Georgia Medicaid Disability Determination Process: A Complete Guide to SSA Disability Standards for Medicaid Eligibility

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By Brevy Care Team · Last verified May 12, 2026

For Medicaid pathways that require disability as an eligibility criterion, the federal definition of disability under Section 1614(a)(3) of the Social Security Act controls. Georgia is a Section 1634 state, meaning Supplemental Security Income recipients are automatically enrolled in Medicaid based on the Social Security Administration's disability determination. Where SSA has not made a determination, the Georgia Disability Adjudication Section of the Department of Human Services performs an independent determination using the same five-step sequential evaluation process for adults under 20 CFR 416.920 and the three-step sequential evaluation process for children under 20 CFR 416.924. This guide translates the federal disability determination framework for Georgia families and explains exactly how disability is defined, how the sequential evaluation works, how the Listing of Impairments applies, how residual functional capacity and medical-vocational grids operate, how Georgia handles independent Medicaid disability determinations, and how the five-level appeals process works when disability is denied. :::

::: callout Key takeaways

1. The federal definition of disability for Medicaid purposes is the Social Security Administration definition under Section 1614(a)(3) of the Social Security Act, used for Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and most Medicaid disability pathways.
2. For adults, disability means the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
3. For children under 18, disability means a medically determinable physical or mental impairment which results in marked and severe functional limitations and which has lasted or can be expected to last for a continuous period of not less than 12 months.
4. Adult disability is evaluated through a five-step sequential evaluation process under 20 CFR 416.920: substantial gainful activity, severe impairment, Listing of Impairments, past relevant work, and other work in the national economy.
5. Child disability is evaluated through a three-step sequential evaluation process under 20 CFR 416.924: substantial gainful activity, severe impairment, and meeting/medically equaling/functionally equaling the Listing.
6. Georgia is a Section 1634 state under Section 1634 of the Social Security Act, meaning SSA determines eligibility for both SSI and ABD Medicaid, and SSI recipients are automatically enrolled in Medicaid.
7. Where Medicaid eligibility requires a disability determination but SSA has not made one, the Disability Adjudication Section (DAS) of the Georgia Department of Human Services performs an independent determination under contract with SSA, using medical consultants, psychological consultants, and vocational specialists.
8. The five levels of administrative review for disability denials are initial determination, reconsideration, administrative law judge hearing, Appeals Council review, and federal district court.
9. Disability determinations apply across multiple Georgia Medicaid pathways including Aged Blind and Disabled (ABD) Medicaid, Medicaid Buy-In for Working Disabled, Katie Beckett TEFRA, Section 1915(c) HCBS waivers, and Medicare Savings Programs for individuals under age 65.
10. Brevy at brevy.com is your digital ally helping you navigate Georgia Medicaid disability determinations. This information is not legal advice. For your specific situation, contact DCH, DAS, SSA, or a qualified disability advocate. :::

Why disability determination matters for Georgia Medicaid

A substantial portion of Georgia Medicaid coverage flows through pathways that require disability as an eligibility criterion. Aged, Blind, and Disabled (ABD) Medicaid covers low-income adults under age 65 who meet the federal definition of disability. The Medicaid Buy-In for Working Disabled program under Section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act allows working individuals with disabilities to maintain Medicaid coverage with higher income and resource limits. The Katie Beckett TEFRA pathway under Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (codified at Section 1902(e)(3) SSA) allows children with disabilities to qualify for Medicaid based on the child's own income and resources rather than the parents', provided the child meets institutional level of care and can be served in the community cost-effectively. Section 1915(c) Home and Community-Based Services waivers in Georgia, including the Community Care Services Program (CCSP), the New Options Waiver and Comprehensive Supports Waiver (NOW/COMP) for intellectual and developmental disabilities, the Independent Care Waiver Program (ICWP), and the Service Options Using Resources in Community Environments waiver (SOURCE), all require institutional level-of-care determinations and most require disability determinations. Medicare Savings Programs (Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individual programs) for individuals under age 65 generally require either Medicare entitlement (which itself typically requires SSDI disability) or an independent disability determination.

Across all these pathways, the federal definition of disability is the same: the Social Security Administration definition. Understanding how the SSA defines disability, how the sequential evaluation works, and how Georgia coordinates with SSA is essential for Georgia families navigating the Medicaid disability pathways.

The federal definition of disability

Adult definition under Section 1614(a)(3)(A) of the Social Security Act

The federal definition of disability for adults appears at Section 1614(a)(3)(A) of the Social Security Act. An adult is considered disabled if they are unable to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

Several elements of this definition warrant translation. First, the standard is inability to engage in any substantial gainful activity, not merely inability to perform prior work. The question is whether the individual can engage in any substantial gainful activity that exists in significant numbers in the national economy. Second, the impairment must be medically determinable, meaning it must be established by objective medical evidence from acceptable medical sources. Subjective complaints alone are insufficient. Third, the impairment must satisfy a duration requirement: either it must be expected to result in death or it must have lasted or be expected to last for a continuous period of not less than 12 months. Short-term impairments, no matter how severe, do not qualify.

The same definition under Section 223(d) of the Social Security Act applies for Social Security Disability Insurance (SSDI) purposes. SSI and SSDI share the medical definition of disability; they differ in non-disability eligibility requirements (SSI is means-tested; SSDI requires sufficient work history).

Child definition under Section 1614(a)(3)(C) of the Social Security Act

For children under age 18, a different standard applies under Section 1614(a)(3)(C). A child is considered disabled if they have a medically determinable physical or mental impairment which results in marked and severe functional limitations and which has lasted or can be expected to last for a continuous period of not less than 12 months.

The child standard differs from the adult standard in important ways. First, the focus is on marked and severe functional limitations rather than inability to engage in substantial gainful activity. Most children do not work, so the work-capacity framework does not apply. Second, the evaluation considers limitations in six functional 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 yourself, and health and physical well-being. Third, the standard requires a finding of marked limitation in at least two domains or extreme limitation in one domain to functionally equal a Listing.

The sequential evaluation process for adults

Adult disability determinations follow a five-step sequential evaluation process under 20 CFR 416.920 (for SSI claims) and 20 CFR 404.1520 (for SSDI claims). The two regulations are essentially identical in their medical evaluation framework. The decisionmaker proceeds through the steps in order and stops at the first step that establishes a definitive finding of disabled or not disabled.

Step 1: Substantial gainful activity

The first step asks whether the claimant is engaging in substantial gainful activity. SGA is defined at 20 CFR 416.970 as work activity that is both substantial (involves significant physical or mental activities) and gainful (done for pay or profit, even if no profit is realized).

The SGA earnings threshold is updated annually based on the national average wage index; SSA publishes current-year amounts each fall. Blind individuals have a higher threshold than non-blind individuals. Earnings above the applicable threshold generally establish SGA at Step 1, resulting in a finding of not disabled regardless of medical condition.

For self-employed individuals, the SGA analysis is more complex. Three alternative tests apply: the significant services and substantial income test, the comparability of work test, and the worth of work test. A self-employed individual whose work is comparable to that of unimpaired individuals or who provides services worth more than the SGA threshold can be found engaging in SGA even with low net earnings.

For SSDI claimants, special provisions allow continued benefits during a trial work period and extended period of eligibility even when earnings exceed SGA. Nine trial work months within a 60-month rolling window exhaust the trial work period; SSA publishes the current-year monthly earnings threshold that triggers a trial work month. After the trial work period, an extended period of eligibility allows reinstatement of benefits without new application if earnings later drop below SGA.

For SSI claimants, Section 1619(a) allows continued cash benefits at a reduced amount when earnings exceed SGA but countable income remains below the break-even point. Section 1619(b) continues Medicaid coverage even after SSI cash benefits stop when earnings exceed the break-even point but remain below a specified threshold. The 1619(b) provision is critical for working individuals with disabilities who would otherwise lose Medicaid coverage upon employment. Contact SSA for Georgia's current 1619(b) earnings threshold.

