When the IRS published Revenue Procedure 2026-24, nearly every health savings account figure moved up for 2027. The self-only contribution limit rose from $4,400 to $4,500, and the family limit went from $8,750 to $9,000. Minimum high-deductible plan deductibles climbed to $1,750 and $3,500. Out-of-pocket maximums rose to $8,700 and $17,400.
One number didn't budge: the monthly cap on direct primary care fees, which stays at $150 for an individual and $300 for a household. For retirees between 55 and 65 — the group most likely to be paying for their own coverage — that frozen number is worth understanding before open enrollment.
What Changed in 2026
Direct primary care is a membership model. You pay a physician a flat monthly fee for routine visits, basic labs, and direct phone or text access, with no insurance billing in between. Retirees often pair it with a cheap high-deductible plan that handles catastrophic events.
Until this year, that pairing created a tax problem. A direct primary care membership looked like "first-dollar" health coverage to the IRS, which disqualified you from contributing to an HSA. The One Big Beautiful Bill Act fixed that for months beginning after December 31, 2025. A qualifying direct primary care service arrangement no longer breaks HSA eligibility, and the fees themselves count as qualified medical expenses.
The fix comes with a ceiling. Fees across all your arrangements must stay at or under $150 a month individually, $300 for more than one person.
The Age Problem
Direct primary care practices price by age. Adults average roughly $85 a month nationally, but pricing surveys put patients 65 and older in the $100 to $175 range, reflecting more complex care. Practices serving people in their 60s frequently sit right at $150 — or just above it.
That is the trap. The cap is a cliff, not a phase-out. At $150 a month you can still fund an HSA. At $160, you cannot contribute at all while enrolled — not a reduced amount, none. For a 60-year-old, that is $4,500 plus the $1,000 catch-up available at 55 and older, forfeited over $120 a year in membership fees.
The Asymmetry Worth Knowing
Exceeding the cap costs you contributions, not reimbursements. If your membership runs $200 a month, you can still pay it from existing HSA dollars as a qualified medical expense. You simply can't add new money while enrolled.
That distinction matters for someone who has already built a substantial HSA balance and is spending it down before Medicare. Losing the ability to contribute may be an acceptable trade. For someone still accumulating, it rarely is.
Practical Takeaways
- Ask for the annualized number. The cap is tested on a fixed, periodic fee annualized — $1,800 a year individually. Quarterly or annual billing is fine if it stays under that line.
- Negotiate to the cap. A practice quoting $165 may hold at $150. It is a specific number with a specific tax consequence; say so.
- Confirm the arrangement qualifies. The provider must practice family medicine, internal medicine, geriatrics, or pediatrics, or be a nurse practitioner, clinical nurse specialist, or physician assistant. Arrangements covering procedures requiring general anesthesia, prescription drugs other than vaccines, or labs beyond typical primary care do not qualify.
- Watch the household math. Two individual memberships at $150 each blow through the $300 household ceiling only if both are counted against one covered individual — the caps are aggregate per person, so read your paperwork.
- Remember the Medicare wall. HSA contributions stop when Medicare begins. The pre-Medicare years are your last window, which is exactly why protecting eligibility during them is worth $120 of negotiation.
Because the cap is indexed but rounded to no increase this cycle, expect it to stay flat again unless inflation pushes it over the rounding threshold. Plan around $150, not around next year's hoped-for bump.
Sources: IRS Revenue Procedure 2026-24; Ameriflex, "New IRS Rules for HSA-Compatible Direct Primary Care"; World Insurance Associates, "2027 HSA, HDHP, DPCSA & Excepted Benefit HRA Limits"; Journal of Accountancy; Mosaic Medicine direct primary care cost survey