Key Health Care Issues We are Tracking in 2026 in the Carolinas

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05.18.2026

While 2025 saw significant federal and state legislative changes, the health care landscape in North and South Carolina continues to evolve in 2026. Health care providers, legal counsel, investors in health care providers, and health care executives must remain attentive to these developments as they will shape strategic planning and compliance efforts throughout the year. While not an exhaustive list, we summarize below several key legislative and regulatory issues we are monitoring in 2026.

1. Medicaid Finance Restructuring and the OBBB Act Impact

Public Law 119-2, colloquially referred to as the One Big Beautiful Bill Act (the “OBBB”),[1] passed by slim margins in the U.S. Senate (51-50) and U.S. House (218-214) and was signed into law by President Trump on July 4, 2025.[2] Its Medicaid provisions represent some of the most significant changes to the program in recent history. The Congressional Budget Office estimates these reforms will reduce the federal deficit by $886.8 billion over 2025–2034,[3] while the RAND Corporation projects state Medicaid budgets will shrink by $664 billion during the same period.[4] Among the key changes, the OBBB subjects any new provider tax enacted after July 4, 2025 to a 0% indirect hold harmless threshold, effective October 1, 2026.[5]

Beginning December 31, 2026, adults aged 19 through 64 enrolled in the ACA Medicaid expansion must have their eligibility redetermined every six months[6] and demonstrate 80 hours per month of work, volunteering, or educational engagement to maintain coverage, though the legislation exempts certain vulnerable populations, including pregnant women, caregivers, veterans, and those already subject to other work requirements.[7] The CBO estimates these community engagement requirements will leave an additional 5.3 million people without health insurance by 2034.[8]

North Carolina

Because North Carolina expanded Medicaid in late 2023, the state is vulnerable to the OBBB’s expansion-targeted cuts.[9]

• HASP and Medical Debt Relief: The state’s Healthcare Access and Stabilization Program (HASP) is a directed payment model that increases Medicaid rates closer to the cost of care.[10] In its third year, covering services from July 2025 to June 2026, the HASP program will include nearly $6.5 billion in gross revenue if all North Carolina hospitals continue to participate in the medical debt relief initiative.[11] However, moving through 2026, this funding mechanism faces a complex new reality: under preliminary Centers for Medicare & Medicaid Services (CMS) guidance issued on February 2, 2026, the OBBB—which CMS refers to as the Working Families Tax Cuts legislation—caps State Directed Payments in expansion states at 100% of Medicare rates.[12] While HASP likely qualifies for a temporary grandfathering period extending to 2028, the new guidance explicitly forbids any increase to the total dollar amount of grandfathered programs.[13] This effectively freezes the $6.5 billion revenue pool, forcing hospitals to navigate tightening federal financial caps while absorbing the ongoing costs of their debt relief compliance.

• Administrative and Cost Pressures: Administratively, the OBBB requirements pose a significant financial burden.[14] The North Carolina Department of Health and Human Services (NCDHHS) anticipates needing millions more each quarter for tracking system upgrades, vendor contracts, and increased county staffing to handle semiannual eligibility checks.[15] Further straining the budget, state Medicaid spending on applied behavioral analysis (ABA) and autism therapy surged 347% between 2022 and 2025 and is projected to exceed $1.1 billion by 2027.[16] To address these pressures, Governor Josh Stein proposed a $1.4 billion critical needs budget that includes $319 million for Medicaid,[17] and NC Medicaid Assistant Secretary Melanie Bush has reportedly outlined three financing options under discussion with lawmakers and hospital groups: (i) redirecting more hospital-related funding into interagency transfers; (ii) increasing the share of insurance premium tax revenue dedicated to Medicaid expansion; or (iii) tapping into savings generated by expansion in other state departments.[18] On April 30, 2026, Governor Stein signed House Bill 696 into law, fully funding Medicaid through the remainder of FY 2026 while imposing heightened eligibility verification, program integrity measures, and oversight of ABA services.[19]

South Carolina

• State Directed Payments Vulnerability: While South Carolina’s status as a non-expansion state shields it from many of the OBBB’s disruptive provisions, the state faces its own challenges regarding its State Directed Payments. South Carolina relies heavily on its Health Access, Workforce, and Quality (HAWQ) program, which projects $2.57 billion in payments for state fiscal year 2026.[20] If hospitals are forced to make deep cuts to services due to federal funding constraints, rural safety-net facilities face high risk of operational distress.

2. Healthcare Workforce Modernization and Capacity Building

State-level workforce expansion initiatives have become critical in 2026 as the national healthcare system faces unprecedented strain. The Health Resources and Services Administration (HRSA)—the primary federal agency responsible for ensuring access to health care services for people who are uninsured, isolated, or medically vulnerable—projects severe nationwide shortages by 2038 across the entire care continuum, spanning clinical medicine, nursing, behavioral health, and long-term support services.[21] Recent data from the National Resident Matching Program (NRMP)—the organization that uses a mathematical algorithm to match medical school graduates with residency programs based on mutual preferences—shows shifting trends in the primary care pipeline, including a 1.4% decrease in the overall primary care fill rate on 2026 Match Day.[22]

In response to these predicted shortfalls, both North Carolina and South Carolina are advancing workforce expansion initiatives this year to address ongoing clinical personnel shortages and stabilize their rural infrastructure. 

