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Objective. To examine the evolution of Children's Health Insurance Program (CHIP) and Medicaid programs after passage of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), focusing on policies affecting eligibility, enrollment, renewal, benefits, access to care, cost sharing, and preparation for health care reform.

Methods. Case studies were conducted in 10 states during 2012—which included key informant interviews and consumer focus groups—and a national survey of state CHIP program administrators was conducted in early 2013.

Results. Despite the recession that persisted during much of the study period, many states expanded children's coverage by raising upper income eligibility limits or by covering new groups made eligible by CHIPRA. Simplifying rules and procedures for enrollment and renewal continued to be a major priority for CHIP and Medicaid, and CHIPRA played a direct role in spurring innovation. CHIPRA's outreach grants played an important role in supporting and supplementing state outreach efforts. Important legacies of CHIPRA are the law's mandatory requirements for comprehensive dental benefits coverage and mental health parity for all types of CHIP programs. Although most states already offered generous coverage of these benefits, the mandate may have protected them from cuts during the economic downturn. Federal Maintenance of Effort rules were a crucial protection for CHIP, especially during the recession when state budget shortfalls could have led to program cuts.

Conclusions. Passage of the Affordable Care Act has raised questions surrounding the future role of CHIP in a reformed health care system. A growing number of stakeholders have recommended a 2-year extension of federal CHIP funding to allow complex transition issues to be resolved.