When Linda and Jim Kowalski retired in 2022, they figured Medicare would handle the heavy lifting on medical bills. Within two years, Jim needed daily help bathing and dressing after a stroke, and Linda learned that the three crowns her dentist recommended would run more than $4,500 out of pocket. Original Medicare covered neither.
Their story is far from unusual. A 65-year-old couple retiring in 2024 can expect to spend roughly $373,000 on out-of-pocket health care over the course of their retirement, based on projections that combine Fidelity Investments’ annual Retiree Health Care Cost Estimate with long-term care cost data. Fidelity’s 2024 estimate puts lifetime medical expenses at $165,000 per person, or $330,000 per couple, covering Medicare premiums, deductibles, copays, and prescription drugs but explicitly excluding long-term care. Once custodial care costs are layered in, the total for many households climbs well into the mid-six figures.
The two biggest cost drivers sitting outside that Fidelity number, long-term custodial care and routine dental work, fall almost entirely beyond Original Medicare’s benefit structure. For the roughly 34 million Americans still enrolled in traditional fee-for-service Medicare, according to CMS enrollment data, understanding those gaps is not optional. It is the difference between a secure retirement and a financial crisis.
What Original Medicare actually covers
Original Medicare has two parts. Part A covers inpatient hospital stays, skilled nursing facility care (up to 100 days following a qualifying three-day hospital stay), hospice, and some home health services. Part B covers outpatient care, doctor visits, preventive screenings, lab work, durable medical equipment, and an Annual Wellness Visit. Together, they form the backbone of federal health coverage for Americans 65 and older.
But the program was designed in 1965, and its benefit structure still reflects mid-century assumptions about what “medical care” means. As the Medicare.gov overview spells out, Original Medicare does not cover long-term custodial care, routine dental work, dentures, most vision care, or hearing aids. These are not minor omissions. They represent some of the most expensive and most common needs people face after 65.
The long-term care gap
Long-term custodial care, the kind of daily help with bathing, dressing, eating, and transferring that millions of older Americans eventually need, is the single largest uncovered risk in retirement. A dedicated Medicare.gov page on long-term care states plainly that Medicare and most health insurance plans, including Medigap supplemental policies, “don’t pay for this type of care.”
The price tag is staggering. The Genworth Cost of Care Survey, the most comprehensive national dataset on long-term care pricing, found in its most recent edition that the national median cost of a private room in a nursing home was $9,733 per month, or nearly $117,000 a year. A home health aide averaged $6,292 per month. Those figures have only risen since, driven by labor shortages and inflation in the care sector.
The likelihood of needing that care is higher than most people assume. The Administration for Community Living, part of the U.S. Department of Health and Human Services, estimates that about 56% of Americans turning 65 today will need some form of long-term care services during their remaining years. Roughly one in five will need care for longer than five years.
Without Medicare coverage, the bill falls on one of three sources: personal savings, private long-term care insurance (which fewer insurers offer and fewer consumers purchase each year), or Medicaid. Medicaid does cover long-term care, but only for people who meet strict income and asset limits that vary by state. For many middle-income retirees, qualifying means spending down nearly everything they have saved. And there is a catch many families do not learn about until it is too late: under federal law, states can pursue estate recovery, seeking reimbursement from a deceased beneficiary’s estate for Medicaid-funded long-term care costs.
The dental exclusion
Dental coverage follows the same pattern. Guidance from the Centers for Medicare & Medicaid Services confirms that Medicare generally excludes dental services, including “the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth.” Only narrow exceptions apply, typically when dental work is medically necessary as part of another covered procedure, such as jaw reconstruction after an accident or dental clearance before an organ transplant.
Routine cleanings, fillings, crowns, root canals, and dentures all fall outside the standard benefit. That leaves retirees to pay cash, buy a standalone dental plan, or skip care altogether. The consequences of skipping can be serious. A 2020 systematic review published in the Journal of the American Heart Association found that periodontitis was independently associated with increased risk of cardiovascular events. Untreated oral infections can also lead to emergency hospitalizations that Medicare does end up paying for, an irony that health policy researchers have flagged for years.
