On May 22, the House passed a reconciliation bill, the One Big Beautiful Bill Act, which would partially pay to extend expiring tax cuts by cutting Medicaid. The Congressional Budget Office (CBO) estimates that the bill would reduce federal Medicaid spending by $793 billion over ten years and 10.3 million fewer people would be enrolled in Medicaid in 2034, including 1.3 million people with Medicare, otherwise known as “dual-eligible individuals”. The loss of Medicaid coverage for Medicare beneficiaries stems from delaying implementation of two rules that aimed to streamline the enrollment process and make it easier for people to maintain Medicaid coverage by reducing administrative barriers. Dual-eligible individuals would be disproportionately impacted by these provisions, comprising nearly 60% of the 2.3 million Medicaid enrollees who are estimated to lose coverage as a result of delaying these rules under the House reconciliation bill (Figure 1). Instead of placing a moratorium on implementation of the rules, the recently released Senate reconciliation language would prohibit nearly all of the provisions in the rules from ever being implemented.

Dual-eligible individuals have low incomes and modest savings. The 1.3 million people that would no longer have Medicaid if the eligibility and enrollment rules were not implemented would retain their primary health insurance coverage under Medicare, but lose Medicaid coverage of Medicare premiums, and in most cases, cost sharing, which are provided through Medicare Savings Programs (MSPs) administered by state Medicaid programs. Many would also lose coverage of Medicaid benefits that supplement their Medicare coverage, such as long-term care, dental services, and non-emergency medical transportation.

The loss of Medicaid coverage for Medicare beneficiaries stems from provisions in the House bill that would delay implementation of two Biden administration rules until 2035. The two rules that would be delayed under the House reconciliation bill were intended to make it easier for people to enroll in and maintain Medicaid coverage by minimizing administrative burden in the following ways.

• One rule aimed to reduce barriers to enrollment in the Medicare Savings Programs (MSPs), under which Medicaid pays Medicare premiums, and in most cases, cost sharing for low-income Medicare beneficiaries. Among other changes, the rule would automatically enroll Medicare beneficiaries with Supplemental Security Income (SSI) into the MSPs and would more closely align the MSP application to the application for Medicare’s Part D prescription drug Low-Income Subsidy (LIS).
• The second rule would more broadly streamline application, enrollment, and renewal processes in Medicaid. Among the changes most relevant for dual-eligible individuals are new requirements for states to assist applicants with procuring appropriate documentation to validate income and assets, a requirement to renew Medicaid coverage only once per year, and a prohibition on requiring in-person interviews as part of the application process

CBO estimates that delaying these two rules would reduce federal spending by $167 billion over 10 years, making this the second largest source of cuts to federal Medicaid spending in the bill. Illustrating why administrative burdens may make it hard for dual-eligible individuals to maintain Medicaid, prior KFF research finds that among people who newly become eligible for both Medicare and Medicaid, 28% lose Medicaid coverage within the first year despite living on fixed incomes.

Although states have already implemented some of the rules’ provisions (Table 1), if the rules are delayed, it is expected that further implementation will cease and states may resume some practices that were prohibited under the rules. For example, 38 states report sending pre-populated renewal forms to Medicaid enrollees who qualify because they are ages 65 and older or have a disability, a practice they may discontinue if the rules are delayed. Alternatively, it’s possible that some states will reinstate requirements for applicants to submit paper documentation or report for in-person interviews. In a few cases, states will be required to reinstate application requirements or be prohibited from using more streamlined application processes.

Losing Medicaid coverage would substantially increase out-of-pocket costs for low-income Medicare beneficiaries. Because Medicare beneficiaries who qualify for Medicaid typically have very low incomes and little to no savings, the loss of Medicaid payment for the costs of Medicare’s premiums and cost sharing could make their Medicare coverage unaffordable. For example, the first rule would automatically enroll low-income Medicare beneficiaries who receive Supplemental Security Income (SSI) into a MSP. Without the MSP, such people must pay 20% of the $967 SSI monthly benefits for the $185 Medicare Part B monthly premium in 2025. (In order to qualify for SSI, individuals must have low incomes, limited assets, and either be over age 64 or have a qualifying disability.) This same individual would have additional out-of-pocket costs if they went to the doctor or were admitted to the hospital. Those additional out-of-pocket costs could discourage low-income beneficiaries from using health care and is the reason for CBO’s estimate that delaying implementation of the rules would reduce Medicare spending by $11 billion over 10 years.

Additionally, some of the 1.3 million Medicare beneficiaries expected to lose Medicaid under the House reconciliation bill may also lose subsidies that help pay for prescription drug premiums and cost sharing. Medicare beneficiaries with Medicaid are automatically enrolled in the Medicare Part D Low-Income Subsidy (LIS), which provides assistance with Part D prescription drug premiums and cost sharing. Illustrating the connection between Medicaid enrollment and LIS coverage, between December 2024 and January 2025, the number of LIS recipients decreased by 1 million, following Medicaid disenrollments that stemmed from the unwinding of the Medicaid continuous enrollment provision. Before the decline, LIS enrollment had been slowly but steadily growing over time.

Medicaid is a major source of financing for mental health and substance use disorder care. It covers nearly one-third of all adults with mental illness and nearly one-quarter of adults with substance use disorders (SUD), including many people with more intensive behavioral health needs. This includes adults with serious mental illness (SMI) and nearly half of all adults with opioid use disorder (OUD). Because Medicaid covers a large share of people with behavioral health conditions and finances a substantial share of treatment services and medications, it plays a central role in access to behavioral health care.   

