Keystone Family Health Plan

What Keystone Family Health Plan does

Keystone Family Health Plan (doing business as Keystone First) is a Pennsylvania Medicaid managed care health plan headquartered at 200 Stevens Drive in Philadelphia. Founded in 1982 as Mercy Health Plan at Misericordia Hospital, the organization entered into a 1996 partnership with Keystone Health Plan East (the managed care entity of Independence Blue Cross) to form Keystone Mercy Health Plan, and rebranded to Keystone First in 2012 with backing from Independence Blue Cross and Blue Cross Blue Shield of Michigan. It holds coverage through Vista Health Plan, an independent licensee of the Blue Cross and Blue Shield Association, and operates as part of the AmeriHealth Caritas family of companies. It earned full NCQA accreditation in 1992, the first Medical Assistance plan to do so.

Keystone First serves more than 300,000 Medical Assistance (Pennsylvania Medicaid) recipients across five southeastern Pennsylvania counties: Bucks, Chester, Delaware, Montgomery, and Philadelphia. Members receive coverage through Pennsylvania's HealthChoices program under capitated contracts with the Pennsylvania Department of Human Services; no premiums are charged to eligible members. The product portfolio includes a core Medicaid HMO plan, two subsidiaries (Keystone First CHC for Community HealthChoices/LTSS and Keystone First VIP Choice for Medicare/dual-eligible coverage), pharmacy services with prior authorization routing via CoverMyMeds and Surescripts, and a Digital Member Portal plus iOS/Android mobile applications. Distribution relies on a contracted provider network, the NaviNet provider portal, a 24/7 member services call line, bilingual materials, and physical community infrastructure (a Wellness and Opportunity Center in Chester and a Mobile Wellness and Opportunity Center deployed across the service area).

Specialized care management and community programs include the Bright Start prenatal program (~12,000 births/year with 50% flagged high-risk, built on the Optum OB Care platform), Moms2B for members with prior premature deliveries, Gift for Life mammogram outreach with Fox Chase Cancer Center, the 12-week Lose to Win diabetes and weight management program with five YMCA branches, Healthy Hoops asthma education, Youth.Philly.Fit with City Year, 4 Your Kid's Care (which reduced pediatric ER visits by 25% in its first year), Toothy Tune-Ups with St. Christopher's, Health Ministry (faith-based outreach recognized by NCQA and AHIP), and Tools for Tomorrow job readiness training. Technology integrations include WebMD Ignite for member health content, CoverMyMeds and Surescripts for pharmacy prior authorization, Optum OB Care for maternity management, NaviNet for provider administration, and Healthsparq for provider directory. Enrollment is routed through state-administered PA Enrollment Services rather than direct consumer selection, with community outreach and provider referrals supplementing acquisition.

Name

Keystone Family Health Plan

Legal name

Keystone Family Health Plan

Website

https://keystonefirstpa.com

Company type

Private

Founded year

1982

Operating status

Operating

Headcount range

101–250 employees

Short description

Keystone First is a Pennsylvania Medicaid managed care health plan serving 300,000+ Medical Assistance recipients across five southeastern Pennsylvania counties under capitated contracts with the state Department of Human Services, and is part of the AmeriHealth Caritas family of companies with Independence Blue Cross as parent.

Ownership category

akta.pro rank

Product category

Medicaid Managed Care

NAICS

Other Individual and Family Services (62419), Child and Youth Services (624110)

SIC

Services-Health Services (8000), Services-Social Services (8300)

akta.pro primary industry

Children’s & Family Medicaid Managed Care Plans (HLAEAEAF)

Keywords

• Medicaid managed care
• Health insurance plan
• Medical assistance coverage
• Healthcare benefits administration
• Community health services

Headquarters

HQ city

Philadelphia

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2C

Offering type

Services

Cost components

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

Revenue model

1. Medicaid Capitated Premium Payments: Keystone First operates as a Medicaid managed care organization receiving capitated premium payments from the Pennsylvania Department of Human Services (DHS) for each enrolled member. The plan assumes responsibility for providing covered healthcare services to members within the five-county service area.

