What Medicare doesn't cover — the gaps that surprise everyone

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

I got the call from my sister on a Tuesday. Our mother had fallen in the bathroom and fractured her hip. The surgery went fine, they said at the hospital. She'd go to a skilled nursing facility for rehabilitation. Three weeks, maybe four. The surgeon seemed confident.

I didn't think about Medicare coverage. I was thinking about her pain and whether she'd walk again. The nursing facility social worker was the one who said it clearly: "Medicare will cover the skilled nursing care through day 100, but if your mother needs ongoing help with her daily activities after her rehabilitation ends, that's not covered. We need to talk about payment options."

That was the moment the gap became real. My mother had excellent Medicare coverage. She'd paid into the system her whole life. But Medicare wasn't going to pay for the help she might need if she couldn't dress herself or bathe herself or cook her meals when the rehabilitation ended. That gap would cost my family tens of thousands of dollars.

Most people don't understand that Medicare covers medical care, not living assistance. Those are not the same thing. Your parent could have complete Medicare coverage for their health problems and still face financial catastrophe if they need long-term help with daily life.

The Biggest Gap: Long-Term Custodial Care

The largest and most destructive gap in Medicare is long-term custodial care—the help your parent needs if they can't bathe themselves, dress themselves, cook their meals, or manage their medications without assistance. This is not medical care. This is daily living assistance. Medicare does not cover it.

A nursing home that provides custodial care—where the patient needs help with activities of daily living but not medical care,is not covered by Medicare. An assisted living facility, where your parent has an apartment but staff help with meals and personal care, is not covered by Medicare. An in-home aide who helps your parent bathe and dress and manage the day, without providing medical care, is not covered by Medicare.

This gap is the reason families go bankrupt. A year in a nursing home costs $100,000 or more in many parts of the country. Three years of in-home care costs $150,000 to $200,000. Medicare covers nothing of these costs if the care is custodial rather than medical.

The distinction matters legally, and it determines what you pay. If your parent is in a nursing home receiving skilled physical therapy after a hip fracture, that's covered. If your parent stays in the same nursing home one day past when the physical therapy ends, that transition day forward is not covered. The building is the same. The nurses are the same. But the coverage stops.

This isn't Medicare being stingy. This is Medicare being what it was designed to be: a medical insurance program. It was never designed to pay for housing or personal care. But most families need that housing and personal care to be paid for at some point, and Medicare's boundaries create a false cliff where coverage ends.

Routine Care Medicare Leaves Out

Beyond long-term custodial care, Medicare has specific carve-outs for services that seem like they should be covered but aren't.

Dental work is not covered by Medicare. Your parent can have a toothache, an abscess, or tooth decay, and Medicare will not pay for a dental visit, a filling, a root canal, or an extraction. The only exception is dental work that happens while your parent is in the hospital as an inpatient for another reason. Walk in with a painful tooth, and you're paying out of pocket. Medicare won't help.

Routine vision care is not covered. Eye exams to check your parent's vision aren't covered. Eyeglasses aren't covered. Contact lenses aren't covered. If your parent has age-related macular degeneration or glaucoma or cataracts, those are covered as medical conditions. But the eye exam that detects them isn't covered unless it's done by a primary care doctor or specialist as part of another medical evaluation.

Hearing aids are not covered. Your parent can have moderate or severe hearing loss and Medicare will not pay for a hearing aid, a hearing test, or the fitting. This affects quality of life, cognition, and safety, but it's not covered. Even though hearing loss is associated with dementia, cognitive decline, and isolation, Medicare categorizes hearing aids as a personal device, not a medical service.

These carve-outs seem arbitrary until you understand the history. When Medicare was created in 1965, dental, vision, and hearing services were not considered essential medical services. They were seen as optional or cosmetic. That framework stuck, even though we now understand that dental health affects cardiac health, vision affects safety, and hearing affects mental health.

Why These Gaps Exist: Medicare's Original Mission

Understanding why these gaps exist helps you stop expecting Medicare to cover things it was never designed to cover.

Medicare was created to provide medical care to people over 65, not to pay for housing or daily living assistance. Medicaid covers long-term custodial care, but only if your parent qualifies financially (typically with assets under $2,000). Medicare and Medicaid are different programs with different purposes, and their boundaries create gaps for people in the middle,those with too many assets for Medicaid but not enough to privately pay for years of care.

The dental, vision, and hearing carve-outs come from the 1960s when these services were considered luxuries, not necessities. Dentures and glasses were personal items. Hearing aids barely worked. The framework never updated, even though the evidence changed.

Understanding this history doesn't fix the problem, but it stops you from fighting the wrong battle. You can't argue your way into Medicare covering your parent's hearing aid by pointing out that hearing loss affects cognition. Medicare's coverage rules don't work that way. The rules are set by Congress, not by medical evidence or reasonableness.

