North Carolina Medicaid Reimbursement Rates 2026–2027: Guide

North Carolina Medicaid reimbursement rates are the amounts the state uses to pay for healthcare services covered under Medicaid. There’s no rate that fits every service.

Two providers can bill the same service and get paid differently. The code, your provider type, the fee schedule, modifiers, place of service, units, date of service and coverage rules all move the number. So does the payer, whether that’s NC Medicaid Direct or a managed-care plan. Get one of those details wrong. Your number is off.

For providers, billers or practice managers the best place to start is the NC Medicaid Fee Schedule and Covered Codes Portal. It has past fee schedules, rate lookups, covered procedure codes and covered revenue codes. If you’re comparing rates across states check out our guide to Medicaid reimbursement rates by state to see how North Carolina stacks up.

What Are NC Medicaid Reimbursement Rates?

North Carolina’s Medicaid program goes beyond listing covered services for eligible residents. The state uses a payment schedule that determines how medical providers are compensated for each service and how payments are calculated. This approach allows for a wider range of benefits. Members can access care such, as doctor visits, dental services, mental health support and ABA therapy. They can also get medical equipment, home health care, personal care and HCBS services. Inpatient hospital care, prescription medications, lab tests, therapies and transportation are all included.

Just because a rate is listed in a fee schedule doesn’t mean that’s what you’ll actually get paid. Coverage guide, prior authorization, medical necessity, billing policies, modifiers, units, provider type, place of facilities and payer-specific requirements all affect how a claim is processed.

Beneficiaries should know this: reimbursement rates are for providers or health plans not for what you pay out of pocket. If you’re asking about your eligibility start with North Carolina Medicaid income limits.

Where to Find the NC Medicaid Fee Schedule

The official source is the North Carolina Department of Health and Human Services (NCDHHS) through its NC Medicaid Fee Schedule and Covered Codes Portal.

The portal is split into tools: downloading fee schedules looking up rates checking covered procedure codes and reviewing covered revenue codes. Both current and older schedules are available in one place.

NCDHHS through its Division of Health Benefits and the NC Medicaid program also shares provider information, clinical coverage policies and Medicaid Bulletins.

How to Look Up an NC Medicaid Reimbursement Rate

To check a CPT, HCPCS, CDT or other procedure rate follow these seven steps:

1. Identify the code. Start with the CPT, HCPCS, CDT, revenue code or other billing code.
2. Choose the fee schedule. Different provider types and services have schedules.
3. Check the date. A rate from year might not be current.
4. Review. Settings. A modifier or place of service can change the payment.
5. Check. Billing limits. Some services are priced per unit per visit or per day.
6. Confirm coverage and authorization. A listed rate doesn’t mean every claim is approved.
7. Identify the payer. Find out if payment comes through NC Medicaid Direct or a managed-care plan.

For billing or coverage questions NC Medicaid’s provider resources point you to NCTracks and health-plan resources. The provider page includes links to the fee-schedule portal, clinical coverage policies, Medicaid Bulletins, provider enrollment and NCTracks support.

Does NC Medicaid Have One Rate?

No.

Think of it like this:

Code + provider type + fee schedule + effective date + modifier + place of service + units + coverage + payer = payment context.

Ask “How much does NC Medicaid pay for CPT 99213?”. You won’t get a clear answer unless you include all the rest. The same goes for HCPCS, CDT, DME and other codes.

A published rate is the starting point. Always check the billing picture before using it for a claim, contract, budget or reimbursement estimate.

NC Medicaid Direct vs. Managed Care Rates

North Carolina runs its program in two parts: NC Medicaid Direct and NC Medicaid Managed Care. The difference matters more than many providers think.

Managed care covers Standard Plans, Behavioral Health, Intellectual/Developmental Disabilities Tailored Plans, the EBCI Tribal Option and the statewide Children and Families Specialty Plan. Providers contract with health plans (PHPs). Current Standard Plans include AmeriHealth Caritas North Carolina, Healthy Blue of North Carolina UnitedHealthcare of North Carolina and Carolina Complete Health in areas.

Don’t assume a managed-care claim is the same as a fee-for-service claim under NC Medicaid Direct. Often it’s not.

