HRA,FSA,HSA Comparison - OCA - Flexible and compliant Pre-Tax Benefits and COBRA Administration backed by industry-leading support.

Plan Design or Compliance Issue	HSAs	HRAs	Health FSAs
Internal Revenue Code
Who is eligible?	Any individual who is covered under an HDHP (as defined in Code §223), is not entitled to Medicare, and cannot be claimed as a tax dependent. With certain exceptions, the individual cannot have any non-HDHP health coverage.	Any employee, subject to employer-designed exclusions. Eligibility may or may not be tied to HDHC. For ICHRAs and QSEHRAs, the individual generally must have qualifying health coverage.^*	Any employee who is eligible for the employer’s major medical coverage, subject to employer-designed exclusions.
Are self-employed individuals (including sole proprietors, partners in a partnership, and more-than-2% shareholders in a Subchapter S corporation) eligible?	Yes. But they will not be eligible to participate in a cafeteria plan used to fund HSAs in the workplace.	No.	No.
Is funding with cafeteria plan salary reductions permitted?	Yes, but limited.	Not for HRA, but it is permitted for HDHC. ICHRA participants can be permitted to use salary reduction funding for portion of individual health insurance premiums not funded through the ICHRA.	Yes, but limited.
Who can contribute?	HSA holder or any other person (including holder’s employer or family member).	Employer only (except for COBRA premiums and possibly other employee after-tax contributions). ICHRA or QSEHRA participants may fund the portion of individual health insurance premiums not funded through the ICHRA or QSEHRA.	Employer or employee.
Can unused amounts be carried over to the next year?	Yes.	Yes.	Generally no, but may amend plans to allow carryover of up to $570, or a grace period of up to 2-1/2 months during which claims may be incurred.

^* HDHC means high-deductible health coverage. Employers that have HRAs often couple them with HDHC, limiting HRA eligibility to those employees who elect HDHC. Note that HDHC does not need to satisfy the deductible or other requirements of Code §223 for an HSA-qualified HDHP (high-deductible health plan).

