The impact of claims denials is widely recognized by lawmakers and the public. According to a January 2026 KFF poll, two-thirds (66%) of insured adults believe delays and denials of health care services by health insurance companies are a “major problem.” One-third (33%) of insured adults say they have had a health insurance company deny coverage for a certain health care service or medication prescribed by their doctor in the past two years. The Affordable Care Act (ACA) requires insurers to report transparency data for all non-grandfathered health plans sold on and off the Marketplace, including fully-insured and self-funded employer health plans. Partial implementation of this federal requirement began with the 2015 plan year; however, it has so far been limited to qualified health plans (QHPs) offered on the federally facilitated Marketplace, HealthCare.gov (including state-based Marketplaces that rely on HealthCare.gov for eligibility and enrollment functions). It does not yet include QHPs offered on state-based Marketplaces or group health plans.

This brief analyzes federal transparency data published by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov in 2024. Similar to KFF’s previous analyses of these data, a downloadable working file based on CMS’s public use file is available on the right-hand side of this brief.

Key Takeaways

• Insurers of qualified health plans (QHPs) sold on HealthCare.gov denied 19% of in-network claims in 2024 and 37% of out-of-network claims for a combined average of 20% of all claims, all similar to 2023.
• The in-network denial rate ranged from 3% to 36%, with significant variation by insurer and by state. Three percent of reporting insurers had in-network denial rates of 30% or higher in 2024, a decrease from 17% in 2023.
• Of the limited information available on in-network claims denial reasons, the most common reasons cited by insurers in 2024 included “Other” [reason not listed] at 36%, followed by administrative reasons (25%). Nine percent of denials were for lack of prior authorization or referral, and only 5% of denials were for lack of medical necessity. Insurers do not report what types of services were denied.
• Consumers rarely appeal denied claims (fewer than 1% of denied claims were appealed), and when they do, insurers usually uphold their original decision (66% of appeals were upheld).
• Marketplace enrollees filed at least 5,881 external appeals in 2024, or 4% of all upheld internal appeals. Due to the suppression of small values, the rate at which external appeals were upheld could not be calculated.
• Rapidly developing artificial intelligence (AI) tools may reduce administrative errors that can lead to improper denials, predict whether a claim will be paid, and assist providers and patients in appealing a denial, but federal oversight and guardrails to protect consumers may be a challenge.

Introduction

As part of the annual QHP certification process, issuers (referred to as insurers in this brief) must report certain denied claims information to CMS for plans that were offered in the previous year that they want to offer in the upcoming year. The ACA requires the data to be made available to federal and state insurance regulators and to the public. The current dataset only includes information about claims for benefits (medical and prescription drugs combined) made after a service was provided (post-service claims); it does not include information about denied requests for prior authorization (a claim decision made before a service is provided, also called a “pre-service” claim).

Insurers participating in the Marketplace in 2026 reported aggregated data on all HealthCare.gov QHPs they offered in 2024. Additionally, plan-level data from 2024 are reported for plans returning in 2026, including the number of in- and out-of-network claims submitted and denied, and reasons for claims denials. Among insurers participating in HealthCare.gov states in 2024, 52 are either not participating in 2026 or offered plans in states that have since switched to operating their own marketplaces, and therefore, did not provide claims denial information. (See the Methods section for details.) Among returning insurers, such denial information was only reported for 75% of their claims (the share of claims attributable to returning plans), because not all plans offered in 2026 were also offered in 2024 and vice versa. Additionally, only 62% of plans in the CMS dataset were also offered in 2024 and are included in the plan-level reporting for denial reasons. See the Methodology section for more details.

Claims Denials and Appeals in 2024

Insurer-level Claims Denials Data

Insurers reported receiving about 496 million claims in 2024, with 91% (451 million claims) filed for in-network services. Of these in-network claims, approximately 85 million were ultimately denied, resulting in an average in-network denial rate of 19% (Figure 1). Out-of-network claims totaled 44 million, with an overall higher denial rate of 37%. Claims that were initially denied, then subsequently resubmitted and paid, are not included as denied claims in the denial rate.

Although the composition of HealthCare.gov states has continued to change since the inception of transparency reporting, the overall in-network denial rate in 2024 is similar to previous years (Figure 2).

Insurer denial rates for in-network claims received in 2024 varied widely, ranging from 3% to 36%. Seventeen of the 157 reporting insurers had an in-network denial rate of less than 10%, while 26 insurers had a denial rate of 25% or more (Figure 3). About 3% of reporting insurers had in-network denial rates of 30% or higher in 2024, a decrease from 14% in 2023.

Denial rates also varied geographically (Figure 4). The state with the highest average in-network denial rate for HealthCare.gov insurers was Hawaii (27%), and the lowest average was in South Dakota (7%). South Dakota also had the lowest average denial rate in 2023 (6%). Average denial rates have the potential to obscure variation. For example, while the average denial rate for insurers in Texas was about the same as the national average, denial rates for insurers in Texas had greater variability than any other state included in this analysis, ranging from 12% to 36% (the highest single insurer-level denial rate in the country).

Denial rates vary substantially by insurer. Table 1 shows denial rates for claims filed in HealthCare.gov states by parent companies that received more than 5 million claims in 2024. (State-specific Blue Cross and Blue Shield parent companies are listed separately in the table below because they operate independently of one another.) For in-network claims processed by these parent companies, the average in-network denial rate was 19%, ranging from 8% (Elevance Health) to 25% (Oscar Health). There was less variability in 2024 than in 2023, when the lowest average denial rate by large parent companies was 14% (Centene), and the highest was 35% (Blue Cross Blue Shield of Alabama).

Plan-level Claims Denial Data

In addition to insurer-level data, insurers also report certain claims data at the plan level. Insurers reported about 79 million denial reasons, excluding denials for claims being out-of-network, for claims that were denied at some point in the adjudication process during the 2024 coverage year. In all, insurers reported on about 66 million in-network claims at the plan level that were ultimately denied that year.

Denials by Metal Level

Denial rates varied only slightly between most plan metal levels. On average, in 2024, HealthCare.gov insurers denied 19% of in-network claims in their bronze plans, 20% in silver plans, 17% in gold plans, 18% in platinum plans, and 22% in catastrophic plans. These are similar to 2023 except for catastrophic and platinum plans, which denied an average of 26% of in-network claims that year.

Denial Reasons

CMS requires HealthCare.gov insurers to report the reasons for claims denials at the plan level. Specified denial reason categories include:

• Denials due to lack of prior authorization or referral
• Denials due to an out-of-network provider
• Denials due to an exclusion of a service
• Denials based on medical necessity (reported separately for behavioral health and other services)
• Denials due to enrollee benefit reached
• Denials due to a member not being covered
• Denials due to investigational, experimental, or cosmetic procedure
• Denials for administrative reasons (which include claims that were duplicated, missing information, untimely, for an unapproved provider, or that met other criteria)
• Denials for all other reasons not specified above

A claim might be denied for more than one reason and on more than one submission, and each denial reason is tallied separately (see the Data Limitations section for more information). The distribution of denial reasons, shown in Table 2, likely includes multiple reasons per claim as the data set does not indicate the total number of claims denied at some point in the adjudication process, nor the number of times a given claim was denied. Of in-network claims, 13% of denials were because the claim was for an excluded service, 9% of denials were due to lack of prior authorization or referral, and only 5% were based on medical necessity. The share of denial reasons related to administrative reasons was 25%, the most common reason aside from “other” (36%).

Insurers also had wide variability in their use of denial reasons. While 5% of all in-network claim denials by HealthCare.gov plans were based on medical necessity, several plans reported much higher shares for medical necessity reasons. For example, 38% of denial reasons for Molina Healthcare of Mississippi were due to medical necessity. Similarly, while 9% of all in-network denials by HealthCare.gov plans were based on lack of prior authorization or referral, some plans reported a much larger share. For example, 97% of denial reasons for Blue Cross Blue Shield of Arizona were for lack of prior authorization or referral.

Plans may apply utilization review techniques differently. For example, individual insurer policies and practices may affect the balance between denials for failure to obtain referral/prior authorization and medical necessity denials, as greater use of prior authorization would shift utilization review to before a service is provided and possibly decrease the number of denials due to medical necessity. However, without more detail on the types of claims subject to these denials, it is not possible to discern the possible implications for patients. Additionally, denials captured in the CMS data do not reflect the share or types of services covered by insurers.

Appeals Data

CMS requires insurers to report the total number of denied and internally appealed claims at the insurer level. Internal appeal is a process that allows consumers to challenge a denied claim made by their health insurer. As in KFF’s previous analyses of federal claims denial data, we find that consumers rarely appeal denied claims, and when they do, insurers usually uphold their original decision.

