A CMMI model built to get GLP-1s to Medicare and Medicaid beneficiaries at a negotiated price. Half of it has already been delayed indefinitely.
The BALANCE Model is the federal government’s attempt to answer the affordability problem in the previous lesson through a negotiated price rather than through coverage restriction. It is also a live illustration of why model status must be checked before it is cited.
What it is
BALANCE is “a new Center for Medicare and Medicaid Innovation (CMMI) model” intended to “increase access to GLP-1 medications and healthy lifestyle interventions to help people on Medicare and Medicaid improve their overall health.”
Participation in BALANCE is voluntary for drug manufacturers, state Medicaid agencies, and Medicare Part D plans. That is three separate voluntary decisions, and the oncology lesson in the specialty course established how thin participation can get when a voluntary model asks for something.
On price, manufacturers agreed to a $245 net price per 30-day supply for all model drugs in 2027 for the Medicare program. For Part D plans, cost sharing would be “limited to $245 for a 30-day supply in the deductible phase” with “$50 per month for enhanced plans.”
Where it stands
| Component | Status |
|---|---|
| Medicaid | Implementation “on a rolling basis from May 1, 2026 through January 1, 2027” |
| Medicare Part D | ”Indefinite delay in implementation” announced as of April 2026 |
| Model end date | December 2031 |
The Medicaid side is proceeding. The Medicare side, originally planned to run January 2027 through December 2031, is delayed with no announced date.
The statutory problem underneath
Medicare has a statutory exclusion on covering drugs for weight loss. BALANCE works around it through model authority, which raises the question the rulemaking course taught learners to ask: what happens when the model ends?
KFF states it plainly: “it is unclear whether Part D plan sponsors would be able continue to cover GLP-1 drugs for the treatment of obesity once the model ended if Medicare’s statutory exclusion on weight loss drugs is not lifted.”
That is the Section 1115A pattern the rulemaking course described. A model can test something the statute otherwise forbids, and only Congress or a certified national expansion can make it permanent.
Worth remembering: this lesson is dated on purpose. As of this writing the Medicaid component is rolling out and the Medicare component is indefinitely delayed, and either could change. The transferable point is not the current status but the habit: before citing any model as a fact about how the system works, check its stage, its participation, and whether it has been delayed, amended, or terminated. This curriculum has now documented several models that were announced and then cancelled, rules that were finalized and then left unenforced, and a court decision that vacated an audit methodology. Checking status is not pedantry, it is the difference between describing the system and describing a press release.
Key takeaways
- BALANCE is a voluntary CMMI model covering GLP-1 access in Medicare and Medicaid, running through December 2031.
- Manufacturers agreed to a $245 net price per 30-day supply for the Medicare program in 2027.
- Medicaid implementation is rolling from May 2026; the Medicare component is indefinitely delayed as of April 2026.
- Medicare’s statutory weight loss exclusion means coverage may not survive the model’s end without legislation.
Sources
Check your understanding
What is the status of the BALANCE Model's Medicare component?
The Medicaid piece is rolling out while the Medicare piece is delayed indefinitely. Citing the model as an operating Medicare program would be wrong as of this writing.