Plan Design or Compliance Issue	HSAs	HRAs	Health FSAs
What medical expenses are eligible for reimbursement?	Otherwise unreimbursed Code §213(d) medical expenses of account holder, spouse, and dependents incurred after HSA established, other than insurance premiums (with limited exceptions for COBRA coverage, long-term care insurance, health coverage while drawing unemployment compensation, and, if 65 or older, any health insurance except a Medicare supplemental policy).	Otherwise unreimbursed Code §213(d) medical expenses of employee, spouse, children until the end of the year in which they turn 26, and dependents, incurred while coverage is in effect, including premiums for eligible health insurance and long-term care insurance, subject to employer-designed limitations. ICHRAs can also reimburse Medicare premiums. Cannot reimburse qualified long-term care services so long as the HRA is an FSA.	Otherwise unreimbursed Code §213(d) medical expenses of employee, spouse, children until the end of the year in which they turn 26, and dependents, incurred during the coverage period. Cannot reimburse insurance premiums. Cannot reimburse qualified long-term care services.
Are distributions (or cash-outs) for nonmedical expenses permitted?	Yes. Distributions cannot be restricted to pay or reimburse only qualified medical expenses. However, distributions for nonmedical expenses are taxable and subject to a 20% excise tax (certain exceptions apply).	No.	No.
Must coverage be elected/provided for a full 12-month period, and are there prohibitions on midyear changes?	Not for an HSA. IRS guidance confirms that the 12-month coverage and election change rules do not apply even for HSAs offered through a cafeteria plan. Yes, for an HDHP funded through a cafeteria plan.	Not for an HRA. Yes for HDHC funded through a cafeteria plan.	Yes.
Do the uniform coverage rules apply, requiring the annual coverage amount to be available as of the first day of the plan year?	No. But IRS guidance indicates that employers may choose to accelerate funding of HSA salary reduction elections under a cafeteria plan, or of employer HSA contributions outside of a cafeteria plan, so long as certain requirements are met.	No. Coverage may be prorated by plan design (e.g., employee has $100 credited to a bookkeeping account each month).	Yes.
Can amounts that are unused at termination of active employment continue to be spent down?	Yes. HSAs are nonforfeitable and portable.	Yes. HRA can permit unused amounts to be used until depleted to pay for claims incurred after termination (COBRA may also apply).	Generally no. Cannot use unused amounts to pay for claims incurred after termination (except as COBRA or a plan’s grace period may allow).
Plan Design or Compliance Issue	HSAs	HRAs	Health FSAs
To be reimbursable, must claims be incurred during current period of coverage?	No. Distributions for qualifying medical expenses will be tax-free if incurred at any time after the HSA is established. State trust law determines when an HSA is established.	Yes, although claims incurred but not reimbursed due to an insufficient HRA balance can be reimbursed in subsequent year if the individual was a participant when the claims were incurred and is still a participant.	Yes.
Is expense substantiation required?	Yes. HSA account holder must retain records.	Yes.	Yes.
Is independent claims adjudication required? That is, must someone other than the covered employee/individual process and approve the claim?	No.	Yes.	Yes.
Can an individual participate in more than one of these vehicles at the same time?	A traditional, general-purpose health FSA or HRA will make an individual ineligible for an HSA. But a specially designed health FSA or HRA will not prevent HSA eligibility.	An employee who is covered by an HRA may also participate in a health FSA. A traditional, general-purpose HRA will make an individual ineligible for an HSA. But an ICHRA or QSEHRA limited to insurance premium reimbursement, a limited-purpose HRA, a high-deductible HRA, a suspended HRA or a retirement HRA will not prevent HSA eligibility.	An employee who is covered by a health FSA may also participate in an HRA. A traditional, general-purpose health FSA will make an individual ineligible for an HSA. But a limited-purpose health FSA or a high-deductible health FSA will not prevent HSA eligibility.
Are there ordering rules that apply?	No. HRA or health FSA participants do not need to exhaust their HSAs before seeking payment or reimbursement through the HRA or health FSA. (Note: The box above describes the limited HRA or health FSA designs that do not interfere with HSA eligibility.) Cannot reimburse expenses that have been reimbursed elsewhere.	Yes. Generally, health FSAs must be payors of last resort vis-a-vis an HRA. But HRAs and health FSAs can be drafted to require that the HRA pays only after health FSA amounts are exhausted. Cannot reimburse expenses that have been reimbursed elsewhere.	Yes. Generally, health FSAs must be payors of last resort vis-a-vis an HRA. But HRAs and health FSAs can be drafted to require that the HRA pays only after health FSA amounts are exhausted. Cannot reimburse expenses that have been reimbursed elsewhere.
Do Code §105(h) nondiscrimination requirements apply?	No, for an HSA, but employer contributions made outside a cafeteria plan are subject to comparability requirements. Yes, for a self-insured HDHP.	Yes. Note that separate eligibility requirements apply to ICHRAs and QSEHRAs.	Yes.
Do Code §125 nondiscrimination requirements apply?	Yes, for an HSA or HDHP offered under a cafeteria plan.	No. HRAs cannot be offered under a cafeteria plan. But the nondiscrimination rules will apply to HDHC offered under a cafeteria plan.	Yes, for health FSAs offered under a cafeteria plan.
