Georgia Medicare Advantage Network Rules (2026)

More than half of Georgia's Medicare beneficiaries are enrolled in a Medicare Advantage (Part C) or other private health plan rather than Original Medicare. As of March 2026, CMS counted 1,132,147 of the state's 2,016,427 Medicare beneficiaries in Medicare Advantage and other health plans, and 884,280 in Original Medicare.1 For those Georgians, the Georgia Medicare Advantage network rules of their plan often matter more than the underlying Medicare benefit framework, because the network decides which doctors and hospitals can deliver covered care without an unexpected out-of-pocket bill.

Here is the reassurance up front: federal law gives you real protection. Your plan must keep a network adequate to deliver every covered service, give you advance notice and continued access if a provider it dropped was treating you, cover emergency care at any hospital at in-network cost, and give you a multi-level appeal if it says no. The rest of this guide turns each of those rights into a step you can take.

The Medicare Advantage network framework is set by Section 1852(d) of the Social Security Act, operationalized by 42 CFR 422.112 and 42 CFR 422.116, and elaborated by annually updated CMS Health Services Delivery (HSD) tables. The HSD tables set maximum time and distance standards and minimum provider counts across many specialty types and five county designation categories: Large Metro, Metro, Micro, Rural, and CEAC (Counties with Extreme Access Considerations).

You are also protected by 42 CFR 422.111 provider directory accuracy requirements (directories updated at least every 30 days, with civil penalties for material inaccuracies), 42 CFR 422.112(b)(5) continuity-of-care protections when a provider treating you leaves the network, 42 CFR 422.113 emergency and post-stabilization coverage at any hospital, and 42 CFR 422 Subpart M appeal rights that culminate in federal district court review. One common myth this guide corrects: the No Surprises Act does not cover Medicare Advantage enrollees. MA members are excluded from it because they already hold the older, stronger 42 CFR 422.113 protection.

This guide explains the Georgia Medicare Advantage network rules end to end: the statutory and regulatory architecture, the HSD tables, the differences between HMO, HMO-POS, PPO, and other plan types, how to verify whether a provider is in-network, what happens when a plan drops a provider mid-year, the correct emergency-coverage rule, the network adequacy exception process for rural and CEAC counties, the appeals framework, and the network footprints of the carriers selling MA plans in Georgia.

Brevy is an eldercare company helping families navigate Medicare, Medicaid, and senior-care decisions. This guide is education, not legal or insurance advice. For personalized network and plan-selection help, contact GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling.2

Why Georgia Medicare Advantage network rules matter

For Original Medicare beneficiaries, network is largely a non-concept. Original Medicare pays any Medicare-enrolled provider in the United States that accepts assignment, and most do. A beneficiary in Atlanta can see a specialist in Houston, Boston, or Los Angeles and Medicare pays the same way. Network adequacy is not a meaningful constraint.

Medicare Advantage operates differently. MA plans build networks of contracted providers, hospitals, and facilities and steer beneficiaries to those networks through cost-sharing differentials. For HMO plans, out-of-network services are generally not covered at all (except emergencies and urgent care outside the service area). For PPO plans, out-of-network services are covered but typically at substantially higher cost-sharing. Every MA plan must still cover everything Original Medicare covers except hospice, and every plan caps in-network out-of-pocket spending.3 Provider selection is therefore central to the value of MA enrollment.

The network framework matters most when:

A beneficiary needs specialty care. Most network adequacy disputes arise around specialty access: cardiology, oncology, neurology, orthopedic surgery, gastroenterology, urology, ophthalmology. Specialists often have narrower in-network availability than primary care.

A beneficiary lives in rural or remote Georgia. Network adequacy challenges concentrate in rural and CEAC counties. Plans may not have any in-network cardiologist within 30 miles, requiring the network adequacy exception process or out-of-network exceptions.

A provider terminates the contract mid-year. Providers leave plan networks for many reasons: contract negotiations break down, the provider moves practices, the practice is acquired. Beneficiaries can lose access to their long-time PCP or specialist with little warning.

A beneficiary travels out of state. Beneficiaries traveling for vacation, family, or seasonal residence may need care while away from their plan's service area.

A beneficiary has a medical emergency. Emergency services receive special treatment under 42 CFR 422.113, which covers care at any hospital at in-network cost-sharing, but knowing your rights matters when the bills arrive.

A beneficiary is dual-eligible. Medicare-Medicaid dual eligibles have additional protections, particularly under D-SNP plan rules that integrate Medicare and Medicaid benefits.

Section 1852(d) and the statutory framework

Section 1852(d) of the Social Security Act establishes the basic statutory obligation of every Medicare Advantage plan to provide adequate access to covered services. The text is brief but carries enormous regulatory weight: MA plans must "demonstrate to the satisfaction of the Secretary that the MA organization has sufficient providers under contract to provide all covered services to enrollees." That single phrase, "sufficient providers under contract to provide all covered services," is the legal foundation for the entire network adequacy framework.

The statute does not specify what "sufficient" means; that has been left to CMS to operationalize through regulation and sub-regulatory guidance. The principal vehicles are 42 CFR 422.112 (the access-to-services rule), 42 CFR 422.116 (the network adequacy methodology added effective CY 2021), 42 CFR 422.111 (the disclosure and provider directory rule), and the annually-issued Medicare Managed Care Manual (CMS IOM Pub. 100-16), particularly Chapter 4 (Benefits and Beneficiary Protections).

The statutory framework also includes:

• Section 1852(a): MA plans must provide all Original Medicare-covered services
• Section 1852(b): anti-discrimination, including no discrimination based on health status
• Section 1852(g): grievance and appeal rights (operationalized in 42 CFR 422 Subpart M)
• Section 1852(j): special needs plans framework
• Section 1854: bidding and payment rules (affects what plans can afford to pay providers, indirectly shaping network)

42 CFR 422.112: the operational access-to-services rule

42 CFR 422.112 establishes what plans must actually do. The major elements:

422.112(a) General requirements

Each MA plan must "ensure that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan, including ensuring that services are provided in a culturally competent manner to all enrollees."

