A Message from NCTracks on Behalf of NC Medicaid NC Medicaid Rate Reductions - Effective Oct. 1, 2025

A Message from NCTracks on Behalf of NC Medicaid

Fee schedules impacted by rate reductions will be released Oct. 1 2025, but are subject to change if additional appropriations are made available.

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 on the page linked below: 

https://medicaid.ncdhhs.gov/blog/2025/09/25/nc-medicaid-rate-reductions-effective-oct-1-2025

 

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.

Additional Information

Additional guidance can be found on the NC Medicaid provider bulletin webpage as available. The updated fee schedules will be published to the NC Medicaid Covered Codes and Fee Schedules Portal on October 1, 2025. 

If you have additional questions regarding the fee schedule changes or the date on which fee schedules will be available, please contact the DHB Provider Reimbursement Team at medicaid.providerreimbursement@dhhs.nc.gov.
Thank you for your continued partnership and dedication to serving North Carolina’s Medicaid beneficiaries.

Contact

medicaid.providerreimbursement@dhhs.nc.gov