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Michael:

Thank you for publishing the draft implementation framework and for stating that OHCA will first use existing case records and automated data exchange before requiring members to produce additional documentation.

We respectfully recommend that implementation reporting preserve a reproducible administrative-outcome chain using aggregate, de-identified data. If operationally feasible, please publish or retain for later public reporting, by month and county or comparable geography:

• the number of expansion adults evaluated under the requirement;
• the number whose compliance or exemption was verified automatically from existing data;
• the number asked to provide additional documentation;
• broad exemption category counts, without personally identifying information;
• initial adverse determinations attributable to the work-requirement process;
• reconsiderations/appeals, reversals, reinstatements, and time to resolution;
• coverage closures attributable to the rule versus closures for unrelated eligibility reasons; and
• any available measure of whether verification or documentation delays differ materially by rural geography.

For American Indian/Alaska Native members and other exempt populations, the same principle is important: an exemption should not become an avoidable documentation barrier when reliable state or federal data already establish it. We are not asking OHCA to expose tribal status or any identifiable member information; aggregate reporting or a simple count of automated versus member-supplied verification would be sufficient.

The purpose of this request is measurement, not a presumption about the rule’s effects. A decline in enrollment by itself would not establish causation. Separating automatic verification, documentation requests, adverse determinations, reversals, and unrelated eligibility changes would support more meaningful evaluation.

Please preserve source dates, denominator definitions, and methodology changes with any published metrics so comparisons remain reproducible over time.

Thank you for considering this data-quality recommendation and for the work involved in implementing the federal requirement.

OHCA Response:
Thank you for the comment. OHCA appreciates the recommendation regarding the use of aggregate, de-identified data to evaluate implementation of the community engagement requirement. OHCA will consider federal reporting requirements, data availability, system capabilities, and member privacy protections as implementation and monitoring processes are developed.

Consistent with OHCA’s public comment posting practices, the comment above was lightly edited to remove identifying information. These edits did not change the substance of the comment.

Joy:

On behalf of approximately 360,000 AARP members in Oklahoma, AARP Oklahoma writes to provide consumer-focused insights and recommendations as the state implements Medicaid community engagement requirements in accordance with the One Big Beautiful Bill Act (OBBBA, P.L. 119-21) and the Centers for Medicare & Medicaid Services (CMS) interim final rule released on June 1, 2026 (IFR). As Oklahoma begins implementing these new requirements, we strongly urge you to do everything possible to prevent eligible people from unnecessarily losing health coverage, including family caregivers, people who are medically frail, older adults with serious illnesses or disabilities, and others who rely on Medicaid to stay healthy and financially secure. We believe this can be accomplished through careful outreach and identification, straightforward verification procedures, and adoption of available flexibilities under the law.

As the state continues its work on implementation, we offer the following recommendations:

Oklahoma has 770,000 family caregivers who are the backbone of Oklahoma’s long-term care system, and many of these caregivers rely on Medicaid to keep themselves healthy so they can continue providing care to their loved ones. CMS adopted an expansive definition of “family caregivers” that are exempt from the community engagement requirements in the IFR that broadly aligns with how the term is defined in the RAISE Family Caregivers Act. AARP fought hard for this exemption at the federal level, and now Oklahoma can make sure it is successfully implemented. Family caregivers keep older adults and individuals with disabilities healthy, safe, and living in their homes, reducing reliance on institutional care. Family caregivers enrolled in Medicaid are providing an extraordinary level of support – averaging 35 hours of unpaid care each week. They need to keep their Medicaid coverage to continue effectively providing that care.

Identifying these caregivers should be a top priority for Oklahoma. The IFR acknowledges that “[m]any family caregivers do not automatically identify themselves as caregivers or recognize themselves in the role of a family caregiver for a variety of reasons.” This creates an important opportunity for Oklahoma to develop clear, easy-to-understand outreach materials that help family caregivers see whether they may qualify for an exemption, with clear explanations of the relationships, living arrangements, caregiving tasks, and types of care recipients that qualify.

In addition, we urge Oklahoma to develop detailed, plain language screening questions for Medicaid applications and renewals that will identify family caregivers and help them verify their status as exempt individuals, including family caregivers of older adults who need assistance in performing activities of daily living. As referenced in the IFR, examples of effective caregiver screening questions can be found in the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS) Caregiver Module, the National Academy of State Health Policy’s Caregiver Communications and Marketing Toolkit, and screening questions developed by AARP and the National Alliance for Caregiving for their “Caregiving in the US 2025” report.

The IFR requires states to first attempt ex parte verification, using existing reliable data and information available to the state to determine if an individual qualifies for an exemption or meets the community engagement requirements; if this is not possible, states may then request reasonably available documentation from the applicant to prove eligibility. Ensuring a smooth and effective ex parte verification system in the state will help protect coverage for qualified Oklahomans. We share as a resource a recent paper that highlights potential data sources that Oklahoma could use to identify family caregivers and verify that they meet the criteria for exempt individuals, either through ex parte verification or as documentation provided by applicants.

These sources include:

• records, including those related to Medicaid home and community-based services and hospital discharge paperwork where individuals are listed as family caregivers for loved ones;
• documents showing they’ve been appointed as fiduciaries or representatives to manage a loved one’s benefits or finances; and
• evidence of participation in family caregiver support programs or caregiver-related tax filings.

When documentation is not reasonably available, the IFR requires states to accept “other information” to determine if an individual is an exempt individual or in compliance with community engagement requirements. We urge you to establish clear guidelines for what “other information” will be accepted and clearly communicate these guidelines to applicants. This information should be straightforward to attain, such as a signed form from a licensed health care provider or social services agency indicating that the family caregiver is providing regularly occurring care that is not solely incidental in nature.