Appeal to Insurer (Internal Appeal). Of the approximately 85 million in-network denied claims in 2024, HealthCare.gov consumers appealed at least 262,982 – an appeal rate of less than 1%. (CMS suppresses reporting of observations lower than 10, so the number of externally appealed claims could be higher). Insurers upheld 165,863 (66%) denials on appeal. Relatedly, the 2023 KFF Survey of Consumer Experiences with Health Insurance found that only one in ten insured adults who reported experiencing a problem with their insurance in the past year had filed a formal appeal.

Appeal to Third Party (External Appeal). Consumers whose denial is upheld at internal appeal may have the right to an independent external appeal (also called external review) for certain types of claims. Among insurers that reported at least 10 external appeals in 2024, Marketplace enrollees externally appealed at least 5,881 claims in 2024 (again, the number of externally appealed claims could be higher due to CMS suppression of values under 10). Among insurers that reported at least 10 external appeals in 2024, 4% of upheld appeals were externally appealed. Due to the suppression of small values, the rate at which external appeals were upheld could not be calculated.

It is not well known that consumers can appeal claims denials through an external appeal process. KFF’s 2023 consumer survey found that just 40% of consumers believed they have a legal right to appeal to a government agency or independent medical expert, while 51% said they were unsure if they had appeal rights, and 9% did not believe they had this right. Furthermore, Marketplace enrollees (34%) were less likely to know they had external appeal rights compared to those with Medicare (58%) and Medicaid (45%).

Data Limitations

While the CMS data allows users to glean insights into HealthCare.gov insurers’ claims denials to a degree not broadly available for other market segments, it currently has several gaps and limitations. Because the current data do not link denial reasons to the services that were denied, neither the share of total claims denied for a given reason nor the type of service most often denied can be calculated. Claims initially denied but then paid cannot be identified from the data set, nor can the set of denial reasons associated with a given claim. For example, if the initial submission of a claim misspelled a patient’s name and was denied because the patient could not be identified, the claim may be denied again after being corrected and resubmitted if the claim were for a service that was not covered. Each of these reasons is reported individually, irrespective of whether a claim is resubmitted to correct the deficit, denied, or ultimately paid with or without appeal. In addition, the adjudication process employed by the insurer may affect how denial reasons are reported. Although publicly reported data allow for multiple reasons throughout the life of a claim, in practice, insurers may file denial reasons sequentially and not capture all applicable reasons for denying claims, such as denying claims from an unidentifiable enrollee before determining whether the claim was for a medically necessary procedure. Lastly, claims that are denied do not necessarily indicate that services are not ultimately paid by the insurer, such as when a new claim is filed instead of resubmitting the original. In these cases, the original claim would be counted as denied, even if the new claim was ultimately paid. 

Federal reporting on denials could be more useful when presented as claims ever denied for a given reason, instead of tallying the total reasons. Also, reporting that includes denial information about all claims from all insurers in the previous year, and not just those attributable to plans that are returning to the Marketplace next year, would provide a more complete understanding of claims denials. Additionally, information about the types of services approved and denied (e.g., specialty of service and type of prescription drug) would give a more comprehensive picture of insurer practices and what type of care insurers actually cover. Information about appeals, especially external appeals, could provide insight into how this consumer protection mechanism works for patients. Information about what services required prior authorization and how often the prior authorization itself was approved and denied is another data element not included in the CMS data. Many insurers in the individual and group market report this information to the National Association of Insurance Commissioners (NAIC), but these specific data points are not available to the public.

Other Claims Data

With few exceptions, complete, uniform claims denial data are currently only available for plans sold on HealthCare.gov, making it difficult to directly compare these data to other segments of the private insurance market. However, related claims data from other sources are available and can provide some insights. Recent data for government health insurance programs, such as Medicare and Medicaid, largely focus on denials of prior authorization requests. (Prior authorization is a process used by health insurers that requires providers to obtain approval before a service or other benefit is covered, whereas the claims denial data in this analysis is based on claims the insurer receives after the service has been rendered.)

Other Private Insurance Claims Data

State Reporting Requirements

Some states require insurers to report certain claims denial data to the state, which are then made publicly available. For example, California requires all insurers on its state-based Marketplace, Covered California, to annually report claims data similar to what is available for HealthCare.gov insurers. In plan year 2023, insurers with complete claims data denied an average of 21% of in-network claims, similar to HealthCare.gov insurers. (Insurer-level claims data is not currently available for the 2024 plan year.)

Health insurers in Connecticut with at least 1,000 enrollees must report annual data on claims payment practices, prior authorization requests and denials, claims denial reasons, and several other metrics for all private market segments. In 2024, the largest insurers in Connecticut had an overall denial rate of 14%.

Vermont requires insurers of state-regulated health plans (individual and group) with at least 2,000 enrollees or that offer insurance through the Vermont Health Benefit Exchange to report certain pre- and post-service claims denial data to the state, including breakdowns by mental health, substance use disorder services, and prescription drugs. In 2024, these insurers denied an average of 8.5% of total claims received.

Connecticut’s and Vermont’s claims denial data are not directly comparable to those reported by Covered CA or HealthCare.gov insurers for several reasons, including that those states’ data include group health plans, and claims data are not separated by network status. As interest in insurer claims practices and transparency continues, more states may implement claims data reporting. These state laws, however, do not apply to self-funded health plans sponsored by private employers, which, nationally, cover most insured people under age 65, resulting in a patchwork of different requirements across the country.

National Association of Insurance Commissioners

The National Association of Insurance Commissioners (NAIC), via the Market Conduct Annual Statement (MCAS), collects uniform data annually on claims denials, prior authorization requests, appeals, and more from many insurers in the individual and group markets in nearly every U.S. state. MCAS data are intended to help state insurance regulators monitor the market conduct of insurance companies, and insurers can use this information to identify areas to improve performance. However, full MCAS health insurance data are shared with state regulators only, not the general public or CMS. A limited national summary published by the NAIC shows that the average claims denial rate for both in- and out-of-network claims (excluding pharmacy) in 2024 was 16%.

Prior Authorization Data for Government Health Insurance Programs

Medicare

Medicare Advantage, which covers more than half of all Medicare beneficiaries, has come under scrutiny in recent years over concerns about policies and processes related to prior authorization denials. According to a KFF analysis of federal data, Medicare Advantage plans fully or partially denied 4.1 million prior authorization requests in 2024, for an overall denial rate of nearly 8%. The use of prior authorization in traditional Medicare is relatively new and is only used for a limited set of services. According to KFF analysis, in 2024, CMS denied about 143,000 prior authorization requests for traditional Medicare beneficiaries, for a denial rate of about 23%.

Medicaid Managed Care

Medicaid managed care organizations (MCOs), which deliver care to the majority of Medicaid enrollees, often require prior authorization to determine if the requested service or medication is appropriate and medically necessary. A 2023 federal report found that Medicaid MCOs denied more than 2 million prior authorization requests in 2019, for an overall prior authorization denial rate of nearly 13%.

Looking Forward

A January 2025 KFF poll about the public’s priorities for the incoming Congress and President Trump’s second term found that more than half (55%) of U.S. adults thought closer regulation of insurers’ decisions to approve or deny claims for health services or prescription drugs should be a “top priority.” Although CMS has expressed an interest in possibly using the claims denial data to conduct compliance in an effort to improve the accuracy of the data issuers submit, so far, the federal government has not used the available claims denial data to conduct oversight of insurers, nor to develop tools or indicators to help consumers see and compare differences across plans. Providing the public with accessible information and more transparency about how claims review and appeals operate for each insurer, in all market segments, could better enable consumers and employers to make more informed choices when purchasing private coverage. This includes:

Broadening the Data Collected and Disclosed

Planned additions for the coming year. Starting in the next few months, as part of the federal QHP certification process for plan year 2027, insurers will report to CMS additional data elements: whether claims received and denied were for behavioral health or non-behavioral health services; data on pre-service claims; and denial reasons for out-of-network claims that mirror the current denial reasons for in-network claims. In addition, a 2024 CMS interoperability regulation requires QHP issuers to publicly report specific prior authorization metrics on their websites by March 31, 2026, according to a recently released 2027 Draft Letter to Issuers in the Federally-facilitated Exchanges. While a specific format for the public display of this information is not required, CMS has issued templates.