Is a trust account required?	Yes.	No, not by the Code, but possibly by ERISA (e.g., unclear if trust required for COBRA premiums or any other after-tax contributions).	No, not by the Code, but possibly by ERISA (no trust if health FSA complies with ERISA Tech. Rel. 92-01, including that reimbursements are made directly out of the general assets of the employer).
Are account earnings taxable?	No (except unrelated business income will be taxed under Code §511).	If reimbursements are made directly out of the general assets of the employer and account funds are not set aside in a separate account, there are no earnings to be taxed. If funds are deposited in a VEBA, earnings generally are not taxable.	If reimbursements are made directly out of the general assets of the employer and account funds are not set aside in a separate account, there are no earnings to be taxed. If funds are deposited in a VEBA, earnings generally are not taxable.
May debit cards be used?	Yes. But HSA distributions cannot be restricted to eligible medical expenses, so if a debit card is used, other means of withdrawal must also be allowed.	Yes.	Yes.
ERISA (for ERISA-covered employers)
Is it an ERISA plan? (If a plan is subject to ERISA, various requirements will apply. We highlight a few of those requirements below.)	Generally no, unless employer takes action that triggers ERISA under DOL guidance. Employer contributions alone do not trigger ERISA.	Yes, unless plan maintained by governmental entity or church (ERISA does not apply).	Yes, unless plan maintained by governmental entity or church (ERISA does not apply).
Is there a funding requirement?	The Code requires that HSA contributions be put in a trust or custodial account. ERISA’s trust requirements will also apply to an employer-sponsored HSA that is an ERISA plan.	No. Employers may decide to fund (i.e., set aside funds) as potential liability increases. But any such funding may invoke ERISA’s trust requirement if amounts are segregated from general assets.	No. Although there is no requirement to set funds aside in a separate account, an employer may choose to do so. But any such funding may invoke ERISA’s trust requirement if amounts are segregated from general assets.
Are there plan assets for ERISA purposes?	Generally, no. But yes for an employer-sponsored HSA that is an ERISA plan (i.e., employer contributions and employees’ pre-tax salary reductions would be plan assets).	With no employee contributions, HRAs generally do not have plan assets so long as all reimbursements are paid directly out of general assets of the employer and not from a special fund segregated from the general assets of the employer.	Yes. Even for plans that are treated as “unfunded” under ERISA Tech. Rel. 92-1, salary reduction amounts are plan assets for purposes of ERISA’s exclusive benefit and fiduciary duty rules.
Plan Design or Compliance Issue	HSAs	HRAs	Health FSAs
Is an ERISA Form 5500 required to be filed?	Generally, no. Presumably yes for an employer-sponsored HSA that is an ERISA plan. But because HSAs are individual trusts or custodial accounts, it is uncertain how an employer would be required to comply with its Form 5500 obligation.	Yes. Exception for small (fewer than 100 participants) unfunded plan.	Yes. Exception for small (fewer than 100 participants) unfunded plan.
Do ERISA SPD and other disclosures, and adherence to ERISA’s benefit claims procedures, apply?	Generally, no. Yes for an employer-sponsored HSA that is an ERISA plan. How ERISA claims procedures would apply is uncertain since HSA claims are generally self-adjudicated.	Yes.	Yes.
Do ERISA fiduciary rules apply?	Generally, no. Yes for an employer-sponsored HSA that is an ERISA plan.	Yes.	Yes.
Is a plan document required?	Generally, no. Yes for an employer-sponsored HSA that is an ERISA plan.	Yes.	Yes.
Other Laws
Do HIPAA’s portability and health status nondiscrimination provisions apply?	Yes, for an HDHP and maybe for an employer-sponsored HSA that is an ERISA plan. Special rules apply to governmental plans and to church plans.	Yes, although certain exceptions apply.	Yes. Exception for most (not all) health FSAs funded with salary reductions.
Do HIPAA’s administrative simplification (including privacy) provisions apply?	Yes, for an HDHP and for an employer-sponsored HSA that is an ERISA plan. Likely not for an HSA that is not an ERISA plan.	Yes.	Yes.
Does COBRA apply?	Generally no, for HSAs. But there is some uncertainty as to whether ERISA’s COBRA provisions may apply to an HSA that is an ERISA plan and whether PHSA’s COBRA provisions may apply to HSAs sponsored by state and local government employers. Yes, for HDHP.	Yes. Rarely, an HRA providing ≤ $500 in coverage will satisfy the terms of the special rule limiting COBRA obligations for qualifying health FSAs. QSEHRAs are not subject to COBRA’s requirements.	Yes. But there is a special rule limiting COBRA obligations for qualifying health FSAs.
Are Creditable Coverage Disclosures Required Under Medicare Part D?	No, for HSAs. Yes, for HDHP.	Yes.	No.
Do the Medicare Secondary Payer (MSP) reporting rules apply?	Generally no, for HSAs. Yes, for HDHP.	Yes.	No.

Note that when an HRA is coupled with HDHC, the combined arrangement may look and operate very much like an HSA. There are significant differences, however. For example, HDHC coverage that is provided in conjunction with an HRA does not need to qualify as HSA-eligible HDHP coverage under Code §223.Sponsors of an HRA +HDHC arrangement have more freedom in plan design (e.g., the HDHC deductible is not required to be within the range prescribed by Code §223 for an HSA+HDHP). But unlike HSAs, which do not have an independent claims adjudication requirement, no reimbursements can be made under an HRA (or a health FSA) without independent claims adjudication. Finally, employee contributions cannot be made to an HRA on a pre-tax salary reduction or other tax-advantaged basis, while HSAs may be funded through deductible employee contributions.

Chart Comparing HSAs, HRAs, and Health FSAs