Oklahoma Medicaid · OHCA · SoonerCare

Oklahoma TEFRA /
Katie Beckett

A Plain-Language Family Guide  ·  Applying, Qualifying, Renewing, Appealing

How to apply The three ways to qualify Forms & links Common denial reasons Appeal deadlines
Please read first: This guide was written by an Oklahoma parent, not by a lawyer. It has not been reviewed or approved by an attorney, and it is not affiliated with, endorsed by, or produced by OHCA or the State of Oklahoma. It is general information, not legal advice, and using it is at your own risk. Every child's case is different and program rules change without notice. Verify everything against OHCA's own published pages, which are linked throughout, and get advice from a qualified attorney or advocate before acting on anything here. Last updated: August 2026.

Start Here

This guide covers the whole TEFRA process in Oklahoma — from the first phone call to Social Security through a fair hearing appeal. Pick the situation that matches yours and jump straight to it.

Updated August 2026. This version adds the three institutional level-of-care pathways in full (including the functional-age route that does not depend on IQ), a complete step-by-step application walkthrough with direct links to every OHCA form, and a corrected appeals section covering the 10-day window for continuing coverage — a deadline printed on OHCA's own appeal form.

01

What is TEFRA / Katie Beckett?

TEFRA stands for the Tax Equity and Fiscal Responsibility Act of 1982. In Oklahoma it is administered by the Oklahoma Health Care Authority (OHCA) as part of SoonerCare (Medicaid). You may also hear it called the Katie Beckett program, named after a real child from Iowa whose story changed federal law. TEFRA is federal law, not an Oklahoma invention: the short federal rule behind it, 42 CFR § 435.225, is only a few paragraphs long and names the three kinds of institutional care that define eligibility — the three doors in Section 2.

The simple version: Before 1982, a seriously ill child could only qualify for Medicaid if they stayed in a hospital or nursing facility. If the family took the child home, Medicaid coverage could be lost — even if the parents could provide the same care at home for far less cost. TEFRA fixed that. It allows states to extend Medicaid to children who need institutional-level care but are being cared for at home.

TEFRA exists so that children who need the level of care provided in a hospital or nursing facility can receive that care at home — with Medicaid coverage — instead of being institutionalized. That is its entire purpose.

Key Facts

  • Not based on family income. Only the child's own income and resources are counted. Parents' income is what disqualifies most of these children from SSI in the first place — TEFRA is the workaround.
  • Not based on diagnosis. Eligibility is based on the level of care the child requires, not the name of the condition. Two children with the identical diagnosis can get opposite answers — one approved, one denied — because the determination is about what care that child needs day to day. A diagnosis is the starting point of the conversation, not the answer to it.
  • For children under age 19. Note that OHCA's published level-of-care criteria are phrased as "age 18 years and younger."
  • Reviewed annually. Meeting the criteria at each renewal is required to stay enrolled. There is no lifetime limit and no expiration.
  • TEFRA children stay in traditional SoonerCare. OHCA lists children covered under TEFRA among the groups excluded from SoonerSelect managed care. This matters for appeals — your appeal goes to OHCA directly, not to a health plan.

What that means when you compare notes with other families. Another family's approval or denial tells you very little about your own case, even when the diagnosis matches. Their child's care needs, documentation, and specialists are different from yours. Peer groups are genuinely useful for learning what questions get asked and what documentation has been requested — but do not conclude your child will be denied because someone else's was, and do not assume you are covered because someone else was. Build your file around your own child's care.

Official OHCA program page: TEFRA Children Overview. Bookmark it — it holds the current forms and contact information, and it changes without announcement.

02

The Three Ways to Qualify

To meet TEFRA's level-of-care condition, your child must be found to need the care provided in one of three kinds of institution. The three categories come straight from federal law — 42 CFR § 435.225 names the hospital, skilled nursing facility, and intermediate care facility levels — and Oklahoma writes the detailed criteria for each. These are separate, independent doors. Your child only has to fit through one.

Door 1
ICF/IID
Intellectual or developmental disability. IQ ≤ 70 or a functional age test.
Door 2
Nursing Facility
Complex medical needs requiring skilled nursing-level care. No IQ requirement at all.
Door 3
Hospital
Needs beyond what a nursing facility provides. The highest of the three.

A misunderstanding worth naming: because OHCA asks every applicant age 3 and over for IQ testing, it is easy to conclude that an IQ above 70 ends the conversation. It does not. An IQ above 70 closes one of three doors. The nursing facility and hospital pathways contain no cognitive criterion at all, so a child with typical cognition and significant medical needs is evaluated entirely on those criteria instead.

1. ICF/IID Level of Care Intermediate Care Facility · IID

This is the intellectual and developmental disability pathway. The child must be expected to meet the criteria for at least 30 days.

If your child is age 3 or older, they must have a diagnosis of intellectual disability or developmental disability, and a psychological evaluation completed within the last 12 months that includes both intelligence testing yielding a full-scale IQ and a full-scale functional or adaptive assessment yielding a composite functional age.

Two alternative routes — you only need one:
(a) A full-scale IQ of 70 or less; or
(b) A full-scale functional or adaptive assessment showing a composite functional age that does not exceed 50% of the child's chronological age.

In no case is eligibility granted where the functional age is greater than 8 years, 0 months.

Route (b) is the one families overlook. A child with an IQ of 78 and severe adaptive deficits may still qualify here. For a 10-year-old, a composite functional age at or below 5 years, 0 months meets the standard — regardless of what the IQ score says. Adaptive functioning and intelligence are different measurements, and Oklahoma's rule accepts either.

