Medicaid Nursing Home Rates by State

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North Carolina

Medicaid nursing facility payment · Statewide price · researched October 2026

North Carolina’s Medicaid agency and its state plan are the official source for these rules. This page summarizes them as researched in October 2026; check the state’s own documents, listed under Sources, before relying on them.

At a glance

Rate method

Statewide price

Case-mix level

Facility average

Classification

Transitioning to PDPM

Rate updates

Quarterly

Managed care (LTC)

Short stays only

Quality program

None

Paid outside the rate

Small

Bed hold

Leave only

Published rates

Rates only

Assisted living

Limited

Personal needs allowance

$70 / month

Overview

• North Carolina sets a new rate for each home every calendar quarter.
• Per diem = direct care rate + standard indirect rate + capital (fair rental value) + an assessment adjustment (the Medicaid share of the provider tax) + two flat add-ons: a 'direct care facility stabilization' add-on ($41.71/day from 4/1/2026) and a uniform $37.74/day (since 7/1/2023).
• The direct ceiling is 105% of the statewide Medicaid day-weighted median base-year direct cost, and the indirect rate is 100% of the median.
• The legacy direct formula pays the lesser of the ceiling or the home's own cost, plus a 100% 'incentive allowance' for the difference.
• In practice every home gets its share of the ceiling scaled by its Medicaid case mix, whatever its own cost.
• Direct care is moving from RUG-III to PDPM case mix on a six-step blend that started 10/1/2026 and ends 1/1/2028 (see case_mix.pdpm_transition).
• Medicaid case mix is one average per home, not per resident.

What matters in North Carolina

• $79.45 a day of flat add-ons ($41.71 stabilization plus $37.74 uniform) sits on every rate, regardless of cost or acuity.
• Direct care moves from RUG-III to PDPM (federal acuity system) in six quarterly steps, finishing 1/1/2028.
• Case mix is one average per home, reset quarterly, so every Medicaid resident in a home earns the same rate.
• Managed care pays 95% of Medicare for days 1-20 and 80% after, but only for the first 90 days.
• Medicare coinsurance days usually pay $0: Medicaid pays its rate minus Medicare's payment, capped at the coinsurance.
• Hospital bed hold is not paid; therapeutic leave is paid at the full rate for up to 60 days a year.

Frequently asked

Does a North Carolina home that spends below the direct care ceiling receive less?

No. Every home receives the ceiling-based direct care rate regardless of its own spending.

What do North Carolina managed care plans pay for short nursing home stays?

Plans pay 95% of the Medicare rate for days 1-20 and 80% after that, and only for the first 90 days.

Which part of a North Carolina home's rate responds to acuity during the PDPM blend?

The direct care component, through one Medicaid case-mix average per home reset quarterly. It moves from RUG-III to PDPM in six quarterly steps, finishing 1/1/2028.

How much is paid outside the posted rate in North Carolina?

Small; the only item is a managed care directed payment of up to $5.65M for SFY2027.

What does North Carolina Medicaid pay on Medicare coinsurance days?

Lesser-of: Medicaid pays its rate minus Medicare's payment, capped at the coinsurance, which is usually $0.

How is the North Carolina nursing home provider tax charged?

$35.48 per non-Medicare day for most homes, $11.47 for homes above 42,000 days, and $0 for CCRCs and tribal homes.

How the rate is set

How the method got here

Verified October 11, 2026

Cost basis

Uses cost reports

Yes

Cost report

Medicare CMS-2540 (freestanding) or CMS-2552 (hospital-based), plus NC Medicaid supplemental schedules, for fiscal periods ending after 9/30/2011 (4.19-D .0104(b)). Desk audits cover all base-year reports, plus at least 50 risk-based field audits. A separate annual Capital Data Survey feeds FRV.

Base year and rebasing

No fixed rebasing cycle; the state selects the base year (4.19-D .0102(a)). The plan text names FY2005 cost reports as the base for rates effective 1/1/2008, and no later direct or indirect rebase is written into the plan. Between rebases the ceiling, each home's base-year per diems and the indirect rate are trended each year by the index. The statewide direct ceiling was $150.33 on 10/1/2025. SPA 25-0026 sets out how a future PDPM rebase would work. Its example uses an October 2025-September 2026 cost report period, with CMI quarters 12/31/2025-9/30/2026; no rebase date is scheduled.

