Georgia Medicaid CMO Enrollment and Disenrollment: A Complete Guide to Section 1932(a), 42 CFR 438.54, 42 CFR 438.56, and Georgia Families

::: hero Georgia Medicaid CMO Enrollment and Disenrollment

Many Georgians receive their Medicaid benefits not directly from the state but through one of four Care Management Organizations: Amerigroup Community Care of Georgia, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia. The CMO a member is enrolled in determines which providers they see, which prior authorization rules apply to their care, which care coordinator (if any) follows their case, what value-added services they have access to, and how they navigate appeals when something goes wrong. The choice of CMO matters in ways that members often do not realize until after enrollment, by which point switching can feel difficult and the original choice can feel locked in.

In fact, federal Medicaid law gives members substantially more enrollment flexibility than most realize. Section 1932(a) of the Social Security Act, added by the Balanced Budget Act of 1997, requires states with mandatory managed care to provide members with a meaningful choice between plans, an initial window after initial enrollment to switch plans without cause, an annual open enrollment thereafter, and good-cause disenrollment at any time for specified reasons. The Code of Federal Regulations at 42 CFR 438.54 details the enrollment process requirements, 42 CFR 438.56 governs disenrollment, and 42 CFR 438.71 mandates a beneficiary support system to help members navigate these choices. The CMS 2016 and 2024 Medicaid Managed Care Final Rules strengthened information requirements and member protections.

This guide translates Georgia's enrollment and disenrollment framework for families. We walk through the federal architecture (Section 1932(a) and its implementing regulations), the Georgia implementation through the Georgia Families program and the DCH enrollment broker, the choice counseling process, the auto-assignment algorithm, the initial choice period, annual open enrollment, good-cause disenrollment categories, provider continuity protections, excluded populations and carve-outs, the practical factors families should consider when choosing a CMO, and how members switch when their current CMO is not meeting their needs. The goal is to demystify a set of rules that determine the practical shape of Medicaid for Georgia families and that members have more leverage over than they typically realize.

If you are choosing a CMO for the first time, want to switch CMOs, or have questions about enrollment: call DCH Member Services or contact the Georgia Families enrollment line. For comparative plan information and choice counseling, the DCH enrollment broker can help. For appeals or grievances, contact your CMO first; for State Fair Hearings, contact DCH. :::

::: callout Key takeaways

1. Four CMOs deliver Georgia Families Medicaid. Amerigroup Community Care, CareSource Georgia, Peach State Health Plan, and Wellpoint Georgia.
2. Section 1932(a) SSA gives you the right to choose. Federal law requires meaningful choice between plans, an initial choice period after enrollment, annual open enrollment, and good-cause disenrollment at any time.
3. Actively select your CMO if possible. If you do not select, DCH auto-assigns you. Auto-assignment uses an objective algorithm but cannot account for everything you care about (like which doctors are in network).
4. You have an initial period to switch without cause. After your initial enrollment, you can change CMOs for any reason during the initial choice period. Contact DCH Member Services.
5. Annual open enrollment lets you switch each year. DCH operates an annual open enrollment period when any enrolled member can change CMOs without cause.
6. Good-cause disenrollment is available at any time. You can switch outside the initial choice period or annual window if your provider is not in network, if you have access problems, if quality is poor, or for other specified reasons.
7. Provider continuity is protected during transitions. Under 42 CFR 438.62, ongoing treatment, prior authorizations, and complex care plans transfer when you change plans.
8. Some populations are excluded or have different pathways. Long-term care recipients, some dual-eligibles, some Katie Beckett members, and certain other categories may not be in managed care or may have specific carve-outs. :::

The four Georgia CMOs

By Brevy Care Team · Last verified May 12, 2026

Before walking through the enrollment framework, it helps to know who the four CMOs are. Each operates under a multi-year contract with the Georgia Department of Community Health, receives a capitated monthly payment per enrolled member, and bears financial risk if costs exceed the capitated amount.

Amerigroup Community Care of Georgia. A subsidiary of Elevance Health (formerly Anthem), Amerigroup has been in Georgia since the program's inception. It has a broad statewide network, particularly strong in metro Atlanta and many parts of the state. Amerigroup is one of the largest CMOs in Georgia by enrollment.

