Medicare AdvantageReimbursementMedium impact
MA00.033r, 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 payments for Medicare Advantage plans. The policy is effective January 1, 2026, defining specific services that qualify for additional reimbursement beyond the fixed monthly capitation rate.
Action Required
Before January 1, 2026: Primary care billing teams working with Medicare Advantage HMO and HMO-POS plans must review the updated policy to identify which services can be billed above capitation. Update billing workflows to ensure proper coding and billing for services that qualify for additional payment beyond the capitation rate. Contact the payer for specific service lists if not detailed in the full policy document.