If the claimant is not engaging in SGA at Step 1, evaluation proceeds to Step 2.

Step 2: Severe medically determinable impairment

Step 2 asks whether the claimant has a severe medically determinable impairment that meets the duration requirement. An impairment is medically determinable when it is established by objective medical evidence from an acceptable medical source. Subjective complaints alone are insufficient. The impairment is severe when it imposes more than minimal limitations on basic work activities.

Basic work activities include physical functions (walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, handling), capacities for seeing, hearing, and speaking, understanding and carrying out simple instructions, using judgment, responding appropriately to supervision and coworkers, and dealing with changes in a routine work setting.

Where the claimant has multiple impairments, they are evaluated in combination. An individual impairment that would not be severe on its own may combine with other impairments to constitute a severe impairment.

The duration requirement at Step 2 mirrors the definitional requirement: the impairment must have lasted or be expected to last for a continuous period of not less than 12 months, or be expected to result in death. A serious but temporary impairment expected to resolve within 12 months does not satisfy the duration requirement.

If the claimant has a severe medically determinable impairment meeting the duration requirement, evaluation proceeds to Step 3.

Step 3: Listing of Impairments

Step 3 asks whether the claimant's impairment meets or medically equals a Listing of Impairments. The Listing of Impairments appears at 20 CFR Part 404 Subpart P Appendix 1 and catalogs specific medical conditions that, when established by required medical evidence and satisfying specified clinical criteria, establish disability without further evaluation.

Adult listings are organized by body system. Listing 1.00 covers musculoskeletal disorders. Listing 2.00 covers special senses and speech. Listing 3.00 covers respiratory disorders. Listing 4.00 covers cardiovascular disorders. Listing 5.00 covers digestive disorders. Listing 6.00 covers genitourinary disorders. Listing 7.00 covers hematological disorders. Listing 8.00 covers skin disorders. Listing 9.00 covers endocrine disorders. Listing 10.00 covers congenital disorders affecting multiple body systems. Listing 11.00 covers neurological disorders. Listing 12.00 covers mental disorders. Listing 13.00 covers cancer (malignant neoplastic diseases). Listing 14.00 covers immune system disorders.

Each specific listing within these body systems specifies required clinical findings, laboratory results, or functional measurements that establish disability. For example, Listing 4.02 (chronic heart failure) requires documented systolic or diastolic heart failure while on prescribed treatment, with specific cardiac criteria (such as ejection fraction measurements), AND specified functional limitations. Both the medical and functional criteria must be satisfied.

Medical equivalence applies where the claimant's impairment, while not meeting all specific criteria of a listing, is at least equal in severity and duration to the criteria of any listed impairment. Medical equivalence determinations require review by a medical consultant.

If the impairment meets or medically equals a listing at Step 3, the claimant is disabled. The sequential evaluation ends. If not, evaluation proceeds to Step 4.

Step 4: Past relevant work

Step 4 introduces the residual functional capacity (RFC) assessment. RFC is what the claimant can still do despite their impairments, considered in a work setting on a regular and continuing basis (8 hours per day, 5 days per week).

RFC has physical components (exertional and non-exertional) and mental components. Exertional components include lifting, carrying, standing, walking, sitting, pushing, and pulling. Non-exertional physical components include postural limitations (climbing, balancing, stooping, kneeling, crouching, crawling), manipulative limitations (reaching, handling, fingering, feeling), visual limitations, communicative limitations, and environmental limitations (temperature extremes, humidity, noise, vibration, fumes, hazards). Mental components include the ability to understand and carry out instructions, respond appropriately to supervision and coworkers, and deal with changes in a routine work setting.

Exertional levels under 20 CFR 416.967 are sedentary (lift 10 pounds occasionally, mostly sitting), light (lift 20 pounds occasionally, frequent standing/walking), medium (lift 50 pounds occasionally), heavy (lift 100 pounds occasionally), and very heavy (lift more than 100 pounds occasionally).

After determining RFC, the decisionmaker compares it to the demands of past relevant work. Past relevant work is work performed within the last 15 years, lasted long enough for the claimant to learn it, and was performed at the SGA level. If the claimant retains the RFC to perform past relevant work as it was actually performed or as generally performed in the national economy, the claimant is not disabled at Step 4.

If the claimant cannot perform past relevant work, evaluation proceeds to Step 5.

Step 5: Other work in the national economy

At Step 5, the burden of proof shifts from the claimant to SSA to demonstrate 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 grids at 20 CFR Part 404 Subpart P Appendix 2 direct decisions in many cases. The grids are organized by exertional level (Table 1 sedentary, Table 2 light, Table 3 medium) and within each table contain rules based on age category, education, and previous work experience.

Age categories under 20 CFR 416.963 are younger individual (under age 50), closely approaching advanced age (age 50 through 54), advanced age (age 55 through 59), and closely approaching retirement age (age 60 through 64). The grids treat older claimants more favorably because the regulations recognize that vocational adjustment becomes more difficult with age.

Education categories under 20 CFR 416.964 include illiterate or unable to communicate in English, marginal education (6th grade or less), limited education (7th through 11th grade), and high school education or above.

Previous work experience categories include unskilled, semi-skilled with non-transferable skills, semi-skilled with transferable skills, skilled with non-transferable skills, and skilled with transferable skills.

The grids provide rules that direct decisions of disabled or not disabled. For example, grid rule 201.14 directs a finding of disabled where the claimant is of advanced age, has a high school education that does not provide for direct entry into skilled work, has unskilled or no transferable skills, and is limited to sedentary work. Grid rule 202.21 directs a finding of not disabled for a younger individual with limited education and unskilled work history limited to light work.

Where non-exertional limitations significantly reduce the claimant's ability to perform a full range of work at a given exertional level, the grids serve only as a framework and a vocational expert may be needed to identify specific occupations the claimant can perform. Mental impairments and pain limitations often require non-grid analysis with vocational expert testimony.

The sequential evaluation process for children

Child disability claims follow a three-step sequential evaluation under 20 CFR 416.924.

Step 1: Substantial gainful activity

A child engaging in SGA is not disabled. This rarely applies to children but can occur for older minors with significant earnings.

Step 2: Severe medically determinable impairment

The child must have a severe medically determinable impairment satisfying the 12-month duration requirement. Severity for children means more than minimal effect on functioning, parallel to but not identical to the adult standard.

Step 3: Meets, medically equals, or functionally equals a Listing

The child must meet, medically equal, or functionally equal a Listing of Impairments. Child listings appear at 20 CFR Part 404 Subpart P Appendix 1 Part B (sections 100.00 through 114.00). These parallel adult listings but contain age-appropriate criteria.

Examples of frequently encountered child listings include 109.08 (type 1 diabetes mellitus), 110.08 (failure to thrive), 112.04 (depressive, bipolar and related disorders), 112.06 (anxiety and obsessive-compulsive disorders), 112.08 (personality and impulse-control disorders), 112.10 (autism spectrum disorder), 112.11 (neurodevelopmental disorders including ADHD), and 112.15 (trauma- and stressor-related disorders).

Functional equivalence applies when the child does not meet or medically equal a specific listing but has limitations that functionally equal a listing. Functional equivalence is evaluated in six domains of functioning:

1. Acquiring and using information
2. Attending and completing tasks
3. Interacting and relating with others
4. Moving about and manipulating objects
5. Caring for yourself
6. Health and physical well-being

A child functionally equals a Listing when they have either marked limitation in two of the six domains or extreme limitation in one domain. Marked limitation means more than moderate but less than extreme; it seriously interferes with the child's ability to initiate, sustain, or complete activities. Extreme limitation means very serious interference; it very seriously limits a child's ability to function in that domain.

The Listing of Impairments in detail

Structure and use

The Listing of Impairments at 20 CFR Part 404 Subpart P Appendix 1 contains both Part A (adult listings) and Part B (child listings). Each specific listing identifies required medical evidence and clinical criteria that, when satisfied, establish disability at Step 3 without further evaluation.