CareSource Georgia. A nonprofit MCO with parent CareSource headquartered in Dayton, Ohio. CareSource entered Georgia more recently than Amerigroup or Peach State. As a nonprofit, CareSource emphasizes community investment and care coordination programs distinct from for-profit competitors.

Peach State Health Plan. A subsidiary of Centene, Peach State has been in Georgia since the program's inception. Peach State has a broad statewide network and is one of the largest CMOs in Georgia by enrollment.

Wellpoint Georgia. Also under the Elevance Health umbrella (same parent as Amerigroup), Wellpoint represents a newer entry to the Georgia market. Although the parent company is the same as Amerigroup, the network composition, value-added services, and operational model differ.

These four CMOs are the plans members choose between for managed care. The Georgia Families program is the umbrella name DCH uses for managed care, similar to how California uses Medi-Cal Managed Care or New York uses Medicaid Managed Care as program names.

The federal statutory foundation

The federal framework for Medicaid managed care enrollment rests on a small set of statutory provisions, primarily in Section 1932 of the Social Security Act, with implementing regulations in 42 CFR Part 438. Understanding the framework matters because it defines what members can expect from the enrollment process and what choices they have.

Section 1932(a)(1) SSA: state plan authority for mandatory managed care

Section 1932 was added to the Social Security Act by the Balanced Budget Act of 1997. It provides state plan authority for mandatory Medicaid managed care enrollment without requiring a Section 1115 waiver. Before BBA 1997, states wanting to require members to enroll in managed care had to obtain Section 1115 demonstration approval, which was slower and more administratively complex.

Under Section 1932(a)(1), states can establish mandatory managed care for most Medicaid populations through their state plan, subject to the protections in the rest of Section 1932.

Section 1932(a)(2) SSA: excluded populations

Section 1932(a)(2) lists populations excluded from mandatory enrollment, though states can include them with conditions. Excluded categories include:

• Dual-eligible Medicare-Medicaid enrollees (states can include with specific provisions)
• American Indians and Alaska Natives (always voluntary)
• Children with special health care needs in certain categories
• Foster children in some cases
• Children receiving SSI

States can voluntarily enroll these populations in managed care but cannot mandate it without Section 1115 authority.

Section 1932(a)(3) SSA: freedom of choice between plans

When a state operates mandatory managed care, beneficiaries must have a choice of at least two plans, or be able to access fee-for-service if only one plan is available in their area. This freedom of choice between plans is a foundational protection: the state can require managed care enrollment, but cannot require enrollment in a specific plan if alternatives are available.

Georgia, with four CMOs, easily meets this requirement.

Section 1932(a)(4) SSA: enrollment process and choice period

This section requires:

• Default enrollment processes for members who do not actively select a plan, with safeguards
• Information provided before enrollment so members can make informed choices
• An initial choice period to switch without cause after enrollment
• Annual open enrollment thereafter

The initial choice period and annual open enrollment are critical protections. They mean enrollment is not locked in indefinitely, and members have real opportunities to change plans.

Section 1932(a)(5) SSA: information requirements

Members must receive:

• Comparative plan information
• Plan-specific benefit information
• Provider network information
• Quality and performance information

This information must be provided in a form members can understand, in their primary language where feasible, and in accessible formats for members with disabilities.

Section 1115 demonstration authority

For populations not covered by Section 1932 state plan authority, states use Section 1115 demonstrations. Some of Georgia's managed care framework has historically operated under Section 1115 authority for specific populations.

Federal regulations

42 CFR 438.54: enrollment processes

The implementing regulation for Section 1932(a)(4). It establishes detailed enrollment process requirements:

Active enrollment processes. States must establish procedures for beneficiaries to actively select a plan:

• Written information about available plans
• Toll-free choice counseling
• Reasonable time to make a choice
• Comparative information on plans
• Help understanding plan differences

Default enrollment processes. For beneficiaries who do not actively select within the choice period:

• Auto-assignment based on objective criteria
• Consideration of family enrollment continuity (assign to same plan as other family members where possible)
• Consideration of provider continuity (assign to plan where existing provider is in network where data is available)
• Consideration of plan capacity (balance enrollment across plans)

Initial choice period. After initial enrollment (whether through active choice or auto-assignment), members can switch plans for any reason during an initial choice period.

Annual open enrollment. After the initial choice period, members can switch plans during an annual open enrollment period without good cause.

