MAHA ELEVATE
Lifestyle Medicine Enters the Medicare Payment Lexicon
In 2022, approximately 45 percent of Medicare beneficiaries had four or more chronic conditions. Those beneficiaries accounted for nearly 90 percent of total Medicare spending. The arithmetic of chronic disease in the Medicare population is not complicated: a system that spends the overwhelming majority of its resources treating downstream complications of conditions rooted in nutrition, physical inactivity, sleep disruption, and chronic stress is a system structurally misaligned with its own spending drivers. Medicare has never lacked awareness of this problem. What it has lacked is a payment mechanism for addressing the upstream behaviors. The fee schedule pays for office visits, procedures, imaging, and pharmaceuticals. It does not pay for the structured lifestyle interventions that the clinical evidence increasingly identifies as the most effective first-line treatment for the conditions consuming the budget.
MAHA ELEVATE is CMMI’s attempt to build that evidence base from inside Medicare’s own population. Announced December 11, 2025, the Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence model is a $100 million, three-year program funding up to 30 cooperative agreements to test whole-person functional and lifestyle medicine interventions that Original Medicare does not currently cover. It is the first CMMI model to focus explicitly on proactive, holistic, patient-centered functional or lifestyle medicine approaches to care. It is also the smallest model in the 2025 CMMI portfolio by dollar amount, the most constrained by design, and the one most dependent on whether its evaluation produces results strong enough to justify future coverage decisions.
What MAHA ELEVATE Is and What It Is Not#
MAHA ELEVATE is an incubation model. It is not a payment model in the way that MSSP, ACO REACH, or BALANCE are payment models. It does not create a new reimbursement pathway, modify the fee schedule, or establish shared savings mechanisms. It provides grant funding through cooperative agreements to organizations that will deliver lifestyle medicine interventions to Original Medicare FFS beneficiaries and collect the cost and quality data CMS needs to determine whether those interventions should eventually become covered Medicare services.
The distinction matters because it defines the model’s ceiling. A cooperative agreement funds a program. It does not create a benefit. MAHA ELEVATE awardees will deliver services to beneficiaries at no cost. Those services will not appear on Medicare claims. They will not generate encounter data in the way that a Part B service would. The model’s value proposition is entirely prospective: if the data from these 30 programs demonstrates that lifestyle medicine interventions reduce chronic disease progression and lower Medicare spending, CMS gains the evidentiary basis for a future coverage determination or a future CMMI model that operates through the claims system rather than through grants.
This is the HCIA-to-MDPP pathway. CMS funded the original Diabetes Prevention Program through a Health Care Innovation Award to the YMCA. That model test demonstrated that group-based lifestyle coaching could produce weight loss and Medicare savings in the prediabetes population. The CMS Office of the Actuary certified the model in 2016, and CMS expanded it as the Medicare Diabetes Prevention Program, a covered Part B preventive service. MAHA ELEVATE is designed to generate the same kind of evidence across a broader set of chronic conditions and a wider range of interventions.
The MDPP precedent is both instructive and cautionary. The MDPP was a genuine policy achievement: the first CMMI model expanded into a permanent Medicare benefit. It was also, by the metric of beneficiary reach, a disappointment. CMS projected that more than 50,000 beneficiaries would use the benefit in its early years. Through the first six years, enrollment remained far below projections. Supplier availability was geographically uneven, concentrated in the Northeast and sparse in the Mountain West and Sunbelt. Reimbursement was inadequate: one safety net health system estimated receiving $108 in Medicare payment against $553 in year-one delivery costs per participant. The performance-based payment structure discouraged suppliers serving racial and ethnic minority populations, where attendance rates and weight loss outcomes were lower but diabetes prevalence was higher. The RTI International final evaluation found that beneficiaries who enrolled achieved strong clinical outcomes, with more than half achieving at least five percent weight loss and 80 percent of those maintaining it. But enrollment was the constraint, not efficacy.