The Listing serves two important functions. First, it allows expedited determinations for the most clearly disabling conditions. Second, it sets a benchmark of severity against which medical equivalence claims can be evaluated.

Frequently encountered adult listings

Listing 1.04 (disorders of the spine): Requires compromise of a nerve root or the spinal cord with specific clinical findings including nerve root compression characterized by neuroanatomic distribution of pain, limitation of motion of the spine, motor loss accompanied by sensory or reflex loss, and positive straight-leg raising test (sitting and supine) if there is involvement of the lower back. This listing has been restructured into 1.15 (disorders of the skeletal spine) and 1.16 (lumbar spinal stenosis).

Listing 4.02 (chronic heart failure): Requires medically documented systolic or diastolic heart failure while on a regimen of prescribed treatment, with specific cardiac criteria, plus one of several specified functional limitations.

Listing 11.04 (vascular insult to the brain): Requires sensory or motor aphasia resulting in ineffective speech or communication; or disorganization of motor function in two extremities; or marked physical and mental limitation persisting for at least 3 consecutive months after the insult.

Listing 12.04 (depressive, bipolar and related disorders): Requires medical documentation of either depressive disorder or bipolar disorder characterized by specified symptoms (criterion A), PLUS either extreme limitation of one or marked limitation of two of four areas of mental functioning (criterion B), OR serious and persistent disorder with documented history of at least 2 years of medical treatment plus marginal adjustment evidence (criterion C).

The four areas of mental functioning in criterion B are: understand, remember, or apply information; interact with others; concentrate, persist, or maintain pace; and adapt or manage oneself.

Listing 12.06 (anxiety and obsessive-compulsive disorders): Similar structure to 12.04, with criterion A requiring documented anxiety disorder, panic disorder, or obsessive-compulsive disorder with specified symptoms, and criterion B/C parallel to 12.04.

Listing 14.09 (inflammatory arthritis): Requires either persistent inflammation or persistent deformity of one or more major peripheral weight-bearing joints with inability to ambulate effectively, OR specified inflammation or deformity of major peripheral joints in upper extremities with inability to perform fine and gross movements effectively, OR involvement of two or more organs/body systems with specified findings, OR ankylosing spondylitis or other spondyloarthropathies with specified findings, OR repeated manifestations with specified findings.

Frequently encountered child listings

Listing 109.08 (type 1 diabetes mellitus): For children under age 6, requires specific complications. For children age 6 to under age 18, requires meeting specified criteria related to glycemic control or frequency of hospitalizations for diabetes-related complications; consult the full listing text at 20 CFR Part 404 Subpart P Appendix 1 for current criteria.

Listing 112.10 (autism spectrum disorder, child): Requires medical documentation of qualitative deficits in verbal communication, nonverbal communication, and social interaction AND restricted/repetitive patterns of behavior, interests, or activities (criterion A), PLUS extreme limitation in one of four areas or marked limitation in two of four areas (criterion B). Areas are parallel to adult mental listing criteria adapted for children.

Listing 112.11 (neurodevelopmental disorders): Covers ADHD and other neurodevelopmental disorders with documented manifestations plus marked/extreme limitations in functional areas.

Residual functional capacity assessment

Definition and importance

Residual functional capacity (RFC) under 20 CFR 416.945 is the most a claimant can still do in a work setting on a regular and continuing basis (8 hours per day, 5 days per week) despite their impairments. RFC is the critical analytical bridge between medical findings (Step 3) and vocational analysis (Steps 4 and 5).

Physical RFC components

Physical RFC addresses both exertional and non-exertional capacities.

Exertional capacities include the amount of weight a claimant can lift and carry (occasionally and frequently), how long the claimant can stand and walk during an 8-hour workday, how long the claimant can sit during an 8-hour workday, and whether the claimant has limitations in pushing and pulling with arms or legs.

Non-exertional physical capacities include postural limitations (climbing ramps/stairs/ladders, balancing, stooping, kneeling, crouching, crawling), manipulative limitations (reaching, handling, fingering, feeling, gross and fine motor functions), visual limitations (near acuity, far acuity, depth perception, accommodation, color vision, field of vision), communicative limitations (hearing, speaking), and environmental limitations (temperature extremes, humidity/wetness, noise, vibration, fumes/odors/dusts/gases, hazards).

Mental RFC components

Mental RFC addresses understanding and memory, sustained concentration and persistence, social interaction, and adaptation.

Understanding and memory includes ability to remember locations and work-like procedures, understand and remember very short and simple instructions, and understand and remember detailed instructions.

Sustained concentration and persistence includes ability to carry out very short and simple instructions, carry out detailed instructions, maintain attention and concentration for extended periods, perform activities within a schedule and maintain regular attendance and be punctual, sustain an ordinary routine without special supervision, work in coordination with or proximity to others, make simple work-related decisions, and complete a normal workday and workweek without interruptions from psychologically based symptoms.

Social interaction includes ability to interact appropriately with the general public, ask simple questions or request assistance, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers, and maintain socially appropriate behavior.

Adaptation includes ability to respond appropriately to changes in the work setting, be aware of normal hazards and take appropriate precautions, travel in unfamiliar places or use public transportation, and set realistic goals or make plans independently of others.

RFC assessment process under SSR 96-8p

Social Security Ruling 96-8p provides the framework for RFC assessment. RFC must be based on all relevant medical and other evidence in the case record, including treating source records, consultative examination findings, third-party statements, and claimant's own statements about symptoms and limitations.

Symptom evaluation under SSR 16-3p requires consideration of objective medical evidence, the nature and intensity of symptoms, factors that aggravate or relieve symptoms, treatment received, side effects of medications, and other factors that bear on the claimant's symptoms. The decisionmaker must articulate how the claimant's symptoms were evaluated and explain how the conclusions are consistent with the objective medical evidence.

Medical-vocational grids in detail

How the grids work

The medical-vocational grids at 20 CFR Part 404 Subpart P Appendix 2 are tables that combine four factors to direct a finding of disabled or not disabled:

1. Residual functional capacity (sedentary, light, or medium)
2. Age category (younger, closely approaching advanced, advanced, closely approaching retirement)
3. Education (illiterate, marginal, limited, high school, high school with direct entry into skilled work, college)
4. Previous work experience (no work, unskilled, semi-skilled with transferable skills, semi-skilled without transferable skills, skilled with transferable skills, skilled without transferable skills)

Each combination of factors produces a grid rule number (for example, 201.01, 202.10, 203.05) that directs a finding.

Pattern of grid decisions

The grids systematically favor findings of disabled with increasing age, lower education, and lack of transferable skills. The policy basis for this pattern is the recognition that older workers, less-educated workers, and workers without transferable skills face greater difficulty adjusting to new work.

For sedentary RFC: A 50-year-old (closely approaching advanced age) with limited education and unskilled work is generally directed to disabled (rule 201.09 or 201.10). A 55-year-old (advanced age) with limited education and any work history is generally directed to disabled (rule 201.12 or 201.14). A 60-year-old with even more flexibility may still be directed to disabled.

For light RFC: A 55-year-old (advanced age) with limited education and unskilled work is directed to disabled (rule 202.01). A younger individual (under 50) with similar profile is generally directed to not disabled (rule 202.16 or 202.17).

For medium RFC: Generally directs not disabled for younger individuals and those closely approaching advanced age. May direct disabled for advanced age with very limited education and unskilled work in some configurations.

Non-grid cases

The grids serve only as a framework where non-exertional limitations significantly reduce the claimant's ability to perform a full range of work at the determined exertional level. In such cases, vocational expert testimony identifies specific occupations the claimant can perform given their RFC.

Mental impairments are inherently non-exertional and almost always require vocational expert analysis. Pain limitations that affect concentration, persistence, or pace require non-grid analysis. Environmental limitations (such as inability to be around fumes or noise) that significantly limit the occupational base require vocational expert input.