More useful data on reasons for denial. More than half of the reasons for a denial are either due to administrative reasons or an “other” category. Exploring ways to get more specific information about what is happening in the plan’s claims review process, especially when a claim is initially reviewed, could help policymakers address delays in patients receiving needed care and improper denials without a long and protracted second internal review and appeal. For instance, specific information about how many initial denials relate to administrative or coding errors or requests for information already provided could be useful in evaluating plan and provider performance and addressing improper denials.

Collecting employer data. Transparency of pricing data is a stated priority for the Trump administration, and the ACA requires group health plans to disclose claims denial and other data; however, these requirements still have not been implemented at the federal level. Since most people under age 65 have employer-sponsored coverage, efforts to provide more information about this market could begin to address concerns about insurer denials. Federal mental health parity regulations updated in 2024 require employer plans (and non-group plans) to collect and evaluate certain data, including the number and percentage of certain claim denials. However, the Trump administration has indicated that the requirements will not be enforced by the federal government.

Assessing the Impact of Artificial Intelligence in Claims Review

The use of artificial intelligence (AI) by both health plans and providers in the review and appeal of health claims could have both positive and negative implications for consumers. Health plans already use proprietary automated systems for claims processing, largely unknown to the public, but AI presents new challenges for oversight as well as opportunities to help patients navigate the complexities in health care. New tools being rapidly developed and promoted might reduce administrative errors that lead to improper denials, predict in advance whether a claim will be paid, and assist providers and patients in appealing a denial. However, concerns about accuracy, privacy, and bias in AI models have resulted in calls from consumer advocates, insurers, and providers for new consumer protections and/or oversight. States have begun to pass legislation, some focused on making sure a human is involved where claims are denied, regulators can audit the data used to train AI systems, and technology companies are required to test and disclose outcome metrics.

Congress has not enacted new laws to regulate AI specifically, and the Trump administration has stated its position that state laws to regulate AI should not apply. The CMS WISeR model is now testing the use of AI to make prior authorization decisions for specific services in traditional Medicare. Public information about the specific technology being used in the model is limited.

Key issues moving forward include how and whether the federal government will provide guardrails for how this technology is used, not just for claims review, but for an increasingly wide variety of administrative and clinical tasks that have a direct and indirect impact on patients.

Closer Examination of Independent External Review

The information available on independent review for the federal Marketplace continues to show a small number of external appeals. No information is provided about the types of services that are being evaluated under external review, and publicly-available data on the number of upheld internal appeals that are overturned in an external appeal are limited. Other researchers have started to look deeper at external review outcomes using other data sources. One recent study examined external review decisions (not limited to Marketplace plans) involving coverage of specific cancer genetic tests in four states where data are publicly available. It found that almost half of all external review decisions overturned the initial denial, and 30% of denials specifically for cancer genetic tests were overturned, with wide variation across states and types of genetic tests.

Looking for Information About Voluntary Insurer Prior Authorization Changes

In June 2025, the Trump administration announced a pledge by many of the largest health insurers to act to “fix [the] broken prior authorization system.” Insurers voluntarily committed to make several changes, including reducing the scope of prior authorization requirements by January 1, 2026, and providing better transparency about authorization decisions and appeals. While some insurers have made general announcements about changes, information about specific process improvements and reductions in prior authorization requirements is limited, and a recent report and KFF polling indicate that prior authorization is still a problem for many consumers.

Methodology

Our analysis of the CMS Transparency in Coverage 2026 Public Use File (published September 26, 2025) includes insurers with more than 1,000 claims submitted and excludes stand-alone dental plans and small group (SHOP) plans. Of the 183 major medical insurers offering plans in 2026 in HealthCare.gov states, 156 reported receiving more than 1,000 claims and showed data on claims received and denied in 2024. Comparison with the QHP Landscape PY2026 Individual Medical file showed that, among insurers participating in HealthCare.gov states in 2024, 52 are not participating in 2026. (This number does not include the two insurers in the transparency public use file that are not actually offering plans in 2026. Since one of those insurers submitted claims information for its 2024 plans, that issuer is still included in our analysis.) Twenty-two HealthCare.gov insurers participated in Illinois and Georgia in 2024. Since then, these two states have switched to operating their own marketplaces. Excluding insurers operating in these two states, 30 participated in 2024 but did not participate in 2026.

Calculation of claims denial rates includes information provided by insurers on plans offered in 2024 but not in 2026. The number of denied claims reflects only the final adjudication status. A claim may be initially denied, then resubmitted and approved; claims that are paid even after initial denial do not count as denied in the claims denial rate calculation.

Twenty-five insurers offering plans in 2026 did not offer plans in 2024. Among states that offered plans on HealthCare.gov in both 2024 and 2026, 38% of plans available in 2026 were not available in 2024; of the 4,415 plans offered in 2024, only 2,514 (57%) were offered in 2026 and are included in the plan-level reporting of information on denial reasons. Half (the median) of the returning insurers did not provide statistics on denial reasons for more than 20% of claims filed in 2024, as they were associated with plans not being offered in 2026. Calculation of denial reasons excluded claims that were denied as out-of-network in all totals. Since out-of-network denials may depend more on plan type than insurer processes, the analysis focused on in-network claims.

To obtain the parent company name, the QHP Landscape PY2026 Individual Medical file was merged with the Medical Loss Ratio Submission Template header using HIOS plan identification numbers to find NAIC company codes. The NAIC identifier was then mapped to a parent company name using the Enrollment by Segment Exhibit data from Mark Farrah Associates. A small number of insurers could not be mapped by this method, so parent company names were entered manually. Statistics calculated at the parent company level do not include plans offered in market segments other than on-exchange ACA plans offered in HealthCare.gov states.

The external appeal rate assumes that all external appeals went through an internal appeal first and was calculated as the number of external appeals filed over the number of internal appeals upheld. CMS does not report values under 10. When calculating statistics with suppressed values, they were assumed to be zero. Additional considerations for using CMS transparency public files can be found here.

GLP-1s, a class of drugs used to treat type 2 diabetes, obesity, cardiovascular disease, and other conditions, have exploded in popularity in recent years due to their demonstrated effectiveness, but are often not covered by insurance, particularly for the treatment of obesity. According to KFF polling, about half (56%) of GLP-1 users say these drugs were difficult to afford, including one in four who say they were “very difficult” to afford. The Trump administration is pursuing various approaches to lowering the cost and expanding coverage of these medications. These approaches include striking “most-favored nation” deals with GLP-1 manufacturers Novo Nordisk and Eli Lilly, providing access to discounted prices for GLP-1s through TrumpRx, and implementing a new demonstration program called the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model to expand Medicare and Medicaid coverage of GLPs for obesity, which is currently subject to statutory limitations (prohibited in Medicare, permissible but not required in Medicaid). In addition, the GLP-1 drug semaglutide (branded as Ozempic, Wegovy, and Rybelsus) was selected for Medicare drug price negotiation in 2025, with a negotiated price set to take effect in 2027.

This brief describes current coverage of GLP-1s in Medicare and Medicaid, the Centers for Medicare & Medicaid Services’ (CMS) efforts to expand access and lower costs for GLP-1s through temporary demonstration programs including the BALANCE Model, and potential impacts on beneficiaries and program budgets.

Current law prohibits Medicare from covering obesity drugs and gives states flexibility to cover weight loss drugs under Medicaid

Limitations on coverage for obesity drugs in Medicare and Medicaid mean that millions of people who have obesity and might benefit from taking GLP-1s may be unable to access them unless they are able to pay the full cash price out of their own pockets, which would likely be prohibitive for people with Medicaid who must have low incomes to qualify for the program, as well as for many people on Medicare with low and modest incomes. Under the Medicare Part D outpatient prescription drug benefit program, Part D plans are required to cover a minimum of two drugs in each therapeutic category and class, but from the outset, Medicare has been prohibited by law from covering medications when used specifically for weight loss. People on Medicare can get GLP-1s covered by Part D plans only if they are used for a medically accepted FDA-approved indication other than obesity, like type 2 diabetes, cardiovascular disease risk reduction, or sleep apnea.

Under the Medicaid Drug Rebate Program (MDRP), state Medicaid programs must cover nearly all of a participating manufacturer’s FDA-approved drugs for medically accepted indications. However, federal law gives states the option whether to cover drugs used for weight loss. As a result, GLP-1 coverage for medically accepted FDA-approved indications other than obesity is required while access to GLP-1s to treat obesity under Medicaid is currently limited. Only 13 states provided coverage as of January 2026, down from 16 states in 2025, likely reflecting the significant costs of coverage and recent state budget challenges and federal funding cuts.  

