North Carolina Medicaid is updating parts of its fee schedule between 2026 and 2027.
The biggest changes include an 18% rate increase for personal care services, a longer DME rate floor, and new maternity billing codes starting in 2027.
This guide breaks down what’s confirmed, what’s proposed, and where to find official rates.
Quick Summary:
- Personal Care Services (PCS) rates rose 18% on August 1, 2026
- DME reimbursement floor now runs through June 30, 2029
- Maternity billing codes switch to AMA codes on January 1, 2027
- Expansion adult renewals move to every 6 months in 2027
- A full 2027 dollar-amount fee schedule has not been published yet
- Not sure if you qualify? Try our Medicaid Eligibility calculator in 2026
What Is the NC Medicaid Fee Schedule?
The fee schedule is a list of prices. It shows how much NC Medicaid pays providers for each service. Every code, like a doctor visit or medical equipment item, has its own rate.
North Carolina updates this list throughout the year. It is not one single yearly book. Instead, NCDHHS posts changes as they happen through official bulletins and rate updates.
Who Uses the Fee Schedule?
Doctors, hospitals, and equipment suppliers use it to bill Medicaid correctly. Case managers use it to plan care within budget limits. Patients can use it to understand what services cost the state.
Confirmed 2026 Rate Changes
Several rate changes are already locked in for 2026. These affect personal care, medical equipment, and specific behavioral health services. Each change has an official effective date and funding source.
Personal Care Services (PCS) Rate Increase
Starting August 1, 2026, all applicable PCS procedure codes got a permanent 18% rate increase. This covers services under NC Medicaid Direct and the Community Alternatives Program, including CAP/C, CAP/DA, and CAP/CD.
The 2026 Appropriations Act, also called Senate Bill 257, set aside $70.8 million in yearly state funding to pay for it.
Medicaid Rate Floor Extension
North Carolina extended its Medicaid rate floor through June 30, 2029. This rule protects providers of durable medical equipment (DME) and other applicable services.
It guarantees payment of at least 100% of the lesser of the supplier’s usual rate or the maximum Medicaid fee-for-service rate.
Alliance Health Managed Care Rates
Alliance Health, a managed care organization, set new rates effective January 1, 2026, for substance use treatment codes. H0011, for clinically managed residential withdrawal, pays $307.89. H0013, for medically monitored intensive treatment, pays $354.10. H0015, for intensive outpatient programs, pays $250.15.
Upcoming 2027 Fee Schedule Changes
North Carolina has several confirmed changes taking effect on January 1, 2027. These involve billing codes, renewal timelines, and coverage rules. Providers should start preparing now.
Maternity Billing Code Transition
On January 1, 2027, NC Medicaid Direct and NC Medicaid Managed Care will remove all current maternity codes. This includes global billing codes. They will be replaced with new American Medical Association maternity CPT codes.
Providers can start using transition billing guidance on September 1, 2026. For pregnancies where delivery or the postpartum visit happens after January 1, 2027, bill E/M codes 99202 through 99215. Add the TH modifier and the correct ICD-10-CM code with gestational weeks.
Services completed before January 1, 2027, can still use old codes. This includes antepartum-only codes 59425 and 59426. Health plans cannot force individual E/M billing for care given before the deadline.
Beneficiary Recertification and Coverage Changes
Starting January 1, 2027, expansion adults ages 19 to 64 will renew coverage every 6 months instead of once a year. This is a big change for anyone tracking their Medicaid Eligibility in 2026 status heading into 2027.
Retroactive coverage is also shrinking. Most adults aged 19 to 64 will get 1 month of retroactive coverage instead of 3. Children, pregnant women, and people who are aged or disabled will get 2 months instead of 3.
Expansion adults will also need to meet an 80-hour-per-month work or community service requirement. This rule starts January 1, 2027, alongside the renewal and retroactive coverage changes.
Federal Provider Enrollment Fee
The federal fee for Medicaid provider enrollment is $750 for calendar year 2026. This fee applies to providers enrolling or re-enrolling in the Medicaid program.
Legislative Proposals and Federal Alignment
Not every rate change is final yet. Some updates are still moving through the legislature or depend on federal decisions. These are worth watching closely.