If your child is under age 3, the route is a diagnosis of developmental disability plus evaluation by the SoonerStart Early Intervention Program using the Battelle Developmental Inventory, 2nd edition, with findings of at least −2.0 standard deviations in at least two total domain areas.

Who can perform the evaluation: a licensed psychologist, a school psychologist certified by the Oklahoma Department of Education, a certified psychometrist, a psychological technician working under a psychologist, or a licensed behavioral health professional (LBHP). A school-based evaluation done for an IEP can often be used — ask before paying privately.

Re-evaluation schedules conflict between OHCA sources. OHCA's public Institutional Level of Care overview describes re-evaluations at ages 3 and 6 for children approved under age 6. The current administrative rule (OAC 317:35-9-48.1) describes a different cycle: at application, then two years later (no later than three), then again on the same interval. Ask your worker in writing which schedule applies to your child, and keep the answer.

2. Nursing Facility Level of Care The medically complex pathway

This is the pathway built around medical complexity rather than cognition, and it contains no cognitive or IQ requirement of any kind. The child must be expected to meet the criteria for a minimum of 30 days. Oklahoma's criteria have three parts, and all three must be documented:

(i) The child has a long-term medical or physical condition which significantly diminishes their functional capacity.

(ii) The child requires health-related services that are so inherently complex that they can only be safely and effectively provided by technical or professional medical personnel — such as a registered nurse or licensed practical nurse — and are ordinarily provided in a nursing facility. Without these services, the child is at risk of being institutionalized in a nursing facility.

(iii) The services needed are above general supervision but can be provided safely in the child's home. They are usually required 24 hours per day and are ordinarily provided on a nursing facility inpatient basis.

The services must be ordered by a physician, and must be greater than what an ICF/IID provides but less than what a hospital provides.

Read part (ii) carefully. It describes the nature of the care — how complex it is — not who is standing in your kitchen performing it. The question the rule asks is whether the care is the kind that a facility would assign to a licensed nurse. Whether a trained parent happens to perform it competently at home is a different question, and it is not the one the rule poses. If a denial turns on who provides the care rather than what care is required, that is worth identifying precisely, because it is a departure from the text of the criterion.

What counts as inherently complex care

  • Clean intermittent catheterization (CIC), particularly through a surgical channel
  • Tube feeding — G-tube, GJ-tube, NG-tube — including pump setup, monitoring, and medication administration
  • Tracheostomy care and ventilator management
  • Permanent surgical ostomy care
  • BiPAP, CPAP, and other respiratory device management
  • Airway clearance therapy (CoughAssist, Vest system, suctioning)
  • Bowel management programs via surgical stoma (ACE / MACE flushes)
  • Bladder irrigation of a surgically augmented bladder
  • IV or injectable medication administration
  • Wound care requiring clinical judgment
  • Rescue medication administration for seizure disorders
  • Ongoing clinical observation and assessment where a change in condition requires a skilled response
A useful test: would a nursing facility assign this task to a licensed nurse rather than an aide? If yes, it is skilled care — regardless of who performs it in your home.

A concrete federal benchmark for tube feeding. Medicare's skilled-services regulation, 42 CFR § 409.33(b)(2), lists as an example of skilled nursing: enteral feeding that comprises at least 26% of daily calorie requirements and provides at least 501 mL of fluid per day. It is a Medicare rule, so it applies to a Medicaid level-of-care question by analogy rather than directly — but it is the federal government's own written line for when tube feeding is skilled, and a child whose feeds meet those numbers meets it by arithmetic.

The U.S. Supreme Court has held that clean intermittent catheterization for a child with spina bifida and neurogenic bladder is a health service that need not be performed by a physician, and one a school must provide through qualified health personnel (Irving Independent School District v. Tatro, 468 U.S. 883 (1984)). It later applied the same line to continuous nursing services for a ventilator-dependent student — rejecting the argument that care stops counting as nursing care because it is extensive or continuous (Cedar Rapids Community School District v. Garret F., 526 U.S. 66 (1999)). Both are special-education cases, not Medicaid cases, so they apply here by analogy — their value is that the Court treated these exact procedures as health services, not routine caretaking.

3. Hospital Level of Care The highest level

The narrowest and highest of the three doors. The child must be expected to meet the criteria for at least 60 days — note that this is longer than the 30-day expectation for the other two pathways.

The child must need services that (i) are ordinarily provided in a hospital setting for the care and treatment of inpatients, and (ii) are provided in a hospital maintained primarily for the care and treatment of patients with disorders other than a mental health diagnosis.

The services must be ordered by, and provided under the direction of, a physician, and must be greater than the services provided in either an ICF/IID or a nursing facility.

This pathway typically applies to children who are technology-dependent at a level that would otherwise keep them admitted — for example, children requiring continuous ventilator support with frequent skilled intervention. If your child has had repeated or prolonged admissions, discuss this pathway with the treating specialist rather than defaulting to the nursing facility standard.

Read OHCA's own criteria in full: Institutional Level of Care. Print this page and bring it to the physician appointment. Doctors write far better letters when they can see the exact standard being applied.

03

What the Law Actually Says

TEFRA eligibility rests on two federal texts that say the same thing. The statute — 42 U.S.C. § 1396a(e)(3), added by TEFRA § 134 and also cited as Social Security Act § 1902(e)(3) — and its implementing regulation, 42 CFR § 435.225. Oklahoma's rules operate underneath both. Each contains exactly three conditions. All three must be met.