MAHA ELEVATE’s designers appear to have absorbed at least some of these lessons. The cooperative agreement structure avoids the reimbursement inadequacy problem by providing upfront funding rather than performance-based claims payment. Organizations will receive approximately $3.3 million each over the three-year performance period, enough to cover intervention delivery, administration, and data collection. The tradeoff is scale: 30 cooperative agreements serving Original Medicare FFS beneficiaries in selected geographies cannot produce the population-level enrollment that a national Part B benefit would. MAHA ELEVATE is not attempting to treat millions of beneficiaries. It is attempting to produce rigorous data from a manageable number of programs to inform the policy decision about whether to treat millions.
The Six Pillars and the Evidence Question#
CMS has organized MAHA ELEVATE around six interconnected focus areas: nutrition, physical activity, sleep, stress management, harmful substance avoidance, and social connection. Every proposal must incorporate nutrition or physical activity. Three awards are reserved for interventions addressing dementia. Proposals must target one or more chronic conditions and identify specific evidence-based interventions.
The language CMS uses to describe these focus areas, “functional or lifestyle medicine,” carries definitional weight that the model’s design carefully navigates. Lifestyle medicine and functional medicine are related but distinct fields with different evidence bases, different professional organizations, and different reputations within mainstream clinical practice.
Lifestyle medicine, as defined by the American College of Lifestyle Medicine, applies evidence-based behavioral interventions to prevent, treat, and reverse chronic disease. Its six-pillar framework, nutrition, physical activity, sleep, stress management, avoidance of risky substances, and positive social connections, maps directly onto MAHA ELEVATE’s focus areas. The evidence base for these interventions is substantial. The DPP clinical trial and its 21-year follow-up demonstrated that structured lifestyle intervention reduced diabetes incidence by 58 percent in the intervention group, a finding that held across racial and ethnic subgroups and age brackets. Subsequent randomized controlled trials have demonstrated the effects of structured nutrition and exercise programs on blood pressure, lipid profiles, HbA1c, and cardiovascular risk.
Functional medicine is a more contested category. The Institute for Functional Medicine describes it as a systems biology approach that identifies and addresses root causes of disease. Functional medicine practitioners may use dietary interventions, stress management, and exercise programming that overlap substantially with lifestyle medicine. They may also use testing, supplementation, and treatment protocols that have thinner evidentiary support. CMS’s decision to include both terms, “functional or lifestyle medicine,” in the model description was deliberate. It creates a tent large enough to accommodate the lifestyle medicine establishment, the functional medicine community, and the integrative health providers who operate between them. The requirement that proposals be supported by peer-reviewed literature and demonstrate scientifically documented health improvements is the mechanism CMS uses to filter the applicant pool toward evidence rather than philosophy.
This filtering mechanism will be tested in the application process. The NOFO, expected in early 2026, will establish the specific evidence thresholds and evaluation criteria. The most competitive proposals will come from organizations that can demonstrate prior implementation of structured lifestyle interventions with published outcomes data, HIPAA-compliant data infrastructure, and the capacity to recruit and retain Medicare FFS beneficiaries in multi-year programs. Academic medical centers with existing integrative medicine divisions, ACOs already funding lifestyle interventions from shared savings, FQHCs with established nutrition and exercise programming, and mature digital health platforms with longitudinal engagement data are all plausible applicants.
The organizations most likely to struggle are those with strong clinical programming but weak data infrastructure, or strong evidence for younger populations but limited experience with Medicare beneficiaries. The Medicare FFS population served by MAHA ELEVATE skews older, sicker, and more functionally limited than the commercially insured populations where most lifestyle medicine research has been conducted. Whether a yoga-based stress reduction program that works for a 45-year-old executive works for a 74-year-old with four chronic conditions, moderate cognitive impairment, and limited transportation is not a question that existing literature answers well.
Who Can Participate and How the Money Works#
The eligible applicant pool is intentionally broad. CMS has listed private practices, health systems, accountable care organizations, academic organizations, community-based organizations, FQHCs, Rural Health Clinics, senior living communities, state and local governments, functional medicine centers, lifestyle medicine centers, preventive medicine centers, and integrative medicine centers. Organizations can apply individually or through partnerships and may submit multiple distinct proposals.