Substantial gainful activity in detail

The current threshold

The SGA earnings threshold is updated annually based on the national average wage index; SSA publishes current-year amounts each fall. The blindness threshold is higher than the non-blind threshold because the Social Security Act provides a more favorable standard for individuals who meet the definition of statutory blindness.

Counting earnings

For wage earners, gross earnings (before taxes and most deductions) generally count. Impairment-related work expenses (IRWE) can be deducted from earnings before applying the SGA test. IRWE include the cost of items or services that are needed because of the individual's disability and that are paid by the individual.

For self-employed individuals, net earnings from self-employment generally apply, but special tests evaluate whether services are substantial regardless of net earnings.

Section 1619(a) and 1619(b) protections

For SSI recipients who start working, Section 1619(a) of the Social Security Act allows continued SSI cash benefits at a reduced amount when earnings exceed SGA but countable income remains below the break-even point. This break-even point varies based on individual circumstances but generally allows continued partial SSI cash benefits up to a point.

Section 1619(b) is even more important for Medicaid purposes. When earnings reach a level that ends SSI cash benefits, Section 1619(b) continues Medicaid coverage as long as:

1. The individual would still be eligible for SSI except for earnings
2. The individual continues to be disabled
3. The individual needs Medicaid to continue working
4. The individual's gross earnings are below a specified threshold

Earnings below Georgia's Section 1619(b) threshold preserve Medicaid coverage even after SSI cash benefits stop. Contact SSA for the current Georgia-specific threshold. This is a critical protection for working individuals with disabilities.

Individuals whose earnings exceed the 1619(b) threshold may still maintain Medicaid through the Medicaid Buy-In for Working Disabled program (Section 1902(a)(10)(A)(ii)(XIII) SSA) at higher income and resource thresholds with a sliding-scale premium.

Trial work period for SSDI

For SSDI recipients, a trial work period allows nine months of trial work within a 60-month rolling window during which earnings do not affect disability determinations. SSA publishes the current-year monthly earnings threshold that triggers a trial work month. After exhausting the nine trial work months, an extended period of eligibility provides a window during which the individual can stop and restart benefits without a new application based on whether monthly earnings exceed SGA.

Georgia as a Section 1634 state

What Section 1634 means

Section 1634 of the Social Security Act authorizes states to enter agreements with the Social Security Administration under which SSA determines Medicaid eligibility for the aged, blind, and disabled, and the state automatically enrolls SSI recipients in Medicaid. Section 1634 states include the majority of states and most use SSI criteria for Medicaid eligibility for ABD pathways.

Georgia's Section 1634 status

Georgia is a Section 1634 state. This means:

• SSI recipients in Georgia are automatically enrolled in Medicaid. No separate Medicaid application is needed.
• SSA's medical determination of disability for SSI applies for Medicaid purposes.
• SSA's income and resource determinations for SSI generally apply for Medicaid (with limited variations under state plan).

What this means in practice

For most ABD Medicaid applicants in Georgia, the disability determination is made by SSA as part of the SSI application process. If the SSI claim is approved, Medicaid follows automatically. If the SSI claim is denied based on excess income or resources but the disability finding is favorable, Medicaid can still apply under different pathways (such as the Medicaid Buy-In or institutional care pathways that allow higher income/resources).

If the SSI claim is denied based on a finding of not disabled, the same finding generally applies for Medicaid purposes. However, certain Medicaid pathways (such as Katie Beckett) may require an independent disability determination because the pathway has different financial eligibility rules and may serve children whose families have not pursued SSI.

209(b) states are different

Some states are not Section 1634 states. They are 209(b) states under Section 1902(f) of the Social Security Act, named for Section 209(b) of the 1972 Social Security Amendments that authorized this alternative. 209(b) states use more restrictive Medicaid eligibility criteria than SSI, requiring a separate state Medicaid determination. A small number of states are 209(b) states; Georgia is NOT among them.

The Georgia Disability Adjudication Section

Organizational structure

The Disability Adjudication Section (DAS) is within the Georgia Department of Human Services (DHS), not the Department of Community Health (DCH). DAS operates under a contractual agreement with the Social Security Administration to perform disability determinations for SSA. This dual role means DAS:

1. Makes initial and reconsideration disability determinations for SSI and SSDI claims (as the SSA contractor)
2. Makes disability determinations for Medicaid applicants who have not gone through SSA (when needed for Medicaid eligibility under specific pathways)

DAS staffing and process

DAS employs disability adjudicators (lay adjudicators trained in disability evaluation), medical consultants (physicians), psychological consultants (psychologists or psychiatrists), vocational specialists, and quality assurance reviewers.

The typical process for a DAS determination is:

1. Application is received from SSA field office or DFCS Medicaid intake
2. Adjudicator develops medical evidence by requesting records from treating providers
3. If treating source evidence is insufficient, adjudicator orders consultative examination (CE) with an independent physician or psychologist
4. Medical consultant reviews the medical evidence and assesses whether listings are met
5. If listings not met, vocational specialist assesses RFC and applies sequential evaluation through Steps 4 and 5
6. Final determination is reviewed for quality assurance
7. Written determination sent to claimant (and to DCH if for Medicaid purposes)

Processing time

Federal targets aim for initial determinations within approximately 4 to 6 months on average. Reconsideration determinations typically take 3 to 5 months. However, backlogs and case complexity can extend these timeframes significantly.

For Medicaid purposes, federal regulations require eligibility determinations to be completed within a specified period when disability determination is required. DCH and DAS coordinate to meet this standard, though disability cases requiring extensive medical development may extend the timeline under extraordinary circumstances provisions.

Medical evidence requirements

Acceptable medical sources

Under 20 CFR 416.913, acceptable medical sources for establishing medically determinable impairments include:

• Licensed physicians (medical or osteopathic doctors)
• Licensed psychologists
• Licensed optometrists (for visual disorders)
• Licensed podiatrists (for foot and ankle conditions)
• Qualified speech-language pathologists (for speech impairments)
• Licensed audiologists (for hearing loss)
• Licensed advanced practice registered nurses (for impairments within their scope of practice)
• Licensed physician assistants (for impairments within their scope of practice)

Non-acceptable medical sources (such as chiropractors, naturopaths, certain therapists, and family members) can provide evidence about functional limitations but cannot alone establish medically determinable impairments.

Required evidence

Adequate medical evidence should include:

• Objective findings: imaging results (X-rays, MRIs, CT scans), laboratory results, electrocardiograms, electroencephalograms, audiograms, vision testing, pulmonary function testing
• Clinical examination findings: range of motion, strength testing, neurological examination, mental status examination
• Treatment history: dates of treatment, treatment modalities, response to treatment
• Current medications and dosages
• Side effects of medications
• Treating physician statements about specific functional limitations (medical source statements)

Consultative examinations

When treating source evidence is insufficient, DAS arranges a consultative examination (CE) with an independent physician or psychologist under contract. CEs may include:

• General physical examination
• Specialty examinations (orthopedic, cardiological, neurological, ophthalmological)
• Psychological consultative examinations (mental status examination, intelligence testing, personality testing)
• Specific testing (pulmonary function, exercise tolerance, range of motion)

The CE provider's role is to provide an independent medical opinion based on the examination and review of available records. CE results inform but do not override treating source evidence; both are weighed in the overall analysis.

The appeals process

Five levels of administrative review

When DAS or SSA denies a disability claim, claimants have five levels of administrative review available.

Level 1: Initial determination

The initial determination is made by a DAS adjudicator with input from medical and psychological consultants and vocational specialists. The written notice sent to the claimant explains the basis for denial and the claimant's right to request reconsideration. The claimant has 60 days from receipt of the notice to request reconsideration or to file a new application. Good cause for late filing can extend the deadline.

Level 2: Reconsideration

Reconsideration is a fresh review of the file by a different DAS adjudicator with input from different medical and psychological consultants. The claimant may submit additional medical evidence, treating source statements, and other information. The reconsideration determination is generally based on the file and any new evidence; no hearing is held.

