Medicare AdvantageReimbursementMedium impact
MA00.033q, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Independence Blue Cross·Family Medicine, Internal Medicine, General Practice +1 more·Medical Policy
Effective date
Jan 1, 2025
We identified it
Jun 19, 2026
Summary
This Medicare Advantage policy update defines which services Primary Care Providers can bill above their capitation rates for HMO and HMO-POS plans. This affects how capitated primary care practices handle billing for services that exceed their contracted per-member-per-month payments.
Action Required
By January 1, 2025: Primary care providers with HMO/HMO-POS capitation contracts must review the updated policy to identify which services can be billed above capitation. Update billing workflows to ensure proper identification and billing of covered services that exceed capitated amounts. Contact payer to clarify specific services covered under this policy.