Even with these coverage limits on obesity drugs in place, utilization and gross spending on GLP-1 drugs for approved uses in Medicare and Medicaid have increased considerably in recent years. In 2024, there were 8.4 million prescriptions and $8.6 billion in spending on GLP-1s in Medicaid, and 21.8 million claims and $27.5 billion in gross spending (excluding rebates) on GLP-1s in Medicare (Figure 1).

CMS is proposing temporary expansions of Medicare and Medicaid coverage of GLP-1s for obesity through demonstration programs

CMS has proposed a two-step approach to expanding coverage of GLP-1s for obesity in Medicare – a temporary payment demonstration for 2026, known as the Medicare GLP-1 Bridge, and a new Center for Medicare and Medicaid Innovation (CMMI) model, known as the BALANCE Model, beginning January 2027. For Medicaid, GLP-1 coverage will be expanded through the BALANCE Model beginning in May 2026. The BALANCE Model ends for both state Medicaid agencies and Medicare Part D plans in December 2031. (See Figure 2 for a timeline of key activities associated with the GLP-1 coverage demonstrations.)

Medicare coverage of GLP-1s for obesity begins in July 2026 through the Medicare GLP-1 Bridge, prior to implementation of the BALANCE Model

Until implementation of the BALANCE Model for Part D plans begins in January 2027, CMS will provide Part D beneficiaries with coverage of select GLP-1s for obesity from July 1, 2026 to December 31, 2026 through the Medicare GLP-1 Bridge, which is a separate short-term demonstration established using Section 402 demonstration authority. The Medicare GLP-1 Bridge is a nationwide demonstration program that will be separate from Part D coverage, meaning Part D sponsors will not have to opt into the demonstration for eligible beneficiaries to gain access, nor will Part D sponsors bear any financial risk for costs incurred by their enrollees associated with the demonstration.

According to FAQs released by CMS in March 2026, Medicare beneficiaries enrolled in Part D plans who meet the eligibility criteria will have access to GLP-1 medications approved for weight reduction (Wegovy and Zepbound) at a copayment of $50 per month. For a beneficiary to qualify, their provider must submit a prior authorization request that attests the beneficiary is being prescribed the drug to reduce excess body weight and ongoing maintenance of weight reduction and that they fall into one of three categories related to BMI and other clinical diagnostic criteria (Figure 3).

Manufacturers have agreed to provide Wegovy and Zepbound at a net price of $245 per month supply. When participating beneficiaries fill a prescription for one of these drugs, pharmacies will collect the $50 copayment and submit claims to a central processor for reimbursement. Pharmacies will be reimbursed by CMS at no lower than the wholesale acquisition cost (WAC) of a drug, less the beneficiary copay, plus a dispensing fee and, as applicable, sales tax. Manufacturers will then owe money back to CMS for the difference between the WAC and the negotiated $245 net price.

Because this payment demonstration operates outside coverage under a Part D plan, the $50 copayment toward these medications will not count toward a participating beneficiary’s Part D deductible or the $2,100 out-of-pocket maximum, and copayments will stay consistent at $50 per month, regardless of the Part D benefit phase a beneficiary is in when they fill the prescription. Medicare beneficiaries who are already receiving coverage from their Part D plan for a GLP-1 for a Medicare-covered use, such as type 2 diabetes, cardiovascular disease risk reduction, or sleep apnea, will continue to access the drug through their Part D plan and not through the Medicare GLP-1 Bridge, which will only provide coverage of GLP-1s when used for obesity.

For beneficiaries enrolled in the Low-Income Subsidy (LIS) program, the LIS cost-sharing subsidies will not apply in the Medicare GLP-1 Bridge. This may make it more difficult for low- and modest-income beneficiaries who are otherwise eligible to participate to take advantage of coverage under the short-term demonstration in 2026 if the $50 monthly copayment is unaffordable.

For participating beneficiaries to maintain Medicare coverage of their GLP-1 medication for obesity after the Medicare GLP-1 Bridge ends at the end of 2026, they will need to be enrolled in a Part D plan that chooses to participate in the BALANCE Model in 2027. This could mean having to switch Part D plans for the coming year, with potential cost and coverage implications for other medications beneficiaries use.

The BALANCE Model expands coverage of GLP-1s for obesity in Medicaid beginning in 2026 and under Medicare beginning in 2027

According to CMS, the BALANCE Model aims to increase access to GLP-1 medications and healthy lifestyle interventions to help people on Medicare and Medicaid improve their overall health. Under this model, CMS will negotiate with manufacturers of GLP-1s to provide lower prices to the state Medicaid programs and Medicare Part D plans that choose to participate in the model. For beneficiaries to be eligible under the BALANCE Model in either Medicaid or Medicare Part D (including Part D LIS enrollees), providers must attest that they meet certain clinical criteria, including qualifying for a GLP-1 for a currently covered use (such as type 2 diabetes or sleep apnea) or for use to treat obesity based on similar clinical criteria as applied in the Medicare GLP-1 Bridge (Figure 3).

In addition to offering lower prices for GLP-1s, this model will provide patients with access to lifestyle support programs at no cost, which are intended to support medication adherence as well as increase GLP-1 effectiveness. (Details about these programs are not yet available.) These lifestyle support programs will be provided by participating manufacturers. As part of their agreements with CMS, the manufacturers must demonstrate how these lifestyle support programs will meet the program requirements, including encouraging healthy eating and increasing physical activity, supporting medication adherence, ensuring engagement with the program on a regular basis, and ensuring availability of this program to all patients receiving these medications, either online or offline for those who have limited digital access. However, prescribing providers will not be required to document that patients are actively participating in these lifestyle support programs as part of attesting to their eligibility for the model based on other clinical criteria.

Participation in the BALANCE Model is voluntary for drug manufacturers, state Medicaid programs, and Medicare Part D plans

Participation in BALANCE is voluntary for drug manufacturers, state Medicaid agencies, and Medicare Part D plans. The date for manufacturers to notify CMS of their interest in participating was January 8, 2026; for Medicare Part D plans is April 20, 2026; and for state Medicaid programs is July 31, 2026 (Figure 2).

Drug Manufacturers

During the model pre-implementation period in early 2026, CMS negotiated with Novo Nordisk and Eli Lilly to come to agreement on the key parameters of the model, including details about pricing of the model drugs, cost sharing, rebate calculations, access policies (i.e., coverage criteria and prior authorization policies), the length of the agreement, data sharing arrangements, and agreement on lifestyle supports that will be offered. Both manufacturers have agreed to participate in the model, and the following medications will be included: all formulations of Mounjaro, Ozempic, Rybelsus, and Wegovy, the KwikPen formulation of Zepbound, and, if approved by the FDA, the tablet formulation of Orforglipron. The manufacturers have agreed to a $245 net price per 30-day supply for all model drugs in 2027 for the Medicare program though the net price for state Medicaid programs is confidential to the public. CMS and manufacturers may renegotiate terms in the future depending on certain circumstances such as changes in the FDA labeling, new clinical evidence, or new products launched.

State Medicaid Programs

Participation. For state Medicaid agencies that opt to participate in the model, implementation will be on a rolling basis from May 1, 2026 through January 1, 2027. To participate in the model, state Medicaid programs must sign a State Agreement with CMS and then adopt supplemental rebate agreements (SRAs) with each participating manufacturer that reflects the standard key terms that the participating manufacturers and CMS have agreed to. While states typically develop their own utilization management strategies, the model key terms establish standardized coverage criteria (Figure 3). States may offer broader coverage but cannot make coverage criteria more restrictive, and the Medicaid key terms must apply equally in both fee-for-service and Medicaid managed care. Although the Medicaid component of the BALANCE Model will launch May 1, the deadline for the state Medicaid agency Request for Applications (RFA) is July 31, 2026.

Cost. The discounted GLP-1 net price for state Medicaid programs will be available through additional supplemental rebates (on top of statutory rebates through the MDRP). To participate in the model, state Medicaid programs must terminate or update any existing SRAs with participating manufacturers. While the original announcement of the MFN deals with Eli Lilly and Novo Nordisk noted Medicaid programs would also have access to the $245 price available to Medicare, the final negotiated discounted price available to state Medicaid programs mentioned in the state Medicaid RFA is not available to the public, only participating states. The model will not affect out-of-pocket costs for Medicaid enrollees, which are limited to nominal amounts under federal law.

