Individuals with serious mental illness face multiple barriers to accessing care and experience disproportionately poor health outcomes. Starting in 2011, New York State undertook a series of major reforms of its Medicaid system designed to address these concerns. In this commentary we review three reforms that aim to change the way New York Medicaid is delivered and experienced, especially for underserved individuals with SMI: Health Homes, Behavioral Health Managed Care, and the Delivery System Reform Incentive Payment Program. We describe the history of these reforms' and their core themes: coordination and collaboration, cross-sector collaborations to address social determinants of health, prevention and early intervention, and financial reform. We describe the challenges and opportunities these reforms present for improving the health and health care of Medicaid members with SMI, both in New York and as models for change elsewhere.