Last Year Treasury Listed HSA Guidance as a Priority. Its New 121-Project Plan Doesn't.

A year ago, Treasury put HSA rules on its list of things to get done. On September 29 it published the next list, and that item isn’t on it.

The 2026-2027 Priority Guidance Plan lists 121 projects that Treasury and the IRS plan to work on from October 1, 2026, through September 30, 2027. Forty of them implement the One, Big, Beautiful Bill Act. None of those 40 is under section 223, the part of the tax code that decides whether a direct primary care membership costs a patient the right to contribute to a health savings account.

If you run a DPC practice with HSA patients, or you’re pricing one now, that tells you something practical. The guidance you have is the guidance you’re likely to be working from for a while.

Two plans, one missing line

Treasury publishes a priority guidance plan every year. It’s a work list, and the plan says so plainly: it “does not provide any deadline for completing the projects.”

The 2025-2026 plan, dated September 30, 2025, also had 40 items in its tax law section. The last one read: “Guidance under §223 regarding changes to health savings accounts and high-deductible health plans.”

Ten weeks later, on December 9, 2025, the IRS released Notice 2026-5, which covers three HSA changes from the 2025 law: telehealth, bronze and catastrophic plans, and direct primary care service arrangements. Treasury and the IRS asked for comments “on all aspects of this notice” by March 6, 2026.

The new plan’s tax law section runs 40 items again. It covers scholarship credits, Trump accounts, depreciation, opportunity zones and more. Section 223 appears once in the whole document, in the appendix of routine annual releases: the revenue procedure that sets HSA inflation-adjusted amounts, slotted under May 2027.

Why did the item drop off? The plan doesn’t say for any single project. Its cover letter gives two general reasons that projects from last year are missing: “they were completed or reflect a change in priorities.” Either reading is consistent with the text. Neither is confirmed by it.

What the notice already settles

Notice 2026-5 is 20 questions and answers, and ten of them deal with direct primary care. Some are generous to practices. A-13 lets a fee cover up to a year at a time if it stays fixed, periodic and within the monthly limit on an annualized basis. Its own 2026 example is $1,800 a year for one person.

Others are strict. A-11 says “the sole compensation for care provided under a DPCSA must be the fixed periodic fee,” so an arrangement that bills members separately for care provided under the membership doesn’t qualify. A-18 says fees an employer pays, including through a cafeteria plan, aren’t expenses the employee can reimburse from an HSA.

Some answers are narrow, and one question is set aside. A-17 says “primary care services” is not defined by reference to the Medicare HCPCS codes. What the statute supplies instead is three exclusions: procedures that need general anesthesia, prescription drugs other than vaccines, and lab services not typically done in an ambulatory primary care setting. Footnote 5 records Treasury’s understanding that the ACA lets marketplace plans provide coverage through a direct primary care medical home plan, then adds: “Nothing in this notice is intended to provide any interpretive guidance with respect to ACA section 1301(a)(3).”

Those gaps are where a follow-up rule would have done its work. The new plan doesn’t schedule one.

A new item with no detail

One line in the new plan could matter here, and it says almost nothing. Under “Other Priorities,” item 2 reads: “Guidance on health care related tax matters.” It doesn’t appear in last year’s plan, and the document gives no section number, no scope and no description.

That could cover HSAs. It could cover something unrelated. Reading DPC into it would be guessing.

What to watch

Start with the plan’s own updates. It says Treasury intends to update it “during the plan year to reflect additional items that become priorities, guidance that is published during the plan year, and projects that may result from legislative developments.” Treasury has posted quarterly updates in some past years, on the IRS priority guidance page. A section 223 item added to the plan would be the clearest early sign of new DPC rules.

Then May 2027, when the routine HSA revenue procedure is listed. The plan describes it as setting “the 2027 inflation adjusted amounts” for HSAs.

Then Congress. The last of the three triggers in that update clause is legislation. Treasury interprets section 223, but Congress writes it. The statute sets the $150 monthly fee limit, or $300 for an arrangement that covers more than one person, along with the three exclusions from primary care.

Until one of those moves, the notice is the document to write membership terms to. If your agreement bills separately for anything provided under the membership, A-11 is the answer you’ll be held to.