AmeriHealth Caritas

What AmeriHealth Caritas does

AmeriHealth Caritas is a Philadelphia-based managed care organization founded in 1983 that administers government-sponsored and commercial health insurance products for low-income, chronically ill, and dual-eligible populations across 13 states and the District of Columbia. Its core product portfolio comprises Medicaid managed care plans (including Keystone First in Pennsylvania, Blue Cross Complete of Michigan, and First Choice in South Carolina), Medicare Dual-Eligible Special Needs Plans under the VIP Care brand, Health Insurance Marketplace plans under AmeriHealth Caritas Next, managed long-term services and supports (LTSS) including the Pennsylvania Community HealthChoices contract covering nearly 400,000 lives, behavioral health services through the PerformCare subsidiary, and (until end of 2026) pharmacy benefit management through PerformRx, with contracts transitioning to OptumRx. The company is 61.3% owned by Independence Health Group and operates with 5,001-10,000 employees.

The underlying technology stack integrates whole-person care coordination, value-based care contracting (PerformPlus suite including SPARC models for small and rural providers), proprietary PBM technology (PerformRx), specialty pharmacy operations (PerformSpecialty), and population health analytics. Revenue is generated primarily through capitation payments from state Medicaid agencies on a per-member-per-month basis, Medicare Advantage premiums for D-SNP enrollees, Marketplace premiums, and ancillary pharmacy and care management fees. The company pursues a multi-channel go-to-market combining state government RFP participation, broker/agent distribution for Marketplace products, provider network recruitment, and community-based outreach (Healthy Hoops, Bright Start, Mission GED, Pathways to Work) to address social determinants of health and differentiate on health equity outcomes. Strategic direction is heavily influenced by state-level contract cycles, with active expansion into Indiana and Idaho offset by the planned exit from the PBM vertical in 2026.

Name

AmeriHealth Caritas

Legal name

AmeriHealth Caritas

Website

https://amerihealthcaritas.com

Company type

Private

Founded year

1983

Operating status

Operating

Headcount range

5,001–10,000 employees

Short description

AmeriHealth Caritas is a Philadelphia-based managed care organization administering Medicaid, Medicare D-SNP, Marketplace, LTSS, and behavioral health plans for low-income and chronically ill populations across 13 states and the District of Columbia, majority-owned by Independence Health Group.

Ownership category

akta.pro rank

Product category

Managed Care / Health Insurance

NAICS

Direct Life, Health, and Medical Insurance Carriers (52411)

SIC

Hospital & Medical Service Plans (6324), Services-Health Services (8000)

akta.pro primary industry

Care Management & Population Health Program Administration (HLAEALAG)

akta.pro secondary industries

Medicare Advantage (MA) Plans (FSAIAGAA), MA-PD Plans (Medicare Advantage with Prescription Drug Coverage) (FSAIAGAG)

Keywords

• Medicaid managed care
• Medicare advantage plans
• Pharmacy benefits management
• Behavioral health services
• Long-term care services

Headquarters

HQ city

Philadelphia

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure, Supply Chain

Revenue model

1. Medicaid Managed Care Capitation: States pay a set amount per member per month (capitation) to AmeriHealth Caritas for administering Medicaid health benefits. The company arranges for provision of covered healthcare services to enrollees and bears responsibility for managing costs within the capitated amount.
2. Medicare Advantage D-SNP Premiums: Revenue from Medicare Advantage Dual-Eligible Special Needs Plans for beneficiaries entitled to Medicare Part A, enrolled in Medicare Part B, and receiving Medical Assistance. Plans provide supplemental benefits beyond original Medicare.
3. Health Insurance Marketplace Premiums: Revenue from individual and family health plans offered on and off the Health Insurance Marketplace through AmeriHealth Caritas Next brand. Plans cover 10 essential health benefits and are offered in gold, silver, and bronze tiers.
4. Pharmacy Benefits Management (PerformRx): In-house PBM services providing formulary management, drug benefit structuring, prescription claims processing, pharmacy contracting, and cost control for Medicaid, Medicare, and commercial clients. Company announced closure of PerformRx PBM at end of 2026.
5. Specialty Pharmacy (PerformSpecialty): URAC accredited specialty pharmacy providing high-cost medications for complex chronic conditions with customized care teams and patient management programs.
6. Behavioral Health Managed Care (PerformCare): Full-service behavioral health managed care through PerformCare, serving Medicaid, Medicare, wellness, and specialty products including I/DD services, substance use treatment, and suicide prevention.
7. Long-Term Services and Supports (LTSS): Managed LTSS programs for elderly, disabled, and those needing help with everyday activities. Includes non-rehabilitative nursing facility-level care and home-based support services.