In recent years, many states have used Medicaid to expand the behavioral health treatment continuum and improve access to care. While increasing spending, these changes have helped address longstanding gaps in access to community-based treatment as well as higher levels of care. Benefit expansions have also helped to support state efforts to respond to the opioid epidemic and to build out the behavioral health crisis continuum of care. However, recent federal policy changes, including financing and coverage changes in the 2025 reconciliation law and a more tenuous fiscal climate for states may make those gains harder to sustain. The reconciliation law requires states to implement work requirements (at application and renewal) for Medicaid expansion adults, which is the primary coverage pathway for people with mental health or substance use disorders. These requirements are expected to result in coverage losses, which may interrupt treatment and medication access.  

Against this backdrop, this brief examines recent state trends in Medicaid behavioral health coverage and payment and state coverage of select treatment models for people with serious mental illness—a population that has historically faced significant barriers to care. The brief draws on the annual Medicaid budget surveys, conducted by KFF and Health Management Associates (HMA). The 2025 survey included additional detail about coverage of Certified Community Behavioral Health Clinics (CCBHCs) (as a provider type), Assertive Community Treatment (ACT), and Coordinated Specialty Care for First Episode Psychosis (CSC-FEP).

How do recent Medicaid trends reflect state efforts to address mental health and substance use needs?

Behavioral health services are not a specifically defined category of Medicaid benefits. Some fall under mandatory Medicaid benefit categories, such as physician services, while others fall under optional benefit categories, such as rehabilitative services. The ability to cover optional benefits and place limits on items and services results in variation across states. State Medicaid benefit design is also shaped by broader fiscal conditions and federal policy changes.

State efforts to expand Medicaid behavioral health benefits reflect both state priorities and federal opportunities. Since the pandemic and intensifying opioid crisis, behavioral health has become a top priority for many state Medicaid programs. States have focused on expanding access (including in schools), integrating care, and addressing social determinants of health. Federal opportunities, including the SUPPORT Act and American Rescue Plan Act (ARPA), have driven expansions in SUD treatment and crisis services. States have also taken steps to promote more coordinated and integrated care, including adding coverage for services provided under the Collaborative Care Model (CoCM) and enrolling provider types such as CCBHCs that offer a broad continuum of behavioral health services in one setting. Some of these initiatives are part of broader behavioral health state transformation efforts.

Behavioral health has been the most frequently cited category of Medicaid benefit expansion in KFF’s annual budget survey over the past decade.  Annually, KFF’s Medicaid budget survey asks state Medicaid officials about recently implemented or planned benefit changes (i.e., benefit enhancements or additions and restrictions or eliminations). In every survey over the past 10 years, behavioral health services were the most frequently reported area of benefit expansions. States reported expansions across the full care continuum of behavioral health services, including institutional, residential, outpatient, home and community-based, peer supports, and crisis services. These trends show how states have used Medicaid to help address longstanding gaps in care and respond to emerging mental health and substance use needs; however future trends are less clear. For example, California’s FY 2026-27 proposed budget would make mobile crisis services optional for counties, rather than statewide and counties that continue to offer the service would have to finance the full non-federal share of costs.

States have also raised fee-for-service (FFS) provider payment rates to help strengthen access to behavioral health services. Even when states add benefits, access may still be limited by provider shortages and narrow networks. Increasing provider rates is one way states have tried to address Medicaid workforce shortages, though rate increases also often face fiscal headwinds. KFF’s Medicaid budget survey asks state Medicaid officials to report annual FFS rate changes for certain provider types. Beginning in FY 2024, KFF’s Medicaid budget survey asked states to report FFS rate changes specifically for outpatient behavioral health clinicians (e.g., psychiatrists, psychologists, clinical social workers, mental health counselors, and marriage and family therapists). More than half of states reported implementing FFS rate increases for one or more outpatient behavioral health providers in FY 2024 and about half of states in FY 2025. The two previous surveys, which asked more broadly about FFS rate increases for any behavioral health provider, found similar numbers of states planning to increase behavioral health provider rates in FYs 2022 and 2023. The size and scope of the rate increases varied, with some states targeting specific provider types or services, while others implemented broader increases. Although most Medicaid enrollees are now in managed care plans, state-set FFS rates often serve as a benchmark or floor for managed care payments in many states. The FY 2025 KFF survey suggests that behavioral health rate increases may be slowing, consistent with reimbursement rate trends for other provider types. About one quarter of states reported plans to increase outpatient behavioral provider rates in FY 2026. This slowdown may reflect the end of pandemic-era federal funds and anticipated federal funding reductions under the 2025 reconciliation law.

What does the FY 2025 KFF budget survey show about selected behavioral health provider types and treatment models?

The FY 2025 annual budget survey asked about state coverage of select optional behavioral health services and provider types: CCBHCs, which provide a broad array of coordinated services in a single setting, and two specialized treatment models for people with SMI: Assertive Community Treatment (ACT) and Coordinated Specialty Care for First Episode Psychosis (CSC-FEP).

