Georgia Medicaid Providers and Network Adequacy: A Complete Guide to CMS-2439-F, Provider Directories, and Continuity of Care

Network adequacy is the requirement that a Medicaid managed care plan have enough in-network providers, distributed appropriately by geography, and available with reasonable wait times, to actually deliver the covered services that the plan nominally provides. The principal federal authorities are Section 1932(b)(5) of the Social Security Act, 42 CFR 438.68 (network adequacy standards), 42 CFR 438.206 (availability of services), 42 CFR 438.207 (assurances of adequate capacity), 42 CFR 438.62 (continuity of care), 42 CFR 438.10 and 42 CFR 438.10(h) (provider directories), 42 CFR 438.214 (provider selection), and 42 CFR 438.358 (External Quality Review). The most consequential recent change is CMS Final Rule CMS-2439-F, published in the Federal Register on May 10, 2024 (89 FR 41002), which fundamentally restructured Medicaid managed care access through quantitative time-and-distance standards, appointment wait time standards, secret shopper studies, and a Beneficiary Advisory Council. The No Surprises Act of 2020 (Consolidated Appropriations Act 2021 Division BB) further strengthened provider directory accuracy requirements. Mental health parity at 42 CFR 438.910 imposes network composition obligations that intersect with network adequacy. In Georgia, the Department of Community Health enforces network adequacy through CMO contracts with Amerigroup Community Care, CareSource Georgia, and Peach State Health Plan, supplemented by carve-out contractors DentaQuest (dental), Avesis (vision), and MTM/Modivcare (Non-Emergency Medical Transportation). This guide translates the network adequacy framework for Georgia families, providers, and stakeholders: what counts as an adequate network, how providers enroll, how directories must operate, what continuity of care protects, and how to respond when the network falls short.

What network adequacy is and why it matters

By Brevy Care Team · Last verified May 12, 2026

Network adequacy is the operational backbone of managed care. A Medicaid managed care plan nominally covers a broad set of benefits, but those benefits are accessed through in-network providers. If the plan's in-network providers are too few, located too far away, or unable to see patients within reasonable wait times, the benefits become theoretical. The enrollee has Medicaid coverage but cannot get care.

Federal Medicaid law has long required that managed care plans maintain adequate networks. The statutory hook is Section 1932(b)(5) of the Social Security Act, which requires state Medicaid managed care contracts to ensure adequate access. Regulatory implementation has evolved through CMS rulemaking, with the 2016 Managed Care Final Rule (CMS-2390-F) and the 2024 Final Rule (CMS-2439-F) being the two most consequential restructurings.

Network adequacy is not a single standard. It is a multi-dimensional requirement that addresses:

1. Capacity: enough providers in total to serve the enrolled population.
2. Geographic distribution: providers located close enough to enrollees, with consideration for rural and urban differences.
3. Timeliness: providers available to provide care within reasonable wait times, varying by service type and clinical urgency.
4. Type diversity: enough variety of provider types to address the full range of covered services.
5. Cultural and linguistic capacity: providers who can serve the population's cultural and linguistic needs.
6. Disability accessibility: facilities accessible to individuals with disabilities.
7. Telehealth: as an addition to in-person networks, not a substitute.

Network adequacy intersects with several other Medicaid frameworks:

• Mental health parity (42 CFR 438.910): network composition for mental health and substance use disorder services must be comparable to that for medical and surgical services.
• Continuity of care (42 CFR 438.62): network changes cannot disrupt ongoing treatment without protected transition periods.
• Provider directory accuracy (42 CFR 438.10): the network is only useful if enrollees can find it.
• External Quality Review (42 CFR 438.358): the state validates network adequacy annually through an independent quality review organization.

The federal network adequacy framework

Section 1932(b)(5) of the Social Security Act

The principal statutory authority. Section 1932(b)(5) requires state Medicaid managed care contracts to ensure adequate access to services, with particular attention to:

• Hours of operation.
• Geographic distance.
• Language accessibility.
• Cultural competence.
• Specialty care availability.

42 CFR 438.68: Network adequacy standards

42 CFR 438.68 is the principal regulatory standard, substantially revised by CMS-2439-F in May 2024. The current standard requires states to establish quantitative network adequacy standards for specified provider types using:

1. Time and distance standards: maximum travel time or distance from enrollee location to nearest in-network provider.
2. Appointment wait time standards: maximum time between request for appointment and being seen.
3. Provider-to-enrollee ratio standards: in some contexts.