Condition 1
Level of Care
The child requires the level of care provided in a hospital, skilled nursing facility (SNF), or intermediate care facility (ICF). This is where the three pathways in the previous section come from.
Condition 2
Appropriate for Home
It is appropriate to provide that level of care outside of an institution — i.e., at home.
Condition 3
Cost-Effective
The estimated Medicaid cost of home care is no higher than the estimated cost of appropriate institutional care.

Alongside these three, the ordinary Medicaid mechanics still apply: the child must be under 19, meet the Social Security definition of disability, and would have to be eligible for Medicaid if they were in the institution. Oklahoma defines what each level of care means — that is where the published criteria in Section 2 come from — but a decision has to rest on those published criteria. A requirement that appears in neither the federal regulation nor OHCA's own published criteria, such as the credentials of the person providing the care at home, is not part of the standard. And because the three conditions appear in the statute itself, not only in the regulation, the standard does not depend on any one agency rule staying on the books.

The identity of the caregiver is NOT in this regulation. Nothing in § 435.225 requires a licensed nurse to be performing the care in the home. The regulation asks what care the child needs — not who is currently providing it. If it asked the second question, no home-based child could ever qualify, and the program would defeat its own purpose.

Oklahoma's State Rule

Oklahoma's rule (OAC 317:35-5-4.2) adds that the care must be "inherently complex" and can "only be safely provided by technical or professional medical personnel." Read in context, this language describes how complex the care is. It is a description of the nature of the service, not a credentialing requirement for the person delivering it at home.

An interpretation that reads this as requiring a licensed professional physically in the home would add an eligibility condition found in neither the federal regulation nor OHCA's own published criteria, contradict the program's stated purpose, and produce the result of penalizing trained parents for competently providing the care their child needs.

It would also sit oddly with the program's own origin. TEFRA § 134 was enacted because Katie Beckett was being kept in a hospital when her care could be delivered at home — the barrier Congress removed was a funding rule that followed the child's location, not a judgment about who was qualified to provide the care. The precise composition of her home care team is not something this guide can state with confidence, and it does not need to: the argument rests on the text of the criteria, which say nothing about caregiver identity either way.

Case Law Worth Knowing

  • Irving ISD v. Tatro (U.S. 1984) — clean intermittent catheterization for a child with spina bifida is a health service that need not be performed by a physician, and one a school must provide through qualified health personnel.
  • Cedar Rapids v. Garret F. (U.S. 1999) — a school must provide continuous one-on-one nursing services for a ventilator-dependent student. The Court applied a bright-line test — nurse-level care is a health service; only physician-required care is excluded — and rejected the argument that care stops being nursing care because it is extensive or continuous.
  • Fisher v. Oklahoma Health Care Authority, 335 F.3d 1175 (10th Cir. 2003) — binding in Oklahoma; optional Medicaid programs must still comply with the ADA's integration requirements.
  • Olmstead v. L.C. (U.S. 1999) — unjustified institutionalization of people with disabilities can constitute discrimination under the ADA.

How these apply: Tatro and Garret F. were decided under special-education law (the IDEA), not Medicaid law, so in a Medicaid dispute they are persuasive by analogy rather than direct authority. Their value is specific: the Supreme Court treated these exact procedures as health services requiring trained personnel — not routine caretaking — and refused to let the sheer volume of care change that classification. Fisher is directly binding in the Tenth Circuit, which includes Oklahoma.

A 2026 development worth understanding. In June 2026 the U.S. Department of Justice's Office of Legal Counsel issued an opinion narrowing the federal executive branch's reading of the Olmstead integration mandate. Two things matter for families: first, an OLC opinion is an executive-branch legal position — it does not bind courts or state administrative law judges, and Fisher remains Tenth Circuit precedent. Second, and more importantly, the opinion concerns antidiscrimination law, not Medicaid eligibility law. It does not mention or analyze 42 CFR § 435.225. Your child's eligibility argument runs through the Medicaid regulation, which is untouched. The practical takeaway is to lead with § 435.225 and the level-of-care criteria rather than with Olmstead, and to treat ADA arguments as a secondary layer.

04

How to Apply, Step by Step

The Oklahoma TEFRA application has an unusual first step: you generally need a denial letter from Social Security before OHCA can process your application. Nothing else moves until you have it, and it can take weeks. Start there.

Apply for SSI — and request the denial letter

To establish that your child meets the disability requirement, you must apply for Supplemental Security Income (SSI) if you have not already. For most TEFRA families the SSI application is expected to be denied, because the parents' income or resources are too high. That denial is the document OHCA needs.

Call SSA at 1-800-772-1213. Say: "I want to file an SSI application on behalf of my child, and I need a denial notice so I can apply for TEFRA." If SSA tells you your income is too high, specifically request the written denial notice — it is not always sent automatically.

One important wrinkle: if your income is too high, SSA may decline to make a disability determination at all. If that happens, OHCA's Level of Care Evaluation Unit (LOCEU) can make the disability determination instead. Do not let a family member or worker tell you the application is dead because SSA never ruled on disability.

Request the TEFRA application packet from OHCA

You do not download the full packet — you request it and OHCA emails it to you. Do this while you are waiting on the SSA letter so the two run in parallel rather than back to back.

Call 405-522-7752 or email TEFRAFax@okhca.org and ask for a TEFRA application packet. A worker will be assigned and will typically schedule a phone interview.

Complete the two core forms

Two forms carry the application. The financial form establishes that only the child's own income and resources count. The assessment form is where the medical case is actually made — treat it as the most important document you will submit.

