CMS BALANCE Model: What Healthie Customers Need to Know (And How to Configure Your Account)

April 2, 2026

CMS's new BALANCE Model is expanding GLP-1 coverage for Medicare and Medicaid patients for the first time. Here's how to get your Healthie workflows ready before coverage goes live.

On December 23, 2025, CMS announced the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model, a voluntary innovation model designed to expand access to GLP-1 medications for weight management among Medicare and Medicaid beneficiaries. Since then, CMS has released eligibility criteria, pricing details, and application deadlines for states and Part D plans. The picture is now clear enough to act on.

The BALANCE Model aims to increase access to select GLP-1 medications and healthy lifestyle interventions for people with Medicare and Medicaid. If GLP-1s have been out of reach for your Medicare and Medicaid patients, that's about to change. The organizations that get their documentation, intake, and monitoring workflows right now will be the ones ready to serve them on day one.

How BALANCE Works

Drug manufacturers, state Medicaid programs, and Medicare Part D plans may all choose whether to participate. Nothing is mandatory. As part of this voluntary structure, CMS negotiates directly with GLP-1 manufacturers for lower net prices and standardized coverage terms, including guaranteed net pricing, potential out-of-pocket limits for beneficiaries, and evidence-based lifestyle support offerings.

CMS has completed negotiations with Eli Lilly and Novo Nordisk. The following medications are included in the BALANCE Model: all formulations of Mounjaro, Ozempic, Rybelsus, and Wegovy; the KwikPen formulation of Zepbound; and, pending FDA approval, the tablet formulation of Orforglipron. These are included for both currently covered indications (such as type 2 diabetes) and weight management indications.

For the full BALANCE Model beginning in 2027, manufacturers have agreed to a net price of $245 per 30-day supply for Medicare. The Medicaid net price is subject to confidential negotiated terms between CMS and participating states.

Medication access is only part of the picture. All beneficiaries receiving GLP-1s for weight management will be provided access to a lifestyle support program at no cost, provided by the manufacturer. That creates a direct integration point for your clinical team, and the question is how your workflows and documentation hold up around it.

Who BALANCE Serves

BALANCE is designed to reach Medicare Part D and Medicaid beneficiaries who need GLP-1 medications for weight management but have historically lacked coverage. Currently, Medicare and Medicaid generally do not cover GLP-1 medications for weight loss due to a statutory exclusion. The BALANCE Model is designed to fill this gap.

CMS has published the clinical eligibility criteria. To qualify, a provider must attest that the patient is being prescribed the medication to reduce excess body weight and maintain weight reduction in combination with current and ongoing lifestyle modification, and that the patient meets one of the following BMI thresholds:

• BMI of 35 or higher (age 18 or older), or
• BMI of 30 or higher (age 18 or older) with a diagnosis of type 2 diabetes, obstructive sleep apnea, or noncirrhotic MASH with moderate to advanced liver fibrosis (stages F2 to F3)

The Medicare GLP-1 Bridge has an additional eligibility tier: BMI of 30 or higher with a diagnosis of heart failure with preserved ejection fraction, uncontrolled hypertension (systolic blood pressure above 140 mm Hg or diastolic above 90 mm Hg while on two antihypertensive medications), or chronic kidney disease stage 3a or above. Full eligibility details are available on the CMS Medicare GLP-1 Bridge FAQ page.

You can start identifying likely-eligible patients in your panel right now, before coverage goes live. Keep in mind that final coverage will depend on which states and plans opt in and the specific prior authorization criteria they adopt.

In Healthie: Use client tags to flag patients who may meet BALANCE criteria by BMI threshold, relevant diagnosis, or payer type. Tags are filterable across your full client list, so when coverage opens in your state or plan, you can move quickly on outreach rather than starting from scratch.

Key Dates

The BALANCE Model is rolling out in phases. Your readiness timeline depends on your patient population.

Medicaid coverage launches on a rolling basis starting May 1, 2026. The deadline for the state Medicaid agency RFA is July 31, 2026, so states not yet participating still have time to apply.

The Medicare GLP-1 Bridge runs July 1 through December 31, 2026, giving eligible Medicare Part D beneficiaries early access to Wegovy and Zepbound at a $50 monthly copay, before the full BALANCE Model launches for Part D plans in January 2027. The Bridge operates outside the standard Part D benefit flow, meaning Part D sponsors do not need to opt in for eligible beneficiaries to access it.

For Part D plans, the application deadline is April 20, 2026, with participation confirmed by June 1, 2026. One important contingency: the BALANCE Model in Medicare Part D will only move forward if at least 80% of Part D beneficiaries are enrolled in participating plans. CMS will notify applicants whether that threshold is met by April 30, 2026. The full BALANCE Model for Part D, if the threshold is reached, runs January 1, 2027 through December 2031.

