Even in the wake of the Supreme Court ruling that made the Affordable Care Act's (ACA) Medicaid expansion voluntary for states, Medicaid remains a centerpiece in the laws effort to expand coverage and reform the nations health care system. In addition to the now-optional eligibility expansion, the ACA includes many other Medicaid-related provisions, such as the option to expand Medicaid early (before 2014), the requirement to modernize eligibility and enrollment systems, and testing of new delivery systems. A related provision gives states the option to create a Basic Health Program that could resemble Medicaid. This brief describes ten states experiences with and decisions about implementing these selected major Medicaid provisions. At this juncture in ACA implementation, the states are assiduously working on many different fronts to prepare for the 2014 coverage expansions while also taking advantage of various ACA-related opportunities to save costs and improve their programs.