Pricing tiers

Go-to-market motion1 record

Distribution channels5 records

Marketing channels5 records

Core offering

Keystone Family Health Plan (d/b/a Keystone First) is a Medicaid managed care health plan that provides Medical Assistance (Pennsylvania Medicaid) coverage to more than 300,000 low-income individuals and families across Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. The plan offers core health benefits (primary care, preventive, emergency, prescription, behavioral health) funded through capitated payments from the Pennsylvania Department of Human Services, supplemented by care management programs (Bright Start prenatal, Moms2B), wellness initiatives (Lose to Win, Healthy Hoops, Gift for Life, Toothy Tune-Ups), and community-based outreach including Wellness and Opportunity Centers.

Product overview

Keystone First is a Medicaid managed care health plan serving over 300,000 Medical Assistance recipients in five southeastern Pennsylvania counties. The offering is a platform-ecosystem combining a core health plan with integrated digital portals (Member Portal, NaviNet Provider Portal), a mobile application (iOS/Android), pharmacy services (formulary, prior authorization, NDC billing), and an array of specialized care management and community wellness programs. Key programs include Bright Start prenatal care (delivering ~12,000 babies/year), Healthy Families Safe Communities, the Wellness and Opportunity Center in Chester, a Mobile Wellness Center, Health Ministry, Gift for Life mammogram outreach, Lose to Win diabetes management, and Tools for Tomorrow job readiness. The plan leverages third-party integrations including WebMD Ignite (health library), CoverMyMeds and Surescripts (pharmacy prior authorization), Optum OB Care (maternity management), and NaviNet (provider portal).

