Capitated Model
Guidance for the Capitated Model, where a state, and a health plan enter into a three-way contract to provide comprehensive, coordinated care.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: April 02, 2020
| 09/10/2024: CMS released the Demonstration End Enrollment Decisions memo for capitated model states. More information is available below. |
Under the capitated model, the Centers for Medicare & Medicaid Services (CMS), a state, and a health plan enter into a three-way contract to provide comprehensive, coordinated care.
In the capitated model, CMS and the state will pay each health plan a prospective capitation payment. More information on rate setting:
- Joint Rate-Setting Process for the Capitated Financial Alignment Model (03/19/2019) (PDF)
- Proposed Changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017 Memo (10/28/2015) (PDF)
- Medicare A/B Payment to Medicare-Medicaid Plans Participating in the Financial Alignment Initiative for Contract Year 2016 Memo (11/12/2015) (PDF)
Demonstration Transitions
NEW! Demonstration End Enrollment Decisions (09102024) (PDF): This memo for capitated model states discusses end-of-demonstration enrollment and operational considerations, and provides deadlines by which states should make operational decisions.
Medicare-Medicaid Plan Performance Data
Under the capitated model, CMS is collecting a variety of measures that examine plan performance and the quality of care provided to enrollees. The Medicare-Medicaid Plan (MMP) performance data published here represent currently available data on MMP performance on certain Medicare Parts C and D quality measures as well as select CMS core that MMPs are required to report.
- 2024 MMP Performance Data Technical Notes (PDF)
- 2024 MMP Performance Data File (XLSX) (XLS)
- MMP Performance Data Technical Notes Archive (ZIP)
- MMP Performance Data File Archive (ZIP)
For additional information on the longer term vision for a quality ratings strategy and the way that information on MMP performance will be publicly reported during the interim period see:
- Medicare-Medicaid Plan Quality Ratings and Performance Data Strategy Update (06/15/2016) (PDF)
- Medicare-Medicaid Plan Quality Ratings Strategy (11/06/15) (PDF)
State Demonstrations
To participate in the Financial Alignment Initiative, each state had to submit a proposal outlining its proposed approach. States interested in the new financial alignment opportunities were required to submit a letter of intent by October 1, 2011. When a proposal meets the standards and conditions for the Financial Alignment Initiative, CMS and a state will develop a memorandum of understanding (MOU) to establish the parameters of the demonstration.
Prior to enrolling or marketing under the capitated model, each health plan must pass a readiness review.
Visit these pages for more information about CMS approved demonstrations in specific states:
For more information, please email MMCOcapsmodel@cms.hhs.gov.
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