PDF
TEFRA Financial Application — Form 08OA002E-002 Includes voter registration. Complete in full.
PDF
TEFRA-1 Assessment Form — English · Spanish The medical heart of the application. See Section 5 for what makes this survive review.
On out-of-pocket costs: if your child has private insurance you intend to keep, document only your actual monthly costs for the listed services. If a service is not covered by your insurer, or you have no third-party coverage, list the full cost of the service.

Gather the supporting documentation

OHCA lists the following as what to submit with a TEFRA application. Check every applicable item off before submitting — a missing item is a reason for the file to sit.

  • SSA denial letter — due to excess income and/or resources
  • Current medical documentation from an MD or DO the child actually sees — specialist or PCP — dated within the last 90 days
  • Current IEP or educational plan, if applicable
  • Developmental tool such as a SoonerStart Battelle or DP-3, if the child is under age 3
  • Psychological evaluation with full-scale IQ and age equivalency, if the child is age 3 or over
  • Out-of-pocket expenses statement

Note the psychological evaluation requirement. OHCA asks for an IQ and age-equivalency evaluation for every applicant age 3 and over — not only for children pursuing the ICF/IID pathway. A typical or above-average IQ score in that report does not end your application. It simply means your child's case rests on the nursing facility or hospital pathway, where IQ is irrelevant. Make sure the report also contains adaptive functioning scores and a composite functional age, because that may open the ICF/IID door anyway.

Submit — and build a paper trail while you do it

OHCA accepts submissions three ways. Use more than one, and document each.

  • Email: TEFRAFax@okhca.org — attach everything as PDFs and request a read receipt
  • Fax: 405-530-3312 — keep the transmission confirmation page
  • Mail: Oklahoma Health Care Authority, Attention: TEFRA Unit, 4345 N. Lincoln Blvd., Oklahoma City, OK 73105 — send certified with return receipt, and a second copy by regular first-class mail the same day
Why layer it: Oklahoma families have repeatedly reported cases closed for "failure to respond" to notices they never received. A certified mail green card, an email timestamp, and a fax confirmation are three independent proofs that you submitted on a specific date. Keep a complete copy of everything before it leaves your hands.

Log every contact from day one

Start a single running document on the day you first call SSA. One line per contact: date, method, who you spoke to, what was said, what was promised. Include unanswered calls and unreturned emails — those entries are often the most valuable ones later.

If someone gives you a verbal approval, denial, or deadline over the phone, write down the date, time, name, and exact words the same day, then send a short email confirming what you were told. A verbal representation that nobody papered is worth very little; the same statement confirmed in writing is evidence.

Some families are also directed to their local Oklahoma Human Services office, which can determine whether the child qualifies for other SoonerCare programs first. If your child qualifies another way, that route is generally considered before TEFRA. Both agencies can be involved — ask directly whether your case sits with OHCA's TEFRA Unit, with an OHS social services specialist, or both, and get the name and direct number for each.

05

What OHCA Is Looking For

Oklahoma's TEFRA reviewer — typically a nurse case manager — evaluates your submitted documentation and makes a recommendation to approve or deny. What happens inside that review is not published. What is published is the criteria the review is applied against — so the practical approach is to document each criterion directly rather than to guess at the reviewer's process.

The Physician Letter Is the Most Important Document

The physician documentation carries the medical case. A generic letter that says "this child has complex needs" does not address any specific criterion. The letter must be specific, clinical, and structured around the criteria in Section 2.

Do not let your doctor write a generic letter without guidance. TEFRA applies specific published criteria that a physician has no reason to know from clinical practice alone. Bring a draft to the appointment and ask the physician to review, modify, and sign it. This is completely appropriate, it saves the physician time, and it is one of the highest-leverage steps in the whole process.

A strong physician letter should include:

  • An explicit level-of-care statement naming the pathway: "In my medical opinion, this child requires a level of care equivalent to that provided in a skilled nursing facility."
  • Named skilled nursing procedures performed daily, with clinical detail and frequency for each one.
  • A statement that these procedures would be performed by licensed nursing staff in any institutional setting. This sentence maps directly onto Oklahoma's "inherently complex" criterion.
  • A "but-for" statement: "Without this care, institutional placement would be medically necessary." Oklahoma's rule literally asks whether the child is at risk of nursing facility institutionalization without the services.
  • Consequences of losing each care component — what specifically would happen if each treatment stopped.
  • Documentation of functional limitations (ADLs) — what the child cannot do independently, in objective terms.
  • The trajectory — are care needs increasing, stable, or decreasing? Upcoming surgeries belong here.

Documenting Each Criterion

Medical Equipment & Ostomies
Devices and surgical anatomy are concrete, verifiable facts that map directly onto "inherently complex" care. List every one explicitly — G-tube, ventilator/BiPAP, tracheostomy, permanent surgical ostomies — with the ordering physician's name attached.
Skilled Nursing Procedures
Each procedure needs to be named, described clinically, tied to a specific physician order, and given a frequency. Vague language is weaker than precise clinical descriptions.
Functional Limitations (ADLs)
Document specifically what the child cannot do independently: toileting, bathing, dressing, mobility, transfers, eating, airway management. Use objective exam findings and standardized scores where possible.
School / Daily Life Supports
Document help received at school — school nursing involvement, aide training requirements, nursing directives, IEP health sections, health logs. This shows the level of care extends beyond the home and is recognized by other professionals.
Consequences Without Care
For each major care component, state specifically what would happen if it stopped. Prior documented complications are far more powerful than predicted future risks.
Cost-Effectiveness
If private insurance is your primary coverage, this prong is usually easy to satisfy — Oklahoma Medicaid is the secondary payer at home versus the primary payer for full institutional costs.

