Under the Affordable Care Act of 2010 (ACA), an estimated 32 million Americans will gain health insurance coverage by 2014 through: (1) expansion of Medicaid to people earning up to 133 percent of the federal poverty level; (2) premium subsidies for people earning between 134 percent and 400 percent of the federal poverty level; and (3) health insurance exchanges through which individuals and small businesses may compare coverage options and purchase insurance. The ACA requires these statebased exchanges to create one integrated process that determines consumer eligibility for the full range of subsidies (including Medicaid) and to facilitate enrollment across the spectrum. As states set out to design exchanges and determine how they will function, the question becomes: Once a person is deemed eligible for Medicaid, is he or she best enrolled through the exchange or through a separate Medicaid enrollment system?

• By fully integrating Medicaid with their health insurance exchanges, states can reap numerous cost efficiencies in administration, enrollment strategies, consumer outreach and infrastructure.
• Consumers will benefit from an integrated system, which will provide easier mobility and continuity of coverage across insurance options as incomes and eligibility fluctuate.
• Although states will have great flexibility in integrating Medicaid and their exchanges, they will need federal assistance with tracking individuals newly eligible for Medicaid and using federally managed data to make eligibility determinations.