The specified provider types include:

• Primary care (adult and pediatric)
• OB-GYN
• Behavioral health (outpatient mental health and SUD, both adult and pediatric)
• Specialist providers (designated by state)
• Hospitals
• Pharmacy
• Pediatric subspecialty (where applicable)
• Long-term services and supports providers

The state must define each standard, monitor compliance, validate through External Quality Review, and publicly report.

42 CFR 438.206: Availability of services

Requires managed care entities to maintain a network sufficient to provide adequate access to all covered services. The network must include:

• Sufficient total capacity to serve the population.
• Variety of provider types to address the full benefit package.
• Geographic distribution consistent with the enrolled population.
• 24-hour, 7-day-a-week access to emergency services.
• Telehealth as an addition to (not a substitute for) in-person network.

42 CFR 438.207: Assurances of adequate capacity

Requires the managed care entity to give the state assurance of adequate capacity:

1. At the time the contract is signed.
2. Annually thereafter.
3. Any time there is significant change (5% or greater change in services, benefits, geographic service area, payments, or contracting practices that would affect network adequacy).

The assurance must document the number and type of providers, geographic locations, cultural and linguistic capabilities, and whether the network can serve the population.

42 CFR 438.214: Provider selection

Requires the managed care entity to have written policies for selection and retention of providers. Policies must address credentialing consistent with state law, non-discrimination, disclosure of selection criteria, and the right to terminate.

42 CFR 438.62: Continuity of care

Requires the managed care entity to ensure continuity of care during transitions. Three principal transition scenarios:

1. Enrollee transitions into the plan: especially during enrollment in a managed care program or when changing plans.
2. Provider leaves the network: voluntary departure.
3. Plan terminates a contract with a provider: involuntary termination.

Continuity of care protections typically require the plan to allow the enrollee to continue seeing an out-of-network or terminated provider for a defined period (typically 60 to 90 days) for ongoing treatment needs.

42 CFR 438.10: Information requirements and provider directories

Requires the managed care entity to maintain a provider directory that lists current and prospective providers, includes provider name, address, phone, specialty, qualifications, languages, identifies providers accepting new patients, updates within 30 days of changes, and is available online and in print upon request.

42 CFR 438.10(h): Directory content and accuracy

The 2016 final rule and 2024 final rule strengthened directory requirements. Plans must:

• Update directories at least once every 30 days.
• Verify provider information with each provider quarterly.
• Indicate whether providers are accepting new patients.
• Identify cultural and linguistic capabilities.
• Show telehealth availability.

The No Surprises Act of 2020 (CAA 2021 Division BB)

The No Surprises Act, enacted as part of the Consolidated Appropriations Act 2021, imposed federal provider directory accuracy requirements on all health insurance plans (commercial, Medicare Advantage, federal employee health plans). Plans must update directories every 90 days, verify with providers every 90 days, establish a process for consumers to confirm provider network status, and hold consumers harmless for relying on inaccurate directory information. Medicaid managed care directories under CMS-2439-F align with this framework.

CMS Final Rule CMS-2439-F (May 10, 2024)

The most consequential Medicaid managed care rule since 2016. Published in the Federal Register on May 10, 2024 at 89 FR 41002. Effective with phased implementation through July 9, 2027. Key provisions:

Quantitative network adequacy standards (42 CFR 438.68 revised):

• Time-and-distance: state-specific based on rural and urban geography.
• Appointment wait times: for routine, urgent, and behavioral health appointments.
• Required reporting and validation by the state.

Secret shopper studies (new):

• States must contract with an independent entity to conduct secret shopper studies.
• Studies measure whether providers in the directory are actually accepting new patients, are reachable, and offer appointments within standards.
• Results must be publicly reported.

Enrollee experience surveys (revised):

• Required Consumer Assessment of Healthcare Providers and Systems (CAHPS) administration.
• Enrollee experience reporting.

Quality strategy (revised):

• States must publish a comprehensive Medicaid managed care quality strategy.
• Public input required.
• Annual reporting.

Payment rate disclosure:

• States must publish managed care fee schedules and capitation rates.
• Public access through state Medicaid websites.