Components

Component	Method	Notes
direct care - legacy (RUG-III)	Statewide ceiling = 105% of the Medicaid day-weighted median base-year direct cost (case-mix-neutralized nursing plus non-case-mix costs). The ceiling is split between each home's case-mix part (RN/LPN/aide wages, benefits, agency staff) and its non-case-mix part (nursing supplies, dietary, activities, social services, direct ancillaries), using that home's own base-year cost shares. Rate = case-mix share of the ceiling x the home's Medicaid resident-day-weighted CMI + non-case-mix share. It is set as the lesser of that or the home's cost x CMI, plus a 100% 'incentive allowance' for any difference, so it always equals the ceiling-based amount.	4.19-D .0102(b)(2). Being phased out from 10/1/2026. From 4/1/2026 the RUG-III CMI is frozen at the values used for the 1/1/2026 direct rate, including any MDS audit impacts (.0105(f)).
direct care - PDPM	PDPM direct rate = (statewide ceiling x 65% x the home's neutralized Medicaid PDPM CMI) + (statewide ceiling x 35%). The ceiling is $150.33 as of 10/1/2025, trended forward until a rebase. Unlike the legacy rate, the 65/35 split is the same for every home.	4.19-D .0102(b)(4), SPA 25-0026. Blended with the legacy rate from 10/1/2026 to 1/1/2028. New facilities follow the same blend.
direct care facility stabilization add-on	Flat per Medicaid resident day, the same for every home: $31.90 from 11/1/2022; $55.23 from 10/1/2025; $45.02 from 1/1/2026; $41.71 from 4/1/2026 onward.	4.19-D .0102(b)(5). It started on the same date (11/1/2022) as the restructured provider assessment, which 'reinvest[s] additional provider tax collections ... into an increase in Medicaid SNF-specific per diem rates'. That suggests the add-on is tax-funded (inferred, not stated).
indirect	One standard rate for all homes: 100% of the Medicaid day-weighted median base-year indirect cost per diem (A&G, laundry/linen, housekeeping, plant operation, capital/lease, indirect ancillaries; property ownership/use and mortgage interest excluded). Not case-mix adjusted. Trended each year by the index.	4.19-D .0102(b)(6)-(7). Standard since 10/1/2003. It was $35.82 on the 10/1/2020 rate file; no current value captured.
capital (FRV)	Facility-specific fair rental value, reset each April 1. See capital field.	4.19-D .0102(d).
nursing facility assessment adjustment	Adds to the rate the assessment cost incurred for Medicaid residents. In past rate files this per-day amount equaled the assessment rate per day.	4.19-D .0102(c). See provider_tax.
uniform add-on	$37.74 per patient day added to the final rate since 7/1/2023. It made permanent, and replaced, a temporary $27.28 increase.	4.19-D .0102(h); SL 2023-134.

Inflation

Skilled Nursing Facility Market Basket without capital (Global Insight / S&P), using the most current quarterly release available as of August 1. Applied once a year to the direct ceiling, each home's base-year direct per diems and the indirect rate (4.19-D .0102(e)). The PDPM ceiling of $150.33 (10/1/2025) is also 'trended forward' with this index.

Verified October 11, 2026

Case mix

System

Transitioning to PDPM

Applied at

Facility average

How it works

Each home gets one direct rate per quarter from the average case mix of its Medicaid residents (resident-day-weighted). Every Medicaid resident in the home is paid that same rate (4.19-D .0102(b), .0105).

Classification

RUG-III 5.12b, 34-group, index maximizer (legacy), run on the Optional State Assessment (OSA) since 10/1/2023. Weights range from SE3 2.08 to PA1 0.57. Moving to a PDPM-based index that uses only 3 of the 5 PDPM components: Nursing 68%, NTA (non-therapy ancillary) 22%, SLP (speech) 10%. PT and OT are left out. The index uses federal component weights (e.g. Nursing ES3 3.84 down to PA1 0.62) and is multiplied by a budget-neutrality factor. Note: the SPA cover letter says 'RUG IV', but the state plan and policy 2B-1 both specify RUG-III 34.

Applies to

Direct care case-mix part only. Legacy: each home's own case-mix share of the ceiling. PDPM: 65% of the ceiling. Non-case-mix direct, indirect, FRV, assessment and add-ons are not case-mix adjusted.

