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ValueBlue Base Rates Set for 2027
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 22, 2026
Summary
Highmark is launching the ValueBlue partial capitation program for professional providers effective January 1, 2027, replacing traditional fee-for-service reimbursement with PMPM (per-member-per-month) base rates adjusted by member health factors and provider performance metrics. Billing teams must review 2027 base capitation rates by region and line of business, access the 2027 PAF Report, and understand that payments are retrospective and subject to quality/efficiency adjustments of up to ±40% and ±20% respectively.
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What to do
by Jan 1, 2027 · 1 steps
01Billing and provider operations teams must (1) review the 2027 PMPM base capitation rates by line of business and region (Commercial 18+: $6.24–$7.27; Commercial under 18: $17.65–$24.24; Medicare Advantage: $27.05–$37.94, varying by Western PA, Central PA, Northeastern PA, and Southeastern PA) in the provider bulletin; (2) access the 2027 PAF Report in the Static Reports Application within Provider Facing Analytics (PFA) to understand individual provider performance adjustment factors; (3) review the ValueBlue User Guide via the Provider Resource Center (requires Availity Essentials login) for complete details on Member Adjustment Factor (MAF), Performance Adjustment Factor (PAF), and capitation payment mechanics; (4) understand that capitation payments are retrospective and subject to quality and ED utilization efficiency scoring, with high performers eligible for up to 40% payment increase and lower performers subject to up to 20% decrease; and (5) familiarize staff with the new ValueBlue Connect incentive program.
If missed: Failure to implement capitation billing workflows by the effective date will result in payment processing errors and revenue leakage under the new reimbursement model.
Original notice
ValueBlue Base Rates Set for 2027
providers.highmark.com · Always check the source before changing claims.
Related changes
See all Highmark changes →ValueBlue Partial Capitation Reimbursement Begins Jan. 1, 2027HighEffective Jan 1, 2027 · Provider BulletinValueBlue Base Rates Set for 2027HighEffective Jan 1, 2027 · Provider BulletinValueBlue Base Rates Set for 2027HighEffective Jan 1, 2027 · Provider BulletinBrowse every Highmark change in the policy list