Georgia Medicaid Section 1115 Demonstrations (2026): Pathways & P4HB

Georgia runs two Medicaid Section 1115 demonstrations: Pathways to Coverage, a limited expansion with an 80-hour work rule, and Planning for Healthy Babies, a family-planning program. Pathways covers adults 19 to 64 with income up to 100% of the federal poverty level who complete 80 hours a month of qualifying activity. Planning for Healthy Babies covers women 18 to 44 with income at or below 211% of the federal poverty level for family-planning care. Neither is a senior program. This guide explains how Section 1115 demonstrations work, who qualifies for each Georgia program, and where aged or disabled adults should look instead.

A Section 1115 demonstration is a federal Medicaid waiver. Section 1115 of the Social Security Act (42 U.S.C. 1315) lets the Secretary of Health and Human Services approve a state project that waives standard Medicaid rules or pays for things Medicaid normally does not, when the Secretary judges the project likely to promote the objectives of Medicaid.1 Georgia uses that authority for two programs: Pathways to Coverage, a limited Medicaid expansion with a work rule, and Planning for Healthy Babies (P4HB), a family-planning program.2,3

In This Guide

• Who These Programs Are Not For
• How a Georgia Medicaid Section 1115 Demonstration Works
• Pathways to Coverage
• Planning for Healthy Babies (P4HB)
• Georgia Medicaid Section 1115: Pathways vs P4HB
• The Work-Requirement Litigation
• How to Apply and Appeal
• Frequently Asked Questions
• Contact Directory
• Learn More

Who these programs are not for

Both Georgia Section 1115 demonstrations target younger, non-disabled adults: Pathways covers adults 19 to 64, and P4HB covers women 18 to 44.2,3 Neither covers nursing-home care, in-home long-term care, or the aged and disabled population that most eldercare readers are researching.

If you are 65 or older, or have a disability, or are arranging care for an aging parent, these are not your programs. Look instead at the Georgia Medicaid hub for aged, blind, and disabled (ABD) eligibility, and at Georgia's long-term-care and home and community-based services pathways. A family caregiver seeking payment should start with Georgia's caregiver-pay options, not Pathways. The rest of this guide covers what these two demonstrations actually do, and how a younger adult or a woman of reproductive age qualifies.

How a Georgia Medicaid Section 1115 demonstration works

A Section 1115 demonstration rests on two powers in 42 U.S.C. 1315. First, the Secretary may waive compliance with the standard Medicaid state-plan requirements in Section 1902 of the Act, to the extent and for the period the Secretary finds necessary. Second, costs of the approved project that would not otherwise be Medicaid-matchable are treated as expenditures under the state plan. That second power lets a state cover a population or a benefit Medicaid rules would not normally allow.1

The Secretary's authority is conditional. A demonstration may be approved only when it is "likely to assist in promoting the objectives" of Medicaid. Federal courts have read that objective as furnishing medical assistance, meaning coverage, and have held that the Secretary cannot approve a project that cuts coverage without analyzing and justifying the loss.4

Budget neutrality

A demonstration must be budget neutral, meaning it does not cost the federal government more than running the state's Medicaid program the usual way. That condition has always come from CMS policy rather than from Section 1115 itself: CMS says budget neutrality has never been required in statute, and that it has applied shifting methodologies to determining it over time. Through the end of 2026, CMS enforces it by comparing projected "with waiver" spending against a "without waiver" baseline, and that baseline sets an expenditure limit the state cannot exceed. Excess federal funds must be returned to CMS.

