The American Osteopathic Association Commission on Osteopathic College Accreditation (AOA COCA) is recognized by the US Secretary of Education as the only accrediting agency for osteopathic predoctoral education. To maintain its recognition with the US Secretary of Education, the AOA COCA is required to adhere to all federal laws and regulations associated with the recognition of accrediting agencies. The authors discuss changes in the policies and procedures applicable to review of substantive changes in existing colleges of osteopathic medicine. Also included is a review of AOA COCA-approved class sizes of the accredited colleges of osteopathic medicine.