Differentiator

Problem solved

Functional benefit

Products and services

• Keystone First Medicaid Health Plan Pennsylvania's largest Medical Assistance (Medicaid) managed care health plan covering over 300,000 recipients across Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. Includes primary care, preventive care, emergency services, prescription drugs, behavioral health, and specialty care funded through PA DHS capitated payments.
• Keystone First Mobile App iOS and Android mobile application for members to access benefits, find providers, view claims, and manage their health plan on the go.
• Member Portal Online portal for members to access benefits, claims, prior authorizations, formulary, and personal health information.
• NaviNet Provider Portal Provider-facing portal for claims, billing, prior authorization lookup, member intervention requests, and communications with Keystone First.
• Prior Authorization Lookup Tool Online self-service tool allowing providers to enter CPT codes to determine whether outpatient services require prior authorization.
• Secure Contact Form Online form for members and providers to submit inquiries, disputes, fraud reports, HIPAA privacy requests, and general questions.
• Pharmacy Services Pharmacy benefits including formulary (preferred drug list following PA DHS PDL plus supplemental formulary), pharmacy directory, prior authorization, and NDC billing information.
• Bright Start Prenatal Program High-risk pregnancy care management program coordinating medical care and social services for expectant mothers. Includes case management, dental screenings, behavioral health screenings, postpartum outreach, and doula services. Delivered approximately 12,000 babies per year with 50% considered high-risk.
• Moms2B Intensive maternity care management program for members with prior premature deliveries or serious medical conditions. Uses mobile technology, provides cell phones, and arranges transportation to appointments.
• Gift for Life Mammogram outreach program partnering with Fox Chase Cancer Center and mobile mammography vans to deliver screenings at convenient neighborhood locations for women who have never had or have not had a mammogram in over two years.
• Lose to Win 12-week diabetes and weight management program presented in partnership with five YMCA branches. Includes fitness programs, personalized wellness coaching, nutrition workshops, and cooking demonstrations; participants receive a year-long YMCA membership upon completion.
• Healthy Hoops Health education program using basketball to help children with asthma and their families learn about disease management through nutrition, medication use, and monitored exercise.
• Youth.Philly.Fit. Child wellness program in partnership with City Year engaging 6th through 8th graders from eight Philadelphia middle schools with physical activities and healthy food choice education.
• 4 Your Kid's Care Pediatric ER utilization reduction program encouraging ongoing relationships with primary care practitioners. Reduced pediatric ER visits by 25% in its first year.
• Toothy Tune-Ups Pediatric oral health program where dentists and hygienists provide children with oral assessments, cleanings, sealants, fluoride treatments, fillings, and referrals.
• Health Ministry Program Faith-based health and wellness education program delivered in churches, synagogues, and mosques. The 40-Day Journey component engages women in a 6-week educational series on nutrition, exercise, and medication compliance.
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Child health outreach team telephonically contacting parents and guardians to educate about and schedule age-appropriate periodic well visits, screenings, and preventive services for children up to age 21.
• Community Outreach Solutions (COS) Team Field outreach team making home visits to help vulnerable members schedule preventive care appointments, arrange transportation, and address barriers to accessing healthcare.
• Let Us Know Program Clinical resource program allowing providers to notify Keystone First's Rapid Response and Outreach Team (RROT) about members needing assistance with missed appointments, behavioral health, medication noncompliance, ER misuse, or social determinants of health.
• Keystone First Wellness and Opportunity Center Fixed-location community center at 1929 W. 9th Street, Chester, PA 19013 offering art classes, music, exercise/fitness, educational opportunities, job training, GED classes, cooking demonstrations, weekly food pantry, caregiver support, health education and screenings, and assistance understanding plan benefits.
• Mobile Wellness and Opportunity Center Mobile unit bringing health education, screenings, healthy food demonstrations, fitness classes, job readiness events, baby showers, and training to community locations throughout southeastern Pennsylvania.
• Tools for Tomorrow Quarterly job readiness webinar series (10 a.m.-11 a.m. on Zoom) open to the community at no cost, covering skill identification, resume writing, online job searching/networking, and interview preparation.
• Retention Unit Eligibility maintenance support partnering with the Pennsylvania Department of Public Welfare to help members navigate caseworker access and maintain Medical Assistance eligibility.
• Health Library Member health education tool powered by WebMD Ignite offering quizzes and calculators on eating healthy, exercise, mental health, smoking cessation, stress management, substance use, and weight management (BMI tools).
• Healthy Families, Safe Communities Safety and wellness initiative addressing gun safety, teen dating violence, bullying, prescription medicine abuse, and food insecurity for both members and providers.

Named customers3 records

Segments5 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration7 records

Feature4 records

Partnerships

14 partnerships are on record, tiered core, secondary and minor.

• Vista Health PlancoreOthersVista Health Plan provides coverage as an independent licensee of the Blue Cross and Blue Shield Association, enabling Keystone First to serve the health insurance needs of Philadelphia and southeastern Pennsylvania.
• YMCA of Philadelphia and VicinitysecondaryStrategic or Co-development PartnerPartnership with five local YMCA branches to deliver the Lose to Win diabetes and weight management program, including fitness programs, personalized wellness coaching, nutrition workshops, and cooking demonstrations.
• Fox Chase Cancer CentersecondaryStrategic or Co-development PartnerPartnership with Fox Chase Cancer Center for the Gift for Life mammogram program, delivering breast cancer screenings to members at convenient neighborhood locations.
• City YearsecondaryStrategic or Co-development PartnerPartnership with City Year to implement Youth.Philly.Fit program promoting healthy lifestyle to children in 6th through 8th grade at eight Philadelphia middle schools.
• St. Christopher's Hospital for ChildrensecondaryStrategic or Co-development PartnerPartner for Toothy Tune-Ups dental program, providing children with oral assessments, cleanings, sealants, fluoride treatments, and ongoing dental care referrals.
• Philadelphia Transitional Work CorporationsecondaryStrategic or Co-development PartnerPartnership for job creation program providing paid work experience and training to Medical Assistance recipients, with goal of permanent employment.
• Philadelphia County Assistance OfficessecondaryStrategic or Co-development PartnerCollaboration for transitional work program providing employment opportunities and training for Medical Assistance recipients.
• People's Emergency CenterminorStrategic or Co-development PartnerPartner in job creation program providing employment opportunities for individuals receiving Medical Assistance.
• Pennsylvania Department of Human ServicescoreOthersState agency that administers Medical Assistance program and contracts with Keystone First as a HealthChoices managed care organization. Also partners for Retention Unit helping members maintain eligibility.
• Welfare PridesecondaryStrategic or Co-development PartnerPartnership to help members navigate eligibility issues and establish expedited processes for caseworkers and County Assistance Offices.
• Lackawanna Mobile MammographysecondaryChannel Partner/ Reseller/ DistributorMobile mammography partner enabling delivery of breast cancer screenings to members at convenient neighborhood locations like grocery stores.
• AmeriHealth CaritascoreOthersParent company family of health plans. The Keystone First website is hosted on AmeriHealth Caritas infrastructure. Careers page links to AmeriHealth Caritas careers site.
• Optum OB CaresecondaryTechnology or IntegrationTechnology platform for Bright Start maternity program providing provider resources, user guides, and training for obstetric care management.
• WebMD IgnitesecondaryTechnology or IntegrationHealth information and tools provider powering the Health Library with interactive quizzes and calculators for member health education.