North Carolina

• NC ROOTS Hubs: To offset the financial strains placed on rural providers, North Carolina applied for and was awarded $213 million in federal funding for 2026 through the Rural Health Transformation Program (“RHTP”),[23] a $50 billion fund established under the OBBB.[24] NCDHHS is utilizing these funds to establish “NC ROOTS” (Rural Organizations Orchestrating Transformation for Sustainability) Hubs.[25] These locally governed, regional networks will coordinate medical, behavioral health, and social services, making it easier for rural residents to access comprehensive care close to home.[26] Additionally, North Carolina has pledged portions of its RHTP award to “investing in the rural health care workforce” and “supporting more rural providers in transitioning to value-based care models, where providers are paid based on keeping people healthy and out of the hospital rather than on how many services are provided.”[27]

• Healthcare Workforce Reforms Act: On the licensure front, on July 1, 2025, Governor Josh Stein signed into law House Bill 67 (Session Law 2025-37), the Healthcare Workforce Reforms act.[28] Effective January 1, 2026, North Carolina officially joins the Interstate Medical Licensure Compact (IMLC), providing an expedited pathway for out-of-state physicians to secure medical licenses in North Carolina.[29] The law also creates the Internationally-Trained Physician Employee (ITPE) license, establishing a direct pathway for foreign-trained physicians.[30] 

South Carolina

South Carolina is pursuing parallel workforce stabilization strategies with a focus on workplace safety, rural clinical capacity, and educational pipelines.

• Rural Health Transformation Program: South Carolina applied for and was awarded more than $200 million in federal funding for 2026 through the RHTP. The South Carolina Department of Health and Human Services (SCDHHS) announced that its first round of RHTP grants were opened on April 2, 2026 with applications due by June 1, 2026.[31] South Carolina’s first year RHTP grants will focus on “one-time, high-impact investments” in the following areas:
  • “Health IT infrastructure and remote patient monitoring to strengthen care coordination;
  • Expansion of evidence‑based chronic disease programs;
  • Mobile crisis response and community care sites to expand access;
  • Facility enhancements, healthcare workforce investments, and a Masterclass Training Series.”[32]
• The HALO Act: The Helping Alleviate Lawful Obstruction (HALO) Act (H. 4763) is designed to protect first responders and healthcare workers from interference and workplace violence.[33] The amended legislation makes it a misdemeanor to knowingly violate a verbal warning to step back from a first responder (up to 25 feet) or from a healthcare worker within a medical facility (at a distance necessary for safe, unencumbered treatment).[34] To violate the law, the individual must intend to impede duties, attempt physical harm, or—in the case of healthcare workers—harass them.[35] Violations carry a fine of up to $500 and up to 60 days in jail.[36] After passing both chambers with amendments, the bill is now in conference committee as of May 14, 2026.[37]
• Rural Emergency Hospitals: Senate Bill 895 amends the State Health Facility Licensure Act to ensure that hospitals converting to Rural Emergency Hospital (REH) status under federal law retain their state “hospital” classification. Without this change, facilities that convert to REH status— a federal designation that permits rural hospitals to provide emergency and outpatient services without maintaining inpatient beds—risked losing their state licensure status as hospitals.[38] The General Assembly passed S. 895 unanimously, and it was ratified on May 14, 2026, taking effect upon the Governor's approval.[39]

3. Scope of Practice

Efforts to modify historical scope of practice barriers for advanced practice providers (such as physician assistants (PAs) and advanced practice registered nurses (APRNs) remain a highly contested priority in most states.[40] 

North Carolina

• PA Supervision Reforms: Pending the adoption of final rules by the North Carolina Medical Board—currently proposed to take effect on July 1, 2026[41]—North Carolina PAs with over 4,000 hours of clinical experience as a licensed PA and 1,000 hours in a specific specialty will be exempt from the requirement to designate a specific supervising physician, provided they work in team-based settings.[42] Note, however, the law still requires physician supervision for PAs in perioperative settings and prohibits PAs from performing final interpretations of diagnostic imaging.[43]

• The SAVE Act: The SAVE Act (H514/S537) was reintroduced in early 2025 with bipartisan support to grant full practice authority to APRNs by eliminating the requirement for mandated physician supervision.[44] According to the North Carolina Nurses Association, Dr. Chris Conover with Duke University’s Center for Health Policy and Inequalities Research estimates North Carolina could save between $932.9 million and $8.9 billion in healthcare spending each year by granting APRNs full practice authority.[45] However, the bill faces opposition from the North Carolina Medical Society, which argues that removing physician involvement compromises patient safety.[46] While the legislation remains eligible for consideration in the 2026 session, both H514 and S537 have remained stalled in committee since their introduction in the spring of 2025.[47]

South Carolina

• APRN Full Practice Authority: South Carolina has seen a similar legislative push to grant greater practice autonomy to APRNs and PAs. Introduced for the 2025-2026 session, House Bill 3580 and Senate Bill 45 would authorize the State Board of Nursing to grant full practice authority to APRNs, eliminating the need for a practice agreement with a supervising physician.[48] To qualify for full practice authority, an APRN must, among other requirements, complete 2,000 clinical practice hours.[49] The bill also includes provisions allowing APRNs to perform medical acts via telemedicine and telehealth under a practice agreement.[50]

• PA Practice Independence: South Carolina’s companion legislation, House Bill 3579 and Senate Bill 44, would similarly eliminate PAs requirement for a supervisory agreement.[51] Instead, PAs with more than 2,000 hours of postgraduate clinical experience (and an additional 1,000 hours if transitioning to a new medical specialty) would be permitted to practice independently under an “Attestation Statement” submitted to the SC Board of Medical Examiners, confirming their qualifications and commitment to appropriate collaboration without transferring supervisory or legal responsibility to a physician.[52]

