What AmeriHealth Caritas North Carolina does

AmeriHealth Caritas North Carolina is a private Medicaid managed care organization that operates as a Prepaid Health Plan (PHP) under contract with the North Carolina Department of Health and Human Services (NCDHHS). The company provides comprehensive Medicaid benefits to eligible North Carolina residents across all 100 counties through a contracted provider network, with services spanning primary care, specialist visits, hospital and behavioral health care, pharmacy, vision, non-emergency medical transportation, and long-term services and supports (LTSS). The plan is a subsidiary of AmeriHealth Caritas, a mission-driven managed care organization with more than 40 years of Medicaid experience, and was launched in 2019 coincident with North Carolina's transition to Medicaid Managed Care.

The platform combines a member-facing digital ecosystem (Member Portal, AHC Mobile app, CARE Card rewards) with a provider-facing infrastructure (NaviNet portal, HHAeXchange EVV integration, NCTracks credentialing) and a population health management model that coordinates physical, behavioral, and social-determinants interventions. Specialized programs include Bright Start (pregnancy), NC InCK (integrated pediatric care in five counties), Quit For Life (tobacco cessation), and a 24/7 behavioral health crisis line. Five regional Wellness and Opportunity Centers in Asheville, Charlotte, Greensboro, Fayetteville, and Greenville anchor community-based outreach. Revenue is generated exclusively through capitation: NCDHHS pays per-member-per-month premiums to ACNC, which assumes risk for delivering the covered benefit package, with secondary exposure to quality bonus pools tied to HEDIS and CAHPS performance. Key vendor partners include PerformRx (PBM), Modivcare (transportation), HHAeXchange (EVV), NaviNet (provider portal), WebMD Ignite (health education), and Quit For Life.

Name

AmeriHealth Caritas North Carolina

Legal name

AmeriHealth Caritas North Carolina

Website

https://amerihealthcaritasnc.com

Company type

Private

Operating status

Operating

Short description

AmeriHealth Caritas North Carolina is a private Medicaid managed care Prepaid Health Plan serving North Carolina Medicaid beneficiaries statewide across all 100 counties, delivering physical, behavioral, and social-support benefits under capitation contracts with NCDHHS.

Ownership category

akta.pro rank

Product category

Medicaid Managed Care

NAICS

Direct Health and Medical Insurance Carriers (524114)

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

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

akta.pro secondary industry

Medicaid Expansion (ACA Adult) Managed Care Plans (HLAEAEAB)

Keywords

• Medicaid managed care
• Healthcare coordination services
• Population health management
• Managed care organization
• Health plan administration

Headquarters

HQ city

Raleigh

HQ country

United States

HQ region

North America

Offices8 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

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

Revenue model

1. Capitated Premium Revenue: AmeriHealth Caritas North Carolina operates as a Prepaid Health Plan (PHP) receiving capitated payments from the North Carolina Medicaid program. Revenue is generated through per-member-per-month (PMPM) premiums paid by the state for each enrolled Medicaid beneficiary, with the organization assuming responsibility for providing covered benefits to members within the contracted service area.
2. Quality Incentive Revenue: Additional revenue opportunities through quality bonus programs tied to HEDIS performance metrics, member satisfaction scores (CAHPS surveys), and other quality indicators. The organization offers care management programs and wellness initiatives designed to improve member health outcomes.
3. Care Management and Administrative Services: Revenue supports integrated health care management programs including individualized care plans, behavioral health services, LTSS coordination, and community outreach through Wellness and Opportunity Centers.

Pricing tiers

Go-to-market motion1 record

Distribution channels6 records

Marketing channels9 records

Core offering

AmeriHealth Caritas North Carolina administers Medicaid managed care coverage as a Prepaid Health Plan contracted by the North Carolina Department of Health and Human Services. The organization receives capitated per-member-per-month premiums for enrolled North Carolina Medicaid beneficiaries and delivers covered benefits, including physical and behavioral health care, pharmacy, long-term services and supports, non-emergency medical transportation, and wellness programs, through a contracted statewide provider network. It also runs member incentive programs such as the CARE Card Rewards Program and targeted programs including Bright Start pregnancy support, NC InCK, and Quit For Life smoking cessation.

Product overview

AmeriHealth Caritas North Carolina is a Medicaid managed care organization offering a platform-plus-services model. The core offering combines an integrated Care Management model with a digital member ecosystem (Member Portal/Mobile App, CARE Card Rewards Program) to coordinate physical health, behavioral health, and social support services for North Carolina Medicaid beneficiaries. Key product modules include the CARE Card Rewards incentive program, the Bright Start pregnancy program, NC Integrated Care for Kids (NC InCK), Quit For Life smoking cessation, Non-Emergency Medical Transportation (via Modivcare), Vision Services (eyeglasses via Nash Optical and Robertson Optical), a Prior Authorization Lookup Tool, Pharmacy Benefit Management (via PerformRx), and a NaviNet-based Provider Portal for claims, eligibility verification, and EVV through HHAeXchange. The Wellness and Opportunity Centers provide in-person community support complementing the digital platform.