Beneficiary Advisory Council:

• States must establish a Beneficiary Advisory Council with consumer representation.
• Council must meet regularly and provide input to the state Medicaid agency.

42 CFR 438.358: External Quality Review

Requires state Medicaid agencies to conduct annual EQR of managed care entities through an independent External Quality Review Organization (EQRO). Georgia's EQRO is HSAG (Health Services Advisory Group). EQR includes validation of performance measures, validation of performance improvement projects, review of compliance with regulatory standards including network adequacy, network adequacy validation, encounter data validation, and information system review.

42 CFR 438.910: Mental health parity and network composition

The 2016 Medicaid Parity Final Rule codified at 42 CFR 438.910 requires that NQTLs applied to MH/SUD benefits (including network composition standards) be comparable to and applied no more stringently than NQTLs applied to medical and surgical benefits. The September 2024 MHPAEA Final Rule strengthened network composition analysis requirements further. The intersection of parity and network adequacy is one of the most consequential enforcement areas: a thin behavioral health network is potentially both a network adequacy violation and a parity violation. Detail on parity is available in our mental health parity guide.

Provider enrollment in Medicaid

ACA 2010 Section 6401 and 42 CFR Part 455 Subpart E

The Affordable Care Act enhanced provider enrollment and screening requirements:

• Application fee for institutional providers.
• Background checks.
• Site visits for moderate and high-risk providers.
• Termination cross-program (Medicare/Medicaid).
• Provider revalidation every five years.

Implementing regulations at 42 CFR Part 455 Subpart E establish risk tiers:

• Limited risk: physicians, group practices, hospitals, FQHCs, RHCs.
• Moderate risk: ambulance, day services for intellectual and developmental disabilities, hospice, pharmacy, portable x-ray, behavioral health agencies.
• High risk: durable medical equipment suppliers (new enrollees), home health agencies (new enrollees).

Each tier has different screening requirements. 42 CFR 455.434 requires pre-enrollment site visits for moderate and high-risk providers. ACA Section 6501 created cross-program termination authority: a provider terminated from Medicare or another state's Medicaid program is terminated from all state Medicaid programs.

Provider revalidation

Providers must revalidate every five years. Failure to revalidate results in termination from Medicaid. CMS makes the revalidation cycle and process accessible through state Medicaid systems.

Anti-Kickback Statute and Stark Law compliance

42 CFR 1001.952 (Anti-Kickback Statute safe harbors) and 42 USC 1395nn (Stark Law) constrain provider arrangements. Common safe harbors include personal services and management contracts, space rental, equipment rental, and bona fide employment. Provider arrangements must be structured to fit within applicable safe harbors and exceptions or face substantial civil and criminal exposure. Detail on program integrity is available in our encounter data and program integrity guide.

Georgia provider enrollment

DCH Office of Provider Enrollment

The single point of provider enrollment for Georgia Medicaid. Contact:

• Phone: 1-800-766-4456
• Website: dch.georgia.gov

The Provider Enrollment process includes:

1. Initial enrollment application through the Gateway Provider portal.
2. Verification of licensure, certification, accreditation.
3. Site visit for moderate or high-risk providers.
4. Background screening.
5. Provider Type / Specialty designation.
6. Revalidation every five years.
7. Termination procedures.

Georgia CMO credentialing

Each Georgia CMO operates its own credentialing process within the framework of DCH provider enrollment. Common CMO credentialing requires:

• Valid Georgia professional license.
• DEA registration (where applicable).
• Professional liability insurance.
• Board certification (preferred for most specialties).
• Background check.
• Practice site verification.
• Provider directory listing accuracy commitment.

A provider must be credentialed by each CMO with which they want to participate. National Committee for Quality Assurance (NCQA) standards inform many CMO credentialing processes.

Carve-out provider networks

Several benefits are delivered through carve-out contractors rather than directly through the CMOs:

• Dental: DentaQuest Georgia administers dental benefits for all three CMOs. DentaQuest builds its own dental provider network.
• Vision: Avesis administers vision benefits.
• Non-Emergency Medical Transportation (NEMT): MTM/Modivcare arranges NEMT through a transportation provider network.
• Pharmacy: each CMO administers its own pharmacy benefit through a Pharmacy Benefits Manager (PBM).
• Behavioral health: each CMO administers its own BH benefit. Some have BH carve-out subcontractors; others integrate BH directly.