422.112(a)(1) Establishing network adequacy

Plans must "maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all benefits to all enrollees."

422.112(a)(2) Direct or arranged provision

Plans may meet network requirements either through direct contracts with providers or through arrangements with provider networks or networks of networks.

422.112(a)(3) Female enrollees

Female enrollees must have direct access to women's health specialists for routine and preventive women's health care services. PCP referral cannot be required for this access.

422.112(a)(4) Specialists for ongoing care

Plans must have procedures to ensure that enrollees with chronic, complex, or serious medical conditions have a process for receiving specialist care without going through the PCP each visit (standing referrals).

422.112(a)(8) Emergency services

Plans must cover emergency services at any hospital regardless of network status, with cost-sharing no higher than in-network rates. This rule, together with 42 CFR 422.113, is the baseline emergency framework for Medicare Advantage, independent of the No Surprises Act.

422.112(a)(10) Out-of-area renal dialysis

Plans must cover dialysis when an enrollee is temporarily out of service area.

422.112(b)(5) Continuity of care

When a plan terminates a provider contract, the plan must "make a good faith effort to provide written notice of a termination of a contracted provider at least 30 calendar days before the termination effective date" to affected enrollees, and must provide continued access for active treatment.

CMS Health Services Delivery (HSD) tables

The HSD tables are the operational backbone of network adequacy. CMS issues them annually via Health Plan Management System (HPMS) memoranda and bid review processes. The tables establish:

Maximum time and distance standards

For each combination of (specialty type, county designation category), the HSD table specifies a maximum time and maximum distance from a high percentage of enrollees to at least one in-network provider of that specialty. Standards are tightest in Large Metro counties (short distance and travel-time limits) and most permissive in CEAC counties. Check the current CY HSD criteria memorandum from CMS HPMS for the specialty- and county-specific limits.

Minimum provider count

For each (specialty, county) combination, the HSD table also specifies a minimum number of in-network providers. Counts scale with county population, with the largest minimums in Large Metro counties and the smallest in CEAC counties. See the current CY HSD criteria memorandum for the exact numbers by specialty and designation.

County designation categories

CMS classifies every county into one of five categories by population density and accessibility. The standard a plan must meet is tightest in Large Metro and loosest in CEAC. Find your own county's designation in the current CY CMS county designation table.

Specialty types tracked

CMS HSD tables track many specialty types and facility types, including: primary care providers; cardiology, endocrinology, gastroenterology, nephrology, neurology, oncology (medical/surgical/radiation), pulmonology, rheumatology; surgical specialties (general, vascular, cardiothoracic, neurosurgery, orthopedic surgery, plastic surgery); women's health (OB-GYN); mental health (psychiatry); pediatric subspecialties; and facility types (acute care hospitals, psychiatric hospitals, SNFs, inpatient rehabilitation facilities, outpatient infusion centers, outpatient dialysis facilities, ASCs).

How plans demonstrate compliance

Each year during the bid submission and review process, plans submit HSD tables to CMS showing their provider/facility counts and locations relative to their projected enrollee distribution. CMS evaluates whether the plan meets standards in each county-specialty combination. Plans that fall short must either:

• Contract additional providers
• Request a network adequacy exception
• Decline to offer the plan in non-compliant counties

42 CFR 422.111: provider directory accuracy

Provider directories are how beneficiaries actually identify in-network providers. The accuracy of those directories is therefore central to whether the network rules deliver real protection. 42 CFR 422.111 establishes requirements:

Content requirements (42 CFR 422.111(b))

Provider directories must include for each in-network provider:

• Name and contact information (address, phone, email if available)
• Specialty
• Board certification status
• Hospital affiliations
• Whether the provider is accepting new patients
• Languages spoken by the provider or office staff
• Office hours (where applicable)
• Cultural competency credentials (where applicable)

Format requirements

• Online directory must be available 24/7 and searchable
• Print directory must be available upon request, delivered within 7 business days
• Multiple language and accessibility formats available

Update frequency (42 CFR 422.111(h))

• Plans must update directories "no less frequently than every 30 days"
• Network changes must be reflected within 30 days
• Terminated providers must be removed promptly

CMS audit and enforcement

CMS conducts regular secret-shopper audits of MA provider directories. Recent CMS audits have repeatedly found a substantial share of provider directory entries contained at least one material inaccuracy, and civil monetary penalties (CMPs) can be assessed for non-compliance. The most common inaccuracies:

• Provider no longer at the listed address (often the provider moved practices)
• Provider not accepting new patients despite directory indication
• Provider no longer participating in the plan
• Specialty mismatch
• Disconnected or incorrect phone numbers

Beneficiary hold harmless

When a beneficiary relies on inaccurate directory information and receives services from a provider listed as in-network who turns out to be out-of-network, plans must hold beneficiaries harmless under CMS guidance interpreting 42 CFR 422.111(h)(2). The beneficiary should:

1. Document the directory listing (screenshot, print, date)
2. Request that the plan honor in-network cost-sharing
3. If denied, file an appeal under 42 CFR 422 Subpart M
4. Escalate to CMS Regional Office Atlanta (404-562-7150) if necessary

Worked example 1: Margaret, age 72, Atlanta

Margaret, age 72, lives in Atlanta and has been enrolled in Humana Medicare Advantage HMO for the past 5 years. Her PCP is Dr. Smith at a Piedmont Healthcare-affiliated practice. In May 2026, Margaret receives a letter from Humana stating Dr. Smith's practice is being terminated from the Humana network effective August 1, 2026 (90 days notice).

Margaret is in active treatment for diabetes type 2 (well-controlled, ongoing medication management, quarterly HbA1c) and recent diagnosis of mild cognitive impairment (under evaluation, neuropsychology testing planned for July). She is not pregnant, not at end of life, not in acute treatment for cancer.