Acuity measured from

Two CMIs are computed each calendar quarter: an all-resident facility CMI and a Medicaid CMI. Since 10/1/2021 both are time-weighted, averaging every assessment active during the quarter by resident day (before that, a point-in-time snapshot on the last day of the quarter). Medicaid CMI covers residents whose per diem payer is Medicaid or Medicaid-pending. It is used for the rate; the facility CMI neutralizes base-year cost. Quarters end 3/31, 6/30, 9/30 and 12/31. Delinquent MDS (>121 days since the prior ARD): Medicaid residents get the lowest CMI (RUG 'AAA'/BC1; PDPM 'BC1' lowest in each component). Since 10/1/2023, a federally required assessment without a matching OSA is delinquent for all its days, and Medicare/other-payer records then get SE3 (the highest).

Updated

Quarterly. The rate changes in the second quarter after the CMI quarter (e.g. the CMI for the quarter ending 12/31 sets the April 1 rate). Exception: the legacy RUG-III CMI is frozen at its 1/1/2026 values from 4/1/2026.

Move to PDPM

SPA 25-0026 (submitted to CMS 12/18/2025, proposed effective 10/1/2025; CMS approval not confirmed). (a) From 10/1/2025, MDS assessments are also grouped into PDPM Nursing/NTA/SLP groups. (b) From 4/1/2026, the RUG-III CMI behind the legacy rate is frozen at the 1/1/2026 values (including MDS audit impacts). (c) PDPM is phased in for direct care on a quarterly blend of legacy/PDPM: 10/1/2026 83%/17%; 1/1/2027 67%/33%; 4/1/2027 50%/50%; 7/1/2027 33%/67%; 10/1/2027 17%/83%; 1/1/2028 0%/100% (complete). (d) Budget neutrality: each rate period the PDPM CMI is multiplied by a factor = estimated legacy (RUG-III) direct spend / estimated PDPM direct spend. Statewide direct spend therefore cannot exceed the RUG-III level, but individual homes can gain or lose. There is no facility hold-harmless in the SPA text. (e) The PDPM direct ceiling stays at the 10/1/2025 value of $150.33, trended, until the next rebase. (f) New facilities: blended from 10/1/2026 and PDPM-only from 1/1/2028. Source: https://medicaid.ncdhhs.gov/spa-25-0026-proposed-amendment-se…

Verified October 11, 2026

Low-acuity residents

None found. There is no reduced or flat rate for low case-mix residents. Case mix is a facility average, so a low-acuity resident is paid the home's single quarterly rate and lowers the home's average CMI (lowest RUG-III weight PA1 = 0.57). Related rules that are not low-acuity carve-outs: delinquent or missing-OSA Medicaid assessments get the lowest CMI (RUG 'AAA'/BC1, PDPM BC1 lowest per component), and residents who fail NF level-of-care criteria are not covered. Checked: 4.19-D (SPA 25-0026 full plan pages .0101-.0107) and Clinical Coverage Policy 2B-1 (amended 8/1/2024).

Verified October 11, 2026

Capital

Fair rental value (4.19-D .0102(d)), the only payment for capital; new rate each April 1 from the Capital Data Survey (period ending the prior 9/30). Construction cost: $222.96/sq ft (10/1/2021), indexed each year by the RSMeans historical cost index and RSMeans location factor (first 3 zip digits). Square feet: the home's actual per bed, capped at 700 sq ft, with a floor of 325-425 by age. Equipment: $9,000/bed. Depreciation: 2.00%/yr on the weighted average age, with a maximum age of 37.5 years from 2026 (25% floor of new value) and no recapture. Land: 15% of the fixed replacement value. Rental factor: rolling 3-year average 10-year Treasury yield + 3.0%, with a 7.5% floor and 9.5% ceiling. The Medicaid share of the FRV is divided by the greater of Medicaid days from the latest audited cost report or 85% occupancy x Medicaid utilization. Renovations of at least $500/bed lower the age. Homes past the maximum age get no more than a $1.00/day annual FRV increase.

Verified October 11, 2026

Budget adjustment factor

(1) PDPM budget-neutrality factor, applied each rate period during and after the transition (estimated RUG-III direct spend / estimated PDPM direct spend) (4.19-D .0105(h)). (2) A 10% NF rate cut took effect 10/1/2025 because no state budget was enacted. NCDHHS announced the reversal on 12/10/2025; FFS claims were reprocessed from the 1/13/2026 check write, and PHPs had 30 days after loading the fee schedule. SPA 25-0026 was revised to drop the cut (state fiscal impact $0 SFY2026-27). (3) Head injury rates have been frozen at 6/30/2015 levels since 12/1/2016, and geropsych fee schedules at 7/1/2012 levels.

