custodian really justs acts as a bank for you and provides the proper reporting to the IRS.

You the account owner are responsible for keeping all the records of the distributions. The HSA custodian only provides the mechanisms for distributions (checks, debit card, online billpay, ACH transferrs, etc...). You decide when and how to pay any qualified expenses. The ATM feature of the debit card can be dangerous and result in large non-qualified distributions for the uninitiated.
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Re: Self reimbursement from HSA

Postby tadamsmar » Sun Dec 16, 2012 4:44 am

The only scenario where you have to prove that tax-free HSA withdrawals went for qualified expenses is the scenario of a federal tax audit. To prove it, you will need the receipts. This is sometimes referred to as the HSA shoebox rule.

As far as I can tell, to be prepared for an audit, you need to keep all the required receipts as long as your HSA could be audited. In principle, that could happen after you kick.

From where I set at this minute, I can look to my right and see huge pile of records (a foot tall and 2 feet wide) on a shelf that my wife promised to keep organized years ago. That is part of our "shoebox". And, we are relatively healthy.

There are some online records that I keep. My health insurance provider (GEHA) and associated online pharmacy (Medco, but they recently changed their name) keep a about 18 months of online claims records. I dump a year's worth of screen images of those to a file.

Actually, to determine your qualified expenses, you need more than the receipts since you need to subtract various types of non-personal payments from the receipts. You need medical insurance EOBs, records of insurance payments for drugs, FSA records, maybe some tax deduction records, and probably some others that I can't think of.
Last edited by tadamsmar on Sun Dec 16, 2012 11:46 am, edited 2 times in total.
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Re: Self reimbursement from HSA

Postby pshonore » Sun Dec 16, 2012 10:05 am

You should be aware that taking reimbursements will result in the Custodian sending tax form 1099-SA. You must then include Form 8889 in your tax return to tell the IRS that the distribution was for qualified medical expenses (Part II - Line 15). Failure to include this form (which is a very common error) will result in the IRS deeming the distributions to be taxable income and subject to a 20% penalty as well. As others have stated, the IRS usually accepts your figure as stated unless your return gets audited in which case all bets are off
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Re: Self reimbursement from HSA

Postby tarnation » Sun Dec 16, 2012 12:56 pm

tadamsmar wrote:As far as I can tell, to be prepared for an audit, you need to keep all the required receipts as long as your HSA could be audited. In principle, that could happen after you kick.
you mean as long as your return can be audited?

There are some online records that I keep. My health insurance provider (GEHA) and associated online pharmacy (Medco, but they recently changed their name) keep a about 18 months of online claims records. I dump a year's worth of screen images of those to a file.
actually now geha has the eob PDF available online for download

Actually, to determine your qualified expenses, you need more than the receipts since you need to subtract various types of non-personal payments from the receipts. You need medical insurance EOBs, records of insurance payments for drugs, FSA records, maybe some tax deduction records, and probably some others that I can't think of.

I thought eob's were sufficient evidence of qualified expenses in case of audit.
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Re: Self reimbursement from HSA

Postby FrugalInvestor » Sun Dec 16, 2012 12:59 pm

texasdiver wrote:Put every medical related receipt in a big folder and let them accumulate over the years. Then any time you want to tap into your HSA for any reason you can spend it without penalty up to the amount of receipts you have saved. Even if it's 10 years from now and you are spending the HSA for a Caribbean cruise.


As long as you haven't been reimbursed for the expenses from an insurance carrier or used the expenses as a deduction on your income taxes.
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Re: Self reimbursement from HSA

Postby kaneohe » Sun Dec 16, 2012 5:06 pm

FrugalInvestor wrote:
texasdiver wrote:Put every medical related receipt in a big folder and let them accumulate over the years. Then any time you want to tap into your HSA for any reason you can spend it without penalty up to the amount of receipts you have saved. Even if it's 10 years from now and you are spending the HSA for a Caribbean cruise.


As long as you haven't been reimbursed for the expenses from an insurance carrier or used the expenses as a deduction on your income taxes.


so the shoebox would have to also have to include every EOB and income tax form since the HSA started ?
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Re: Self reimbursement from HSA

Postby tadamsmar » Sun Dec 16, 2012 7:16 pm

tarnation wrote:
tadamsmar wrote:As far as I can tell, to be prepared for an audit, you need to keep all the required receipts as long as your HSA could be audited. In principle, that could happen after you kick.
you mean as long as your return can be audited?