State Medicaid recognition of Certified Community Behavioral Health Clinics (CCBHCs) as a provider type continues to grow. CCBHCs are a federally defined model of comprehensive community-based behavioral health clinics that provide or coordinate a core set of mental health and substance use services and serve patients regardless of an ability to pay. In FY 2025, KFF’s Medicaid budget survey asked state officials whether they recognized CCBHCs as a specific enrolled provider type for Medicaid reimbursement in FY 2025 or planned to add the recognition in FY 2026. Nineteen states reported recognizing CCBHCs as an enrolled provider type (Figure 1), up from nine in FY 2022, and several other states reported plans to add CCBHCs as a provider type in FY 2026. This growth has occurred alongside expanded federal support for the Section 223 CCBHC Medicaid demonstration, which gives participating states a pathway to certify CCBHCs, use prospective payments, and receive enhanced federal match rates. States may also add  CCBHCs as a provider type through other pathways, including Section 1115 demonstration waivers and Medicaid state plan authority, a state option made permanent through the 2024 Consolidated Appropriations Act. Recognizing CCBHCs as a distinct Medicaid provider type can support more flexible payment approaches, certification of CCBHCs against federal defined criteria, and make CCBHC services easier to identify in claims data.  However, formal recognition can require additional state administrative capacity, coordination across state agencies, and operational and budgetary changes. Some states may instead cover behavioral health services provided by CCBHCs through existing provider categories, while others may already have community mental health systems with state-defined service arrays that serve a similar function. Research suggests that CCBHCs have improved access to outpatient behavioral health care, with some evidence of reductions in acute behavioral health care use, such as emergency departments or hospitalization. More than 500 CCBHCs now operate across 46 states, DC, and Puerto Rico.

In FY 2025, two-thirds of states reported FFS coverage for Assertive Community Treatment (ACT), an evidence-based model for people with serious mental illness who need intensive support to remain stable in the community. ACT uses small, multidisciplinary teams to provide 24-hour individualized support in the community and can intensify support when symptoms worsen. It is designed for people with the most serious needs, including those whose severe symptoms and lack of illness awareness can make it difficult to stay engaged in treatment and have higher risk of repeated hospitalization and other disruptions to stable community living. Research suggests that ACT can reduce hospitalizations and improve engagement in care, especially for people with the highest needs and when services are implemented with fidelity to the ACT model. The American Psychiatric Association (APA) guidelines recommend ACT for patients with schizophrenia who have a history of poor engagement with services leading to frequent relapse or social disruption. In KFF’s FY 2025 Medicaid budget survey, 34 states including D.C. reported that ACT is covered under FFS Medicaid for adults (Figure 2).  Even in states that report Medicaid coverage for ACT, workforce and infrastructure constraints may limit access. For example, only about one-quarter (27%) of mental health facilities serving people with SMI reported offering ACT services in 2023. Budget pressures may also affect the availability of these services. In Idaho, 2025 budget cuts interrupted ACT services for people who  relied on ACT to stay stable in the community, and media reporting documented that some Medicaid enrollees receiving ACT services died after the disruption. Idaho later restored funding, though rebuilding these services may be difficult and costly.

Far fewer states reported FFS coverage for Coordinated Specialty Care for First Episode Psychosis (CSC-FEP), an evidence-based early intervention model for people experiencing a first episode of psychosis. KFF’s FY 2025 Medicaid budget survey asked state officials whether they provide FFS reimbursement for CSC-FEP codes in FY 2025 or plan to do so in FY 2026. Seven states reported covering this service in FY 2025 (Figure 2) and several more states reported plans to add coverage in FY 2026. CSC-FEP emerged in the late 2000s as an early intervention model designed to connect people experiencing psychosis for the first time to coordinated treatment to reduce the serious and potentially lasting effects of untreated psychosis. This model includes coordinated medication management, therapy, family support and education, and other services. Research shows that people who receive this treatment experience fewer psychotic symptoms, fewer preventable hospitalizations, and better outcomes in work, school, and quality of life. The APA  guidelines recommend CSC-FEP for patients with schizophrenia experiencing a first episode of psychosis. In addition to the seven states reporting coverage for this model in FY 2025, four more states reported plans to add coverage for CSC-FEP in FY2026, and Virginia reported that coverage approved by its General Assembly will begin in FY 2027. Some states reported that these services are funded outside of Medicaid through the  federal Community Mental Health Services Block Grant, which requires states to set- aside 10%  of funds for  evidence-based programs for people with early serious mental illness.

In a landmark case earlier this year, K.G.M. v. Meta Platforms, Inc. et al., a jury held major social media platforms responsible for the mental health harm of an adolescent due to their platforms’ addictive design features. This case underscores growing concerns about adolescent mental health and substance use and draws attention to the factors that may be linked to these concerns. In recent years, a large share of adolescents reported heavy screen time and social media use, trauma exposure – including direct and indirect exposure to gun violence – loneliness, and sleep deprivation. These experiences are tied to poor mental health outcomes, including anxiety and depression. Meanwhile, suicide death rates remain high among adolescents and overdose deaths reached record numbers amid the opioid epidemic.

