Medicaid vs. Medicare Advantage Network Requirements: Key Differences

Two Federal Frameworks, Very Different Implementations

Medicare Advantage network requirements are set by CMS and applied uniformly across all states. Medicaid managed care network requirements are set by CMS's Medicaid managed care regulations (42 CFR Part 438) but implemented by each state through its managed care contracts — which means the specific standards vary significantly from state to state.

For plans operating in both programs — particularly D-SNPs, which must satisfy both — understanding these differences is essential for building networks that can pass both reviews without duplicate work.

MA Network Standards: Key Characteristics

• Standards are quantitative time-and-distance thresholds set by CMS annually
• Applied uniformly across all states — the same urban threshold applies in California and Ohio
• 22 specialty categories evaluated for most plan types
• Exception filings are available for counties where the supply of providers is insufficient to meet threshold
• Annual filing tied to the bid submission calendar (typically June–July for the following benefit year)
• Enforced by CMS's Medicare Part C and D Oversight and Enforcement Group

Medicaid Network Standards: Key Characteristics

• Federal floor set by 42 CFR 438.206 — states must ensure enrollees have access to services with reasonable promptness
• Each state translates that federal floor into specific time-and-distance or provider-to-member ratio standards in its managed care contract
• States may require FQHC and RHC inclusion as a contract condition — not just as a good-faith adequacy measure
• Many states require provider directory submissions on a quarterly or semi-annual basis
• State-specific specialty requirements — some states require specific provider types (e.g., certified nurse midwives, doulas) that are not part of MA adequacy standards
• Enforcement is by the state Medicaid agency, not CMS directly — though CMS can intervene if a state fails to enforce its own standards

FQHC and RHC Requirements: A Critical Difference

FQHCs and RHCs have a special status in Medicaid that they do not have in Medicare Advantage. Medicaid managed care plans are required to include FQHCs and RHCs in their networks and pay them at the published prospective payment system (PPS) rate — not the plan's contracted rate. For MA plans, FQHCs are desirable network partners but not legally required.

D-SNP plans must understand this distinction clearly: your Medicaid contract requires FQHC inclusion and PPS payment; your MA contract does not have the same requirement. These are managed through different contracting templates with different payment terms.

D-SNP Crosswalk Challenges

When a provider is in your MA network but not your Medicaid network — or vice versa — it creates a coverage gap for your dual-eligible members. The most common crosswalk problems include:

• Providers who participate in Medicare but not your state's Medicaid program — these can count toward MA adequacy but not Medicaid adequacy
• FQHC look-alike providers that don't carry formal FQHC designation — they satisfy Medicaid access in some states but not the FQHC contract requirement
• Providers who contract with the plan's MA division under different terms than the Medicaid division — leading to conflicting credentialing records

Filing Cadences

MA adequacy is filed annually on CMS's benefit year calendar. Medicaid adequacy is filed on the state's contract calendar, which varies widely — some states require quarterly provider directory attestations, others file annually. Plans managing both must maintain a compliance calendar that tracks both filing schedules and ensures data consistency between submissions.