There are some online records that I keep. My health insurance provider (GEHA) and associated online pharmacy (Medco, but they recently changed their name) keep a about 18 months of online claims records. I dump a year's worth of screen images of those to a file.
actually now geha has the eob PDF available online for download

Actually, to determine your qualified expenses, you need more than the receipts since you need to subtract various types of non-personal payments from the receipts. You need medical insurance EOBs, records of insurance payments for drugs, FSA records, maybe some tax deduction records, and probably some others that I can't think of.

I thought eob's were sufficient evidence of qualified expenses in case of audit.


Yes, as long as the last tax form that reports an HSA withdrawal matched by that qualified expense can be audited.

I meant that I download the EOBs. Last I check they only kept 18 months of them.

Are the EOBs sufficient? That would be good, I wonder where that is documented? There have probably been plenty of audits of income tax deductions for medical expenses and I would think the same rules would apply to qualified HSA expenses.
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Re: Self reimbursement from HSA

Postby texasdiver » Sun Dec 16, 2012 7:48 pm

tadamsmar wrote:
tarnation wrote:
tadamsmar wrote:As far as I can tell, to be prepared for an audit, you need to keep all the required receipts as long as your HSA could be audited. In principle, that could happen after you kick.
you mean as long as your return can be audited?

There are some online records that I keep. My health insurance provider (GEHA) and associated online pharmacy (Medco, but they recently changed their name) keep a about 18 months of online claims records. I dump a year's worth of screen images of those to a file.
actually now geha has the eob PDF available online for download

Actually, to determine your qualified expenses, you need more than the receipts since you need to subtract various types of non-personal payments from the receipts. You need medical insurance EOBs, records of insurance payments for drugs, FSA records, maybe some tax deduction records, and probably some others that I can't think of.

I thought eob's were sufficient evidence of qualified expenses in case of audit.


Yes, as long as the last tax form that reports an HSA withdrawal matched by that qualified expense can be audited.

I meant that I download the EOBs. Last I check they only kept 18 months of them.

Are the EOBs sufficient? That would be good, I wonder where that is documented? There have probably been plenty of audits of income tax deductions for medical expenses and I would think the same rules would apply to qualified HSA expenses.


EOBs are sufficient for cafeteria plans. I'm still new to HSAs so still figuring these things out and haven't made any withdrawals yet.

However there are medical expenses that may not generate EOBs such as certain medical supplies and over the counter meds. I'll need to read up on the rules myself but if they match those for cafeteria plans then there are a variety of potential claimable expenses that won't go through insurance because they are retail purchases and for those you'll need the receipts.
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Re: Self reimbursement from HSA

Postby papito23 » Sun Dec 16, 2012 8:15 pm

I "reimburse myself" at the end of each year from my HSA account, keeping track of medical expenses throughout the year on an excel sheet. I would rather have things "balanced" at the end of each year to keep it simple (at least to me). Some keep funds in an HSA as extra tax-advantaged space, but investment options may be limited. Not worth the hassle for me, as I have space elsewhere.
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Re: Self reimbursement from HSA

Postby FrugalInvestor » Sun Dec 16, 2012 8:16 pm

kaneohe wrote:
FrugalInvestor wrote:
texasdiver wrote:Put every medical related receipt in a big folder and let them accumulate over the years. Then any time you want to tap into your HSA for any reason you can spend it without penalty up to the amount of receipts you have saved. Even if it's 10 years from now and you are spending the HSA for a Caribbean cruise.


As long as you haven't been reimbursed for the expenses from an insurance carrier or used the expenses as a deduction on your income taxes.


so the shoebox would have to also have to include every EOB and income tax form since the HSA started ?


I don't know that I do it just right, but I keep receipts attached to EOB's (I pay most medical bills with a credit card by phone and request that a receipt be mailed). Those that are used as tax deductions go in my tax return file with all other return documentation. Those that are not claimed go in my unclaimed medical expenses file to be used at a later date if needed to document withdrawals.
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Re: Self reimbursement from HSA

Postby tarnation » Sun Dec 16, 2012 9:02 pm

tadamsmar wrote:
tarnation wrote:
tadamsmar wrote:As far as I can tell, to be prepared for an audit, you need to keep all the required receipts as long as your HSA could be audited. In principle, that could happen after you kick.
you mean as long as your return can be audited?