To address growing mental health and substance use concerns several measures were introduced. This includes the 2022 Bipartisan Safer Communities Act (BSCA), which allocated funds to strengthen school-based mental health services, particularly in high-need areas, and utilize Medicaid to expand youth services. In 2021, the U.S. Surgeon General declared a youth mental health crisis and released an advisory outlining a wide range of recommendations to support this population. However, recent policy actions under the second Trump Administration have rolled back some of these efforts. Funding for school-based mental health services via the BSCA was disrupted, prompting questions about how to retain school mental health providers and reach students in need. Other, large-scale changes to insurance are expected to negatively impact coverage and access to care in the coming years. This includes changes to Medicaid, which provides coverage to nearly 40% of children and teens. Additionally, the President’s budget for 2027 proposes cuts to agencies engaged in mental health and substance use disorder services, including ongoing efforts to restructure SAMHSA. SAMHSA also oversees the 988 crisis hotline – which was recently linked to decreased adolescent suicide mortality. Funding for 988 remains flat in 2027, though previous actions have already impacted services, including the removal of an extension line to assist LGBTQ individuals. LGBTQ youth are more likely to experience suicidality compared to their peers.

This brief analyzes the latest data (2024) from the CDC WONDER mortality database and the National Survey on Drug Use and Health to examine the prevalence of adolescent mental health conditions and substance use, related deaths, and access to behavioral health services.

1. Despite some modest improvements, many adolescents experience poor mental health and substance use issues.

In 2024, 15% of adolescents (or 3.8 million) reported a past year major depressive episode (MDE) and 19% (or 4.9 million) reported moderate to severe symptoms of anxiety (Figure 1). The share of adolescents with an MDE decreased from 21% in 2021 during the pandemic – the oldest trend data available – to 15% in 2024. Additionally, a survey of high school students found that the share of students reporting feelings of sadness and hopelessness – which can be indicative of depressive disorder – increased from 30% in 2013 to 42% in 2021, before slightly declining to 40% in 2023. While NSDUH data on anxiety cannot be trended over time, other survey data suggest that diagnosed anxiety has increased over time among adolescents, with prevalence remaining higher than pre-pandemic levels. Anxiety is the most common mental health condition in this population.

In 2024, 7.8% (or 2 million) adolescents reported having a substance use disorder in the past year (Figure 1). This is a slight decrease from the 9.2% of adolescents reporting a past year substance use disorder in 2021 – the oldest trend data available. A prior KFF analysis found that the use of drugs and alcohol among high school students slightly declined from 2017 to 2023, despite the surge in drug overdose deaths during pandemic years.

Among adolescents with mental illness and/or substance use disorder, over half have private insurance and 4 in 10 have Medicaid. However, Medicaid is a major payer for mental health and substance use services for youth. Medicaid can facilitate access to care in schools and its Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit requires coverage of medically necessary services and maintains low out-of-pocket costs.

2. Substance use is higher among adolescents with mental illness compared to adolescents without mental illness.

In 2024, the use of any illicit drug was significantly higher among adolescents with a past year MDE than their counterparts (33% vs. 12%); and among adolescents with symptoms of anxiety than their counterparts (26% vs. 10%) (Figure 2). The co-occurrence of poor mental health and substance use is common. In a CDC convenience sample survey of teens, ages 13 to 18, who used substances in the last 30 days, 40% reported using substances to cope with anxiety or depression.

Marijuana, a drug that is now legally available to adults in many states, has been linked to the onset of psychoticdisordersamong youth, and is used by a large share of adolescents with an MDE (25%) and adolescents with symptoms of moderate to severe anxiety (18%). Adolescents without a past year MDE or anxiety were significantly less likely to report marijuana use (8% and 7%, respectively). Marijuana use among adolescents is associated with earlier onset of psychosis, with more frequent use linked to increased risk of adverse mental health outcomes, including schizophrenia. Further, the presence of the compound THC in marijuana has increased over time and is linked to psychotic symptoms and disorders.

3. Suicide deaths among adolescents are slowly trending downward but remain higher than a decade ago.

In the past decade, adolescent suicide deaths increased and peaked in 2018 (1,750 deaths), followed by a gradual decline through 2024 (1,478 deaths, Figure 3). There was a 5% decrease in adolescent suicide deaths from 2023 to 2024 (1,555 vs. 1,478). These deaths are more prevalent among adolescent males and are more rapidly increasing for adolescents of color compared to their White peers. Although suicide deaths are higher for adolescent males than their peers, serious thoughts of suicide are higher for adolescent females. Data on the suicide deaths was not available by LGBQ+ identity. However, LGBQ+ youth are more likely to report suicidality than their heterosexual peers. It is possible that some suicides are misclassified as drug overdose deaths since it can be difficult to determine whether drug overdoses are intentional.

More than 17,000 adolescents died by suicide over the past decade and over 4 in 10 of these deaths involved a firearm (Figure 3). Access to firearms, particularly in the home, is a risk factor for suicide deaths among children and adolescents. 

4. After surging during the pandemic, drug overdose deaths among adolescents sharply declined in 2024 but remain above pre-pandemic levels.

The sharp decline in drug overdose deaths among adolescents was driven by a reduction in opioid-related deaths: 557 deaths in 2023 vs. 272 in 2024 (Figure 4). Despite decreases in substance use among adolescents, adolescent drug overdose deaths more than doubled during the COVID-19 pandemic. This shift was largely due to drugs laced with opioids, particularly the synthetic opioid, fentanyl. Opioid-related deaths among adolescents jumped from 165 in 2019 to 396 in 2020 and continued to increase for several years before declining by approximately 50% between 2023 and 2024 (from 557 to 272, Figure 5). These trends mirror broader trends in opioid-related deaths across the total U.S. population.