Mirroring the dynamic in North Carolina, the South Carolina Medical Association opposes the bills, arguing that the training and education required for nurse practitioners and PAs does not adequately prepare them to practice independently without physician collaboration or supervision. As of late March 2026, these South Carolina APRN and PA scope expansion bills remain stalled in their respective House and Senate committees. Given the ongoing workforce shortages, these scope-of-practice debates will likely continue to resurface in future sessions.[53]

Beyond physicians and advanced practice providers, South Carolina is also considering expanded roles for pharmacists. Senate Bill 449, which authorizes pharmacists and physicians to enter into Collaborative Practice Agreements for medication management and related patient care services, was ratified on May 14, 2026 and takes effect upon approval by the Governor, with implementation subject to forthcoming regulations.[54] Senate Bill 477—aimed at clarifying the Pharmacy Access Act to expand pharmacists’ authority to dispense and administer hormonal contraceptives under standing orders or written joint protocols—was ratified on May 14, 2026 and takes effect upon approval by the Governor.[55]

4. Impacts of repeal of CON in South Carolina; roll back of CON in North Carolina

South Carolina

The South Carolina General Assembly previously enacted the State Health Facility Licensure Act (the “Act”), overhauling the prior State Certificate of Need and Health Facility Licensure Act and drastically reducing its scope.

We covered in prior articles that beginning in 2023, the Act eliminated Certificate of Need (CON) requirements for the vast majority of the 18 services and technologies previously subject to CON review. However, the Act provided a three-year sunset provision to the repeal of CON requirements for:

• Construction of new hospitals; and
• Addition of beds in existing hospitals
• both being subject to limited exceptions.

2026 marks the final year of this sunset provision. Beginning January 1, 2027, hospitals across South Carolina may pursue expansion opportunities similar to those realized by laboratories, cath labs, ASCs, and imaging centers in 2023.

For more than half a century, hospital expansion and development in South Carolina has been subject to CON. The expiration of the sunset provision on January 1, 2027, will usher in a new era of outside investment and growth. Throughout 2026, health systems that have cemented their presence through acquisition are likely finalizing expansion plans and beginning project rollouts in anticipation of the sunset. The market has already attracted substantial regional and national investment, and significant growth is expected from both existing players and new players using the repeal of CON as an opportunity to enter South Carolina’s health care market.

Notably, nursing homes and home health agencies will remain subject to CON approval under the Act.

North Carolina

In 2026, North Carolina lawmakers are expected to continue their efforts to repeal or restrict the state’s remaining CON requirements.

• Senate Bill 370, introduced in 2025, would completely repeal North Carolina’s CON laws but was not approved before the legislative session adjourned. The bill remains on the agenda in 2026, and legislators are likely to continue targeting CON restrictions as neighboring states like South Carolina deregulate to attract growth and investment.
• The case of Singleton v. N.C. Dep’t of Health & Hum. Servs. remains ongoing. On December 12, 2025, a bipartisan Superior Court panel again upheld North Carolina’s CON law as constitutional. Dr. Singleton has filed another appeal with the State Supreme Court, likely to be reviewed in 2026.⁶¹

5. Potential reform of Medical Malpractice laws in South Carolina

South Carolina has pursued multiple tort reform initiatives in recent years. In 2025, the legislature introduced S. 244, a bill addressing joint and several liability and allocation of fault among plaintiffs, defendants, and non-parties. At the time, the bill was an ambitious effort that appeared to have considerable support but it has remained in the Senate Judiciary Committee since April 3, 2025. We will be tracking the bill’s progress to see if it is picked back up before the 2026 legislative session adjourns.

The General Assembly is now directly targeting medical malpractice laws through H. 4544, introduced May 8, 2025, and revitalized in early March 2026.⁶² The bill seeks to amend exceptions to the limitations on noneconomic damages in S.C. Code § 15‑32‑220(E).

Changes to Noneconomic Damages Caps

If passed, the limitations for noneconomic damages rendered against any “healthcare provider or healthcare institution” would not apply where specified exceptions are met. H. 4544 would revise these exceptions so that the limitations would not apply if a court or jury determines, “by clear and convincing evidence, that the defendant:⁶³

1. Acted in a willful, wanton, or reckless manner;
2. Has pled guilty to or been convicted of a felony arising from the same course of conduct complained of by the plaintiff and that the act or course of conduct is a proximate cause of the plaintiff’s damages;
3. Acted or failed to act while under the influence of alcohol or drugs to the degree that his judgment was materially and appreciably impaired; or
4. The defendant engaged in fraud or misrepresentation related to the claim.”

The bill would also remove “gross negligence” as an exception to the noneconomic damages cap. This aligns with earlier recommendations from the South Carolina Hospital Association (SCHA), which urged removal of the gross negligence exception to bring “financial predictability and cost control to the medical malpractice landscape in our state.”⁶⁴ The SCHA also clarified that, “while patients harmed by negligence deserve fair compensation, the current system creates career-ending risks for providers and jeopardizes access to care statewide.”⁶⁵

Redefinition of “Occurrence”

H. 4544 would also amend the definition of “occurrence” in S.C. Code § 15‑78‑30(g) to mean:

“an unfolding sequence of events which proximately flow from a single act of negligence. For purposes of this chapter, where multiple acts or omissions constituting negligence occur without a break in the causal chain, and result in substantially the same injury, harm, or damages, such acts or omissions shall be deemed a single occurrence, regardless of whether committed by one or more individuals or entities.”