Renewals are not a formality. Meeting the criteria must be re-established annually. Build the renewal packet with the same seriousness as the original application, use the same layered submission and logging approach from Section 4, and put your child's name and case number in the subject line of any email submission. Never assume that prior approvals carry forward on their own.

06

Common Denial Reasons — and How to Respond

These are denial rationales Oklahoma families have reported hearing — gathered from family accounts, because OHCA does not publish its denial reasons. Click any card to expand the analysis and counter-response.

"Does not meet level of care"
What's happening
A frequently reported denial reason. Families who have gotten past it generally describe the problem as documentation that was not clinical enough for the reviewer to identify specific skilled nursing procedures. A denial in these words does not tell you which criterion was actually found unmet.
Response
First, ask in writing which of the three pathways was evaluated and which specific criterion was not met. Then resubmit with a revised physician letter that names each procedure explicitly, states the institutional equivalency, and includes the "but-for" language. Attach specialist notes that independently confirm skilled care.
"Parents are providing the care, not a licensed nurse"
What's happening
This argument has no basis in 42 CFR § 435.225. The federal regulation asks what care the child NEEDS — not who is currently providing it. Caregiver identity is not an eligibility condition anywhere in federal law, and Oklahoma's "inherently complex" language describes the nature of the care, not the credentials of the person at home.
Response
Cite 42 CFR § 435.225 directly and note that the three conditions do not include caregiver credentials. Point out that TEFRA was created specifically so parents could provide institutional-level care at home. If a reviewer says the child "could qualify if a nurse came to the home," that is a tacit admission that the care need is skilled nursing-level — the only variable being proposed is who performs it, not what is needed. Get that statement in writing if you can.
"Child is doing well / condition is stable"
What's happening
This reasoning treats a good outcome as evidence that the care producing it is unnecessary. Clean imaging, good labs, and consistent school attendance are what a functioning care regimen produces — they are evidence the regimen is working, not evidence the need has resolved. Nothing in the level-of-care criteria asks whether the child is currently deteriorating.
Response
Document what happens when the care stops or is reduced. Prior complications and hospitalizations are the strongest counter. Have the physician state explicitly: "This child is doing well because of the current care regimen. The regimen must continue unchanged to maintain these outcomes." The Jimmo v. Sebelius settlement established that skilled-care coverage does not require the patient to be improving — maintaining a stable condition through skilled care is itself a covered skilled purpose. Jimmo is a Medicare settlement, so it applies to a Medicaid level-of-care question by analogy rather than directly, but it is a federal articulation of exactly this principle.
"Child can walk / go to the bathroom independently"
What's happening
This turns on imprecise language in the record. "Walks" and "toilets" cover an enormous range. A child who walks with a walker for household distances and catheterizes through a surgical stoma with adult assessment is not the same as a child who walks freely and uses a bathroom unaided — but a chart note saying "ambulatory, toilets self" describes both.
Response
Be precise, and make the physician be precise. "Walks with a walker for household distances" is different from "walks independently." "Performs catheterization with adult supervision and assessment via surgical stoma" is different from "uses the bathroom on their own." Document the clinical specifics with exact examination findings.
"TEFRA is temporary, not a lifelong program"
What's happening
There is no durational limit in 42 CFR § 435.225. Annual renewal is the federal standard — meeting the criteria at renewal is all that is required. Eligibility ends at 19 because that is the program's age limit, not because enrollment expires.
Response
Cite the regulation. If the child's qualifying conditions are permanent or progressive — congenital anatomy, surgical modifications, progressive neuromuscular disease — document that explicitly. Permanent conditions do not have expiration dates.
"Not enough documentation of specific abilities or deficits"
What's happening
Requests of this kind ask for objective, specific functional documentation rather than diagnoses alone. A diagnosis names a condition; it does not establish what the child can and cannot do, and the criteria are written around function.
Response
Obtain objective findings: physical and occupational therapy evaluations, neurology exam findings, adaptive functioning scores, pulmonary function test data, growth measurements. Numbers and exam findings from credentialed providers are more convincing than narrative descriptions. Families who have won on this point report submitting three things specifically: deficits in life skills at home, the extent of help received at school, and what happens when therapy or care is missed.
"IQ is above 70 — does not qualify"
What's happening
IQ ≤ 70 is one route into one of the three pathways. It is not the only qualifying route. Where a child's needs are primarily medical, the cognitive threshold may not be the criterion the case should rest on at all.
Response
Two moves. First, check the alternative ICF/IID route — a composite functional age at or below 50% of chronological age qualifies regardless of IQ, so make sure the psychological evaluation reports adaptive functioning and functional age, not just FSIQ. Second, and independent of IQ entirely: shift the case to the nursing facility standard, which contains no cognitive criterion. Medical equipment — G-tube, ostomies, BiPAP, trach, vent — maps directly onto its "inherently complex" language. See Section 2.
"You failed to respond to our notices"
What's happening
Oklahoma families have reported cases closed for non-response to notices they never received — including notices routed to spam folders and calls to coordinator numbers that went unanswered or were disconnected. Email is not a guaranteed-delivery medium, and delivery to a spam folder is a known failure mode rather than user error.
Response
Appeal immediately and produce your contact log. Federal due process standards require adequate notice before terminating benefits. State plainly, with dates, what you did receive, what you did not, and every attempt you made to reach OHCA. Going forward: check spam weekly during renewal season, confirm in writing which email address is on file, and ask that notices also be sent by postal mail.
07

