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Health Plan Activities/Policies

Fee Schedules in Capitation Provider Contracts

The WSMA believes health plans should include an attachment in capitation-based physician or non-physician provider contracts entitled, "Compensation Schedule for Capitation Contracts" that includes the following: A) the amount to be paid per enrollee, per month; B) the manner in which the insurer will determine who is an enrollee at the beginning of any particular month; C) the precise terms of the stop loss arrangement; D) the boundaries of the service area; E) the fee-for-service schedule to which this compensation arrangement will revert in the event the number of enrollees assigned to physicians or non-physician providers falls below a designated actuarial minimum and what that minimum is; F) the number of covered lives and the fee-for-service schedule upon which physicians or non-physician providers will be paid for those covered services provided to enrollees not specifically made a part of the capitation arrangement. Physicians shall have the right to audit the books and records of the company or a payer solely for purposes of determining the accuracy of any capitation payment; and, G) the complete list of services expected in return for compensation. (Res C-8, A-99) (Reaffirmed A-17)


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Abbreviations for House of Delegates report origination:

EC – Executive Committee; BT – Board of Trustees; CPA – Council on Professional Affairs; JC – Judicial Council; CHS – Community and Health Services

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