Reshaping HSA Strategy

A new HSA telehealth strategy has been legally available to every HDHP sponsor in the country for a full year, and most employers still have not touched it.

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On July 4, 2025, the One Big Beautiful Bill Act (OBBBA) became law and quietly rewrote two rules that shape how employees use their HSAs every single day. It made pre-deductible telehealth coverage permanent, and it opened the door for Direct Primary Care (DPC) to sit alongside an HSA instead of disqualifying it.

A year in, the guidance has settled, the IRS has clarified the operational details, and employers finally have a clear runway to build a real HSA telehealth strategy instead of a patchwork of pandemic-era workarounds. Yet plenty of plan sponsors are still running their benefits program as if the law never changed. If that is your organization, this anniversary is your sign that there is tested, IRS-confirmed plan design upside sitting on the table.

What OBBBA Changed for HSA Telehealth Strategy and Direct Primary Care

Before OBBBA, HSA-qualified high-deductible health plans (HDHPs) could only offer free or low-cost telehealth on a pre-deductible basis under temporary pandemic-era relief, and that relief had already lapsed for calendar-year plans at the end of 2024. Direct Primary Care memberships, meanwhile, were treated as disqualifying coverage that could knock an otherwise eligible employee out of HSA contributions entirely.

Telehealth Goes Permanently Pre-Deductible

OBBBA permanently reinstated the safe harbor allowing HDHPs to cover telehealth and other remote care services before the deductible is met, without jeopardizing an employee’s HSA eligibility. The IRS confirmed the provision applies retroactively to plan years beginning on or after January 1, 2025, which means employers who paused first-dollar telehealth coverage when the earlier relief expired can reinstate it now and back-date the change.

The IRS guidance also drew a clear boundary worth building into any HSA telehealth strategy: the safe harbor covers the virtual visit itself, but it does not extend to in-person services, medical equipment, or prescriptions dispensed as a result of that visit.

Direct Primary Care No Longer Disqualifies HSA Eligibility

The second change is arguably the bigger structural shift. A Direct Primary Care Service Arrangement, or DPCSA, is now defined by statute as something other than a “health plan,” so enrolling in one no longer blocks an employee from contributing to or using an HSA. Under the terms laid out in the Congressional Research Service’s summary of H.R. 1’s health coverage provisions, a DPCSA qualifies for this treatment as long as the fee stays fixed and periodic, and it does not include services requiring general anesthesia, prescriptions beyond vaccines, or lab work outside a standard primary care setting.

There is a dollar ceiling worth building into plan design early: DPC fees are treated as a qualified medical expense reimbursable through an HSA only up to $150 per month for an individual or $300 per month for a family. Structure a DPC benefit above that threshold and it risks falling back into “health plan” territory, which reopens the exact disqualification problem OBBBA was written to solve.

Enrolling in a Direct Primary Care arrangement no longer disqualifies an otherwise HSA-eligible individual from contributing to their HSA. IRS Notice on OBBBA HSA provisions, December 2025

Why Your HSA Telehealth Strategy Needs a Second Look This Year

Plan design changes of this size do not happen on impulse, and most benefits teams reasonably waited for the dust to settle before rewriting plan documents. That dust has settled. The IRS issued detailed operational guidance in December 2025 clarifying exactly how the telehealth safe harbor and DPCSA rules apply, so the ambiguity that made a wait-and-see approach sensible last year is largely resolved.

That timing lines up well with open enrollment planning. If your HSA telehealth strategy has not already been rebuilt around pre-deductible virtual care or a DPC option, this anniversary is a natural checkpoint to put it on the agenda before renewal decisions lock in.

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Where Employer Adoption Actually Stands One Year In

The data suggests a lot of employers are still catching up to what the law now allows. Telehealth usage has leveled off at what one industry analysis called a “new steady state,” with virtual visits holding around 6 to 7 percent of primary care bookings after their pandemic-era peak. Despite that plateau, telehealth is no longer a novelty benefit. It is baseline infrastructure that employees expect, and OBBBA simply removed the tax-eligibility friction that used to sit in the way of paying for it before the deductible.

DPC adoption tells a similar story from a different angle. Employer-sponsored DPC memberships have grown well past the pilot-program stage, and the removal of the HSA disqualification risk is one of the factors analysts point to as accelerating that shift into 2026.

Building an HSA Telehealth Strategy and DPC Plan Design That Works

A one-year anniversary is a good excuse to actually audit your plan design against what the law allows, rather than what it allowed when you last touched the document. A few places to start:

None of this requires a plan overhaul. It requires a plan design review, and that is exactly where a strategic employee benefits approach earns its keep, translating a regulatory change into a plan document update, a contribution structure, and a communication plan your employees will actually use. Employers already running level-funded plans are often best positioned to move fast here, since plan design flexibility is already built into how the arrangement works.

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Frequently Asked Questions About HSA Telehealth Strategy Under OBBBA

The Bottom Line

OBBBA did not add a new tax-advantaged account or invent a new benefit category. It removed two specific obstacles that used to sit between employees and care they already wanted to use: virtual visits before the deductible, and a flat-fee primary care relationship outside the insurance system. One year in, the guidance is settled and the adoption data shows employers are moving. The only real question left is whether your HSA telehealth strategy has caught up with what is legally allowed, or whether it is still running on last year’s rules.

This article is provided for general informational purposes and does not constitute legal or tax advice. Employers should work with qualified legal or tax counsel before updating plan documents or contribution structures.