Tips, Tricks & Lessons Learned

Draft the physician letter yourself — then have the doctor sign it
TEFRA applies specific published criteria that physicians have no reason to know from clinical practice, so a letter written from scratch is unlikely to address them point by point. It is completely appropriate to draft the letter yourself using clinical facts from your child's records, bring it to the appointment, and ask the physician to review, modify, and sign. This saves the physician time and ensures nothing critical is omitted.
Print OHCA's level-of-care criteria and bring them to the appointment
A physician who can see the exact standard being applied can write to it directly. Hand them the Institutional Level of Care page and point to the specific criterion you are asking them to address.
Know which pathway you are arguing before you write anything
A letter aimed at the ICF/IID criteria and a letter aimed at the nursing facility criteria look completely different. Decide first. If your child has medical equipment or requires skilled procedures, the nursing facility pathway lets the case rest entirely on the medical facts, and cognitive testing becomes beside the point.
Time the physician letter to the submission date
OHCA asks for medical documentation dated within the last 90 days. Letters dated too far before submission may be flagged as outdated. Request the letter as soon as you receive the renewal paperwork, and submit everything as close together as possible.
Lead with equipment and ostomies
Equipment and surgical anatomy are the least arguable facts in the file. A G-tube either exists or it does not; a stoma is permanent or it is not. Diagnoses invite interpretation about severity, while devices do not. If your child has any of these, put them in the first paragraph of the physician letter rather than buried in a diagnosis list, so the clearest evidence is not the last thing read.
Make sure the psych eval reports functional age, not just IQ
Oklahoma's ICF/IID pathway accepts a composite functional age at or below 50% of chronological age as an alternative to an IQ of 70 or less. If the evaluator reports only a full-scale IQ, you may lose that route by default. Ask specifically for adaptive functioning scores and a composite functional age before the evaluation is finalized.
Collect school documentation proactively
School nursing directives, IEP sections covering health needs, aide training requirements, and any logs maintained by school staff are powerful evidence. They show the level of care extends beyond the home and is recognized by other professionals as skilled care. A school nurse's daily log is contemporaneous clinical documentation created by someone with no stake in your application.
Get specialist letters, not just a PCP letter
A treating specialist (urologist, pulmonologist, GI, neurology) who writes "skilled nursing care" into their own clinical notes is more powerful than a PCP letter alone. Ask your specialists to include TEFRA-relevant language in their clinic notes or to write a short supporting letter. Documentation created in the ordinary course of treatment carries more weight than a letter written for the application.
Document consequences — not just current care
Oklahoma's nursing facility criterion asks whether, without these services, the child is at risk of being institutionalized. That is a question about consequences, so answer it directly: for each major care component, document what specifically happens when it stops. Prior hospitalizations, documented deteriorations, and failed reduction attempts are the strongest evidence available, because they already happened and are in the record.
Address the "doing well" trap directly
If your child is doing well because of the care regimen, a reviewer may wrongly conclude the care is no longer necessary. Have the physician explicitly state that positive outcomes are the result of the current care regimen, and that the regimen must continue unchanged to maintain those outcomes. Preempt this — do not wait to rebut it.
Put verbal representations in writing the same day
If a worker tells you something significant over the phone — an approval, a denial rationale, a deadline, a requirement — write down the date, time, name, and exact wording immediately, then send a short confirming email. Verbal statements evaporate. The same statement, confirmed in writing and never contradicted, becomes evidence you can use if the agency's position later changes.
Ask for the reason in writing before you argue with it
When told a denial is coming, ask in writing which of the three pathways was evaluated, which specific criterion was found unmet, and what documentation would satisfy it. A vague denial is hard to fight. A specific one tells you exactly what to fix — and if the stated reason is not in the regulation, it also tells you that you have a strong appeal.
If denied, file the appeal before you finish building your case
The deadline is short and unforgiving. File first, then keep gathering documentation — you can supplement afterward. See Section 8 for the exact deadlines, including the 10-day window printed on the appeal form itself.
Contact your state legislator
If you are denied and believe the denial is wrong, contacting your state representative or senator is a legitimate advocacy step — particularly if you believe the denial pattern is broader than your individual case. Find yours at oklegislature.gov.
08

If You Are Denied

Read this section the day the notice arrives, not the week after. The deadline that preserves coverage during an appeal is ten days — printed on the appeal form itself, and far shorter than the 30-day filing deadline quoted elsewhere.

The two deadlines that matter
10Calendar Days
If your child's benefits or services are being discontinued or reduced, your appeal must be received by the OHCA Grievance Docket Clerk within 10 calendar days of the date on your notice if you want coverage to continue while the appeal is decided. Miss this window and you may still appeal — but coverage stops in the meantime.
30Calendar Days
The outside deadline. Your appeal must be filed within 30 calendar days of the date on your notice. OHCA's rule provides that an appeal sent by mail is deemed filed on the date the agency receives it — not the date you post it. Do not rely on mail. Email or fax it, and keep the confirmation.

Always follow the deadline printed on your specific notice. Different Oklahoma programs and notice types carry different windows, and rules change — OHCA's own administrative rules reference 30-day and 60-day periods in different sections. The figures above are taken from the LD-1 form itself, which is the document a family actually files, and TEFRA children are on the traditional SoonerCare track it describes — but if your notice says something different, the notice governs. When in doubt, file immediately rather than researching.