42 CFR 438.56: disenrollment

Governs the rules for disenrollment from a managed care plan:

Disenrollment by the state. Limited to specified grounds:

• Member loses Medicaid eligibility
• Member moves outside the plan's service area
• Plan terminates contract or becomes unavailable
• Member becomes part of an excluded population

Disenrollment by the member. Two pathways:

• Without cause: during the initial choice period and annual open enrollment
• With cause (good-cause): at any time, for specified reasons

42 CFR 438.56: good-cause disenrollment categories

The regulation lists the specific reasons that constitute "good cause" for disenrollment outside the standard windows:

• Member needs services not available in the plan but available elsewhere
• Member's provider is no longer in the plan's network (and the member wants to follow the provider)
• Poor quality of care as documented or substantiated
• Lack of access to services covered under the contract
• Lack of providers experienced in dealing with the member's specific care needs
• Plan's failure to address the member's grievance to the member's satisfaction
• Other good cause as determined by the state

Good-cause disenrollment is available at any time, not just during the initial choice period or annual open enrollment. This means a member who experiences any of these problems can switch plans whenever the problem arises.

42 CFR 438.71: beneficiary support system

Establishes requirements for state-operated beneficiary support systems:

• Choice counseling
• Information about plan selection
• Assistance with grievances and appeals
• Coordination with ombudsman programs
• Help for members with disabilities
• Language access

42 CFR 438.10: information requirements

Detailed requirements for member-facing information:

• Provider directories (online and printed)
• Member handbook content
• Notice of action requirements
• Comparative information for plan selection
• Language access requirements

42 CFR 438.62: continuation of benefits during plan transition

Protects members transitioning between plans:

• Continued access to providers for a period
• Continued authorization of ongoing treatment plans
• Transfer of records and care coordination information
• Smooth handoff of complex cases
• Pregnancy continuity through delivery

This regulation is what prevents a plan transition from interrupting ongoing treatment, ongoing chemotherapy, ongoing pregnancy care, or other complex care.

42 CFR 438.230: subcontracts

Requirements for behavioral health subcontractors and other CMO subcontractors. Affects network composition because behavioral health may be delivered through a subcontractor that has a different provider network than the CMO's primary network.

42 CFR 431.51: freedom of choice

The underlying Medicaid freedom-of-choice principle. Modified by Section 1932 for mandatory managed care, but still operative for fee-for-service members and for the choice between plans.

CMS guidance

CMS 2016 Medicaid Managed Care Final Rule

The 2016 rule modernized the managed care framework, strengthening:

• Provider directory requirements (currency, accuracy, accessibility)
• Member handbook content and format
• Comparative information for plan selection
• Network adequacy standards
• Member communications including language access
• Information for members with disabilities

CMS 2024 Medicaid Managed Care Access Final Rule

The 2024 rule strengthened:

• Appointment wait time standards (enforceable)
• Secret shopper network validation
• Member experience survey requirements
• Network adequacy enforcement
• State accountability mechanisms

Implementation of the 2024 rule is ongoing as of this writing, with state implementation rolling out through 2026 and beyond.

CMS State Medicaid Manual Section 2087

Operational guidance on enrollment processes for managed care, including specific procedural requirements.

Georgia implementation: Georgia Families

Georgia Families is the umbrella name for Georgia's Medicaid managed care program. Georgia Families covers most Medicaid populations through the four CMOs and is the public-facing brand for managed care in Georgia.

DCH Enrollment Broker

The Department of Community Health contracts with an enrollment broker to operate the choice counseling process. The enrollment broker:

• Provides comparative plan information
• Answers member questions about plan selection
• Helps members enroll
• Operates the toll-free choice counseling line
• Coordinates with DFCS on eligibility transitions

The enrollment broker is the practical point of contact for most members making CMO choices.

