A $350,000 attending who fills every tax-advantaged account available through a typical academic employer can shelter more than $115,000 in 2026 — and cut their federal tax bill by five figures in the process. Most physicians capture less than a third of that, not because they cannot afford to contribute, but because nobody ever showed them the full list of accounts or the order to fill them.
This is the full list. Every account, the exact 2026 IRS limit, who gets access, and a worked example for a $350,000 attending at the end. The numbers below come from IRS Notice 2025-67 (retirement limits) and Rev. Proc. 2025-19 (HSA limits) — they are the 2026 figures, not last year's.
One framing note before the details: physicians start saving 7 to 10 years later than other professionals and compress a 40-year accumulation window into 25 or 30. The accounts in this guide are how you compensate for that compression. A dollar sheltered at 35% marginal tax does more work than a dollar invested in a taxable account, every single year it compounds.
The 2026 limits, all in one table
| Account | 2026 limit | Notes |
|---|---|---|
| 401(k)/403(b)/457(b) employee deferral | $24,500 | Per plan type — 457(b) is a separate limit |
| Catch-up, age 50+ | $8,000 | On top of the deferral |
| Super catch-up, age 60–63 | $11,250 | Replaces the $8,000 catch-up (SECURE 2.0) |
| §415(c) total DC limit (employee + employer + after-tax) | $72,000 | The ceiling that makes the mega backdoor Roth possible |
| Traditional/Roth IRA | $7,500 | Per person, including spouse |
| IRA catch-up, age 50+ | $1,100 | |
| HSA, self-only coverage | $4,400 | Requires HDHP enrollment |
| HSA, family coverage | $8,750 | |
| HSA catch-up, age 55+ | $1,000 | Per spouse, but requires separate HSAs |
The Roth IRA income phase-out for 2026: single filers $153,000–$168,000 MAGI, married filing jointly $242,000–$252,000. Nearly every attending is above the top of those ranges, which is why the backdoor Roth section below exists.
Quick takeaway
The single number to memorize for 2026: $24,500. That is the employee deferral limit for your 401(k) or 403(b) — and separately, again, for a 457(b) if you have one.
401(k) and 403(b): the foundation
Your employer plan is the first account to fill, for two reasons: the deferral is large ($24,500), and the match is free money you forfeit if you under-contribute.
Hospital and health-system physicians usually have a 403(b); private groups and physician-owned practices usually have a 401(k). For contribution purposes they are nearly identical: you defer up to $24,500 of salary pre-tax (or Roth, if the plan allows), your employer adds a match or a fixed contribution, and the combined total of everything — your deferral, the employer money, and any after-tax contributions — is capped at $72,000 under §415(c).
Two decisions matter here.
Pre-tax or Roth deferral? At attending income, the pre-tax deferral usually wins. A married attending with $350,000 of household income sits in the 24% federal bracket for 2026 (taxable income between $211,400 and $403,550 MFJ); a single attending at that income is in the 35% bracket. Deferring pre-tax at 24–35% and withdrawing in retirement at a likely lower average rate is the standard play. Roth deferrals make more sense early in your career, in low-tax years (fellowship, parental leave, a partial year), or if you expect to retire into a higher bracket than you are in now.
Match mechanics. If your employer matches per-paycheck rather than annually, front-loading your $24,500 in the first half of the year can cost you matching dollars in the back half unless the plan has a true-up provision. Read your summary plan description or ask HR one question: "Does the plan true-up the match at year end?" If no, spread your deferrals across all 26 pay periods.
If you are 50 or older, add the $8,000 catch-up for a $32,500 deferral. If you are 60 through 63, the SECURE 2.0 super catch-up replaces it: $11,250, for a $35,750 total deferral. Those four years are the single best deferral window of your career — use them.
The 457(b): a second $24,500 most physicians ignore
Here is the fact that surprises attendings every time: the 457(b) deferral limit is separate from the 401(k)/403(b) limit. If your employer offers both — and most academic medical centers and many nonprofit health systems do — you can defer $24,500 into each. That is $49,000 of pre-tax deferrals before any employer money, any IRA, or any HSA.
There is one distinction you must understand before contributing, because it changes the risk profile entirely:
- Governmental 457(b) (state university hospitals, county health systems, VA-adjacent entities): your money is held in trust for you. It is functionally a second 403(b), and you can withdraw at any age after separation with no early-withdrawal penalty — a quietly excellent feature for physicians considering early retirement.
