AmeriHealth Caritas Pennsylvania

What AmeriHealth Caritas Pennsylvania does

AmeriHealth Caritas Pennsylvania is a Pennsylvania-licensed, for-profit Medicaid managed care organization (MCO) that contracts with the Pennsylvania Department of Human Services (DHS) to deliver Medical Assistance benefits to eligible low-income populations across 62 counties in the Central, Northeast, Northwest, and Southwest regions of the state. The plan serves over 400,000 members and provides comprehensive coverage including medical, dental, vision, behavioral health, substance use disorder treatment, long-term services and supports, and pharmacy benefits under a capitated per-member-per-month (PMPM) reimbursement model negotiated with the state. It is a subsidiary of AmeriHealth Caritas and traces its origins to 1983, when Misericordia Hospital staff in West Philadelphia launched Mercy Health Plan with 300 members; the plan became the first Medical Assistance MCO to earn full NCQA Accreditation in 1992 and was reorganized as AmeriHealth Mercy Health Plan in 1996 following a partnership with AmeriHealth First.

The operating platform combines a member-facing Member Portal and AHC Mobile App (iOS/Android) with a provider-facing NaviNet portal, electronic prior authorization via CoverMyMeds and Surescripts, a pharmacy locator powered by Darwin Rx, and a HealthSparq-integrated provider directory. Pharmacy benefit management follows the PA DHS statewide Preferred Drug List effective January 1, 2020, supplemented by an internal formulary. Distribution is anchored by a network of 2,762+ participating pharmacies and a community-based ecosystem that includes two physical Wellness and Opportunity Centers (Reading, Hazleton), a 2025-launched Mobile Wellness & Opportunity Center, a 24/7 Nurse Call Line staffed by Sirona Health, and sub-brand programs such as Healthy Hoops (asthma/obesity management reaching 60,000+ children across 10+ states), Bright Start maternity, the Women's Wellness Initiative, and Moms2B baby showers.

Revenue is generated exclusively through capitated PMPM premiums paid by the Pennsylvania DHS, with member cost-sharing limited to nominal copays per state guidelines. Member acquisition is driven by state Medicaid eligibility determination and enrollment rather than traditional sales, and the company recruits providers into its network through credentialing. The GTM motion is therefore a B2G contract posture supplemented by community outreach, provider network development, and partnerships with 15+ community organizations (including FQHCs, the Salvation Army, Water Street Mission, and the WIC program) to address social determinants of health. The company is HIPAA-compliant, NCQA-accredited, and operates as a privately held subsidiary with no public funding or M&A activity in the source data.

Name

AmeriHealth Caritas Pennsylvania

Legal name

AmeriHealth Caritas Pennsylvania

Website

https://amerihealthcaritaspa.com

Company type

Private

Founded year

1983

Operating status

Operating

Headcount range

11–50 employees

Short description

AmeriHealth Caritas Pennsylvania is a Medicaid managed care health plan serving over 400,000 Medical Assistance recipients across 62 Pennsylvania counties under a capitated contract with the Pennsylvania Department of Human Services, and is a subsidiary of AmeriHealth Caritas.

Ownership category

akta.pro rank

Product category

Medicaid Managed Care

NAICS

Ambulatory Health Care Services (621)

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

Managed Care Entity Administration for Medicaid (MCO/PHP/PIHP/PAHP) (HLAEAEAJ)

akta.pro secondary industry

Integrated Physical-Behavioral-Social Care (Whole-Person) Medicaid Plans (HLAEAEAI)

Keywords

• Medicaid managed care
• Health insurance plans
• Pharmacy benefit management
• Care coordination services
• Community health programs

Headquarters

HQ city

Harrisburg

HQ country

United States

HQ region

North America

Offices4 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

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

Revenue model

1. Medicaid Capitated Premiums: The company receives fixed per-member-per-month (PMPM) capitation payments from the Pennsylvania Department of Human Services (DHS) to provide comprehensive Medicaid managed care coverage. Premium amounts are negotiated with the state based on actuarial calculations of expected healthcare utilization.
2. Pharmacy Benefit Management: Pharmacy services including prescription drug coverage, prior authorization, and formulary management. While drugs are covered for members, the primary revenue comes from the capitated premium with pharmacy as a covered benefit.

