Grassley and Miller-Meeks Pitch DPC on HSAs. Their Op-Ed Skips the Cap

Iowa’s senior U.S. senator and one of its House members spent a newspaper column this week telling families they can pay for direct primary care out of a health savings account. That’s true. The column leaves out the number that decides how well it works for any given family: $150 a month.

Sen. Chuck Grassley and Rep. Mariannette Miller-Meeks, who represents Iowa’s 1st District, wrote the piece for the Burlington Hawk Eye, published Oct. 27. It credits what they call the “Republican Working Families Tax Cuts Act” and says that “Iowa families can use their health savings accounts (HSAs) to improve access to primary care.”

The federal guidance behind that sentence runs 16 pages. A few of its limits are the ones a DPC patient is most likely to trip over.

What the law actually changed

The column’s tax law is the one enacted July 4, 2025, as Public Law 119-21. The IRS calls it the One, Big, Beautiful Bill Act in Notice 2026-5, the guidance that explains its HSA provisions.

According to the notice, section 71308 of the law made two changes to 26 U.S.C. § 223. A qualifying direct primary care service arrangement no longer counts as a “health plan” that blocks someone from contributing to an HSA. And an HSA can now pay for coverage under one. Both apply to months beginning after Dec. 31, 2025.

Before that, the notice says, someone enrolled in a DPC arrangement “generally was not eligible to contribute to an HSA.”

The law also limits who can deliver the care. The notice defines primary care practitioners as physicians whose primary specialty is family, internal, geriatric or pediatric medicine, plus nurse practitioners, clinical nurse specialists and physician assistants. The fee must be the sole compensation, paid as “a fixed periodic fee.”

The $150 line

Here’s the part the column doesn’t mention. An arrangement stops qualifying for the contribution rule if a person’s aggregate DPC fees for a month “exceed $150 (or $300 for any such arrangement that covers more than one individual).” The notice says that limit adjusts for inflation for taxable years after 2026.

Going over it doesn’t make the fee ineligible for HSA payment. Q&A-20 of the notice says fees above the limit “will be treated as medical expenses reimbursable from an HSA” but “will disqualify the covered individual from eligibility for making HSA contributions while the individual is enrolled.”

So a family can spend existing HSA dollars on a family membership priced above the cap. It just can’t keep putting new money into the account while it’s enrolled. For a household that chose an HSA for the tax break, that’s a real cost.

The law also excludes some services from primary care, the notice explains: procedures that require general anesthesia, prescription drugs other than vaccines and lab services “not typically administered in an ambulatory primary care setting.”

Three more limits, and one claim the guidance doesn’t cover

Three other answers in the notice change how you might talk to patients about this.

Start with employer-paid fees. If an employer pays the DPC fee, “including by salary reduction through a section 125 cafeteria plan,” the worker can’t reimburse it from the HSA. The notice says those payments are not the worker’s expense.

The insurance plan can’t pay it either. Under Q&A-15, a high-deductible plan can’t cover a DPC membership before the deductible is met.

And the fees don’t count toward that deductible. Q&A-16 says membership fees a patient pays are not out-of-pocket amounts for items and services the HDHP covers.

The column also says families can use “their HSA or flexible spending account (FSA)” to pay for a membership. The DPC provision amends § 223, the HSA section of the tax code. Notice 2026-5 addresses HSAs and does not mention flexible spending accounts anywhere in its text. If a patient asks you about using an FSA, this guidance won’t answer the question.

The Iowa piece

The column says DPC “was enabled under state law in 2018 and further protected in 2026.” The record backs both dates.

Iowa’s DPC statute is chapter 135N of the Iowa Code. Its history note lists a 2018 act and a 2022 amendment. Today the chapter covers “direct health care agreements,” and its definition of health care services includes dental care. It says an agreement “shall be deemed to not be insurance” and requires a bold notice telling the patient so.

The 2026 protection is House File 2434, which took effect July 1. As DPC Insider reported in June, it bars health insurers from denying coverage of a covered benefit, or charging more for it, solely because a DPC provider outside their network made the referral.

What changes for an Iowa family, and when

Nothing changes because of the column. The federal rules have applied since Jan. 1, and the column adds no new law.

What a family can check now is the fee. A family price above $300 a month can cost that family its HSA contributions. A price under the cap doesn’t settle the question by itself, because the arrangement still has to meet the law’s other conditions.

The cap is the one moving piece. Because the notice ties it to inflation after 2026, a family should look for the 2027 figure before assuming $150 still holds next year. And if you run a DPC practice in Iowa, your family tier is now part of your patients’ tax planning, whether or not anyone in Washington mentions it.