The Choice Counseling Process step by step

When a Georgia Medicaid applicant is determined eligible for managed care enrollment:

1. Eligibility determination is conducted by DFCS county offices, Georgia Gateway, or other authorized eligibility workers
2. DCH sends a choice counseling letter explaining the four CMOs, their networks, and benefits
3. The member has approximately 60 days to actively select a CMO from among the four available in their service area
4. If the member actively selects, the chosen CMO becomes effective on the next enrollment cycle (typically the first of the following month)
5. If the member does not select within the window, DCH auto-assigns the member based on the auto-assignment algorithm
6. Coverage begins with the selected or assigned CMO on the effective date
7. The initial choice period starts on the effective date, allowing the member to switch plans without cause

The Auto-Assignment Algorithm

When a member does not actively select, DCH's auto-assignment algorithm considers:

• Family continuity. If other family members are already in a CMO, the new enrollee is preferentially assigned to the same CMO. This reduces administrative complexity and coordinates care across the family.
• Provider continuity. If the member has an established provider whose CMO network can be identified, the algorithm tries to assign to a CMO where that provider is in-network.
• Plan capacity. The algorithm balances enrollment across the four CMOs to avoid overloading any single plan.
• Geographic considerations. Some CMOs have stronger networks in certain regions (rural vs urban, north Georgia vs south Georgia), and the algorithm considers geographic fit.
• Member health needs where data is available. Where DCH has information about the member's chronic conditions or special needs, the algorithm may consider which CMO has the strongest network for those conditions.

The algorithm operates objectively, but it cannot substitute for active member choice in many circumstances. Members who care about specific providers, specific specialists, or specific aspects of CMO operations are strongly encouraged to actively select rather than accept auto-assignment.

Why active selection matters

Three concrete reasons to actively select:

1. Provider networks differ across CMOs. If your primary care doctor, your child's pediatrician, your OB/GYN, or your specialists are not in the auto-assigned CMO's network, you will need to either find new providers or switch CMOs (which takes time and creates care continuity gaps).
2. Prior authorization rules differ. Each CMO has its own list of services that require prior authorization, its own clinical criteria, and its own appeal processes. The CMO you are in determines how easy or difficult it is to access specific services.
3. Value-added services and care coordination differ. Each CMO offers different value-added benefits (transportation assistance, doula support, behavioral health programs, member rewards) and operates different care coordination models.

The choice counseling letter and the enrollment broker provide comparative information. Take the time to review it.

The 90-Day Choice Period

During the initial choice period after enrollment (whether through active choice or auto-assignment), members can switch CMOs without needing to provide a reason. To switch:

• Call DCH Member Services
• Submit a request through Georgia Gateway
• Contact the enrollment broker

The switch typically takes effect on the first of the following month. Provider continuity protections under 42 CFR 438.62 apply during the transition.

Annual Open Enrollment

DCH operates an annual open enrollment period. During open enrollment, all enrolled members can switch CMOs without cause. The new CMO assignment takes effect at the start of the next benefit period.

Watch for DCH communications about open enrollment timing. Members should review their CMO each year to ensure it continues to meet their needs, particularly if providers have left the network, if care coordination has been inadequate, or if a different CMO has improved features.

Good-Cause Disenrollment

At any time, members can request good-cause disenrollment for specified reasons matching the federal categories. The process is:

1. Member contacts DCH or files a written request
2. DCH evaluates the basis for good-cause, sometimes requesting documentation
3. If approved, the member is transferred to a new CMO
4. The new CMO becomes effective at the next benefit period (typically the first of the following month)
5. Provider continuity protections apply during transition

Common good-cause situations in Georgia include:

• Primary care provider is not in the assigned CMO's network and the member wants to continue with that provider
• A specialist needed for ongoing care is not in network
• Access difficulties such as appointment delays or geographic gaps
• Quality of care concerns that have been documented
• Cultural or language barriers that the CMO cannot adequately accommodate
• A service denial that the CMO did not adequately address through grievance

For good-cause disenrollment requests, members should:

• Document the specific reason
• Note any communications with the CMO that show the issue was raised and not resolved
• Identify the alternative CMO they want to switch to
• Request the switch through DCH

Excluded Populations and Carve-Outs

Some Georgia Medicaid members are not enrolled in managed care or have different enrollment pathways:

Long-Term Care recipients in nursing facilities. Fee-for-service for LTC services. CMO involvement may exist for acute care in some configurations.

Some dual-eligibles. Medicare-Medicaid coordination affects enrollment. Some dual-eligibles are voluntarily in CMOs; others are not.

Some Katie Beckett (TEFRA) members. Complex pediatric cases may have specific carve-outs or specialized enrollment.

Some Aged-Blind-Disabled (ABD) members. Specific categories may have different enrollment pathways.

Foster children. Generally enrolled in a single CMO designated for foster children, with carve-outs for specific services.

Native Americans and Alaska Natives. Voluntary enrollment in CMOs.