Under 42 CFR 422.112(b)(5), Margaret has continuity-of-care rights:

• For routine diabetes management: must transition to a new in-network PCP by August 1
• For the active mild cognitive impairment workup: she can request extended access to Dr. Smith to complete the active diagnostic evaluation, which her plan grants through October 31

Margaret calls Humana member services. She invokes her continuity-of-care right and provides Dr. Smith's office details. Humana approves 90-day extended access for the cognitive workup. Margaret schedules the July 2026 neuropsychology testing with Dr. Smith and the follow-up consultation, both billed at in-network cost-sharing.

In parallel, Margaret uses Humana's online provider directory to find a new in-network PCP near her home. She finds Dr. Jones at Piedmont Atlanta (still in-network despite Dr. Smith's practice being terminated). Margaret schedules a transition visit with Dr. Jones in mid-July. Dr. Jones receives Margaret's records and continues her diabetes management beginning August 1.

By October 31, Margaret has completed her cognitive workup with Dr. Smith (mild cognitive impairment, no dementia, recommended follow-up annual). She transitions any further mild cognitive impairment monitoring to Dr. Jones.

42 CFR 422.112(b)(5): continuity-of-care protections

When a plan terminates a provider contract mid-year, the affected beneficiaries are protected by federal continuity-of-care rules. The major provisions:

Notification

• Plan must give 30 days written notice of provider termination
• Notice must identify the terminated provider, the effective date, alternative in-network providers, and continuity-of-care rights
• For PCP terminations, plan must facilitate selection of new PCP

Continuity-of-care benefits

What 42 CFR 422.112(b)(5) actually guarantees is the good-faith advance notice plus continued coverage of an active course of treatment from the terminated provider through a reasonable transition period. The regulation ties the length to the clinical episode, not to a flat number. Plans commonly grant up to about 90 days for an active acute course, but the trigger is the course of treatment:

Active treatment of an acute condition: continued access for the active course of treatment, commonly up to about 90 days. Examples: an ongoing chemotherapy regimen, recent surgical recovery, active wound care, active rehabilitation.

Inpatient hospital admission: continued coverage through the entire admission, regardless of length.

Pregnancy second or third trimester: through delivery and the post-partum period.

End-of-life care (hospice): through end of life.

Do not confuse this with a separate 90-day rule. When you switch Medicare Advantage plans mid-treatment, the CMS-4201-F final rule requires your new plan to honor an existing prior authorization for at least 90 days while you transition. That 90-day honor is about plan switching; the continuity-of-care benefits above are about a provider leaving the plan you keep.

Beneficiary-initiated transition

If the beneficiary terminates the provider relationship (vs. plan termination), no continuity-of-care protection applies. The beneficiary must use in-network providers immediately.

Provider-initiated termination

If a provider chooses to leave the plan network, continuity-of-care still applies (the relevant trigger is the contract termination, not who initiated it).

Annual Election Period switching

If the timing of plan provider termination overlaps with the Annual Election Period (October 15 to December 7) or Medicare Advantage Open Enrollment Period (January 1 to March 31), beneficiaries can use those windows to switch plans if their preferred provider's new plan is acceptable.

Plan type differences

The plan type you choose sets the network rules you live under. Here is how the four common Medicare Advantage structures compare:

HMO (Health Maintenance Organization)

HMO plans operate as closed networks: services are covered only when delivered by in-network providers (with exceptions for emergencies and urgent care outside the service area). HMOs typically:

• Require beneficiaries to select a primary care physician (PCP)
• Require PCP referral for specialist visits (some "open access" HMOs do not)
• Have lower premiums than PPO plans
• Offer comprehensive supplemental benefits (dental, vision, hearing, transportation, OTC allowance)
• HMOs are the most common MA plan type in Georgia

Out-of-network services in HMO plans are generally not covered. The beneficiary pays full charges directly to the out-of-network provider, with no plan payment.

HMO-POS (Point of Service)

HMO-POS plans are a hybrid: primary HMO structure with limited out-of-network benefits ("point of service" option). The plan specifies which services can be obtained from out-of-network providers and at what cost-sharing. Typical POS benefit allows specialist consultations or imaging from out-of-network providers at meaningfully higher coinsurance than in-network.

PPO (Preferred Provider Organization)

PPO plans cover out-of-network services but at higher cost-sharing. Typical structure:

• In-network: lower coinsurance, sometimes flat dollar copays
• Out-of-network: higher coinsurance (often no negotiated rate; the provider can bill the full charge minus plan payment, though balance billing rules apply)
• No PCP referral required for specialists
• Higher premium than HMO plans

PPOs are the second most common MA plan type in Georgia.

Private Fee-for-Service (PFFS)

PFFS plans largely phased out after the Medicare Improvements for Patients and Providers Act. The remaining PFFS plans pay providers per Medicare fee schedule and providers must accept terms at each service. Network is essentially "any provider who accepts the PFFS terms," which is operationally similar to Original Medicare with the plan as intermediary. PFFS enrollment is small.

Special Needs Plans (SNPs)

SNPs are MA plans with restricted enrollment to specific populations:

• D-SNP (Dual Eligible Special Needs Plan): for Medicare-Medicaid dual eligibles. Network often includes integrated Medicaid contractors.
• C-SNP (Chronic Condition Special Needs Plan): for enrollees with specific chronic conditions (diabetes, cardiovascular, end-stage renal, HIV/AIDS, etc.). Network tailored to the chronic condition.
• I-SNP (Institutional Special Needs Plan): for enrollees residing in long-term care facilities. Network includes the facility and its providers.

D-SNP enrollment in Georgia is a meaningful and growing share of the MA market.

Worked example 2: James, age 68, Macon

James, age 68, lives in Macon and is enrolled in UnitedHealthcare Medicare Advantage PPO. He is newly diagnosed with stage III colon cancer following a screening colonoscopy and biopsy at Atrium Health Navicent (in-network). His oncologist recommends treatment at the Emory Winship Cancer Institute in Atlanta (approximately 90 miles away). James researches and finds his preferred surgical oncologist at Winship is out-of-network for his UnitedHealthcare PPO.

James has options:

Option A: Switch to a UnitedHealthcare plan that includes Winship in-network. Plan switching requires AEP (October 15 to December 7) or MAOEP (January 1 to March 31). It is currently May. James cannot switch immediately unless he qualifies for a Special Election Period (SEP).