Medicare Part D Plans

Participation. Part D plan sponsors must apply to participate in the model by April 20, 2026, and after CMS confirms eligibility, plan sponsors will indicate whether they will participate in the model by June 1, 2026. Participants can include sponsors of Part D stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs), including Special Needs Plans (SNPs), and employer plans that offer Part D. Eligible plan types exclude Defined Standard benefit plans, which charge a standard 25% coinsurance amount for all covered drugs and do not vary cost sharing by drug type or formulary tier, although plan sponsors can indicate if they wish to convert a Defined Standard benefit plan to another basic benefit type in order to become eligible. Participation is at the plan sponsor level, and plan sponsors can choose which of their specific plan benefit packages will be part of the model. However, CMS will require plan sponsor participants to include all of their enhanced alternative plans and 90% of their enrollment in basic plans.

Cost sharing. Part D plans must adopt specific cost-sharing limits under the basic benefit plan structure as agreed upon by CMS and manufacturers. Cost sharing for model drugs will be limited to $245 for a 30-day supply in the deductible phase and a lower amount in the initial coverage phase: $50 per month for enhanced plans and employer group plans and $125 per month for basic plans (though plan sponsors can choose to apply lower cost-sharing amounts to model drugs as long as they do so uniformly across all model drugs). Once beneficiaries reach their out-of-pocket maximum (set at $2,400 in 2027), they will pay $0 for their medications, including for model drugs. Part D plans participating in the model are required to place all model drugs on the same formulary tier, cover all medically accepted indications for model drugs, and apply the same cost sharing to all indications.

Participation incentives. Because the model is voluntary for Part D plan sponsors, CMS has designed financial incentives to encourage plan participation. The primary approach to be taken in 2027 involves an optional narrowing of the risk corridor thresholds to reduce the range of spending where PDPs bear full risk for actual costs higher than their bids (Figure 4). Model participants will qualify for this additional financial protection if they opt in and have higher-than-average utilization of model drugs relative to other similar plan participants. In future model years, CMS is considering additional payment incentives, including higher direct subsidy payments based on an adjustment factor to the beneficiary risk score in participating plan bids.

CMS is aiming for a “critical mass” of Part D sponsors to participate and has established a threshold participation rate of 80% for 2027. This participation rate will be calculated as the number of beneficiaries enrolled in Part D plans applying to participate in the model divided by the total number of beneficiaries in all Part D plans (excluding enrollment in special needs plans and employer plans from these calculations, even though they are eligible to participate in the model, but including enrollment in Defined Standard benefit plans, even though they are ineligible to participate). (This calculation method could produce a different participation rate than it would be if the calculation was based on enrollment in all eligible plans that apply to participate divided by enrollment in all eligible plan types overall. CMS has not explained the rationale for their chosen method.) If the 80% threshold is not met, CMS will not move forward with the BALANCE Model in Medicare in 2027. CMS will notify Part D plan sponsor applicants whether this threshold is met by April 30, 2026. If the participation threshold isn’t met for BALANCE, which will be known by the end of April, CMS has not indicated if or how it would affect the implementation of the GLP-1 Bridge.

Millions of people with Medicare and Medicaid could benefit from expanded coverage of GLP-1s for obesity

Overall, the BALANCE Model could greatly expand access to GLP-1s depending on the level of participation by drug manufacturers, state Medicaid agencies and Part D plans. In addition to providing coverage of these drugs for obesity, which would be a new indication in Medicare and in most states under Medicaid, this model would also allow beneficiaries in participating states and Part D plans to access GLP-1s for obesity at a lower out-of-pocket cost than if they were to purchase them with cash at the direct-to-consumer prices offered by the manufacturers. For Medicare Part D enrollees who already have coverage of a GLP-1 due to a currently covered indication, they might face lower out-of-pocket costs if their current cost-sharing amounts are higher than the cost-sharing limits that have been established for the BALANCE Model ($50 for enhanced plans, $125 for basic plans). Additionally, this model will provide access to a lifestyle support program to promote healthy behaviors and increase the effectiveness of GLP-1s, which could provide improvements in health along with sustained weight reduction.

However, there are factors that could limit the reach of this model for both the Medicaid and Medicare populations. For example, if the level of participation by state Medicaid agencies is relatively low, the impact of this model for Medicaid recipients may not be very far reaching. In addition, state Medicaid agencies can choose to participate in the model initially but then decide to drop out of the model in later years, which could result in disruptions in coverage.

Within Medicare, if participation by Part D plan sponsors is less than the 80% threshold, CMS has stated that it will not launch the model in Medicare in 2027. This sets up the possibility that Medicare beneficiaries could have coverage of GLP-1s for obesity under the Medicare GLP-1 Bridge in the latter half of 2026 but then lose access in 2027 if the BALANCE model is not implemented. Similarly, beneficiaries will need to be enrolled in a participating plan in order to maintain coverage of GLP-1s for obesity in 2027, which could mean switching plans and disrupting current coverage.

Assuming the BALANCE Model launches in 2027 with at least 80% participation, Part D plans could drop out of the model in future years, which could interrupt treatment, or require frequent plan changes for Medicare Part D enrollees to maintain access. It is unclear from CMS documentation whether they will reassess the 80% participation threshold in each model year for the model to continue. It is also unclear whether Part D plan sponsors will be able continue to cover GLP-1 drugs for the treatment of obesity once the model ends if Medicare’s statutory exclusion on weight loss drugs is not lifted.

Another uncertainty for Part D enrollees in terms of their out-of-pocket costs is the impact of the model on Part D premiums. Participating plan sponsors will factor the cost of the model into their bids for contract year 2027, and assuming the participation threshold is met, plans may incur higher costs, which would be incorporated into the bids of plans that most beneficiaries are currently enrolled in. That could have the effect of increasing Part D premiums across the board, although Medicare Advantage plans can use rebates to buy down Part D premiums, but this is not an option for stand-alone PDPs. It is possible that CMS could modify the parameters of the Part D PDP premium stabilization demonstration to provide greater premium subsidies for PDP plan sponsors that participate in the BALANCE Model. The ultimate effect on Part D plan bids and premiums is unknown at this time.

The potential federal and state budgetary impacts of expanded coverage of GLP-1s for obesity in Medicare and Medicaid are unknown

CMS documentation does not include potential federal or state budgetary impacts from either the BALANCE Model or the Medicare GLP-1 Bridge. Spending on GLP-1 drugs for currently covered uses under Medicare and Medicaid has increased substantially in a relatively short period of time and could increase further with expanded coverage of GLP-1s for obesity, even at the lower net prices for these medications under both demonstrations.

The law requires Innovation Center models to either maintain or reduce program expenditures. The model will test whether lower negotiated prices as applied to currently covered indications will lower program spending. It is unclear how the new negotiated prices under the model for state Medicaid programs (which remain confidential) compare to the net prices state Medicaid programs are currently paying for these drugs, but Medicaid already typically pays lower prices than other payers for prescription drugs. In general, without knowing what Medicaid and Medicare generally are currently paying for these drugs on net, it is uncertain whether the lower prices that will be made available to state Medicaid programs and Part D plans under the BALANCE Model for currently covered uses of GLP-1s will generate enough savings to offset the additional costs from expanded use of these medications for obesity. If state Medicaid programs estimate the costs from expanded use will outweigh the savings, initial state Medicaid participation may be limited, especially given recent state budget challenges and federal funding cuts.

Evaluations will also determine whether improvements in health related to the use of these drugs and associated reductions in healthcare utilization are significant enough to maintain or reduce health care costs in the Medicaid and Medicare programs, after taking into account expanded use and coverage of GLP-1s for the treatment of obesity. Even with lower prices, there is little evidence to date to suggest that the expanded use of GLP-1s will be offset by lower spending on other health care services in the short term, even though the drugs do provide significant health benefits to users.  

The cost of the Medicare GLP-1 Bridge is not discussed in CMS documentation about this demonstration. The federal government is likely to incur additional spending under this demonstration due to paying for GLP-1s for obesity, which is not currently covered under Medicare. In addition, because the demonstration will operate outside the Part D benefit, the manufacturers won’t be responsible for providing the manufacturer price discount on eligible GLP-1s (10% in the Part D initial benefit phase and 20% in the catastrophic phase). While many prior section 402 demonstrations have had to conform to budget neutrality rules by the Office of Management and Budget (OMB), some demonstrations have been able to move forward without this requirement. Given the short timeframe of the GLP-1 demonstration, it is unlikely that there will be cost offsets from improved health due to increased GLP-1 use for obesity that can be documented.