That changes on January 1, 2027. The Working Families Tax Cut legislation added a new subsection 1115(g), and from that date CMS will not approve a new demonstration, renewal, or amendment unless the CMS Chief Actuary certifies that it is not expected to increase federal spending compared with the state's program without the demonstration. The new approach drops the expenditure limit and the budget-neutrality cap entirely. In their place, a demonstration expected to increase federal Medicaid spending would simply not be approved. The new requirement reaches Medicaid demonstrations in every state, the District of Columbia, and the territories, but not CHIP Section 1115 demonstrations. CMS is preparing a proposed rule to implement it.6

Public notice, monitoring, and evaluation

The demonstration lifecycle is governed by 42 CFR Part 431, Subpart G. Before a state submits a new or extension application, it must run at least a 30-day public comment period and hold at least two public hearings on separate dates and locations. CMS then runs its own 30-day federal comment period and will not decide for at least 45 days after a complete application arrives.7

Once approved, the state must submit annual reports documenting operations, coverage impact, quality, cost, access, and beneficiary satisfaction, with a draft annual report due no later than 90 days after each demonstration year ends. The state must also obtain CMS approval of an evaluation design and cooperate with an independent evaluation.8 The operating contract between CMS and the state, the Special Terms and Conditions (STCs), sets the eligibility, benefits, cost sharing, reporting, and budget-neutrality cap for each demonstration and is amended over the demonstration term.

States across the country use this authority for very different ends. CalAIM in California, TennCare in Tennessee, and MassHealth in Massachusetts are all Section 1115 demonstrations. Georgia's two demonstrations sit at the narrower end of that range.

Pathways to Coverage

Pathways to Coverage is Georgia's Section 1115 demonstration that offers a limited Medicaid expansion tied to a work or qualifying-activity requirement.

Who qualifies for Pathways

Pathways covers adults between 19 and 64 years of age with household income up to 100% of the federal poverty level who complete at least 80 hours per month of qualifying activity.2 It does not cover adults who already qualify for Medicaid under another category, including parents and caretaker relatives under the parent/caretaker limit, pregnant women, people receiving Supplemental Security Income (SSI), and people who qualify through a disability.

Qualifying activities

To enroll and to keep coverage, a member must complete at least 80 hours per month of qualifying activity. Qualifying activities are:2

• Working (paid or unpaid, full-time, part-time, or self-employment)
• Job training or education, including on-the-job training, registered apprenticeships, job-readiness activities, and post-secondary education
• Volunteering or community service
• Being a parent or legal guardian of a child under age 6 who is enrolled in Medicaid (added effective October 1, 2025)

Activities must be documented. Work is verified through pay stubs or tax records, education through enrollment records, and volunteering through the organization's logs.2

Reporting, cost sharing, and renewal

Effective October 1, 2025, members report their qualifying activities and hours only at application and at annual renewal, not every month.2 Under the original design, members had to report every month, and high rates of non-reporting drove enrollees who were in fact working or studying off the rolls. Georgia moved to application-and-renewal reporting to reduce that churn.

Pathways members are required to pay a copayment for certain services. Copayments are not required for Pathways members under age 21.2 Coverage now begins on the first day of the month in which an application is received, so approved applicants are covered back to the start of their application month.2

Pathways enrollees complete a full redetermination at annual renewal, when they also confirm qualifying activity. Failure to complete renewal by the deadline can end coverage; a member can re-enroll by documenting qualifying activity and completing the renewal steps, with coverage reinstated the first day of the month after the steps are done.2

Benefits and delivery

Pathways provides a comprehensive Medicaid benefit package delivered through the Georgia Department of Community Health and the Georgia Families care management organizations (CMOs). Covered services include physician care, inpatient and outpatient hospital care, prescription drugs, behavioral health, preventive services, family planning, maternity care if a pregnancy occurs, emergency services, durable medical equipment, and laboratory and radiology. Members choose a CMO at enrollment or are auto-assigned.

Planning for Healthy Babies (P4HB)

Planning for Healthy Babies is Georgia's Section 1115 family-planning demonstration. It extends Medicaid family-planning coverage to women who would not otherwise qualify, with the goal of reducing low-birthweight and very-low-birthweight births.

Who qualifies for P4HB

To enroll in P4HB, a woman must have family gross income at or below 211% of the federal poverty level, be between 18 and 44 years of age, be a Georgia resident, be a U.S. citizen or have qualified proof of citizenship, be able to become pregnant, and not be eligible for any other Medicaid or managed-care program.3 A woman who qualifies for full Medicaid under another category is enrolled in full Medicaid instead of P4HB.