Legislative efforts to add a comprehensive dental benefit to Medicare have stalled repeatedly. A provision in the 2021 Build Back Better Act would have phased in dental, vision, and hearing coverage under Part B, but it was stripped from the final Inflation Reduction Act signed in August 2022. As of June 2026, no comparable proposal has advanced to a floor vote in either chamber of Congress.
What about Medicare Advantage?
More than 33 million Medicare beneficiaries, roughly half of all enrollees, have opted for Medicare Advantage (Part C) plans run by private insurers. These plans must cover everything Original Medicare covers, and most layer on supplemental benefits: routine dental, vision, hearing, and sometimes limited allowances for in-home support services.
But Medicare Advantage does not close the gaps as fully as many enrollees expect. Dental benefits in Advantage plans are frequently capped at $1,000 to $2,500 per year, well below the cost of major restorative work like crowns, bridges, or implants. And while some plans have introduced modest stipends for personal care hours, true long-term custodial care, the kind that runs $6,000 to $10,000 a month for years, remains largely uncovered even in the most generous Advantage offerings. Enrollees also face network restrictions and prior authorization requirements that do not apply under Original Medicare, which can limit access to specialists and delay treatment.
How to plan around the gaps
Retirement planning specialists say the most important step is confronting these gaps early, ideally a decade or more before leaving the workforce. Several strategies can help reduce exposure:
- Medigap (Medicare Supplement) policies cover Part A and Part B cost-sharing, including deductibles and coinsurance, but they do not cover long-term care or dental. They are most useful for controlling predictable out-of-pocket medical costs and protecting against large hospital bills.
- Standalone dental plans are available through the Medicare marketplace and private insurers. Annual benefit caps are typically modest, but these plans can offset the cost of preventive care and basic procedures, reducing the chance that small problems become expensive ones.
- Long-term care insurance remains the most direct way to cover custodial care, but premiums have risen sharply over the past decade and fewer carriers still offer traditional policies. Hybrid products that combine life insurance with long-term care riders have gained traction as an alternative, though they require a significant upfront premium or lump-sum payment.
- Health Savings Accounts (HSAs) allow tax-free accumulation and withdrawal for qualified medical expenses. The catch: contributions are only permitted while enrolled in a high-deductible health plan, which means the funding window closes when Medicare enrollment begins at 65. Workers who start maximizing HSA contributions in their 50s can build a meaningful reserve.
- Dedicated savings targets built into retirement plans can earmark funds specifically for health care. Even if the $373,000 projection does not match every household’s experience, using it as a planning benchmark helps avoid the most common and most costly mistake: assuming Medicare will cover everything.
Why this number should change how you plan
Any single estimate of lifetime health care costs in retirement is, by nature, an average built on assumptions about inflation, longevity, and patterns of illness. A couple that stays healthy into their late 80s may spend far less. A pair of retirees who face dementia, repeated hospitalizations, and years in assisted living could spend far more. Fidelity’s model, the most widely cited in the financial planning industry, is updated annually using actuarial data, but it remains a projection, not a bill.
What the $373,000 figure communicates reliably is the scale of the risk. Federal sources confirm that Original Medicare excludes long-term custodial care and routine dental services. Cost data, even imperfect cost data, shows that those exclusions can translate into six-figure exposure over a 20- to 30-year retirement. The gap between what retirees expect Medicare to cover and what it actually pays for remains one of the most consequential blind spots in American financial planning.
The Inflation Reduction Act’s drug price provisions, which began capping out-of-pocket Part D costs at $2,000 per year in 2025, have eased one piece of the burden. But they do nothing for the two largest uncovered categories. Long-term care and dental remain squarely on the retiree’s tab.
For the Kowalskis and millions of couples like them, the lesson arrived after the bills did. For those still working and still planning, the lesson is available now, and the math is hard to ignore.
David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