Scale indicators4 records

Recent moves8 records

Expansion highlights5 records

Broad incumbents

• Centene Corporation: The largest U.S. Medicaid managed care operator and the parent of multiple state-specific Medicaid plans. Comparable as a broad incumbent competing in the same Medicaid managed care category, though not directly licensed in PA under the same name.
• AmeriHealth Caritas: Keystone First's parent corporate family and a multi-state Medicaid managed care operator. Directly comparable because Keystone First's infrastructure, careers, and digital platforms are hosted on AmeriHealth Caritas systems, and the two share clinical and operational programs.
• Independence Blue Cross: Keystone First's parent company and a major southeastern Pennsylvania commercial health insurer. Comparable as the corporate parent and as an adjacent health plan brand within the same regional ecosystem.

Direct peers

• Molina Healthcare of Pennsylvania: A national Medicaid managed care organization operating in Pennsylvania under HealthChoices. Direct competitor for Medical Assistance enrollment in the five-county area.
• Aetna Better Health of Pennsylvania: A national carrier's Medicaid managed care plan offering Medical Assistance coverage in Pennsylvania. Competes for the same HealthChoices members in the southeastern service area.
• Geisinger Health Plan Family: A Pennsylvania-based Medicaid managed care product under HealthChoices, serving Medical Assistance recipients in central and northeastern PA with provider-aligned care models analogous to Keystone First.
• Gateway Health / Highmark Wholecare: A Pennsylvania Medicaid and dual-eligible managed care plan serving low-income members across multiple regions, including the Philadelphia area. Direct competitor for HealthChoices enrollment.
• Health Partners Plans: A Philadelphia-based, provider-sponsored Medicaid managed care plan serving Medical Assistance recipients in southeastern Pennsylvania. Direct competitor for the same five-county HealthChoices contract.
• UPMC for You: A Pennsylvania-based Medicaid managed care plan operating under the HealthChoices program, including the southeastern region. Competes head-to-head with Keystone First for the same Pennsylvania DHS contract.
• UnitedHealthcare Community Plan of Pennsylvania: UnitedHealth Group's Medicaid managed care product in Pennsylvania, serving Medical Assistance recipients in the same regions as Keystone First. Direct competitor with substantially greater national scale.

Market position

Strengths4 records

Weaknesses4 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Facebookfacebook.com/Keystone-First-101516962045555
• LinkedInlinkedin.com/company/keystone-mercy-health-plan
• Instagraminstagram.com/keystonefirst

Compliance1 record

Revenue estimate

Valuation estimate

Number of profiles

Profiles1 record

Subsidiaries2 records

Funding overview

Funding rounds

Investors

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

M&A

Investments

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

Frequently asked questions about Keystone Family Health Plan