Reconsideration approval rates are historically low, in part because reconsideration uses the same medical and vocational analysis framework as initial determination, with similar staff and similar evidence. Most successful appeals occur at the next level (ALJ hearing). After reconsideration, claimants have 60 days to request an administrative law judge hearing.

Level 3: Administrative law judge hearing

The administrative law judge (ALJ) hearing is the most consequential level of administrative review. Hearings are held before SSA ALJs at hearing offices located in Atlanta, Macon, Savannah, and Albany. The ALJ conducts a de novo review of the case, not bound by prior determinations.

At the hearing, the claimant may:

• Testify under oath about symptoms, treatment, and functional limitations
• Be represented by an attorney or non-attorney representative
• Call witnesses (treating physicians, family members, vocational experts retained by the claimant)
• Submit additional medical evidence (subject to five-business-day rule)
• Cross-examine SSA's vocational expert and medical expert if called

The ALJ may call a vocational expert to testify about the existence of jobs in the national economy and may call a medical expert to opine on listings, RFC, and onset date.

ALJ approval rates are historically higher than reconsideration rates. Representation by attorney or non-attorney representative significantly improves outcomes.

The ALJ issues a written decision typically within 30 to 90 days after the hearing. The decision may be fully favorable, partially favorable (approving disability but with a different onset date or duration), or unfavorable. After an unfavorable ALJ decision, the claimant has 60 days to request Appeals Council review.

Level 4: Appeals Council review

The Appeals Council, located in Falls Church, Virginia, is the final level of administrative review. The Appeals Council reviews ALJ decisions for errors of law, abuse of discretion, contradictory evidence, or policy issues. The Appeals Council may:

• Decline to review (most common outcome)
• Affirm the ALJ decision
• Modify the ALJ decision
• Reverse the ALJ decision
• Remand the case to the ALJ for further proceedings

After an Appeals Council action that exhausts administrative remedies, the claimant has 60 days to file a civil action in federal district court.

Level 5: Federal district court

A claimant may file a civil action in the U.S. District Court for the Northern District of Georgia, Middle District of Georgia, or Southern District of Georgia, depending on the claimant's residence. The court reviews the administrative record for substantial evidence and legal error. The court may affirm, reverse, remand, or remand with directions. Further appeal lies to the U.S. Court of Appeals for the Eleventh Circuit.

Continuing benefits during appeal

For SSDI recipients with continuing disability reviews (CDR) finding medical improvement, claimants may elect to continue receiving benefits during their appeal under Section 205(g) of the Social Security Act. This election preserves benefits during ALJ hearing review. For Medicaid coverage, similar continuation provisions may apply pending appeal.

Specific Medicaid pathways requiring disability

Aged, Blind, and Disabled (ABD) Medicaid

ABD Medicaid covers individuals who are age 65 or older, blind, or disabled and meet financial eligibility criteria. For individuals under age 65, disability determination is required. SSI recipients automatically qualify under Georgia's 1634 status. Non-SSI applicants get a DAS determination.

Financial criteria for ABD Medicaid include the SSI income standard (federal benefit rate plus state supplement, if any) and the SSI resource standard. Georgia generally follows SSI standards; contact DCH or SSA for current resource limits.

Medicaid Buy-In for Working Disabled

The Medicaid Buy-In program under Section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act allows working individuals with disabilities to maintain Medicaid coverage with higher income and resource limits in exchange for paying a sliding-scale premium based on income.

Eligibility requires:

• Disability determination (SSA or DAS)
• Employment (work for pay)
• Income within program limits (contact DCH for current income thresholds)
• Resources within program limits (often higher than SSI limits)

The Buy-In is critical for individuals whose work earnings exceed SSI and 1619(b) thresholds but who still need Medicaid for ongoing healthcare needs related to their disabilities.

Katie Beckett TEFRA pathway

The Katie Beckett TEFRA pathway under Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982, codified at Section 1902(e)(3) of the Social Security Act, allows children with disabilities to qualify for Medicaid based on the child's own income and resources rather than the parents' income and resources.

Eligibility requires:

• Child under age 18 (or 19 in certain circumstances)
• Disability determination meeting child standard under Section 1614(a)(3)(C)
• Institutional level of care (typically nursing facility or ICF/IID level)
• Determination that the child can be appropriately served in the community
• Determination that community care is cost-effective compared to institutional care
• Child's own income and resources within limits

Katie Beckett is critical for families whose children have severe disabilities requiring intensive medical or behavioral services but who would not qualify for Medicaid based on family income. The pathway disregards parental income and resources entirely.

Section 1915(c) HCBS waivers

Georgia operates several Section 1915(c) Home and Community-Based Services waivers, each with specific disability and level-of-care requirements:

• Community Care Services Program (CCSP) for elderly and disabled adults needing nursing facility level of care
• New Options Waiver (NOW) and Comprehensive Supports Waiver (COMP) for individuals with intellectual and developmental disabilities
• Independent Care Waiver Program (ICWP) for individuals with severe physical disabilities
• Service Options Using Resources in Community Environments (SOURCE) for elderly and disabled adults

Each waiver requires institutional level-of-care determination and most require disability determination (either by SSA or DAS depending on circumstances).

Medicare Savings Programs

Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs provide assistance with Medicare premiums and cost-sharing. For individuals under age 65, Medicare entitlement typically requires SSDI disability. For these populations, the underlying SSDI disability determination establishes eligibility for MSP.

Worked examples

Example 1: Robert age 62 Atlanta with congestive heart failure

Robert is a 62-year-old former construction worker living in Atlanta. He suffered a heart attack 18 months ago and has been diagnosed with congestive heart failure with an ejection fraction of 25 percent. His cardiologist documents New York Heart Association Class III symptoms (marked limitation of physical activity, comfortable at rest but ordinary activity produces fatigue, palpitation, dyspnea, or anginal pain). Robert applied for SSDI, which was approved, and he was also referred for SSI based on low income/resources. Georgia automatically enrolled Robert in Medicaid based on his SSI award.

Sequential evaluation analysis at SSA:

Step 1: Robert is not working, not engaging in SGA. Proceeds to Step 2.

Step 2: Congestive heart failure is a severe medically determinable impairment with documentation meeting the 12-month duration requirement. Proceeds to Step 3.

Step 3: Listing 4.02 (chronic heart failure) requires documented systolic or diastolic heart failure with specific cardiac criteria while on prescribed treatment, AND specified functional criteria. Robert's cardiologist documents that his ejection fraction of 25 percent and his hospitalization history satisfy the listing's cardiac and functional criteria. The listing is met.

Decision: Disabled at Step 3. Robert qualifies for SSI and (under Georgia's 1634 status) Medicaid. His ABD Medicaid coverage allows continued cardiology care, medications, and any future hospitalizations or device implantation.

Example 2: Linda age 35 Macon with major depressive disorder

Linda is a 35-year-old former customer service representative in Macon. She has been diagnosed with major depressive disorder recurrent severe with psychotic features, generalized anxiety disorder, and post-traumatic stress disorder. She has been hospitalized twice in the past 12 months for acute exacerbations. Her treating psychiatrist documents that Linda cannot maintain regular work attendance, cannot tolerate interaction with strangers, and has frequent intrusive thoughts that interfere with concentration.

Linda applied for ABD Medicaid and SSI. SSA referred her case to DAS for medical determination.

Sequential evaluation analysis at DAS:

Step 1: Linda is not engaged in SGA (last worked 14 months ago). Proceeds to Step 2.

Step 2: Major depressive disorder, GAD, and PTSD are severe medically determinable impairments with documentation meeting the 12-month duration requirement. Proceeds to Step 3.

Step 3: Listing 12.04 (depressive, bipolar and related disorders). Criterion A requires medical documentation of depressive disorder with at least five specified symptoms. Linda's psychiatric records document depressed mood, diminished interest, decreased energy, feelings of worthlessness, difficulty concentrating, thoughts of suicide, and changes in appetite/sleep. Criterion A is satisfied.

