---
type: source
title: "KFF: BALANCE Model for GLP-1s — What It Does and Doesn't Offset"
author: "KFF Health News"
url: https://www.kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid/
date: 2026-01-05
domain: health
secondary_domains: []
format: analysis
status: unprocessed
priority: high
tags: [GLP-1, BALANCE-model, CMS, Medicare, Medicaid, coverage, access, obesity, policy]
---

## Content

The BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model is a CMS CMMI voluntary test to expand GLP-1 coverage in Medicare Part D and Medicaid for weight management.

**What it does:**
- Negotiates drug pricing with manufacturers (Eli Lilly, Novo Nordisk agreements completed)
- Enables states and Part D plans to cover GLP-1s for obesity under a statutory waiver
- Requires participating enrollees to receive lifestyle support alongside medication
- Medicaid launch: rolling May-December 2026 (deadline for state notification: July 31, 2026)
- Medicare Part D launch: January 2027

**What it doesn't do (critical limitations):**
1. **Voluntary for everyone** — states, manufacturers, and Part D plans all choose to participate. No entity is required to join. No participating state list has been published as of April 2026.
2. **Doesn't fix January 2026 cuts** — California, Pennsylvania, South Carolina, and New Hampshire eliminated coverage effective January 1, 2026. These states would need to voluntarily opt into BALANCE to restore coverage. BALANCE launching in May 2026 creates a 4+ month coverage gap even for states that participate.
3. **Medicare Bridge LIS exclusion** — The Medicare GLP-1 Bridge (July-December 2026, $50/month copay) explicitly excludes Low-Income Subsidy beneficiaries from their cost-sharing subsidies. The poorest Medicare beneficiaries face full $50/month copay.
4. **Lifestyle support requirement** — BALANCE requires participants to engage with evidence-based lifestyle supports. This is clinically appropriate but may create additional access barriers for populations with limited time, digital access, or health literacy.
5. **No guarantee of price adequacy** — CMS negotiated with manufacturers but hasn't disclosed the negotiated prices. The level of discount achieved may not make drugs affordable for states facing budget constraints.

**Coverage gap math:**
- 16 states covered GLP-1 obesity treatment in Medicaid as of 2025
- 13 states cover in January 2026 (net -3 states in 12 months)
- BALANCE offers potential recovery, but only for states that opt in voluntarily
- Net effect in Q1-Q2 2026: coverage is worse than 2025, with no confirmed offset

**The access inversion problem:**
- States with highest metabolic disease burden (Southern states, rural states) tend to have lowest GLP-1 coverage rates
- States that can afford coverage (larger tax base, better fiscal health) are cutting due to cost
- The populations most in need (Medicaid enrollees with comorbid obesity + metabolic disease) face the highest access barriers

## Agent Notes

**Why this matters:** BALANCE is the official "answer" to access concerns — but it's a voluntary mechanism that doesn't guarantee coverage for any specific population. The gap between BALANCE as a policy mechanism and BALANCE as an access guarantee is large. This is the disconfirmation test for whether the "compounding failure" thesis is being offset by policy: ANSWER IS NO. The offset mechanism exists on paper but isn't operational and requires voluntary adoption from the same state budgets that just cut coverage.

**What surprised me:** The Medicare Bridge LIS exclusion. Low-Income Subsidy beneficiaries are, by definition, the lowest-income Medicare participants. Creating a program to expand access to GLP-1s and then explicitly excluding cost-sharing protections for the poorest beneficiaries is a structural contradiction. The $50/month copay is a meaningful barrier for someone on $800-900/month SSI.

**What I expected but didn't find:** Any committed list of states that have signed up for BALANCE as of April 2026. The model was announced January 2026, state notification deadline is July 31, 2026. We're 4 months post-announcement and no public participation list. This is consistent with states needing time to evaluate, but it means there's no confirmed coverage expansion yet.

**KB connections:**
- The "structural separation" of BALANCE enrollment from state coverage cuts means the compounding failure pattern (Session 21) is NOT being offset
- 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]] — voluntary models face similar participation limitations
- The LIS exclusion is a specific instance of access being structurally inverted: program designed for access, structured to exclude the lowest-income

**Extraction hints:**
- Claim candidate: "The BALANCE model offers voluntary GLP-1 coverage expansion but does not offset the January 2026 state coverage retreats — creating a net coverage gap for Medicaid beneficiaries in 2026 that voluntary participation mechanisms cannot close in the near term"
- The LIS exclusion is extractable as a specific claim about how access programs can replicate access inversions through their own design
- Consider connecting to Session 19's "SELECT trial finding" pattern: knowledge advancing while infrastructure retreats

**Context:** KFF's analysis is the authoritative source for Medicare/Medicaid policy interpretation. The NCPA (National Community Pharmacists Association) formally announced the model January 5, 2026. Multiple law firm analyses (Mintz, ReedSmith) confirm the voluntary structure and limitations.

## Curator Notes (structured handoff for extractor)

PRIMARY CONNECTION: [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]]
WHY ARCHIVED: The BALANCE model is the policy response to GLP-1 access concerns, and its voluntary structure means it provides no guaranteed offset to the January 2026 coverage cuts. This is direct evidence that compounding access failures are not being systematically addressed.
EXTRACTION HINT: Focus on the gap between BALANCE as mechanism vs. BALANCE as guarantee. The LIS exclusion is the sharpest evidence of structural access inversion.