Georgia Medicaid Provider Manual

DCH's principal provider guidance document. Updated regularly. Available at the DCH provider portal. The Provider Manual specifies billing codes, reimbursement, prior authorization, documentation, and policy requirements. CMO provider manuals supplement the DCH manual with plan-specific information.

Network adequacy by service type

Federal regulation does not specify exact time-distance or appointment wait time numbers; states define them. The numbers below reflect typical Georgia standards as implemented under CMS-2439-F.

Primary care (adult and pediatric)

• 30 minutes or 10 miles urban time-distance.
• 60 minutes or 30 miles rural time-distance.
• 10-day routine appointment wait time.
• 1-day urgent appointment wait time.

OB-GYN

• 30 minutes or 10 miles urban time-distance.
• 60 minutes or 30 miles rural time-distance.
• 14-day routine appointment wait time.
• 7-day prenatal appointment wait time.

Behavioral health (outpatient)

The most network-inadequate area in Georgia and nationally. Typical standards:

• 30 minutes or 30 miles time-distance (urban and rural).
• 10-day routine appointment wait time.
• 6-hour appointment wait time for crisis.
• 48-hour appointment wait time for post-discharge from inpatient psychiatric.

Specialty care

• 30 minutes or 30 miles urban time-distance.
• 90 minutes or 60 miles rural time-distance.
• 20-day routine appointment wait time.

Hospitals

• 30 minutes or 10 miles urban time-distance.
• 60 minutes or 30 miles rural time-distance.

Pharmacy

• 15 minutes or 5 miles urban time-distance.
• 30 minutes or 10 miles rural time-distance.

Dental

• 30 minutes or 10 miles urban time-distance.
• 60 minutes or 30 miles rural time-distance.
• 30-day routine appointment wait time.

Telehealth in network adequacy

42 CFR 438.206(c)(1)(ii)

Allows managed care plans to use telehealth as part of network adequacy demonstration, but only as an addition to in-person network, not as a substitute. Plans must offer:

• In-person provider access meeting time-distance standards.
• Telehealth as an additional option for enrollees who prefer or require it.

CMS-2439-F clarified that telehealth cannot fully substitute for in-person network for required provider types. The rule recognizes that telehealth is essential for certain services (especially behavioral health) and certain populations (rural, mobility-limited) but cannot fully replace in-person care.

Georgia telehealth

Georgia Medicaid covers telehealth for:

• Established primary care visits.
• Behavioral health (extensively expanded post-2020).
• Medication management.
• Some specialty consultations.

Originating site, distant site, and synchronous/asynchronous rules apply per the Georgia Medicaid Telehealth Manual.

Provider directories

Why directory accuracy matters

A provider directory is the practical entry point to the network. Enrollees use the directory to find providers, confirm in-network status, and schedule appointments. If the directory is inaccurate (listing providers who have closed practices, are not accepting new patients, or have moved), the network's effective access is much lower than its nominal access.

Studies of Medicaid managed care directories have repeatedly found significant inaccuracy. The most common issues:

1. Phantom providers: listed but unreachable or no longer practicing.
2. Closed panels: listed but not accepting new patients.
3. Wrong specialty: listed under a specialty the provider does not actually practice.
4. Stale contact information: phone, address, or email no longer current.
5. Inactive status: listed but the provider has retired, moved, or terminated.

Federal directory requirements

42 CFR 438.10(h) (revised by CMS-2439-F) requires Medicaid managed care directories to:

1. Update at least every 30 days.
2. Verify with each provider at least quarterly.
3. Indicate whether providers are accepting new patients.
4. Identify cultural and linguistic capabilities.
5. Show telehealth availability.
6. Be available online and in print upon request.
7. Include accessibility features for individuals with disabilities.

The No Surprises Act of 2020 (CAA 2021 Division BB Section 116) imposes similar requirements on commercial and Medicare Advantage plans. The two frameworks are intentionally aligned.

Holding plans accountable for directory accuracy

The No Surprises Act includes consumer hold-harmless provisions: if a consumer relies on inaccurate directory information and incurs out-of-network charges as a result, the consumer pays only in-network cost-sharing and the plan is responsible for the balance. Medicaid managed care does not have a fully parallel hold-harmless provision, but CMS expects plans to maintain accurate directories and not penalize beneficiaries for directory inaccuracies.