Criterion B requires extreme limitation of one or marked limitation of two of four areas of mental functioning: understand/remember/apply information; interact with others; concentrate/persist/maintain pace; adapt/manage oneself. Linda's treating psychiatrist provides a medical source statement documenting marked limitations in interact with others, concentrate/persist/maintain pace, and adapt/manage oneself. Criterion B is satisfied with marked limitations in three of four areas.

Decision: Disabled at Step 3. Linda qualifies for ABD Medicaid. Her Medicaid coverage funds ongoing psychiatric medications, therapy, and any future hospitalizations.

Example 3: Carlos age 8 Savannah with autism spectrum disorder

Carlos is an 8-year-old child in Savannah diagnosed with autism spectrum disorder level 2 (requiring substantial support). His family has private insurance but the insurance does not adequately cover the intensive behavioral therapies, speech-language pathology, occupational therapy, and educational supports Carlos needs. The family is applying for Katie Beckett TEFRA Medicaid, which would qualify Carlos for Medicaid based on his own income/resources (zero) rather than the family's income.

DAS performs the disability determination using the child standard.

Child sequential evaluation:

Step 1: Not applicable (Carlos is 8 and not working).

Step 2: Autism spectrum disorder is a severe medically determinable impairment with documentation extending well beyond the 12-month duration requirement. Proceeds to Step 3.

Step 3: Listing 112.10 (autism spectrum disorder, child) requires medical documentation of qualitative deficits in verbal communication, nonverbal communication, and social interaction AND restricted/repetitive patterns of behavior, interests, or activities (criterion A), PLUS extreme limitation in one or marked limitation in two of four areas (criterion B).

Carlos's developmental pediatrician documents qualitative deficits in all three social communication areas and restricted/repetitive patterns including insistence on sameness, stereotyped motor mannerisms, and highly restricted interests. Criterion A is satisfied.

For criterion B, the speech-language pathologist's evaluation documents marked limitation in interact with others (substantially below age-appropriate norms for reciprocal social interaction). The occupational therapist's evaluation documents marked limitation in adapt/manage oneself (difficulty with transitions, frequent meltdowns, inability to engage in age-appropriate self-care during sensory dysregulation). The psychologist's comprehensive evaluation supports both findings. Criterion B is satisfied with marked limitations in two of four areas.

Decision: Disabled at Step 3 under child listing 112.10. Carlos meets the disability requirement for Katie Beckett. The next steps for Katie Beckett eligibility involve institutional level-of-care determination (typically through the Georgia Department of Behavioral Health and Developmental Disabilities for I/DD-related cases or DCH for medical complexity cases) and cost-effectiveness determination.

Example 4: Patricia age 58 Augusta with degenerative disc disease

Patricia is a 58-year-old former bookkeeper in Augusta. She has multilevel lumbar degenerative disc disease, lumbar stenosis, and chronic radicular pain. She underwent two back surgeries with limited improvement. Her treating orthopedic surgeon has recommended she limit lifting to 10 pounds occasionally, alternate sitting and standing, and avoid prolonged sitting more than 30 minutes at a time. She last worked 10 months ago when she could no longer tolerate the prolonged sitting required for bookkeeping.

Patricia applied for SSDI and SSI. The initial determination at DAS was unfavorable. Patricia appealed and her case went to an ALJ hearing in Atlanta.

ALJ analysis:

Step 1: Not engaged in SGA.

Step 2: Severe musculoskeletal impairment meeting duration requirement.

Step 3: Listing 1.15 (disorders of the skeletal spine) requires neuroanatomic distribution of pain, limitation of motion of the spine, motor loss accompanied by sensory or reflex loss, AND inability to use upper extremities or inability to ambulate effectively. The ALJ determines that while Patricia has documented stenosis and pain, the medical records do not establish complete inability to ambulate effectively (she can walk short distances). Listing not met.

Step 4 and 5 require RFC assessment. The ALJ determines Patricia's RFC is sedentary work with a sit-stand option at will, no prolonged sitting more than 30 minutes at a time, no overhead reaching, no climbing of ladders/ropes/scaffolds, occasional postural activities, and no concentrated exposure to hazards.

Step 4 past relevant work: Bookkeeping is sedentary unskilled-to-semi-skilled work. The vocational expert testifies that with Patricia's sit-stand option restriction, she cannot return to bookkeeping as actually or generally performed (which requires prolonged sitting).

Step 5 other work: The vocational expert is asked whether there is other work in the national economy Patricia can perform with her RFC. Initially the vocational expert identifies sedentary unskilled occupations (assembler, inspector, sorter). However, on cross-examination by Patricia's representative, the vocational expert acknowledges that the sit-stand option at will and 30-minute sitting limitation eliminate most production-line sedentary occupations.

Medical-vocational grid analysis: Patricia is age 58 (advanced age), has a high school education that does not provide for direct entry into skilled work, and has past semi-skilled work without transferable skills (her bookkeeping skills do not transfer to other sedentary occupations available with her sit-stand limitation). Grid rule 201.14 directs a finding of disabled for an individual of advanced age with high school education without direct entry into skilled work and unskilled or no transferable skills limited to sedentary work.

Decision: Disabled at Step 5 under the medical-vocational grid framework. Patricia qualifies for SSDI. Because her SSDI benefit amount and other resources place her below SSI limits, she also qualifies for SSI and (under Georgia's 1634 status) Medicaid.

Example 5: Marcus age 28 Albany with cerebral palsy working part-time

Marcus is a 28-year-old with cerebral palsy living in Albany. He has spastic diplegia affecting both lower extremities, requiring forearm crutches for ambulation, with mild upper-extremity involvement. Marcus has worked part-time as a data entry clerk for the past 18 months, earning $1,200 per month. He needs Medicaid to continue receiving physical therapy and maintain his durable medical equipment (forearm crutches, ankle-foot orthoses, custom seating for his wheelchair he uses for longer distances). Marcus was an SSI recipient as a child but lost SSI eligibility when his earnings began.

Analysis:

Step 1 SGA: Marcus's $1,200 monthly earnings are below the applicable SGA threshold. He is not engaging in SGA. Proceeds to Step 2.

Step 2: Cerebral palsy is a severe medically determinable impairment meeting the 12-month duration requirement.

Step 3: Listing 11.07 (cerebral palsy) requires either disorganization of motor function in two extremities resulting in extreme limitation, OR marked limitation in physical functioning and marked limitation in one of four areas of mental functioning, OR significant interference with communication ability. Marcus's neurologist documents disorganization of motor function in both lower extremities resulting in extreme limitation (he cannot ambulate without forearm crutches). Listing met.

Decision: Disabled at Step 3.

Medicaid pathway analysis: Marcus's earnings ($14,400 annually) are below Georgia's 1619(b) threshold, so he could potentially maintain SSI Medicaid under Section 1619(b) if he had previously been on SSI cash benefits.

If Marcus had not been a prior SSI recipient or fell outside 1619(b) protections, he would qualify for the Medicaid Buy-In for Working Disabled. The Buy-In allows working individuals with disabilities to have higher income and resource limits than standard ABD Medicaid in exchange for a sliding-scale premium based on income.

The disability determination through DAS or via SSA establishes the foundational requirement. The Medicaid Buy-In then accommodates Marcus's work earnings.

Example 6: Ramona age 6 Columbus with type 1 diabetes

Ramona is a 6-year-old child in Columbus diagnosed with type 1 diabetes mellitus at age 4. She requires multiple daily insulin injections, continuous glucose monitoring, and constant supervision for diabetes management. Despite intensive management, she has had three hospitalizations in the past 12 months (two for diabetic ketoacidosis and one for severe hypoglycemia requiring hospitalization for stabilization). Her family is applying for Katie Beckett TEFRA Medicaid because the supplies, devices, and monitoring required exceed family insurance coverage.

DAS performs the disability determination using the child standard.

Child sequential evaluation:

Step 1: Not applicable.

Step 2: Type 1 diabetes is a severe medically determinable impairment meeting the 12-month duration requirement.

