Georgia Medicaid Disability Determination (2026 Guide)

For most Georgia Medicaid pathways that require disability, the Georgia Medicaid disability determination is the federal Social Security Administration (SSA) decision, not a separate state test. Georgia is a Section 1634 state, so a person approved for Supplemental Security Income (SSI) is enrolled in Medicaid automatically. When SSA has not already decided, the Disability Adjudication Section (DAS) of the Georgia Department of Human Services makes the determination using the same federal rules. This guide explains how disability is defined, how the five-step evaluation works, the 2026 figures that decide close cases, and how to appeal a denial.

In This Guide

• Why the Georgia Medicaid disability determination matters
• How SSA defines disability
• The five-step evaluation for adults
• How children are evaluated
• Working while disabled: SGA, 1619(b), and the Buy-In
• Georgia as a Section 1634 state
• The Disability Adjudication Section
• How to appeal a denial
• Medicaid pathways that require disability
• Frequently Asked Questions
• Learn More

Why the Georgia Medicaid disability determination matters

Several Georgia Medicaid pathways require a disability finding before anything else. Aged, Blind, and Disabled (ABD) Medicaid covers low-income adults under 65 who meet the federal disability definition. The Georgia Working Disabled Medicaid Buy-In lets workers with disabilities keep coverage at higher income and resource limits. The Katie Beckett TEFRA pathway qualifies a child on the child's own income and resources rather than the parents'. Georgia's four Section 1915(c) Home and Community-Based Services (HCBS) waivers and the Medicare Savings Programs for people under 65 also turn on a disability finding.

In every one of these, the test is the same: the SSA definition of disability under Section 1614(a)(3) of the Social Security Act.1 Understanding how SSA applies that definition, and how Georgia coordinates with SSA, is the key to navigating any disability-based Medicaid pathway in the state.

How SSA defines disability

Adults: Section 1614(a)(3)(A)

For adults, disability means the inability to engage in any substantial gainful activity because of a medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or is expected to last at least 12 continuous months.1

Three elements decide most cases. The test is the inability to do any substantial gainful work that exists in significant numbers in the national economy, not just the inability to return to a prior job. The impairment must be medically determinable, established by objective evidence from an acceptable medical source rather than self-report alone. And it must meet the 12-month duration requirement; a severe but short-term condition does not qualify. SSDI applies the same medical standard, so SSI and SSDI differ mainly in their non-medical rules rather than in how disability itself is judged.

Children: Section 1614(a)(3)(C)

The adult test above carries its own statutory carve-out: it applies except as provided in subparagraph (C), which sets a separate standard for children. For a child under 18, disability means a medically determinable impairment that results in marked and severe functional limitations and that can be expected to result in death or has lasted or can be expected to last at least 12 continuous months.1 The child standard looks at functioning across six domains rather than work capacity: acquiring and using information, attending and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for oneself, and health and physical well-being.

The five-step evaluation for adults

Adult claims follow a five-step sequential evaluation under 20 CFR 416.920 (SSI) and the parallel 20 CFR 404.1520 (SSDI). The decisionmaker works the steps in order and stops at the first one that settles the case.

Step 1: Are you working at the SGA level?

The first question is whether the claimant is performing Substantial Gainful Activity (SGA), defined at 20 CFR 416.971 as work that is both substantial and done for pay or profit. In 2026, earnings above $1,690 per month generally establish SGA and end the claim at step one, regardless of the medical condition. The higher $2,830 level for statutorily blind individuals applies to SSDI only; blind SSI applicants face no SGA limit at all.2 Impairment-related work expenses can be deducted from earnings before the SGA test is applied. If the claimant is not performing SGA, the evaluation moves to step two.

Step 2: Is the impairment severe?

Step two asks whether the claimant has a severe, medically determinable impairment that meets the 12-month duration requirement. An impairment is severe when it imposes more than a minimal limitation on basic work activities. Multiple impairments are considered in combination, so conditions that are not severe alone may be severe together. If a severe impairment is present, the evaluation moves to step three.

Step 3: Does it meet a Listing?

Step three asks whether the impairment meets or medically equals a condition in the Listing of Impairments at 20 CFR Part 404 Subpart P Appendix 1. The Listings catalog specific conditions, organized by body system, that establish disability when the required medical and functional criteria are documented. A diagnosis alone is not enough; each clinical, laboratory, or functional criterion in the listing must be satisfied. Where an impairment does not meet a listing exactly but is equal in severity, a medical consultant can find it medically equivalent. If a listing is met or equaled, the claimant is found disabled and the evaluation ends. If not, it moves to step four.

Step 4: Can you do your past work?

Step four introduces residual functional capacity (RFC) under 20 CFR 416.945: the most a person can still do in a work setting on a regular and continuing basis (eight hours a day, five days a week) despite their impairments. RFC covers physical capacities (exertional limits like lifting and standing, and non-exertional limits like postural, manipulative, and environmental restrictions) and mental capacities (understanding, concentration, social interaction, and adaptation). The decisionmaker compares the RFC to the demands of past relevant work, meaning work the claimant performed at the SGA level within the lookback period SSA's regulations set. Confirm the current lookback with SSA or a representative before assuming an older job still counts against you. If the claimant can still do that work, the finding is not disabled. If not, the evaluation moves to step five.