Verified October 11, 2026

Add-ons and money outside the rate

Paid outside the posted rate

Level

small

Estimate

SFY2027 SDP: up to $5,650,000 total ($3,625,000 federal, $2,025,000 non-federal), built into PHP capitation. Preprint Table 2: plan payments rise from 50.7% to 55.3% of average commercial rate (+4.6 pts). Renewal of SFY23-SFY26 arrangement.

Components

42 CFR 438.6(c) minimum fee schedule: 95% of Medicare for days 1-20 of a managed care NF admission, 80% after, while the member stays in the PHP (short stays; members >90 days move to FFS). Non-federal share = state general revenue (Q34a), not IGT. No NF UPL/IGT supplemental found in 4.19-D.

Source

https://www.medicaid.gov/medicaid/managed-care/downloads/NC_F…

Verified October 11, 2026

Payments by owner type

Applies

yes

Detail

The SFY2027 directed payment approval limits the Medicare-based short-stay minimum to non-state government-owned NFs (up to $5.65M). State-operated NFs are paid reasonable cost under Medicare principles, outside the prospective system. How many homes and how big the gap is were not found, and it is unconfirmed whether private homes also get the 95%/80% minimum.

Funding

Not stated.

Source

https://www.medicaid.gov/medicaid/managed-care/downloads/NC_F…

Verified October 11, 2026

Quality program

Notes

None found. No NF quality or value-based add-on appears in 4.19-D (full text, SPA 25-0026) or in the NF directed payment (a fee schedule with no quality measures). The 'incentive allowance' in the direct formula is not a quality payment; it pays the gap between cost and the ceiling.

Verified October 11, 2026

Provider tax

Charged

per non-Medicare day

Standard amount

$35.48 per non-Medicare day for homes with <= 42,000 annual patient days (1/1/2026); set below the federal 6% cap; rates after 3/31/2026 not captured

Tiers

Who	Test	Amount
> 42,000 annual patient days (volume test on total days, not Medicaid days)	volume	$11.47 per non-Medicare day (1/1/2026)
CCRCs	ccrc	$0
tribal facilities	other	$0

Lower for high-Medicaid homes

no

Returned in the rate

Assessment adjustment in the per diem (the Medicaid share of the tax), plus from 11/1/2022 reinvestment into higher per diems (the direct care facility stabilization add-on).

Source

https://medicaid.ncdhhs.gov/blog/2026/01/26/skilled-nursing-f…

Verified October 11, 2026

Provider tax notes

Nursing facility provider assessment, per non-Medicare day, set below the federal 6% cap. It is tiered by size: homes with >42,000 annual patient days pay a lower rate than all others, and CCRCs and tribal facilities pay $0. Rates: 11/1/2022 $8.64 / $26.74; 7/1/2025 $9.99 / $30.92; 10/1/2025 posted $10.37 / $32.09, retroactively revised to $10.73 / $33.20; 1/1/2026 $11.47 / $35.48 (large / small). Before 11/2022 it was $7.18 / $13.68 at a 48,000-day threshold. Due monthly within 15 days through the NHA portal; non-payment can trigger a 10% rate cut or up to a 100% withhold. Returned through the rate's assessment adjustment (Medicaid share) and, from 11/1/2022, a reinvestment into higher per diems (the stabilization add-on). Rates after 3/31/2026 were not captured.

Verified October 11, 2026

Supplemental payments

(1) MCO directed payment: minimum fee schedule of 95%/80% of Medicare for short-term (<=90 day) managed care NF stays. The SFY2027 approval covers 'non-state government owned' NFs, up to $5.65M ($3.625M federal). CMS's preprint table shows plan payments rising from 50.7% to 55.3% of the average commercial rate. CMS called it 'likely' grandfathered under the 2025 federal law (P.L. 119-21 section 71116), which requires grandfathered directed payments to phase down from rating periods starting on or after 1/1/2028. (2) No NF UPL or IGT supplemental payment found in 4.19-D. (3) State-operated NFs are paid reasonable cost under Medicare principles, outside the prospective system.