Pricing tiers

Go-to-market motion4 records

Distribution channels8 records

Marketing channels8 records

Core offering

AmeriHealth Caritas is a managed care organization that administers government-sponsored and commercial health plans for Medicaid, CHIP, Medicare Dual-Eligibles (D-SNPs), and Health Insurance Marketplace populations across 13 states and DC. It delivers care coordination, behavioral health, long-term services and supports, and in-house pharmacy benefits management through its subsidiaries PerformRx, PerformSpecialty, and PerformCare. Its core deliverable is whole-person managed care with capitated reimbursement from state agencies and premium-based individual plans.

Product overview

AmeriHealth Caritas operates as a managed care organization (MCO) offering a platform-plus-modules architecture. The core offerings include Medicaid managed care plans across 13 states and DC, Medicare Dual-Eligible Special Needs Plans (AmeriHealth Caritas VIP Care), Individual and Family Health Plans (AmeriHealth Caritas Next), Long-Term Services and Supports (LTSS), and Behavioral Health Care (PerformCare). The portfolio includes wholly-owned subsidiaries PerformRx (pharmacy benefits management) and PerformSpecialty (specialty pharmacy). Supporting modules include community health outreach programs (Bright Start maternal health, Healthy Hoops, Health Empowerment Tour), workforce development (Mission GED, Pathways to Work), value-based care programs (PerformPlus/SPARC), and social determinants interventions (Let Us Know program). Regional sub-brands include Keystone First (Pennsylvania) and Select Health of South Carolina/First Choice.

Differentiator

Problem solved

Functional benefit

Brands

• AmeriHealth Caritas VIP Care: Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP) for beneficiaries eligible for both Medicare and Medicaid
• AmeriHealth Caritas Next
• AmeriHealth Caritas VIP Care Choice
• First Choice Next
• First Choice VIP Care
• Keystone First VIP Choice

Products and services

• Medicaid Managed Care Comprehensive Medicaid managed care organization (MCO) services for low-income and chronically ill populations including Medicaid and CHIP beneficiaries across multiple states.
• AmeriHealth Caritas VIP Care (D-SNP) Medicare Dual-Eligible Special Needs Plans (D-SNPs) for individuals entitled to Medicare Part A, enrolled in Part B, and receiving Medical Assistance, including those with cognitive disabilities, physical impairments, or chronic conditions.
• AmeriHealth Caritas Next Individual and family health plans offered on and off the Health Insurance Marketplace with gold, silver, and bronze tier options covering 10 essential health benefits.
• Long-Term Services and Supports (LTSS) Comprehensive LTSS programs for elderly and disabled individuals requiring assistance with activities of daily living including bathing, dressing, eating, and medication management, including Pennsylvania Community HealthChoices covering nearly 400,000 people.
• PerformCare (Behavioral Health Managed Care) Full-service behavioral health managed care providing mental health services, intellectual and developmental disability (I/DD) services, substance use treatment, and suicide prevention programs.
• PerformRx (Pharmacy Benefits Management) URAC- and NCQA-accredited pharmacy benefits manager providing formulary management, drug benefit structuring, prescription claims processing, pharmacy contracting, and cost control. Contracts transferring to OptumRx effective January 1, 2027.
• PerformSpecialty (Specialty Pharmacy) URAC-accredited specialty pharmacy providing high-cost specialty pharmaceuticals for complex and chronic health conditions with personalized care teams and disease management programs.
• Community HealthChoices Pennsylvania-based managed LTSS program covering nearly 400,000 people, coordinating physical health and long-term services and supports under a $7 billion+ program.
• Keystone First AmeriHealth Caritas Pennsylvania Medicaid managed care plan serving Philadelphia and southeastern Pennsylvania, including CHIP and Community HealthChoices.
• Select Health of South Carolina (First Choice) South Carolina health plan offering Medicaid managed care, Health Insurance Marketplace plans (First Choice Next), and Dual-Eligible Special Needs Plans (First Choice VIP Care).
• PerformPlus with SPARC Value-Based Contracting Suite of value-based care programs including SPARC (Small Providers and Rural Communities) models for small and rural providers, episode-based solutions, and programs aggregating performance metrics across participating providers. Implemented in Louisiana and New Hampshire Medicaid plans.