Multiple actions may have contributed to the decline in overdose deaths, including school-based initiatives for youth. Policy actions implemented in response to the opioid epidemic include expanded access to treatment, public awareness campaigns, and improved fentanyl detection. Schools have also responded to the overdose crisis in multiple ways. For example, in the 2024-2025 school year, 52% of public schools offered fentanyl education to students and 77% stored naloxone – a nasal spray to reverse opioid overdose. However, challenges remain, such as adolescents obtaining drugs through social media which may be contaminated with fentanyl.

5. Adolescents receive mental health services in a variety of settings, including schools; however, recent policy changes may affect access in the future.

Six out of ten adolescents with a past year MDE reported receiving mental health treatment in 2024 (Figure 5). Many of these adolescents report receiving outpatient care in a variety of settings, including through telehealth treatment (33%). Thirty-one percent of adolescents with a past year MDE report taking prescription medication (31%).

Approximately 3 in 10 youth with a past year MDE obtain care through school health or counseling services; however, changes in funding put access to school-based mental health services at-risk. During the second Trump Administration, ongoing policy changes may impact youth access to mental health services. This includes rolling back funds to broaden access to mental health and trauma services in schools that were originally allocated through the Bipartisan Safer Communities Act.

Among the 2.4 million adolescents in need of substance use care in 2024, only 30% received treatment. This may be linked to limited access to buprenorphine and residential addiction treatment facilities among this population. Additionally, many residential addiction treatment facilities do not have availability for adolescents and are costly. These facilities often do not provide buprenorphine to adolescents with opioid use disorder.

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 proposing to implement 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, and potential impacts on beneficiaries and program budgets. It also describes recent changes to the administration’s plans for temporary coverage of GLP-1s in Medicare, including an indefinite delay in implementation of the BALANCE Model in Part D and an extension of a separate short-term program, called the Medicare GLP-1 Bridge, which was originally scheduled to run from July-December 2026 but will now run through the end of 2027.

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 (not 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 initially 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, that was originally scheduled to begin in January 2027 and end in December 2031. CMS has recently announced an indefinite delay in implementation of the BALANCE Model, however, and an extension of the GLP-1 Bridge through the end of 2027 (as described below).

For Medicaid, GLP-1 coverage will be expanded through the BALANCE Model beginning in May 2026 and ending 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 and will be extended through the end of 2027

CMS will provide Part D beneficiaries with coverage of select GLP-1s for obesity from July 1, 2026 to December 31, 2027 (originally December 31, 2026) through the Medicare GLP-1 Bridge, which is a 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.

Medicare beneficiaries enrolled in Part D plans who meet the eligibility criteria will have access to GLP-1 medications approved for weight reduction (all formulations of both Foundayo and Wegovy and the KwikPen formulation of 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 eligible GLP-1s under the Bridge program 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 in 2026 (increasing to $2,400 in 2027), 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 and 2027 if the $50 monthly copayment is unaffordable.

At this time, it is uncertain how participating beneficiaries will be able to maintain Medicare coverage of their GLP-1 medication for obesity after the Medicare GLP-1 Bridge ends at the end of 2027, pending further action from CMS to implement the BALANCE Model in Medicare Part D in 2028, as described below.

The BALANCE Model was designed to expand coverage of GLP-1s for obesity in Medicaid and Medicare Part D

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 negotiated 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, 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, cardiovascular disease risk reduction, 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, but there was insufficient interest among Medicare Part D plans to move forward in 2027

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 was April 20, 2026; and for state Medicaid programs is July 31, 2026 (Figure 2).

On April 21, 2026, the day after the application deadline for Medicare Part D plan sponsors to participate in the BALANCE Model, CMS announced that it would not be moving forward with implementation of the BALANCE Model in Medicare in 2027 and instead would be extending the Medicare GLP-1 Bridge to run through the end of 2027. CMS said that this was in part to allow for collection of additional data on GLP-1 utilization to share with Part D plan sponsors ahead of potential implementation of BALANCE in Part D. CMS also stated they received feedback from plans that an extension of the BRIDGE would facilitate a smoother transition to potential implementation of BALANCE in Part D. At the same time, it was also reported that major Part D plan sponsors were reluctant or unwilling to participate in the BALANCE Model as it was originally designed. The discussion below of Medicare Part D participation in BALANCE reflects implementation details under CMS’s original design. However, implementation of this model in Medicare faces an uncertain future, since CMS has not yet announced specific plans to restart or restructure the model for future years. The delay in implementation of the BALANCE Model within Medicare Part D will not affect plans for implementation of the model within Medicaid beginning in 2026.

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 Foundayo, Mounjaro, Ozempic, Rybelsus, and Wegovy, and the KwikPen formulation of Zepbound. 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 needed to apply to participate in the model by April 20, 2026. Participants could 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 could indicate if they wished to convert a Defined Standard benefit plan to another basic benefit type in order to become eligible. Participation was defined at the plan sponsor level, and plan sponsors could choose which of their specific plan benefit packages would be part of the model. However, CMS required plan sponsor participants to include all of their enhanced alternative plans and 90% of their enrollment in basic plans.