The funding flows through cooperative agreements, not contracts and not grants in the traditional sense. A cooperative agreement is a federal funding instrument in which CMS maintains substantial involvement in the program’s design and execution. Awardees will work with CMS to create plans for data collection, quality measurement, beneficiary recruitment, and cost containment. This collaborative structure gives CMS more influence over how the interventions are delivered and measured than a standard grant would, which is appropriate for a model whose primary purpose is evidence generation.
The $100 million budget is allocated across two cohorts. Cohort 1 launches September 1, 2026. Cohort 2 launches in 2027. Each awardee receives funding for a three-year performance period. The per-award allocation of approximately $3.3 million must cover the intervention itself, program administration, and data collection and reporting. It cannot be used for food, even though nutrition is a mandatory component of every proposal. It cannot be used for services already billable to Original Medicare. This creates a boundary condition: MAHA ELEVATE funds the services Medicare does not currently cover. Any clinical services a beneficiary receives that Medicare already pays for, office visits, labs, imaging, continue flowing through the standard FFS claims system.
The food exclusion is notable. CMS has identified “Food as Medicine” as a specific pathway within MAHA ELEVATE, and the Epstein Becker Green analysis identified Food as Medicine benefits as one of the model’s signature opportunities. But the cooperative agreement funding cannot purchase food. Organizations can provide nutrition education, dietary coaching, meal planning support, and structured nutritional interventions. They cannot buy groceries for beneficiaries. The distinction reflects a longstanding tension in Medicare policy between coverage of services and coverage of the social determinants that make those services effective. MA plans have been offering food-related supplemental benefits through SSBCI since 2019. Original Medicare has no analogous mechanism. MAHA ELEVATE acknowledges the importance of nutrition while reinforcing the boundary between what Medicare pays for and what it does not.
The Dementia Carve-Out#
Three of the 30 cooperative agreement awards are reserved for interventions addressing dementia. This carve-out reflects both the scale of dementia as a Medicare cost driver and the emerging evidence base for lifestyle interventions in cognitive decline.
Medicare spending on beneficiaries with Alzheimer’s disease and related dementias is approximately three times higher per capita than spending on beneficiaries without dementia. Much of that spending reflects the downstream costs of cognitive decline: hospitalizations for falls, infections, and behavioral crises; skilled nursing facility stays; and home health episodes. If lifestyle interventions can slow cognitive decline or delay the onset of functional impairment, the spending implications are substantial.
The evidence base, while growing, is earlier-stage than the evidence for lifestyle interventions in diabetes, hypertension, or cardiovascular disease. The FINGER trial and its multi-country replication studies have demonstrated that multi-domain lifestyle interventions combining nutrition, exercise, cognitive training, and vascular risk management can slow cognitive decline in at-risk older adults. The U.S. POINTER study, the American adaptation of FINGER, is ongoing. The three reserved MAHA ELEVATE awards provide an opportunity to test these interventions specifically within the Medicare FFS population, where the clinical heterogeneity and comorbidity burden are higher than in the research populations studied to date.
The dementia carve-out also positions MAHA ELEVATE within the administration’s broader Alzheimer’s and dementia policy. The model’s willingness to fund non-pharmacological interventions for cognitive decline complements the FDA’s ongoing evaluation of anti-amyloid therapies and CMS’s national coverage determination for Leqembi. Lifestyle intervention and pharmaceutical intervention are not competing approaches; they address different aspects of the disease process. MAHA ELEVATE’s dementia awards could produce the evidence needed to establish a structured lifestyle intervention as a standard complement to emerging drug therapies.
The MAHA Political Context#
MAHA ELEVATE’s name is not incidental. The “Make America Healthy Again” framing connects the model directly to the health policy agenda that HHS Secretary Robert F. Kennedy Jr. has articulated since taking office. The MAHA agenda emphasizes chronic disease prevention, food system reform, reduction of environmental toxins, and skepticism toward pharmaceutical-first treatment paradigms. MAHA ELEVATE is the CMMI model most closely aligned with that agenda.