There are some online records that I keep. My health insurance provider (GEHA) and associated online pharmacy (Medco, but they recently changed their name) keep a about 18 months of online claims records. I dump a year's worth of screen images of those to a file.
actually now geha has the eob PDF available online for download

Actually, to determine your qualified expenses, you need more than the receipts since you need to subtract various types of non-personal payments from the receipts. You need medical insurance EOBs, records of insurance payments for drugs, FSA records, maybe some tax deduction records, and probably some others that I can't think of.

I thought eob's were sufficient evidence of qualified expenses in case of audit.


Yes, as long as the last tax form that reports an HSA withdrawal matched by that qualified expense can be audited.

I meant that I download the EOBs. Last I check they only kept 18 months of them.

Are the EOBs sufficient? That would be good, I wonder where that is documented? There have probably been plenty of audits of income tax deductions for medical expenses and I would think the same rules would apply to qualified HSA expenses.

since I wasn't sure, I checked pub 969
From Pub 969 http://www.irs.gov/pub/irs-pdf/p969.pdf
Code: Select all
Recordkeeping. You must keep records sufficient to show that:

    The distributions were exclusively to pay or reimburse qualified medical expenses,

    The qualified medical expenses had not been previously paid or reimbursed from another source, and

    The medical expenses had not been taken as an itemized deduction in any year.


IMO, That sounds very onerous, like "Unfair Burden", i.e. proving a negative. An EOB would satisfy the first condition. No amount of paperwork saved could satisfy the second. Saving every tax return from the date of service to the date of reimbursement should satisfy the third.
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Re: Self reimbursement from HSA

Postby grabiner » Sun Dec 16, 2012 9:30 pm

tarnation wrote:Since I wasn't sure, I checked pub 969
From Pub 969 http://www.irs.gov/pub/irs-pdf/p969.pdf
Code: Select all
Recordkeeping. You must keep records sufficient to show that:

    The distributions were exclusively to pay or reimburse qualified medical expenses,

    The qualified medical expenses had not been previously paid or reimbursed from another source, and

    The medical expenses had not been taken as an itemized deduction in any year.


IMO, That sounds very onerous, like "Unfair Burden", i.e. proving a negative. An EOB would satisfy the first condition. No amount of paperwork saved could satisfy the second. Saving every tax return from the date of service to the date of reimbursement should satisfy the third.


And the same problem applies for regular reimbursement of medical expenses. If you wrote a check to a hospital for $1000, you can't prove that your insurance didn't reimburse you later, but I doubt that the IRS normally requires you to prove it. The IRS might require you to prove that you didn't reimburse yourself twice from the HSA for the same expense.

I have once been reimbursed more than a year after the fact. I had a conventional plan and didn't deduct medical expenses that year, but if I had deducted them, I would have needed to report the reimbursement as income the following year.
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Re: Self reimbursement from HSA

Postby Walleye12 » Sun Dec 16, 2012 9:58 pm

Thank for the advice everyone! One question: Do I need EOBs for prescriptions? I can't find any EOB for that on the website.

Thanks!
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Re: Self reimbursement from HSA

Postby FrugalInvestor » Sun Dec 16, 2012 10:18 pm

TJ2012 wrote:Thank for the advice everyone! One question: Do I need EOBs for prescriptions? I can't find any EOB for that on the website.

Thanks!


We do not receive EOBs for our prescriptions. I just save the receipts.
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Re: Self reimbursement from HSA

Postby tadamsmar » Mon Dec 17, 2012 7:43 am

TJ2012 wrote:Thank for the advice everyone! One question: Do I need EOBs for prescriptions? I can't find any EOB for that on the website.

Thanks!


For GEHA, there is a separate mail order pharmacy (medco) and they have records on their website. But usually on the routine prescriptions are filled via the mail order pharmacy.
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Re: Self reimbursement from HSA

Postby tadamsmar » Mon Dec 17, 2012 7:56 am

tarnation wrote: From Pub 969 http://www.irs.gov/pub/irs-pdf/p969.pdf
Code: Select all
Recordkeeping. You must keep records sufficient to show that:

    The distributions were exclusively to pay or reimburse qualified medical expenses,

    The qualified medical expenses had not been previously paid or reimbursed from another source, and

    The medical expenses had not been taken as an itemized deduction in any year.


IMO, That sounds very onerous, like "Unfair Burden", i.e. proving a negative. An EOB would satisfy the first condition. No amount of paperwork saved could satisfy the second. Saving every tax return from the date of service to the date of reimbursement should satisfy the third.