Step 3: Listing 109.08 (type 1 diabetes mellitus). For children age 6 and over, the listing requires meeting specified criteria related to glycemic control or frequency of hospitalizations for diabetes-related complications.

Ramona's treating endocrinologist documents that her hospitalization history — three diabetes-related inpatient stays within the prior 12 months — satisfies the listing's hospitalization frequency criteria.

Decision: Disabled at Step 3 under child listing 109.08. Ramona meets the disability requirement for Katie Beckett. Next steps involve institutional level-of-care determination and cost-effectiveness determination.

Common misconceptions

Treating physician opinions are always binding

Treating physician opinions receive significant consideration but are not automatically binding. Under the post-2017 articulation framework, SSA evaluates medical opinions for supportability (how well-supported by relevant evidence) and consistency (how consistent with other evidence). A well-supported and consistent treating opinion typically carries significant weight; a poorly-supported or inconsistent opinion may receive less weight.

Working at all disqualifies you from disability

Working below the SGA threshold does not preclude disability. Many individuals with disabilities work part-time within these limits and qualify for disability benefits. Section 1619(b) and the Medicaid Buy-In allow continued Medicaid coverage even with substantial earnings.

VA disability automatically means SSA disability

The Department of Veterans Affairs uses a different disability rating system than SSA. VA evaluates service-connected impairments against rating schedules with percentage ratings (10 percent, 20 percent, etc., up to 100 percent permanent and total). SSA evaluates impairments against work capacity using the sequential evaluation process. A 100 percent permanent and total VA rating triggers expedited SSA processing but does not automatically establish SSA disability.

Having a listed condition automatically establishes disability

Listings establish disability only when ALL specified criteria are met. Having a diagnosis of a listed condition is not enough; the medical evidence must satisfy each clinical, laboratory, or functional criterion specified in the listing. Many claimants with listed conditions do not meet all criteria and proceed through Steps 4 and 5.

Starting work will cause you to lose Medicaid

This is often false. Section 1619(b) preserves Medicaid for working SSI recipients up to substantial income thresholds. The Medicaid Buy-In for Working Disabled provides another pathway for higher earners. Trial work period and extended period of eligibility for SSDI provide additional protections. Most working individuals with disabilities can maintain Medicaid coverage through one of these mechanisms.

Children's disability uses the same standard as adults

The child standard under Section 1614(a)(3)(C) focuses on marked and severe functional limitations rather than inability to engage in substantial gainful activity. Sequential evaluation for children has three steps rather than five. Different listings apply (Part B of Appendix 1) and functional equivalence in six domains is the path for many child claims that do not strictly meet a listing.

Denial at the initial level means the claim is hopeless

Initial denials are common. Reconsideration approval rates are low, but ALJ hearing approval rates are substantially higher. Many strong claims are denied initially and approved at ALJ hearing. Representation by an experienced disability attorney or non-attorney representative substantially improves outcomes at the ALJ level.

Practical guidance for Georgia families

Documenting your disability

For both initial determinations and appeals, comprehensive documentation is essential:

1. Identify all treating providers and request complete medical records
2. Request specific medical source statements from treating physicians describing functional limitations (lifting, standing/walking, sitting, postural, manipulative, mental, environmental)
3. Maintain a symptom journal noting daily activities, limitations, and impact of treatment
4. List all medications with dosages and side effects
5. Document failed work attempts (jobs you tried but could not maintain due to impairments)
6. Document daily living impacts (need for assistance with personal care, household tasks, transportation)
7. Have family members, friends, or caregivers prepare third-party function reports describing their observations of your limitations

Choosing representation

Most claimants benefit from representation, especially at the ALJ hearing level. Options include:

• Private disability attorneys (no fee unless successful; contingency fee capped at 25 percent of past-due benefits, subject to SSA's published maximum dollar amount)
• Non-attorney representatives (similar fee structure)
• Free legal services through Georgia Legal Services Program, Atlanta Legal Aid Society, and Disability Rights Georgia for qualifying low-income claimants
• Disability advocacy organizations for specific populations

The National Organization of Social Security Claimants' Representatives (NOSSCR) maintains a directory of qualified representatives. The State Bar of Georgia and local bar associations can provide referrals to disability attorneys.

Understanding appeal deadlines

Strict 60-day deadlines apply at each level of administrative appeal. Late filings can extinguish appeal rights unless good cause for late filing is established. Track all dates carefully:

• 60 days from initial determination to request reconsideration
• 60 days from reconsideration determination to request ALJ hearing
• 60 days from ALJ decision to request Appeals Council review
• 60 days from Appeals Council action to file federal court action

When in doubt about a deadline, file promptly and seek representation rather than waiting.

Coordinating with Medicaid eligibility

For Georgia Medicaid applicants whose eligibility depends on disability determination:

1. Submit Medicaid application through DFCS or Georgia Gateway promptly
2. If you have an SSI award, ensure SSI status is verified for automatic Medicaid enrollment
3. If you do not have an SSI determination, expect DCH-DAS coordination for an independent Medicaid disability determination
4. Federal regulations require Medicaid eligibility determinations to be completed within specified time limits for disability cases
5. If processing extends beyond 90 days due to extraordinary circumstances, document this and inquire about retroactive coverage when finally approved

Final notes

For Georgia families navigating the Medicaid disability determination process, understanding the federal Social Security Administration framework is essential. The federal definition of disability under Section 1614(a)(3) of the Social Security Act controls. The five-step sequential evaluation process for adults under 20 CFR 416.920 and the three-step sequential evaluation process for children under 20 CFR 416.924 provide the analytical structure. The Listing of Impairments at 20 CFR Part 404 Subpart P Appendix 1, residual functional capacity assessment under SSR 96-8p, and the medical-vocational grids at 20 CFR Part 404 Subpart P Appendix 2 supply the substantive standards.

Georgia's Section 1634 state status means that SSA disability determinations for SSI recipients automatically establish Medicaid eligibility. For applicants not going through SSA, the Disability Adjudication Section of the Georgia Department of Human Services performs Medicaid disability determinations using the same federal framework, with medical consultants, psychological consultants, and vocational specialists conducting the analysis.

The five-level appeals process (initial determination, reconsideration, administrative law judge hearing, Appeals Council review, federal district court) provides robust opportunities for review when disability is denied. Strong documentation, careful adherence to appeal deadlines, and qualified representation substantially improve outcomes.

Brevy at brevy.com is your digital ally helping you navigate Georgia Medicaid disability determinations, the SSA framework, the Disability Adjudication Section process, and the appeals path. This information is not legal advice and is not a substitute for individualized counsel. For your specific situation, contact DCH at 1-866-211-0950, DAS at 404-657-3000, SSA at 1-800-772-1213, or consult with a qualified disability attorney, Georgia Legal Services Program at 404-377-0701, Atlanta Legal Aid Society, or Disability Rights Georgia at 404-885-1234.

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What is the federal definition of disability for Medicaid purposes?

For adults, disability under Section 1614(a)(3)(A) of the Social Security Act is the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. For children under 18, disability under Section 1614(a)(3)(C) is a medically determinable physical or mental impairment which results in marked and severe functional limitations and which has lasted or can be expected to last for a continuous period of not less than 12 months.

What is the five-step sequential evaluation process?

The five-step sequential evaluation process under 20 CFR 416.920 (SSI) and 20 CFR 404.1520 (SSDI) for adults proceeds through: Step 1 substantial gainful activity (engaging in SGA = not disabled), Step 2 severe medically determinable impairment meeting 12-month duration (no severe impairment = not disabled), Step 3 Listing of Impairments (meeting or medically equaling a listing = disabled), Step 4 past relevant work (able to perform past work = not disabled), and Step 5 other work in national economy (able to perform other work = not disabled). The evaluation stops at the first step that establishes a definitive finding.

What is the three-step sequential evaluation for children?

