As states consider implementation options under the Affordable Care Act, they face a series of critical decisions that will affect the design of insurance exchanges. Many of those decisions have the potential to affect health insurance options for children and how they obtain and retain coverage.
Insurance policies for children will be sold through exchanges, either as part of family coverage or as an individual children’s plan. As states weigh various design options, the impact on children should be considered. States may pursue several goals with respect to children and exchanges, including:

  • Promoting Continuity of Coverage. As family income fluctuates, children may transition from Medicaid into and the exchange and back again. To prevent churn and the associated administrative problems, states can make a priority of ensuring continuity of care between exchanges and Medicaid/CHIP. They can do that by requiring health plans and providers to participate in all three markets, or creating incentives for them to do so; they can implement a Basic Health Plan, through which families can remain together in one plan; or they can assess provider market characteristics and establish incentives for providers to participate in more than one market.
  • Creating a One-Stop Portal for Public Programs. If states are interested in creating a one-stop portal, they may want to consider horizontally integrating all social services programs, instead of vertically integrating eligibility and enrollment in Medicaid, CHIP, and exchanges. With horizontal integration, there would be one IT system, with one application for enrollment. Given that children are often enrolled in more than one social service program, horizontal integration eases the burden on families that are applying for multiple programs for their children. It can, however, be extremely resource intensive, with high start-up costs and a potential for increased enrollment across all programs.
  • Maintaining Benefit Packages and Cost-Sharing Requirements. Once benefit and cost-sharing structures are more clearly defined, governors may want to compare those structures with existing state Medicaid and CHIP eligibility and cost-sharing provisions. Such a comparison can identify areas where children transitioning between Medicaid/CHIP and exchanges could experience large changes in coverage and financial accountability. States should also consider which state benefit mandates they will continue to provide (e.g., autism services for children) and assess the costs of continuing to provide those services.
  • Emphasizing Outreach Activities. If states are interested in promoting exchange insurance options, they will want to consider how to educate the public about health reform. States can design marketing campaigns for education, target outreach for specific populations, and consider how to use consumer assistance grants and "navigator" programs most effectively. States can also draw from previous experiences and apply best practices from outreach campaigns designed during CHIP implementation to publicize, and enroll children in, public coverage.

This issue brief was developed based on input during a daylong meeting hosted by the National Governors Association Center for Best Practices. Participants at the meeting included state government officials, general health care experts, federal representatives, and individuals from nonpartisan health policy institutions.