Differentiator

Problem solved

Functional benefit

Products and services

• AmeriHealth Caritas North Carolina Medicaid Managed Care Health Plan Capitated Medicaid managed care plan delivering physical and behavioral health, pharmacy, long-term services and supports, and non-emergency transportation to eligible North Carolina Medicaid beneficiaries across all 100 counties.
• CARE Card Rewards Program Rewards program that loads funds onto a reloadable CARE Card when members complete preventive activities such as well-child visits, prenatal and postpartum care, and Care Needs Screening.
• Care Management and Care Coordination Care coordination service in which nurse care managers help members schedule appointments, understand medications, access specialists, and connect with community resources, with specialized chronic disease management tracks.
• Bright Start Pregnancy Program Prenatal and postpartum support program that provides educational materials, care management, high-risk pregnancy coordination with local health departments, and the Keys to Your Care weekly text program for pregnant Medicaid beneficiaries.
• NC Integrated Care for Kids (NC InCK) Integrated care program for Medicaid children in five North Carolina counties that coordinates medical, behavioral, social, and educational services through the NC InCK model.
• Quit For Life Tobacco Cessation Program Smoking and tobacco cessation program providing personalized quit plans, nicotine replacement gum or patches, Text2Quit text-message coaching, and a mobile app for Medicaid members.
• Non-Emergency Medical Transportation Transportation benefit that arranges and covers rides to Medicaid-covered medical appointments within 75 miles, delivered through the Modivcare app and including public transit, taxis, wheelchair vans, and mileage reimbursement.
• Vision Services Vision benefit covering routine eye exams, state-supplier eyeglasses for children under 21 and adults, and an extra second pair of glasses through Robertson Optical Laboratories and LabLizard online ordering.
• Pharmacy Benefit Management (PerformRx) Pharmacy benefit service delivering prescription drug coverage, a medication look-up tool, prior authorization, and in-network pharmacy location, administered by PerformRx PBM.
• AHC Mobile App and Member Portal Member-facing mobile application and web portal that allow NC Medicaid beneficiaries to access benefits, search for providers, view CARE Card balances, and manage their coverage.
• Behavioral Health Crisis Line Twenty-four hour, seven-day-a-week behavioral health crisis hotline at 1-833-712-2262 with TTY access, providing intervention for mental health and substance use crises.

Quantifiable outcome

• $75 maximum CARE Card rewards per fiscal year for completing healthy activities
• +1 more outcomes

Named customers1 record

Segments7 records

Ideal customer profiles1 record

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration12 records

Feature4 records

Partnerships

Twelve partnerships are on record, tiered core, flagship and minor.

• PerformRxcoreTechnology or IntegrationPerformRx serves as AmeriHealth Caritas North Carolina's pharmacy benefit manager (PBM), administering pharmacy services including prior authorization for drugs, medication lookup tools, and pharmacy provider services at 1-866-885-1406. PerformRx handles the NC Medicaid pharmacy benefit administration under the managed care contract.
• ModivcarecoreTechnology or IntegrationModivcare provides non-emergency medical transportation services for AmeriHealth Caritas North Carolina members. Services include arranging rides to medical appointments within 75 miles, with transportation types including public transit, taxis, wheelchair vans, and mileage reimbursement. The Modivcare mobile app allows members to schedule and manage transportation.
• HHAeXchange (HHAX)coreTechnology or IntegrationHHAeXchange provides the electronic visit verification (EVV) system required by NCDHHS for home health services. ACNC and HHAX offer providers free tools for meeting EVV requirements including a provider portal for visit submission that automatically creates claims for payment.
• Nash OpticalcoreTechnology or IntegrationNash Optical is the state-designated supplier for the first pair of Medicaid eyeglasses for children under age 21 and for adults per NCDHHS requirements. Providers must order eyeglass fabrication through NCTracks, with Nash Optical shipping directly to providers for dispensing to members.
• Robertson Optical LaboratoriescoreTechnology or IntegrationRobertson Optical Laboratories provides the second pair of glasses as an extra benefit to AmeriHealth Caritas North Carolina Medicaid managed care members. Providers order through LabLizard online portal, with eyeglasses shipped to ACNC vision providers for dispensing to eligible members.
• NCTrackscoreTechnology or IntegrationNCTracks is the centralized provider enrollment and credentialing system for North Carolina Medicaid. Providers must first be credentialed through NCTracks before receiving a contract from AmeriHealth Caritas North Carolina. The system handles provider re-credentialing every five years.
• ECHO HealthcoreTechnology or IntegrationECHO Health provides electronic funds transfer (EFT) and electronic remittance advice (ERA) enrollment for provider payments. Providers are encouraged to enroll in EFT using the ECHO Health enrollment link to receive provider stabilization payments and standard claim reimbursements.
• Quit For LifecoreStrategic or Co-development PartnerQuit For Life is a smoking cessation program offered to AmeriHealth Caritas North Carolina members at no cost. The program provides personalized quit plans, quit guides, internet access, medications (nicotine gum or patches), Text2Quit text message support, and a mobile app to help members stop using tobacco products.
• LabLizardcoreTechnology or IntegrationLabLizard is the online ordering portal through which ACNC vision providers order eyeglasses from Robertson Optical Laboratories. Each ACNC vision provider receives unique account credentials to access the portal for placing member eyeglass orders.
• NC Medicaid (NCDHHS)flagshipChannel Partner/ Reseller/ DistributorThe North Carolina Department of Health and Human Services (NCDHHS) contracts with AmeriHealth Caritas North Carolina as a Prepaid Health Plan (PHP) to provide Medicaid managed care services. AmeriHealth Caritas NC receives capitated premium payments from NC Medicaid in exchange for providing covered benefits to enrolled beneficiaries across all 100 North Carolina counties.
• North Carolina Medical SocietyminorStrategic or Co-development PartnerThe North Carolina Medical Society is working with AmeriHealth Caritas North Carolina to support providers impacted by Hurricane Helene. The society is conducting practice impact surveys to help PHPs coordinate provider response and recovery efforts.
• NaviNetcoreTechnology or IntegrationNaviNet is a free web-based multi-payer provider portal used by ACNC providers for eligibility verification, claims status inquiries, prior authorization requests, and other electronic transactions through a secure single sign-on platform.

