FSA vs. HSA: What’s the difference?

It's no secret that health care costs in the US are extremely high -- high enough that nearly 30 million people in the US remain uninsured. Even for those who do have insurance, out-of-pocket health expenses can add up and leave people with sticker shock.

Two types of accounts can save you money on those out-of-pocket costs, such as deductibles and co-payments: a Health Savings Account (HSA) or a Flexible Spending Account (FSA). Depending on your health insurance plan and your employer, you may be eligible for one or the other, and taking advantage of either is a good idea if you qualify.

The qualifications for, and advantages of, HSAs and FSAs differ. This guide breaks down the basics so you can confidently choose the right plan.

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What is a Health Savings Account (HSA)?

An HSA is essentially a savings account with tax advantages, but it must be used in conjunction with a High Deductible Health Plan (HDHP). An HDHP is simply a type of insurance plan with a lower monthly payment but a higher deductible when it comes time to pay for medical expenses (a minimum of $1,350 for an individual and $2,700 for a family, as of 2019).

In addition to the HDHP, to qualify for an HSA, you mustn't be eligible for Medicare and you can't be claimed as a dependent on someone else's tax return.

You can contribute money to your HSA via a payroll deduction from your gross (pretax) income, and those contributions are tax deductible. Like any other kind of savings account, you can earn interest on the money in your HSA. Plus, that interest earned is also tax-free.

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When you withdraw funds for qualified medical expenses, those funds are withdrawn tax-free, too. You can use your HSA for a broad range of medical expenses, including vision exams and eyeglasses, prescription drugs, chiropractic care, hospital stays and more.

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If you're worried about the deductible cost with an HDHP, consider these key HSA benefits that can help offset it: 

• There's long-term savings potential: If you don't spend your HSA funds on medical costs, they keep accumulating.
• Withdrawing money for qualified medical expenses is tax-free.
• HSA interest isn't taxed.
• You're not limited to the yearly contribution: If you don't have high medical or out-of-pocket medical expenses now, you can use more later if, say, you need surgery.
• HSAs are portable accounts, so you get to keep your money even if you switch employers.
• Self-employed individuals can contribute to an HSA.

In general, you'll save enough with an HSA to compensate for the HDHP, even if you do end up with a high deductible event one day.

What is a Flexible Spending Account (FSA)?

Flexible Spending Accounts, also called Flexible Spending Arrangements, are similar to HSAs, but there are a few key differences. For one, you don't need an HDHP to open an FSA. Instead, FSAs can be used with any health care plan and most employers offer them as part of a benefits package.

You actually don't need to be covered by health insurance to open an FSA, but you shouldn't use an FSA as a replacement for a health plan. If you can't afford both, you should put your money toward health insurance.

Unlike HSAs, FSAs don't work well for long-term savings because the money expires at the end of the calendar year. What you put in -- you have to use it or you'll lose it. Sometimes there's a grace period for withdrawals up until tax day of the following year, but that's not always the case, so don't count on it.

A new carryover rule allows employers to choose whether employees can carry $500 from their FSA into the next calendar year, but not all employers offer this. Also, $500 isn't much compared with the maximum annual contribution of $2,700, so it's still better to use up your funds.

Also unlike an HSA, you must declare your contribution amount each calendar year, and once you make that declaration, you generally can't change it until the next year. If you declined to open an FSA during open enrollment, you'll likely have to wait until the next open enrollment to do so.

Some other things to keep in mind about FSAs: FSAs aren't portable like HSAs, so you forfeit your accrual when you change jobs; FSAs don't earn interest; and self-employed individuals aren't eligible for an FSA.

• Withdrawals can be made for child care expenses as well as medical expenses.
• You can contribute to your FSA using your gross pay, which means the contributions are tax-free.
• Funds used for eligible medical expenses don't incur taxes. 

One other big benefit to keep in mind: With an FSA, the amount you declare is available to you at the first of the year, and you pay for it through each paycheck throughout the year -- as opposed to an HSA, which you contribute small amounts to with each paycheck so the balance grows over time.

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Things to consider when choosing an FSA or HSA

The purpose of HSAs or FSAs is to cover eligible health expenses, such as co-payments at the doctor's office, deductibles, some prescription medications, lab tests and medical imaging. Generally, any money spent at a doctor's office, dentist's office, hospital, urgent care center, emergency room or other health care institution is an eligible expense.

Internal Revenue Service (IRS) Publication 502 notes that neither an FSA nor an HSA can be used to cover expenses that are "merely beneficial to general health, such as vitamins or a vacation."

Your employer plays a role in which plan you can get. Many employers offer both plans, but some offer only one. Self-employed individuals can't open an FSA, so an HSA is their only option out of the two. The type of account your employer offers often depends on the health insurance coverage the company provides.

If you have a family, take that into account. FSAs are more family-friendly because you can often use FSA funds for childcare expenses.

What are the penalties for withdrawing funds?

With an FSA, penalties for withdrawing your funds depends on your employer. You may have to submit paperwork such as receipts and reimbursement forms to your employer to use the money in your FSA.

With an HSA, if you use your funds for nonmedical expenses prior to age 65, you must declare that money on your income tax form for the year, and it's subject to a penalty.

However, neither account usually incurs penalties as long as you spend the money on eligible expenses.

So, which one is better?

Overall, HSAs are more flexible and key benefits include rollover potential, portability and self-employed eligibility. The downside is the HDHP required.  

FSAs can be advantageous to those who don't plan on switching jobs and are savvy with what they spend their FSA funds on, so they don't lose them.

If you qualify for an HSA, it's usually the better option, but if you don't, an FSA can still provide great value.

Can I have both at the same time?

Only if your FSA is designated as a "limited-purpose FSA (LPFSA)." LPFSAs have a specified purpose and don't cover the broad range of medical expenses covered by your HSA. Currently, LPFSAs cover only dental and vision expenses. To qualify for an LPFSA, you must have both an HDHP and an HSA.