Section 1115 demonstration enrollees. Some Georgia Section 1115 programs have specific enrollment rules.

These exclusions and carve-outs evolve over time as Georgia restructures its managed care landscape and as federal policy changes.

Provider Continuity Protections

When a member transitions between CMOs (or in initial enrollment), Georgia protects continuity:

• Existing prior authorizations honored for a transition period
• Continued access to current providers during transition, particularly for ongoing complex care
• Transfer of medical records and care coordination information
• Continuation of ongoing complex treatment plans
• Special protections for pregnancy (continued OB/GYN care through delivery and postpartum)
• Special protections for ongoing chemotherapy or radiation therapy
• Special protections for ongoing mental health treatment
• Special protections for transplant patients
• Continuity for children with special health care needs

If you are switching CMOs and have ongoing complex care, contact both the outgoing and incoming CMO care coordinators to coordinate the transition. Document your prior authorizations and bring them to the new CMO.

Information Requirements

DCH and the CMOs are required to provide:

• Member handbook with detailed benefit information, prior authorization rules, and grievance/appeal procedures
• Provider directory (online and printed) with current network information
• Comparative information at choice counseling
• Notices of action with appeal rights when services are denied
• Quality data summaries from the EQRO Annual Technical Report
• Language access for limited-English-proficiency members
• Disability accommodations for members with disabilities

Members who do not receive required information should request it from their CMO or DCH.

Practical decision factors for choosing a CMO

Choosing among the four CMOs involves comparing several practical factors. Members benefit from doing this comparison actively rather than accepting auto-assignment.

Provider network

The single most important factor for most families is whether their preferred providers are in the CMO's network:

• Primary care doctor
• Specialists for ongoing chronic conditions
• Pediatricians for children
• OB/GYN for pregnant women or women planning pregnancy
• Mental health providers
• Dentists (where Medicaid covers adult dental)

Check each CMO's provider directory before selecting. The directory is available online and through the enrollment broker. Be aware that provider directories can be inaccurate (this is a known industry-wide issue), so when possible, also call the provider's office to confirm they accept the specific CMO.

Prior authorization rules

Different CMOs have different prior authorization policies. If you need frequent specialty care, MRIs, DME, behavioral health services, or other utilization-managed services, the specific CMO's rules matter. The member handbook lists prior authorization requirements.

Care coordination model

Each CMO has slightly different care coordination approaches. Members with chronic conditions, complex care needs, or behavioral health needs should consider which CMO's model best fits.

Geographic considerations

CMO networks differ across Georgia regions:

• Metro Atlanta: all CMOs have substantial networks
• South Georgia (Savannah, Brunswick, Albany, Valdosta): networks vary
• North Georgia (Athens, Gainesville, Dalton): networks vary
• Rural Georgia: network adequacy is a more significant differentiator

Member experience

The EQRO Annual Technical Report and CAHPS member experience surveys provide quality data for comparing CMOs. DCH publishes summary information that members can review.

Value-added services

CMOs offer optional value-added services that vary across plans:

• Doula support (some plans)
• Enhanced behavioral health programs
• Member rewards programs
• Supplemental dental or vision benefits
• Transportation beyond NEMT minimums
• Asthma or diabetes management programs
• Maternal health programs

Family enrollment

Families generally benefit from all members being in the same CMO for coordination and reduced administrative complexity. The auto-assignment algorithm considers this, and members should consider it when actively selecting.

Worked examples

The following six scenarios illustrate how the enrollment and disenrollment framework operates for Georgia families.

Maria, 35, Albany: first-time Medicaid enrollment and active CMO selection

Maria is 35, lives in Albany, and works in retail. She applies for Medicaid for the first time after losing employer coverage due to a job change. DFCS determines her eligible under the parent/caretaker relative category. She receives a choice counseling letter from DCH listing the four CMOs.

Maria has an established primary care doctor and a daughter with asthma who sees a pediatrician. She calls the enrollment broker:

• She asks which CMOs include her doctor and her daughter's pediatrician in network
• The broker confirms that Peach State and Wellpoint include both, but Amerigroup and CareSource only include one of the two
• She asks about behavioral health (her daughter sees a therapist) and confirms Peach State has the strongest behavioral health network in Albany
• She asks about asthma management programs

She actively selects Peach State Health Plan. Her coverage begins on the first of the next month. Within the initial choice period, she has visited her primary care doctor, her daughter has seen the pediatrician, and the asthma management program has started. Active selection saved her from the disruption of having to change providers or pursue good-cause disenrollment.

