PGP and capitation: what they are and how to manage them.

Colombian regulation defines it as a payment for a defined group of people, agreed before services are delivered, with frequencies of use adjusted to the group's health risk and to changes in the size of the population. Unlike capitation, it is not limited to low-complexity care.

In practice it is negotiated over a population and a package of services: for example, the people with hypertension and diabetes in one municipality, with their check-ups, tests and medicines for the year. The provider (IPS) receives the agreed amount in the instalments the contract sets and answers for that care actually happening.

Modalidad de pago por grupo de personas determinadas, mediante la cual se pacta por anticipado el pago de una suma fija global para la prestación de servicios o el suministro de tecnologías en salud a esa población durante un periodo de tiempo definido…

The health insurer (EPS) assigns the provider an identified population and pays the same amount for each person over the agreed period, whether or not that person comes in. That sum covers what the population might need from a set of low-complexity services: for example, general practice, nursing, health promotion and prevention, and basic lab tests, depending on what is contracted.

Capitation is not the UPC. The UPC is what the system pays each EPS per member: in 2026, COP 1,658,912 a year in the contributory regime and COP 1,541,706 in the subsidized one. The provider's capitation is negotiated separately and only covers the contracted services, so it is a fraction of that amount.

Modalidad de pago prospectiva que aplica para la prestación o provisión de la demanda potencial de un conjunto de servicios y tecnologías en salud, que se prestan o proveen en los servicios de baja complejidad…

One agreement can combine modalities: for example, capitation for primary care, PGP for a chronic-care program and fee-for-service for everything else. The regulation recognizes a fourth: payment per case, package or basket, a fixed sum for each case treated of a defined condition.

It is required in every PGP or capitation contract and forms part of the agreement. The regulation asks it for at least four elements:

Population

The total population and the population eligible for each service, with its profile: risk factors, coexisting conditions and their severity.

Frequencies

How often each service will be used over the contract term. If the contract covers an integrated care pathway (RIAS), the frequencies come from the regulation that governs it.

Costs

The agreed cost of each service.

Monitoring

How often it will be monitored and evaluated, which can never be equal to or longer than the contract term.

Services are written with the codes of the Ministry's reference tables, such as CUPS for procedures. The arithmetic is simple: people × frequency × cost, service by service. The total is the contract's value.

Each indicator has its technical sheet, a baseline, targets, thresholds and compliance ranges. There are quality indicators (timeliness, access, patient safety, experience), management indicators (use of services, billing, objections, receivables) and health outcome indicators.

Monitoring is joint and looks at the technical, operational and financial sides. It checks the minimum frequencies per person set by the technical standards and puts the integrated care pathways and chronic and high-cost conditions first. Whatever is outside the provider's control cannot be objected to: the nota técnica and the indicators are adjusted instead.

If the contract sets incentives or objection percentages for non-compliance, they are calculated from the per-capita distribution of the value and the weight of each service in the nota técnica.

A nota técnica is an estimate, and over a year the population, the network, the illnesses and the costs all change. Resolución 2335 de 2023 requires adjustments to be planned for at least seven situations:

• The population grows or shrinks because members are reassigned.
• A change in the provider network shifts the population or the frequencies.
• The disease profile does not match the population profile the EPS delivered.
• The territory prioritizes services because of public health or primary care indicators.
• The incidence of chronic or high-cost conditions rises.
• Monitoring shows changes in frequencies of use or in costs.
• A force majeure event or unforeseeable circumstance occurs.

The regulation separates two risks that must be in the nota técnica where they apply: primary risk, the unavoidable variation in how many people fall ill and how seriously; and technical risk, the variation in resource use or complications from unforeseeable factors in care. Asking for an adjustment takes data: who joined the population, what changed in its illnesses, which frequencies moved.

1. Frequencies that are not met

   If the provider fails, without justification, to meet the minimum frequencies for health promotion and prevention, the maternal and perinatal pathway or chronic-care follow-up, the EPS can deduct their value at the nota técnica price and deliver them through another provider in its network.

   Decreto 441 de 2022, art. 2.5.3.4.5.5 (opens in a new tab)

2. A member list that is out of date

   Phone numbers that no longer answer cost missed check-ups. And when ADRES, the fund that administers the system's money, orders a refund for deceased members, the provider returns, in proportion, what it received for them since their death.

   Decreto 441 de 2022, art. 2.5.3.4.5.4; Resolución 2335 de 2023, art. 13 (opens in a new tab)

3. The complication that ends up in the emergency room

   Care the provider was meant to give that ended up with another provider, through a referral or an emergency, is paid to that provider and, with prior notice, can be deducted from the contract at the nota técnica value.

   Decreto 441 de 2022, art. 2.5.3.4.5.4 (opens in a new tab)

4. An advance without an invoice

   From November 2026, a provider that receives a capitation or PGP advance by direct payment must invoice on time, with the RIPS service records. If it does not, it gets no new direct-payment scheduling until it corrects it.

   Resolución 1809 de 2026, arts. 6 and 11 (opens in a new tab)

5. A close without evidence

   At the close the parties sign a record with what was delivered, the indicators and the nota técnica. Whatever was not recorded during the year is hard to defend that day.

   Decreto 441 de 2022, art. 2.5.3.4.6.2 (opens in a new tab)

The closing record (acta de liquidación) states how the contract was monitored, how far each party met its obligations, and the final indicators and nota técnica. In it the parties can declare each other released (paz y salvo).

Automatic renewal can be agreed, but the amounts are updated for every term and, before the extension starts, the nota técnica is adjusted with what monitoring showed.

The 2026 UPC

It rose 9.03% in the contributory regime and 16.49% in the subsidized one.

Capitation, by the full month

The billing period runs from the first to the last day of the month, and the invoice cannot be issued before it starts.

The monthly value, reported ahead

The EPS reports the monthly value of the capitation contract by the 15th business day of the previous month, so the direct payment can be scheduled.

Advances need invoices

With an advance, the electronic invoice with RIPS is mandatory: for capitation, within five business days of the payment; for PGP, within the first five business days of the following month.

The unique contract code

Direct payment requires the unique contract code (CUCON) from SIIFA, on the dates set by Resolución 1962 de 2025; until then, the contract number.