If your premium just jumped and you’re wondering what you can actually control right now, this one’s for you.
If your ACA premium jumped this year, you’re not imagining it and you’re not alone.
The extra subsidies that kept a lot of marketplace plans affordable expired at the start of 2026, and subsidized enrollees are now facing premium increases that average well over 100 percent nationally. Texas is one of the hardest-hit states in the country, with millions of enrollees feeling it directly, some watching a monthly payment triple with no change in their actual plan.
You can’t undo that. What you can do is get smarter about the money already sitting in an HSA or FSA, because most people are leaving it underused out of a mistaken idea of what it actually covers. That account isn’t just for prescriptions and copays.
Physical therapy is already covered, in almost every case. Binders, compression garments, and other gender-affirming gear often qualify too, they just usually need one extra document most people have never heard of. Here’s how all of it actually works.
What actually counts as a “qualified medical expense”
The IRS defines this more broadly than most people assume. It’s not just doctor visits and prescriptions. Amounts you pay for therapy received as medical treatment count as a medical expense. So does a long list of services and supplies connected to diagnosing, treating, or managing a real health condition.
The test isn’t whether something feels like general wellness. It’s whether a provider is treating something specific. That distinction is the whole game, and it’s why two people buying the exact same item can get two completely different answers from their HSA or FSA administrator.
Physical therapy is already covered
If a physical therapist is treating you for something specific, chest wall tightness, post-surgical recovery, chronic pain, a gait issue, your visits already qualify as a medical expense. No special form, no extra letter, just your normal receipt or superbill saved and submitted.
This is one of the more reliable categories in the whole HSA and FSA system, which makes it worth checking your balance before you assume physical therapy is off the table this year. If cost has been the thing standing between you and care, it is worth a second look before you rule it out.
Binders, compression garments, and other gender-affirming gear
This is the part most people don’t know. Chest binders, compression garments, packers, and KT tape fall into a category called durable medical equipment, or DME, meaning equipment and supplies a provider orders for extended use. HSA and FSA administrators do reimburse a real list of gender-affirming DME. It’s just categorized as “non-standard,” which is bureaucratic language for “you’ll need one extra piece of paper.”
We’ve written before about how to check whether your plan actually covers your gender-affirming care in the first place, and this works the same way. The coverage exists. You just have to know how to ask for it.
How to actually get a letter of medical necessity
A letter of medical necessity is a short statement from your provider saying a specific item or service is necessary to treat a specific diagnosis. It’s not complicated, but it is specific. A vague note that says “for wellness” gets rejected more often than one that says “post-surgical compression garment, prescribed to support healing and manage swelling.”
Ask directly. Whether it’s your physical therapist, your primary care provider, or your gender-affirming care specialist, ask them to name your diagnosis and explain why the item or service is medically necessary, not just helpful.
Keep every receipt together with the letter. Most administrators want both submitted at once, and reimbursement moves a lot faster when you’re not digging through your inbox after the fact.
Call your HSA or FSA administrator before you buy anything expensive. Preauthorization requirements vary by plan, and ten minutes on the phone beats finding out after the fact that a $200 purchase was never going to be reimbursed.
What usually doesn’t qualify without extra paperwork
General gym memberships, personal training sessions, and supplements are the classic denials. Not because they can never qualify, but because on their own they read as general health improvement rather than treatment for a specific diagnosis. If a physician is prescribing personal training or group classes to manage a documented condition, a letter of medical necessity can sometimes get it over that line. It’s the exception, though, not the rule, so don’t assume it’ll work without asking first.
Final Thoughts
Nobody should have to choose between rent and physical therapy this year, and the truth is a lot of people are being forced into exactly that math right now. You can’t fix what happened to your premium. You can make sure the money already set aside for your care isn’t sitting there unused because nobody told you what it was actually for.
Want help figuring out what your HSA or FSA actually covers for your care? Book a free 15-minute consult with our physical therapy team.
