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 at or below 211% of the federal poverty level for family-planning care. Neither is a senior program. This guide explains how the demonstrations work, who qualifies for each, 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, P4HB women 18 to 44.2,3 Neither covers nursing-home care, in-home long-term care, or the aged and disabled population most eldercare readers are researching.

If you are 65 or older, 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 the two demonstrations do and who 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. The D.C. Circuit read that objective as furnishing medical assistance, meaning coverage, and held in 2020 that the Secretary could not approve a project cutting coverage without analyzing the loss. The Supreme Court later vacated that judgment as moot, so it is reasoning worth knowing rather than binding law.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 Section 1115 itself: CMS says budget neutrality has never been required in statute, and that it has applied shifting methodologies 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, with excess federal funds 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, and it is not retroactive: CMS expects to keep its current review practices for approvals issued before January 1, 2027. 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. None of those periods is absolute: CMS may waive the federal and state notice procedures, in whole or in part, to expedite a decision on a request addressing a natural disaster, a public health emergency, or another sudden emergency threat to human life.7

Once approved, the state must submit annual reports documenting operations, coverage impact, quality, cost, access, and beneficiary satisfaction. The draft annual report is due no later than 90 days after each demonstration year ends, or on whatever schedule the demonstration's Special Terms and Conditions set: the 90 days is a default the STCs can displace. The state must then publish that draft on its public website within 30 days of sending it to CMS, hold a public forum within six months of implementation and annually after that, and obtain CMS approval of an evaluation design and cooperate with an independent evaluation. Those postings and forums are where a Georgian can see how Pathways is actually performing.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 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 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 reported every month, and high non-reporting drove enrollees who were in fact working or studying off the rolls. Georgia moved to application-and-renewal reporting to cut 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. Missing the renewal 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.2

Benefits and delivery

Pathways provides a comprehensive Medicaid benefit package 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 lab and radiology. Members pick 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 18 to 44, 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 that instead.

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. Inter-Pregnancy Care adds limited primary care for chronic conditions affecting future pregnancies, such as hypertension and diabetes, plus Resource Mothers case management. 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 why it survived turns on the litigation over its predecessors.

In Gresham v. Azar, decided February 14, 2020, the U.S. Court of Appeals for the D.C. Circuit affirmed the vacatur of the HHS Secretary's approval of Arkansas's Arkansas Works demonstration, holding it arbitrary and capricious: the Secretary identified alternative objectives, better health outcomes and beneficiary independence, instead of analyzing whether the demonstration would promote Medicaid's principal objective of health coverage. Two limits matter. The ruling reached Arkansas only. Kentucky terminated its own demonstration after argument and its consolidated appeal (Stewart v. Azar) was dismissed rather than decided, so the D.C. Circuit never struck Kentucky's waiver down. And the opinion no longer stands: on April 18, 2022 the Supreme Court granted a motion to vacate the judgment and ordered the case dismissed as moot.4 Many Arkansas enrollees had already lost coverage.

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. CMS's extension-and-amendment approval letter is dated September 23, 2025, the amended Special Terms and Conditions stamp the amendment September 30, 2025, and Georgia put the changes into effect October 1, 2025; the demonstration is temporarily extended 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 no later than January 1, 2027. CMS's implementing rule sets its reach: the requirement applies in states that elected the Affordable Care Act adult group through the state plan, and in states with a Section 1115 demonstration covering a similar population. Georgia never took the expansion, so it is caught by that second route, through Pathways itself, on the same timetable. CMS states that Georgia is the only state still running a community-engagement program as a condition of Medicaid eligibility for certain adults. The date is a deadline with a route past it rather than a wall: CMS may temporarily exempt a state that asks and shows a good-faith effort, and no such exemption can run past December 31, 2028.5

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, and the document that governs how is the notice itself. It carries the binding filing instructions and the deadline that applies to your case, so file the way it tells you to and by the date it prints. Eligibility paperwork runs through Georgia Gateway, a DFCS county office, or the DFCS Customer Contact Center at 1-877-423-4746. Do not route an appeal through the DCH Medicaid Member Services line at 1-866-211-0950; that line covers benefits, ID cards, and provider listings, and a call there can cost you days you may not have. If you were already enrolled and want benefits to continue while the hearing is pending, DFCS says that request must be made within 12 days of the closure notice, and you may be required to repay those benefits if the decision goes against you. Hearings themselves are held by the Georgia Office of State Administrative Hearings (OSAH), reachable at 404-657-2800 or toll-free at 1-877-809-0007. 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 404-524-5811.10,9,11,12

Contact directory

Learn More

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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.