North Carolina Medicaid Spend Reconciliation

Every CMS-64 service category for FY2024, and how much of each appears in this claims dataset.

24%Low coverage

These claims represent 23.7% of North Carolina’s total Medicaid spending in FY2024, measured against the state’s own CMS-64 filing.

79% of enrollees are in comprehensive managed care, so most of their care is paid by capitation and never becomes a provider claim. The remainder is capitation, supplemental and DSH payments, Medicare premiums for dual eligibles, drug rebates and administration — none of which are claim-level. See the full reconciliation.

Total Medicaid spending, FY2024

$28,887,230,741

CMS-64 Total Net Expenditures, as North Carolina filed it

Visible in claims

$6,848,492,342

23.7% of the program

Published per-enrollee spending

$1,036PMPM

CMS-64 total ÷ 2,323,109 avg enrollees. Both figures published by CMS — not derived from these claims.

Categories this dataset can see$8,141,706,153

Services paid as provider claims. Coverage below 100% typically means part of the category is delivered through managed care, or billed with codes this dataset does not carry.

Read the category rows as indicative, not exact. The state total above is a like-for-like comparison and is sound. Individual rows are not, because the two columns are attributed differently: claims are categorised by billing code, while the CMS-64 is categorised by the authority the state pays under. A home visit billed under a 1915(c) waiver and the same visit billed under the state plan carry identical codes, so this dataset cannot tell them apart while North Carolina books them on different lines. That is why some rows exceed 100% while their neighbours sit near zero — it reflects where the state books the spending, not a discrepancy in the amount.

Service category	CMS-64 (state total)	Seen in claims	Coverage
Nursing Facility	$2,311,626,956	$226	0%
Hospital (Inpatient & Outpatient)	$1,505,226,653	$448,566,229	30%
Home & Community-Based Services	$1,331,702,508	$1,270,368,450	95%
Prescribed Drugs	$741,253,497	$37,248,347	5%
Dental	$400,756,268	$362,627,782	90%
Other Care Services	$289,392,149	$52,890,236	18%
Physician & Surgical	$269,027,042	$1,119,524,471	416%
Home Health	$203,621,908	$693,538,933	341%
Hospice	$154,020,929	$452,194	0%
Behavioral Health	$144,731,448	$1,169,447,984	808%
Non-Emergency Transportation	$139,223,377	$110,735,092	80%
Clinic Services	$136,530,199	$700,327	1%
School-Based Services	$115,619,747	$0	0%
FQHC & Rural Health Clinic	$114,278,354	$114,691,451	100%
Laboratory & Radiology	$68,921,461	$493,428,016	716%
Therapy Services	$65,012,481	$382,923,909	589%
Targeted Case Management	$63,607,470	$191,425,641	301%
Screening & Preventive	$43,719,460	$95,596,669	219%
DME & Supplies	$34,844,858	$304,289,579	873%
Other Practitioners	$8,026,920	$0	0%
Family Planning	$562,468	$0	0%

Categories no claims dataset can see$20,745,524,588

These are real spending — they are simply not paid as claims to providers, so no claims-based analysis will ever contain them. This is the bulk of the difference between the two figures above.

Service category	CMS-64 (state total)
Managed Care Capitation	$20,941,238,106
Medicare Premiums (Duals)	$713,458,273
Supplemental & DSH Payments	$661,210,626
Other CMS-64 Lines	$166,281,792
Drug Rebates & Collections	-$1,736,664,209

The table adds up. The categories above sum to $28,887,230,741, which is North Carolina’s CMS-64 Total Net Expenditures for FY2024 exactly. Every line the state filed is accounted for in one of the two tables — nothing is dropped or double-counted.

Sources: CMS-64 net expenditures from the CMS MBES/CBES quarterly expenditure reports (FY2024); enrollment from the CMS Medicaid and CHIP applications, eligibility determinations and enrollment data; managed-care share from the CMS managed care enrollment reports. Claims figures are from the public T-MSIS provider extract. Methodology.