Verified October 11, 2026

Other add-ons

(1) Direct care facility stabilization add-on, per Medicaid day: $31.90 (11/1/2022), $55.23 (10/1/2025), $45.02 (1/1/2026), $41.71 (4/1/2026 and after). (2) Uniform add-on of $37.74/day since 7/1/2023 (SL 2023-134; replaced a temporary $27.28). (3) Religious dietary add-on: for homes where at least 50% of residents need religious diets; capped at 140% of the base-year neutralized median direct cost (4.19-D .0102(g)). (4) COVID-era outbreak/response rates (2020-2022) have ended.

Verified October 11, 2026

Units paid separately

(1) Ventilator: higher direct rates or a negotiated all-inclusive per diem for homes that specialize in ventilator patients. The rate is based on budget projections, no higher than the home's projected cost and no lower than the statewide average direct + indirect rate, then indexed each year. No FRV is added. Prior approval is required, and the rate applies to ventilator patients only. (2) Head injury intensive rehab: a negotiated all-inclusive rate for CARF-accredited homes with at least 50% of beds in head-injury rehab; frozen at 6/30/2015 rates since 12/1/2016; includes the assessment adjustment but not FRV. (3) Geropsychiatric units (policy 2B-2): a negotiated all-inclusive direct + indirect rate, capped at the statewide averages, with no FRV; the fee schedule was set at 7/1/2012 levels. (4) State-operated NFs: reasonable cost under Medicare principles. (5) Out-of-state NFs: the lesser of the NC statewide average direct + indirect rate or the home state's rate. (6) Hospital swing beds are covered under 2B-1. Rates for these units are on the fee schedule site.

Verified October 11, 2026

Payment rules

Managed care for long-term care

Status

short_stay

Detail

Standard and Tailored Plans pay up to 90 days; long stays are fee-for-service (NC Medicaid Direct)

Verified October 11, 2026

Who pays

mixed. Long-stay residents are paid fee-for-service through NC Medicaid Direct. Standard Plans and Tailored Plans (PHPs, prepaid health plans) cover nursing facility admissions only up to 90 consecutive days for members whose only coverage is Medicaid. After 90 days the member is disenrolled to NC Medicaid Direct on the first of the following month. Dual eligibles are not in Standard Plans (assumed from the 'only coverage is NC Medicaid' wording; not checked separately).

Verified October 11, 2026

Managed care rate floor

Yes, and it is ABOVE the FFS rate for short stays. Since 1/1/2023 the plans (Standard Plans, Tailored Plans, CFSP) must pay at least 95% of the facility's adjusted Medicare (PDPM) rate for days 1-20 and 80% for day 21 onward, until the member moves to Medicaid Direct. The Medicare rate is adjusted down for drugs, lab and radiology, which Medicaid pays outside the per diem. This is a 42 CFR 438.6(c) minimum-fee-schedule directed payment, renewed for 7/1/2026-6/30/2027 (CMS approval 6/16/2026, control NC_Fee_NF_20260701-20270630). The approval letter limits it to 'non-state government owned' NFs, up to $5.65M. State plan add-ons such as the $37.74 must also pass through: PHPs must 'adjust provider reimbursement rates by no less than the associated dollar amount change in the fee schedule'. Sources: https://medicaid.ncdhhs.gov/blog/2023/02/06/increased-nursing… ; https://www.medicaid.gov/medicaid/managed-care/downloads/NC_F… ; https://medicaid.ncdhhs.gov/blog/2023/10/19/legislated-medica…

Verified October 11, 2026

Included in the daily rate

Included (2B-1 section 5.5.1): room and board; all nursing, including restorative; PT, OT and speech therapy; personal hygiene and skin care items; medical supplies and equipment (Attachment B, including oxygen and related supplies); OTC drugs, biologicals and emergency drugs; therapeutic diets and supplements; social services; activities; therapeutic leave; and non-ambulance transport to medical care. Paid separately: prescription drugs (through the pharmacy program), lab and radiology (the managed care Medicare-based floor is reduced for drugs/lab/radiology 'that NC Medicaid covers outside of the per-diem'), physician services, and ambulance transport. Ancillary costs (therapy, oxygen, IV, billable supplies, life-sustaining equipment, medical transport) are captured as direct or indirect ancillary costs in the cost report and built into the per diem.

Verified October 11, 2026

Bed hold

Hospital stays

Not paid. 'Medicaid has no provision for bed hold'; holding a bed during a hospital stay is a private agreement between the resident and the facility (2B-1 section 7.4; 42 CFR 483.15(d)).