Option B: Stay with his current PPO and use the out-of-network benefit. Out-of-network coinsurance is meaningfully higher than in-network. For 2026 the federal in-network MA out-of-pocket maximum is capped at $9,250, but plans may set a higher combined or out-of-network limit, so James would face substantial out-of-pocket exposure for an extended out-of-network treatment course.4

Option C: Use in-network oncology at Atrium Navicent Cancer Center, which has surgical oncology and medical oncology and is part of the Wellstar/Atrium combined system. Cost-sharing tops out at the plan's in-network MOOP.

James consults with his PCP and the Navicent tumor board. He learns that the standard of care for stage III colon cancer is well-established and Navicent has the surgical and chemotherapy resources to deliver it. He elects to stay in-network at Navicent. He pursues surgery (sigmoid resection) and adjuvant chemotherapy (FOLFOX regimen) at Navicent. His total out-of-pocket is capped at his plan's in-network MOOP.

The lesson: PPO out-of-network coverage exists but the cost differential is meaningful. Many MA enrollees who experience serious illness encounter the network constraint and must choose between higher-cost out-of-network care and accepting in-network alternatives. The choice is not always wrong, but it is real.

Network adequacy exception process

When a plan cannot meet HSD standards in a particular county due to genuine provider scarcity, CMS may grant a network adequacy exception. Common conditions of exceptions:

• Plan must document attempts to contract with all available providers in the area
• Plan must demonstrate that the gap cannot be filled by available providers
• Plan must arrange alternative access via:
  • Telehealth coverage at no cost-sharing
  • Out-of-network coverage at in-network rates for the specialty
  • Transportation assistance to providers in adjacent counties
  • Mobile clinics or visiting specialists

Most exceptions are granted in rural and CEAC counties where provider scarcity is endemic.

Worked example 3: Patricia, age 75, Savannah

Patricia, age 75, lives in Savannah and has Aetna Medicare Advantage HMO. She develops shortness of breath and her PCP refers her for cardiology evaluation. She finds an in-network cardiologist at Memorial Health Mercer Cancer Center, but the next available appointment is 8 weeks out. Patricia's PCP feels evaluation is needed sooner.

Patricia calls Aetna and requests an exception for out-of-network cardiology at in-network rates due to network inadequacy (excessive wait time). Aetna investigates and confirms that in-network appointment availability exceeds its access standards for a non-urgent specialist consultation. Aetna grants the exception and authorizes Patricia to see an out-of-network cardiologist at St. Joseph's/Candler in Savannah at in-network cost-sharing.

Patricia is evaluated within 10 days at St. Joseph's/Candler. The cardiologist diagnoses early heart failure (HFpEF), starts treatment, and refers her back to the Aetna in-network cardiologist for ongoing follow-up. The exception was time-limited to the urgent evaluation and not extended to ongoing care, which returns to in-network as soon as availability permits.

Worked example 4: Henry, age 78, rural Tifton

Henry, age 78, lives in Tifton (Tift County, designated Rural by CMS). He develops atrial fibrillation and his PCP refers him for cardiology and electrophysiology evaluation. The nearest in-network cardiologists are at Tift Regional Medical Center (limited cardiology services) and Phoebe Putney in Albany (about 50 miles away). Electrophysiology services are not available close to Henry's home in his current MA plan's network.

Tift County carries the Rural designation. CMS HSD standards are more permissive in Rural counties than in Large Metro, so Henry's plan can still meet HSD if it contracts with an electrophysiologist within the Rural distance/time band in Macon or Albany.

Henry's plan has filed a network adequacy exception for electrophysiology in Tift County. The exception arrangement: out-of-network coverage at in-network rates for any electrophysiology services within Georgia, plus a no-cost telehealth consult option through a partnered electrophysiology telehealth service for second-opinion consultation.

Henry uses the telehealth electrophysiology consultation for the initial evaluation, then travels to Phoebe Putney in Albany for the ablation procedure (at in-network rates per the exception). Round-trip travel is approximately 50 miles. His plan covers the procedure at in-network cost-sharing. The exception arrangement works as intended.

Out-of-network emergency care: the rule that actually protects you

Emergency medical care is the area of strongest beneficiary protection, but the law that delivers it is the one most consumer pages get wrong. For Medicare Advantage, the protection is 42 CFR 422.113, not the No Surprises Act.

Section 1852(d)(1)(E) and 42 CFR 422.113

Under Section 1852(d)(1)(E) and 42 CFR 422.113, Medicare Advantage plans must cover emergency and urgently needed services at any hospital, in or out of network, at no greater cost-sharing than in-network emergency services, with no prior authorization required. Medicare covers emergency department services for an injury, a sudden illness, or an illness that quickly gets much worse; coverage outside the United States is limited to rare situations.5 This rule is older and broader than the No Surprises Act, and it is the basis for your emergency coverage anywhere in the United States.

Prudent layperson standard

"Emergency medical condition" is defined by the prudent layperson standard: a medical condition manifesting itself by acute symptoms of sufficient severity that a prudent layperson, possessing average knowledge of health and medicine, would reasonably expect could result in serious jeopardy to health, serious impairment of bodily function, or serious dysfunction of any organ or body part. The standard is based on the patient's reasonable belief at the time, not retrospective diagnosis.

Urgent care outside service area

Plans must cover urgently needed services outside the plan's service area at in-network cost-sharing when the beneficiary cannot reasonably obtain care from in-network providers in the service area.

Post-stabilization services

Once the patient is stabilized, services at the out-of-network facility convert to non-emergency. The plan may direct transfer to an in-network facility. If transfer is not arranged within a reasonable time, the post-stabilization services continue at in-network rates.

Why the No Surprises Act does not apply to you

This is the correction at the heart of this topic. Hospital billing pages and general explainers routinely tell readers that the No Surprises Act (Public Law 116-260, effective January 1, 2022) protects them from out-of-network emergency bills. For people with commercial or Marketplace insurance, it does. For Medicare and Medicare Advantage enrollees, it does not. The No Surprises Act specifically excludes federal health programs because Medicare and MA enrollees already hold stronger protection under 42 CFR 422.113.