Eleanor, 78, Atlanta: dual-eligible enrollment and Medicare-Medicaid coordination

Eleanor is 78, lives in Atlanta, and is dual-eligible for Medicare and Medicaid. She has chronic conditions and uses Medicare as her primary insurance with Medicaid as supplemental.

For dual-eligibles, CMO enrollment depends on several factors:

• Whether Medicaid LTC is involved
• Whether Eleanor is on a Medicare Advantage plan with Medicaid coordination
• Whether her care is in a nursing facility

Eleanor lives at home, is on Original Medicare, and uses Medicaid for cost-sharing assistance and certain Medicaid-only services (some long-term services, dental, hearing). DCH offers voluntary CMO enrollment for many dual-eligibles. Eleanor's choices:

• Stay in fee-for-service Medicaid (default for many dual-eligibles)
• Voluntarily enroll in a CMO

She consults with her case manager, who recommends staying in fee-for-service because her existing providers participate. She declines voluntary CMO enrollment.

Marcus, 45, rural Bulloch: good-cause disenrollment after bad CMO experience

Marcus is 45, lives in rural Bulloch County, and has been enrolled in Amerigroup for 6 months. His primary care doctor recently left Amerigroup's network because of a contract dispute. The nearest in-network primary care doctor is 30 miles away. He has tried to get prior authorization for an MRI and faced delays. He is past his initial choice period and the annual open enrollment is 5 months away.

Marcus calls DCH Member Services and explains:

• His primary care provider is no longer in network
• He wants to follow that provider to a CMO that includes them
• He has access problems (30 miles to alternative in-network providers)

DCH approves his good-cause disenrollment. He is transferred to CareSource, which his primary care doctor accepts. The switch becomes effective on the first of the following month. His existing MRI prior authorization request is transferred and CareSource honors it, avoiding further delay.

Jamil, 8, Newport: Katie Beckett enrollment for pediatric special needs

Jamil is 8, lives in Newport, and has complex special needs including a feeding tube, ongoing physical therapy, and a developmental disability. He is enrolled through Katie Beckett (TEFRA) Medicaid eligibility.

Katie Beckett enrollment for managed care is more complex than standard enrollment because Jamil's care involves multiple specialists, durable medical equipment, and ongoing therapies. His care coordinator helps the family:

• Compare CMO networks for his specialists
• Compare DME providers in each CMO
• Compare prior authorization processes for his ongoing therapies
• Consider continuity of his existing providers

The family selects Wellpoint because Jamil's developmental pediatrician, his physical therapist, and his DME supplier are all in network. Family continuity (Jamil's siblings are in standard Medicaid) is also considered: the siblings are assigned to Wellpoint to keep the family in one CMO.

Diana, 35, Macon: annual open enrollment switch

Diana is 35, lives in Macon, and has been in CareSource for two years. She has been generally satisfied but her CMO's prior authorization for her ADHD medication has become more cumbersome. During the most recent annual open enrollment, she:

• Reviews comparative plan information
• Checks whether her primary care doctor, her psychiatrist, and her dentist are in other CMO networks
• Compares prior authorization rules for ADHD medications
• Confirms that Peach State Health Plan has simpler prior authorization for her medication regimen and includes all her providers

She submits an annual open enrollment switch to Peach State. The switch becomes effective at the start of the next benefit period. Her prior authorizations are transferred and Peach State honors them through the transition.

Tasha, 22, rural to urban relocation

Tasha is 22, moves from rural Coffee County to Atlanta for a new job. She has been on Medicaid through Wellpoint, which has a strong network in metro Atlanta. After her move, her enrollment continues seamlessly because:

• Her Medicaid eligibility is maintained
• Her CMO (Wellpoint) operates in both regions
• She updates her address through Georgia Gateway and DFCS
• She is reassigned to a new primary care provider in Atlanta from Wellpoint's network

If her CMO had not had a strong network in Atlanta, she would have had good-cause disenrollment under "provider not available in new service area." But because Wellpoint operates in both areas, she keeps her plan.