This change, consistent with prior SCHA recommendations, could consolidate multiple negligent acts, even if those acts are committed by different providers or different entities, into a single occurrence where the injury is substantially the same.⁶⁶

H. 4544 passed the House of Representatives unanimously on March 25, 2026 and now awaits review by the Senate Judiciary Committee.⁷³ We will be closely monitoring the bill’s progress in 2026 given its potential to reshape medical malpractice exposure and claims strategy in South Carolina.

6. Continued Expansion of use of AI

The integration of Artificial Intelligence (AI) into clinical decision support and utilization management continues to prompt states to establish their own regulatory environments in the absence of a unified federal framework. 

North Carolina

• AI Leadership Council: To centralize the state’s approach to AI, Governor Josh Stein established the North Carolina AI Leadership Council via Executive Order 24.[56] Co-chaired by the Secretary of the North Carolina Department of Information Technology and the Secretary of the North Carolina Department of Commerce (or designee), the 25-member council is explicitly tasked with developing a State AI Strategic Roadmap and delivering policy frameworks by June 30, 2026.[57]

• Medical Board Guidance: On the clinical front, the North Carolina Medical Board issued formal position statements addressing the use of AI in patient care, noting that licensees retain responsibility for patient care and management when using clinical decision-making support tools such as augmented or artificial intelligence.[58] The Board emphasized that if a licensee uses AI and suggests a course of treatment that deviates from the AI’s recommendation, they must document the rationale behind the deviation; conversely, blindly implementing the recommendations of an AI tool without a corresponding rationale may fall below the standard of care.[59]

• Pending Legislation: While legislative proposals like Senate Bill 287 (targeting AI in utilization reviews) and Senate Bill 624 (targeting chatbot licensing) were introduced in 2025, they have seen no movement in over a year.[60]

South Carolina

• AI in Utilization Management: A South Carolina lawmaker introduced Senate Bill 443 (S. 443), targeting the use of AI in utilization management.[61] The legislation legally mandates that no actions can be taken regarding healthcare coverage decisions based solely on results derived from AI or automated decision-making tools.[62] The bill requires that a licensed health care professional “meaningfully review” and supervise any coverage decisions derived from these tools when used to modify or deny prior authorization requests.[63] While S. 443 remains eligible for consideration in the 2026 session, it has remained stalled in committee since its introduction in March 2025.[64]

• AI in Therapy: Introduced in January 2026, South Carolina Senate Bill 788 restricts the use of AI in therapy to limited administrative or supplemental tasks requiring patient consent.[65] The legislation also prohibits AI‑only therapy services and forbids AI from making clinical decisions, interacting directly with clients, or generating treatment plans without professional oversight.[66] Following a favorable committee report with amendment in late March 2026, the South Carolina Senate adopted the committee amendment and unanimously passed S.B. 788 on second reading on April 28, 2026, advancing the bill toward final Senate consideration.[67] In response to the bill, the American Telemedicine Association (ATA Action) has expressed concern that its overly broad language and lack of exemptions for FDA-cleared products could inadvertently prevent clinicians from utilizing beneficial AI technologies that are consistent with their standard of care.[68]

• Consumer Protection: In February 2026, Senator Leber introduced Senate Bill 963, the “Consumer Protections in Interactions with Artificial Intelligence Systems Act,” to, among other things, prohibit algorithmic discrimination arising from use of high-risk AI systems.[69] The bill mandates that developers of high-risk AI systems conduct impact assessments and use reasonable care to protect consumers from any known or reasonably foreseeable risks of algorithmic discrimination.[70] The legislation grants the Attorney General exclusive enforcement authority, classifying violations as unfair trade practices; it remains in the Senate Committee on Banking and Insurance.[71]

As AI capabilities continue to evolve, health care providers and organizations in both states should monitor these legislative developments closely. The patchwork of proposed regulations reflects broader national uncertainty about how to balance innovation with patient safety, and facilities using AI-driven tools for clinical or administrative functions may need to adapt quickly as new requirements take effect.

7. Legislative Efforts to Restrict Noncompetes in Physician Employment Agreements

Legislative efforts to restrict the use of noncompete provisions in physician employment agreements is one of the most pressing issues across the current healthcare landscape in both South Carolina and North Carolina.

South Carolina

Senate Bill 46

Introduced in early 2025, S. 46 declares certain contract provisions that interfere with the physician–patient relationship to be against public policy and unenforceable.⁸⁹ These “contravening” provisions include:

• Any restriction on a physician’s ability to practice medicine in any geographic area for any period after termination of a partnership, employment, or professional relationship;
• Any restriction on a physician’s ability to continue treating, advising, or consulting with any current patient at that patient’s request after departure; and
• Any restriction on a physician’s right to establish a physician–patient relationship with any patient who requests it upon the physician’s departure.

House Bill 4767

On January 13, 2026, several members of the House of Representatives introduced H. 4767, which similarly seeks to prohibit noncompete clauses in physician contracts, protect patient choice, and define impermissible restrictions.⁸² The bill:

• Declares any restriction on a physician’s ability to practice in any geographic area for any period post-termination to be “[i]mpermissible, unenforceable, and void…”;
• Prohibits restrictions on a physician’s ability to continue providing treatment, advice, or consultation to current patients at their request after departure; and
• Prohibits restrictions on a physician’s right to establish new physician–patient relationships at a patient’s request upon leaving an employer.⁸³

H. 4767 passed the House on March 26, 2026, and was introduced in the Senate the same day, where it has been referred to the Senate Committee on Labor, Commerce, and Industry.⁸⁴ As of late April 2026, H. 4767 has been placed on the agenda of the Senate Labor, Commerce, and Industry Committee, marking the bill’s first substantive Senate consideration following House passage.[72]

Supporters of this legislation, including the South Carolina Medical Association (SCMA) and hospitals who do not currently utilize physician noncompetes, argue that banning physician non-competes will:

• Increase competition in physician recruitment;
• Potentially lower costs and improve quality; and
• Preserve patients’ ability to follow their preferred physicians through job changes.⁸⁵

Opponents, primarily those hospitals currently utilizing physician noncompetes and independent physician practices, warn that the legislation could fuel provider turnover and threaten access to care, particularly in rural areas.⁹⁴ Given its strong momentum, H. 4767 has the potential to significantly reshape physician recruitment, retention, and contracting across South Carolina.