Quantifiable outcome

• 45% reduction in inpatient admissions per member per year
• +11 more outcomes

Named customers12 records

Segments7 records

Ideal customer profiles4 records

Technology focussed No

API detail

Has API

Yes

API docs

API detail

Core technology

AI maturity

App detail

Integration4 records

Feature12 records

Partnerships

20 partnerships are on record, tiered core and minor.

• NC Community College SystemcoreStrategic or Co-development Partner · 15 May 2026Partnership to address healthcare workforce shortage through $6 million Boost program expansion including Wake Technical Community College expansion and Bridge pilot program for short-term healthcare credentials.
• Wake Technical Community CollegecoreStrategic or Co-development Partner · 15 May 2026$3 million expansion funding for students pursuing healthcare degrees as part of Boost program addressing statewide healthcare workforce shortfall.
• Nest HealthminorStrategic or Co-development PartnerLaunch of Nest Origin in-home prenatal services program for Medicaid beneficiaries in New Orleans, Louisiana. Program reports 60% reduction in ED utilization and 2:1 ROI for AmeriHealth Caritas Louisiana. Outcomes to be studied by University of Pennsylvania researchers.
• Local Food Bank (Pennsylvania)coreStrategic or Co-development PartnerValue-based program partnership in Pennsylvania where food bank is actively involved in members' care ensuring proper food and nutrition after medical encounters. Tracks outcomes as part of value-based care construct through Caring Communities virtual ACO.
• Louisiana State University (LSU) Health Sciences CenterminorStrategic or Co-development PartnerPartnership for Population Health Clerkship offering fourth-year medical students and residents four-week remote rotation in Medicaid managed care, population health, strategy, quality improvement, cost reduction, and health equity. Also hosts AmeriHealth Caritas Health Policy Honors Program for LSU medical students.
• Metropolitan Area Neighborhood Nutrition Alliance (MANNA)minorStrategic or Co-development PartnerPartnership for nutritious meal delivery to AmeriHealth Caritas members with qualifying health needs in Philadelphia area as part of social determinants of health initiatives.
• Mom's MealsminorStrategic or Co-development PartnerNationwide partnership for nutritious meal delivery to members with qualifying health needs as part of emergency food and social determinants of health programs.
• YMCAminorStrategic or Co-development PartnerCollaboration for diabetes management program using in-person educational sessions including personalized wellness coaching, tailored exercise plans, nutrition workshops, and cooking demonstrations to improve health of members with Type 2 diabetes.
• Cristo Rey Philadelphia High SchoolminorStrategic or Co-development PartnerWork Study Program partnership providing high-school students from low-income backgrounds hands-on experience with mentoring, coaching, and cross-functional skill development.
• National Gay & Lesbian Chamber of CommerceminorChannel Partner/ Reseller/ DistributorLGBTQ+-owned business certification and diversity organization partnership supporting supplier diversity initiatives.
• National Minority Supplier Development Council (NMSDC)coreChannel Partner/ Reseller/ DistributorNational minority supplier development organization partnership. AmeriHealth Caritas is two-time NMSDC Corporation of the Year and 2022 Forefront 50 Company award recipient.
• Women's Business Enterprise CouncilminorChannel Partner/ Reseller/ DistributorWomen-owned business certification organization partnership supporting supplier diversity; named 2022 Partner of the Year.
• Urban LeagueminorChannel Partner/ Reseller/ DistributorCivil rights organization partnership supporting economic empowerment and diversity initiatives.
• Minority Business Development AgencyminorChannel Partner/ Reseller/ DistributorFederal agency partnership supporting minority-owned business development and supplier diversity.
• African American Chamber of CommerceminorChannel Partner/ Reseller/ DistributorRegional chamber partnership supporting African American business development and supplier diversity.
• Hispanic Chamber of CommerceminorChannel Partner/ Reseller/ DistributorRegional chamber partnership supporting Hispanic business development and supplier diversity.
• District of Columbia Department of Small and Local Business DevelopmentminorChannel Partner/ Reseller/ DistributorGovernment agency partnership supporting small and local business development in DC market.
• National Association of Community Health Centers (NACHC)coreStrategic or Co-development PartnerFQHC National Advisory Board partnership with AmeriHealth Caritas to improve health and well-being of underserved communities through strategic guidance, advocacy, and leadership for FQHC leaders nationwide.
• OptumRx (UnitedHealth Group)coreTechnology or IntegrationTaking over PerformRx PBM contracts in 13 states on January 1 following AmeriHealth Caritas decision to close PerformRx PBM. Inheritance includes Independence Health Group contracts.
• National Committee for Quality Assurance (NCQA)minorStrategic or Co-development PartnerParticipation in NCQA inaugural Measuring Patient Engagement Learning Collaborative to inform and develop best practices in digital wellness, condition management, and patient engagement strategies.

