Georgia Medicare Advantage Network Rules Guide

Most Georgia Medicare beneficiaries enrolled in a Medicare Advantage (Part C) plan receive their Medicare benefits through a private plan rather than directly from CMS. For those Georgians, the network rules of their MA plan often matter more than the underlying Medicare benefit framework, because the network determines who can deliver covered services without unexpected out-of-pocket cost.

The Medicare Advantage network framework is governed 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 establish maximum time and distance standards and minimum provider counts across many specialty types and across five county designation categories: Large Metro, Metro, Micro, Rural, and CEAC (Counties with Extreme Access Considerations).

Beneficiaries are protected by 42 CFR 422.111(b) and (h) provider directory accuracy requirements (updates required at least every 30 days, with civil penalties for material inaccuracies), 42 CFR 422.112(b)(5) continuity-of-care protections (extended access to a terminated provider for active treatment, through delivery for pregnancy second/third trimester, through end of life for hospice), the No Surprises Act (Public Law 116-260, effective January 1, 2022) banning balance billing for out-of-network emergency services, and 42 CFR 422 Subpart M appeal rights culminating in federal district court review.

This guide explains the Medicare Advantage network rules framework end-to-end: the statutory and regulatory architecture, the operational 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 terminates a provider mid-year, the No Surprises Act protections for emergency care, the network adequacy exception process for rural and CEAC counties, the appeals framework, and the network footprints of the major Georgia MA carriers (Humana, UnitedHealthcare, Aetna, Wellcare, Cigna, Kaiser Permanente Georgia, and Anthem Blue Cross Blue Shield).

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 assistance, contact GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling.

By Brevy Care Team · Last verified May 13, 2026

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 incentivize beneficiaries to use 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. Provider selection is therefore central to the value proposition 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 federal law (the No Surprises Act and longstanding Medicare emergency rules), but knowing your rights matters when 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 pre-dates the No Surprises Act and remains the baseline emergency framework.

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 counties into five categories based on population density and accessibility:

Large Metro: high-population urban counties (Atlanta core: Fulton, DeKalb, Cobb, Gwinnett, Clayton, Henry, Cherokee, Forsyth, Paulding, and other metro Atlanta counties)

Metro: medium-population urban counties (Bibb/Macon, Richmond/Augusta, Chatham/Savannah, Muscogee/Columbus, and many other Georgia counties)

Micro: small urban centers (numerous Georgia counties)

Rural: low-density counties without significant urban centers (a large share of Georgia counties)

CEAC (Counties with Extreme Access Considerations): counties with severe provider scarcity. Several Georgia counties carry the CEAC designation; check the current CY CMS county designation table for the latest list.

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 active mild cognitive impairment workup: she can request 90-day extended access to Dr. Smith for completion of the diagnostic evaluation 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

For specific clinical scenarios, the plan must continue to cover services from the terminated provider for a transition period:

Active treatment of acute conditions: 90 days extended access. Examples: ongoing chemotherapy regimens, recent surgical recovery, active wound care, active rehabilitation.

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

Pregnancy second/third trimester: through delivery and post-partum (4-6 weeks).

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

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 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

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 higher combined or out-of-network MOOP limits, so James would face a substantial out-of-pocket exposure for an extended out-of-network treatment course.

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 in-network appointment availability exceeds CMS access standards (typically 14 days for 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 6: 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 $0 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 and the No Surprises Act

Emergency medical care is the area of strongest beneficiary protection. Multiple federal laws apply:

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

Medicare Advantage plans must cover emergency services at any hospital, regardless of network status, at no greater cost-sharing than in-network emergency services. This is a longstanding Medicare rule predating the No Surprises Act.

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.

