Medicare and Medicaid have different network rules, and they work in opposite ways

Medicare has networks. Medicaid usually does not — or has much looser ones. This is the single biggest difference between how the two programs connect you to doctors.

With Medicare, you pick a plan (Original Medicare or a private plan called Medicare Advantage), and that plan has a network of doctors and hospitals it pays. If you go to someone outside the network, you pay more or the plan refuses to pay at all. You need to check the network before you schedule.

With Medicaid, most states let you see any doctor who accepts Medicaid, period. There is no list to check. The doctor either takes Medicaid or does not. A few states run Medicaid like a managed care plan with networks, but even then the networks are usually wider than Medicare's. You do not have to pick a plan first and then find doctors inside it — you find a doctor who takes Medicaid and go.

Key Takeaways

  • Medicare requires you to choose a plan with a specific network, and going outside that network costs you significantly more money.
  • Medicaid in most states has no network at all — you can see any doctor or hospital that accepts Medicaid, without picking a plan first.
  • A small number of states run Medicaid through managed care plans that do use networks, but those networks are typically broader than Medicare networks.
  • Before scheduling a Medicare appointment, always check whether the doctor is in your plan's network; with Medicaid, you only need to confirm the provider accepts Medicaid.

How Medicare networks actually work

If you have Original Medicare (the federal program run directly by the Centers for Medicare & Medicaid Services), there is no network. You can see any doctor in the United States who accepts Medicare, and Medicare pays its share. The doctor bills Medicare directly.

If you have a Medicare Advantage plan (a private insurance plan that replaces Original Medicare), that plan has a network. The plan publishes a list of in-network doctors, hospitals, and specialists. When you see an in-network provider, you pay your copay or coinsurance and the plan pays the rest. When you see an out-of-network provider, you either pay the full bill yourself or the plan pays nothing — it depends on the plan and whether it is an emergency.

Medicare Advantage networks vary by plan and by region. A large network in one county might be tiny in the next county over. You have to check the specific plan's directory before you book an appointment. The plan's website or customer service line can tell you whether a particular doctor is in or out of network.

How Medicaid networks work (or do not)

In most states, Medicaid has no network at all. You do not pick a plan. You simply find a doctor or hospital that accepts Medicaid and make an appointment. Medicaid pays its share; you pay your share (usually nothing, or a small copay). The provider bills Medicaid directly.

This means you have more freedom with Medicaid than with Medicare Advantage — you are not locked into a list of approved doctors. But it also means you have to call ahead and confirm that a provider actually accepts Medicaid. Many doctors accept Medicare but not Medicaid, or accept Medicaid but have stopped taking new patients. Acceptance is not automatic.

A handful of states — including New York, California, and Florida — run Medicaid through managed care plans that do use networks. Even in those states, the networks are usually much wider than Medicare Advantage networks, and you may have the option to see an out-of-network provider without a referral. Check your state's Medicaid website or your plan documents to see whether your state uses managed care networks.

What to do before you schedule an appointment

With Medicare Advantage, always check the plan's network directory first. Call the plan's customer service number (on your insurance card) or search the plan's website. Ask whether the specific doctor is in network. If the doctor is out of network and it is not an emergency, you will pay more or the plan will not pay at all.

With Medicaid, call the doctor's office directly and ask: "Do you accept Medicaid?" If they say yes, ask whether they are taking new patients. That is usually all you need to do. If your state runs Medicaid through managed care, you may also want to check whether the doctor is in your plan's network, but being out of network is usually less of a penalty than it is with Medicare.

If you have both Medicare and Medicaid (called "dual may be able to access"), the rules are more complex. Medicaid is the secondary payer, which means Medicare pays first. You still need to check both programs' rules before you schedule. Your state's Medicaid office or a local Area Agency on Aging can walk you through this.

Why the difference exists

Medicare Advantage plans use networks because they are private insurance companies trying to control costs. By steering you to certain doctors and hospitals, they negotiate lower prices and manage how much they spend.

Medicaid does not use networks in most states because Medicaid is designed to cover low-income people, and the program prioritizes access over cost control. Forcing people to pick a plan and then find doctors inside it creates a barrier. Letting people see any Medicaid-accepting provider is simpler and reaches more people.

States that do run Medicaid through managed care plans usually do so to try to control spending, similar to Medicare Advantage. But even in those states, the law often requires the plans to cover out-of-network care in certain situations, like emergencies or when a service is not available in network.

What happens if you see an out-of-network provider

With Medicare Advantage, the consequences depend on your plan. Some plans charge you a higher copay or coinsurance for out-of-network care. Some plans do not cover out-of-network care at all, except in emergencies. A few plans cover out-of-network care at the same rate as in-network care. Read your plan's Summary of Benefits and Coverage document to know your plan's rule.

With Medicaid, if you see a provider who does not accept Medicaid, Medicaid will not pay. You will owe the full bill. If you see a provider who accepts Medicaid but is out of network (in a state that uses managed care), your plan may still pay, though you might pay a higher copay. Call your plan before you go to confirm.

In an emergency, both Medicare Advantage and Medicaid will usually pay for out-of-network emergency care. But do not assume — call your plan or Medicaid office as soon as you can after the emergency to report it and confirm coverage.

Finding doctors who accept your coverage

For Medicare, use the Medicare Provider Search tool on Medicare.gov. You can search by name, location, or specialty. The tool tells you whether the provider accepts Medicare and whether they are accepting new patients.

For Medicaid, your state's Medicaid website usually has a provider directory. You can also call your state's Medicaid customer service line (the number is on your Medicaid card) and ask for a list of doctors in your area who accept Medicaid. Some states' directories are easier to use than others — if you get stuck, call 211 (a free referral line) and ask for help finding a Medicaid provider.

If you have both Medicare and Medicaid, start with the Medicare provider search. Then call the doctor's office and confirm they accept Medicaid as well. This ensures you are covered by both programs.

Frequently Asked Questions

Can I see any doctor I want with Medicaid?

In most states, yes — as long as the doctor accepts Medicaid. You do not have to pick a plan first. In a few states that run Medicaid through managed care, you do pick a plan, but the networks are usually broad and you may be able to see out-of-network doctors. Call your doctor's office and ask if they accept Medicaid.

Do I have to stay in my Medicare Advantage network?

No, but it costs you more. In-network providers cost you a copay or coinsurance. Out-of-network providers either cost you much more or are not covered at all, depending on your plan. Emergencies are usually covered out of network. Check your plan documents or call customer service before you schedule.

What if my doctor is in my Medicare network but not my Medicaid network?

If you have both programs, call the doctor's office and ask them to confirm they accept both Medicare and Medicaid. Many doctors accept one but not the other. If they accept only Medicare, you can still see them, but Medicaid will not pay its share.

How do I know if my state's Medicaid uses networks?

Check your state's Medicaid website or call the customer service number on your Medicaid card. They can tell you whether your state uses managed care plans with networks. Even if it does, you usually have the option to see an out-of-network provider — ask about your specific plan's rules.

What do I do if a doctor says they do not accept Medicaid anymore?

Call your state's Medicaid office or use the state's provider directory to find another doctor who does accept Medicaid. If you have been seeing this doctor for a while, ask the Medicaid office whether they can help you transition to a new provider or whether there are any exceptions.