The Medicare gap checklist
Medicare leaves real holes. Each hole has a WA program that fills it, and most families never apply. This is the working list.
6 minute read. Last reviewed 2026-06-14.
Medicare is not full coverage. It pays for hospital and doctor visits with copays, and a separate Part D plan covers prescription drugs, but it leaves out long-term care, dental, hearing, vision, and a long list of out-of-pocket costs that add up fast on a fixed income. Washington has a program for almost every gap. The hard part is knowing which program fills which gap, and that the parent has to apply. This is a working checklist. Walk down the list, find the gaps that match your parent's situation, and click through to the WA program that covers it.
What to do
Each entry is one thing Medicare does not fully cover, and the WA program that fills it.
- Step 1The Part B premium
Medicare deducts about $202.90 a month from Social Security for Part B in 2026. WA's Medicare Savings Programs (QMB, SLMB, QI) pay this premium for eligible seniors. QMB also wipes out Part A and B copays. Income limits run from $1,483 a month for QMB up to $1,855 a month for QI. WA does not count assets the way other states do. See /programs/medicare-savings-program.
- Step 2Prescription drug copays and the Part D deductible
Even with a Part D plan, drugs add up. Extra Help (Low-Income Subsidy, LIS) wipes out the Part D deductible and caps standard copays at $5.10 for generics and $12.65 for brand drugs in 2026. Members who also have Medicaid or QMB pay no more than $4.90 per covered drug. Income limit is roughly $1,995 a month for a single senior. Apply at ssa.gov/extrahelp. See /programs/medicare-extra-help-lis.
- Step 3In-home personal care
Medicare does not pay for help with bathing, dressing, meals, or other day-to-day tasks at home. WA Medicaid does, through the COPES waiver. Financial rules are more generous than basic Medicaid, and in many cases a family member can be the paid aide. A free CARE assessor visits the home to rate need. See /programs/copes-waiver.
- Step 4Long-term residential care
Medicare covers only short-term skilled nursing after a hospital stay (up to 100 days with copays from day 21). For ongoing assisted living or nursing facility care, WA Apple Health (Medicaid) covers eligible seniors. The Medically Needy program offers a spenddown path for those whose income is just over the regular limit. See /programs/apple-health-medically-needy.
- Step 5Adult dental
Original Medicare does not cover routine dental. WA Apple Health (Medicaid) does, for adults. Cleanings, fillings, extractions, root canals on front teeth, and dentures are all covered. DentistLink at 1-844-888-5465 connects Apple Health adults to a participating dentist. See /programs/apple-health-classic-medicaid.
- Step 6Hearing aids and vision
Original Medicare does not cover hearing aids or routine vision exams and glasses. WA Apple Health covers both for adults. Some Medicare Advantage plans also include these as supplemental benefits, check your plan. SHIBA can help compare what each plan actually covers.
- Step 7Fitness and falls prevention
Medicare does not pay for a gym membership. Some Medicare Advantage plans bundle SilverSneakers or Renew Active. WA also funds free senior fitness and balance classes through every Area Agency on Aging, including EnhanceFitness and A Matter of Balance. See /programs/enhancefitness and /programs/a-matter-of-balance.
- Step 8Transportation to medical appointments
Medicare does not cover transportation to a routine doctor visit. WA Apple Health covers non-emergency medical transportation (NEMT) for enrolled members. Some Medicare Advantage plans include a ride credit. ORCA LIFT, reduced-fare transit, and county volunteer driver programs cover the rest. See /benefits/help_paying_care.
- Step 9Caregiver support for the family
Medicare pays nothing for the family member doing the caring. WA's Family Caregiver Support Program (FCSP) funds respite, training, counseling, and equipment. Worker caregivers can also use WA Paid Family and Medical Leave to take paid time off. See /programs/family-caregiver-support-program and /programs/wa-paid-family-medical-leave.
When to bring in a professional
When the gap is bigger than this checklist can carry.
Talk to a SHIBA counselor before signing up for or switching a Medicare plan. SHIBA is free, statewide, and not selling insurance. If a Medicare claim was denied, or a hospital bill arrived that should not have, the WA legal aid hotline CLEAR Sr can connect a free attorney. Both lines below.
- SHIBA (Statewide Health Insurance Benefits Advisors)
Free Medicare counseling. Phone, video, or in person. Run by the WA Office of the Insurance Commissioner.
- CLEAR Sr (Northwest Justice Project)
Free legal help for any WA resident age 60 plus, including Medicare denials and surprise medical bills.