NC Medicaid Cuts Shrink Covered Patient Base
Healthcare providers serving North Carolina Medicaid patients should plan for smaller payer volume and more frequent eligibility reviews.
Updated on Nov. 2, 2026 in Healthcare
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North Carolina's restrictions on Medicaid eligibility for noncitizens took effect October 1, 2026, and about 10,500 people have lost coverage. State Health Director Lawrence Greenblatt projects roughly $50 billion in Medicaid cuts over the next 10 years, affecting healthcare providers and the adults and families who rely on the program.
Why it matters
The changes stem from HR 1, the One Big Beautiful Bill Act signed in July 2025, which reshaped federal Medicaid eligibility rules that states must implement. For operators in healthcare and adjacent businesses, the shift means a shrinking base of covered patients and tighter reimbursement exposure as eligibility reviews and new requirements roll out.
About 10,500 people have lost Medicaid coverage under the noncitizen restrictions, measured against more than 730,000 enrollees in the state's expansion program. State Health Director Lawrence Greenblatt projects approximately $50 billion in Medicaid cuts over the next decade, while the state received a $213 million Rural Health Transformation award in its first year.
The players
North Carolina Department of Health and Human Services
The state agency that administers Medicaid and the expansion program, implementing federal eligibility rules across the state's health care system.
Lawrence Greenblatt
North Carolina's State Health Director, who announced the projected $50 billion in Medicaid cuts over the next decade.
Donald Trump
The current President of the United States, who signed the HR 1 budget legislation that reshaped federal Medicaid eligibility in July 2025.
The details
The restrictions limit Medicaid eligibility for noncitizens, though certain groups may remain covered, including qualifying lawful permanent residents, certain lawfully residing children and pregnant women, people with Cuban or Haitian entrant status, and citizens of Micronesia, the Marshall Islands, or Palau living in the U.S. Affected expansion recipients will face eligibility reviews twice yearly instead of annually, with redeterminations processed at county DSS offices. Beginning January 1, 2027, adults must complete 80 hours a month of work, school, or volunteering, or meet an alternative household earnings threshold.
Timeline
December 2023: North Carolina expanded Medicaid eligibility.
July 2025: President Trump signed HR 1, the One Big Beautiful Bill Act.
October 1, 2026: Noncitizen coverage restrictions took effect.
October 28, 2026: The public health commission held a joint meeting on the Medicaid changes.
January 1, 2027: New work and renewal requirements take effect.
Market Landscape
North Carolina is implementing the eligibility restrictions and work requirements enacted through HR 1, the One Big Beautiful Bill Act signed in July 2025, following its December 2023 Medicaid expansion. The state's expansion program, which enrolls more than 730,000 individuals and where over one-third of enrollees live in rural communities, now faces a tightening federal framework.
Healthcare providers serving Medicaid populations should model a smaller covered patient base and plan for more frequent eligibility redeterminations that may interrupt billing and scheduling. Operators should also monitor the January 2027 work requirements, since coverage gaps tied to documentation could shift patient volume and payer mix.
The takeaway
Healthcare operators should treat the January 1, 2027 work and renewal requirements as the next major payer-mix event and build the twice-yearly review cycle into their revenue forecasts. Track enrollment changes at county DSS offices, since those figures will show whether the 10,500 coverage losses expand as new requirements begin.
What happens next
New Medicaid work and renewal requirements take effect January 1, 2027, requiring affected adults to meet the 80-hour monthly activity standard or the alternative household earnings threshold.
Further reading
For broader context on the healthcare sector's exposure to public coverage policy, see Healthcare coverage on We are Main Street.
Source note: This article includes information reported by Carolina Journal.
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