- Non-governmental 457(b) (private nonprofit hospitals — the majority of health systems): the assets legally belong to your employer until paid out, and they are exposed to the employer's creditors in a bankruptcy. Distribution options are also rigid — many plans force a lump sum or a short payout schedule at separation, which can dump six figures of ordinary income into a single tax year.
A non-governmental 457(b) is still usually worth funding for a financially stable employer — a 24–35% immediate tax deferral covers a lot of risk — but check your system's credit rating and read the distribution options before you commit. If your hospital is mid-merger or running operating losses, think harder.
Important
Non-governmental 457(b) assets are your employer's property until distributed. If the hospital goes bankrupt, you stand in line with its other unsecured creditors. Fund it with eyes open.
The backdoor Roth IRA: $7,500 per spouse, every year
At attending income you cannot contribute directly to a Roth IRA — the 2026 phase-out tops out at $168,000 single / $252,000 MFJ. The backdoor Roth is the lawful workaround: contribute $7,500 to a traditional IRA as a nondeductible contribution (no income limit applies to nondeductible contributions), then convert it to Roth. There is no income limit on conversions. Done cleanly, the tax bill on the conversion is zero or a few dollars.
A married couple does this twice — $15,000 per year into Roth, even if one spouse has no earned income (a spousal IRA contribution rides on the working spouse's income). Over a 25-year attending career at 7% growth, the annual $15,000 becomes roughly $1,015,000, every dollar of it tax-free in retirement.
The one thing that breaks the backdoor Roth is the pro-rata rule: if you hold any pre-tax money in any traditional, SEP, or SIMPLE IRA on December 31 of the conversion year, the conversion is partially taxable. The fix is rolling those pre-tax balances into your employer 401(k)/403(b) before year end. We cover the full mechanics, including Form 8606, in a dedicated step-by-step guide.
The mega backdoor Roth: the $72,000 ceiling
The §415(c) limit — $72,000 in 2026 — caps the total of your deferral, your employer's contributions, and a third category most physicians have never used: after-tax (non-Roth) contributions. If your plan permits after-tax contributions and lets you convert them to Roth while still employed, you can fill the entire gap between $72,000 and what you and your employer already contribute, then convert it to Roth. That is the mega backdoor Roth.
The math for a physician deferring $24,500 with a $14,000 employer contribution: $72,000 − $24,500 − $14,000 = $33,500 of after-tax space, convertible to Roth annually. That is more than four times the regular backdoor Roth.
The catch is plan support. Both features — after-tax contributions and in-service conversion — must be written into your plan document, and most hospital 403(b) plans include neither. Large university plans and physician-group 401(k)s are the most common places it actually works. Independent contractors running a solo 401(k) can build it in deliberately. Check your summary plan description before assuming you have it; we cover the verification process in a separate guide.
The HSA: the best account in the tax code, used wrong by most physicians
If you are enrolled in a qualifying high-deductible health plan, the 2026 HSA limits are $4,400 self-only and $8,750 family, plus a $1,000 catch-up at 55. The HSA is the only account with a triple tax advantage: contributions are pre-tax, growth is tax-free, and withdrawals for qualified medical expenses are tax-free. Contribute through payroll and the dollars also escape the 6.2% Social Security tax (on income up to the 2026 wage base of $184,500) and 1.45% Medicare tax — no other account does that.
The mistake is treating it as a spending account. Used as a retirement account — contribute the maximum, invest it, pay current medical costs out of pocket, and keep receipts — the HSA compounds untouched for decades. $8,750 per year for 20 years at 7% is roughly $383,000, available tax-free against the medical costs that are all but guaranteed in retirement. After 65, non-medical withdrawals are simply taxed as ordinary income, so the worst case is that it behaves like a traditional IRA with a payroll-tax bonus.
Key insight
The HSA is the only account where the IRS never taxes the money — not going in, not growing, not coming out (for medical costs). For a physician in the 32–35% bracket, every $8,750 contribution saves roughly $2,800–$3,060 in federal income tax immediately, before the payroll tax savings.