Pricing tiers

Go-to-market motion1 record

Distribution channels4 records

Marketing channels7 records

Core offering

AmeriHealth Caritas Pennsylvania is a Medicaid managed care health plan that provides Medical Assistance benefits — including medical, dental, vision, behavioral health, substance use treatment, long-term services and supports, and prescription drug coverage — to more than 400,000 eligible Pennsylvanians across 62 counties under a capitated contract with the Pennsylvania Department of Human Services. The plan operates member and provider portals, a pharmacy benefit program with formulary/PDL compliance and electronic prior authorization, a mobile app, and a 24/7 nurse triage line to coordinate care and member services.

Product overview

AmeriHealth Caritas Pennsylvania operates as a Medicaid managed care health plan serving over 400,000 Medical Assistance recipients across Pennsylvania. The core offering is the Medicaid health plan providing medical, dental, vision, and pharmacy benefits through an integrated platform. The product portfolio centers on a Member Portal for member self-service and a NaviNet Provider Portal for provider transactions. Supporting services include Pharmacy Benefits Management with formulary and prior authorization tools, an AHC Mobile App, and community-focused wellness programs including the Mobile Wellness & Opportunity Center, physical Wellness and Opportunity Centers, Healthy Hoops (asthma/obesity management), Women's Wellness Initiative, and Bright Start maternity program. Additional value-added services include a 24/7 Nurse Call Line, Prior Authorization Lookup Tool, and secure member-provider communication via the Secure Contact Form.

Differentiator

Problem solved

Functional benefit

Brands

• Healthy Hoops: An innovative asthma and obesity management program that uses basketball as a platform to teach asthmatic children and their families how to manage asthma through proper nutrition, exercise, and appropriate medication use.
• Bright Start
• Wellness and Opportunity Center

Products and services

• AmeriHealth Caritas Pennsylvania Medicaid Health Plan Core Medicaid managed care health plan providing Medical Assistance benefits including medical, dental, vision, behavioral health, substance use treatment, and pharmacy coverage to more than 400,000 eligible Pennsylvanians across 62 counties under contract with the Pennsylvania Department of Human Services.
• Pharmacy Benefits Management Prescription drug coverage including state-mandated Preferred Drug List (PDL) compliance, supplemental formulary management, prior authorization (CoverMyMeds and Surescripts electronic prior authorization), pharmacy locator (Darwin Rx), and NDC billing support for Medicaid members.
• Member Portal Online portal for Medicaid members to access benefits, find providers and pharmacies, view claims, manage prescriptions, and access health resources.
• NaviNet Provider Portal Provider-facing portal for claims submission, eligibility verification, prior authorization requests, and provider communications serving the AmeriHealth Caritas network of physicians, hospitals, and clinics.
• AHC Mobile App Mobile application for iOS and Android providing Medicaid members with on-the-go access to benefits, provider search, health information, and member services.
• Mobile Wellness & Opportunity Center Mobile community resource unit delivering health education, screenings, fitness classes, job training, and nutrition programs to underserved areas across Pennsylvania at no cost to members.
• Wellness and Opportunity Centers (Reading and Hazleton) Physical community centers in Reading and Hazleton offering exercise classes, educational programs, job training, caregiver support, GED assistance, and diabetes-focused programs for Medicaid members and local residents.
• Healthy Hoops Program Asthma and obesity management program using basketball as a platform to teach children ages 3-18 and their families proper nutrition, exercise, and medication management; nationwide program reaching 60,000+ families across 10+ states and the District of Columbia.
• Women's Wellness Initiative Women's health program addressing spiritual, social, physical, mental, and environmental factors with a focus on heart disease, breast cancer, and cervical cancer prevention through wellness empowerment fairs.
• Bright Start Maternity Program Maternity program providing information and resources for safe pregnancies and healthy babies, encouraging prenatal and postpartum care for pregnant Medicaid members.
• 24/7 Nurse Call Line Confidential 24/7 nurse triage service available at 1-866-566-1513 providing health triage, care guidance, and level-of-care recommendations for Medicaid members when their primary care providers are unavailable.
• Prior Authorization Lookup Tool Online CPT code lookup tool for providers to determine which outpatient services require prior authorization before delivery under the AmeriHealth Caritas Pennsylvania Medicaid plan.

Quantifiable outcome

• Decreased emergency room utilization through primary care access
• +2 more outcomes

Named customers3 records

Segments4 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration6 records

Feature8 records

Partnerships

Nine partnerships are on record, tiered core.

