The Centers for Medicare & Medicaid Services (CMS) has announced a new initiative called the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model. This model outlines how the administration plans to explore expanding access to obesity care with certain GLP-1 medications for people enrolled in Medicare and Medicaid. The model will also pair medication access with evidence-based lifestyle supports.

Participation in the BALANCE Model is voluntary. GLP-1 drug manufacturers may choose whether to participate by agreeing to CMS-defined pricing and access terms. State Medicaid programs and Medicare insurance plans (Part D plans) may also choose whether to participate. No manufacturers, states or Medicare plans are required to join, and access will depend on which entities opt in.

What CMS is planning to do

Through the BALANCE Model, CMS plans to:

  • Work with voluntary GLP-1 manufacturers to establish pricing and access terms
  • Create a standardized pathway for participating Medicaid programs and Medicare plans to cover these medications
  • Pair medication access with lifestyle and nutrition supports grounded in current scientific evidence
  • Evaluate how the model affects access to care, health outcomes, costs and people’s experiences

Key dates to know

What we don’t know yet 

Several important details have not been finalized, including:

  • When beneficiaries will know whether their state Medicaid program or Medicare plan is participating
  • What the enrollment process will look like
  • The exact clinical criteria for individual eligibility to the programs
  • What lifestyle and nutrition supports will be offered
  • Whether lifestyle and nutrition supports will differ by drug manufacturer
  • Because participation is voluntary for manufacturers and plans, we don’t know how many people will participate in the programs

An important first step
Most people living with obesity who rely on Medicare or Medicaid face barriers to accessing obesity treatments. The BALANCE Model signals CMS’s interest in testing new approaches that recognize obesity as a chronic disease and explore ways to improve access to evidence-based care. There is still a lot to learn about the BALANCE Model. The Obesity Action Coalition will continue to monitor this initiative closely and work with the administration to help ensure people living with obesity who rely on Medicare and Medicaid have increased access to evidence-based treatments.