By December 1999, all states, territories, and the District of Columbia had received federal approval to expand coverage under SCHIP (CMS 2002a). States launched their SCHIP programs at different times. Most states started enrolling children during 1998; however, a few began as early as October 1997, and a few did not start until 1999. By March 2002, 16 states were operating separate programs, 21 were operating Medicaid expansion programs, and 19 were operating combination programs (CMS 2002b). State programs have evolved steadily; one indication of this dynamism is that, by March 2002, 106 state plan amendments had been submitted to and approved by DHHS and seven more were under review.