The practical effect is the same or better than what the No Surprises Act provides to commercial members:

• No balance billing for emergency services at an out-of-network hospital, because the plan covers them at in-network cost-sharing.
• No prior authorization for emergency care.
• Post-stabilization care is covered until the plan arranges a reasonable transfer to an in-network facility.

So if you are an MA enrollee and a billing office cites the No Surprises Act, the substance of your protection is real, but the legal source is 42 CFR 422.113. Cite that section when you dispute an emergency bill.

Worked example 5: Robert, age 80, Columbus

Robert, age 80, lives in Columbus and is enrolled in Wellcare Medicare Advantage HMO. While visiting family in Atlanta on a weekend, he experiences sudden severe chest pain. His family calls 911. He is transported by EMS to the nearest hospital, which happens to be Northside Hospital Cherokee (out-of-network for Wellcare).

Robert is admitted, diagnosed with non-ST-elevation myocardial infarction (NSTEMI), undergoes cardiac catheterization and stent placement, and is hospitalized for four days. Hospital and physician charges run well into the tens of thousands of dollars.

Under emergency rules:

• Emergency services (the cath, the stent procedure, the inpatient admission while medically necessary): covered at in-network cost-sharing by Wellcare. Wellcare pays Northside Cherokee at Medicare rates plus any contractual or negotiated amount.
• Robert's cost-sharing: limited to his plan's in-network inpatient hospital copay schedule for the days of his stay
• No balance billing: Northside Cherokee cannot bill Robert for the difference between billed charges and Wellcare's payment, because 42 CFR 422.113 caps his cost-sharing at the in-network level
• Post-stabilization: once Robert was stabilized, Wellcare could have directed transfer to an in-network Columbus hospital. Wellcare reviewed and determined that completing the admission at Northside Cherokee was medically appropriate (transfer of a post-cath patient was not warranted), so the entire admission was covered.

Robert's total out-of-pocket cost is limited to in-network inpatient cost-sharing under his plan.

If Robert had been billed separately by the out-of-network anesthesiologist or radiologist who took part in his emergency care at Northside Cherokee, those professional services are part of the emergency episode and are also covered at in-network cost-sharing under 42 CFR 422.113. The protection flows from the Medicare Advantage emergency rule, not from the No Surprises Act.

Georgia MA carrier-specific network footprints

For 2026, CMS counts 180 Medicare Advantage plans available in Georgia, up from 178 in 2025. That is a statewide total, not the number of plans any one person can choose among. A KFF analysis of the CMS landscape files, which counts only plans open to general enrollment and excludes special-needs and employer plans, puts the average Georgia beneficiary's actual choice at 47 plans offered by an average of 8 insurers.1 Plan lineups and provider networks shift every plan year, so verify the current details directly. To reach any carrier's member services, use the phone number printed on the back of your member ID card, or look the plan up on the Medicare Plan Finder. The notes below describe each carrier's general Georgia footprint, not a specific plan's network.

Humana

Statewide network presence across Georgia's 159 counties. Multiple plan types offered:

• Humana Honor (HMO and PPO): standard MA plans
• Humana Gold Plus (HMO): broad supplemental benefits
• Humana Choice (PPO): out-of-network coverage
• Humana CareSource HMO and Humana D-SNP plans

Humana's provider network in metro Atlanta includes Emory, Wellstar, Northside, Piedmont, and many community physician practices. In rural Georgia, Humana relies on regional health systems (Phoebe, Memorial Mercer, Atrium Navicent, Tift Regional, etc.).

UnitedHealthcare

Statewide network through UnitedHealthcare's broad PPO and HMO platforms. UnitedHealthcare AARP-branded plans are common.

Notable features: integration with Walmart (over-the-counter benefit deliveries), large dental and vision supplemental benefit network, OptumRx pharmacy network.

Aetna (CVS Health)

Statewide network. Integration with CVS Pharmacy (mail-order prescriptions, MinuteClinic urgent care).

Wellcare (Centene)

Established Georgia MA carrier. Network primarily HMO with regional variation. Strong presence in the Medicare-Medicaid dual eligible market through D-SNP plans coordinated with Georgia DCH Medicaid.

Kaiser Permanente Georgia

Service area limited to north metro Atlanta (Cobb, DeKalb, Fulton, Gwinnett, and parts of adjacent counties). Closed staff-model HMO: members receive all services at Kaiser Permanente facilities from Kaiser-employed physicians. No out-of-network coverage (except emergencies and urgent care).

This integrated delivery model is unusual in Georgia and offers strong care coordination but with the geographic limitation. Members who move outside the Kaiser service area must select a different MA plan.

Cigna

Active Georgia MA carrier with major metro coverage and a growing rural footprint. Strong specialty pharmacy and care management programs.

Anthem Blue Cross Blue Shield

Anthem (Elevance Health) operates Blue Cross Blue Shield of Georgia. Statewide network leveraging BCBS GA's traditional commercial provider relationships.

Other and exit carriers

Devoted Health, Bright HealthCare (exited many markets), Allwell, and Peoples Health also operate in Georgia. Some carriers have entered and exited the GA market in recent years; beneficiaries should review their plan's status each AEP.

Worked example 6: Linda, age 67, north Atlanta

Linda, age 67, lives in Roswell (Fulton County, north metro Atlanta) and just retired. She is considering Medicare Advantage plans for her January 2026 effective date. She has Kaiser Permanente through her former employer and has been pleased with the integrated care model.