The three components

P4HB has three components, all for women 18 to 44 at or below 211% of the federal poverty level:3

• Family Planning (FP): family-planning services for uninsured women in that income range.3
• Inter-Pregnancy Care (IPC): for uninsured women who are within three years of delivering a very-low-birthweight baby. IPC adds primary-care and chronic-condition services beyond family planning.3
• Resource Mothers (RM): community health worker outreach and support for women within three years of a very-low-birthweight delivery.3

What P4HB covers

The Family Planning component covers contraceptive services and supplies, sterilization (subject to federal informed-consent and waiting-period rules), an annual exam, pregnancy testing, screening and treatment for sexually transmitted infections, and cervical and breast cancer screening. The Inter-Pregnancy Care component adds limited primary care for chronic conditions that affect future pregnancies, such as hypertension and diabetes, along with the Resource Mothers case-management support. P4HB does not cover care unrelated to family planning or inter-pregnancy care.

Georgia Medicaid Section 1115: Pathways vs P4HB

Both demonstrations are delivered through the Georgia Families CMOs.2,3

The work-requirement litigation

Pathways is the only Medicaid work requirement operating in the country, and understanding why it survived requires the litigation that struck down its predecessors.

In Gresham v. Azar (consolidated with Stewart v. Azar), decided February 14, 2020, the U.S. Court of Appeals for the D.C. Circuit held that the HHS Secretary acted in an arbitrary and capricious manner in approving Arkansas's and Kentucky's Section 1115 work-requirement demonstrations, because he failed to analyze whether they would promote Medicaid's primary objective of furnishing medical assistance, meaning health coverage.4 Many Arkansas enrollees had already lost coverage before the rulings.

Georgia's Pathways was approved separately and is structured as a new coverage category for people in the coverage gap rather than a requirement layered onto an already-eligible population. After a later administration tried to rescind parts of the approval, a federal court ruled for Georgia and reinstated the demonstration. Pathways launched July 1, 2023, and CMS approved an extension on September 25, 2025 that continues it through December 31, 2026.2

A separate, broader change is now coming from Congress. Under the 2025 budget-reconciliation law, states must implement a new federal Medicaid community-engagement (work) requirement for the Affordable Care Act expansion adult group no later than January 1, 2027. CMS has noted that Georgia is currently the only state running a work requirement as a condition of Medicaid eligibility, and Georgia, like every expansion state, is subject to the new federal requirement.5

How to apply and appeal

Apply for Pathways or P4HB

Apply through Georgia Gateway or by calling the DFCS Customer Contact Center at 1-877-423-4746. You can also apply in person at a county Division of Family and Children Services (DFCS) office or by mail. One application covers all Georgia Medicaid programs, and eligibility staff determine which program you qualify for. If you qualify for full Medicaid under any category, you are enrolled in full Medicaid rather than a demonstration.9

For Pathways, you will document identity, citizenship, income, household composition, and qualifying activity. For Pathways-specific questions, including qualifying-activity reporting, call the Pathways member services line at 1-844-241-1900. For P4HB, eligibility staff route you to Family Planning or, if you are within three years of a very-low-birthweight delivery, to Inter-Pregnancy Care.

Keep your coverage

For Pathways, confirm your qualifying activity at application and again at annual renewal, complete your renewal on time, and report changes in income, household, or address.2 For P4HB, renew annually and report changes; if you become pregnant, contact DCH to transition to full Pregnancy Medicaid.

Appeal a denial

If your Pathways or P4HB application is denied or your coverage is terminated, you can appeal. File the appeal within 30 calendar days of the notice through Georgia Gateway, by calling 1-866-211-0950, by mail, or in person at a DFCS office. Request a fair hearing before the Georgia Office of State Administrative Hearings (OSAH) at 404-651-7500 if your appeal is not resolved. You can request continuation of benefits during the appeal if you were already enrolled. Free legal help is available from Georgia Legal Services Program at 1-833-457-7529, or in metro Atlanta from Atlanta Legal Aid Society at 404-524-5811.10,9

Contact directory

Learn More

Find personalized help understanding Georgia Medicaid demonstrations 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.