How to start a skilled nursing facility in North Carolina

North Carolina requires a Nursing home license from North Carolina DHHS, Division of Health Service Regulation — Nursing Home Licensure and Certification Section to operate a skilled nursing facility. Fee: Non-refundable initial license fee of $470 per facility plus $19 per bed.

License required

Yes

License

Nursing home license

Issuing agency

North Carolina DHHS, Division of Health Service Regulation — Nursing Home Licensure and Certification Section

Fee

Non-refundable initial license fee of $470 per facility plus $19 per bed.

Renewal

Renew online through the DHSR licensure site, reporting utilization data used for the State Medical Facilities Plan.

Certificate of need

Required

Medicare certification

Separate from the state license. The state survey agency runs an unannounced standard health survey, a Life Safety Code survey and an emergency-preparedness survey against 42 CFR Part 483 Subpart B. For a Medicare SNF the state certifies and the CMS Location decides Medicare participation; for a Medicaid-only NF the state's certification is final and the state Medicaid agency decides participation.

Regulation

N.C.G.S. Chapter 131E, Article 6, Part 1 (Nursing Home Act) and Article 9 (CON); 10A NCAC 13D

1. Check the State Medical Facilities Plan for a need determination for nursing home beds
2. Submit a Certificate of Need application on the SMFP review schedule (no new beds without a CON)
3. Obtain DHSR construction plan approval
4. Submit the initial license application with the room/bed breakdown form and fees
5. Pass the licensure survey; for Medicare/Medicaid complete federal certification and enroll with NC Medicaid

Program

NC Medicaid (NCDHHS Division of Health Benefits), including NC Medicaid Managed Care

Enrollment portal

NCTracks Provider Portal

Fiscal agent

GDIT (NCTracks; the enrollment page still lists the call center under the firm name CSRA)

Application fee

North Carolina charges a $100 NC Medicaid Provider Application Fee on enrollment and on revalidation/reverification applications. It was waived from late 2021 to June 30, 2023 and reinstated July 1, 2023. Institutional provider types also pay the federal fee, which NCTracks lists as $750 for 2026. Under the federal rule (42 CFR 455.460), institutional providers pay the CMS application fee when they first enroll, re-enroll or revalidate. The fee is $750 for calendar year 2026. Individual physicians and non-physician practitioners do not pay it. A fee already paid to Medicare or to another state's Medicaid program counts.

Fingerprinting

Fingerprint-based criminal background checks are required for all high-risk providers and for anyone owning 5% or more of one. Fingerprints already on file with Medicare (confirmed in PECOS) can be accepted unless the provider was moved up to high risk. A provider is moved to high risk after a fraud-based payment suspension, an overpayment, an exclusion, or a similar trigger. Under federal rules (42 CFR 455.434 and 455.450), the state places provider types in 'limited', 'moderate' or 'high' risk levels. High-risk providers, and anyone who owns 5% or more of one, must submit fingerprints for a criminal background check.

Site visit

Under federal rule (42 CFR 455.432), the state must visit moderate- and high-risk providers before and after enrollment. Every enrolled provider must allow unannounced on-site inspections. The NCTracks pages we reviewed do not give a state list of provider types that get site visits.

Revalidation

NC calls revalidation 'recredentialing' or 'reverification'. It is due every five years, and NC law requires the $100 fee each time. Providers get notices in the NCTracks message inbox, with reminders 50, 20 and 5 days before the due date if they have not applied. A provider who misses the due date is suspended from Medicaid. Recredentialing includes a criminal background check on all owners and managing relationships. Time-limited enrollees, such as out-of-state providers, are exempt.

Full North Carolina Medicaid enrollment guide →

For this business

Required (licensing source)

CON program

Yes

Program

Certificate of Need

Agency

NC Department of Health and Human Services, Division of Health Service Regulation, Healthcare Planning and Certificate of Need Section

Services covered

• new health service facilities (hospitals, nursing homes, adult care homes, kidney disease treatment centers, long-term care hospitals, psychiatric and chemical dependency facilities as defined)
• changes in bed capacity
• capital expenditures over $4,000,000 to develop or expand a health service
• dialysis and home health services new to a facility
• home health agency and hospice offices; hospice, hospice inpatient and hospice residential facilities
• major medical equipment over $2,000,000 and specified services (e.g., MRI only in counties of 125,000 or fewer)
• operating rooms and GI endoscopy rooms; specialty-to-multispecialty ASC conversions
• relocation between service areas; mobile medical equipment

North Carolina certificate of need details →

State minimum wage

$7.25 an hour

Effective

2009-07-24

Scheduled increases

No scheduled change found in the official sources reviewed.

Rate pass-through

SL 2023-134, s. 9E.15 raised Innovations waiver rates to fund direct care worker wage increases. To get the increase, each provider files an attestation with its LME/MCO, reports at the end of the state fiscal year on how the funds were used, and keeps its own documentation showing it met the legislative requirements.

HCBS 80/20 rule

Federal baseline: 42 CFR 441.302(k) requires the state to show that each provider spends at least 80% of Medicaid payments for homemaker, home health aide and personal care services under 1915(c) waivers on direct care worker pay and benefits. Compliance starts 2030-07-09 (for managed care, the first rating period starting on or after that date); annual payment-adequacy reporting under 441.311(e) starts 2028-07-09. A state may set a lower share for state-defined small providers and exempt providers facing hardship, each only through a public notice-and-comment process. The eCFR text has not changed since 2024-07-09. No state-published 80/20 implementation step (small-provider criteria, hardship exemption or reporting guidance) was found for this state in the official sources reviewed.

Skilled nursing facilities — active organization NPIs (NPPES)

926 (as of Sep 13, 2026)

Medicare/Medicaid-certified nursing homes (CMS Care Compare)

419 (as of Aug 1, 2026)

Total Medicaid and CHIP enrollment (latest reported month)

2,811,382 (as of Jun 1, 2026)

All North Carolina Skilled nursing Medicaid rates, ranked →