Defined benefit plans: the heavy artillery for practice owners
Everything above applies to employed physicians. If you own your practice or earn substantial 1099 income — locums, medical directorships, expert witness work — one more tier exists: the cash balance defined benefit plan. Instead of capping contributions at $72,000, a DB plan caps the benefit at retirement, and the allowable annual contribution to fund that benefit grows with age. A physician-owner in their 50s can often contribute $150,000–$300,000 per year pre-tax on top of a 401(k).
DB plans carry real costs — actuarial administration, a multi-year funding commitment, mandatory contributions for eligible employees — so they fit a specific profile: stable high income, age 45+, and few or no non-physician employees. They deserve their own full treatment, but if you are a practice owner reading this guide and stopping at $72,000, you are leaving the largest deduction in the tax code unexamined.
Where retirement contributions meet your student loans
For attendings still carrying federal loans, pre-tax retirement contributions do double duty: every dollar you defer lowers the adjusted gross income that drives your income-driven repayment amount. If you are pursuing PSLF, that is not a side effect — it is strategy. Lower IDR payments mean less paid out of pocket over your 120 qualifying payments, and the difference is forgiven tax-free at the end.
Run the numbers on a concrete case: an attending earning $300,000 who defers $24,500 into a 403(b), $24,500 into a 457(b), and $8,750 into a family HSA has reduced AGI by $57,750. On an IDR plan calculating payments at roughly 10% of discretionary income, that is in the neighborhood of $5,775 less per year in required loan payments — money that stays invested in your retirement accounts instead of going to a balance that PSLF will forgive anyway. Over the four to seven attending years most physicians spend finishing their 120 payments, the combined effect routinely exceeds $25,000.
Two cautions. First, this only favors maximum deferrals if you genuinely expect forgiveness — if you plan to pay your loans off, lower payments now just mean more interest later. Second, IDR payments are set from the AGI on your most recent tax return, so the savings arrive on a one-to-two-year lag. Time your recertification with that lag in mind, especially in the first attending years when your tax return still shows resident income.
Roth deferrals, by contrast, do nothing for your AGI. For a PSLF-pursuing attending, that tilts the pre-tax versus Roth decision even further toward pre-tax inside the employer plan — you can still build Roth assets through the backdoor and mega backdoor routes, which never affected your AGI to begin with.
The max-everything worked example: a $350,000 attending
Assumptions, stated explicitly: a 45-year-old academic hospitalist earning $350,000 W-2, married filing jointly, spouse not employed. The university offers a 403(b) with a $14,000 employer contribution, after-tax contributions with in-service Roth conversion, and a non-governmental 457(b). The family is enrolled in an HDHP.
Example calculation
2026 maximum sheltering, line by line:
| Account | Amount | Tax character |
|---|---|---|
| 403(b) employee deferral | $24,500 | Pre-tax |
| 403(b) employer contribution | $14,000 | Pre-tax |
| 403(b) after-tax → mega backdoor Roth ($72,000 − $38,500) | $33,500 | Roth |
| 457(b) deferral | $24,500 | Pre-tax |
| HSA (family, via payroll) | $8,750 | Pre-tax, triple-advantaged |
| Backdoor Roth IRA — physician | $7,500 | Roth |
| Backdoor Roth IRA — spouse | $7,500 | Roth |
| Total sheltered | $120,250 |
Pre-tax deferrals the physician controls: $24,500 + $24,500 + $8,750 = $57,750. At this couple's 24% federal marginal rate, that is roughly $13,860 of federal income tax avoided in 2026, plus state tax savings and roughly $127 of Medicare tax avoided on the payroll HSA contribution. Pennsylvania, notably, does not tax 401(k)/403(b) deferrals going in or retirement distributions coming out — but it also gives no deduction for HSA contributions made outside payroll. Run your own state's rules.
Could this physician actually save $120,250 on $350,000 gross? After the pre-tax deferrals, federal and state tax, and the Roth-side contributions of $48,500, the family is living on roughly $130,000–$145,000 — tight but real, and many dual-income physician households or single physicians with moderate housing costs do exactly this. The point of the example is not that everyone should hit $120,250. It is that the ceiling is far higher than the $24,500 most attendings believe it is, and every tier you add compounds for the rest of your career.
The fill order
When you cannot fund everything, fund in this order:
- 401(k)/403(b) up to the full employer match — a 50–100% instant return.
- HSA to the maximum — the only triple-advantaged dollars available.
- 401(k)/403(b) to the full $24,500.
- Backdoor Roth IRA(s) — $7,500 each.