During the legislative interim, we will closely monitor discussions regarding physician noncompete agreements occurring outside the State House, as this issue is likely to resurface in the upcoming legislative session.

North Carolina

Senate Bill 978

Filed April 30, 2026, S.B. 978 seeks to amend Chapter 66 of the North Carolina General Statutes by adding §§ 515-519 to address the use of nondisclosure agreements and non-compete clauses in “health care professional” contracts.[73] Proposed § 66-515 defines “[n]on-compete clause or clause” as “[a]n agreement that restricts a party from engaging in certain types of employment or business activities for a specified period of time within a specified geographic area,” and defines “[h]ealth care professional” as “[a]n individual who is a licensed physician, physician assistant, advanced practice registered nurse as defined by the North Carolina Board of Nursing, or registered nurse.”[74] While proposed § 66-517 prohibits the use of a “non-compete clause”, it does so only for “employment contract[s] for a health care professional employed by a hospital. . .,” limiting the scope of the proposed ban.[75]

Adding further protections, proposed § 66-518 states that “[a]ny policy, nondisclosure agreement, non-compete clause, medical staff bylaw, or any other type of contractual agreement with a health care professional shall not prohibit the provision of new practice information upon request by a patient, and, if available, the recipient of that request shall provide that information upon that request.”[76] Unlike proposed § 66-517, the scope of § 66-518 is not limited to a “health care professional employed by a hospital,” meaning that it could impact all health care professional contracts entered into after July 1, 2026.[77]

Throughout 2026, we will be closely tracking this bill’s progress and its momentum as it begins its journey through the North Carolina Senate.

8. The Regulation of Pharmacy Benefit Managers (PBMs)

North Carolina

On July 9, 2025, North Carolina Governor Joshua Stein signed into law Senate Bill 479, the SCRIPT Act. According to the North Carolina General Assembly’s description, the SCRIPT Act, which went into effect October 1, 2025, does the following to regulate PBMs within the state:

• Modify the pharmacy of choice provisions in G.S. 58-51-37.
• Implement licensing and regulation of pharmacy services administrative organizations (PSAO).
• Require PBMs to report to the Department of Insurance (DOI) and act as a fiduciary in all of their contractual dealings.
• Apply the prescription drug coverage provisions of Chapter 58 (Insurance) to PBMs.
• Clarify that the pharmacy of choice provisions of Chapter 58 apply to PBMs.
• Allow independent pharmacies to decline to fill a prescription and refer a patient if that can be done without causing harm to the patient.
• Make changes to and recodify the pharmacy audit procedures in Chapter 90 (Health and Allied Occupations).
• Require PBMs to reimburse affiliated and non-affiliated pharmacies the same rate for the same services.
• Require drug manufacturers to notify interested parties about price increases.
• Require the Board of Pharmacy to report on the number of openings and closings of small and large pharmacies each year.
• Make violation of many of these provisions unfair trade practices.
• Require the State Health Plan (SHP) to study the economic feasibility of incorporating many of these provisions into the SHP when the third-party administrative services contract is renewed.[78]

Additionally, North Carolina Senate Bill 257, which went into effect December 1, 2025, requires the North Carolina Department of Insurance (NCDOI) to begin licensing PBMs. According to the NCDOI, this change “promote[s] pricing transparency for patients and establish[es] standards and criteria for the regulation and licensure of PBMs providing services for Health Benefit Plans in North Carolina.[79]

On February 17, 2026, NCDOI Commissioner Mike Causey and Attorney General Jeff Jackson published a co-authored letter addressed to the state’s PBMs clarifying the SCRIPT Act’s purpose and its requirements. The letter states that the SCRPIT Act “bolsters and expands the legal and regulatory framework and enforcement authority of the [NCDOI] over PBMs.” The letter also states that “the NCDOI and NCDOJ are focused on promoting a robust, transparent and stable insurance market while also ensuring the safety and fair treatment of North Carolina consumers,” and that “North Carolina’s SCRIPT Act represents a shift toward PBM transparency, accountability and consumer protections.”

The letter then concludes by reminding PBMs licensed in the state that pursuant to the SCRIPT Act, PBMs must: (1) allow any willing pharmacy to participate in their networks, (2) not require that a consumer purchase prescription drugs exclusively through a mail-order pharmacy, and (3) ensure that reimbursement rates for an independent pharmacy or a pharmacy in a pharmacy desert must at least cover the acquisition cost for the covered drug, device or service.[80]

South Carolina

South Carolina has not passed significant PBM legislation since Act 30 (S.520) was signed into law  on May 16, 2023 and took effect January 1, 2024. Although the 2026 legislative session has yet to officially adjourn, it does not appear that lawmakers in South Carolina will propose any changes to its current PBM legislation in 2026.

