CommercialReimbursementMedium impact
00.10.01am, 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, 2026
We identified it
Jun 19, 2026
Summary
This policy update clarifies which services HMO and HMO-POS primary care providers can bill above their capitation rates. The policy becomes effective January 1, 2026, and affects how certain services are reimbursed for capitated providers.
Action Required
Before January 1, 2026: Primary care providers with HMO or HMO-POS capitation contracts must review the updated policy to understand which services can be billed above capitation rates. Billing team should update procedures to ensure proper identification and billing of non-capitated services for HMO patients.