MedicaidReimbursementMedium impact
NC Medicaid Managed Care Capitation Rates – Updated Care Management Assumptions for SFY 2027
NC Medicaid - NCDHHS·NC·Managed Care
Effective date
Jul 1, 2026
We identified it
Jul 18, 2026
Summary
NC Medicaid updated care management capitation rate assumptions effective July 1, 2026, establishing $11.34 PMPM as the expected average cost for whole-person care management staffing within NC Medicaid Managed Care Standard Plans and Advanced Medical Home (AMH) Tier 3 practices. This is a reference rate for negotiation purposes; NCDHHS has not set minimum care management fees and expects Standard Plans and practices to establish mutually agreeable rates based on care management intensity and breadth.
Action Required
By June 1, 2026: Billing and managed care contracting teams should review current care management rate agreements with NC Medicaid Standard Plans against the new $11.34 PMPM benchmark. If your practice is an AMH Tier 3 provider, verify that negotiated care management rates are commensurate with the intensity and breadth of services provided and align with NCDHHS Advanced Medical Home Provider Manual requirements. Ensure compliance with care management program requirements outlined in the AMH Provider Manual. Contact the NC Medicaid Contact Center (888-245-0179) or AMH team (medicaid.advancedmedicalhome@dhhs.nc.gov) to obtain the detailed May 31, 2026 Care Management Assumptions document to verify your staffing model assumptions match NCDHHS expectations. Documentation of care management services and staffing ratios should be maintained to support rate justification. No immediate claims processing changes are required, but rate renegotiations may be necessary if current agreements fall significantly below the benchmark.