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The American Journal of Managed Care September 2019
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Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
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Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness

Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
The authors studied Kansas Medicaid enrollees with serious mental illness and their experiences with integrated managed care and unmet needs.

Objectives: To inform state Medicaid programs and managed care organizations, as well as to build their capacity to serve enrollees with complex needs related to serious mental illness (SMI).

Study Design: Quantitative and qualitative analyses of survey results from a sample of Medicaid enrollees with SMI in Kansas in 2016 and 2017 (N = 189).

Methods: Surveys were conducted by telephone or in person at community mental health centers. Analyses of descriptive statistics from closed-item responses and coded transcripts were used to identify major themes in open-item responses.

Results: Respondents reported high rates of comorbid physical and mental health conditions and current or past tobacco use. Most were unemployed, and some were homeless or living in unstable conditions. Participants indicated a need for better information and communication; improved access to prescriptions, dental care, reliable transportation, medical supplies, and equipment; and a wider physician/provider network. They wanted care coordinators to provide more frequent and responsive contact, better information about benefits and resources, and help navigating the system.

Conclusions: Individuals with chronic and complex conditions can be challenging for managed care organizations to support, especially Medicaid enrollees with SMI, who experience high rates of comorbid physical health conditions and complex healthcare needs. To the extent that managed care organizations can help this population navigate their coverage and use more of the available benefits, barriers to care and unmet needs can be reduced or eliminated and outcomes subsequently improved.

Am J Manag Care. 2019;25(9):450-456
Takeaway Points

Managed care organizations can better serve Medicaid enrollees with serious mental illness by helping them use more of the available benefits and removing identified barriers to care. This study adds to the knowledge base about actions that managed care organizations can undertake to improve care for this population, including:
  • Frequent contact between care coordinators and enrollees with serious mental illness
  • Understandable explanation of benefits and help navigating services
  • Expanded access to needed medications
  • Coverage for dental care beyond checkups
  • Reliable and accessible nonemergency medical transportation
  • Access to medical supplies and equipment for comorbid conditions
  • Geographically expanded provider networks, including specialists
Affordable Care Act reforms and Medicaid expansion have increased insurance coverage and access to care for individuals with serious mental illness (SMI), but the most effective way to implement reforms to meet individual needs for this population is still unclear.1-3 Currently, 38 states and the District of Columbia contract with comprehensive managed care organizations (MCOs) to coordinate and integrate healthcare coverage for at least some of their Medicaid enrollees, and this number is likely to grow.4 The premise underlying this use of managed care is that coordination will improve enrollees’ care experiences and lower program costs by reducing rates of crisis and acute care, decreasing duplication of services, and improving medication management.1,5-7 Individuals with chronic and complex conditions can be the most challenging for MCOs to support, especially Medicaid enrollees with serious mental illness (SMI), who experience higher-than-average rates of chronic medical illnesses and disability and have complex healthcare needs.8 Given this population’s significant healthcare requirements, historically poorer outcomes, greater unmet needs, and potential for increased enrollment via Medicaid expansion, their experiences are of interest to MCOs.

Little information exists on the outcomes of individuals with SMI in Medicaid managed care. Although each state Medicaid program is unique, state-specific studies provide helpful insights into the managed care experiences of Medicaid enrollees with chronic and complex needs. For example, a 2013 survey of Medicaid enrollees with disabilities—administered within 8 months of the Kansas Medicaid transition to managed care—found that 46% of respondents experienced at least 1 problem accessing care or services after implementation.9 Problem areas included limitations in covered benefits, small provider networks, lack of effective communication with MCOs, difficulties with care coordination, and issues with nonemergency medical transportation. Similarly, a 2013-2014 study found that Illinois Medicaid enrollees with SMI fared worse than enrollees with other disabilities and had more unmet needs under both Medicaid fee-for-service and managed care models.10

Since 2013, Kansas Medicaid (KanCare) has been administered by 3 for-profit MCOs, which are paid on a capitated basis. Prior to this time, behavioral health services were provided through a capitated managed care arrangement, whereas physical health services were covered on a fee-for-service basis. Approximately 26,600 adults with SMI were enrolled in KanCare as of 2012, the great majority of whom receive services through 1 of 26 community mental health centers (CMHCs) in the state.11,12 Kansas is among the states with the longest experience with integrated managed care for physical and mental health and thus is an important benchmark for other states moving to integrate mental health benefits through MCOs. As the healthcare and Medicaid landscapes continue to evolve, it is important that policies and practices incorporate beneficiaries’ perspectives in order to identify and address barriers to care.13 This study extends knowledge about integrated managed care experiences of enrollees with SMI and barriers to care.


This study used primary data collected via survey from KanCare enrollees with SMI and was approved by the University of Kansas Institutional Review Board.


The sample consisted of adult Medicaid enrollees who received services and support from 6 CMHCs in Kansas. These CMHCs serve urban, suburban, and rural parts of the state and recruited participants via flyers, newsletter articles, and mailings that included a toll-free number to take a phone survey and dates when they could complete the survey in person at their local CMHC. Survey administrators read a study information document to all participants and obtained verbal consent.

Survey respondents (N = 189) ranged in age from 18 to 83 years (with 36% in the largest age group, 50-59 years) and were primarily women (68%) and white (60%), with less than 10% identifying themselves as Hispanic. Stakeholder checks with CMHC staff confirmed that sample demographics were typical of the SMI Medicaid population that they serve.14

Survey Instrument and Administration

The authors developed the survey in consultation with the Health Care Foundation of Greater Kansas City (now Health Forward Foundation) and the participating CMHC directors.15 The survey consisted of demographic items and closed- and open-ended questions about respondents’ satisfaction and experiences with KanCare, possible areas of unmet need, and suggestions for improvement.15 Questions from existing federal and state surveys were included to facilitate comparisons with the Kansas population. The authors administered surveys between October 2016 and February 2017.

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