What Covers These Gaps: The Real Sources of Payment

If Medicare doesn't cover custodial care, dental, vision, and hearing, what does?

Medicaid covers long-term custodial care if your parent's financial assets are below the state's limit. This is the primary source of payment for nursing home care in America. Most nursing homes get payment from Medicaid once a patient's Medicare benefits end. But Medicaid requires your parent to spend down their assets first. If your parent has $500,000 in savings, they'll need to use that money for care before Medicaid kicks in. The process is called "estate planning" if you do it before the crisis, and "spending down" if you do it after you're already in crisis.

Long-term care insurance, if purchased before the need arises, covers custodial care. Some families buy these policies while the parent is still healthy. The policies pay a daily amount toward nursing home or in-home care if the parent becomes unable to perform daily living activities. But these policies need to be purchased years in advance, while the parent is insurable. They're expensive, and they come with their own limitations.

Out-of-pocket payment is how most families cover the gaps. Your parent pays from their savings. Family members contribute. The house is sold. Assets are liquidated. This is the financial reality for millions of American families. The gaps in Medicare create direct financial burden on adult children.

Medicare Advantage plans sometimes include coverage for dental, vision, or hearing as part of their benefit package. If your parent has a Medicare Advantage plan, they might get a dental benefit that covers cleanings and basic work. Some plans include hearing aid benefits. But these benefits are limited compared to commercial insurance, and they come with restrictions on which providers you can use.

Medicare Advantage as Partial Solution

Medicare Advantage plans are offered by private insurance companies and function as an alternative to Original Medicare. They must cover everything Medicare covers, but they can add benefits. Many Advantage plans include some level of dental, vision, and hearing coverage.

The coverage is limited. A dental benefit might cover two cleanings a year and basic work, but not major restorative work. A vision benefit might cover an eye exam and a pair of glasses every two years, but not contacts. A hearing benefit might cover a hearing aid every few years, but not the premium models. It's better than nothing if cost is your main concern.

The trade-off is that Medicare Advantage plans use networks, meaning your parent can't see any doctor they want. If your parent's primary care doctor doesn't participate in the network, or if their specialist doesn't, they'll have to switch or pay more out of pocket. For someone with multiple chronic conditions who has been seeing the same doctors for years, this trade-off might not be worth it.

Some families make the switch for the dental or vision benefits. Others stay with Original Medicare because the doctor access matters more. There's no right answer, only the choice that works for your parent's specific situation.

Planning for the Gaps Before They Become Crises

The gaps in Medicare don't change, but your parent's ability to pay for them changes as they age. Planning now prevents financial shock later.

Understand these gaps now while you're not in crisis. Read about what Medicare doesn't cover. Make a list for your parent. Have the conversation about what happens if they need dental work or hearing aids or custodial care. This conversation is uncomfortable, but it's less uncomfortable than discovering the gaps when your parent is in the hospital with a discharge date looming.

They affect your financial planning. If your parent is going to need long-term care at some point, that affects what you save, what your parent saves, and what assets you protect. A lawyer who specializes in elder law can help with this planning, but you need to start before the crisis arrives.

Explore Medicaid planning if your parent's assets are moderate. If your parent has $300,000 in savings and might someday need nursing home care, an elder law attorney can explain whether and how to structure assets so your parent qualifies for Medicaid after their assets are spent down appropriately. This is legal and proper planning, not fraud. But it requires knowing the rules and the timeline.

Consider long-term care insurance while your parent is healthy. If your parent is over 75, the insurance becomes expensive and less practical. But if your parent is 60 and relatively healthy, the premium might be reasonable, and the coverage could protect family assets. Each policy is different, so comparing options matters.

Talk to your parent about what they want if custodial care becomes necessary. Would they prefer to stay in their home with in-home aides? Would they prefer a facility? Would they want aggressive rehabilitation if they had a stroke, or would they prefer comfort care? These preferences affect the costs you'll face and the planning you'll do.

The Reality of These Gaps

My mother eventually came home from the nursing facility. She needed a cane and physical therapy, but she recovered enough to manage most daily activities. We didn't need years of custodial care. We were lucky. But the gap was real. We'd have paid it if we needed to. It would have destroyed our savings, but we'd have done it.

That's how the gaps in Medicare work for most families. The gaps are real. They create financial catastrophe. But they're not discussed much because Medicare marketing focuses on what's covered, not on what isn't. Your parent sees "Medicare covers medical care" and thinks that's going to be sufficient. Then something happens,a fall, a stroke, a cancer diagnosis,and you discover that "medical care" doesn't mean what most people think it means.

These gaps are why adult children end up paying for their parent's care in ways they never anticipated. These gaps are why long-term care insurance exists. These gaps are why elder law attorneys specialize in Medicaid planning. These gaps are real, and they're going to affect your family. Understanding them now means you can plan instead of react.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's cognitive health or safety, consult with their healthcare provider or contact your local Area Agency on Aging for guidance and support.