9. Scope of Practice Changes for Pharmacists in North Carolina

In 2025, North Carolina signed into law H.B. 67 which sought generally to enact healthcare workforce reforms for the state of North Carolina. Those reforms included significant updates to North Carolina’s pharmacy practice landscape. Part V of H.B. 67 amended the definition of the “Practice of Pharmacy” found at § 90-85.3A of the North Carolina General Statutes to include the administration of drugs and to allow pharmacists to “order and perform a CLIA-waived test and initiate treatment pursuant to the result of the CLIA-waived test for influenza in accordance with statewide protocols.” However, the amended language clarifies that “[a] pharmacist shall not treat a health condition under this section with any controlled substance classified in Schedules I through IV.”[81] Among other things, Part V also adds § 58-3-241 to the North Carolina General Statutes requiring “[a] health benefit plan offered by an insurer in this State [to] cover healthcare services provided by a pharmacist if. . . the services or procedure was performed within the pharmacist’s licensed lawful scope of practice. . . and [t]he health benefit plan would have covered the service if the service or procedure had been performed by another healthcare provider.”[82]

Part VII of H.B. 67 makes significant revisions to the pharmacist collaborative practice agreement requirements found at § 90-18(c)(3a) which now states that “[t]he provision of health care services by a licensed pharmacist under a collaborative practice agreement with one or more physicians shall be performed in accordance with rules developed by a joint subcommittee of the North Carolina Medical Board and the North Carolina Board of Pharmacy and approved by both Boards. For the purposes of this subdivision, “health care services” means medical tasks, acts, or functions authorized through a written agreement by a physician and delegated to a pharmacist for the purpose of providing drug therapy, disease, or population health management for patients.” Part VII also updates the qualifications and limitations for “clinical pharmacist practitioners” found at § 90-18.4 as well as an expanded list of requirements that must be met by all “clinical pharmacist practitioners and supervising physicians engaging in collaborative practice. . .” including the requirement that “[h]ealth care services delegated by a supervising physician, such as initiating, changing, or discontinuing drugs, or ordering tests or devices, to assist with drug therapy, disease, or population health management, must be included in the written agreement between the supervising physician and the clinical pharmacist practitioner.”[83]

Both Parts V and VII of H.B. 67 took effect October 1, 2025.

Maynard Nexsen will be following these and other key health care and life sciences issues in the Carolinas throughout 2026.

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[_{1] Although widely referred to as the One Big Beautiful Bill, the law has no official short title because that designation was removed during the Senate amendment process. The Centers for Medicare & Medicaid Services refers to the legislation as the Working Families Tax Cuts.}

_{[2] Pub. L. No. 119-21, 139 Stat. 72 (2025), https://www.govinfo.gov/content/pkg/PLAW-119publ21/pdf/PLAW-119publ21.pdf.}

_{[3] Cong. Budget Off., Public Law 119-21, to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Title VII, Finance, Subtitle B, Health, Chapter 1, Medicaid, at 1 (Oct. 28, 2025), https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf.}

_{[4] Preethi Rao et al., State-Level Impacts of Key Medicaid Provisions in the One Big Beautiful Bill Act, RAND Corporation, at 4 (Feb. 26, 2026), https://www.rand.org/content/dam/rand/pubs/research_reports/RRA4000/RRA4098-1/RAND_RRA4098-1.pdf.}

_{[5] Ctrs. for Medicare & Medicaid Servs., Letter Regarding Sections 71115 and 71117 of Working Families Tax Cuts Legislation on Provider Taxes (Nov. 14, 2025), https://www.medicaid.gov/medicaid/downloads/providertax_dcl_11142025.pdf. In addition to the 0% threshold for newly enacted taxes, the OBBB establishes a separate phase-down of the indirect hold harmless threshold for Medicaid expansion states. Beginning in Fiscal Year (FY) 2028, the applicable threshold for these states drops to the lower of 5.5% or their July 4, 2025, applicable percentage. This limit decreases by 0.5% annually until reaching a permanent floor of 3.5% in FY 2032. See id.}

_{[6] Pub. L. No. 119-21, § 71107, 139 Stat. 72 (2025), https://www.govinfo.gov/app/details/PLAW-119publ21.}

_{[7] Pub. L. No. 119-21, § 71119, 139 Stat. 72 (2025), https://www.govinfo.gov/app/details/PLAW-119publ21.}

_{[8] Supplemental Cost Estimate, Cong. Budget Off., 6 (Oct. 28, 2025), https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf; Preethi Rao et al., State-Level Impacts of Key Medicaid Provisions in the One Big Beautiful Bill Act, RAND Corporation, 8 (Feb. 26, 2026), https://www.rand.org/content/dam/rand/pubs/research_reports/RRA4000/RRA4098-1/RAND_RRA4098-1.pdf.}

_{[9] See N.C. Gen. Stat. § 108A-54.3C; Will One Big Beautiful Bill rescue South Carolina’s rural hospitals?, S.C. Inst. of Med. & Pub. Health (Aug. 1, 2025) (“Expansion states expect to see large numbers of recipients fall off Medicaid rolls, as those rolls expanded access to more people.”), https://imph.org/will-one-big-beautiful-bill-rescue-south-carolinas-rural-hospitals-or-break-them/.}

_{[10] See What is the Healthcare Access and Stabilization Program (HASP)?, NCIOM (Oct. 9, 2024), https://nciom.org/what-is-the-healthcare-access-and-stabilization-program-hasp/.}

_{[11] Press Release, N.C. Dep’t of Health & Hum. Servs., Hospital Payment Program and Medical Debt Relief Initiative Approved for Another Year (Feb. 5, 2025), https://www.ncdhhs.gov/news/press-releases/2025/02/05/hospital-payment-program-and-medical-debt-relief-initiative-approved-another-year.}