Also, you might need to keep it all organized for the executor of your will. I think there are circumstances where you might want your executor to get money out of your HSA tax-free and into your estate. I recall coming to that conclusion year's ago, but I don't recall the details.

And there are FSAs. I have used a LEXFSA (limted-expense FSA) while funding a HSA. Also, sometimes a family will cease to qualify for a HDHP (or no longer find it preferable) but still be in the work force and be using an FSA while having an HSA (this is our situation). You need to keep records on the FSA in order to prove you are not double dipping when you make tax-free withdrawals from an HSA at some future date.

I find the shoebox to be a pain. Because we had the HDHP for a limited time, we only have $9000 in my wife's HSA. I'd just liquidate it tax-free if I could because I think it's just too small to fool with. But it lives on because our qualified expenses are low and/or I cover them with an FSA when I can. (Of course, I'm lucky to be able to complain about low qualified expenses.)

You can just save the records and not take the time to organize them. But if you ever want to make tax-free withdrawals from the HSA you will typically have organize the mess into a spreadsheet to figure out our cumulative qualified expenses.
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Re: Self reimbursement from HSA

Postby tarnation » Mon Dec 17, 2012 4:30 pm

tadamsmar wrote:
tarnation wrote: From Pub 969 http://www.irs.gov/pub/irs-pdf/p969.pdf
Code: Select all
Recordkeeping. You must keep records sufficient to show that:

    The distributions were exclusively to pay or reimburse qualified medical expenses,

    The qualified medical expenses had not been previously paid or reimbursed from another source, and

    The medical expenses had not been taken as an itemized deduction in any year.


IMO, That sounds very onerous, like "Unfair Burden", i.e. proving a negative. An EOB would satisfy the first condition. No amount of paperwork saved could satisfy the second. Saving every tax return from the date of service to the date of reimbursement should satisfy the third.


Also, you might need to keep it all organized for the executor of your will. I think there are circumstances where you might want your executor to get money out of your HSA tax-free and into your estate. I recall coming to that conclusion year's ago, but I don't recall the details.

And there are FSAs. I have used a LEXFSA (limted-expense FSA) while funding a HSA. Also, sometimes a family will cease to qualify for a HDHP (or no longer find it preferable) but still be in the work force and be using an FSA while having an HSA (this is our situation). You need to keep records on the FSA in order to prove you are not double dipping when you make tax-free withdrawals from an HSA at some future date.

I find the shoebox to be a pain. Because we had the HDHP for a limited time, we only have $9000 in my wife's HSA. I'd just liquidate it tax-free if I could because I think it's just too small to fool with. But it lives on because our qualified expenses are low and/or I cover them with an FSA when I can. (Of course, I'm lucky to be able to complain about low qualified expenses.)

You can just save the records and not take the time to organize them. But if you ever want to make tax-free withdrawals from the HSA you will typically have organize the mess into a spreadsheet to figure out our cumulative qualified expenses.
Instead of shoebox, I keep a large manila envelope and at the end of the year, I figure the amount reimbursable and write it on the outside, then start another one. When we get ready to withdraw we will just use one of those amounts on the outside, then drop that envelope into the tax folder for that year.
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Re: Self reimbursement from HSA

Postby Sidney » Mon Dec 17, 2012 5:49 pm

tarnation wrote:Instead of shoebox, I keep a large manila envelope and at the end of the year, I figure the amount reimbursable and write it on the outside, then start another one. When we get ready to withdraw we will just use one of those amounts on the outside, then drop that envelope into the tax folder for that year.

You can simplify it even more. Most providers will generate a year-end statement for you. We typically use a very small number of doctors, one dentist and one pharmacy. I do keep all the receipts but after the end of the year, I go to the pharmacy/doctor/dentist and they produce a statement showing all the charges and payments that clear to zero.
I always wanted to be a procrastinator.
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Re: Self reimbursement from HSA

Postby lightheir » Mon Dec 17, 2012 7:10 pm

Off topic, but if anyone has a good answer or link,would appreciate it to the following question:

What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?
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Re: Self reimbursement from HSA

Postby interplanetjanet » Mon Dec 17, 2012 7:12 pm

lightheir wrote:Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed

Can't you just roll your HSA funds out once a year to the provider of your choice, and invest things there?
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Re: Self reimbursement from HSA

Postby Auream » Mon Dec 17, 2012 10:57 pm

interplanetjanet wrote:
lightheir wrote:Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed

Can't you just roll your HSA funds out once a year to the provider of your choice, and invest things there?