The political alignment creates both opportunity and risk. The opportunity is institutional support at the highest levels of HHS, which translates into faster model development timelines, prominent public communication, and alignment with the Secretary’s stated priorities. The risk is that the model becomes associated with the more controversial elements of the MAHA agenda, particularly the strains of anti-vaccine sentiment, skepticism toward evidence-based medicine, and promotion of unvalidated alternative therapies that have characterized some of Kennedy’s public statements. CMS’s design choices, the evidence requirements, the peer-reviewed literature standard, the positioning as a support to and not a replacement for conventional medicine, read as deliberate insulation against these risks. The model funds what can be proven, not what is believed.
The American College of Lifestyle Medicine, which represents more than 15,000 health professionals, has publicly endorsed both MAHA ELEVATE and ACCESS. The National Association of ACOs welcomed the model as an opportunity to build the evidence base for interventions that ACOs already fund from shared savings. The Primary Care Collaborative expressed support for the model’s emphasis on prevention over procedure volume. These endorsements from mainstream medical organizations provide institutional credibility that separates MAHA ELEVATE from the more polarizing elements of the MAHA political brand.
The critical question is whether the model survives a change in administration. MAHA ELEVATE’s three-year cooperative agreements will run through at least 2029. If a new administration takes office in January 2029, the first-cohort programs will be in their final year and the second-cohort programs will have two years remaining. Cooperative agreements are more durable than many policy instruments because they create binding contractual obligations. But the model’s findings, and the coverage decisions they inform, will depend on whether future CMS leadership chooses to act on the evidence MAHA ELEVATE produces.
The ACCESS and BALANCE Intersection#
MAHA ELEVATE’s position within the 2025 CMMI portfolio is best understood in relation to the two models it was designed to complement.
ACCESS is the 10-year voluntary model that creates outcome-based payments for technology-supported chronic care management. ACCESS pays providers and technology companies to deliver measurable health improvements in beneficiaries with hypertension, obesity, prediabetes, diabetes, chronic kidney disease, cardiovascular disease, musculoskeletal pain, and depression or anxiety. Where ACCESS creates a new payment mechanism for technology-enabled chronic disease management, MAHA ELEVATE generates the evidence base for the lifestyle interventions that technology might deliver. A digital health company participating in ACCESS might use an app-based platform to deliver structured nutrition coaching and physical activity programming. If MAHA ELEVATE demonstrates that similar interventions improve outcomes and reduce costs, the evidence strengthens the case for the technology platform’s role in ACCESS.
BALANCE covers the pharmaceutical intervention that sits alongside lifestyle modification. GLP-1 medications are approved for use in conjunction with diet and exercise. Every BALANCE beneficiary must have access to a manufacturer-funded lifestyle support program. MAHA ELEVATE tests what a more rigorous, independently delivered lifestyle intervention looks like without the drug. For a beneficiary who achieves weight loss through BALANCE’s GLP-1 coverage and subsequently discontinues the medication, the lifestyle medicine approaches tested in MAHA ELEVATE offer a potential framework for maintaining that weight loss without continued pharmacotherapy.
The three models together describe a policy arc: MAHA ELEVATE builds the evidence for lifestyle intervention as a standalone approach. BALANCE provides pharmacological treatment paired with lifestyle support. ACCESS creates the payment infrastructure for technology to deliver both. Whether CMS conceived of these three models as an integrated platform from the outset or assembled them from parallel policy tracks that converged is less important than the fact that they function as a coherent system. The chronic disease prevention theory running through all three is that Medicare spending can be reduced by intervening earlier, with different tools, and measuring whether those tools work.
The Measurement Problem#
MAHA ELEVATE’s value depends entirely on what its evaluation shows. CMS has stated that the model will collect cost and quality data to inform future coverage decisions and future CMMI models. The evaluation framework has not been fully specified, but the model’s design implies several measurement challenges that will determine whether the evidence produced is actionable.
