North Carolina Medicaid Fee Schedule 2026: What Changed and Why

As of July 2026, the North Carolina Medicaid fee schedule is defined by a mandatory “Rate Restoration.”

Provider reimbursement rates were legally restored to the levels in effect on September 30, 2025, after a rate cut was reversed.

This guide explains what happened, which services are affected, and how to find the exact rates for your provider type.

Quick Summary

• North Carolina reversed a 3%–10% Medicaid rate cut and restored September 2025 rates as the 2026 baseline
• There is no single 2026 master fee schedule PDF — providers use the restored 2025 rates
• ABA, dental, and other service categories each have specific 2026 updates
• 2026 income limits determine which patients qualify for coverage — see Medicaid income limits by state in 2026
• You can check your own coverage status using our Medicaid Eligibility in 2026 guide

What Is the NC Medicaid Fee Schedule?

The Medicaid fee schedule is a list of approved payment rates. It tells doctors, dentists, and other providers exactly how much NC Medicaid will pay for each service. Rates are organized by procedure code, so each code has its own dollar amount.

Who Sets the Rates

NCDHHS sets fee schedule rates under federal Medicaid rules. The agency updates these rates through its Division of Health Benefits.

How Managed Care Fits In

Most NC Medicaid patients are enrolled in a Prepaid Health Plan (PHP), not NC Medicaid Direct. PHPs must follow the state’s fee schedule but manage their own claims and payment systems.

Why 2026 Is Different

The 2026 fee schedule story is really about a reversal. A round of cuts from late 2025 was rolled back, so the “new” 2026 rate is actually the old, higher rate from before the cuts.

Critical 2026 Fee Schedule Updates

The single biggest fee schedule event of 2026 is the rate reduction reversal. It affects nearly every provider type that bills NC Medicaid, from primary care doctors to behavioral health providers.

The Rate Cut and the Reversal

On October 1, 2025, NCDHHS reduced Medicaid reimbursement rates by 3% to 10% across many service categories, citing state funding limits. Following legal challenges and an administrative directive, the state reversed course. All Medicaid provider reimbursement rates for 2026 were restored to the levels that were active on September 30, 2025.

Effective Dates and Claims Reprocessing

The restoration applies retroactively, so claims for 2026 dates of service are paid at the restored, higher rate. NC Medicaid Direct and PHP health plans were directed to reprocess affected claims automatically. Providers generally do not need to resubmit claims for this adjustment.

Where the Updated Files Were Posted

Updated fee schedule files reflecting the restored rates were posted to the PHP Contract Data Utility (PCDU) and the NCDHHS Fee Schedules and Covered Codes Portal by January 5, 2026. Corrected payments for NC Medicaid Direct began appearing in the January 13, 2026 check write, while PHP-managed claims followed a longer timeline based on each plan’s system update schedule.

Specific Service Updates for 2026

Not every service category moved through this reversal the same way. Some, like ABA therapy, have specific restored rates and new oversight rules. Others, like dental care, are still under active review.

ABA (Applied Behavior Analysis) Services

Rates for common ABA billing codes were restored to pre-cut levels. Code 97153 returned to $20.81, and code 97155 returned to $32.22, both per 15-minute unit. Alongside the rate restoration, House Bill 696 introduced new oversight rules in 2026, including stricter in-person assessment requirements and a 50% cap on telehealth supervision for ABA providers.

Dental Services

Dental reimbursement has not seen the same clear resolution. As of April 2026, the North Carolina Dental Society was actively pushing for higher Medicaid dental reimbursement rates. A confirmed, widespread rate increase for dental services has not yet been codified into a final published 2026 fee schedule.

Other Provider Categories

Physician, hospital, ambulance, and other fee schedules follow the same general restoration pattern described above. Because each provider type has its own file on the NCDHHS portal, you should always check the specific schedule for your service type rather than assume a single statewide number applies.

How Eligibility Connects to the Fee Schedule

A fee schedule only matters if a patient is actually eligible for Medicaid. NC’s 2026 income limits determine which patients are billable under these restored rates in the first place.

2026 Income Limits

For most adults ages 19–64, North Carolina uses 138% of the Federal Poverty Level (FPL) as the cutoff. In 2026, that works out to about $1,835 per month for a single adult and about $3,795 per month for a family of four. Children, pregnant women, seniors, and people with disabilities may qualify under different income rules.

Redetermination Changes

Starting December 31, 2026, low-income adults in the expansion group will face eligibility redetermination every 6 months instead of the traditional 12 months. This means more frequent paperwork, but it does not change the income limits themselves.

Where to Check Your Own Status

For a full breakdown of who qualifies and how income limits work by household size, see Medicaid Eligibility in 2026.

How to Access the Official Fee Schedules

For the exact dollar amount tied to a specific CPT or HCPCS code, you need the official state files. Here is your next step.

Step 1: Go to the Portal

Visit the NCDHHS Fee Schedules and Covered Codes Portal.

Step 2: Select Your Provider Type

Choose your category, such as Physician, Dental, or Ambulance, from the list of available fee schedules.

Step 3: Find the Right File

Look for a file labeled “January 2026” or “Restored Rates 2025.” If no 2026-specific file is listed for your category, the September 2025 file is the active legal reference.

If you are a provider and cannot find a rate for your service, check the PHP Contract Data Utility (PCDU) or contact your Prepaid Health Plan representative directly, since PHPs manage their own distributed rate schedules.

What This Means If You’re a Patient, Not a Provider

Most people searching for a “fee schedule” are actually trying to confirm whether their Medicaid coverage or a specific service is still active and paid for. The rate restoration does not change what services Medicaid covers. It only affects how much providers are paid.

Your Coverage Is Not Affected by the Rate Fight

If you already qualify for NC Medicaid, this rate restoration does not change your benefits or your coverage start date. It affects provider payments, not patient eligibility.

If a Provider Says They “Don’t Take Medicaid” Right Now

Some providers paused new Medicaid patients during the 2025 rate cuts. With rates restored, check back with your provider, since the financial reason for turning away Medicaid patients may no longer apply.

FAQ

Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against official Medicaid.gov and state agency guidelines | Last Updated: July 2026

Last Updated: July 2026

Sources:

• NC Medicaid, “Medicaid Rate Reduction Reversal Update,” medicaid.ncdhhs.gov
• NC Medicaid, “Fee Schedules and Covered Codes Portal,” medicaid.ncdhhs.gov
• DB101 North Carolina, “Income-Based NC Medicaid,” nc.db101.org

Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility, contact your state Medicaid office or visit Medicaid.gov.