ValueBlue Base Rates Set for 2027

Starting Jan. 1, 2027, Highmark is launching the ValueBlue partial capitation program announced in the evolving primary care reimbursement update.   

The ValueBlue base capitation rate uses past medical claims to estimate what kind of care the member may need. The payment is then adjusted based on factors like the member's:

• Age
• Gender
• Current health conditions
• Long-term (chronic) illnesses
• Recent serious health issues

This helps make sure providers are paid an accurate amount each month for their Highmark patients, based on each patient's health needs.

What You Need to Do

• Review the 2027 base capitation rate and performance adjustment factor (PAF) information below.
• View your 2027 PAF Report in the Static Reports Application in Provider Facing Analytics (PFA).
• Review the ValueBlue Connect incentive program.

2027 Base Rate

The 2027 PMPM base capitation rates by line of business (LOB) and geographical region are shown below.

Note: Base rates vary among the regions listed above because of differences in percentage of population with chronic conditions, healthcare utilization history, social determinants of health, and other factors.

Member Adjustment Factor (MAF): Adjusting for Patient Health and Risk Scores

The MAF reflects the anticipated healthcare needs of your attributed member population.

• Commercial and Medicare members are assigned an MAF that can be found on the monthly attributed member roster. This roster will be available in Value Insight Center (VIC) starting in 2027.
• Risk scores are a key driver of the Commercial and Medicare Advantage MAFs. You can review risk scores in VIC.

Performance Adjustment Factor (PAF): Quality and Efficiency Scoring

In 2027, ValueBlue will have two components that Highmark uses to measure the PAF.

• Quality: Uses the metrics shown in the ValueBlue User Guide.

• Efficiency: Uses the Emergency Department (ED) Utilization metric.

Highmark uses the PAF to adjust payments to primary care physicians (PCPs) based on their performance. High-performing PCPs can receive up to a 40% increase in PAF, while lower-performing PCPs may experience a decrease of up to 20% in PAF. You can view your 2027 PAF Report in the Static Reports application on the PFA platform. 

Note: ValueBlue capitation payments are retrospective. For complete details on base rates, MAF, PAF, and other program components, refer to the ValueBlue User Guide.

• To access the user guide, go to the ValueBlue and ValueBlue Connect page of the Provider Resource Center (PRC) and click on the "ValueBlue FAQs" button. (You must be logged into the Availity Essentials portal to view the user guide on the ValueBlue Frequently Asked Questions page.)

Explore ValueBlue Connect

We’re also introducing a new complementary program, ValueBlue Connect, offering additional opportunities to earn incentive payments while supporting your efforts to deliver high-quality, preventive care.

Review the benefits of ValueBlue Connect and additional program information on the PRC's ValueBlue and ValueBlue Connect page.