By now you know that pre-tax retirement contributions reduce your MAGI — the income number that Medi-Cal actually checks. But retirement accounts aren't the only tool that does this.
If your employer offers a Flexible Spending Account (FSA) or if you're enrolled in a high-deductible health plan that comes with a Health Savings Account (HSA), those contributions can also reduce your MAGI — and they do something a retirement account can't: they let you spend the money right now on things your family needs.
Braces for your kids. Contact lenses. Over-the-counter medications. Sunscreen. Tampons and menstrual products. Bandages, thermometers, first aid kits. Hundreds of items your family buys anyway — all purchased with dollars that were never taxed.
"A retirement account grows your future. An FSA or HSA pays for your present — with pre-tax dollars that also lower the income number your benefits are based on."
FSA vs HSA — what's the difference?
How they reduce your MAGI
FSA contributions are deducted from your paycheck before income taxes are calculated — which means they reduce the gross income reported to the IRS, and by extension, your MAGI. If your employer offers an FSA and you elect to contribute $2,000 for the year, your MAGI drops by $2,000.
HSA contributions work similarly. Contributions made through payroll deduction reduce your MAGI before they're reported. Contributions made directly to your HSA (not through payroll) are deducted on your tax return as an "above-the-line" deduction — meaning they reduce your MAGI regardless of whether you itemize deductions.
FSA/HSA + IRA = more total MAGI reduction
You can contribute to both a Traditional IRA and an FSA or HSA in the same year. They reduce different categories of income, but together they compound your total MAGI reduction. A family contributing $3,000 to an FSA and $5,000 to a Traditional IRA could lower their MAGI by $8,000 — potentially bridging a large gap between their actual income and their benefits threshold.
What can you actually spend it on?
This is where FSAs and HSAs get genuinely useful for everyday families. Since the CARES Act in 2020, the eligible expense list expanded significantly. Here's a sample of what you can buy tax-free:
The full list runs to thousands of items. The IRS-eligible expense list is published in IRS Publication 969, and a searchable database is available at FSAstore.com's eligibility list.
Braces and orthodontia are FSA/HSA eligible
Orthodontic treatment — including traditional braces and clear aligners — is an eligible medical expense under both FSA and HSA rules. If your children need braces, using an FSA or HSA to pay means you're covering that cost with pre-tax dollars. On a $5,000 orthodontic bill, that could save a family $1,000 or more in taxes depending on their bracket — and simultaneously lower the MAGI that determines their benefit eligibility.
The HSA triple tax advantage
The HSA, in particular, is one of the most tax-advantaged accounts in the entire tax code — better than a Roth IRA in some respects. It has what's called a triple tax advantage:
- Contributions are pre-tax (reduce your MAGI now)
- Growth is tax-free (invest unused funds in an index fund and they grow without taxes)
- Withdrawals for medical expenses are tax-free (spend it on eligible expenses and pay nothing)
After age 65, HSA funds can be withdrawn for any purpose (not just medical) and are taxed as ordinary income — exactly like a Traditional IRA. This makes an HSA essentially a retirement account with an additional bonus: use it for medical expenses before retirement and you never pay tax on that money at all.
You can only open an HSA if you have an HDHP
To be eligible for an HSA, you must be enrolled in a qualifying High-Deductible Health Plan (HDHP). In 2026, that means a plan with a deductible of at least $1,700 for individual coverage or $3,400 for family coverage. Many Covered California plans qualify — check your plan documents or call your insurance company to confirm. If you're on Medi-Cal, you are not eligible for an HSA.
A real example: FSA + IRA together
Family of 3, gross income $40,000 — Medi-Cal threshold $36,777
In this example, neither the IRA alone nor the FSA alone would have been enough to get under the Medi-Cal threshold. Combined, they get this family $2,000 under — protecting their health coverage, reducing their tax bill, and giving them $2,000 in tax-free spending for their family's medical needs.
IRS Publication 969 & the DHCS Income Chart
For the full list of HSA and FSA eligible expenses, see IRS Publication 969 ↗. For what counts as income for Medi-Cal purposes, see the DHCS Income & Deductions Chart (PDF) ↗. Both are also linked from our Resources page.
See how FSA + IRA changes your MAGI
Use the benefits cliff calculator to model your total MAGI after both retirement and FSA contributions — and see where you land relative to your threshold.
Try the calculator →Want to open a Traditional IRA to stack with your FSA? See our recommended brokerages →