Continuity of care

42 CFR 438.62

The plan must ensure continuity of care during transitions, allow continued access to current providers for specified periods after enrollment, provider termination, or contract changes, communicate clearly with enrollees about provider changes, and honor active prior authorizations from previous coverage during transition periods.

Typical continuity periods

• New enrollment: 90 days to continue with prior primary care or specialty providers not in the new network.
• Pregnancy: through the end of pregnancy and the 12-month postpartum period under Georgia's CAA 2023 Section 5112 extension.
• Active chronic disease management: 90 days; longer for documented active episodes.
• Cancer treatment: through the current course of chemotherapy or radiation.
• Transplant: through the procedure and post-procedure recovery.
• Mental health and substance use disorder treatment: 90 days, longer for active treatment episodes.
• Skilled nursing or rehabilitation episode: through the active treatment episode.

Provider termination protections

When a CMO terminates a provider (voluntarily or involuntarily), 42 CFR 438.62 requires:

1. Notice to affected enrollees at least 60 days in advance (where feasible).
2. Identification of in-network alternatives.
3. Continuity of care for ongoing treatment, as above.
4. Honoring of prior authorizations during the transition.

If the provider terminates voluntarily, the CMO must give enrollees notice and alternatives. If the CMO terminates the provider, the same applies. Either way, ongoing treatment cannot be disrupted without protected transition periods.

Georgia network challenges

Behavioral health

Georgia has chronic behavioral health provider shortages, particularly:

• Pediatric psychiatry: concentrated in Atlanta and Augusta, sparse elsewhere.
• Child and adolescent psychotherapy: thin in rural areas.
• Inpatient psychiatric beds for adolescents: limited statewide.
• Addiction medicine specialists: concentrated in metro areas.
• Rural outpatient behavioral health: scarce.

The 2022 Mental Health Parity Act of Georgia (House Bill 1013) included workforce development provisions. Results have been incremental. The combination of CMS-2439-F's behavioral health standards and 42 CFR 438.910 parity requirements gives DCH stronger enforcement tools.

Specialty dental

Georgia Medicaid dental network depth varies significantly. Pediatric dental is comprehensive under CHIP and Medicaid; adult dental is limited. Specialty pediatric dental (orthodontics, oral surgery, special needs) is particularly thin in rural areas. DentaQuest's network covers most of Georgia for routine care, but specialty access often requires travel.

Rural primary care

Georgia has 159 counties. Many rural counties are designated Health Professional Shortage Areas (HPSAs). At least 23 counties have severe primary care shortages. Federally Qualified Health Centers under Section 330 of the Public Health Service Act provide critical safety-net infrastructure (40 or more FQHC organizations across the state). Rural Health Clinics (100 or more) and Critical Access Hospitals fill additional gaps.

Women's health

Obstetric and gynecologic access is concentrated in metro areas. Rural counties often lack obstetricians; pregnant women may travel 60 or more miles for prenatal care. CMS-2439-F's 60-minute or 30-mile rural OB-GYN standard is aspirational in much of Georgia. The state's persistently high maternal mortality rate is intertwined with this access gap.

Post-acute care

Skilled nursing facilities, home health agencies, hospice, and rehabilitation services vary widely. Quality concerns and network gaps are documented in Long-Term Care Ombudsman reports and DCH oversight. Detail on long-term care framework is available in our nursing facility level of care guide.

CMS-2439-F implementation timeline

Phased implementation through July 9, 2027:

• July 9, 2024: rule becomes effective.
• July 9, 2025: initial state implementation of payment rate disclosure and appointment wait time standards.
• July 9, 2026: secret shopper studies begin.
• July 9, 2027: full implementation including Beneficiary Advisory Council.

Georgia is in the active implementation phase as of 2026. DCH has begun publishing payment rate information, building secret shopper contracting capacity, and developing Beneficiary Advisory Council structures.

Worked example 1: Tasha 26 Atlanta pregnant OB-GYN access

Tasha is 26, lives in Atlanta, and enrolled in Peach State Health Plan when she became pregnant. She needs to schedule her first prenatal appointment.

