CommercialReimbursementMedium impact
00.10.01al, 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 policy update clarifies which services HMO and HMO-POS primary care providers can bill above their capitation rates. The policy became effective January 1, 2025 but was posted in February, indicating recent guidance on capitated billing arrangements.
Action Required
Immediately: Review current HMO and HMO-POS contracts to identify which services can be billed above capitation rates. Primary care billing team should verify that services being billed to HMO plans are not already covered under capitation agreements. Update billing workflows to distinguish between capitated and fee-for-service billing for HMO patients.