Step 5: Can you do other work?

At step five, the burden shifts to SSA to show that other work exists in significant numbers in the national economy that the claimant can perform given their RFC, age, education, and work experience. The medical-vocational guidelines (the "grids") at 20 CFR Part 404 Subpart P Appendix 2 direct many decisions, and they treat older claimants more favorably because vocational adjustment becomes harder with age. Where non-exertional limits, such as a mental impairment or significant pain, substantially erode the available work, the grids serve only as a framework and a vocational expert testifies about specific jobs the claimant could or could not perform.

How children are evaluated

Children's claims follow a three-step process under 20 CFR 416.924. Step one screens out a child performing SGA, which rarely applies. Step two requires a severe, medically determinable impairment meeting the 12-month duration requirement. Step three asks whether the impairment meets, medically equals, or functionally equals a child listing in Part B of Appendix 1.

Functional equivalence is the path for many child claims that do not strictly meet a listing. It is measured across the same six domains used in the child definition, and a child functionally equals a listing with either a marked limitation in two domains or an extreme limitation in one. A marked limitation seriously interferes with the child's ability to initiate, sustain, or complete activities; an extreme limitation very seriously limits functioning in that domain.

Working while disabled: SGA, 1619(b), and the Buy-In

Working does not automatically end Medicaid. Three protections matter most in Georgia.

For SSI recipients, Section 1619(b) of the Social Security Act keeps Medicaid in place after earnings stop the SSI cash payment. SSA keeps treating the person as an SSI recipient for Medicaid purposes when they received a regular SSI cash payment for an earlier month in the current period of eligibility, would still qualify for SSI but for the earnings, still have the disabling impairment, pass SSA's Medicaid Use Test (a real three-question screen, not a formality), and have gross earned income at or below the state threshold for the 12-month period being determined.3 Georgia's 2026 charted threshold is $41,927 in gross annual earned income. Earning more than that does not by itself end 1619(b): the SSA field office then works out whether a higher individualized threshold applies, starting from the chart's $24,876 base amount and adding the higher of the person's own Medicaid expenditures or Georgia's $17,051 average per-capita figure, plus any impairment-related or blind work expenses, income excluded under an approved PASS, and the value of publicly funded personal or attendant care. Someone with none of those expenses does not qualify for the higher threshold.4

For SSDI recipients, a trial work period lets a person test work for nine service months, which need not be consecutive, within a rolling 60-month window without losing SSDI cash benefits, as long as the work is reported and the disabling impairment continues. In 2026, a month counts as a service month when earnings are more than $1,210, or when self-employment runs to more than 80 hours. After the trial work period, a 36-month extended period of eligibility pays benefits for any month earnings fall below the SGA level, with no new application required.5

For workers whose earnings exceed the 1619(b) threshold, the Georgia Working Disabled Medicaid Buy-In, authorized under Section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act, keeps Medicaid available at higher income and resource limits in exchange for a sliding-scale premium. Eligibility still requires a disability determination from SSA or DAS.

The resource side of ABD Medicaid follows the SSI standard: countable resources at or below $2,000 for an individual and $3,000 for a couple, alongside the 2026 SSI federal benefit rate of $994 per month for an individual and $1,491 for a couple.6

Georgia as a Section 1634 state

Section 1634 of the Social Security Act lets a state have SSA determine Medicaid eligibility for the aged, blind, and disabled and automatically enroll SSI recipients in Medicaid. Georgia is a Section 1634 state, which means three things in practice:

• SSI recipients in Georgia are enrolled in Medicaid automatically, with no separate Medicaid application.7
• SSA's medical disability finding for SSI applies for Medicaid.
• SSA's SSI income and resource determinations generally apply for Medicaid, including the SSI resource limit of $2,000 for an individual and $3,000 for a couple.6

A smaller group of states, known as 209(b) states under Section 1902(f), apply at least one eligibility criterion more restrictive than SSI's, so some SSI recipients there do not qualify for Medicaid without a separate state determination.7 SSA's operating instructions name eight: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia. Georgia is not among them.3 So for most ABD applicants in Georgia, the disability decision is made by SSA as part of the SSI application; if SSI is approved, Medicaid follows. Some pathways, such as Katie Beckett, still require an independent determination because their financial rules differ and they serve children whose families have not applied for SSI.

The Disability Adjudication Section

The Disability Adjudication Section (DAS) sits within the Georgia Department of Human Services, not the Georgia Department of Community Health, and operates under contract with SSA. DAS plays two roles: it makes the initial and reconsideration disability determinations for SSI and SSDI claims as SSA's contractor, and it makes Medicaid disability determinations for applicants who have not gone through SSA when a specific Medicaid pathway requires one.

