Medicare pays for getting better. It does not pay for needing help.

Ask what Medicare leaves you to pay and the usual answer involves deductibles and percentages. Those are real, and this guide covers them. They are not the problem.

The problem is that federal law excludes whole categories of care from Medicare entirely, by name, in a statute. Not covered at a lower rate. Not covered after a deductible. Excluded. The list includes routine dental work, eyeglasses, hearing aids, care received outside the country, and the single largest expense many households will ever face, which is help with daily living when someone can no longer manage alone.

The organizing idea underneath the whole list is worth stating plainly, because once it is clear the exclusions stop looking arbitrary. Medicare is insurance against getting sick and getting better. It pays for treatment aimed at a diagnosis. It does not pay for the ordinary maintenance of a body, and it does not pay for someone to help you when help, rather than treatment, is what you need.

This guide is educational information. It is not legal, tax or financial advice.

Federal law excludes custodial care from Medicare. That is the statutory phrase, and the regulation defines it by what it is not: custodial care is any care that does not meet the requirements for skilled nursing facility coverage.

Help with bathing, dressing, eating, moving from a bed to a chair and using the toilet is custodial care. It is the reason the great majority of people enter a nursing home and stay in one, and outside one specific setting Medicare does not pay for it at any point, for any length of time, at any age.

That setting is hospice. The statute excludes custodial care except where it is necessary for the palliation or management of a terminal illness, so personal care of exactly the kind excluded everywhere else is covered as part of an elected Medicare hospice benefit. It is worth knowing, because families reading that custodial care is never covered sometimes conclude there is no help available at the very end.

What Medicare does pay for, and the four conditions on it

Medicare covers a stay in a skilled nursing facility only when every one of these holds:

• A hospital stay of at least three consecutive calendar days as an admitted inpatient, not counting the day of discharge. Limited waivers of this requirement exist for people enrolled in certain Medicare Advantage plans and in some accountable care arrangements, so it is worth asking whether one applies rather than assuming it does not.
• Care that requires skilled nursing or skilled rehabilitation, meaning services that need a nurse or a therapist rather than an aide.
• Those skilled services needed on a daily basis.
• Treatment for a condition connected to the hospital stay, or one that arose while being treated for it.

When all four hold, coverage runs up to 100 days in a benefit period. Medicare pays in full for the first 20. From day 21 through day 100 there is a daily coinsurance, which in 2026 is $217 a day. That works out to roughly $17,360 across those 80 days, paid by the patient or by a supplemental policy. After day 100 Medicare pays nothing.

The daily requirement has a precise meaning. Skilled nursing or skilled rehabilitation has to be needed and provided seven days a week, with one exception: where skilled rehabilitation is not available seven days a week, five days a week is enough.

The three day requirement counts days as an admitted inpatient. A hospital can also place a patient under observation, which is classified as outpatient care even though the person is in a hospital bed, wearing a gown, eating hospital food and being seen by hospital staff.

Nothing at the bedside distinguishes the two. The difference is an administrative classification, made and sometimes changed by the hospital, and it has two consequences.

• Observation days do not count toward the three inpatient days that unlock nursing facility coverage. Someone who spends four nights in a hospital under observation and is then discharged to a nursing facility has no Medicare coverage for that facility at all.
• Observation is billed under Part B rather than Part A, which changes the cost sharing and can leave medications given during the stay billed separately.

Hospitals are required to give written notice to a patient who has been receiving observation services for more than 24 hours, explaining that they are an outpatient and what that means. The notice arrives during the stay, which is exactly when someone is least able to act on it, but it is the moment when asking the question still has value.

Routine dental care, eyeglasses and hearing aids are excluded by name in the federal statute. Each exclusion has an edge, and the edges are where the money is.

Dental

The exclusion covers care, treatment, filling, removal or replacement of teeth and the structures directly supporting them. Cleanings, fillings, extractions, dentures and implants sit outside Medicare. The carve-out is for inpatient hospital services connected to a dental procedure where hospitalization is required because of the patient's underlying medical condition or the severity of the procedure. The hospital stay can be covered while the dental work itself is not.

Eyes

Eyeglasses are excluded, as are eye examinations for the purpose of prescribing or fitting them and any procedure done to determine the refractive state of the eye. The exclusion holds even when the refraction happens during an otherwise covered examination. There is one clear exception: after cataract surgery in which an intraocular lens is inserted, one pair of conventional eyeglasses or contact lenses is covered.

Medical eye disease is a separate matter. Treatment for glaucoma, macular degeneration or diabetic retinopathy is treatment of an illness, and that is what Medicare insures.

Ears

Hearing aids are excluded, and so are the examinations done to prescribe or fit them. The exclusion is written to cover air conduction and bone conduction devices, meaning anything that amplifies sound toward a working cochlea. Devices that replace the function of the middle ear, the cochlea or the auditory nerve are outside the exclusion, so cochlear implants and osseointegrated implants can be covered. A diagnostic hearing test ordered by a doctor to investigate a medical problem is also different from a fitting test.