Linda evaluates Kaiser Permanente Georgia Senior Advantage HMO:

• All services delivered at Kaiser facilities (Kaiser Roswell, Kaiser Town Park, Kaiser Sandy Springs, etc.)
• Kaiser-employed physicians (PCPs, specialists)
• Integrated electronic health record
• A low or no monthly premium, low PCP and specialist copays, and low generic-drug cost-sharing (confirm the current year's figures on the plan's Summary of Benefits)
• Network limited to Kaiser facilities (no Emory, no Piedmont, no Northside)

Trade-off considerations:

• Pro: Care coordination is excellent; all physicians have access to same EHR
• Pro: Quality scores are high
• Pro: Low cost-sharing
• Con: No access to Emory Winship Cancer Institute, Piedmont Cancer Institute, or specialty programs outside Kaiser
• Con: If she develops a complex condition requiring Emory expertise, she would need to switch plans

Linda decides Kaiser fits her current health profile (healthy, well-controlled hypertension, no cancer history, no rare conditions). She enrolls. She plans to reassess annually at AEP based on health status changes.

Appealing MA network denials

The 42 CFR 422 Subpart M appeal framework provides multiple levels of review. The standard timelines run faster than most people expect, and the expedited track is faster still when a delay would jeopardize your health:

Level 1: Organization determination

Plan's initial decision on whether to authorize or pay for a service. Beneficiary may request expedited (72 hours) if delay would jeopardize health, or standard (14 days for service requests, 30 days for payment requests).

Level 2: Reconsideration

If denied, beneficiary may request the plan reconsider. Plan has 14 days (service) or 60 days (payment) to decide. Expedited reconsideration: 72 hours.

Level 3: Independent Review Entity (IRE)

If the plan upholds the denial, the case automatically moves to the Independent Review Entity (IRE) under contract with CMS for independent review. Standard: 14 days. Expedited: 72 hours.

Level 4: Administrative Law Judge (ALJ) hearing

If the IRE upholds the denial and the case meets the minimum amount-in-controversy threshold (set annually by HHS in the Federal Register), the beneficiary may request an ALJ hearing. Conducted by HHS Office of Medicare Hearings and Appeals.

Level 5: Medicare Appeals Council (MAC)

Review of the ALJ decision.

Level 6: Federal district court

Final review for cases meeting the federal-court amount-in-controversy threshold (set annually by HHS).

Common network-related appeal scenarios

• Denial of out-of-network referral for medically necessary care unavailable in network
• Denial of continuity-of-care extension
• Denial of in-network cost-sharing when relying on inaccurate directory listing
• Denial of emergency service coverage on basis that service was not "true emergency"
• Denial of post-stabilization services after determination patient was stable

Beneficiary support

• GeorgiaCares SHIP (free): 1-866-552-4464
• Medicare Rights Center: 1-800-333-4114
• Center for Medicare Advocacy: 1-860-456-7790
• Atlanta Legal Aid (low-income): 404-377-0701

Common errors and pitfalls

1. Confusing emergency and urgent care: emergency services are covered anywhere; non-emergency urgent care depends on plan and location.

2. Failing to verify provider directory: directory inaccuracies are common (CMS audits routinely find a large share of entries with at least one error). Always call the provider to confirm acceptance of your plan before scheduling.

3. Assuming all hospital-based providers are in-network: anesthesiologists, pathologists, radiologists, and hospitalists at an in-network facility may contract separately. In an emergency, 42 CFR 422.113 covers these professionals at in-network cost-sharing. For scheduled, non-emergency care, the No Surprises Act does not protect Medicare Advantage enrollees, so confirm the treating professionals (not just the facility) take your plan, and appeal under 42 CFR 422 Subpart M if you were billed out-of-network after relying on an in-network listing.

4. Not invoking continuity-of-care at provider termination: the protection is not automatic; you must request it.

5. Switching plans for one provider: AEP/MAOEP allow plan changes but may disrupt continuity for other providers. Consider the full network change, not just one provider.

6. Out-of-area travel confusion: short-term travel includes emergency and urgent care coverage. Extended absence (6+ months out of service area) can trigger disenrollment for non-residency.

7. PPO out-of-network use without understanding cost: out-of-network coinsurance on an expensive procedure can run into the tens of thousands of dollars before you reach your plan's in-network out-of-pocket maximum (federally capped at $9,250 for 2026). Confirm the cost before scheduling out-of-network care.3

8. HMO out-of-network use: virtually no coverage outside emergencies. Full out-of-pocket cost for non-emergency out-of-network services.

9. Telehealth network confusion: most MA plans cover telehealth in-network. Out-of-network telehealth (e.g., direct-to-consumer providers) generally not covered.

10. Annual network changes: plans modify networks annually. Provider lists at enrollment may not match Year 2 networks. Review during AEP each year.

11. D-SNP cross-coverage: dual eligibles in D-SNPs have integrated Medicare-Medicaid coverage. Network changes can affect both Medicare and Medicaid services.

12. Closed-network plans like Kaiser: limit access to specialty care outside the system. If you have or develop a rare condition, evaluate carefully.

13. Tiered networks in PPO plans: assuming all in-network providers are at the same cost-sharing level. Tier 1 (preferred) often has substantially lower cost-sharing than Tier 2 (standard).

14. Failure to request prior authorization: many MA plans require prior auth for procedures, imaging, DME. Out-of-network use almost always requires auth.

Prior authorization and network rules

Prior authorization is the process by which an MA plan reviews and approves a service before it is delivered. While prior auth is technically distinct from network rules, in practice the two are deeply intertwined: out-of-network services almost always require prior authorization, and even in-network services often do.

What requires prior authorization in Medicare Advantage

Common prior auth triggers across major Georgia MA plans:

• Inpatient hospital admissions (other than emergency)
• Skilled nursing facility admissions
• Inpatient rehabilitation facility admissions
• Home health care
• Hospice transitions
• Durable medical equipment (DME) over a plan-set dollar threshold
• Outpatient surgery
• Advanced imaging (MRI, CT, PET, nuclear medicine)
• Specialty pharmacy drugs
• Outpatient therapy beyond a threshold (typically 20+ visits)
• Out-of-network specialist consultations
• Non-emergency ambulance transport

CMS rules on prior authorization

CMS has tightened MA prior authorization rules in recent years:

• 42 CFR 422.138 (added effective CY 2024): plans cannot use prior auth to circumvent Medicare coverage standards. If Original Medicare would cover the service, MA must too.
• Prior auth approval timeline: 14 days for standard requests, 72 hours for expedited (life/health jeopardy).
• Concurrent review for inpatient stays: plans cannot deny coverage for the full admission once a beneficiary has been admitted; ongoing review must be made daily or per case basis.
• Continuation of approved services: prior authorization approvals must remain valid for the duration of the approved course of treatment, even if it crosses plan years.

