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HighmarkMedicare Advantage · Reimbursement · Provider Bulletin · NY, PA, WV, DEHigh impact

ValueBlue Base Rates Set for 2027

Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 26, 2026

Summary

Highmark is launching the ValueBlue partial capitation program effective January 1, 2027, establishing new base capitation rates by line of business (Commercial 18+: $4.81, Commercial under 18: $21.69, Medicare Advantage: $20.51) and introducing performance adjustment factors (PAF) for primary care providers based on quality metrics and ED utilization. Billing teams must review 2027 PAF reports, understand the new Member Adjustment Factor (MAF) structure, and prepare systems for retrospective capitation payments.

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What to do

by Dec 31, 2026 · 5 steps
01Billing and coding teams must access the Static Reports Application in Provider Facing Analytics (PFA) to review individual 2027 PAF Reports and understand performance adjustment factors that will adjust capitation payments by up to +40% or -20% based on quality and ED utilization metrics.
02Update billing system documentation to account for retrospective capitation payments rather than fee-for-service billing.
03Providers and clinical staff must review the ValueBlue User Guide (accessed via Provider Resource Center/Availity Essentials) to understand MAF calculations and risk score implications for attributed member populations.
04Evaluate participation in the new ValueBlue Connect complementary incentive program and determine enrollment strategy.
05Coordinate with providers to monitor attributed member rosters available in Value Insight Center (VIC) starting January 2027.
If missed: Failure to adapt billing workflows may result in claim processing delays and inaccurate capitation revenue recognition.

Original notice

ValueBlue Base Rates Set for 2027
providers.highmark.com · Always check the source before changing claims.
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