It is important that Oklahomans do not inappropriately lose their coverage due to a lack of awareness about available exclusions or an inability to navigate administrative hurdles. Oklahoma must ensure that our Oklahoma systems, processes, and staffing levels are sufficient to expand outreach capacity, handle inquiries about the new requirements, and process more frequent redeterminations under OBBBA.

Older adults in Medicaid have higher rates of disability and serious illness, and many have significant barriers to employment. Under the OBBBA, Congress explicitly exempted from Medicaid work requirements individuals determined to be “medically frail or otherwise have special medical needs.” The IFR adds to that exemption standard by requiring that a person’s condition also “significantly impair [their] ability to comply with community engagement requirements.”

Under the IFR, states must now assess how an enrollee’s medical condition or disability affects their ability to participate in community engagement activities, such as working, attending school, or volunteering. This is a multidimensional determination that may pose significant difficulty for Oklahoma and enrollees to navigate and could put coverage for older adults at risk.

AARP Oklahoma encourages careful deliberation on implementation of verification requirements for the medical frailty exemption to minimize wrongful coverage loss. As discussed above, one of the most effective ways to ensure that eligible adults qualify for this exemption is through a strong ex parte verification system. Oklahoma should also plan for concerted outreach to medically frail individuals through multiple communication methods in order to assist with verification.

Where an individual may qualify under more than one medical frailty pathway, the state should use the broadest and most administrable category available. Oklahoma should also create broad, clinically realistic screening and individualized review procedures, keep provider verification focused on diagnosis and functional limitation, and work with managed care plans and providers to improve the timeliness of claims and encounter data. Until those systems are reliable and timely, the state should maintain clear alternative verification pathways so medically frail enrollees do not lose coverage because of administrative barriers.

States are required by the OBBBA to verify that individuals comply with the community engagement requirements or meet an exemption at both enrollment and renewal for a minimum of one month, to a maximum of three consecutive months. AARP Oklahoma believes that this look-back window should be set to the federal minimum of one month, as established by the OBBBA. Longer look-back windows will be more difficult for older adults to comply with due to paperwork burdens, and more complex and costly for the state to verify.

AARP believes that Oklahoma should be transparent in publicly reporting on implementation of community engagement requirements. In addition to the monthly enrollment reports already required, the state should collect and publish granular data related to ex parte verification, community engagement compliance and resulting coverage loss, call center metrics, and exemption access and outcomes.

Although not directly related to the new community engagement requirements, we believe the state has another important opportunity to promote access to health care services in Medicaid as it implements the changes in the new federal law. The OBBBA requires states to charge cost-sharing on some care, items, or services as determined by the state up to $35 per service for adults in the expansion population with incomes over 100 percent of the Federal Poverty Level. No cost sharing is permitted for primary care, behavioral health services, emergency services, and services provided in Federally Qualified Health Centers, Rural Health Clinics, and Community Based Health Centers. Importantly, OBBBA does not require states to impose high cost-sharing on any service and states have significant discretion under the law. AARP Public Policy Institute recently released a report that shows how Oklahoma’s current cost-sharing compares to the requirements in OBBBA.

We urge Oklahoma to maintain or impose only nominal cost sharing. Research shows that even small increases in out-of-pocket costs can lead to skipped care, worsened health outcomes, and higher downstream spending for Medicaid. Hardworking Oklahomans don’t need another barrier to staying healthy.

Thank you for your leadership as Oklahoma implements these significant policy changes. We stand ready to discuss these recommendations further and to support your efforts to ensure that implementation is clear, workable, family-centered, and fiscally responsible.

OHCA Response:

Thank you for the comment and recommendations regarding outreach, verification, medical frailty, the community engagement look-back period, and implementation monitoring. OHCA has elected to use the federal minimum one-month look-back period and is developing processes intended to use available reliable data before requesting additional information from members. OHCA will consider the additional recommendations regarding caregiver identification, medical frailty verification, outreach, and reporting as implementation continues.

The recommendation regarding Medicaid cost sharing is outside the scope of this State Plan Amendment and rulemaking but will be considered separately as OHCA implements the applicable federal requirements. 

Ramon:

ViiV Healthcare Company (ViiV) appreciates the opportunity to share comments regarding implementation of community engagement requirements in Oklahoma. We respectfully urge the Oklahoma Health Care Authority to consider the following comments regarding implementation of the new requirements:

• Oklahoma should include HIV/AIDS within the list of conditions that may qualify an individual for a community engagement requirement exclusion as suggested by CMS and in alignment with a definition in federal statute.
• Oklahoma should make exemptions automatic and ex parte, whenever possible; allow for self-attestation when permitted by the IFC; qualify a wide range of practitioners to attest to the severity of an individual’s condition and its impact on their ability to work; and educate practitioners on the forthcoming need for this documentation.

Thank you for considering our input.

OHCA Response:

Thank you for your comment regarding medical conditions that may support a medical frailty exclusion, verification options, and provider documentation.

OHCA is still developing the criteria and processes that will be used to identify individuals who may qualify as medically frail. The Interim Final Rule does not establish an exhaustive list of qualifying conditions, but CMS specifically identifies HIV/AIDS as a condition states may reasonably consider serious or complex when it significantly impairs an individual’s ability to comply with the community engagement requirement.

The Interim Final Rule also requires states, where possible, to verify medical frailty using reliable information available to the state before requesting additional information from the individual, and allows documentation or other information when reliable data are not available.

OHCA will consider these recommendations as it develops its final criteria, verification processes, and provider guidance.