How to file

You file using OHCA's LD-1 Member Appeal Form. Complete every field — OHCA's rule states that an incompletely filled out form, or one missing necessary documentation, will not be heard.

PDF
LD-1 — OHCA Member Appeal Form Includes the continuation-of-benefits election. Fill in every field, attach supporting documents, and sign both signature lines.

Send it to the Grievance Docket Clerk:

  • Email: docketclerk@okhca.org — fastest, and gives you a timestamp
  • Fax: 405-530-3444
  • Phone (questions only): 405-522-7217
  • Mail: Oklahoma Health Care Authority, Grievance Docket Clerk, P.O. Drawer 18497, Oklahoma City, OK 73154-0497

One thing to understand before electing continued benefits. The LD-1 form carries a warning that if you choose to keep receiving services during the appeal and the decision goes against you, you may have to pay for services received during that period. This is a real consideration and you should ask the docket clerk or an advocate how it would apply to your situation before deciding. Note that the form also gives you the option to file within 10 days while explicitly declining continued benefits — you can preserve the fast filing without electing continuation.

What happens next

  • A fair hearing is scheduled before an OHCA Administrative Law Judge, and you are notified in writing of the date and time.
  • You must appear — in person or telephonically. OHCA's rules have changed on which format is the default, and requests for a specific format must be made in writing in advance. Ask the docket clerk which applies to your hearing when it is scheduled.
  • You may bring an authorized representative. The LD-1 form has a section for designating one.
  • Under OHCA's rules, member appeals are ordinarily decided within 90 days of a timely request, and the ALJ's decision is ordinarily issued within 45 days of the close of evidence.
  • The ALJ's decision can generally be appealed further to OHCA's CEO.

Shift your framing at the hearing

The application and renewal stage calls for cooperative, reviewer-friendly documentation. The fair hearing stage is different. Here you cite 42 CFR § 435.225 and Oklahoma's own published level-of-care criteria directly, use Tatro and Garret F. on the character of the procedures, and present your treating physicians. A specialist who has already written "skilled nursing care" into their own clinic notes is a powerful witness, and the ALJ is required to consider the evidence presented.

Above all, be specific about the legal error. If the denial rests on who provides the care rather than what care is required, say so plainly and identify where in the regulation that requirement is supposed to appear. It does not appear anywhere, and that is the point.

Get help — free

Disability Rights Oklahoma (DROK)
Oklahoma's federally designated protection and advocacy agency for people with disabilities — formerly the Oklahoma Disability Law Center (ODLC), renamed in 2026. Same organization, same services. Handles Medicaid disputes including TEFRA. Contact them the day you receive a denial.
drok.org  ·  405-525-7755  ·  Toll free 800-880-7755
Tulsa office: 918-743-6220
Legal Aid Services of Oklahoma
Free civil legal help for income-eligible families, including public benefits and Medicaid appeals.
legalaidok.org  ·  888-534-5243
myOKplan
Legal Aid Services of Oklahoma's free help line for keeping SoonerCare, applying for Medicaid, and navigating coverage problems. A good first call if you are unsure whether you have an appealable notice.
Oklahoma Family Network
Parent-to-parent support organization for Oklahoma families of children with disabilities and special health care needs. Runs family workshops and connects parents with others in the same programs.
09

Forms & Quick Reference

Every form and link in one place

WEB
OHCA TEFRA Program Page The authoritative source. Holds current forms, contact details, and the eligibility list.
WEB
OHCA Institutional Level of Care Criteria All three pathways in OHCA's own words. Print this for the physician appointment.
PDF
TEFRA Financial Application — 08OA002E-002 Financial eligibility form, includes voter registration.
PDF
TEFRA-1 Assessment Form — English · Spanish The medical assessment. Comes in the packet, but you can start early.
PDF
LD-1 Member Appeal Form File within 10 days to keep coverage during the appeal; 30 days outside deadline.
WEB
Social Security — Disability & SSI Step one. Call 1-800-772-1213 and request the denial notice for TEFRA.
WEB
42 CFR § 435.225 — the controlling federal regulation The three conditions. Read it once; it is short.
WEB
42 U.S.C. § 1396a(e)(3) — the TEFRA statute itself — Cornell · SSA compilation (§ 1902) Section 134 of TEFRA, codified in the Medicaid statute. Both pages are very long — search within the page for "(e)(3)".
PDF
CMS Implementation Guide — "Children under Age 19 with a Disability" (the Katie Beckett group) The federal guide states work from when adopting this eligibility group. Written for state agencies, but clear proof the program and its rules are federal.

Contacts

OHCA TEFRA Unit
Requesting an application packet, submitting forms and supporting documents, and renewal questions.
Call 405-522-7752  ·  Email TEFRAFax@okhca.org  ·  Fax 405-530-3312
Mail: OHCA, Attn: TEFRA Unit, 4345 N. Lincoln Blvd., Oklahoma City, OK 73105
OHCA Grievance Docket Clerk
Filing an appeal after a denial, reduction, or termination. This is where the LD-1 goes.
Email docketclerk@okhca.org  ·  Fax 405-530-3444  ·  Phone 405-522-7217
Mail: OHCA Grievance Docket Clerk, P.O. Drawer 18497, Oklahoma City, OK 73154-0497
SoonerCare Member Helpline
General SoonerCare eligibility and benefit questions.
800-987-7767  ·  oklahoma.gov/ohca
Social Security Administration
Filing the child's SSI application and requesting the denial notice needed for TEFRA.
1-800-772-1213  ·  ssa.gov
OK TEFRA Families
Facebook community group for Oklahoma TEFRA families — peer support, shared experiences, and real-time information about what reviewers are currently asking for.
Search "OK TEFRA Families" on Facebook