Prior Authorization: A Workflow Shift Worth Preparing For

Under the Medicare GLP-1 Bridge, prior authorization does not go through the patient's Part D plan. CMS will use a single central processor to manage prior authorization, claims adjudication, and payment to pharmacies. Prescribing providers submit requests to a CMS contractor, which is a routing difference that is easy to miss and costly to get wrong. CMS has indicated it will provide additional information on prior authorization processes in Spring 2026.

In Healthie: Build a charting template specifically for BALANCE and GLP-1 visits that prompts clinicians to document everything needed for prior authorization: BMI, qualifying diagnoses, clinical indication, and attestation that the patient is on or will continue lifestyle modification. Using smart fields, information entered during intake automatically carries into the chart note, so nothing gets re-entered by hand and nothing gets missed. Enable charting pre-fill so follow-up visits pull forward relevant data from the prior session, giving clinicians a running clinical record without starting from zero each time.

Intake Documentation: Capture the Right Data from Day One

Clinical eligibility hinges on documented BMI, qualifying comorbidities, and clinical history. Patients coming in to ask about GLP-1 coverage need that information captured accurately and consistently from their very first visit, because your prior authorization request is only as strong as your documentation.

In Healthie: Update your intake forms to capture BMI, weight history, qualifying diagnoses, and current medications. Healthie's metrics feature lets you embed weight and BMI directly into the intake form as smart fields. When a patient fills them out, values automatically populate their metrics graph and carry forward into future chart notes. You can also create a dedicated client group for BALANCE-enrolled or eligible patients with a corresponding intake flow for that population, keeping workflows clean and consistent across that cohort.

Lifestyle Support: Your Clinical Role Doesn't End at the Prescription

BALANCE pairs GLP-1 access with manufacturer-provided lifestyle support programs, but manufacturers aren't your care team. The clinical relationship, ongoing monitoring, and behavioral coaching remain your work. The organizations that show up consistently between visits will see better outcomes and build stronger patient retention.

In Healthie: Use care plan templates to standardize your GLP-1 support protocol across your patient population. A BALANCE-specific template can include dietary and activity recommendations, patient education materials, and actionable goals patients can track between visits. The goals feature gives patients visibility into what they're working toward and lets your team monitor completion rates over time. For patients who benefit from peer accountability, Healthie's group sessions let you run shared support touchpoints across a GLP-1 cohort without requiring a separate 1:1 visit for every patient.

Longitudinal Monitoring: The Long Game

GLP-1 medications require ongoing clinical oversight across weight, BMI, biometrics, adherence, and side effects. CMS will rigorously evaluate the model's impact on costs, adherence, outcomes, and beneficiary experience. The organizations with clean, longitudinal data will be in the strongest position as CMS monitors performance.

In Healthie: Healthie's metrics dashboard tracks weight, BMI, and custom metrics over time, graphing trends in each client profile for both provider and patient visibility. You can create custom metrics for things like medication adherence notes, side effect flags, and activity levels, and pull them into your charting templates so every visit contributes to a running clinical picture. Healthie also integrates with wearables and health devices including Apple Health, Fitbit, and iHealth scales to sync data automatically, reducing manual burden on both your team and your patients.

What to Watch

Several important details are still forthcoming from CMS, including full prior authorization process documentation for the Bridge (expected Spring 2026), state-by-state Medicaid participation announcements, and confirmation of whether the 80% Part D enrollment threshold is met by April 30, 2026. We're monitoring closely and will update this guide as new information becomes available.

Questions about setting up your Healthie workflows ahead of the July 2026 Bridge launch? Contact our team.

Sources

CMS BALANCE Model overview: cms.gov/priorities/innovation/innovation-models/balance

CMS press release (December 23, 2025): cms.gov/newsroom/press-releases/cms-launches-voluntary-model-expand-access-life-changing-medicines-promote-healthier-living

CMS Innovation Insight (March 9, 2026): cms.gov/priorities/innovation/innovation-insight-affordability-glp-1s-takes-next-step-balance-model-rfas

Medicare GLP-1 Bridge FAQs: cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge

BALANCE Manufacturer RFA: cms.gov/priorities/innovation/files/balance-rfa.pdf

BALANCE State Medicaid RFA: cms.gov/priorities/innovation/files/balance-state-medicaid-rfa.pdf

BALANCE Part D Plans RFA: cms.gov/priorities/innovation/files/balance-part-d-plans-rfa.pdf

KFF analysis (March 24, 2026): kff.org/medicare/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid

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