No Surprises Act (Public Law 116-260, Title I of the Consolidated Appropriations Act 2021)

Effective January 1, 2022, the No Surprises Act adds federal balance-billing protection:

• Balance billing prohibited for emergency services at out-of-network facilities
• Out-of-network professional services at in-network facilities (anesthesiologists, pathologists, radiologists, hospitalists, etc.) also covered at in-network cost-sharing without balance billing
• Air ambulance services out-of-network covered at in-network cost-sharing
• Independent Dispute Resolution (IDR) for payment disputes between plans and out-of-network providers (does not affect beneficiary)

Worked example 4: 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 under the No Surprises Act
• 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 by the out-of-network anesthesiologist or radiologist who participated in his care at Northside Cherokee, those professional services would also be covered at in-network cost-sharing under the No Surprises Act's "out-of-network professionals at in-network facilities" provision (in this case, "out-of-network facility but emergency care," which gets the same treatment).

Georgia MA carrier-specific network footprints

Humana

Among the largest Medicare Advantage carriers in Georgia. 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.).

Member services: 1-800-457-4708.

UnitedHealthcare

Major Georgia MA carrier with a 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.

Member services: 1-800-721-0627.

Aetna (CVS Health)

Major Georgia MA carrier with a statewide network. Integration with CVS Pharmacy (mail-order prescriptions, MinuteClinic urgent care).

Member services: 1-833-570-6670.

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.

Member services: 1-877-374-4056.

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.

Member services: 1-888-865-5813.

Cigna

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

Member services: 1-800-668-3813.

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.

Member services: 1-833-848-1014.

Smaller and exit carriers

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

Worked example 5: 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
• $0 monthly premium
• $0 PCP copay, $40 specialist copay
• $0 generic Part D drugs, modest brand copays
• 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:

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 plan upholds denial, the case automatically moves to MAXIMUS Federal Services (currently the IRE contractor) 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, hospitalists at an in-network facility may contract separately. The No Surprises Act protects against balance billing for out-of-network professionals at in-network facilities.

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: 40 percent coinsurance on a $200,000 procedure is $80,000 (subject to MOOP). Confirm cost before scheduling out-of-network care.

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.

A few more common questions:

What is a Medicare Advantage network? It is the group of doctors, hospitals, and other providers that have contracted with your MA plan to provide services at agreed-upon rates. Services from in-network providers are covered at lower cost-sharing; out-of-network services may not be covered at all (HMO) or covered at higher cost-sharing (PPO).

Can I see any doctor with Medicare Advantage? Generally no. HMO plans cover only in-network providers (except emergencies). PPO plans cover out-of-network but at higher cost. PFFS plans are an exception but are rare.

What does "continuity of care" mean? When your plan terminates a provider contract, you can continue receiving services from that provider for a transition period if you are in active treatment for an acute condition, through delivery and post-partum for pregnancy, or through end of life for hospice. You must request this protection.

What is "urgent care outside the service area"? Care you need urgently while traveling outside your plan's service area but that is not an emergency. MA plans must cover this at in-network cost-sharing. Within the service area, urgent care depends on plan rules.

How do MA plans handle out-of-state travel? Short-term travel: emergency and urgent care covered at in-network cost-sharing. Non-emergency care at out-of-network providers: HMO not covered, PPO covered at higher cost-sharing. Extended absence (6+ months out of service area) may trigger disenrollment for non-residency.

What is a CEAC county? "Counties with Extreme Access Considerations." A CMS designation for counties with severe provider scarcity. Network adequacy standards are most permissive in CEAC counties. Several Georgia counties carry the CEAC designation.

My MA plan's only in-network cardiologist is far away. What can I do? Check whether the plan has a network adequacy exception in your county and what alternative access arrangements exist (telehealth, transportation, out-of-network at in-network rates); request an out-of-network referral for excessive wait time or other access barrier; switch plans at AEP to one with a better local network; or consider Original Medicare with Medigap (no network restrictions).

What is a provider directory, and how accurate is it? A provider directory is the list of in-network providers your plan publishes. CMS requires updates at least every 30 days. CMS audits routinely find a large share of entries with at least one inaccuracy. Always confirm with the provider before scheduling.

Can my MA plan change networks mid-year? Plans add and remove providers throughout the year. The plan must give advance notice before terminating a provider you use. Plans cannot change the overall service area mid-year except in extraordinary circumstances.

What is a D-SNP? Dual Eligible Special Needs Plan: a Medicare Advantage plan restricted to enrollees with both Medicare and Medicaid. D-SNPs typically have integrated Medicare-Medicaid benefits and networks. Several Georgia carriers offer D-SNPs.