Frequently asked questions

::: accordion Q: How do I choose a CMO when I first enroll in Medicaid? A: When DCH determines you are eligible for managed care, you receive a choice counseling letter explaining the four CMOs (Amerigroup, CareSource, Peach State, Wellpoint). You have a limited period to actively select. Contact DCH Member Services, the enrollment broker, or visit Georgia Gateway to select your CMO. Compare provider networks (most important factor), prior authorization rules, care coordination, and value-added services.

Q: What happens if I do not actively select a CMO? A: DCH auto-assigns you using an algorithm that considers family continuity, provider continuity (where data is available), plan capacity, geographic considerations, and your health needs. Auto-assignment is objective but cannot substitute for active member choice. You may end up in a CMO where your preferred doctors are not in network.

Q: Can I switch CMOs after I'm enrolled? A: Yes. You have three pathways: (1) During the initial choice period after enrollment, you can switch without cause for any reason. (2) During the annual open enrollment period, you can switch without cause. (3) At any time, you can request good-cause disenrollment for specified reasons.

Q: What is good-cause disenrollment? A: Good-cause disenrollment lets you switch CMOs outside the initial choice period or annual open enrollment for specified reasons including: your provider is no longer in network, you need services not available in your plan, poor quality of care, lack of access to services, lack of providers experienced in your specific care needs, or your plan's failure to address a grievance to your satisfaction.

Q: How do I request good-cause disenrollment? A: Call DCH Member Services or file a written request. Explain the specific reason and provide any documentation. DCH evaluates and approves or denies the request. If approved, you transfer to a new CMO on the first of the following month.

Q: Can I keep my doctor when I switch CMOs? A: If your doctor is in the new CMO's network, yes. If not, you may need to find a new doctor, but provider continuity protections under 42 CFR 438.62 may allow you to continue with your existing doctor for a transition period, particularly for ongoing complex care, pregnancy, or chemotherapy.

Q: What happens to my prior authorizations when I switch CMOs? A: Existing prior authorizations are typically honored by the new CMO for a transition period. Bring documentation of your prior authorizations to the new CMO and contact their care coordination team to coordinate the transition.

Q: I am pregnant and switching CMOs. Will my OB/GYN coverage continue? A: Yes. Pregnancy continuity protections allow you to continue with your existing OB/GYN through delivery and the postpartum period, even if they are not in the new CMO's network. Contact your new CMO to coordinate.

Q: I am dual-eligible (Medicare and Medicaid). How does CMO enrollment work for me? A: Dual-eligibles often have voluntary CMO enrollment for Medicaid. Whether you should enroll in a CMO depends on whether your Medicaid services align with the CMO's coverage. Many dual-eligibles remain in fee-for-service Medicaid. Discuss with your case manager or DCH.

Q: Are all Georgia Medicaid members in CMOs? A: No. Some populations are excluded or have different pathways: long-term care recipients in nursing facilities are mostly fee-for-service for LTC services, some dual-eligibles are not in CMOs, some Katie Beckett members have specific carve-outs, and some Aged-Blind-Disabled categories have specific arrangements.

Q: How do I know which CMO has my doctor in network? A: Check each CMO's provider directory online or call the CMO directly. The DCH enrollment broker can also help compare networks. When possible, also call the doctor's office to confirm they accept the specific CMO, since provider directories can be inaccurate.

Q: When is annual open enrollment? A: DCH operates annual open enrollment annually. The specific timing varies. Watch for DCH communications about your open enrollment window, or call DCH Member Services to ask about timing.

Q: I'm not happy with my CMO but it's past my initial choice period and not annual open enrollment. What can I do? A: Consider good-cause disenrollment. The specific reasons include provider issues, access problems, quality of care concerns, and grievance failures. Call DCH Member Services to discuss your situation.

Q: I have a complaint about my CMO. What's the difference between a grievance and a disenrollment request? A: A grievance is a formal complaint to your CMO about service quality, access, or treatment. The CMO must respond within specific timeframes. Disenrollment moves you to a different CMO. You can file a grievance without disenrolling, and disenrollment for good cause often requires that you have filed a grievance that the CMO did not adequately address.

Q: What if I'm moving to a different part of Georgia? A: Update your address through Georgia Gateway and DFCS. If your CMO operates in your new area, you stay enrolled but may be reassigned to new providers. If your CMO does not operate in your new area, you can request good-cause disenrollment.