_{[12] See Ctrs. for Medicare & Medicaid Servs., Letter Regarding Section 71116 of the Working Families Tax Cuts Legislation on State Directed Payments (Feb. 2, 2026) (This letter is preliminary in nature and policies will be finalized through notice-and-comment rulemaking.), https://www.medicaid.gov/medicaid/managed-care/downloads/sdp-letter-02022026.pdf.}

_{[13] Id.}

_{[14] Jaymie Baxley, NC faces tight deadline, high costs to implement Medicaid work requirement, N.C. Health News (Jan. 14, 2026), https://www.northcarolinahealthnews.org/2026/01/14/medicaid-work-burden/.}

_{[15] Id.}

_{[16] Andrew Pomeranz, NC Lawmakers Probe Surge in Autism Therapy Costs, Carolina Journal (Mar. 23, 2026), https://www.carolinajournal.com/nc-lawmakers-probe-surge-in-autism-therapy-costs/.}

_{[17] Press Release, N.C. Off. of the Gov., Governor Stein Proposes $1.4 Billion Critical Needs Budget to Keep North Carolina Strong, Including $319 Million for Medicaid and Raises for Law Enforcement, Teachers, Nurses and Other Public Servants (Mar. 9, 2026), https://governor.nc.gov/news/press-releases/2026/03/09/governor-stein-proposes-14-billion-critical-needs-budget-keep-north-carolina-strong-including-319.}

_{[18] Jaymie Baxley, NC faces tight deadline, high costs to implement Medicaid work requirement, N.C. Health News (Jan. 14, 2026), https://www.northcarolinahealthnews.org/2026/01/14/medicaid-work-burden/.}

_{[19] Act Making Various Changes to the Medicaid Program and Other Changes Related to Health and Human Services, Implementing Various Budgetary Adjustments, and Making Other Changes in the Budget Operations of the State, S.L. 2026-1 (enacted April 30, 2026), https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H696v5.pdf.}  

_{[20] S.C. Dep’t of Health & Hum. Servs., SFY 2026 Medicaid Managed Care Capitation Rate Certification (June 18, 2025), https://www.scdhhs.gov/sites/dhhs/files/documents/SFY%202026%20Medicaid%20Managed%20Care%20Certification.pdf.}

_{[21] Health Workforce Projections, Health Res. & Servs. Admin. (Dec. 2025), https://bhw.hrsa.gov/data-research/projecting-health-workforce-supply-demand.}

_{[22] Press Release, Nat'l Resident Matching Program, NRMP Releases Results of the 2026 Main Residency Match for More Than 38,000 Future Residents (Mar. 20, 2026), https://www.nrmp.org/about/news/2026/03/nrmp-releases-results-of-the-2026-main-residency-match-for-more-than-38000-future-residents/.}

_{[23] Press Release, N.C. Off. of the Gov., North Carolina Awarded $213 Million for Rural Health Transformation Program (Dec. 29, 2025), https://governor.nc.gov/news/press-releases/2025/12/29/north-carolina-awarded-213-million-rural-health-transformation-program.}

_{[24] See N.C. Dep’t of Health & Hum. Servs., Rural Health Transformation Program: NC ROOTS Hubs, NCDHHS.gov, https://www.ncdhhs.gov/divisions/office-rural-health/rural-health-transformation-program (last visited Apr. 1, 2026).}

_{[25] See id.}

_{[26] Id.}

_{[27] Id.}

_{[28] Act to Enact Healthcare Workforce Reforms for the State of North Carolina, S.L. 2025-37 (enacted July 1, 2025), https://www.ncleg.gov/EnactedLegislation/SessionLaws/PDF/2025-2026/SL2025-37.pdf.}

_{[29] Id.}

_{[30] Id.}

_{[31] SCDHHS Opens Year-1 Rural Healthcare Transformation Grants on April 2, SC Hospital Association, https://scha.org/news/scdhhs-opens-year%E2%80%911-rural-healthcare-transformation-grants-april-2/ (March 27, 2026).}

_{[32] Id.}

_{[33] Helping Alleviate Lawful Obstruction (HALO) Act, H.B. 4763, 126th Gen. Assemb., Reg. Sess. (S.C. 2026), https://www.scstatehouse.gov/sess126_2025-2026/bills/4763.htm (last visited May 15, 2026).}

_{[34] Id.}

_{[35] Id.}

_{[36] Id.}

_{[37] Id.}

_{[38] S.B. 895, 126th Gen. Assemb., Reg. Sess. (S.C. 2026), https://www.scstatehouse.gov/sess126_2025-2026/bills/895.htm (last visited May 15, 2026).}

_{[39] Id.}

_{[40] See Executive summary: Medicine’s 2026 state policy priorities, Am. Med. Ass’n, https://www.ama-assn.org/system/files/ama-state-legislative-preview-survey-summary.pdf (last visited Mar. 28, 2026).}

_{[41] N.C. Med. Bd., Notice of Text for Proposed Rule 21 N.C. Admin. Code 32S.0227 (filed Feb. 9, 2026), https://www.ncmedboard.org/images/uploads/rules/21_NCAC_32S_.0227_-Team_based_Notice.pdf.}

_{[42] Act to Enact Healthcare Workforce Reforms for the State of North Carolina, S.L. 2025-37 (enacted July 1, 2025), https://www.ncleg.gov/EnactedLegislation/SessionLaws/PDF/2025-2026/SL2025-37.pdf.}