- 457(b) — governmental confidently; non-governmental after assessing employer stability.
- Mega backdoor Roth after-tax space, if your plan supports it.
- Taxable brokerage — no limits, full flexibility, still excellent.
Reasonable people swap 4 and 5, or move a stable governmental 457(b) ahead of the backdoor Roth. Nobody should swap 1 or 2 lower.
Common questions
Do the 401(k) and 403(b) limits combine if I have both?
Yes — the $24,500 employee deferral limit is shared across all 401(k) and 403(b) plans you participate in, even at unrelated employers. If you defer $20,000 at the hospital and moonlight for a group with a 401(k), you have $4,500 of deferral room left, not a fresh $24,500. The 457(b) is the exception: its $24,500 is fully separate.
I switched jobs mid-year. How do I avoid over-contributing?
Your deferrals aggregate across employers, but neither payroll system knows about the other. Track your year-to-date deferral from your final pay stub at the old job and set the new plan's contribution to stop at the combined $24,500. If you overshoot, request a return of excess deferrals from one plan before April 15 of the following year to avoid double taxation.
Should I do Roth or pre-tax deferrals at $350,000 income?
Usually pre-tax for the deferral, Roth for everything else. The deferral saves tax at your marginal rate today (24–35% federal at attending income); the backdoor and mega backdoor Roth dollars cost you nothing extra because they were never deductible anyway. That combination — pre-tax deferrals plus Roth backdoors — builds tax diversification automatically.
Does the $72,000 §415(c) limit include my catch-up contribution?
No. Catch-up contributions sit on top of the §415(c) limit. A 52-year-old can defer $32,500 ($24,500 + $8,000), and the plan's total ceiling effectively becomes $80,000.
My employer's plan has terrible fund options. Should I still contribute?
Almost always yes, up to the full deferral. Even an expensive plan with mediocre index funds beats a taxable account at attending tax rates: a 24–35% immediate deferral plus tax-deferred compounding overwhelms an extra 0.5% in expense ratios over typical holding periods. Pick the cheapest broad-market index funds on the menu, contribute the maximum, and roll the balance to a better home when you change employers. The exception is genuinely abusive plans — annuity-wrapped 403(b)s with 2%+ all-in costs and surrender charges — where it is worth a conversation with HR before committing beyond the match.
What about a SEP-IRA for my moonlighting income?
A solo 401(k) is almost always better than a SEP-IRA for a moonlighting physician, for one decisive reason: a SEP-IRA is a pre-tax IRA, so it triggers the pro-rata rule and quietly breaks your backdoor Roth. A solo 401(k) shelters the same 1099 income without that side effect.
For an unincorporated sole proprietorship or single-member LLC, your maximum employer contribution is technically capped at 25% of adjusted net earnings. Because the calculation requires you to subtract half of your self-employment tax and the contribution itself, the math beautifully simplifies to exactly 20% of your net self-employment earnings (net profit minus half of your self-employment tax). If you incorporate your 1099 side-gig as an S-Corp, the maximum employer profit-sharing contribution is 25% of your W-2 salary.
What to do next
- Pull your most recent pay stub and write down your current per-paycheck deferral. Multiply by your remaining pay periods — will you hit $24,500 by December? If not, raise the percentage this week.
- Ask HR or check your benefits portal for two things: whether a 457(b) exists, and whether your 403(b)/401(k) allows after-tax contributions with in-service conversion.
- If you are HDHP-eligible during open enrollment, price the HDHP against your current plan including the $8,750 HSA contribution in the comparison.
- Open and fund backdoor Roth IRAs for yourself and your spouse — and check for old SEP or rollover IRA balances first, because of the pro-rata rule.
- If you have 1099 income and want to defer earnings for this calendar year, know your deadlines. Thanks to SECURE 2.0, if you are a sole proprietor establishing your very first solo 401(k), you actually have until your tax-filing deadline (typically April 15 of the following year, without extensions) to adopt the plan and retroactively fund both employee deferrals and employer contributions. If it's a subsequent year or your business is an S-Corp, your employee deferral election must be locked in by December 31, while employer profit-sharing pieces can be funded up until your tax-filing deadline (including extensions).
If you are an Attending Financial member, the retirement contribution pacing view on your dashboard tracks each of these limits against your actual payroll deferrals and flags the gap in dollars per month — worth a look before your next paycheck, not after your last one in December.