CMS was aiming for a “critical mass” of Part D sponsors to participate and established a threshold participation rate of 80% for 2027. This participation rate was to be calculated as the enrollment in Part D plans applying to participate in the model divided by the total enrollment in all Part D plans, excluding special needs plans and employer plans, even though they are eligible to participate in the model, but including Defined Standard benefit plans, even though they are ineligible to participate. (This calculation could produce a different participation rate than if it was based on enrollment in all participating plans divided by enrollment in all plans eligible to participate. CMS did not explain the rationale behind their approach.) CMS specified that if the 80% threshold was not met, CMS would not move forward with the BALANCE Model in Medicare in 2027, and that appears to be what occurred, as CMS’s April 21, 2026 announcement suggests.

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 was voluntary for Part D plan sponsors, CMS designed financial incentives to encourage plan participation. The primary approach to encourage participation for 2027 involved 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 would qualify for this additional financial protection if they opted in and had higher-than-average utilization of model drugs relative to other similar plan participants. CMS initially stated that for future model years, the agency was considering additional payment incentives, including higher direct subsidy payments based on an adjustment factor to the beneficiary risk score in participating plan bids.

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

Overall, CMS’s efforts to expand Medicare and Medicaid coverage of GLP-1s for people with Medicare and Medicaid could greatly expand access to these drugs, albeit on a temporary basis, 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, these efforts will 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. 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 these temporary programs 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. And there is no clear path forward for GLP-1 coverage in Medicare after 2027 if the Medicare GLP-1 Bridge is not extended further and the BALANCE Model is not implemented. 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 and 2027 but then lose access in 2028 if the BALANCE Model or another coverage pathway are not implemented.

If the BALANCE Model launches in some future year with at least 80% participation, Part D plans could drop out of the model before the final year (originally 2031), which could interrupt treatment, or require frequent plan changes for Medicare Part D enrollees to maintain access. It is also unclear whether Part D plan sponsors would be able continue to cover GLP-1 drugs for the treatment of obesity once the model ended if Medicare’s statutory exclusion on weight loss drugs is not lifted.

Another uncertainty for Part D enrollees in terms of their out-of-pocket costs is the impact of the BALANCE model on Part D premiums. Participating plan sponsors would factor the cost of the model into their bids. 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 cost to Medicare of covering obesity drugs under Part D has been estimated at between $25 billion and $35 billion over 10 years, which could have been a driving factor in the reluctance or unwillingness of major Part D plan sponsors to participate in the BALANCE model as it was originally designed. The cost to Medicaid of covering obesity drugs has been estimated at $15 billion, with the federal government paying $11 billion and states paying nearly $4 billion of this estimated total.

The law requires Innovation Center models to either maintain or reduce program expenditures. The BALANCE Model is designed to 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. Based on the reluctance of major Part D plan sponsors to participate in the BALANCE Model in 2027 under the original specifications, it appears that sponsors had insufficient data to estimate their added costs associated with covering GLP-1s for obesity.

Evaluations of the model will also determine whether improvements in health related to the use of these drugs and associated reductions in health care 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. Federal spending is expected to increase under this demonstration due to paying for GLP-1s for obesity, which is not currently covered under Medicare, but the amount of the increase is unknown since CMS hasn’t disclosed the projected cost. 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.

While spending on prescription drugs accounts for a relatively small share of overall Medicaid spending, Medicaid drug spending has grown in recent years. As a result, both states and the federal government continue to prioritize the management of rising prescription drug costs. There have been several recent Trump administration prescription drug initiatives, including negotiating “most-favored-nation” (MFN) drug pricing deals. These MFN agreements are based on the premise that the U.S. shouldn’t pay higher prices for prescription drugs than other comparable nations. The deals include agreements by drug manufacturers to provide MFN pricing in Medicaid and other commitments in return for a 3-year reprieve from tariffs, though the specific details of these agreements remain confidential. Though prices vary across countries, studies have shown that drug prices in the U.S. are about three times higher than in other countries.

To make MFN drug prices available to state Medicaid programs, the Centers for Medicare & Medicaid Services (CMS) developed the GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) Model, a drug payment model through which CMS will negotiate supplemental drug rebates based on prices paid in other countries. Given significantly lower drug prices internationally, this approach could result in substantial Medicaid savings, with a recently released White House report estimating that a voluntary MFN framework in Medicaid would save $64.3 billion over a 10-year period. While initial savings would be large and diminish over time – in part due to the fact that prices in other countries might increase as a result – savings would average $6.43 billion a year, or approximately 14% of annual Medicaid prescription drug spending.

However, it is unclear what assumptions were made to develop the administration’s estimates, and there remain several uncertain factors that make it difficult to assess the overall impact the new model will have on Medicaid drug costs. This issue brief provides background on the GENEROUS model, examines the factors that will contribute to the model’s overall impact on Medicaid drug costs, and illustrates how savings will depend on model details that are confidential or uncertain at this time. Key takeaways include:

• The impact of the GENEROUS model on Medicaid prescription drug spending remains unclear due to several uncertain factors related to drug pricing and model participation.
• Existing Medicaid rebates already reduce overall Medicaid prescription drug spending substantially, likely limiting the impact of the GENEROUS model’s MFN supplemental rebate approach.
• GENEROUS model savings will depend on which manufacturers and states participate as well as what drugs are included in the model due to variation in drug rebates (and net prices) as well as spending and utilization trends.

What Is the GENEROUS Model?