Process:

1. Tasha checks the Peach State provider directory online.
2. She filters for in-network OB-GYNs within 10 miles of her zip code.
3. The directory shows 47 in-network OB-GYNs.
4. She calls three to schedule. All confirm they are accepting new Peach State Medicaid patients.
5. She schedules her first prenatal appointment within 7 days (well within the CMS-2439-F prenatal appointment wait standard).

If she had encountered access issues such as closed panels, phantom providers, or extended wait times:

1. File a complaint with Peach State.
2. Request out-of-network authorization for an alternative provider.
3. File a complaint with DCH at 1-866-211-0950.
4. Reference 42 CFR 438.207 and 42 CFR 438.68 standards.
5. Document the directory inaccuracy as input to the CMS-2439-F secret shopper study.

Worked example 2: Eleanor 78 Macon stroke continuity of care

Eleanor is 78, lives in Macon, dual eligible with Amerigroup as her Medicaid CMO. She has an ischemic stroke. After hospital discharge, she is transferred to a skilled nursing facility for post-stroke rehabilitation. The SNF is not in Amerigroup's network.

Continuity of care under 42 CFR 438.62:

1. Eleanor remains in the SNF for ongoing post-stroke rehabilitation.
2. Amerigroup must honor the out-of-network SNF for the continuing rehabilitation episode. Typical continuity for active rehabilitation is through completion of the rehab episode or 90 days, whichever is longer.
3. Amerigroup pays the SNF at in-network or negotiated transition rate.
4. Amerigroup coordinates Eleanor's transition to an in-network SNF if she needs ongoing care beyond the continuity period.
5. Eleanor's prior authorizations for medications, therapies, and DME from her hospital admission must be honored during the transition.

If Amerigroup refuses continuity:

1. File internal appeal.
2. Request external review.
3. File a complaint with DCH.
4. File a complaint with the Medicare ombudsman (since Eleanor is dual eligible).
5. State Fair Hearing.

Worked example 3: Marcus 45 Albany rural diabetes endocrinologist

Marcus is 45, lives in Albany (Dougherty County), enrolled in CareSource Georgia. He has type 2 diabetes with complications including diabetic retinopathy and early nephropathy. His primary care physician at Albany Area Primary Health Care (an FQHC) refers him to an endocrinologist.

CareSource provider directory shows:

• 0 endocrinologists within 30 miles of Albany.
• 2 endocrinologists in Macon (90 miles).
• 4 endocrinologists in Atlanta (180 miles).

Under CMS-2439-F, the rural specialty time-distance standard is 90 minutes or 60 miles. Macon at 90 miles is just over standard distance.

Marcus's options:

1. CareSource arranges telehealth endocrinology consultation (allowed as an addition to in-person network under 42 CFR 438.206(c)(1)(ii) but cannot fully substitute).
2. CareSource authorizes out-of-network endocrinology with associated travel arrangements.
3. CareSource pays for transportation through MTM/Modivcare (NEMT).
4. Marcus files a complaint with CareSource if access remains inadequate.
5. DCH complaint if CareSource fails to address.

This is a common rural network adequacy issue. CMS-2439-F secret shopper studies will validate whether endocrinology access in rural Georgia meets standards. The combination of telehealth, transportation, and out-of-network authorization is typically how rural specialty gaps are bridged.

Worked example 4: Aisha 32 Savannah pediatric BH network gap

Aisha is 32, lives in Savannah. Her 12-year-old son has ADHD with anxiety. She is enrolled in Amerigroup through Medicaid. Her son's pediatrician refers him to a child and adolescent psychiatrist for medication management.

Amerigroup provider directory shows:

• 3 child psychiatrists within 50 miles.
• 1 has closed practice (directory shows current).
• 1 not accepting new patients (was 6 months ago but still listed as accepting).
• 1 has 9-month new patient wait.

CMS-2439-F pediatric BH standards:

• 30 minutes or 30 miles time-distance.
• 10-day routine outpatient appointment wait time.

The 9-month wait dramatically exceeds the 10-day standard. The 50-mile distance also exceeds the 30-mile standard.

Aisha's options:

1. Telehealth child psychiatry: Amerigroup may have in-network telehealth providers.
2. Out-of-network authorization at in-network cost-sharing.
3. Mental health parity complaint to DCH and CMS Region IV under 42 CFR 438.910 (network composition NQTL).
4. CMS-2439-F secret shopper study documentation.
5. State Fair Hearing if denial is upheld.
6. Reference the September 2024 MHPAEA Final Rule outcomes data requirements showing disparate BH access.