The Three Federal Conditions (42 CFR § 435.225)

Condition What It Means Who Decides
1. Level of Care Child requires care provided in a hospital, nursing facility, or ICF/IID OHCA nurse reviewer / LOCEU
2. Appropriate for Home Home care is safe and appropriate for this child Physician certification
3. Cost-Effective Home Medicaid cost ≤ institutional Medicaid cost OHCA calculation

The Three Level-of-Care Pathways at a Glance

Pathway Core Test Duration Expected
ICF/IID ID/DD diagnosis plus either FSIQ ≤ 70 or composite functional age ≤ 50% of chronological age (functional age cap: 8y 0m). Under 3: Battelle-2 at −2.0 SD in two or more domains. 30 days
Nursing Facility Long-term condition diminishing functional capacity; inherently complex health-related services requiring technical or professional medical personnel; services above general supervision, usually 24 hours per day. No IQ criterion. 30 days
Hospital Services ordinarily provided to hospital inpatients, physician-ordered and physician-directed, greater than both ICF/IID and nursing facility level. 60 days
Key case law to know if you appeal:
Irving ISD v. Tatro, 468 U.S. 883 (1984) — CIC for a child with spina bifida is a health service that need not be performed by a physician.
Cedar Rapids v. Garret F., 526 U.S. 66 (1999) — a school must provide continuous nursing services for a ventilator-dependent student; extensive care is still nursing care.
Fisher v. Oklahoma Health Care Authority, 335 F.3d 1175 (10th Cir. 2003) — binding in Oklahoma: optional programs must comply with the ADA integration mandate.
Olmstead v. L.C., 527 U.S. 581 (1999) — unjustified institutionalization can violate the ADA.
Tatro and Garret F. are special-education cases and apply by analogy; Fisher is binding Tenth Circuit authority.

About this guide — please read before relying on any of it.

This page was put together by an Oklahoma parent who has been through the TEFRA process, for the benefit of other families. That is its only credential.

  • No attorney has reviewed or approved it. Nothing here has been checked by a lawyer, and reading it does not create an attorney-client relationship with anyone.
  • It is not official. It is not affiliated with, endorsed by, or produced by the Oklahoma Health Care Authority, Oklahoma Human Services, the Social Security Administration, or any government agency.
  • It is general information, not advice about your child. Nobody who wrote this has seen your child's records, and no summary can substitute for a professional who has.
  • Use is at your own risk. Laws, rules, forms, deadlines, phone numbers, and web links change — sometimes without notice, sometimes with no announcement at all. Information that was accurate when written may be wrong by the time you read it.
  • Verify before you act. Every substantive statement here links to an official source. Where a deadline, a form, or a criterion matters to your case, open the linked source and read it yourself, and follow what your own notice says over anything on this page.
  • Get real help for real decisions. For anything consequential — an appeal, a termination, a question about repayment — contact Disability Rights Oklahoma or Legal Aid Services of Oklahoma. Both are free.

If you find something on this page that is out of date or wrong, please say so in the OK TEFRA Families group so it can be corrected for everyone.

A closing word. Nobody publishes how often Oklahoma TEFRA appeals succeed, so treat anyone who quotes you a number with caution — including this guide. What is knowable is this: the criteria are written down, in the regulation and on OHCA's own pages, and an agency can be asked to show which one it applied and how. A denial that is never appealed is never examined by anyone outside the office that issued it. The documentation burden is real and it is exhausting. File the appeal, get the letters, keep the log, and ask for the reason in writing.

10

Contact & Corrections

If your situation is urgent, please do not write here first. This inbox is checked by one parent, in between everything else, and there is no guarantee of a quick reply. If you have received a denial, a termination notice, or anything with a deadline on it, contact one of these instead — both are free, both employ people qualified to advise you, and both are far faster than waiting on an email from me:

Remember the 10-day window: if benefits are being reduced or stopped, your appeal must reach OHCA's Grievance Docket Clerk within ten calendar days of the notice date for coverage to continue during the appeal.

What this form is for

This page is maintained by a parent, not an organization, and it will contain mistakes. The most useful thing anyone can send is a correction.

  • Something here is wrong or out of date — a changed deadline, a dead link, a form OHCA no longer uses, a phone number that rings nowhere.
  • Something is missing or unclear — a question the guide should answer but doesn't, or a section that didn't make sense when you needed it to.
  • Your own experience — what a reviewer asked you for, what documentation worked, what the process actually looked like. This is how the guide stays accurate.

What this form cannot do. I am a parent who has been through this process, not a lawyer, a nurse, or anyone with authority over your case. I cannot tell you whether your child qualifies, review your records, advise you on your appeal, or predict what OHCA will decide. Please do not send medical records, case numbers, or your child's personal health information — I have no secure way to receive them and no ability to act on them. Questions about your own case belong with the organizations above.

Send a correction or a question about the guide

Only needed if you want a reply. Leaving it blank is completely fine — a correction is useful on its own.
Please leave out your child's name, case number, and any medical details. If you are pointing out an error, naming the section helps.

Messages go to the person who maintains this page. There is no organization behind it and no obligation to reply, though corrections are genuinely welcome and will be acted on.

Tweaks