Key Facts

• About half of the world’s population is at risk of being infected with malaria. In 2024, there were an estimated 282 million cases of malaria and 610,000 deaths from malaria worldwide. Sub-Saharan Africa is the hardest hit region in the world.
• While gains have been made over the past two decades in increasing access to malaria prevention and treatment, many challenges (including drug and insecticide resistance and climate change impacts) continue to complicate malaria control efforts in hard-hit areas. In promising developments in recent years, new tools against malaria, including dual-ingredient insecticide-treated nets and the world’s first malaria vaccines, are being integrated into broader health systems.
• The U.S. government (U.S.) has been involved in global malaria activities since the 1950s and, today, is the largest donor government to global malaria efforts.
• Historically, U.S. malaria efforts included activities primarily through the U.S. President’s Malaria Initiative (PMI), which was overseen by the U.S. Global Malaria Coordinator, as well as through other U.S. activities, collectively reaching approximately 30 countries.
• U.S. funding for malaria control efforts and research activities was approximately $1 billion in FY 2026, up slightly from $963 million in FY 2017. Additionally, the U.S. is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which in turn is the largest overall funder of malaria efforts in the world.
• Since the beginning of the second Trump administration, the U.S. global health response has undergone a significant change (including a reorganization of foreign assistance, reductions in funding, and cancellation of programs), fundamentally altering the global health landscape as well as PMI and other U.S. global malaria efforts.

Global Situation¹

Malaria is one of the world’s most common and serious tropical diseases, with about half the world’s population at risk of being infected with malaria. Although preventable and treatable, malaria causes significant morbidity and mortality, with the greatest numbers of cases and deaths in resource-poor regions and among young children.²

Strategies and efforts to address malaria have evolved over time, with global eradication efforts waning in the 1970s, resulting in rising rates.⁴ In the late 1990s, malaria began to receive renewed attention, particularly after the 1998 creation of the Roll Back Malaria Partnership (RBM), now referred to as the RBM Partnership to End Malaria.⁵ In 2000, all nations agreed to global malaria targets as part of Millennium Development Goal 6 (combat HIV/AIDS, malaria, and other diseases). Since then, expanded efforts by the U.S. government, other donor governments, multilateral institutions, and affected countries have helped to increase access to malaria prevention and treatment and reduce cases and deaths, and there has been, at times, discussion of the possibility of finally eradicating the disease.⁶

Today global malaria activities are focused on sustaining, improving, and expanding efforts to control the disease. Still, the rate of progress has stalled in some countries recently, and many challenges continue to complicate malaria control efforts in countries with ongoing malaria transmission, including poverty, poor sanitation, weak health systems, limited disease surveillance capabilities, natural disasters, armed conflict, migration, climate change, and the presence of counterfeit and/or sub-standard antimalarial drugs.⁷

Morbidity and Mortality⁸

• WHO estimates that there were approximately 282 million cases of malaria and 610,000 deaths, mostly among children under the age of five, in 2024. Overall, substantial scale-up of malaria interventions helped reduce the malaria case incidence and death rates over the past two decades, though case incident rates were slightly higher in 2024 than in 2023 due to increased rates in some countries.
• Multidrug-resistant malaria is a widespread and recurring problem, and while highly-effective artemisinin-based combination therapies (ACTs) have been introduced to treat drug-resistant strains, evidence suggests ACT resistance is occurring in parts of Asia and Africa.⁹ Resistance to insecticides has emerged as a problem in Africa, the Americas, Eastern Mediterranean, South-East Asia, and the Western Pacific.¹⁰
• Certain groups, particularly pregnant women and children, are more vulnerable. Making up 76% of all malaria deaths in the Africa region, children under five are especially at-risk of malaria infection, because they lack developed immune systems to protect against the disease. Other high-risk groups include people living with HIV/AIDS, travelers, refugees, displaced persons, and migrant workers entering endemic areas.

Interventions

Malaria control efforts involve a combination of prevention and treatment strategies and tools, such as:

• insecticide-treated bed nets (ITNs),¹¹
• indoor residual spraying (IRS) with insecticides,
• diagnosis and treatment with antimalarial drugs, particularly artemisinin-based combination therapies (ACTs),¹²
• intermittent preventive treatment in pregnancy (IPTp, a drug treatment for pregnant women that prevents complications from malaria for a woman and her unborn child),
• perennial malaria chemoprevention (PMC, formerly called intermittent preventive treatment in infants (IPTi), a drug treatment aimed at reducing adverse effects of malaria in children belonging to age groups at high risk of severe malaria), and
• seasonal malaria chemoprevention (SMC, a treatment course administered at monthly intervals to children belonging to age groups at high risk of severe malaria during the high malaria transmission season).

More recently, in 2021, the World Health Organization (WHO) recommended, and in 2022 prequalified, the first malaria vaccine (RTS,S/AS01 or RTS,S) and in 2023 recommended and prequalified a second malaria vaccine (R21/Matrix-M or R21), both of which have been shown to be safe and effective in preventing malaria in children during clinical trials.¹³ As of February 2026, 25 countries offered these vaccines through routine childhood immunization programs, with more planning to introduce or scale them up, and across these countries, over 10 million children per year are targeted for malaria vaccination.¹⁴ Roll-out of these vaccines will depend on financing and country decisions about whether to adopt the vaccines as part of their national malaria control strategies, among other things.

Access to prevention and treatment services has grown over time, as ITN coverage has increased and the number of ACT treatments procured by the public and private sectors has expanded substantially.¹⁵

Global Goals

Since the late 1990s, new initiatives and financing mechanisms have helped increase attention to malaria and contributed to efforts to achieve global goals; these include the RBM Partnership to End Malaria, a global framework established in 1998 for coordinating malaria efforts among donor governments, major UN agencies, international organizations, and affected countries, among others; and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), an independent, international financing institution established in 2001 that provides grants to countries to address TB, HIV, and malaria (see the KFF fact sheet on the U.S. and the Global Fund).¹⁶

These and other efforts work toward achieving major global malaria goals that have been set through:

• Sustainable Development Goals (SDGs). Adopted in 2015, the SDGs aim to end the malaria epidemic by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”¹⁷
• Global Technical Strategy for Malaria (GTS). Developed in close alignment with the RBM Partnership and adopted by the World Health Assembly in 2015, the GTS includes the goals of reducing malaria incidence and mortality rates by at least 90% by 2030, eliminating the disease in at least 35 new countries, and preventing the disease’s re-establishment in countries that are malaria free.

With these goals, the GTS sets out a vision for countries to accelerate progress towards malaria elimination, and globally, more countries are moving towards elimination. Between 2000 and 2024, 26 countries (Algeria, Argentina, Armenia, Azerbaijan, Belize, Bhutan, Cabo Verde, China, Egypt, El Salvador,  Iraq, Kazakhstan, Kyrgyzstan, Malaysia, Maldives, Morocco, Oman, Paraguay, Saudi Arabia, Sri Lanka, Syrian Arab Republic, Tajikistan, Turkey, Turkmenistan, United Arab Emirates, and Uzbekistan) that were malaria endemic in 2000 have attained three consecutive years of zero indigenous malaria cases and are therefore recognized as having eliminated the disease.¹⁸ In 2024, of 80 malaria-endemic countries, 46 countries worldwide were reported to have been nearing elimination.¹⁹Most recently, in March 2024, WHO along with Ministers of Health in Africa and other partners convened a Malaria Ministerial Conference and signed a declaration committing to accelerating action to end deaths from malaria.²⁰

U.S. Government Efforts

Current Status

Involved in global malaria activities since the 1950s, the U.S. government (U.S.) has historically been the largest government donor to malaria efforts.²¹ It is also the largest donor to the Global Fund, which in turn is the largest overall funder of malaria efforts in the world.²² Since the beginning of the second Trump administration, however, the U.S. global health response has undergone significant shifts, disruption, and retraction, fundamentally altering the global health landscape and U.S. global malaria efforts through the President’s Malaria Initiative (PMI) in particular. Now, as the Trump administration reorganizes foreign aid, it is unclear what the future holds for PMI; multilateral cooperation on malaria (particularly after the U.S. withdrawal from the World Health Organization, or WHO; see below); and malaria vaccine roll-out (especially after the U.S. announced it will withhold funding from Gavi). Additionally, the future of U.S. support for U.S. global malaria research efforts is uncertain as the Trump administration reduces and eliminates foreign research grants. (See the KFF fact sheet on the status of PMI and other U.S. malaria efforts.)

More recently, in September 2025, the State Department released its “America First Global Health Strategy,” which details how the U.S. intends to engage in global health moving forward, including through bilateral health agreements, or Memorandums of Understanding (MOU), with partner countries (see the KFF tracker on these agreements). The strategy is focused on a subset of U.S. global health areas, including malaria, and reemphasizes the U.S. commitment to support the goals laid out by the GTS. The strategy does not, however, mention PMI, and it is unclear how much emphasis will be on malaria efforts going forward, including whether the funding appropriated by Congress for malaria will fully be spent by the administration.

