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 decides under the same federal rules. This guide covers 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

Several Georgia Medicaid pathways require a disability finding first. 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 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. How SSA applies that definition, and how Georgia coordinates with SSA, is the key to 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.

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

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. 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, self-care, 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 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, whatever the medical condition. The higher $2,830 level for statutorily blind individuals applies to SSDI only; blind SSI applicants face no SGA limit. Impairment-related work expenses come off earnings first. 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 meeting the 12-month duration requirement. An impairment is severe when it imposes more than a minimal limitation on basic work activities. Impairments count in combination, so conditions that are not severe alone may be severe together. If one 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 conditions 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 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 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, 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 ones like postural, manipulative, and environmental restrictions) and mental capacities (understanding, concentration, social interaction, adaptation). The decisionmaker compares that RFC to the demands of past relevant work, meaning work 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, it 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 nationally 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 gets 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.

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 test. Step three asks whether it 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 uses the same six domains, and a child functionally equals a listing with a marked limitation in two domains or an extreme limitation in one. A marked limitation seriously interferes with initiating, sustaining, or completing activities; an extreme one 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 when they received a regular SSI cash payment for an earlier month in the current period of eligibility, would still qualify 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. Georgia's 2026 charted threshold is $41,927 in gross annual earned income, and only earnings count. Exceeding it 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 publicly funded personal or attendant care paid from non-Medicaid funds. Someone with none of those expenses does not qualify for the higher threshold. One limit catches couples off guard: 1619(b) protects the working person only, so a non-working SSI-eligible spouse loses Medicaid when their spouse's earnings end the SSI payment, while both members of a couple who are both working keep it.

For SSDI recipients, a trial work period allows 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 impairment continues. In 2026 a month counts as a service month when earnings top $1,210, or when self-employment runs past 80 hours. After that, a 36-month extended period of eligibility pays benefits for any month earnings fall below SGA, with no new application.

For workers earning past 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 for a sliding-scale premium. It 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. Countable is the whole of that test: SSA does not count the home you live in, one vehicle, household goods and personal effects, or up to $100,000 in an ABLE account, among other exclusions, so a homeowner with a car should not read $2,000 as a verdict.

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 enroll SSI recipients automatically. 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.
  • SSA's medical disability finding for SSI applies for Medicaid.
  • SSA's SSI income and resource determinations generally apply for Medicaid, including the SSI countable-resource limit of $2,000 for an individual and $3,000 for a couple.

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. SSA's operating instructions name eight: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia. Georgia is not among them. So for most ABD applicants in Georgia, SSA makes the disability decision as part of the SSI application, and Medicaid follows approval. Some pathways, such as Katie Beckett, still need 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 works under contract with SSA. It plays two roles: as SSA's contractor it makes the initial and reconsideration disability determinations for SSI and SSDI claims, and it makes Medicaid disability determinations for applicants who have not gone through SSA when a pathway requires one.

DAS staffs disability adjudicators, medical and psychological consultants, and vocational specialists. A determination typically runs like this: the case arrives from an SSA field office or Medicaid intake; the adjudicator gathers records from treating providers; if that evidence is thin, 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 goes 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 applying on the basis of disability, against 45 days for everyone else. The standards the agency adopts must cover the period from the date of application, or of transfer from another insurance affordability program, to the date it 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. Two limits ride with that: the agency must document any delay in your case record, and it may not treat the time standard as a waiting period or deny you merely for missing its own deadline.

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 fair-hearing process: the state agency transmits your hearing request to the Georgia Office of State Administrative Hearings (OSAH), at 1-877-809-0007 or 1-404-657-2800. Deadlines differ between the tracks, so use the one printed on your notice. 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.

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. Approval rates here are historically low because the same framework and similar evidence are applied again, so many strong claims are denied at this level and won at the next.

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 much higher here than at reconsideration, and representation improves outcomes. Under SSA's fee-agreement process, SSA approves an agreement only if the fee is no more than 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. But $9,200 is not an absolute ceiling on what you can be charged, because it binds only the fee-agreement route. SSA lists situations where it will not approve an agreement at all, and then the representative must file a fee petition instead, a separate process whose limit neither source read here states. Ask any representative to put the fee arrangement in writing before you sign.

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, and appeal onward to the Eleventh Circuit.

Medicaid pathways that require disability

A disability finding is the gateway to several Georgia programs:

  • ABD Medicaid covers disabled people under 65 within the SSI income and resource limits; SSI recipients qualify automatically, others get a DAS determination.
  • Georgia Working Disabled Medicaid Buy-In keeps Medicaid for workers with disabilities at higher limits, for a premium.
  • Katie Beckett TEFRA qualifies a child on the child's own income and resources, needing the child disability standard plus an institutional level of care meetable cost-effectively at home.
  • HCBS waivers. Four Georgia Section 1915(c) waivers are established by the sources read here: 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 intellectual and developmental disabilities. Treat that as four we can document rather than a census: Georgia's own waiver-programs page also lists the Georgia Pediatric Program (GAPP) for medically fragile children. Every 1915(c) waiver requires an institutional level-of-care determination and rests on federal cost-neutrality and level-of-care tests.
  • 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. That same finding starts the Medicare clock: premium-free Part A begins with the 25th month of SSDI entitlement, and ALS and End-Stage Renal Disease displace that 24-month wait. Georgia Medicare disability eligibility has the full timeline.

