Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE)
Model Summary
1. Executive Summary and Strategic Context
The BALANCE Model is a voluntary model announced December 23, 2025, testing CMS-negotiated pricing and coverage for GLP-1 (glucagon-like peptide-1) medications for weight management in Medicare Part D and Medicaid. BALANCE launches May 2026 for Medicaid and January 2027 for Medicare Part D, with a bridge demonstration for Part D beneficiaries beginning July 2026, running through December 2031.
BALANCE addresses the growing demand for GLP-1 medications (semaglutide/Wegovy, tirzepatide/Zepbound) for obesity treatment, which Medicare Part D currently does not cover for weight loss indications. By negotiating directly with manufacturers, CMS aims to create an affordable access pathway while requiring beneficiaries to participate in lifestyle support programs. The model has immediate significance: approximately 42% of U.S. adults are obese, and GLP-1 medications represent one of the most significant pharmaceutical developments in a generation.
1.1 Strategic Significance
BALANCE is politically and clinically significant. Medicare's statutory exclusion of weight loss drugs (dating to 2003) has been a major policy barrier. BALANCE uses CMMI Section 1115A authority to test coverage of these drugs despite the statutory exclusion, arguing that the model 'tests' whether GLP-1 coverage reduces total cost of care through reduced cardiovascular events, diabetes progression, and obesity-related hospitalizations.
2. Model Architecture
2.1 Timeline and Phasing
| Phase | Beneficiaries | Start Date | Details |
|---|---|---|---|
| Medicaid Coverage | Medicaid enrollees | May 2026 | State Medicaid agencies participate voluntarily |
| Part D Bridge | Medicare Part D | July 2026 | Interim coverage pending full implementation |
| Full Part D | Medicare Part D | January 2027 | Full negotiated pricing and coverage terms |
| Model End | All | December 2031 | 5-year model period concludes |
2.2 Key Features
CMS-Negotiated Pricing: CMS negotiates drug pricing and coverage terms directly with GLP-1 manufacturers on behalf of state Medicaid agencies and Medicare Part D plan sponsors.
Lifestyle Support Programs: Beneficiaries receiving GLP-1 medications must have access to accompanying lifestyle interventions (nutrition counseling, exercise programs, behavioral support).
Manufacturer Participation: Voluntary. Manufacturers choose whether to enter CMS-negotiated agreements.
State/Plan Participation: Voluntary. State Medicaid agencies and Part D plan sponsors choose whether to participate. Notice of Intent deadline: January 8, 2026.
Patient Qualifications: Beneficiaries must meet clinical qualifications set through negotiations (likely BMI thresholds and comorbidity criteria).