Children's disability under 20 CFR 416.924 follows: Step 1 substantial gainful activity (engaging in SGA = not disabled, rarely applies to children), Step 2 severe medically determinable impairment meeting 12-month duration, and Step 3 meeting, medically equaling, or functionally equaling the Listing of Impairments. Functional equivalence requires marked limitation in two of six domains of functioning or extreme limitation in one domain.

What is substantial gainful activity?

The SGA earnings threshold is updated annually based on the national average wage index; SSA publishes current-year amounts each fall. Blind individuals have a higher threshold than non-blind individuals. Earnings above the applicable threshold generally establish SGA at Step 1, precluding a finding of disability regardless of medical condition.

What is the Listing of Impairments?

The Listing of Impairments at 20 CFR Part 404 Subpart P Appendix 1 is a catalog of specific medical conditions that, when established by required medical evidence and satisfying specified clinical criteria, establish disability at Step 3 without further evaluation. Part A contains adult listings organized by body system (1.00 musculoskeletal through 14.00 immune system). Part B contains child listings (100.00 through 114.00). Each listing specifies required findings such as test results, clinical examination findings, and functional measurements.

What is residual functional capacity?

Residual functional capacity (RFC) under 20 CFR 416.945 is what an individual can still do in a work setting on a regular and continuing basis (8 hours per day, 5 days per week) despite their impairments. RFC includes physical (exertional and non-exertional) and mental components. RFC is the analytical bridge between medical findings at Step 3 and vocational analysis at Steps 4 and 5.

What are the medical-vocational grids?

The medical-vocational grids at 20 CFR Part 404 Subpart P Appendix 2 are tables that combine residual functional capacity (sedentary, light, or medium), age category, education, and previous work experience to direct findings of disabled or not disabled at Step 5. The grids systematically favor findings of disabled with increasing age, lower education, and lack of transferable skills.

Is Georgia a Section 1634 state?

Yes. Georgia is a Section 1634 state under Section 1634 of the Social Security Act. This means SSA determines eligibility for both SSI and ABD Medicaid, and SSI recipients are automatically enrolled in Medicaid. A small number of states are 209(b) states that use more restrictive Medicaid eligibility criteria; Georgia is NOT among them.

What is the Disability Adjudication Section?

The Disability Adjudication Section (DAS) is within the Georgia Department of Human Services and operates under contract with the Social Security Administration to perform disability determinations. DAS makes initial and reconsideration determinations for SSI and SSDI claims, and also makes Medicaid disability determinations when needed for specific Medicaid pathways. DAS employs disability adjudicators, medical consultants, psychological consultants, and vocational specialists.

Who is an acceptable medical source?

Under 20 CFR 416.913, acceptable medical sources include licensed physicians, licensed psychologists, licensed optometrists (for visual disorders), licensed podiatrists (for foot and ankle conditions), qualified speech-language pathologists, licensed audiologists, licensed advanced practice registered nurses (within scope), and licensed physician assistants (within scope). Non-acceptable sources such as chiropractors and family members can provide evidence about limitations but cannot alone establish medically determinable impairments.

What is a consultative examination?

A consultative examination (CE) is an independent medical or psychological examination arranged by DAS when treating source evidence is insufficient. CE providers are physicians or psychologists under contract with DAS. CE results inform but do not override treating source evidence; both are weighed in the overall analysis.

What is Section 1619(b)?

Section 1619(b) of the Social Security Act preserves SSI Medicaid coverage for working individuals who would still be eligible for SSI except for their earnings. To qualify, the individual must be unable to afford medical care needed to continue working without Medicaid, must continue to be disabled, and must have earnings below a specified threshold. Contact SSA for Georgia's current 1619(b) earnings threshold. This protection is critical for working individuals with disabilities.

What is the Medicaid Buy-In for Working Disabled?

The Medicaid Buy-In for Working Disabled under Section 1902(a)(10)(A)(ii)(XIII) of the Social Security Act allows working individuals with disabilities to maintain Medicaid coverage with higher income and resource limits than standard ABD Medicaid, in exchange for paying a sliding-scale premium based on income. Eligibility requires a disability determination, employment for pay, income within program limits, and resources within program limits.

What is the Katie Beckett TEFRA pathway?

Katie Beckett TEFRA under Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982, codified at Section 1902(e)(3) of the Social Security Act, allows children with disabilities to qualify for Medicaid based on the child's own income and resources rather than the parents'. Eligibility requires child under age 18, disability determination meeting child standard, institutional level of care, determination that community care is appropriate and cost-effective, and child's own income/resources within limits.

What are the five levels of administrative review for disability denials?

Level 1: Initial determination by DAS. Level 2: Reconsideration by different DAS adjudicator and consultants. Level 3: Administrative law judge (ALJ) hearing before SSA ALJ at hearing offices in Atlanta, Macon, Savannah, or Albany. Level 4: Appeals Council review in Falls Church, Virginia. Level 5: Federal district court action in the Northern, Middle, or Southern District of Georgia.

How long do I have to appeal a denial?

Strict 60-day deadlines apply at each level of administrative appeal. Good cause for late filing can extend the deadline in some cases, but timely filing is strongly recommended. Track all dates carefully and file promptly to preserve appeal rights.

Do I need a lawyer for the appeals process?

Representation is not required but is strongly recommended, especially at the ALJ hearing level. Representation substantially improves outcomes. Private disability attorneys work on contingency (no fee unless successful, fees capped at 25 percent of past-due benefits, subject to SSA's published maximum). Free legal services are available through Georgia Legal Services Program, Atlanta Legal Aid Society, and Disability Rights Georgia for qualifying low-income claimants.

How long does the disability determination process take?

Initial determinations target an average of 4 to 6 months but vary significantly by case complexity. Reconsideration typically takes 3 to 5 months. ALJ hearings can take 6 to 18 months or longer depending on hearing office backlog. For Medicaid purposes, federal regulations require eligibility determinations within specified time limits for disability cases, with extraordinary circumstances exceptions.

What is the Compassionate Allowances program?

Compassionate Allowances is an SSA program that expedites disability determinations for the most serious medical conditions. The list includes over 280 conditions such as certain cancers, ALS, rare disorders, early-onset Alzheimer's disease, and certain genetic conditions. The Quick Disability Determination program also expedites strong claims through fast-track review.

Where can I get help with my Georgia Medicaid disability application or appeal?

Contact DCH Medicaid Member Services at 1-866-211-0950 for general Medicaid questions, the DCH Aged Blind Disabled Eligibility Unit for ABD-specific questions, DFCS Customer Service at 1-877-423-4746, Georgia Disability Determination Services at 404-657-3000, SSA at 1-800-772-1213 (TTY 1-800-325-0778), DCH Office of Appeals for Medicaid appeals, Georgia Legal Services Program at 404-377-0701, Atlanta Legal Aid Society, Disability Rights Georgia at 404-885-1234, AARP Georgia at 1-866-295-7283, 211 Georgia, Georgia Advocacy Office at 404-885-1234, or CMS Region IV for federal Medicaid oversight. :::

Find personalized help navigating Georgia Medicaid disability determinations at brevy.com.

::: cta Need help with Georgia Medicaid disability determination, SSA process, or appeals? These resources can help.

• DCH Medicaid Member Services: 1-866-211-0950
• DCH Aged Blind Disabled Eligibility Unit (contact through DCH Member Services)
• DFCS Customer Service: 1-877-423-4746
• Georgia Gateway: gateway.ga.gov
• Georgia Disability Determination Services: 404-657-3000
• Social Security Administration: 1-800-772-1213
• SSA TTY: 1-800-325-0778
• DCH Office of Appeals (contact through DCH Member Services)
• Georgia Legal Services Program: 404-377-0701
• Atlanta Legal Aid Society (contact through Georgia Legal Services Program)
• Disability Rights Georgia: 404-885-1234
• AARP Georgia: 1-866-295-7283
• 211 Georgia: dial 211
• Georgia Advocacy Office: 404-885-1234
• CMS Region IV (Atlanta): federal Medicaid oversight :::