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

Georgia Medicaid Member Services Verify active coverage and benefits once a disability-based pathway is approved. 1-866-211-0950https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
Social Security Administration Owns the disability finding, the SSI/SSDI determination, and the Section 1619(b) rules. 1-800-772-1213https://www.usa.gov/social-security-disability www.ssa.gov
DFCS Customer Contact Center Medicaid applications, eligibility questions, and the status of a pending case. 1-877-423-4746https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip,
Office of State Administrative Hearings Hearings on Medicaid denials and on benefit reductions or terminations, transmitted to OSAH by state agencies. 1-404-657-2800 (toll-free 1-877-809-0007)https://osah.ga.gov/
Georgia Legal Services Program Free civil legal help in the 154 counties outside metro Atlanta. GLSP does not represent residents of Clayton, Cobb, DeKalb, Fulton, or Gwinnett, and clients generally have income no more than 200% of the federal poverty level or are 60 or older. 1-833-457-7529 (statewide intake)https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip,

Frequently Asked Questions

How does Georgia decide disability for Medicaid?

Georgia uses the federal Social Security Administration definition of disability under Section 1614(a)(3) of the Social Security Act. Because Georgia is a Section 1634 state, an SSI award enrolls a person in Medicaid automatically. When SSA has not already decided, the Disability Adjudication Section of the Georgia Department of Human Services decides under contract with SSA, using the same five-step (adult) or three-step (child) evaluation.

What is the five-step sequential evaluation?

For adults under 20 CFR 416.920, SSA asks in order: (1) Is the person working above the Substantial Gainful Activity level? (2) Is there a severe, medically determinable impairment lasting at least 12 months? (3) Does it meet or equal a listed impairment? (4) Can the person still do past relevant work? (5) Can they do other work existing in the national economy? The evaluation stops at the first step that decides the case.

What is the 2026 SGA limit that affects Medicaid disability?

In 2026 the Substantial Gainful Activity earnings level is $1,690 per month. The $2,830 level for statutorily blind individuals applies to SSDI only; SSI sets no SGA limit for blind applicants. Earnings above the applicable level generally end a claim at step one, and working below it does not by itself establish disability.

Does Georgia being a "1634 state" affect my Medicaid?

Yes. As a Section 1634 state, Georgia has SSA determine eligibility for SSI and ABD Medicaid and enrolls SSI recipients automatically, so there is no separate state disability test for them. A smaller group of "209(b)" states use stricter criteria; Georgia is not one of the eight.

Will I lose Medicaid if I start working?

Usually not. For SSI recipients, Section 1619(b) keeps Medicaid after the cash payment stops when gross earnings stay at or below Georgia's 2026 charted threshold of $41,927 a year, and earning above that does not automatically end coverage: the SSA field office then checks whether a higher individualized threshold applies. For SSDI recipients, a nine-month trial work period and a 36-month extended period of eligibility protect benefits while testing work. Higher earners can use the Buy-In.

How long do I have to appeal a Medicaid disability denial?

It depends which denial you got. An SSI or SSDI denial follows SSA's appeal ladder, where each level generally allows 60 days from receipt of the prior decision. A denied Medicaid application or Medicaid-only disability determination follows Georgia's fair-hearing process through OSAH, on a different clock. The controlling deadline is the one printed on your notice, so read it and file promptly; good cause can sometimes extend it, but do not rely on that.

Learn More

MedicaidGeorgia Medicaid (Hub)Georgia Medicaid 2026: income and asset limits, the EDWP waiver (CCSP and SOURCE), Pathways to Coverage, Miller Trusts, estate recovery, and how to apply. MedicaidAged, Blind, and Disabled (ABD) Medicaid in GeorgiaHow Georgia ABD Medicaid works in 2026: SSI auto-enrollment under Section 1634, the Pickle Amendment, Disabled Adult Child rules, 1619(b), and spend-down. MedicaidGeorgia Medicaid Buy-In for Working DisabledGeorgia Medicaid buy-in options in 2026: how working adults with disabilities keep Medicaid, the income and resource rules, premiums, and how to enroll. MedicaidKatie Beckett TEFRA in GeorgiaGeorgia's Katie Beckett Deeming Waiver (TEFRA) covers a child with a significant disability on the child's own income, through the month the child turns 19. MedicaidGeorgia Medicaid HCBS WaiversGeorgia's four Medicaid HCBS waivers in 2026: who EDWP (CCSP and SOURCE), ICWP, NOW, and COMP serve, the 300% SSI limit, the planning list, and how to apply. MedicaidGeorgia Medicaid Appeals and Fair HearingsHow to appeal a Georgia Medicaid denial, reduction, or termination, keep your benefits during the appeal, exhaust an MCO appeal, and reach an OSAH hearing.

Find personalized help with 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.

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