DAS staffs disability adjudicators, medical and psychological consultants, and vocational specialists. A determination typically runs as follows: the case arrives from an SSA field office or from Medicaid intake; the adjudicator gathers records from treating providers; if that evidence is insufficient, DAS orders a consultative examination with an independent physician or psychologist; a medical consultant assesses whether a listing is met; if not, a vocational specialist assesses RFC through steps four and five; and the written determination is sent to the claimant.

For Medicaid eligibility, federal rules cap how long the determination can take. Under 42 CFR 435.912(c)(3), a state agency's eligibility determination may not exceed 90 days for applicants who apply for Medicaid on the basis of disability, compared with 45 days for all other applicants. The timeliness standards the agency adopts must cover the period from the date of application, or of transfer from another insurance affordability program, to the date the agency notifies the applicant of its decision. The agency must meet the standard except in unusual circumstances, for example when it cannot reach a decision because the applicant or an examining physician delays or fails to take a required action.8

How to appeal a Georgia Medicaid disability determination denial

Which path you use depends on who denied you, and the two are not interchangeable. A denied SSI or SSDI claim moves through SSA's five levels of review, below. A denied Medicaid application or Medicaid-only disability determination goes instead through Georgia's Medicaid fair-hearing process: the state agency transmits your hearing request to the Georgia Office of State Administrative Hearings (OSAH), reachable at 1-877-809-0007 or 1-404-657-2800.9 Filing deadlines differ between the two tracks, so use the deadline printed on the notice you received rather than assuming. Our Georgia Medicaid appeals and fair hearings guide walks the state track in detail.

SSA's five levels each carry a strict filing deadline, generally 60 days from receipt of the prior decision. Good cause can sometimes extend it, but the date on your notice governs and filing promptly is the safe course.

Level 1, initial determination. DAS issues the first decision with the reasons for any denial and the right to ask for reconsideration.

Level 2, reconsideration. A different DAS adjudicator and different consultants review the file, and the claimant may add new medical evidence. Reconsideration approval rates are historically low because the same framework and similar evidence are applied again, so many strong claims are denied here and won at the next level.

Level 3, administrative law judge (ALJ) hearing. An SSA ALJ at a hearing office serving Georgia, in person or by video or phone, conducts a fresh review not bound by the earlier decisions. The claimant can testify, submit new evidence, and cross-examine SSA's vocational or medical experts. Approval rates are substantially higher at this level than at reconsideration, and representation significantly improves outcomes. Under SSA's fee-agreement process, a representative's fee cannot exceed the lesser of 25 percent of the claimant's past-due benefits or a federal maximum of $9,200, which applies to favorable decisions issued on or after November 30, 2024. That cap is not indexed to inflation and has no scheduled change: SSA publishes a Federal Register notice only when it raises the cap. Ask any representative to put the fee arrangement in writing before you sign.10

Level 4, Appeals Council. The Appeals Council in Falls Church, Virginia, reviews the ALJ decision for legal error or unsupported findings and may decline review, affirm, modify, reverse, or remand.

Level 5, federal court. After the Appeals Council, a claimant may file a civil action in the U.S. District Court for the Northern, Middle, or Southern District of Georgia, with further appeal to the Eleventh Circuit.

Medicaid pathways that require disability

A disability finding is the gateway to several Georgia programs:

• ABD Medicaid covers people under 65 who are disabled and within the SSI income and resource limits; SSI recipients qualify automatically, and others receive a DAS determination.
• Georgia Working Disabled Medicaid Buy-In keeps Medicaid for workers with disabilities at higher limits in exchange for a premium.
• Katie Beckett TEFRA qualifies a child on the child's own income and resources, requiring the child disability standard plus an institutional level of care that can be met cost-effectively in the community.
• HCBS waivers. Georgia operates four Section 1915(c) waivers: the Elderly and Disabled Waiver Program (EDWP) for elderly and disabled adults, which delivers its services through the Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE) models rather than as separate waivers, the Independent Care Waiver Program (ICWP) for adults with severe physical disabilities, and the New Options Waiver (NOW) and Comprehensive Supports Waiver (COMP) for people with intellectual and developmental disabilities.11 Every 1915(c) waiver requires an institutional level-of-care determination and rests on federal cost-neutrality and level-of-care tests.12
• Medicare Savings Programs. The Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individual programs help with Medicare costs; for people under 65, the underlying SSDI disability finding establishes eligibility, processed by the Georgia Division of Family and Children Services through Georgia Gateway.13 That same SSDI finding also starts the clock on Medicare itself: premium-free Part A begins with the 25th month of SSDI entitlement, and amyotrophic lateral sclerosis (ALS) and End-Stage Renal Disease displace that 24-month wait. Georgia Medicare disability eligibility walks through the full timeline.14

If your Georgia Medicaid eligibility depends on disability, apply through Georgia Gateway or DFCS promptly, verify any SSI award so automatic enrollment can take effect, and track every appeal deadline. Where to get help:

Learn More

Find personalized help navigating the Georgia Medicaid disability determination at brevy.com.

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