How do tiered networks work? Some MA plans (mostly PPOs) categorize in-network providers into tiers: Tier 1 (preferred, lowest cost-sharing), Tier 2 (standard in-network, higher cost-sharing), and out-of-network (highest). The plan's marketing must disclose tier structure.

What is a closed-network HMO like Kaiser Permanente Georgia? A staff-model HMO where all care is delivered at the plan's own facilities by plan-employed physicians. There is no separate provider network because the plan and providers are the same organization. Highly integrated care but limited specialty access outside the system.

What are the major MA carriers in Georgia? Humana, UnitedHealthcare, Aetna, Wellcare, Cigna, Kaiser Permanente Georgia (north metro only), and Anthem Blue Cross Blue Shield, with smaller carriers also in the market.

Can I keep my current providers when I switch to MA? Only if they are in the network of your selected MA plan. Verify each provider's network status before enrolling. If a key provider is not in any plan's network, consider Original Medicare with Medigap instead.

Does Medicare Advantage cover all the same services as Original Medicare? Yes, MA plans must cover all Original Medicare-covered services (Section 1852(a)). They may impose different cost-sharing structures and prior authorization requirements. They also typically add supplemental benefits.

What if I move to a different state? You may need to disenroll from your current MA plan and select a new plan in your new service area. Moving is a qualifying event for a Special Election Period. Contact your plan and Medicare immediately upon moving.

My PPO plan covers out-of-network. Why does it still cost so much? PPO out-of-network coinsurance is meaningfully higher than in-network. On expensive services this can mean thousands or tens of thousands of dollars. The MOOP cap protects you from unlimited costs, but you can still incur substantial costs before hitting the cap.

Should I have Medicare Advantage or Original Medicare with Medigap? This depends on personal circumstances: provider preferences (Medigap allows any Medicare provider; MA limits to network); supplemental benefits needs; travel patterns; cost; and prescription drug needs. GeorgiaCares SHIP can help analyze your specific situation: 1-866-552-4464.

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 threshold ($500-1,500 typical)
• 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 Medicare Advantage plans restricted to enrollees who have both Medicare and Medicaid. 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:

• $0 premium (Medicare pays the plan; Medicaid covers Medicare cost-sharing)
• $0 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 Medicare Advantage

The Inflation Reduction Act of 2022 (Public Law 117-169) has several provisions affecting Medicare Advantage networks and benefits:

Part D adult vaccines at $0 cost-sharing

All Part D-covered adult vaccines (shingles, RSV, Tdap, MMR, varicella, etc.) are $0 cost-sharing. This applies to Original Medicare Part D and Medicare Advantage Part D combined plans (MA-PD). Plans cannot apply deductibles, copays, or coinsurance to these vaccines. Network rules still apply: vaccines must be obtained at an in-network pharmacy or provider.

Insulin cost-sharing cap

Part B and Part D insulin is capped at $35 per month per prescription. Applies in MA plans.

Part D out-of-pocket cap

A new annual out-of-pocket cap on Part D drug spending now applies in Original Medicare Part D and MA-PD plans, replacing the prior catastrophic coverage threshold. See Medicare.gov drug costs for the current cap.

Medicare drug price negotiation

Medicare now negotiates prices on selected high-cost drugs. Negotiated prices apply in Part D plans including MA-PD.

These changes shift the economic value of certain MA plans and may affect plan network strategies (e.g., specialty pharmacy networks).

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

For Large Metro counties: 5 miles or 10 minutes to a behavioral health specialist (PCPs are not adequate substitutes for mental health specialty care, per CMS). For Rural and CEAC counties, standards are more permissive but still apply.

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 MA plan networks 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. SHIP counselors can review plans against your specific provider preferences and health profile.

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. 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.

Federal law gives you meaningful protection: access standards that are operationalized through CMS HSD tables; provider directory accuracy requirements with civil penalties for non-compliance; continuity-of-care protections when providers leave your plan; emergency care coverage anywhere in the United States; balance billing prohibition under the No Surprises Act; 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.

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.