What Is a Medicaid Rate Floor?

A rate floor is a payment requirement for certain services. For services North Carolina’s managed-care contracts require health plans to pay providers no less than 100% of the applicable NC Medicaid rate floor as long as the rules and exceptions are followed. Some contracts also allow for agreed-upon payment arrangements.

Keep this in mind:

Published NC Medicaid rate → rate floor → health-plan contract → actual claim payment

That’s four steps and the number at each step might be different. Read both the NC Medicaid requirements and your health-plan contract together.

Does a Fee Schedule Rate Guarantee Payment?

No. A fee schedule gives you the payment amount or method.. A claim can still be denied, reduced or adjusted.

Common reasons:

• Coverage status
• Medical necessity
• Prior authorization
• Modifier requirements
• Place of service and units
• Provider enrollment and taxonomy
• Billing limits
• Bundling and claim edits
• Effective dates
• Managed-care contracts
• Claim adjudication rules

Even if a code is in the fee schedule not every beneficiary qualifies for that service. For coverage questions check the NC Medicaid Clinical Coverage Policy and your payer’s own rules.

Major NC Medicaid Rate Changes for 2026

North Carolina made a shift when it reversed the Medicaid rate cuts that started Oct. 1 2025.

NCDHHS announced the reversal effective Dec. 10 2025. The cuts had been between 3% and 10% and affected doctors, hospitals and other providers. NCDHHS worked to restore NC Medicaid Direct fee schedules to the rates before the cuts.

Managed-care claims affected by those cuts were handled differently: health plans had time to update rates and reprocess claims.

That’s why checking the date is so important when comparing 2025 and 2026 rates.

2026 PCS Rate Increase

Personal Care Services got a boost. Starting Aug. 1 2026 NC Medicaid increased PCS procedure-code rates by 18%. This applies to NC Medicaid Direct and specific Community Alternatives Program services including CAP/C, CAP/DA and CAP/CD. The official bulletin shows procedure code 99509 rising from $5.96 to $7.03 for modifiers and settings. Other CAP codes were updated too.

This change also affects PCS services delivered through Standard Plans and Tailored Plans. In those cases health plans handle the implementation. Claim reprocessing for affected dates of service.

2027 NC Medicaid Reimbursement Changes

SFY2027 brings targeted changes, not a state- percentage increase.

Innovations Waiver Rate Changes

NC Medicaid put in place ongoing rate increases for Innovations Waiver Direct Care Workers effective Oct. 1 2026 And retroactive to July 1 2026. The state is funding this with $21.3 million for SFY2027.

Here’s the catch: the funding adds a fixed amount per 15-minute unit so the percentage increase varies depending on the existing rate. Providers must also complete attestation and reporting. Use the procedure-code tables and program guidance not a single percentage for all Innovations services.

Maternity Coding Changes

Watch NC Medicaid Bulletins for 2027 CPT changes, including updates to maternity coding. CPT codes, billing rules and fee schedules change by date. Always confirm the code set and guidance before submitting 2027 claims.

How Different Provider Types Use NC Medicaid Rates

Reimbursement details matter for more than doctors. Each provider type uses the schedule differently.

Physicians and Medical Practices

You’ll use the NC Medicaid physician fee schedule: CPT rates, E/M reimbursement, modifiers and place-of-service rules.

Dentists

Use the NC Medicaid dental fee schedule and CDT codes. Medical CPT rates don’t apply to services.

Behavioral Health and ABA Providers

Expect service definitions, authorization rules, provider qualifications and managed-care requirements.

DME Suppliers

DME and DMEPOS reimbursement uses HCPCS codes, modifiers, rental or purchase rules, units, medical necessity and authorization. Check this separately. It doesn’t follow physician rules.

Home Health, PCS and HCBS Providers

Home health, personal care services, CAP programs and other HCBS services have their rates, units and authorization rules.

Hospitals and Facilities

Hospital reimbursement uses methods, than professional fee schedules. FQHCs, RHCs, nursing facilities and hospitals should use the schedule or method designed for their provider type.

