Medicaid Bulletin

Recent court rulings now require the North Carolina Department of Health and Human Services to reverse provider rate reductions and restore rates to their Sept. 30, 2025, levels.

NC Medicaid Managed Care plans may apply utilization edits and/or prior authorization criteria per the Food and Drug Administration label on drugs when the State has not established criteria and has not prohibited use of criteria.

NC Medicaid is providing updated information to providers about the federal prohibitions on certain providers.

The federal fee for Medicaid enrollment will increase to $750 for calendar year 2026.

NC Medicaid has revised or removed several Tailored Care Management trainings, and identified a refresher and elective curriculum.

Request to Move forms for members in the Children and Families Specialty Plan to move to a Behavioral Health I/DD Tailored Plan do not need to complete a Service-associated Request.

Providers should continue to follow the certification and waiver requirements described below.

This guidance is based on products approved by the FDA and recommended by the CDC Advisory Committee on Immunization Practices.

This guidance is based on the NC Immunization Program/Vaccines for Children guidelines.

Wegovy and Zepbound for indications other than weight loss to be covered based on the indications and usage criteria published in the FDA label, pending updated clinical criteria.