Medicare and Medicaid use networks differently, and the difference matters for your costs

Medicare has networks, but they work differently depending on which type of Medicare you choose. Original Medicare (Parts A and B) has no network — you can see any doctor or hospital in the United States that accepts Medicare, which most do. Medicare Advantage plans (Part C) do have networks, similar to private insurance: you pay less when you see doctors in the plan's network and more (or nothing is covered) when you go out of network.

Medicaid always has a network. Your state Medicaid program contracts with specific doctors, hospitals, and clinics. You must use those providers to get full coverage. If you see someone outside the network without a referral, you may have to pay the full bill yourself, though some states allow out-of-network care in emergencies.

The network rules also depend on whether you are on Medicaid alone, Medicare alone, or both (called "dual may be able to access"). If you are dual may be able to access, you may be enrolled in a special plan that coordinates both programs, and that plan will have its own network.

Key Takeaways

  • Original Medicare (Parts A and B) has no network — you can see any Medicare-accepting provider anywhere in the country.
  • Medicare Advantage plans have networks like private insurance, and you pay more or nothing is covered if you see out-of-network doctors without a referral.
  • Medicaid always has a network set by your state, and you must use in-network providers to avoid paying out of pocket.
  • If you are on both Medicare and Medicaid, you may be in a special dual-may be able to access plan with its own network rules.
  • You can ask your doctor or call your plan to confirm whether a provider is in network before your visit.

How Original Medicare avoids networks

Original Medicare does not restrict you to a list of doctors or hospitals. Any provider who accepts Medicare can treat you, and you pay the same amount no matter which one you choose (as long as they accept assignment, meaning they accept Medicare's payment as full payment for that service). This is one of the main reasons some people prefer Original Medicare — there is no prior authorization, no referral requirement, and no penalty for seeing a specialist without going through a primary care doctor first.

The trade-off is that you pay a deductible and coinsurance for each service. You also have no out-of-pocket maximum, so very high medical bills can cost you more than someone on a Medicare Advantage plan with a network and a yearly cap on costs.

Medicare Advantage plans and their networks

If you choose a Medicare Advantage plan (Part C), you are getting a network-based plan run by a private insurance company. Each plan publishes a list of in-network doctors, hospitals, and specialists. When you see someone in the network, you pay a copay or coinsurance. When you see someone outside the network, you typically pay the full cost yourself, unless it is an emergency or you have a referral from your primary care doctor.

Most Medicare Advantage plans require you to pick a primary care doctor and get referrals to see specialists. Some plans are HMOs (Health Maintenance Organizations), which have stricter networks. Others are PPOs (Preferred Provider Organizations), which allow you to see out-of-network doctors at a higher cost. A few are POS plans (Point of Service), which combine both approaches.

You can look up whether a specific doctor is in your plan's network by calling the plan or visiting its website. Many plans also have a provider search tool online. It is worth checking before your first visit, because the network can change during the year.

Medicaid networks and how they vary by state

Medicaid is run by each state, so the network rules are different in every state. Some states use managed care, meaning your Medicaid is run by a private insurance company under contract with the state, and that company has a network. Other states use fee-for-service Medicaid, where the state pays providers directly and the network is broader (though still not unlimited).

In managed care states, you may have to choose a Medicaid plan when you enroll, or one may be assigned to you. That plan has a network of doctors and hospitals. If you see someone outside the network without permission, you pay the bill. Some states allow emergency out-of-network care without penalty, but you should check your state's rules.

You can find out which Medicaid model your state uses by calling your state Medicaid office or visiting its website. The office name varies by state — it might be called the Department of Health and Human Services, the Department of Social Services, or something similar. Your Medicaid card should have a phone number on the back.

What to do if your doctor is not in network

If you are on a Medicare Advantage plan or managed care Medicaid and your doctor is not in the network, you have a few options. First, ask your doctor if they will accept your plan. Some doctors are in the network but the plan's directory is out of date. Second, ask your plan if they will make an exception and cover the out-of-network visit. Plans sometimes do this if there is no in-network specialist available for your condition.

Third, you can switch plans. If you are on Medicare Advantage, you can switch during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event. If you are on Medicaid, the timing depends on your state — some allow changes any time, others only during open enrollment.

If you are on Original Medicare, this is not a problem: your doctor does not have to be in a network because there is no network.

Dual-may be able to access plans and their networks

If you are on both Medicare and Medicaid (called "dual may be able to access"), you may be enrolled in a special plan that covers both programs. These plans are called D-SNPs (Dual-may be able to access Special Needs Plans) or integrated plans. They have their own networks, which may be different from either a regular Medicare Advantage plan or your state's Medicaid network.

A dual-may be able to access plan's network includes doctors and hospitals that accept both Medicare and Medicaid. This can be narrower than either program alone, because not all providers accept Medicaid. Before you enroll in a dual-may be able to access plan, check whether your current doctors are in the plan's network. If they are not, you may want to stay on Original Medicare and your state's Medicaid instead.

Questions to ask your doctor or plan about networks

Before your visit, call your doctor's office and ask: "Do you accept [name of my plan]?" or "Are you in network for my Medicare Advantage plan?" If the answer is unclear, call your plan directly. Have your member ID card ready.

If you are on Medicaid, ask your Medicaid plan or your state Medicaid office for a current provider directory. Do not rely on an old list, because networks change. If you are on Original Medicare, you can still call ahead to confirm that the provider accepts Medicare assignment, which means they will not bill you more than Medicare allows.

Frequently Asked Questions

Can I see any doctor on Original Medicare?

Yes, as long as they accept Medicare. Most doctors do. You do not need a referral and there is no network. However, you pay a deductible and coinsurance for each service, and there is no yearly cap on your out-of-pocket costs.

What happens if I see a doctor outside my Medicare Advantage network?

You typically pay the full bill yourself. Some plans cover emergency out-of-network care. Call your plan before the visit to ask whether they will cover it, or ask your doctor to get a referral from your primary care doctor, which may allow out-of-network coverage.

Does Medicaid cover out-of-network doctors?

It depends on your state and your plan. Managed care Medicaid plans usually do not cover out-of-network care unless it is an emergency. Fee-for-service Medicaid is broader. Call your state Medicaid office or your plan to find out your state's rules.

How do I learn about my doctor is in my plan's network?

Call your plan's customer service number (on your member ID card) or visit the plan's website and use the provider search tool. You can also call your doctor's office and ask directly. Check before your first visit, because networks change.

If I am dual may be able to access, which network do I use?

If you are in a dual-may be able to access plan, you use that plan's network. If you are on Original Medicare and your state's Medicaid separately, you follow Original Medicare's rules (no network) for Medicare and your state's Medicaid network for Medicaid services.