Scale indicators3 records

Recent moves5 records

Expansion highlights5 records

Emerging players

• Humana: Humana operates Medicaid plans in multiple states and has been expanding its Medicaid footprint, with comparable focus on whole-person care and integrated member programs. Relevant comparable for ACNC's integrated care and value-based services strategy.

Broad incumbents

• UnitedHealth Group (Optum): Parent of UnitedHealthcare Community Plan of NC (a direct competitor) and Optum. Provides scale advantages on analytics, provider network leverage, and behavioral health integration that ACNC must compete against.
• AmeriHealth Caritas (multi-state plans): AmeriHealth Caritas operates Medicaid managed care plans across multiple states (Pennsylvania, Delaware, Florida, Louisiana, Michigan, etc.) under the same parent as ACNC. Provides direct line of sight into operating playbook, clinical programs, and best practices that ACNC leverages.
• Molina Healthcare: Molina is a major multi-state Medicaid managed care operator with comparable business model and member demographics to ACNC. While not currently a NC PHP, Molina is a relevant comparable on size, capitated Medicaid revenue model, and integrated care programs.
• Elevance Health (Anthem): Elevance Health is parent of Healthy Blue (BCBS NC's Medicaid plan) and operates Medicaid managed care plans across many states. Comparable to ACNC's parent (AmeriHealth Caritas / Independence Health Group) in operating model and Medicaid focus.
• Centene Corporation: Centene is the largest US Medicaid managed care insurer and parent of WellCare and Carolina Complete Health — both direct NC competitors to ACNC. Operates the broadest portfolio of state Medicaid contracts and sets competitive benchmarks on benefits, networks, and rates.

Direct peers

• Carolina Complete Health: Carolina Complete Health is a NC Medicaid PHP formed by Centene, the NC Medical Society, and Dogwood Health Trust, directly competing with ACNC. Particularly relevant given its regional/provider-led positioning in NC Medicaid.
• WellCare of North Carolina: WellCare, a Centene subsidiary, is a contracted PHP in NC Medicaid competing directly with ACNC for enrollees. Operates with similar capitated payment economics and benefit structure across all 100 NC counties.
• UnitedHealthcare Community Plan of North Carolina: UnitedHealthcare is a contracted PHP in NC Medicaid Managed Care, directly competing with ACNC for the same beneficiary pool statewide. Operates under the same capitated rate model with comparable benefit requirements and member experience competition.
• Blue Cross and Blue Shield of North Carolina (Healthy Blue): Healthy Blue is one of the five contracted Prepaid Health Plans (PHPs) competing directly with AmeriHealth Caritas NC for North Carolina Medicaid beneficiaries. Operates statewide across all 100 counties under the same NCDHHS contract structure, serving the same population with similar capitated PMPM economics.

Market position

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• YouTubeyoutube.com/@AmeriHealthCaritasNC
• Facebookfacebook.com/AmeriHealthCaritasNorthCarolina
• Instagraminstagram.com/AmeriHealthCaritasNC

Compliance3 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

Investments1 record

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

Frequently asked questions about AmeriHealth Caritas North Carolina