Pharmacy, lab, anesthesia, ambulance and NEMT services each have their reimbursement rules.

How Often Does NC Medicaid Update Rates?

There is no fixed update date for NC Medicaid rates. Changes happen through official channels. These include the fee schedules, Medicaid Bulletins, provider guidance documents, clinical coverage policies and program-specific updates.

Providers should check these sources regularly to stay informed:

• The Fee Schedule and Covered Codes Portal
• NC Medicaid Bulletins
• Clinical Coverage Policies
• NCTracks
• Health-plan provider manuals and contract guidance
• Program-specific announcements

The NC Medicaid provider page points to the Medicaid Bulletin as the best source for the latest information. It’s an idea to bookmark that page.

What About NC Medicaid Rates in Charlotte, Raleigh or Other Cities?

Reimbursement rules for NC Medicaid apply across the state. That means Charlotte, Raleigh, Greensboro, Durham, Winston-Salem, Fayetteville, Asheville and Wilmington do not each have their separate fee schedules.

When people search for things like “NC Medicaid rates Charlotte ” they are usually looking for provider details network-specific rules or service availability.. For actual rate lookups the starting point should always be the statewide fee schedule and covered-code system.

FAQs About North Carolina Medicaid Reimbursement Rates

What are the current North Carolina Medicaid reimbursement rates?

There is no rate across the board. Reimbursement depends on the procedure code, provider type, fee schedule, effective date, modifiers, place of service number of units, coverage rules and whether the payment comes through NC Medicaid Direct or managed care.

Where can I find the NC Medicaid fee schedule?

The official source is the NC Medicaid Fee Schedule and Covered Codes Portal. This tool includes past versions of fee schedules a lookup function and resources for covered codes.

How do I look up an NC Medicaid CPT or HCPCS rate?

First find the code. Then choose the fee schedule. Check the date review modifiers, place of service number of units and coverage requirements. Finally decide whether the claim is for NC Medicaid Direct or managed care.

Are NC Medicaid Direct and managed-care rates the same?

Not always. NC Medicaid Direct fee schedules may set rates or rate floors. Managed-care providers must follow their health plan contracts and other reimbursement rules.

What is the NC Medicaid rate floor?

It is a reimbursement level for certain services under North Carolina’s managed-care rules. Health plans must pay at this floor amount unless there are exceptions or other agreed arrangements.

Does a fee-schedule rate guarantee payment?

No. Coverage, medical necessity, prior authorization, modifiers, units, provider eligibility, claim edits and billing limits can all affect the payment amount.

How often does NC Medicaid update reimbursement rates?

Updates happen through fee schedules Medicaid Bulletins, program- changes and other official guidance. Always check the date. Do not rely on PDFs or third-party rate tables.

What changed in NC Medicaid reimbursement in 2026?

In 2026 North Carolina reversed the reimbursement cuts that began in October 2025. The applicable PCS rates increased by 18% August 1 2026.

Does a code appearing on the fee schedule mean Medicaid covers it?

No. A published rate and coverage are two things. Always check the coverage policy, authorization rules and payer-specific policies.

How can providers verify a disputed Medicaid payment?

Start with the fee schedule and its effective date. Then go over the claim, modifiers, units, place of service, coverage rules and remittance advice. For managed-care claims also review the health-plan contract and provider guidance.

Conclusion

Don’t try to find one number. Medicaid reimbursement in North Carolina is a system. The payment you receive depends on how the code, fee schedule, date, billing details, coverage rules and payer all come together.

Begin with the fee-schedule portal. Then confirm with coverage policies, Medicaid Bulletins, NCTracks and your managed-care provider guidance. The biggest mistake in this work is treating a published rate as a guaranteed payment. Always check everything before you bill. Plan your budget.

Official Resources

• Check Current Rates — NC Medicaid Fee Schedule Portal
• Get Latest Updates — NC Medicaid Bulletin
• Verify Coverage Rules — NC Medicaid Clinical Coverage Policies
• Find Billing Support — NCTracks

Disclaimer: Rates and billing policies change, and this article is only a help guide. It can’t replace current NCDHHS guidance, the official fee guidelines, your provider contract, or advice from a billing professional.