The CMS Innovation Center launched the GENEROUS model in January 2026 with the goal of lowering Medicaid drug spending by offering prices based on what other countries pay. The model is voluntary for manufacturers, though it is expected that the seventeen pharmaceutical companies (e.g. Pfizer, AstraZeneca, etc.) that have signed MFN agreements will participate. Manufacturers now have until June 11, 2026 to apply to participate in the GENEROUS model (the deadline has been extended twice from March 31, 2026 to April 30, 2026 and again to June 11, 2026). The model is also voluntary for states, with states having until July 31, 2026 to submit their application and until August 31, 2026 to execute a state participation agreement with CMS. States may be able to join the model after August 31, 2026 at CMS discretion. The model will run for five years through 2030, though manufacturers and states may voluntarily terminate their participation and key terms between CMS and manufacturers may be renegotiated.

Through the GENEROUS model, CMS will negotiate supplemental drug rebates based on prices paid in other countries (or the “MFN price”). For model drugs (single source or innovator multiple source drugs, also known as brand drugs), CMS will calculate the MFN price based on international pricing data provided by manufacturers across eight other countries (the United Kingdom, France, Germany, Italy, Canada, Japan, Denmark, and Switzerland). The MFN price is the second lowest reported net price after any rebates or discounts and is adjusted by gross domestic product per capita using a purchasing power parity method. CMS will then calculate the supplemental rebate for each model drug that results in a Medicaid net price equivalent to the MFN price (more specifics on the MFN price and Medicaid guaranteed net unit price calculations are available in both the state request for applications (RFA) and the manufacturer RFA). States can select which model drugs they’d like to receive MFN pricing for and must enter into new supplemental rebate agreements (SRAs) that reflect the model’s key terms (states cannot receive additional supplemental rebates outside of the model for drugs they have opted into).

CMS and participating manufacturers will also negotiate uniform coverage criteria, which includes utilization controls such as prior authorization or step therapy. These terms will be based on existing criteria states have negotiated, and states will have to adopt the uniform criteria to access the supplemental rebate for a given drug. States currently negotiate their own SRAs with manufacturers and use an array of payment strategies and utilization controls to manage prescription drug expenditures. States often use placement on a preferred drug list (PDL) and prior authorization as leverage to negotiate supplemental rebates with manufacturers, though the specific strategies vary by state. The negotiation of standardized coverage criteria could help reduce the administrative burden for states and manufacturers of negotiating individual SRAs tied to specific clinical criteria. However, the negotiated criteria may be more broad or more restrictive than the criteria states have already developed, which could have implications for state participation and model savings.

CMS will also conduct GENEROUS model monitoring and evaluation. The law requires Innovation Center models to either maintain or reduce program expenditures, and the model will test whether the MFN supplemental rebate approach can reduce Medicaid drug costs. To the extent negotiated clinical criteria broadens, the model may also increase enrollee access. Throughout the model, CMS will track data and assess the impact of the model on health care spending and access to care as well as audit the manufacturer reported international drug pricing data. GENEROUS works within the existing Medicaid Drug Rebate Program (MDRP) framework and builds on other CMS supplemental rebate models including the Cell and Gene Therapy Access Model and the BALANCE model. Notably, while these models aim to address high drug costs for the Medicaid program, they do not affect out-of-pocket costs for Medicaid enrollees, which are limited to nominal amounts under federal law.

What Are the Potential Impacts on Medicaid Prescription Drug Spending?

The impact of the GENEROUS model on Medicaid prescription drug spending remains unclear due to several uncertain factors related to drug pricing and model participation. Several factors will affect model cost savings (Figure 1), many of which are confidential or not yet available, including:

• While data on gross drug prices is available, data on the size of rebates for specific drugs is proprietary in both Medicaid and internationally, making it difficult to compare net Medicaid prices to net international prices.
• At this time, it also remains uncertain which manufacturers and states will participate in the model and how long participation will last.
• Further, while model documentation makes it clear that states may select model drugs, it remains uncertain whether all drugs in a participating manufacturer’s portfolio will be subject to the model. The RFAs note that “model drugs are limited to all the single source drugs or innovator multiple source drugs of a participating manufacturer”, indicating manufacturers must include all of their covered outpatient drugs. However, the RFAs also report that the listed terms may differ from the final terms, and a CMS presentation to states noted “manufacturers will opt into the model for certain branded Medicaid covered outpatient drugs”, leaving it uncertain whether all of a manufacturer’s drugs will be subject to MFN pricing or if exemptions will be available. Recent letters from the Senate Finance Committee sent to drug manufacturers push for more model details, including which drugs will be included in the model.
• Lastly, details on the uniform coverage criteria for model drugs have not been released, making it difficult to assess the impact the terms may have on drug spending or access.

Existing Medicaid rebates already reduce overall Medicaid drug spending substantially, likely limiting the impact of the GENEROUS model’s MFN supplemental rebate approach. Medicaid programs already pay lower prices, net of rebates, than other payers due to the MDRP, which requires manufacturers to rebate a portion of drug payments to states. Medicaid rebates overall reduced gross Medicaid spending on prescription drugs by 53% on average from FY 2019 to FY 2024 (Figure 2). Rebates for brand drugs are typically even higher, with a Medicaid and CHIP Payment and Access Commission (MACPAC) analysis of FY 2020 data finding a 62% rebate overall for brand drugs.

