---
type: source
title: "CMS Launches BALANCE Model to Expand GLP-1 Access in Medicare Part D and Medicaid"
author: "Centers for Medicare & Medicaid Services"
url: https://www.cms.gov/priorities/innovation/innovation-models/balance
date: 2025-12-23
domain: health
secondary_domains: [internet-finance]
format: policy
status: enrichment
priority: high
tags: [glp-1, cms, balance-model, medicare, medicaid, value-based-care, payment-model]
processed_by: vida
processed_date: 2026-03-16
enrichments_applied: ["value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk.md", "GLP-1 receptor agonists are the largest therapeutic category launch in pharmaceutical history but their chronic use model makes the net cost impact inflationary through 2035.md", "the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness.md"]
extraction_model: "anthropic/claude-sonnet-4.5"
---

## Content

CMS announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model on December 23, 2025. Key features:

**Structure:**
- Voluntary model for Medicare Part D plans and state Medicaid agencies
- Covers GLP-1 medications for weight management and metabolic health improvement
- CMS negotiates drug pricing and coverage terms with manufacturers on behalf of participating plans
- Manufacturer Request for Applications due January 8, 2026

**Timeline:**
- Medicaid agencies: May 2026
- Medicare Part D plans: January 2027
- Bridge demonstration for Medicare Part D: July 2026
- Model testing concludes: December 2031

**Key innovation:**
- Combines GLP-1 medication access with evidence-based lifestyle supports
- Not just drug coverage — requires comprehensive health improvement approach
- CMS exploring incentives including adjustment of capitated payment rates for obesity and increasing government reinsurance

**Payment model interaction:**
- Voluntary participation by manufacturers, plans, and states
- CMS negotiates centrally, reducing plan-level negotiation costs
- Model explicitly designed to test whether combined medication + lifestyle support produces better long-term outcomes and cost savings

## Agent Notes
**Why this matters:** This is the first CMS payment model specifically designed to test the GLP-1 + VBC interaction. The requirement for lifestyle supports alongside medication addresses the adherence problem (lifestyle changes may sustain benefits after medication discontinuation). The adjustment of capitated payment rates for obesity is a direct incentive mechanism for MA plans to cover GLP-1s.
**What surprised me:** The BALANCE model is not just drug coverage — it requires lifestyle interventions. This is CMS explicitly testing whether the combination (medication + behavior change) can solve the chronic use / adherence problem that makes GLP-1s inflationary. If it works, it validates the attractor state thesis more broadly.
**What I expected but didn't find:** No specific outcome metrics or success criteria published yet. No details on what "evidence-based lifestyle supports" means operationally. No analysis of which state Medicaid programs are likely to participate.
**KB connections:** Directly tests [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]]. Also connects to [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]] — the BALANCE model is a policy attempt to move more payment toward genuine risk.
**Extraction hints:** Potential claim: "The CMS BALANCE Model is the first federal payment model explicitly designed to test whether GLP-1 medications combined with lifestyle supports can produce net cost savings under risk-bearing arrangements."
**Context:** CMS Innovation Center models have mixed track records. Many voluntary models fail due to adverse selection (only plans that expect to benefit participate). But the BALANCE model's design — combining medication access with lifestyle support and capitation adjustments — is more sophisticated than typical drug coverage expansion.

## Curator Notes (structured handoff for extractor)
PRIMARY CONNECTION: [[the healthcare attractor state is a prevention-first system where aligned payment continuous monitoring and AI-augmented care delivery create a flywheel that profits from health rather than sickness]]
WHY ARCHIVED: First explicit federal test of the GLP-1 + VBC thesis — if it demonstrates net savings under risk-bearing, it validates the prevention-first attractor state; if it fails, it complicates it
EXTRACTION HINT: Focus on the structural design (medication + lifestyle + payment adjustment) as a test of the attractor state thesis, not just as drug coverage policy


## Key Facts
- CMS announced the BALANCE Model on December 23, 2025
- Manufacturer RFA due January 8, 2026
- Medicaid participation begins May 2026
- Medicare Part D bridge demonstration begins July 2026
- Full Medicare Part D participation begins January 2027
- Model testing concludes December 2031
- CMS negotiates pricing centrally on behalf of participating plans
- Model includes adjustment of capitated payment rates for obesity
- Model includes increased government reinsurance for participating plans