The statute excludes items and services not provided within the United States. For a program this large the rule is remarkably blunt: care received abroad is not covered, whether it was an emergency, whether the traveler was insured for forty years, and whether the treatment would have been fully covered at home.

The exceptions exist but are narrow. They involve inpatient hospital care in specific circumstances, principally where a foreign hospital was closer than any American one during an emergency, or where a foreign hospital is the nearest available to a residence in the United States. Physician and ambulance services connected to such an inpatient stay can follow it. None of that describes an ordinary trip abroad.

Two related exclusions are worth naming here because they surprise people in the same way. Medicare does not pay charges imposed by an immediate relative of the patient, so a family member who gives up work to provide care cannot be paid by Medicare for doing it. And it does not pay for cosmetic surgery, except where required for the prompt repair of an accidental injury or to improve the functioning of a malformed body part.

Medicare does have a home health benefit, and it is genuinely useful. It is also narrower than almost anyone expects, in three specific ways.

To qualify at all, the patient must be confined to the home, must be under the care of a physician or an allowed practitioner working from a plan of care, and must need skilled nursing or therapy. Then comes the limit that matters: the skilled nursing care has to be provided on a part-time or intermittent basis. The benefit is built around a nurse or a therapist arriving, doing something that requires their training, and leaving.

What it does not cover is someone being there. Round the clock care at home, meal delivery, homemaker services and help with bathing and dressing when that is the only care needed all sit outside the benefit.

The regulation contains one sentence that explains the whole design, and it is worth reading twice. If a service could be performed by an average person without medical training, the absence of anyone available to perform it does not make that service skilled.

Almost every insurance policy sold in the United States has an annual out-of-pocket maximum, a figure above which the plan pays everything. Original Medicare does not have one. There is no number, at any income, at which the patient's share stops.

The pieces that make up that share in 2026:

Two of those lines do more damage than their size suggests. The hospital deductible is charged per benefit period rather than per year, and a benefit period restarts after a long enough gap out of hospital and nursing care, so two separate admissions in one year can each carry the full amount. And the 20 percent under Part B has nothing above it, so 20 percent of a long course of treatment is an open figure.

The first four are for a hospital stay that is happening now. The rest are for the quieter time before one.

• During any hospital stay, ask whether the patient is an admitted inpatient or under observation, and ask again every day.
• If a nursing facility is being discussed at discharge, ask the case manager to confirm the number of inpatient days in writing before the transfer.
• Count the days yourself. Three consecutive calendar days as an inpatient, not counting the day of discharge.
• If coverage is ending because skilled care is no longer needed daily, ask for that decision in writing, which is what an appeal is built on.
• If the reason given is that the patient is not improving, say plainly that maintenance care is covered and ask for the decision to be reviewed. Improvement is not the standard.
• If home health is refused or ended, ask which of the three conditions was not met: confined to the home, under a plan of care, or needing skilled care. The answer tells you whether an appeal has anywhere to go.
• Write down what the household would do if one person needed help with daily living for two years. Medicare is not part of that answer, so something else has to be.
• Check whether existing supplemental coverage includes a foreign travel emergency benefit before booking a trip abroad.
• Budget dental, vision and hearing separately from health cover. They are not gaps in the insurance, they are outside it.
• After cataract surgery with a lens implant, claim the one pair of glasses that is covered. It is easy to miss.

Custodial care, foreign care, cosmetic surgery, eyeglasses, hearing aids and relatives' charges are excluded by statute
42 U.S.C. 1395y(a), subsections (4), (7), (9), (10) and (11). Retrieved September 5, 2026.

The regulatory exclusion list, including the cataract eyeglass exception and the cochlear implant carve-out
42 CFR 411.15. Retrieved September 5, 2026.

Three consecutive inpatient days, not counting the day of discharge
42 CFR 409.30(a)(1). Retrieved September 5, 2026.

Skilled services must be needed on a daily basis
42 CFR 409.31(b). Retrieved September 5, 2026.

What "daily basis" means: seven days a week, or five where rehabilitation is not available seven
42 CFR 409.34(a). Retrieved September 5, 2026.

Therapy to maintain function or slow deterioration must be covered, so improvement is not the test
42 CFR 409.44(c). Retrieved September 5, 2026.

Written notice after more than 24 hours of observation services
42 CFR 489.20(y). Retrieved September 5, 2026.

Up to 100 days per benefit period, first 20 paid in full, coinsurance for days 21 to 100
42 CFR 409.61. Retrieved September 5, 2026.

Home health requires being confined to the home and under a plan of care
42 CFR 409.42. Retrieved September 5, 2026.

Home health nursing must be part-time or intermittent, and a service an untrained person could do is not skilled merely because nobody is there to do it
42 CFR 409.44(b). Retrieved September 5, 2026.

2026 amounts: Part A deductible $1,736, hospital coinsurance $434 and $868, nursing facility coinsurance $217, Part B premium $202.90, Part B deductible $283
Centers for Medicare and Medicaid Services, 2026 Medicare Parts A and B Premiums and Deductibles. Retrieved September 5, 2026.