Original Medicare covers a lot, but it leaves some costly holes that catch many beneficiaries off guard. Dental cleanings, hearing aids, long-term nursing home care, and routine eye exams are all examples of services that Medicare simply does not pay for. Understanding these gaps before you need care can save you thousands and help you make smarter decisions about supplemental coverage.
This guide covers the 8 biggest Medicare coverage gaps in 2026, what each gap costs out of pocket, and what options exist to fill them, including Medicare Savings Programs that can help low-income beneficiaries cover costs Medicare does leave on the table.
1. Routine Dental Care
Original Medicare (Parts A and B) pays nothing for routine dental services. That includes cleanings, X-rays, fillings, tooth extractions, dentures, and crowns. The only dental-adjacent care Medicare covers is treatment that is directly tied to a covered medical procedure, such as jaw reconstruction after an injury or tooth removal required before heart surgery.
Out-of-pocket cost estimates for 2026:
- Single tooth crown: approximately $1,500
- Full set of dentures: $3,000 to $5,000 or more
- Annual dental cleaning without insurance: $100 to $300
Some Medicare Advantage (Part C) plans include limited dental benefits, but most come with annual caps of $1,000 to $2,000, leaving more complex procedures largely uncovered.
2. Hearing Aids and Routine Hearing Exams
Medicare does not cover hearing aids or the fittings needed to use them. It also does not cover routine hearing exams, meaning if you want your hearing tested as part of a regular wellness checkup, you will pay out of pocket.
Medicare will cover a hearing and balance exam only if your doctor orders it to diagnose a specific medical condition, not just to check general hearing health.
In 2026, prescription-grade hearing aids for significant hearing loss typically cost $4,000 to $6,000 per pair. Over-the-counter hearing aids (now available since FDA rules changed in 2022) offer a lower-cost option, generally $200 to $1,500, but they are not appropriate for all levels of hearing loss.
3. Routine Vision Care
Medicare does not cover routine eye exams, prescription eyeglasses, or contact lenses. If you just need a checkup and a new prescription, that bill is entirely yours.
There are two exceptions. Medicare Part B covers a yearly dilated eye exam for people with diabetes. It also covers one pair of eyeglasses or contact lenses after cataract surgery.
Outside of those exceptions, routine vision care is a gap. Eyeglass frames and lenses can run $200 to $500 or more without coverage.
Some Medicare Advantage plans include a vision benefit, but like dental, it often comes with caps and exclusions, so read the details carefully.
4. Long-Term Custodial Care
This is one of the most financially devastating gaps in Medicare. Medicare does not pay for custodial care, which is help with daily activities like bathing, dressing, eating, and getting around. This type of care, whether provided in a nursing home or at home, is not covered by Medicare at all.
What Medicare does cover: short-term skilled nursing facility care after a qualifying hospital stay of at least 3 days. Coverage in a skilled nursing facility runs up to 100 days per benefit period, but it is not free beyond the first 20 days.
| Skilled Nursing Facility Days | Your Cost in 2026 |
|---|
| Days 1 to 20 | $0 (Medicare pays 100%) |
| Days 21 to 100 | $194.50 per day coinsurance |
| Day 101 and beyond | You pay 100% |
Once skilled nursing care is no longer needed or the stay exceeds 100 days, Medicare stops paying entirely. The average annual cost of a private room in a nursing home is over $100,000 in 2026. Without long-term care insurance or Medicaid qualification, that cost falls on the beneficiary and their family.
Medicaid does cover long-term care for those who qualify based on income and assets. If you or a family member may need extended nursing home care, checking Medicaid eligibility is an important step.
5. Prescription Drugs Under Original Medicare
Original Medicare Parts A and B do not cover most prescription drugs you take at home. Part A covers drugs administered during a hospital stay. Part B covers a limited set of drugs given in a clinical setting, like infusions or injections during a doctor visit. But the pills you pick up at a pharmacy are not covered by Parts A or B.
To get outpatient drug coverage, you need to enroll in a standalone Medicare Part D plan or choose a Medicare Advantage plan that includes drug coverage.
Part D plans vary significantly in what they cover and what they cost. Each plan has a formulary (list of covered drugs), and if your medication is not on it, you may pay full price. In 2026, the Part D out-of-pocket cap for covered drugs is $2,000 annually, which is a significant improvement from prior years under the Inflation Reduction Act.
If you do not enroll in Part D when you first become eligible and you do not have other creditable drug coverage, you may face a late enrollment penalty that increases your monthly premium permanently.
6. Cosmetic Surgery and Non-Medical Procedures
Medicare does not cover cosmetic surgery or procedures that are not medically necessary. Facelifts, tummy tucks, hair loss treatments, and similar services are excluded entirely.
There is a nuance here. If a procedure addresses a medical condition, Medicare may cover it. For example, eyelid surgery is cosmetic if it is for appearance, but may be covered if drooping eyelids are impairing vision. The medical necessity determination is made by Medicare on a case-by-case basis.
7. Care Received Outside the United States
Original Medicare generally does not pay for health care services received outside the United States. This includes routine care, emergency care, and hospitalization while traveling abroad.
There are three limited exceptions where Medicare Part A or B may cover foreign emergency care:
- You are in the US when an emergency occurs and a foreign hospital is closer than any US hospital
- You are traveling directly between Alaska and another US state and pass through Canada, and an emergency occurs
- You live in the US close to a foreign hospital that is closer or more accessible than the nearest US hospital
Outside of those narrow exceptions, any care received abroad is out of pocket. Some Medigap (Medicare Supplement) plans offer foreign travel emergency coverage, typically up to a lifetime maximum of $50,000 after a deductible.