_{[43] Id.}

_{[44] SAVE Act, H.B. 514 / S.B. 537, 2025-2026 Gen. Assemb., Reg. Sess. (N.C. 2025), https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H514v1.pdf; https://www.ncleg.gov/Sessions/2025/Bills/Senate/PDF/S537v1.pdf.}

_{[45] Savings Estimate for Full Practice Authority, N.C. Nurses Ass’n (Mar. 18, 2025), https://www.ncnurses.org/advocacy/legislative/aprn-full-practice-authority/savings-estimate-for-full-practice-authority/.}

_{[46] Contact Your Legislators; Ask Them to Oppose the SAVE Act, N.C. Med. Soc’y (Mar. 25, 2025), https://ncmedsoc.org/contact-your-legislators-ask-them-to-oppose-the-save-act/.}

_{[47] Bill History for H.B. 514, N.C. Gen. Assemb., https://www.ncleg.gov/BillLookUp/2025/H514 (last visited Apr. 29, 2026); Bill History for S.B. 537, N.C. Gen. Assemb., https://www.ncleg.gov/BillLookUp/2025/S537 (last visited Apr. 29, 2026).}

_{[48] H.B. 3580 / S.B. 45, 126th Gen. Assemb., Reg. Sess. (S.C. 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/3580.htm; https://www.scstatehouse.gov/sess126_2025-2026/bills/45.htm (last visited Apr. 29, 2026).}

_{[49] Id.}

_{[50] Id.}

_{[51] H.B. 3579 / S.B. 44, 126th Gen. Assemb., Reg. Sess. (S.C. 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/3579.htm; https://www.scstatehouse.gov/sess126_2025-2026/bills/44.htm (last visited Apr. 29, 2026).}

_{[52] Id.}

_{[53] Protect Patient Access to Physician-Led Care, S.C. Med. Ass’n, https://www.scmedical.org/advocacy/protect-patient-access-to-physician-led-care/ (last visited Mar. 30, 2026).}

_{[54] Bill History for S.B. 449, 126th Gen. Assemb., Reg. Sess. (S.C. 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/449.htm (last visited May 15, 2026).}

_{[55] Bill History for S.B. 477, 126th Gen. Assemb., Reg. Sess. (S.C. 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/477.htm (last visited May 15, 2026).}

_{[56] Exec. Order No. 24 (N.C. Sept. 2, 2025), https://governor.nc.gov/executive-order-no-24-advancing-trustworthy-artificial-intelligence-benefits-all-north-carolinians.}

_{[57] Id.}

_{[58] N.C. Med. Bd., Position Statement 5.1.5: Licensee Use of Innovative or New Treatment (amended May 2024), https://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/licensee-use-of-innovative-or-new-treatment.}

_{[59] N.C. Med. Bd., Position Statement 3.2.1: Medical Records – Documentation, Electronic Health Records, Access, and Retention (amended Jan. 2026), https://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/medical-records-documentation-electronic-health-records-access-and-retentio.}

_{[60] S.B. 287, 2025 Gen. Assemb., Reg. Sess. (N.C. 2025), https://www.ncleg.gov/BillLookUp/2025/S287  (last visited Apr. 29, 2026); S.B. 624, 2025 Gen. Assemb., Reg. Sess. (N.C. 2025), https://www.ncleg.gov/BillLookUp/2025/S624  (last visited Apr. 29, 2026).}

_{[61] S.B. 443, 126th Gen. Assemb., Reg. Sess. (S.C. 2025), https://www.scstatehouse.gov/sess126_2025-2026/bills/443.htm (last visited Apr. 29, 2026).}

_{[62] Id.}

_{[63] Id.}

_{[64] Id.}

_{[65] S.B. 788, 126th Gen. Assemb., Reg. Sess. (S.C. 2026), https://www.scstatehouse.gov/sess126_2025-2026/bills/788.htm  (last visited Apr. 29, 2026).}

_{[66] Id.}

_{[67] Id.}

_{[68] Letter from Hunter Young, Head of State Gov’t Rels., ATA Action, to Sen. Tom Davis, Chair, S.C. Senate Labor, Com. & Indus. Comm. (Mar. 17, 2026), https://www.americantelemed.org/wp-content/uploads/2026/03/SC-SB-788-ATA-Action-Letter.pdf.}

_{[69] S.B. 963, 126th Gen. Assemb., Reg. Sess. (S.C. 2026), https://www.scstatehouse.gov/sess126_2025-2026/bills/963.htm  (last visited Apr. 29, 2026).}

_{[70] Id.}

_{[71] Id.}

_{[72] S.C. Senate Labor, Commerce & Industry Comm., Agenda, 126th Gen. Assemb., Reg. Sess. (Apr. 30, 2026) (listing H.B. 4767 on the committee agenda for consideration), https://www.scstatehouse.gov/agendas/126s16477.pdf.}

_{[73] https://webservices.ncleg.gov/ViewBillDocument/2025/8383/0/DRS15432-BCfa-5.}

_{[74] Id.}

_{[75] Id.}

_{[76] Id.}

_{[77] Id.}

_{[78] S.B. 479: SCRIPT Act., (S.C. 2025), https://dashboard.ncleg.gov/api/Services/BillSummary/2025/S479-SMBC-90(e6)-v-1}

_{[79] https://www.ncdoi.gov/licensees/life-and-health-licensing/pharmacy-benefit-manager-licensing}

_{[80] https://www.ncdoi.gov/script-act-letter/open}

_{[81] https://www.ncleg.gov/Sessions/2025/Bills/House/PDF/H67v6.pdf.}

_{[82] Id.}

_{[83] Id.}