CY 2024-2025 reforms

The final rule for CY 2024 (CMS-4201-F) and CY 2025 (CMS-4205-F) implemented major reforms:

• Prior authorization decisions must consider beneficiary medical history, not just isolated diagnosis codes
• Internal coverage criteria that are more restrictive than Original Medicare are prohibited
• Denials must include specific clinical reasoning, not boilerplate
• Coverage continuation for transitioning enrollees: at least 90-day grace period for prior auth on existing course of treatment when switching MA plans

How prior auth interacts with network

For in-network providers: prior auth typically required for certain services; provider's office handles the request; beneficiary may not need to do anything.

For out-of-network providers: prior auth almost always required; can be obtained but requires demonstrating medical necessity AND network inadequacy or other valid out-of-network basis; more likely to be denied; appeal route under 42 CFR 422 Subpart M.

Common prior authorization disputes

• Denial of inpatient admission days beyond plan's projected length of stay
• Denial of skilled nursing facility days
• Denial of advanced imaging on basis of clinical criteria
• Denial of out-of-network specialty consultation
• Denial of home health care continuation
• Denial of specialty drug coverage

D-SNP plans and integrated Medicare-Medicaid networks

Dual Eligible Special Needs Plans (D-SNPs) are one of three types of Medicare Advantage Special Needs Plan, restricted to enrollees who have both Medicare and Medicaid.6 For Georgia's substantial dual-eligible population, D-SNPs offer coordinated benefits but also bring additional network complexity.

D-SNP structure

A D-SNP combines:

• Medicare benefits (Parts A, B, and typically D, governed by 42 CFR 422)
• Coordinated Medicaid coverage (typically through a state Medicaid Managed Care Organization contract or direct DCH arrangement)
• Supplemental benefits (dental, vision, hearing, transportation, OTC, food)

Georgia D-SNP carriers

Major D-SNP plans in Georgia (CY 2026):

• Humana Gold Plus D-SNP
• UnitedHealthcare Dual Complete D-SNP
• Aetna D-SNP
• Wellcare Dual Liberty D-SNP
• Anthem Dual Advantage D-SNP
• WellPoint MediBlue D-SNP

Network integration

D-SNPs must have networks that can deliver both Medicare-covered and Medicaid-covered services. This often means:

• Network of Medicare providers (PCPs, specialists, hospitals, etc.)
• Network of Medicaid providers (LTSS providers, behavioral health, community-based services)
• Care coordinators who navigate between Medicare and Medicaid benefits
• Single member ID card for both programs
• Coordinated grievances and appeals (D-SNPs subject to both Medicare 42 CFR 422 Subpart M and applicable Georgia Medicaid appeal rules)

Continuity of care across both programs

When a D-SNP enrollee changes plans, continuity-of-care protections apply to both the Medicare and Medicaid network sides:

• Medicare: 42 CFR 422.112(b)(5) standard 90-day extension for active treatment
• Medicaid: Georgia Medicaid managed care continuity rules (varies by Medicaid program)

FIDE-SNP and HIDE-SNP

Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNP) and Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNP) are advanced D-SNP categories with stronger Medicare-Medicaid integration. Georgia does not currently have FIDE-SNPs (which require state plan amendment and integrated capitation). Some plans operate as HIDE-SNPs.

D-SNP enrollment

Eligibility:

• Must have Medicare Part A and Part B
• Must have Georgia Medicaid (full or partial benefit)
• Continuous eligibility verification by plan
• Loss of Medicaid triggers Special Election Period to switch plans

D-SNP value proposition for duals

D-SNPs typically offer:

• No plan premium (Medicare pays the plan; Medicaid covers Medicare cost-sharing)
• Little or no cost-sharing on most services (Medicaid wraps around)
• Broad supplemental benefits including transportation, healthy food allowances, OTC allowances
• Care coordination across Medicare and Medicaid
• Coordinated LTSS (long-term services and supports) for those who qualify

The trade-off: D-SNP networks may be narrower than non-D-SNP MA plans, and the integration adds complexity around eligibility verification.

The Inflation Reduction Act and your drug coverage

The Inflation Reduction Act of 2022 (Public Law 117-169) changed Part D drug benefits in ways that carry into Medicare Advantage prescription-drug plans (MA-PD): Part D-covered adult vaccines now carry no cost-sharing, covered insulin is capped at a low fixed monthly amount, an annual out-of-pocket cap on Part D drug spending replaced the old catastrophic threshold, and Medicare now negotiates prices on selected high-cost drugs. These are drug-benefit changes, not network changes, but network rules still apply: you must fill prescriptions and get vaccines at an in-network pharmacy or provider. See Medicare.gov drug costs for the current year's figures.

Behavioral health network adequacy

Behavioral health (mental health and substance use disorder treatment) network adequacy has been a persistent challenge across Medicare Advantage plans nationally and particularly in Georgia. CMS introduced strengthened behavioral health network requirements effective CY 2024 (CMS-4201-F) and further CY 2025 reforms.

New behavioral health specialty types in HSD tables (CY 2024+)

CMS added the following specialty types to HSD network adequacy review:

• Clinical psychology
• Licensed clinical social work (LCSW)
• Marriage and family therapy
• Mental health counselors (LPC, LMFT)
• Addiction medicine specialists
• Opioid Treatment Programs (OTPs)

Time and distance standards for behavioral health

In Large Metro counties, the HSD criteria set tight time and distance limits to a behavioral health specialist, and CMS does not treat a primary care provider as an adequate substitute for mental health specialty care. In Rural and CEAC counties the limits are more permissive but still apply. Check the current CY HSD criteria memorandum for the exact time and distance figures by specialty and county.

Telehealth substitution

CMS permits limited telehealth substitution for in-person behavioral health when telehealth is offered and accepted by the enrollee. Telehealth in behavioral health is generally beneficiary-friendly because the modality works well for therapy and many medication management visits.