At the same time, a recent study showed that U.S. drug prices overall were 2.78 times international drug prices (across 33 OECD countries); this differential is similar to those found in other research. Assuming U.S. drug prices are 2.78 times more than international prices, this would mean international prices are about one-third (36%) of U.S. drug prices. Based on this calculation, an MFN approach that reduced prices to international levels would provide a 64% rebate off existing U.S drug prices (Figure 2). The same study found U.S. brand drug prices were 4.22 times international drug prices, which is effectively a 76% rebate. While this is an illustrative example based on non-Medicaid specific drug prices in aggregate, it indicates that an MFN approach could provide substantial discounts given the large difference between drug prices in the U.S. and abroad. However, Medicaid already receives sizeable rebates, signaling there may be limits to this approach when applied to the Medicaid program.

However, rebates and net prices vary substantially by drug, meaning GENEROUS model savings will vary for each model drug (Figure 3). While data on the total rebate for a specific drug is confidential, rebates vary substantially by drug. The minimum federal statutory rebate for a brand drug is 23.1%, but FY 2020 data shows statutory rebates for brand drugs subject to Medicaid’s best price provision and inflationary rebate component are generally much higher, reaching 77% overall. Further, as of January 1, 2024, there is no longer a cap on the total rebate amount if a drug’s price increases quickly over time, meaning overall rebates may now be even higher. In addition to these federal statutory rebates, states have been increasingly negotiating supplemental rebates with manufacturers, with supplemental rebates across states reducing gross Medicaid spending by 7% in FY 2024 (resulting in a higher total rebate estimate of 84% if added to the 77% in statutory rebates for some brand drugs). International countries in the model may also negotiate rebates or discounts. Available studies indicate rebates vary by type of drug and country, ranging anywhere from 0% of gross spending in Japan to about 25% or more in several model countries including Canada, Germany, France, Switzerland.

To illustrate, this analysis examines three example drugs (Drugs A-C), all with a gross Medicaid price of $422 compared with $100 internationally (based on the above study) but with different sized rebates (Figure 3). Some drugs, typically newer drugs with few (or no) competitors in their therapeutic class, may have smaller rebates and large gaps between the net Medicaid and net international price (like Drug A). For example, Biktarvy, the first single tablet combination HIV treatment with the ingredient bictegravir, was FDA approved in 2018 and had an estimated Medicaid rebate of 24% in 2019. It can be difficult for states to secure supplemental rebate agreements for these types of drugs, meaning their inclusion in the model would likely result in savings for states but at a cost to manufacturers.

However, there are also drugs, typically those with more competitors or that have been on the market longer, for which states are already receiving sizeable Medicaid rebates (like Drug B or C). For example, Eliquis, an anticoagulant (or blood thinner), was FDA approved in 2012 and had an estimated Medicaid rebate of 100% in 2019, meaning Medicaid programs are likely paying little to nothing for the drug. In cases where Medicaid rebates are already high, there may not be substantial savings for states through the GENEROUS model, but the impact of the model on manufacturer profits would be mitigated.

Medicaid drug rebates also vary by state, resulting in differing model impacts across states. While federal statutory rebates are required by law and calculated by CMS, the number and magnitude of SRAs vary across states. Medicaid rebates reduced gross Medicaid spending on prescription drugs by 53% on average nationally from FY 2019 to FY 2024, though the percentage varies across states. MACPAC data from FY 2024 shows that drug rebates (including both statutory and state supplemental rebates) reduced gross Medicaid spending on drugs by less than 40% in four states (Kentucky, Oregon, South Dakota, and Virginia) to over 90% in another four states (Delaware, Mississippi, Nevada, and Wyoming). This variation likely reflects differences in the amount and types of drugs paid for as well as differences in SRAs across states. States will likely complete their own internal analyses to assess model impact, including comparing their existing supplemental rebate agreements to what is available under the model and analyzing the impacts of standardized criteria before entering into new model SRAs.

Medicaid drug utilization and spending patterns will also have implications for the Medicaid savings possible under the model. KFF analysis of Medicaid State Drug Utilization Data shows that a relatively small number of drugs account for a large share of Medicaid drug spending (Figure 4). The top five drugs (Biktarvy, Humira, Stelara, Dupixent, and Ozempic) account for 10% of all Medicaid drug spending, and the top 50 drugs account for over one-third of all Medicaid drug spending. Substantial MFN supplemental rebates on the costliest and most utilized drugs for Medicaid programs could result in significant savings (if the drugs are not already subject to sizeable Medicaid rebates), whereas substantial rebates on drugs that are not frequently utilized or only account for a small share of spending would have less of an impact. In addition, the overall number of participating manufacturers and model drugs as well as the number of participating states will affect the magnitude of savings.

Overall, GENEROUS model savings will depend on who participates, both manufacturers and states, and what drugs are included. While these factors remain uncertain at this time, the implications for Medicaid drug costs may become clearer as additional model details become available or if manufacturers respond to recent Senate letters requesting details of the Trump administration’s deals. Looking ahead, substantial state participation will likely indicate the potential for considerable model savings as states may only opt in if they expect the model supplemental rebates to be larger than their current supplemental rebates. States are also currently facing broader state budget pressures and federal Medicaid cuts, which may make some states eager to adopt pharmacy cost containment strategies. Further, manufacturer model participation may increase following the recent announcement of new pharmaceutical tariffs for companies who have not yet entered into MFN deals, though it is not clear what will happen to manufacturer participation when the tariff reprieves end. Once implemented, the GENEROUS model could also have implications for Medicaid prices on drugs from non-participating manufacturers or for the broader drug market, including changes in international prices or manufacturer participation in international markets.