History

The U.S. government’s international response to malaria began in the 1950s through activities at the U.S. Centers for Disease Control and Prevention (CDC) and U.S. Agency for International Development (USAID); early efforts focused on technical assistance but also included some direct financial support for programs overseas.

Starting in the early 2000s, the U.S. assigned a heightened priority to and provided greater funding for bilateral and multilateral malaria efforts. In 2003, the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the legislation that created PEPFAR, the expanded U.S. government response to global AIDS) authorized five years of funding for bilateral malaria efforts and the Global Fund. In 2005, the U.S. launched the President’s Malaria Initiative (PMI), a five-year effort to address malaria in 15 hard-hit African countries, which has since been extended and expanded. In 2008, the Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (which reauthorized PEPFAR) authorized another five years of funding and codified the position of the U.S. Global Malaria Coordinator.²³ (See the KFF fact sheet on PEPFAR, the KFF fact sheet on the Global Fund, the KFF brief on PEPFAR reauthorization legislation, and the KFF dashboard monitoring progress toward global malaria targets in PMI countries.)

President’s Malaria Initiative (PMI)²⁴

Launched in 2005, the President’s Malaria Initiative (PMI) was an interagency initiative to address global malaria led by USAID, until USAID’s recent dissolution, and implemented in partnership with CDC. It was overseen by a U.S. Global Malaria Coordinator, who was appointed by the President and reported to the USAID Administrator, and an Interagency Advisory Group made up of representatives from USAID, CDC, the National Institutes of Health (NIH), the Department of Defense (DoD), the State Department, the Peace Corps, the National Security Council, and other U.S. government agencies.²⁵ USAID served as the lead implementing agency for U.S. global malaria efforts, primarily through PMI, with other agencies also carrying out malaria activities. Collectively, prior to the second Trump administration, U.S. bilateral activities reached approximately 30 countries.²⁶ Now, amid the reorganization of foreign aid and dissolution of USAID, it is unclear how much of a focus on and funding for malaria will continue.

Goals

In 2021, the U.S. released the President’s Malaria Initiative Strategy 2021-2026; its goals included:

• reducing malaria mortality by one-third from 2015 levels in high-burden PMI-supported countries,²⁷
• achieving a greater than 80% reduction from PMI’s original 2000 baseline levels,
• reducing malaria morbidity in PMI-supported countries with high and moderate malaria burden by 40% from 2015 levels,²⁸ and
• assisting at least ten PMI-supported countries to meet the WHO criteria for national or sub-national elimination and at least one country in the Greater Mekong subregion to reach national elimination.

The strategy also stated that these efforts contribute to longer term goals, such as elimination of malaria in a growing number of countries, and aligns with global priorities.²⁹ Today, these PMI goals are not reflected in the America First Global Health Strategy, although it  does reiterate the U.S. commitment to support the global malaria goals laid out by the GTS.

Key Activities³⁰

Prior to the current administration, PMI activities focused on expanding access to and the use of six key malaria control interventions: insecticide-treated bed nets (ITNs), indoor residual spraying (IRS) with insecticides, entomological monitoring, intermittent preventive treatment in pregnancy (IPTp),³¹ diagnosis of malaria and treatment with artemisinin-based combination therapies (ACTs), and seasonal malaria chemoprevention (SMC).³²

They also included a range of malaria control activities, including technical assistance to affected countries, monitoring and evaluation, supply chain management, and commodity procurement (since the start of PMI, U.S. support for commodities, such as ITNs, insecticides, and antimalarial drugs, like ACTs, has increased significantly³³). Additionally, PMI supported activities in the following areas: behavior change communication, health systems strengthening, monitoring and evaluation, operational research, elimination, and community health.³⁴

USAID had also supported regional efforts in Latin America and the Caribbean, including providing technical assistance to support countries in tailoring their approaches for malaria control through its Amazon Malaria Initiative.³⁵ CDC provided technical assistance to these regional efforts and was also designated as the WHO Collaborating Center for Prevention and Control of Malaria,³⁶ though with the U.S. withdrawal from WHO, the future of this partnership remains an open question (see also the KFF fact sheet on the U.S. and WHO). It also remains to be seen how announcements of global health reductions at CDC and the withholding of funding to Gavi could further affect malaria control efforts, including the roll-out of the malaria vaccine.

Additionally, NIH and DoD have been involved in malaria research and development (R&D). NIH has been the lead agency for U.S. malaria R&D efforts (including its International Centers of Excellence for Malaria Research program, which established a global network of malaria research centers in 2010 to support research activities in malaria-endemic countries).³⁷ DoD also supported extensive R&D efforts as well as worldwide malaria disease surveillance, and technical assistance and capacity building with local partners.³⁸ 

Countries Reached

Prior to the current administration, PMI spanned 27 sub-Saharan African “focus countries” (gradually scaled up from three countries in FY 2006), as well as three countries in Southeast Asia under the PMI Greater Mekong Subregion regional initiative.³⁹ Focus countries were selected based on the following criteria:⁴⁰

• high malaria burden,
• alignment of National Malaria Control Plan (NMCP) with WHO standards,
• country capacity to implement national control policies,
• willingness to partner with the US in fighting malaria, and
• involvement of other international donors (e.g., Global Fund; World Bank).

Both USAID and CDC stationed staff in each PMI focus country, though USAID staff were recalled to the U.S. due to the Trump administration’s dissolution of USAID and reorganization of foreign assistance.

Beyond PMI, the Amazon Malaria Initiative spanned several countries in Latin America and the Caribbean, and other U.S. activities may reach more countries. For example, CDC and USAID had carried out activities in additional countries in sub-Saharan Africa, the Caribbean, and Asia.⁴¹

Multilateral Efforts

The U.S. has partnered with international institutions providing support for global malaria funding mechanisms. Key partners have included WHO (although the second Trump administration officially withdrew the U.S. as a member of WHO, halting governance participation, technical assistance, and funding to the organization), the RBM Partnership, and the World Bank. Additionally, the U.S. government is the largest donor to the Global Fund, which has signed over $22 billion in funding for malaria programs worldwide and is the largest overall funder of global malaria efforts.⁴²

Funding⁴³

U.S. funding for malaria, which is specified by Congress in annual appropriations bills and includes support for PMI as well as other malaria control efforts and research activities, has increased slightly over the past decade from $963 million in FY 2017 to approximately $1 billion in FY 2026 (see figure for the latest information). Additional U.S. support for malaria activities is provided through its contribution to the Global Fund. (See the KFF fact sheet on the U.S. Global Health Budget: Malaria/PMI and the KFF budget tracker for more details on historical appropriations for U.S. global malaria efforts.)

Most U.S. bilateral funding for malaria has been provided through the Global Health Programs (GHP) account at USAID with additional funding provided through NIH, CDC, and DoD. In FY 2026, with the dissolution of USAID, funding through the GHP account shifted to the State Department. The majority of U.S. malaria funding has been directed to PMI focus countries, with additional funding directed to other bilateral and regional malaria efforts as well as malaria research activities. It is still unclear, however, whether the funding appropriated by Congress for malaria will fully be spent by the administration.

