In most cases, hospice care in New York is fully covered by Medicare, Medicaid, or VA benefits, with little to no cost to the patient or family. Private insurance and self-pay are also options, but the vast majority of hospice patients are covered through one of these government programs. Here’s how each payer works and what, if anything, you’d owe out of pocket.
Medicare Covers Nearly Everything
Medicare Part A is the most common payer for hospice care nationwide, and it covers hospice in New York at no cost to the patient when you use a Medicare-approved hospice provider. To qualify, two doctors (your hospice physician and your regular doctor) must certify that you have a terminal illness with a life expectancy of six months or less. You also agree to shift your care goals from curative treatment to comfort care, and you sign a statement formally electing the hospice benefit.
Once enrolled, you pay nothing for the core hospice services: nursing visits, pain management, medical equipment, counseling, and home health aides. There are only two small exceptions. Prescription drugs for pain and symptom control carry a copay of up to $5 per medication. And if you use inpatient respite care, which is a short facility stay so your caregiver can rest, you may pay 5% of the Medicare-approved amount for that stay.
One important gap: Medicare does not cover room and board. If you’re receiving hospice at home, this isn’t relevant. But if you live in a nursing home, Medicare pays for the hospice services themselves while the nursing home’s room and board charges remain a separate bill. That cost typically falls to Medicaid, private insurance, or the patient.
New York Medicaid Fills Key Gaps
New York’s Medicaid program covers hospice care and, in some ways, is more generous than Medicare. The medical eligibility threshold is slightly broader: a physician and the hospice medical director must certify a life expectancy of fewer than twelve months per benefit period, compared to Medicare’s six-month standard. As with Medicare, the patient must voluntarily elect hospice care, which means forgoing curative treatment for the terminal illness.
Medicaid covers the same core services Medicare does, plus a few extras. The covered list includes nursing, physician services, social work, home health aides, homemaker services, physical and occupational therapy, speech therapy, medical supplies, nutrition counseling, spiritual and bereavement counseling, psychological services, audiology, respiratory therapy, and pharmaceutical and laboratory services. That’s a wide net designed to address comfort from every angle.
The biggest financial difference is room and board. Unlike Medicare, New York Medicaid reimburses room and board charges for patients receiving hospice care in a skilled nursing facility or hospice residence. For patients who are dually eligible for both Medicare and Medicaid, this is a critical benefit. Medicare pays for the hospice services, and Medicaid picks up the room and board that Medicare won’t cover.
Since October 2013, hospice services for most Medicaid enrollees in New York are managed through Medicaid managed care organizations rather than paid directly by the state on a fee-for-service basis. If you’re enrolled in a managed care plan, your plan is responsible for covering hospice. This shouldn’t change what services you receive, but it does mean your managed care plan coordinates the benefit.
VA Hospice Care Has No Copays
Veterans enrolled in the VA health care system can receive hospice care with zero copays. Hospice is part of the VA’s standard medical benefits package, so any enrolled veteran who meets the clinical criteria (terminal illness, life expectancy of six months or less, comfort-focused care) is eligible. It doesn’t matter whether the VA provides the care directly or contracts with an outside hospice organization. Either way, the veteran pays nothing.
Private Insurance and Self-Pay
New York State recognizes private insurance as a valid payment source for hospice care. Many commercial health plans in New York do include a hospice benefit, though the specifics (covered services, length of benefit, copays) vary by plan. If you or a family member has private insurance, contact the plan directly to confirm what’s covered and whether there’s a network of preferred hospice providers.
Self-pay is an option for patients without insurance coverage, though it’s relatively uncommon given how broadly Medicare and Medicaid apply. Many nonprofit hospice organizations in New York also offer charitable care or sliding-scale fees for uninsured patients.
Special Rules for Children
New York has an important exception for patients under 21. Normally, electing hospice means giving up curative treatment for your terminal illness. But since March 2010, New York Medicaid covers all medically necessary curative services for children under 21 who are also enrolled in hospice. This “concurrent care” rule applies across Medicaid managed care, Family Health Plus, and Child Health Plus. It means a child can receive both aggressive treatment and hospice comfort care at the same time, without the family having to choose one over the other.
What You’ll Actually Pay Out of Pocket
For most families in New York, hospice care costs little or nothing. Here’s a quick breakdown of the potential charges:
- Medicare patients: Up to $5 per prescription for symptom-related drugs, and 5% coinsurance for inpatient respite stays. Everything else is covered.
- Medicaid patients: Typically no out-of-pocket costs. Medicaid even covers room and board in nursing facilities and hospice residences.
- Dual-eligible patients (Medicare and Medicaid): Medicare covers hospice services, Medicaid covers room and board. The small Medicare copays may also be covered by Medicaid.
- Veterans: No copays for any hospice services.
- Private insurance: Varies by plan. Review your policy’s hospice benefit section or call your insurer.
The cost that catches families off guard is room and board for patients in nursing homes. If someone on Medicare (without Medicaid) is living in a nursing facility and elects hospice, Medicare pays the hospice team but not the facility’s daily room charge. That bill continues, and it needs to be covered by Medicaid, long-term care insurance, or the family. For patients receiving hospice at home, this issue doesn’t apply.