Leave days

Paid at the full current Medicaid rate, up to 60 days per calendar year. No more than 15 consecutive days without NC Medicaid prior approval (through the UR contractor). Must be physician-ordered and in the care plan, and is billed as regular days.

Occupancy rule

None.

Notes

The FRV denominator uses at least 85% occupancy, but that has nothing to do with leave days.

Source

https://medicaid.ncdhhs.gov/2b-1-nursing-facilities/download?…

Verified October 11, 2026

Personal needs allowance

Per month

70

Effective

in effect per MA-2270 rev. 2026-06-16

Notes

MA-2270: $70 individual, $140 couple sharing a room; plus guardianship fees, mandatory withholdings, and a work-incentive PNA for ICF-MR residents with earnings. VA A&A/UME portion excluded. Not COLA-indexed.

Confidence

confirmed

Source

https://policies.ncdhhs.gov/wp-content/uploads/MA-2270-LTC-Ne…

Verified October 11, 2026

Medicare coinsurance days

Method

lesser_of

Rule

Lesser-of. State Plan Att. 4.19-D p.23 (TN 03-09, eff. 10/1/2003): no Medicaid payment for days 1-20. For days 21-100, DMA pays coinsurance totaling the Medicaid per diem rate less any Medicare Part A payment, but no more than the Medicare coinsurance amount. Medicare Advantage: not found. Duals are in NC Medicaid Direct, and MA cost-sharing is likely capped the same way.

Effect

The home gets the NC Medicaid per diem minus Medicare's payment, which is usually $0 on SNF coinsurance days.

Confidence

confirmed

Source

https://medicaid.ncdhhs.gov/spa-25-0026-proposed-amendment-se… (Att. 4.19-D p.23, as reprinted in SPA 25-0026)

Medicare Advantage

not addressed: No MA/Part C cost-sharing text found. State Plan Att. 4.19-D p.23 covers Part A days 21-100 only. A NC Medicaid site search for MA crossover returned nothing.

Medicare Advantage source

https://medicaid.ncdhhs.gov/search?keys=Medicare+Advantage+cr…

Verified October 11, 2026

Required care spending

Applies

no

Rule

No spending rule. The legacy direct care formula pays the lesser of the ceiling-based rate or the home's own cost plus a 100% incentive allowance for the difference, so every home gets the ceiling-based direct rate regardless of its own spending; the PDPM rate is likewise ceiling-based.

Source

https://medicaid.ncdhhs.gov/spa-25-0026-proposed-amendment-se…

Verified October 11, 2026

Occupancy rules

Applies

yes

Rule

The Medicaid share of the fair rental value (capital) is divided by the greater of Medicaid days from the latest audited cost report or 85% occupancy x Medicaid utilization. No occupancy test on bed hold.

Source

https://medicaid.ncdhhs.gov/spa-25-0026-proposed-amendment-se…

Verified October 11, 2026

MDS accuracy penalties

Medicaid MDS Validation Program (since 10/1/2004; 2B-1 Attachment J). Contract RN reviewers audit every home each year, on site or remotely, sampling at least 90% Medicaid residents from the roster two quarters back. If more than 25% of sampled MDS values are unsupported, the RUG category is recalculated for all MDS assessments and the direct rate is recalculated, with a possible retrospective rate adjustment. Homes at 26-39% unsupported get an on-site review the next year. Homes at 40% or more get a follow-up review no earlier than 180 days later. Delinquent assessments (more than 121 days, or missing the OSA) get the lowest CMI for Medicaid residents. Audit impacts are locked into the RUG-III CMI frozen for the PDPM transition (4.19-D .0105(f)). Informal reconsideration within 15 business days.

Verified October 11, 2026

Published rates and changes

How often rates change

A home's rate changes

quarterly

When

Jan 1, Apr 1, Jul 1, Oct 1 case-mix update; inflation once a year

Verified October 11, 2026

When rates change

Quarterly: 1/1, 4/1, 7/1 and 10/1 for the direct case-mix update. The index is applied once a year using the market basket available as of August 1. FRV changes each 4/1. Legislated add-ons usually start 7/1 (SFY) or 10/1. PDPM blend steps: 10/1/2026, 1/1/2027, 4/1/2027, 7/1/2027, 10/1/2027 and 1/1/2028 (100% PDPM).