Attribution. MAHA ELEVATE beneficiaries will continue receiving all standard Medicare FFS services. Any changes in their utilization patterns, hospitalizations, emergency department visits, specialist referrals, pharmaceutical spending, will occur against a background of ongoing medical care. Attributing spending changes to the lifestyle intervention rather than to concurrent medical treatment, regression to the mean, or secular trends requires a comparison group design that the cooperative agreement structure makes difficult. Randomization within the programs is possible but adds operational complexity. Historical or geographic comparisons introduce confounding.
Timeline. Lifestyle interventions produce their most significant cost savings over years, not months. The clinical benefits of weight loss, improved glycemic control, blood pressure reduction, and cardiovascular risk modification take time to translate into reduced hospitalizations, fewer procedures, and lower pharmaceutical spending. A three-year performance period may be sufficient to demonstrate clinical improvement but insufficient to demonstrate cost savings. The MDPP evaluation found strong short-term weight loss outcomes but required years of follow-up data to assess spending impacts. MAHA ELEVATE faces the same timeline mismatch between intervention delivery and cost-impact measurement.
Selection. Voluntary participation by beneficiaries introduces selection bias. The Medicare FFS beneficiaries who opt into a lifestyle medicine program are likely to differ systematically from those who do not, in motivation, health literacy, functional status, social support, and baseline health. If the participating beneficiaries are healthier and more engaged than average, the model’s outcomes may reflect participant characteristics rather than intervention effects.
Heterogeneity. Thirty cooperative agreements testing different interventions across different chronic conditions in different populations and geographies will produce heterogeneous results. Some programs will show large effects. Others will show none. Synthesizing these findings into a coherent evidence base that supports or refutes a coverage determination requires an evaluation methodology sophisticated enough to account for variation without averaging it away.
These are not fatal problems. They are the standard challenges of real-world health services research, and CMS’s evaluation contractors have substantial experience addressing them. But they create a scenario in which the model could produce mixed results that are interpreted differently depending on the observer’s prior beliefs about lifestyle medicine. Advocates will emphasize the programs that worked. Skeptics will emphasize the programs that did not. CMS will need to determine whether the aggregate evidence, in all its complexity, justifies the next step.
What Comes Next#
MAHA ELEVATE is the most explicitly experimental model in the 2025 CMMI portfolio. Its $100 million budget is modest by Medicare standards. Its 30 cooperative agreements will reach a fraction of the beneficiary population. Its contribution to Medicare spending reduction during the model period will be negligible in aggregate terms.
Its significance is prospective. If MAHA ELEVATE produces evidence that structured lifestyle interventions can improve clinical outcomes and reduce spending in a Medicare FFS population, that evidence opens a pathway to coverage that has been closed since Medicare’s inception. Original Medicare has never covered the kinds of services MAHA ELEVATE is testing: sustained nutrition coaching, structured physical activity programming, stress management interventions, sleep hygiene protocols, social connection programming. The fee schedule pays for discrete clinical encounters. It does not pay for the ongoing behavioral support that chronic disease prevention requires.
The model’s findings will arrive in a Medicare program that is simultaneously covering GLP-1 medications for weight management through BALANCE, deploying technology-enabled chronic care through ACCESS, and attempting to bend the spending curve on a population in which chronic disease prevalence is increasing as the baby boom cohort ages deeper into Medicare eligibility. If lifestyle medicine can be shown to work in that population, the fiscal and clinical case for permanent coverage becomes difficult to ignore. If it cannot, MAHA ELEVATE will have spent $100 million to confirm what skeptics already believe: that the beneficiaries most burdened by chronic disease are the hardest to reach with behavioral interventions, and that the gap between what works in a clinical trial and what works in Medicare remains wider than the policy ambition that launched the model.
Related Reading#
MCR-06_07 The AI Caregiver Economy: What Medicare Policy Enables and Constrains MCR-05_05 ACOs and the Whole-Person Care Imperative: Behavioral Health, Oral Health, and SUD Integration