Endnotes

1. WHO, World Malaria Report 2025, 2025. ↩︎
2. WHO, World Malaria Report 2025, 2025. WHO, “Malaria fact sheet,” webpage, Dec. 2025, https://www.who.int/en/news-room/fact-sheets/detail/malaria. ↩︎
3. CDC Malaria website, https://www.cdc.gov/malaria/hcp/clinical-features/ ↩︎
4. M. Tanner, D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008. ↩︎
5. Launched by the World Health Organization, the United Nations Children’s Fund, the United Nations Development Programme, and the World Bank “to convene and coordinate an inclusive, multisectoral response to control, eliminate and ultimately eradicate malaria.” RBM Partnership to End Malaria, “RBM Partnership to End Malaria About Us,” webpage, https://endmalaria.org/who-we-are/about-us. ↩︎
6. M. Tanner, D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008; WHO, World Malaria Report 2025, 2025. ↩︎
7. WHO, World Malaria Report 2025, 2025; M. Tanner and D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008; RBM, The Global Malaria Action Plan, 2008; K. Senior, “Climate Change and Infectious Disease: A Dangerous Liaison?”, The Lancet. Vol. 8, No. 2,  2008; CDC, “Preventing Malaria While Traveling,” webpage, https://www.cdc.gov/malaria/prevention/index.html. ↩︎
8. WHO, World Malaria Report 2025, 2025; WHO, “Malaria fact sheet,” webpage, Dec. 2025, https://www.who.int/en/news-room/fact-sheets/detail/malaria. ↩︎
9. WHO, World Malaria Report 2025, 2025; Global Plan for Artemisinin Resistance Containment (GPARC), 2011; Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: Regional Framework for Action 2013-2015, April 2013; Status report on artemisinin resistance and ACT efficacy, December 2019, accessed here: https://apo.who.int/publications/i/item/status-report-on-artemisinin-resistance-and-act-efficacy; “Malaria: Artemisinin partial resistance” webpage, https://www.who.int/news-room/questions-and-answers/item/artemisinin-resistance. WHO, Strategy to respond to antimalarial drug resistance in Africa, 2022. ↩︎
10. To address insecticide resistance, the WHO issued updated guidance in 2023 recommending the use of dual active ingredient ITNs. WHO, Press release: WHO publishes recommendations on two new types of insecticide-treated nets, March 2023. ↩︎
11. In 2023, WHO published recommendations on two new types of dual active ingredient insecticide-treated mosquito nets, designed to provide greater protection against malaria than previously recommended nets. WHO, World Malaria Report 2025, 2025. ↩︎
12. For a detailed description of WHO’s recommendations on the use of drugs to prevent malaria in high-risk groups, please see WHO’s Guidelines for Malaria. WHO, Guidelines for Malaria, August 2025. ↩︎
13. Vaccines that are added to WHO’s prequalification list are endorsed by WHO as having gone through comprehensive evaluation to determine that the vaccine is safe and effective. WHO, Press release: WHO recommends groundbreaking malaria vaccine for children at risk, October 2021. WHO, Press release: WHO recommends R21/Matrix-M vaccine for malaria prevention in updated advice on immunization, October 2023. WHO, Press release: WHO prequalifies a second malaria vaccine, a significant milestone in prevention of the disease, December 2023. ↩︎
14. WHO,  “Malaria vaccines (RTS,S and R21)” webpage, accessed: https://www.who.int/news-room/questions-and-answers/item/q-a-on-rts-s-malaria-vaccine. ↩︎
15. WHO, Malaria Prevention Works: let’s close the gap, April 2017. WHO, World Malaria Report 2025, 2025. ↩︎
16. RBM Partnership to End Malaria website, https://endmalaria.org/; Global Fund website, https://www.theglobalfund.org/en/. ↩︎
17. UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015. ↩︎
18. WHO, World Malaria Report 2025, 2025. ↩︎
19. Countries that were malaria endemic in 2000 and reported fewer than 10,000 malaria cases are said to be “nearing elimination.” WHO, World Malaria Report 2025, 2025. ↩︎
20. WHO, Press release: African health ministers commit to end malaria deaths, March 2024. ↩︎
21. WHO, World Malaria Report 2025, 2025. ↩︎
22. KFF: Global Financing for Malaria: Trends & Future Status, 2014; Mapping the Donor Landscape in Global Health: Malaria, 2013; World Malaria Report 2025, 2025. KFF analysis of OECD DAC CRS database, December 2025. ↩︎
23. U.S. Congress, Public Law 108-25, May 27, 2003; U.S. Congress, Public Law 110-293, July 30, 2008. ↩︎
24. PMI website, https://web.archive.org/web/20250117222257/https:/www.pmi.gov/; USAID, “The President’s Malaria Initiative,” fact sheet, May 2023; PMI, The President’s Malaria Initiative: Eighteenth Annual Report to Congress, 2024; PMI, FY 2017 Greater Mekong Subregion Malaria Operational Plan, 2017; CDC, “President’s Malaria Initiative,” webpage, https://web.archive.org/web/20240424052020/https:/www.cdc.gov/malaria/malaria_worldwide/cdc_activities/pmi.html. ↩︎
25. PMI. “Leadership” webpage, accessed: https://web.archive.org/web/20250122153738/https:/www.pmi.gov/about-us/#leadership. ↩︎
26. KFF analysis of data from the U.S. Foreign Assistance Dashboard website, http://www.foreignassistance.gov, accessed February 2025. PMI, Eighteenth Annual Report to Congress, 2024. CDC, “Malaria’s Global Malaria Activities” webpage, https://web.archive.org/web/20240303033903/https:/www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
27.  The countries targeted by PMI that are considered high burden include Angola, Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo, Ghana, Guinea, Liberia, Mali, Mozambique, Niger, Nigeria, and Sierra Leone. PMI, President’s Malaria Initiative Strategy 2021–2026, 2021. ↩︎
28. The countries targeted by PMI that are considered moderate burden include Madagascar, Malawi, Tanzania, Uganda, and Zambia. PMI, President’s Malaria Initiative Strategy 2021–2026, 2021. ↩︎
29. PMI, President’s Malaria Initiative Strategy 2021-2026, 2021. ↩︎
30. PMI, “What We Do,” webpage, https://web.archive.org/web/20241219104218/https:/www.pmi.gov/what-we-do/. ↩︎
31. Another preventive treatment includes PMC in countries where that treatment is relevant. To date only Sierra Leone had prioritized PMC for PMI support in their NMCPs. PMI, President’s Malaria Initiative Technical FY 2024 Guidance. ↩︎
32. SMC is only recommended for geographic regions where the malaria transmission season is four months or less. PMI, President’s Malaria Initiative Technical FY 2024 Guidance. ↩︎
33. PMI, “Malaria Operational Plans,” webpage, https://web.archive.org/web/20240618003157/https:/www.pmi.gov/resources/malaria-operational-plans-mops/. ↩︎
34. PMI, “What We Do,” webpage, https://web.archive.org/web/20241219104218/https:/www.pmi.gov/what-we-do/. ↩︎
35. USAID, “Malaria: Countries,” webpage, https://web.archive.org/web/20231004093249/https:/www.usaid.gov/global-health/health-areas/malaria/countries. CDC, “CDC’s Global Malaria Activities” webpage, https://web.archive.org/web/20240303033903/https:/www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
36. CDC, “CDC’s Malaria Program,” fact sheet, 2023. ↩︎
37. NIAID: “Malaria,” webpage, https://www.niaid.nih.gov/diseases-conditions/malaria; “International Centers of Excellence for Malaria Research (ICEMR),” webpage, https://www.niaid.nih.gov/research/excellence-malaria-research.  ↩︎
38. KFF, The Department of Defense and Global Health: Infectious Disease Efforts, 2013. ↩︎
39. In September 2017, PMI announced the addition of five new focus countries, bringing the number of PMI programs to 24 in sub-Saharan Africa. PMI. Press release: PMI Launches and Expands in West and Central Africa, September 2017; In April 2023, PMI announced its intention to expand to three more sub-Saharan African countries, increasing the total number of partner countries reached to 30 (27 in Sub-Saharan Africa and 3 in the Greater Mekong Region); the three additional countries include Burundi, The Gambia, and Togo. PMI, U.S. President’s Malaria Initiative Announces Plans to Expand to New Partner Countries, April 2023; PMI, “Where We Work,” webpage, https://web.archive.org/web/20250122154423/https:/www.pmi.gov/where-we-work/. ↩︎
40. PMI, 2011 PMI Fifth Annual Report, April 2011. ↩︎
41. CDC, “CDC’s Global Malaria Activities,” webpage, https://web.archive.org/web/20240303033903/https:/www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
42. Global Fund, Global Fund Data Explorer: https://data.theglobalfund.org/; accessed January 2026. KFF analysis. ↩︎
43. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and the U.S. Foreign Assistance Dashboard website, www.foreignassistance.gov. ↩︎

The Medicaid program finances about 4 in 10 births in the U.S. Federal law requires states to provide pregnancy-related Medicaid coverage through 60 days postpartum. After that period, some postpartum individuals may qualify for Medicaid through another pathway, but others may lose coverage, particularly in non-expansion states. To help improve maternal health and coverage stability and to help address racial disparities in maternal health, a provision in the American Rescue Plan Act of 2021 gave states a new option to extend Medicaid postpartum coverage to 12 months via a state plan amendment (SPA). This new option took effect on April 1, 2022 and was originally available for five years; however, the option was made permanent by the Consolidated Appropriations Act 2023. The Centers for Medicare and Medicaid Services (CMS) released guidance on December 7, 2021 on how states could implement this option.

States that sought to implement extended postpartum coverage prior to April 1, 2022 have done so through a section 1115 waiver or by using state funds. This page tracks state actions to implement extended Medicaid postpartum coverage, including states that have implemented a 12-month postpartum extension, states that are planning to implement a 12-month extension, states with pending legislation to seek federal approval through a SPA or 1115 waiver, and states that have proposed or received approval for a limited coverage extension.

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of March 19, 2026

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of March 19, 2026