Q: My children and I are in different CMOs. Can we be in the same CMO? A: Yes. Family enrollment continuity is a consideration in auto-assignment and can be a reason to actively switch. Contact DCH Member Services to align your family's enrollment.

Q: How do I find the CMO enrollment broker? A: Call DCH Member Services and ask for choice counseling. The enrollment broker operates through DCH and provides comparative plan information.

Q: What information should I get before choosing a CMO? A: Member handbook, provider directory, prior authorization rules, grievance and appeal procedures, value-added services, language access information, and quality data from the EQRO Annual Technical Report. The enrollment broker can provide all of this.

Q: I have limited English proficiency. Can I get help in my language? A: Yes. CMOs and DCH are required to provide language access. Interpretation services are available for choice counseling, member services, and clinical encounters. Ask for an interpreter when you call.

Q: What if Brevy.com has more questions I want to read about? A: Brevy.com publishes detailed guides on Georgia Medicaid managed care plans (the four CMOs), managed care quality (HEDIS, CAHPS, EQRO), how to apply, providers and network adequacy, appeals and fair hearings, and the Aged-Blind-Disabled category. Visit brevy.com for the full Georgia Medicaid library. :::

How to get help with CMO enrollment and disenrollment

::: cta Where to call for help with Georgia CMO enrollment, disenrollment, and choice

• DCH Medicaid Member Services: contact dch.georgia.gov for current number
• Georgia Families enrollment hotline: through DCH Member Services
• Amerigroup Member Services: see your Amerigroup member handbook
• Peach State Health Plan Member Services: see your Peach State member handbook
• CareSource Georgia Member Services: see your CareSource member handbook
• Wellpoint Georgia Member Services: through DCH Member Services
• Georgia Gateway (enrollment portal): gateway.ga.gov
• DFCS (eligibility offices): find your county office at dfcs.georgia.gov
• Right from the Start Medicaid (RSM): apply through DFCS or Georgia Gateway
• Disability Rights Georgia: see disabilityrightsga.org for current contact
• Georgia Legal Services Program (for appeals): see georgialegalservices.org for current contact
• AARP Georgia: see aarp.org/states/georgia for current contact
• 211 Georgia (community resources): Dial 211
• Georgia Long-Term Care Ombudsman: contact DCH for current number
• Healthcare.gov (after Medicaid loss): healthcare.gov

For initial CMO selection, call DCH Member Services or the enrollment broker. To switch CMOs, call DCH Member Services. For appeals or grievances against a specific CMO, contact the CMO's member services first; for State Fair Hearings, contact DCH. For help understanding your rights, contact Georgia Legal Services or Disability Rights Georgia. :::

Final notes

Federal Medicaid law gives Georgia families substantial control over their CMO enrollment. The right to choose actively rather than accept auto-assignment, the initial choice period to switch without cause, the annual open enrollment, and good-cause disenrollment at any time for specified reasons all create meaningful flexibility. The framework recognizes that one-size-fits-all CMO assignment cannot account for every family's specific provider relationships, care needs, geographic situation, and preferences.

In practice, members exercise these rights less than they might. Many accept auto-assignment without realizing they had a choice. Many stay in a CMO that is not meeting their needs because they think switching is harder than it is. Many do not realize good-cause disenrollment is available outside the standard windows.

This guide aims to demystify the framework. The key practical points: actively select your CMO if you possibly can; check provider networks carefully before selecting; remember you have an initial choice period to switch without cause; remember annual open enrollment lets you switch each year; remember good-cause disenrollment is available at any time when something is not working. The DCH enrollment broker and Member Services are your access points for all of this.

Georgia families navigate Medicaid in a complex landscape. Brevy is committed to translating that landscape so families can make informed choices and exercise their rights. We will continue updating this guide as Georgia's CMO contracts evolve, as the 2024 CMS Managed Care Access Final Rule is implemented, and as the program continues to grow.

This article is for educational purposes and does not constitute legal, medical, or financial advice. For specific questions about your Medicaid enrollment, contact DCH Member Services or the enrollment broker. For help with appeals or specific CMO problems, contact your CMO's member services first. For legal help with denials or disenrollment issues, contact Georgia Legal Services Program. Brevy.com and the Brevy Care Team curate this resource to help Georgia families navigate eldercare and family health policy in America.

Find personalized help choosing or switching your Georgia Medicaid CMO at brevy.com.