Indeed. My HSA is currently invested in a 2% HSA checking account, which is a higher rate than any short-term fixed income account I can find (e.g., higher than money market, short term bond funds, heck even Total Bond market). So I keep as much as I can in there and it comprises most of my "cash/bond " allocation.
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Re: Self reimbursement from HSA

Postby Spirit Rider » Mon Dec 17, 2012 11:06 pm

lightheir wrote:What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?
Maximizing the tax-free deferral makes sense from a purely financial point of view. However, I only spend about 1/4 of my HSA contributions. So for me, the ease of reconciling each year's qualified costs and disbursements far exceeds the extra deferral.
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Re: Self reimbursement from HSA

Postby texasdiver » Tue Dec 18, 2012 1:07 am

lightheir wrote:Off topic, but if anyone has a good answer or link,would appreciate it to the following question:

What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?


There are several HSA providers that will let you invest in your choice of Vanguard funds. HSA Bank and HSA administrators to name two. You don't have to stick with the low interest savings account. If your company has you in some other HSA provider I believe you can still open an account with one of these others and do a rollover of funds without any tax issues.
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Re: Self reimbursement from HSA

Postby Novine » Tue Dec 18, 2012 8:02 am

Our local chain pharmacy notes on the receipt if a purchase is "FSA eligible". Typically, anything FSA eligible qualifies as being reimbursable from a HSA so that helps for those items that don't come with an EOB.
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Re: Self reimbursement from HSA

Postby Aptenodytes » Tue Dec 18, 2012 11:35 am

lightheir wrote:Off topic, but if anyone has a good answer or link,would appreciate it to the following question:

What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?

The sense I get from reading threads such as this one is that most of us who can afford to do so are paying medical expenses out of pocket and letting the HSA accumulate. That's what I'm doing, and I see reference to many others doing the same. For me, the low return is beside the point. In my case the HSA is not strictly analogous to an IRA, because my medical expenses are very unpredictable and our family has a moderately high level of health-care-expense risk. Therefore the HSA for me is a hybrid of an emergency fund and a long-term investment vehicle. Accordingly, I am happy to get low returns on it -- the investment portion of the hybrid fits into the fixed income portion of the overall portfolio.
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Re: Self reimbursement from HSA

Postby FrugalInvestor » Tue Dec 18, 2012 11:57 am

Aptenodytes wrote:
lightheir wrote:Off topic, but if anyone has a good answer or link,would appreciate it to the following question:

What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?


My HSA is a part of my portfolio bond allocation. In addition it lowers my current taxes, provides me with income diversification down the road (in some ways similar to a ROTH) and helps insure against unplanned withdrawals from taxable accounts. The only downside as far as I'm concerned are the rather complicated logistics required to minimize overall expenses.

In other words I've joined the hold 'em camp. I doubt that constitutes a consensus though.
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Re: Self reimbursement from HSA

Postby tadamsmar » Tue Dec 18, 2012 2:08 pm

I like that idea of including it in my bond allocation.

As I said, I have a small ($9000) HSA that will never grow because we had reason to stop being in an HDHP. It's at HSABANK and I could put some in Ameritrade but I have never felt like bothering with that.
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Re: Self reimbursement from HSA

Postby FrugalInvestor » Tue Dec 18, 2012 2:55 pm

tadamsmar wrote:I like that idea of including it in my bond allocation.

As I said, I have a small ($9000) HSA that will never grow because we had reason to stop being in an HDHP. It's at HSABANK and I could put some in Ameritrade but I have never felt like bothering with that.


I finally bothered with it but my account is quite a bit larger and I'm continuing to contribute.
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Re: Self reimbursement from HSA

Postby grabiner » Tue Dec 18, 2012 10:25 pm

lightheir wrote:What's the current Boglehead consensus about holding or spending HSA funds? Given that most HSA funds are in really low interest (like essentially zero) yielding accounts with limited options to move them to higher yielding ones unless you're self-employed, are Bogleheads cashing them out quickly or still trying to max out the triple tax savings on them?


Even if your employer chooses to contribute to a particular provider, you can move money between providers; this is analogous to transferring an IRA between custodians. Health Savings Account on the wiki has a list of providers.

Also from that wiki page, the usual consensus is that you should pay medical expenses out of the HSA if you aren't maxing out your tax-deferred accounts, but pay out of pocket and use the HSA as an extension of your IRA if you are maxing out your tax-deferred accounts.
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