Medicare AdvantageCoverageHigh 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
Policy MA00.033r defines which services provided by HMO and HMO-POS primary care providers are paid above capitation (i.e., separately billable rather than bundled into the capitated rate). This recent policy clarifies billing expectations for Medicare Advantage primary care services and establishes which procedures/services bypass the capitation model and are reimbursed as fee-for-service.
Action Required
By December 31, 2025: Billing team must review the full policy text at the provided URL to identify which specific CPT, HCPCS, and ICD-10 codes are listed as payable above capitation for your Medicare Advantage HMO/HMO-POS plans. Update billing system edits and claim submission rules to ensure services covered above capitation are billed separately (not bundled into capitation payments), while capitated services are not submitted for separate reimbursement. Coordinate with providers and front-desk staff to ensure encounter documentation and charge entry reflect the correct billing method. Train billing staff on the distinction between capitated vs. fee-for-service reimbursement for primary care. Failure to bill correctly will result in either denied claims (if services are billed that should be capitated) or missed revenue (if billable services are not submitted). Contact the plan at the policy URL or your Medicare Advantage plan representative if the specific codes are not clearly listed in the policy document.