Scale indicators24 records

Recent moves7 records

Expansion highlights5 records

Direct peers

• Centene Corporation: Centene is the largest Medicaid managed care organization in the US, serving complex populations through its WellCare and other subsidiaries. Directly comparable to AmeriHealth Caritas as a multi-state Medicaid MCO with a focus on government-sponsored healthcare programs.
• Molina Healthcare: Molina is a pure-play Medicaid and government-sponsored managed care company operating across multiple states. Closely comparable to AmeriHealth Caritas in business model (state Medicaid contracts, D-SNP, Marketplace) and target population (low-income, dual-eligible).
• CareSource: CareSource is a nonprofit managed care company specializing in Medicaid, Medicare, and Marketplace plans across multiple states. Comparable to AmeriHealth Caritas as a multi-state MCO with strong mission orientation toward underserved populations and similar product mix.
• Humana: Humana is the second-largest Medicare Advantage insurer with a sizable D-SNP franchise serving dual-eligibles. Highly comparable to AmeriHealth Caritas's D-SNP business, though Humana is much larger and broader in scope (also serves commercial, group, and specialty populations).
• Highmark Health: Highmark is a major Blue Cross Blue Shield licensee in Pennsylvania with Medicaid managed care and integrated delivery system. Directly comparable as a Pennsylvania-based Blues-affiliated MCO with overlapping markets and similar Medicaid/LTSS offerings.

Broad incumbents

• UnitedHealth Group (UnitedHealthcare): UnitedHealth Group operates the largest US health insurer and through Optum is taking over AmeriHealth Caritas's PerformRx PBM contracts. Direct competitor across Medicaid, D-SNP, and Marketplace lines and now a key vendor partner via OptumRx.
• Elevance Health (Anthem): Elevance Health operates Blue Cross Blue Shield plans across multiple states with significant Medicaid managed care presence through Anthem Blue plans. Comparable as a major multi-state MCO serving Medicaid, D-SNP, and commercial populations, though with broader portfolio and Blues brand advantage.
• CVS Health (Aetna): CVS Health owns Aetna, a major health insurer with Medicaid, Medicare Advantage, and D-SNP offerings, plus integrated PBM (Caremark) and retail health. Comparable in product mix and integrated payer-PBM-provider model that AmeriHealth Caritas is moving away from with PerformRx closure.
• HCSC (Health Care Service Corporation): HCSC operates Blue Cross Blue Shield plans in five states and has expanded into Medicaid and Medicare Advantage. Comparable as a multi-state, mission-driven MCO with growing government programs footprint similar to AmeriHealth Caritas's expansion trajectory.

Regional players

• Inland Empire Health Plan (IEHP): IEHP is a nonprofit Medicaid and Medicare-Medicaid Plan serving California's Inland Empire region. Comparable as a Medicaid-focused MCO serving complex populations; recently hired AmeriHealth Caritas's former VP of Medicaid Plans as CFO.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat6 records

Key risks6 records

Key highlights7 records

Customer concentration

• YouTubeyoutube.com/c/AmeriHealthCaritas
• Facebookfacebook.com/amerihealthcaritas
• LinkedInlinkedin.com/company/848248
• Xx.com/amcaritas

Compliance11 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles24 records

Subsidiaries6 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments1 record

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about AmeriHealth Caritas