CMS introduced several new care and payment models in 2025, many focused on drug pricing, chronic disease management and prevention:
1. CMS published plans Dec. 23 for its voluntary “Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth” — or BALANCE — model. Under the model, CMS will negotiate reduced prices with GLP-1 manufacturers for state Medicaid programs and Medicare Part D plans. Eligible manufacturers must have a product that is any combination of GIP, GLP‐1 and glucagon receptor agonist with an FDA-approved active ingredient for weight management. The drug must be proven to reduce body weight by at least 10% on average.
2 and 3. CMS on Dec. 19 proposed two new models aimed at curbing Medicare drug spending by linking payments to international benchmarks. The GUARD model applies to prescription drugs covered under Medicare Part D, while GLOBE targets drugs reimbursed under Medicare Part B, such as injectables administered in physician offices. Both models would benchmark U.S. Medicare payments to prices paid in economically comparable countries, aiming to reduce inflated domestic costs for high-expenditure drugs.
4. CMS on Dec. 11 unveiled the “Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence,” or Elevate, model, a voluntary initiative that will fund up to 30 chronic disease prevention and health promotion pilot projects aimed at integrating lifestyle and evidence-based functional medicine into original Medicare. The model will test interventions like physical activity, nutrition and other wellness-focused strategies that are not currently covered by Medicare, with the goal of slowing or preventing chronic disease. Organizations that participate will receive around $3 million over three years to collect cost, quality and health outcome data.
5. On Oct. 31, CMS finalized a new Ambulatory Specialty Model, a mandatory payment model focused on specialty care for beneficiaries with heart failure and low back pain. The program is set to begin in 2027 and will run through 2031.
6. CMS plans to launch the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model on Jul 1, 2026. ACCESS will test whether tying payments to clinical outcomes can expand the use of digital tools in chronic disease management. The model targets conditions common among Medicare beneficiaries, such as high blood pressure, diabetes, chronic musculoskeletal pain and depression. Participants will receive recurring payments to manage patients’ conditions, with payment tied to achieving specific health outcomes.