Verified October 11, 2026

Posted rates

Home-level rates published

Yes

Where

https://ncdhhs.servicenowservices.com/fee_schedules (current, NC Medicaid Fee Schedule and Covered Code site, since 11/3/2022); archive 2013-2022 at https://medicaid.ncdhhs.gov/providers/fee-schedules/medicaid-…

Format

xlsx and pdf ('Expanded Nursing Facility Fee Schedule')

Cadence

Quarterly (the posted file replaces individual rate letters since 9/2020)

History

The archive page has files from 2013 through 2022, including several COVID-era revisions. Later files are on the ServiceNow fee schedule site (not browsed: JS app).

Home identifier

NPI (10-digit) + facility name

Verified October 11, 2026

Rate build-ups

Published

No

Where

No separate per-facility calculation workbook found. The quarterly 'Expanded Nursing Facility Fee Schedule' is the official rate publication. Since 9/2020 it carries each home's component build-up.

What they show

Per NPI (as of the 10/1/2020 file): Medicaid CMI, direct rate, indirect rate, FRV, assessment, final rate (plus prior-quarter rate and COVID rates at the time). Not shown: base-year costs, ceiling split shares, the ceiling itself, the PDPM blend parts or the neutralization factor (current-file layout not verified).

Format

xlsx/pdf

Example file

https://medicaid.ncdhhs.gov/documents/providers/cost-reports/…

Verified October 11, 2026

Recent changes

Verified October 11, 2026

Assisted living

Medicaid assisted living

Covered

limited

Program

State Plan Personal Care Services (PCS) in congregate settings, Clinical Coverage Policy 3L-1 (amended 1/1/2026). It covers residents of licensed adult care homes (G.S. 131D-2.4) and supervised living group homes (G.S. 122C). The CAP/DA waiver is not used for assisted living.

What is paid

PCS hours only (help with ADLs, by aides employed by the adult care home). Room and board is explicitly not covered. Room and board for low-income adult care home residents is usually paid by State-County Special Assistance, a state/county cash supplement, not Medicaid (not verified this session).

Rate

PCS was paid per 15-minute unit; the direct care rate rose to $5.96 per 15 minutes on 7/1/2023 (SL 2023-134). The current congregate PCS rate was not verified.

Limits

Up to 80 hours per month for adults, plus up to 50 more for those who meet extra criteria (e.g. dementia needing more supervision), based on an independent assessment with prior approval. State plan entitlement: no enrollment cap or waitlist.

Source

https://medicaid.ncdhhs.gov/media/14986/download?attachment

Verified October 11, 2026

Sources

1. SPA 25-0026 Skilled Nursing Facility Rate Methodology (full Attachment 4.19-D), submitted to CMS 12/18/2025 · state plan
2. SPA 25-0026 revised public notice (rate reductions removed; $0 fiscal impact), 12/17/2025 · agency page
3. Clinical Coverage Policy 2B-1 Nursing Facilities (amended 8/1/2024), incl. Attachment J MDS Validation Program · agency page
4. Increased Nursing Facility Rate for Managed Care NF Short Term Stays (bulletin 2/6/2023) · agency page
5. CMS approval + 438.6(c) preprint NC_Fee_NF_20260701-20270630 (6/16/2026) · agency page
6. Legislated Medicaid Provider Rate Increases: SNF, PCS, PDN (bulletin 10/19/2023) · agency page
7. Nursing Facility Cost Assessment page · agency page
8. Assessment Fee Adjustment for SNF Providers (7/2/2025) · agency page
9. Assessment Rate Adjustment for SNF Providers (10/30/2025) · agency page
10. Skilled Nursing Facility Provider Assessment Updates (1/26/2026) · agency page
11. NC Medicaid Rate Reductions effective 10/1/2025 (9/25/2025) · agency page
12. Medicaid Rate Reduction Reversal Update (12/19/2025) · agency page
13. Nursing Facility Fee Schedules Archive (2013-2022) · rate file
14. SNF Q1 2021 Expanded Fee Schedule + memo on posting rates in lieu of rate letters (9/10/2020) · rate file
15. NC Medicaid Fee Schedule and Covered Code site · rate file
16. NC Medicaid Managed Care / Nursing Facility fact sheet and transition-of-care protocol (90-day disenrollment) · agency page
17. Clinical Coverage Policy 3L-1 State Plan PCS Provided in Congregate Settings (amended 1/1/2026) · agency page
18. Medicare crossover / coinsurance rule · regulation
19. Medicare crossover rule · regulation
20. Personal needs allowance · regulation

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