• Booker T. Washington CentercoreStrategic or Co-development PartnerCommunity organization partner collaborating with AmeriHealth Caritas Pennsylvania on community health programs and outreach initiatives.
• Casa GuadelupecoreStrategic or Co-development PartnerCommunity organization providing health and human services, partnering on community health programs and wellness initiatives.
• Hamilton Health Center (FQHC)coreStrategic or Co-development PartnerFederally Qualified Health Center partner providing primary care services and collaborating on community health initiatives.
• Lehigh Valley Health NetworkcoreStrategic or Co-development PartnerRegional health system partner providing hospital and specialty care services to AmeriHealth Caritas Pennsylvania members.
• Pennsylvania Department of Human Services (DHS)coreStrategic or Co-development PartnerState agency that contracts with AmeriHealth Caritas Pennsylvania to provide Medicaid managed care services. DHS determines member eligibility and provides capitated premium payments.
• The Salvation ArmycoreStrategic or Co-development PartnerCommunity organization partner providing social services and collaborating on community health and wellness programs.
• Water Street MissioncoreStrategic or Co-development PartnerFaith-based organization providing services to underserved populations, partnering on addressing social determinants of health.
• WIC Program (Women, Infants, and Children)coreStrategic or Co-development PartnerFederal nutrition program partner providing supplemental foods, health care referrals, and nutrition education for pregnant women, newborns, and children under 5.
• Health Education Advisory Committee (HEAC)coreStrategic or Co-development PartnerAdvisory committee comprising community leaders, healthcare providers, and Medical Assistance consumers working with AmeriHealth Caritas Pennsylvania to develop and implement programs that improve health outcomes.

Scale indicators7 records

Recent moves6 records

Expansion highlights5 records

Direct peers

• Geisinger Health Plan: A Pennsylvania-based integrated delivery network health plan that includes a Medicaid product line competing with AmeriHealth Caritas PA, particularly in central and northeastern PA counties where Geisinger has strong provider density.
• UPMC for You (UPMC Health Plan): A Pennsylvania-based Medicaid managed care plan operated by UPMC Health Plan, directly competing with AmeriHealth Caritas PA for PA DHS contract awards and serving the same Medical Assistance population across overlapping counties.
• Aetna Better Health of Pennsylvania: CVS Health/Aetna's Medicaid managed care plan in Pennsylvania, offering comparable Medicaid benefits to the same DHS-eligible population and competing for PA contract awards alongside AmeriHealth Caritas PA.
• Highmark Wholecare (formerly Gateway Health Plan): A Pennsylvania Medicaid MCO that was rebranded under Highmark, competing head-to-head with AmeriHealth Caritas PA in the state Medicaid managed care market, including dual-eligible and Medicare-Medicaid populations.
• Health Partners Plans: A Philadelphia-based not-for-profit Medicaid MCO with a long-standing PA DHS contract, directly competing with AmeriHealth Caritas PA for member enrollment and provider network participation in the same Medicaid market.
• Molina Healthcare of Pennsylvania: A national Medicaid-focused managed care company operating in Pennsylvania, directly competing for PA DHS contracts and serving similar Medical Assistance populations with comparable capitated benefit designs.
• Keystone First (Independence Blue Cross): Philadelphia-based Medicaid MCO owned by Independence Blue Cross, serving Medical Assistance recipients in southeastern Pennsylvania with comparable benefits, provider-network model, and DHS contracting structure.
• UnitedHealthcare Community Plan of Pennsylvania: The UnitedHealth Group Medicaid MCO operating in Pennsylvania, providing the same Medical Assistance managed care product to low-income populations under a PA DHS contract — directly comparable in benefits and target population.

Broad incumbents

• Centene Corporation: The largest U.S. Medicaid managed care company and parent of multiple state Medicaid plans (including PA-focused products); a broad incumbent competitor that pressures AmeriHealth Caritas PA at the state-procurement level through its scale and PBM platform.
• AmeriHealth Caritas (parent company): The parent organization operating Medicaid and Medicare-Medicaid plans across more than 10 states plus D.C.; provides shared services, technology, and brand backing to AmeriHealth Caritas PA while competing in other state Medicaid markets.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Facebookfacebook.com/AmeriHealth-Caritas-Pennsylvania-102285555300557
• LinkedInlinkedin.com/company/amerihealth-caritas-pa
• Instagraminstagram.com/amerihealthpa
• Xx.com/AmeriHealthPA

Compliance2 records

Revenue estimate

Valuation estimate

Number of profiles

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 AmeriHealth Caritas Pennsylvania