This bulletin communicates the NC Medicaid provider reimbursement rate reductions being implemented by the Division of Health Benefits (DHB) to maintain the NC Medicaid program within the current funding allocated to the Medicaid program by the North Carolina General Assembly (NCGA). Please note that the rate reductions are subject to change if the NCGA provides NC Medicaid with additional appropriations for service programs.
Services to which rate reductions will apply and the corresponding rate reduction percentage that will be applied to the respective fee schedule rates effective Oct. 1, 2025, are listed below. Because reductions apply to procedure codes, impacted procedure codes may appear on more than one fee schedule. Fee schedules impacted by rate reductions will be released on Oct. 1, 2025, and are listed below:
| Reductions by State Medicaid Fee Schedule - Program | Applicable Reduction Percentage* |
|---|---|
Ambulance Services | 3% |
Ambulatory Infusion Therapy Centers | Overlapping physician codes only - 8% |
Ambulatory Surgical Centers | 10% |
Anesthesiology Base Units | Anesthesiology codes - 10%, Overlapping physician codes - 8% |
Auditory Implants | 3% |
Children Developmental Services Agency (CDSA) | CDSA codes - 3%, Overlapping physician codes - 8% |
Chiropractic Services | Chiropractic codes - 3%, Overlapping physician codes - 8% |
Clinical Pharmacist Practitioner (CPP) | CPP codes - 3% Overlapping physician codes - 8% |
Community Alternatives Program | Personal Care-like Services - 8%, Non-Personal Care Services (PCS) codes - 3% |
Dental | 3% Ambulatory Service Center codes - 10% |
Dialysis | 3% |
Dietary and Nutritional Services | Dietary & Nutritional codes - 3%, Overlapping physician codes - 8% |
Durable Medical Equipment | 3% |
Enhanced Mental Health Services | 3% |
Federally Qualified Health Centers | FQHC - 3%, Overlapping physician codes - 8% |
Freestanding Birth Center | 10% |
Hearing Aid Program | 3% |
HIV Case Management | 3% |
Home Health Services | 3% |
Home Infusion Therapy | 3% |
Hospice | Room & Board (0658/0659) only - 10% |
Hospital Outpatient Laboratory | 10% |
Hospitals | 10% |
Indian Tribal (I/T/U) Home Health | 3% |
Indian Tribal (I/T/U) Pharmacy | 0% |
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) | 8% |
Laboratory (Independent Diagnostic Testing Facilities) | Lab & X-ray codes - 3%, Overlapping physician codes - 8% |
Local Health Departments (LHD) | LHD codes - 3%, Overlapping physician codes - 8% |
NC Medicaid State Institutions | 8% |
Nurse Midwives | 8% |
Nurse Practitioner and Certified Registered Nurse Anesthetist (CRNA) | 8% |
Nursing Facility Rates | 10% |
Optical Program | 3% |
Optometry Services | Optometry codes - 3%, Overlapping physician codes - 8% |
Orthotics and Prosthetics | 3% |
Other Behavioral Health Services | Research-Based Intensive Behavioral Health Treatment (RBI-BHT) (97151-97157) - 10% Other - 8% |
Outpatient Specialized Therapies | 3% |
Personal Care Services | 8% |
Pharmacy | 0% |
Physician Administered Drug Program | 0% |
Physician Assistant | 8% |
Physician Services | ER (99281-99285) - 10% Physician codes - 8% |
Podiatry Services | 3% |
Private Duty Nursing | 3% |
Public Ambulance Provider Managed Care | 3% |
Radiological/Imaging Services | 3% |
Rural Health Clinic | RHC codes - 3% Overlapping physician codes - 8% |
Targeted Case Management | 3% |
Vent Facility Rates | 10% |
* Designation of “overlapping physician codes” indicates that a procedure code on that fee schedule will be reduced at the percentage of reduction applicable to the physician services fee schedule. For example, on the Children Development Services Agency (CDSA) fee schedule, overlapping physician codes means there are codes that appear on both the CDSA fee schedule and physician services fee schedule. The physician services codes appearing on the CDSA fee schedule are subject to the 8% reduction. All non-physician services fee schedule codes appearing on the CDSA fee schedule will be reduced by 3%.
Rate Reductions Applicable to Non-Published State Fee Schedule Service
- NC Medicaid is amending the State Plan effective October 1, 2025, to reduce Medical Home Fees by ninety-seven percent (97%) of the State Plan Medical Home Fee rates in effect on September 30, 2025. Managed Care Plans operating a Standard Benefit Plan are expected to follow the State Plan Amendment in paying Medical Home Fees.
- NC Medicaid intends to amend its Managed Care contracts to add State Directed Payment requirements for the following services and at the following amounts:
- Innovations Waiver, 1915(i) and Traumatic Brain Injury (TBI) Waiver services furnished on or after Oct. 1, 2025, to be reimbursed at 97% of the Innovations Waiver, 1915(i) and TBI Waiver service reimbursement rates paid on Sept. 30, 2025.
- Psychiatric Residential Treatment Facilities (PRTFs) as to dates of service on or after Oct. 1, 2025, to be reimbursed at 90% of the reimbursement rate paid to PRTFs on Sept. 30, 2025.
- Non-Emergency Medical Transportation (NEMT) services furnished on or after Oct. 1, 2025, to be reimbursed at 97% of the reimbursement rates paid for NEMT services in effect on Sept. 30, 2025.
- Local Health Department payments for Care Management for At-Risk Children (CMARC) and Care Management for High-Risk Pregnant Women (CMHRP) services effective Oct. 1, 2025, to be paid at 97% of the amount paid to LHDs in effect on Sept. 30, 2025.
- For Behavioral Health Intellectual/ Developmental Disabilities Tailored Plans, Advanced Medical Home Fee(s) paid to Advanced Medical Homes that accrue on or after Oct. 1, 2025, to be reimbursed at no less than $4.85, for each month in which a Member is assigned to the Advanced Medical Home as the Member’s primary care provider, which may be prorated for partial months.
- Managed care plans must ensure in lieu of services continue to be cost effective relative to the applicable state plan service, as such, the plans may make changes to in lieu of service offerings or reimbursement rates.