8. The 20% Cost-Sharing Gap Under Part B
This is technically not an excluded service but it functions like one for many beneficiaries. Under Medicare Part B, after you pay the $283 annual deductible in 2026, Medicare pays 80% of the approved amount for covered services. You are responsible for the remaining 20%.
There is no out-of-pocket maximum on Original Medicare Part B. That 20% can add up quickly for expensive procedures, cancer treatments, or chronic condition management.
| 2026 Medicare Part B Costs | Amount |
|---|
| Standard monthly premium | $202.90 |
| Annual deductible | $283 |
| Your share of approved costs | 20% |
| Annual out-of-pocket maximum | None (Original Medicare) |
Medigap plans can cover some or all of that 20% coinsurance, depending on the plan type. Medicare Advantage plans set their own out-of-pocket maximums, which for 2026 are capped by CMS.
What Fills These Gaps?
Medicare Advantage (Part C)
Medicare Advantage plans are offered by private insurers and must cover everything Original Medicare covers. Many plans also include additional benefits like dental, vision, hearing, and fitness programs. Trade-offs include restricted provider networks and varying levels of prior authorization requirements.
Medigap (Medicare Supplement Insurance)
Medigap plans work alongside Original Medicare. They help cover costs like the Part A and Part B deductibles, the 20% Part B coinsurance, and some offer foreign travel emergency coverage. Medigap does not typically cover dental, vision, hearing, or long-term care.
Medicare Savings Programs
If your income is limited, Medicare Savings Programs (MSPs) can help you afford Medicare itself and reduce the cost-sharing burden of covered services. These are Medicaid-funded programs available through your state.
2026 Medicare Savings Program Income Limits
| Program | Who It Helps | Monthly Income Limit (Individual) | Monthly Income Limit (Couple) |
|---|
| QMB (Qualified Medicare Beneficiary) | Pays Part A and B premiums, deductibles, coinsurance | $1,350 | $1,824 |
| SLMB (Specified Low-Income Medicare Beneficiary) | Pays Part B premium only | $1,616 | $2,184 |
| QI (Qualifying Individual) | Pays Part B premium only | $1,820 | $2,457 |
Resource limits for QMB and SLMB are $9,950 for individuals and $14,910 for couples (2026). These limits exclude your home, one car, and personal belongings.
Qualifying for QMB means providers cannot bill you for Medicare cost-sharing on covered services. That protection alone can be worth thousands of dollars per year.
You apply for Medicare Savings Programs through your state Medicaid agency. The application is separate from Medicare enrollment itself.
Use our free benefits screener to find out which Medicare Savings Programs you may qualify for in minutes.
Medicare Coverage Gaps Summary Table
| Service | Original Medicare Covers? |
|---|
| Routine dental cleanings, fillings, dentures | No |
| Hearing aids and routine hearing exams | No |
| Routine eye exams and eyeglasses | No (with limited exceptions) |
| Long-term custodial care (nursing home, home care) | No |
| Outpatient prescription drugs | No (requires Part D) |
| Cosmetic surgery | No |
| Care outside the United States | No (with rare exceptions) |
| Part B 20% coinsurance with no cap | Leaves gap (no OOP max) |
Frequently Asked Questions
Does Medicare cover dental implants?
No. Original Medicare does not cover dental implants, which are considered routine dental care. Some Medicare Advantage plans offer limited dental benefits, but implants are often excluded or subject to high cost-sharing even in plans that do offer dental coverage.
Does Medicare cover eye exams for glasses or contacts?
No. Medicare does not cover routine eye exams for glasses or contacts. It covers a dilated eye exam once per year for people with diabetes, and one pair of corrective lenses after cataract surgery. Everything else, including standard vision checkups, is out of pocket.
Does Medicare pay for nursing home care long-term?
No. Medicare only pays for skilled nursing facility care for up to 100 days after a qualifying 3-day hospital stay. It does not pay for custodial care, which is what most people need in a nursing home long-term. Medicaid pays for long-term nursing home care for those who qualify.
What is the 20% gap in Medicare Part B coverage?
After you meet the Part B deductible ($283 in 2026), Medicare pays 80% of the approved cost for covered services. You pay the remaining 20%. There is no annual cap on this amount under Original Medicare, so a series of expensive procedures can lead to very high out-of-pocket costs. Medigap plans or Medicare Advantage can help limit this exposure.
Can I get help paying Medicare costs if my income is low?
Yes. Medicare Savings Programs (MSPs) are state-run programs that help pay Medicare premiums, deductibles, and coinsurance for people with limited income and assets. The Qualified Medicare Beneficiary (QMB) program is the most comprehensive, covering Part A and Part B premiums and most cost-sharing. Income limits for 2026 are approximately $1,350 per month for individuals and $1,824 per month for couples, though limits vary slightly by state. Apply through your state Medicaid office or use our free screener to check eligibility.
Does Medicare cover prescriptions at a pharmacy?
Original Medicare Parts A and B do not cover most pharmacy prescriptions. You need to enroll in a Part D plan or choose a Medicare Advantage plan that includes drug coverage. Starting in 2026, the out-of-pocket cap for Part D covered drugs is $2,000 per year under the Inflation Reduction Act changes.
What is a Medigap plan and does it cover dental or vision?
Medigap (Medicare Supplement) plans are private insurance policies that fill some of the gaps in Original Medicare, mainly the deductibles and the 20% Part B coinsurance. Most Medigap plans do not cover dental, vision, hearing, or long-term care. For those, you would need separate standalone coverage or a Medicare Advantage plan.
How do I find out what Medicare Savings Programs I qualify for?
The easiest way is to use the Benefits Navigator free screener, which checks your eligibility for Medicare Savings Programs and other federal assistance programs based on your income, household size, and ZIP code. You can also contact your state Medicaid office directly or call 1-800-MEDICARE.