The pediatric BH access challenge is one of the most consequential network adequacy issues in Georgia. The 2024 MHPAEA Final Rule and CMS-2439-F together provide stronger enforcement tools than have existed historically.

Worked example 5: Jamil 8 Columbus DentaQuest pediatric dental

Jamil is 8, lives in Columbus, enrolled in PeachCare for Kids. Dental is administered by DentaQuest under the Georgia carve-out.

DentaQuest provider directory shows:

• 12 in-network general dentists within 30 miles of Columbus.
• 2 in-network pediatric dentists within 30 miles.
• 1 in-network pediatric orthodontist within 60 miles.

For routine dental: well-covered. For pediatric dental specialty (orthodontics, oral surgery): thin.

Jamil's mother books with a pediatric dentist 12 miles away. The next appointment is in 6 weeks (longer than the CMS-2439-F 30-day routine dental standard).

Options:

1. Accept the 6-week wait if not urgent.
2. Try the alternate pediatric dentist for sooner availability.
3. Use a general dentist for routine cleaning and reserve pediatric dental for more complex needs.
4. File a complaint with DentaQuest and/or DCH if wait times systematically exceed standards.

Worked example 6: Diana 65 rural Georgia dual eligible D-SNP network

Diana is 65, lives in rural Georgia (Hall County). She just enrolled in a D-SNP (Dual Eligible Special Needs Plan) that integrates her Medicare and Medicaid benefits.

D-SNP networks must comply with both frameworks:

• 42 CFR 422.116 (Medicare Advantage network adequacy).
• 42 CFR 438.68 (Medicaid managed care network adequacy as revised by CMS-2439-F).
• 42 CFR 438.62 (continuity of care).

When Diana enrolled, she had:

• A long-time primary care physician at an FQHC.
• A cardiologist for atrial fibrillation.
• A home health agency for weekly nursing visits.
• A wound care specialist for a chronic ulcer.

Continuity:

1. The D-SNP must allow continuation of all four providers for at least 90 days.
2. The D-SNP must work to bring each provider in-network if possible or arrange a clinically appropriate transition.
3. Diana's prior authorizations from prior coverage must be honored during the transition.
4. Olmstead v. L.C. integration principles require the most integrated setting appropriate to Diana's needs, which generally means home-based care over institutional care.

Detail on D-SNP network rules and Medicare/Medicaid coordination is available in our Medicaid managed care plans guide.

Practical guidance for Georgia families

Use the directory but verify

The provider directory is your starting point, not your endpoint. Call the provider's office to confirm:

1. They are still in-network with your CMO.
2. They are accepting new patients.
3. The next available appointment.

Document directory inaccuracies

If a provider listed in the directory is not actually accessible, document it. Your documentation supports DCH complaints, CMO accountability, and CMS-2439-F secret shopper study results.

Use telehealth where appropriate

Telehealth has expanded substantially in Georgia. For behavioral health, medication management, and many primary care follow-ups, telehealth is often a faster and more accessible option than in-person care. Confirm with your CMO whether the specific service is covered through telehealth.

Request out-of-network authorization when needed

If in-network access is inadequate, request out-of-network authorization with in-network cost-sharing. The plan must consider out-of-network access when in-network is inadequate, including for specialty care, behavioral health, and other underserved areas.

Use continuity of care during transitions

If you change CMOs, lose Medicaid coverage temporarily, or your provider leaves the network, request continuity of care under 42 CFR 438.62. The plan must allow continued access to current providers for defined periods.

File complaints when networks fail

Multiple complaint pathways:

• CMO: file with the CMO Member Services line first.
• DCH Medicaid Member Services: 1-866-211-0950 for unresolved issues.
• CMS Region IV: 404-562-7500 for federal Medicaid oversight.
• HHS Office of Civil Rights: 1-800-368-1019 for ADA, Section 504, Section 1557 issues.
• Georgia Department of Insurance: 1-800-656-2298 for commercial network issues (does not apply to Medicaid managed care).

Brevy's role

Brevy at brevy.com is building America's most comprehensive eldercare resource. Network adequacy is one of the most consequential issues for older adults and people with chronic conditions. We translate the federal and state network frameworks into plain language and help families navigate access challenges.