Proposed Dental Rate Increase
House Bill 60 and Senate Bill 805 asked for $52 to $80 million to raise dental reimbursement rates. The goal is to move rates from about 35% of commercial charges up to 46–50%. This is a high legislative priority, but final approved rates are not yet confirmed in the official dental fee schedule.
Federal Physician Fee Schedule for 2027
CMS has proposed a new federal conversion factor of $32.84 for January 1, 2027. This is a $0.56 drop, or 1.68% lower than 2026, for non-APM participants. NC Medicaid often benchmarks its own rates against these federal trends, so this could influence future state rate decisions.
Managed Care and SFY 2027 Capitation Rates
North Carolina’s State Fiscal Year 2027 began on July 1, 2026. NC Medicaid Managed Care Standard Plans use a capitation rate model, meaning plans get a set amount per member each month.
Care Management Rate Assumptions
NCDHHS built $11.34 per member per month into SFY 2027 capitation rates for care management staffing. This number is a cost assumption, not a required payment to providers. Standard Plans and Advanced Medical Homes must still negotiate their own care management rates directly.
Where to Find the Official Fee Schedule
NC Medicaid does not release one full 2027 fee schedule with every dollar amount. Instead, it updates codes and rates continuously online. Always check the official source before billing or budgeting.
- Visit the NC Medicaid Fee Schedules & Covered Codes portal.
- Filter by code status, category, or effective date.
- Download the current fee schedule as an Excel file.
- Check the Fee Schedules Archive for past rates and comparisons.
- Confirm any 2027 dollar amounts directly through this portal, since they were not fully published as of August 2026.
What This Means for Patients and Providers
If you’re a patient, most of these changes affect providers, not what you pay. But renewal timelines and work requirements starting in 2027 could affect your coverage directly. It helps to review your state’s Medicaid Income Limits by State in 2026 before your next renewal date.
If you’re a provider, plan ahead for the maternity code switch and the shorter enrollment fee cycle. Watch for final dental rate approval and the full 2027 fee schedule release. Rates can change quickly once new state or federal budgets pass.
Frequently Asked Questions
Q: Has NC Medicaid released the full 2027 fee schedule yet?
A: No. As of August 2026, North Carolina has not published a complete 2027 fee schedule with dollar amounts for every code. Some changes, like the maternity code transition, are confirmed. Full payment rates should appear on the official NC Medicaid portal once finalized.
Q: What is the NC Medicaid PCS rate increase for 2026?
A: Personal Care Services got a permanent 18% rate increase starting August 1, 2026. It applies to NC Medicaid Direct and CAP programs, including CAP/C, CAP/DA, and CAP/CD. The state funded it with $70.8 million from the 2026 Appropriations Act.
Q: When do NC Medicaid maternity billing codes change?
A: Old maternity and global billing codes end on January 1, 2027. They’re replaced by new AMA maternity CPT codes. Providers can start using transition billing guidance as early as September 1, 2026.
Q: How often will expansion adults renew Medicaid in 2027?
A: Starting January 1, 2027, expansion adults ages 19 to 64 will renew coverage every 6 months. This replaces the current yearly renewal cycle. Retroactive coverage periods are also shrinking at the same time.
Q: Will NC Medicaid dental rates increase in 2026 or 2027?
A: A proposed increase from about 35% to 46–50% of commercial dental rates is pending. House Bill 60 and Senate Bill 805 requested $52–80 million in funding. Final approved rates have not been confirmed yet in the official dental fee schedule.
Q: How much is the DME reimbursement floor in North Carolina?
A: DME providers are guaranteed at least 100% of the lesser of their usual rate or the maximum Medicaid fee-for-service rate. This floor was extended through June 30, 2029. It protects durable medical equipment suppliers from being underpaid.
Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against official NCDHHS and Medicaid.gov guidelines | Last Updated: August 2026
Sources
- NCDHHS, PCS Rate Increase Bulletin
- NCDHHS, Transition to American Medical Association Maternity CPT 2027 Code Changes
- NCDHHS, NC Medicaid Managed Care Capitation Rates: Updated Care Management Assumptions for SFY 2027
- North Carolina General Assembly, Session Law 2026-1 (HB 696)
- CMS, CY 2027 Proposed Physician Fee Schedule Fact Sheet
- NC Medicaid Fee Schedules & Covered Codes Portal
Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility and rate information, contact your state Medicaid office or visit Medicaid.gov.
