Capitation Payments

Payments agreed upon in a capitation contract by a health insurance company and a medical provider. It is a fixed, pre-arranged monthly payment received by a physician, clinic or hospital per patient enrolled in a health plan with a capitated contract. Monthly payment is calculated one year in advance and remains fixed for that year, regardless of how often the patient needs services.

Capitation payments are defined, periodic, per-patient payments (usually monthly) for each individual enrolled in a capitated insurance plan. For example, a provider could be paid per-month, per-patient, despite how many times the patient comes in for treatment or how many services needed. The payment varies, depending on the capitation agreement, but generally they are based on characteristics such as the age of the individual enrolled in the plan. Modifying the plan according to specific characteristics for groups of patients is one way to compensate providers for the medical care expected for similar ailments within a group.