Georgia behavioral health network challenges

Georgia has chronic shortages of psychiatrists, addiction medicine physicians, and licensed therapists, particularly in rural counties. Many counties have zero in-network psychiatrists. MA plans rely heavily on telehealth and network adequacy exceptions.

Provider terminations and the 90/30 day notice

When a Medicare Advantage plan terminates a provider's network contract, federal rules establish notification timing and protective measures for affected enrollees.

30-day general notice

Plans must provide affected enrollees with written notice at least 30 days before the termination effective date. The notice must include:

• Identification of the terminated provider
• Effective date of termination
• List of alternative in-network providers (or instructions for finding one)
• Continuity-of-care rights
• Right to switch plans during the next AEP if a key provider is no longer in-network

Provider initiation versus plan initiation

The notification rule applies regardless of which party initiated the termination. A provider who chooses to leave the network triggers the same beneficiary notification as a plan who chooses to terminate the provider.

Special protections for primary care

For PCP terminations, plans must additionally:

• Help the enrollee select a new PCP (often through an assigned care coordinator)
• Process records transfer to the new PCP
• Coordinate any active referrals or prior authorizations
• Ensure no gap in coverage for ongoing prescriptions

Hospital and facility terminations

When an entire hospital, SNF, or other facility leaves the network, the 30-day notice still applies and continuity-of-care rights extend through any inpatient admission active at termination.

Worked example continued: Margaret's transition

Recall Margaret from earlier, whose PCP Dr. Smith was terminated from Humana effective August 1. Humana sent the 30-day notice on July 1 (technically 30+ days early, often plans aim for 60-90 days to give beneficiaries more time). The notice included:

• Statement that Dr. Smith would no longer be in-network as of August 1, 2026
• Reason for termination (not always disclosed, but in this case "mutual decision to end contract")
• List of 10 alternative in-network PCPs within 5 miles of Margaret's home
• Continuity-of-care rights explanation
• Contact for continuity-of-care requests: Humana Member Services 1-800-457-4708
• AEP reminder for plan changes if needed

Margaret successfully transitioned (described earlier).

How to evaluate Georgia Medicare Advantage network rules during enrollment

When selecting a Medicare Advantage plan during Annual Election Period (October 15 to December 7) or Initial Enrollment Period (around your 65th birthday), evaluating the network is critical. Steps:

1. Identify your current providers

Make a list of all healthcare providers you currently use:

• Primary care physician
• Specialists (cardiologist, oncologist, endocrinologist, etc.)
• Preferred hospitals
• Preferred pharmacies (for Part D coverage)
• Therapists or behavioral health providers
• Dentists or vision providers (for plans with these benefits)

2. Search each plan's provider directory

For each plan you are considering:

• Check the online provider directory at the plan's website
• Search for each of your current providers by name
• Note network status

3. Call providers to confirm

Provider directory inaccuracies are common. Call each provider's office and ask:

• "Do you accept [Plan Name] Medicare Advantage for 2026?"
• "Are you in-network or out-of-network?"
• "Are you accepting new patients on this plan?"

4. Verify hospital network status

Hospitals contract separately. Confirm:

• Your preferred hospital is in-network
• Specifically, the specific facility you would use (some health systems have facilities in different network statuses)

5. Check specialty access

For any chronic conditions:

• Verify specialist availability in your area
• Check wait times for new patient appointments
• Verify your preferred specialist is in-network

6. Pharmacy network

For Part D coverage:

• Check whether your preferred pharmacy is in-network
• Note differences between "standard" and "preferred" pharmacies (preferred typically lower cost)
• Verify mail-order options if applicable

7. Service area verification

Confirm the plan's service area includes your zip code. Some plans have very narrow service areas (county-specific or partial county).

8. Tier and cost-sharing review

For PPO plans with tiered networks, check tier status of each provider. For all plans, compare:

• PCP and specialist copays
• Inpatient hospital copay
• Specialty drug coverage
• Maximum out-of-pocket (MOOP) for in-network and combined

9. Continuity considerations

If you have ongoing treatment, evaluate continuity-of-care implications:

• Will your active treatment be disrupted?
• Will you need to transfer to a new specialist?
• Does the new plan have your treating physician in network?

10. GeorgiaCares SHIP consultation

For free, unbiased Medicare counseling tailored to your situation, contact GeorgiaCares SHIP at 1-866-552-4464 (option 4), Monday through Friday, 8 a.m. to 5 p.m. SHIP counselors do not sell insurance and can review plans against your specific provider preferences and health profile.2

The bottom line: networks determine your real benefit

For the many Georgians enrolled in Medicare Advantage, the network is not a footnote. It is the single most consequential element of plan design after the monthly premium. Every MA plan must cover what Original Medicare covers except hospice and must cap your in-network out-of-pocket spending, but the doctors you can see, the hospitals where you can be admitted, the specialists you can consult, and the costs you actually pay all flow from network design and your understanding of it.3

Federal law gives you meaningful protection: access standards operationalized through CMS HSD tables; provider directory accuracy requirements with civil penalties for non-compliance; continuity-of-care protections when a provider leaves your plan; emergency care coverage at any hospital in the United States under 42 CFR 422.113 (not the No Surprises Act, which excludes Medicare Advantage); and a multi-level appeals framework culminating in federal court review.

You also have practical tools. Annual Election Period (October 15 to December 7) and Medicare Advantage Open Enrollment Period (January 1 to March 31) let you change plans annually. Special Election Periods accommodate qualifying life events. GeorgiaCares SHIP provides free Medicare counseling. Original Medicare with Medigap remains an option if MA networks don't work for your situation, because Original Medicare has no provider network.

The work is being informed. Review your plan's provider directory each AEP. Confirm in-network status with providers directly before scheduling non-emergency care. Invoke continuity-of-care protections when providers leave your plan. Know the appeal process when denials happen. Use the resources available.

For the Georgia families managing complex care, this is where the real Medicare Advantage value calculation lives.

Learn More

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.