HSA/FSA Eligibility for Mattresses: What Mattress Brands Need to Know

Updated: April 11, 2026

For large mattress brands, HSA and FSA acceptance represents a meaningful revenue opportunity but is also an area that demands careful attention when it comes to compliance. The IRS does not explicitly mention mattress eligibility in Internal Revenue Code § 213(d) or IRS Publication 502. Instead, the IRS states in a Revenue Ruling that eligibility depends on whether the mattress meets the Internal Revenue Code’s definition of medical care and whether that purpose is properly substantiated.

This article explains

The IRS’s legal framework for medical expense eligibility
What Revenue Ruling 55-261 says specifically about mattresses
Flex’s position on mattresses

“Medical Care” defined by the IRS

HSA and FSA reimbursement is built on Internal Revenue Code § 213(d), which defines medical care as amounts paid for:

The diagnosis, cure, mitigation, treatment, or prevention of disease, or
The purpose of affecting any structure or function of the human body.

IRS regulations further clarify that an expense is medical only if its primary purpose is medical care, not general health or personal comfort.

These regulations distinguish between:

Expenses incurred primarily for medical care (eligible), and
Expenses for general good health or personal, living, or family expenses (not eligible).

This distinction is critical for mattresses. For more on eligibility, check out Flex’s blog post on HSA/FSA eligibility.

Revenue Ruling 55-261: The IRS Addressing Mattresses Directly

In Revenue Ruling 55-261, the IRS addressed whether a special mattress prescribed for arthritis qualifies as a medical expense. The IRS concluded:

“The expense of a special mattress and plywood boards prescribed for the relief of a physical disease or illness constitutes a medical deduction…”

This ruling is important for two reasons:

The IRS explicitly recognized a medically prescribed mattress as deductible medical care.
The IRS did not impose an incremental cost limitation in its mattress analysis.

Primary Purpose Matters: Incremental Cost Does Not Automatically Apply

A common misconception is that reimbursement must be limited to the incremental cost above a standard mattress. That is not always correct, what matters the most is the primary purpose for the purchase of the mattress.

If a special or particular mattress is prescribed by a physician to treat a diagnosed condition and would not otherwise have been purchased— then its primary purpose for purchase is medical and IRS guidance permits reimbursement of the full cost.

In contrast, IRS guidance applies a “net cost” or incremental cost approach for certain dual-purpose items, most notably food.

The IRS limits reimbursement for special food to the amount exceeding normal consumption costs. The IRS reaffirmed this approach in its updated 2023 FAQ:

The medical expense is limited to the amount by which the cost exceeds the cost of a product that satisfies normal nutritional needs.

In Revenue Ruling 55-261, the IRS did not impose this limitation on mattresses.

Establishing Primary Purpose through a Letter of Medical Necessity (LMN)

For mattresses to be HSA/FSA eligible, it is critical that the purchase be supported by a Letter of Medical Necessity (LMN) and an itemized receipt.

Substantiation must include:

Information describing the service or product
The date of the service or sale
The amount of the expense

Prop. Reg. § 1.125-6(b).

Extending this guidance to LMNs, an adequate LMN for a mattress should include the following:

A diagnosed medical condition
A physician’s prescription of the mattress for the condition
An explanation of how the mattress treats or alleviates the conditions

Now, given that FSAs are Employer sponsored, Employers may impose additional plan-specific documentation requirements or limitations on the reimbursement of mattresses.

Flex’s Position on Mattresses

At Flex, we apply a regulation driven compliance framework.

A mattress may be HSA/FSA eligible when:

A licensed healthcare provider diagnoses a condition (e.g., arthritis, degenerative disc disease, sleep apnea requiring elevation, chronic back pain tied to pathology);
The provider prescribes a specific mattress with identified medical features;
The LMN explains how the mattress mitigates or treats the condition;
The primary purpose is medical, not general wellness.

Incremental Cost Treatment

We do not default to the incremental cost framework when the LMN demonstrates the mattress addresses the diagnosed condition and the mattress’s primary medical purpose of alleviating that condition. In that scenario, reimbursement should be in full.

Risk Mitigation

Flex ensures:

Clear eligibility criteria
Documentation requirements at checkout
Marketing guardrails aligned with IRS language
Audit-ready substantiation standards

Our approach aligns with IRS regulation while enabling compliant revenue growth for merchants and empowering people to get the medical care they need through use of their tax advantage accounts.

At Flex, we also understand that FSAs are Employer sponsored so there may be FSAs that do not take the same stance that we do. This is why we always encourage customers to check with their FSA provider before making any purchase just to ensure a smooth substantiation process.