September 14, 2026
The Honorable Mehmet Oz, MD
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1848-P
P.O. Box 8016
Baltimore, MD 21244-8016

Re: CMS-1848-P, Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies

Dear Administrator Oz:

On behalf of The Obesity Society (TOS), thank you for the opportunity to comment on the proposed rule, “Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program,” CMS-1848-P.

TOS is the leading professional society focused on obesity science, treatment, and prevention. Our members include clinicians, scientists, researchers, educators, and other health professionals committed to improving the health and well-being of people with obesity through research, education, and evidence-based clinical care.  They are leading faculty from medical schools, schools of public health, behavioral health, nutrition, and exercise science throughout the United States.

Obesity is a chronic, complex, and relapsing disease associated with substantial morbidity, impaired quality of life, and increased health care utilization. Multimodal obesity care is the gold standard, and treatments may include nutrition therapy, physical activity interventions, behavioral treatment, pharmacotherapy when clinically appropriate and covered, metabolic and bariatric surgery, and long-term clinical monitoring and support. Medicare payment policy should accommodate this comprehensive, individualized approach rather than treat obesity solely as a lifestyle risk factor or a matter of personal behavior.

TOS supports the Centers for Medicare & Medicaid Services’ efforts to strengthen chronic disease prevention and management, expand access to team-based care, recognize health and well-being coaching services, establish payment for shared medical appointments, improve access to nutrition services in rural communities, and preserve telehealth delivery options. We recommend that CMS explicitly recognize obesity as a chronic disease throughout the final rule and related implementation guidance and ensure that the proposed policies support comprehensive, evidence-based obesity care.

Key TOS recommendation: CMS should recognize registered dietitian nutritionists as qualified to furnish the proposed health and well-being coaching services based on the RDN credential, without requiring an additional health coaching certification.

Our comments focus on the following areas:

1. Shared medical appointments and proposed HCPCS code GSMAS, including telehealth access.
2. Health and well-being coaching services.
3. Recognition of registered dietitian nutritionists as qualified professionals for health and well-being coaching without additional certification requirements.
4. Rural Health Clinic payment for Medical Nutrition Therapy and Diabetes Self-Management Training.
5. Obesity-related quality measurement, including BMI screening and follow-up.
6. Nutrition, lifestyle and health-related improvement activities.
7. Primary care redesign, Annual Wellness Visits and technology-enabled care.
8. Nondiscrimination and people-first language.

I. Shared Medical Appointments and HCPCS Code GSMAS

TOS supports CMS’ proposal to establish coding and payment for shared medical appointments through HCPCS code GSMAS. CMS describes shared medical appointments as voluntary, group-based medical sessions that combine individualized clinical assessment and care with group education, counseling, and peer support. CMS proposes that these sessions include two to 10 patients and be billed once per patient, per session.

TOS particularly appreciates that CMS explicitly identifies obesity, along with diabetes, hypertension, and hyperlipidemia, as a medical condition that may be appropriate for shared medical appointments. This recognition provides a potentially important payment pathway for clinicians delivering structured, evidence-based obesity care in a group setting.

Shared medical appointments can support longitudinal obesity treatment by allowing clinicians and other qualified health professionals to provide medical evaluation, nutrition education, behavior-change support, self-management education, and peer support while retaining individualized assessment and care planning. These services may also improve access for beneficiaries who would otherwise experience long waits or difficulty accessing clinicians with expertise in obesity care.

TOS recommends that CMS finalize HCPCS code GSMAS with the following refinements:

• Explicitly recognize evidence-based obesity treatment as an appropriate use of GSMAS. The final rule and subsequent billing guidance should make clear that people with obesity may receive shared medical appointment services when the program includes individualized clinical assessment and evidence-based obesity treatment.
• Describe obesity as a chronic disease rather than solely as a condition “modifiable with lifestyle change.” Nutrition, physical activity, and behavioral interventions are important components of obesity care, but obesity is not simply the result of individual behavior. Its causes and progression reflect complex biological, genetic, environmental, socioeconomic, and clinical factors.
• Permit multidisciplinary obesity-care teams to participate meaningfully in shared medical appointments. Depending on patient needs, these teams may include physicians, nurse practitioners, physician assistants, registered dietitian nutritionists, behavioral health professionals, exercise professionals, pharmacists, and other qualified health professionals.
• Ensure appropriate valuation of the multidisciplinary services incorporated into GSMAS. CMS should determine whether the proposed payment adequately accounts for program preparation, individualized assessment, documentation, care planning, patient education, behavior-change support, and coordination among participating professionals.
• Do not prevent separate payment for a distinct Medical Nutrition Therapy service solely because an RDN participates in a shared medical appointment. TOS is concerned that bundling all RDN services into GSMAS could undervalue specialized nutrition services and discourage RDN participation. CMS should allow separate payment when an RDN furnishes a distinct, medically necessary MNT service that satisfies applicable coverage, documentation, and billing requirements and is not duplicative of the services represented by GSMAS.
• Apply evidence-based guardrails without creating unnecessary administrative barriers. TOS supports evidence-based protocols, appropriately trained professionals, individualized goals, shared decision-making, and program evaluation. Requirements should be sufficiently flexible to permit clinicians to tailor treatment to each beneficiary’s needs, complications, functional status, and preferences.
• Measure outcomes beyond short-term weight loss. Appropriate outcomes may include improvements in obesity-related complications, physical function, quality of life, treatment engagement, access to care, and achievement of individualized clinical goals.

TOS also supports CMS’ proposal to add GSMAS to the Medicare Telehealth Services List. Telehealth delivery may expand access for rural beneficiaries, people with mobility limitations, individuals with transportation barriers, and beneficiaries who lack ready access to clinicians with expertise in obesity care. CMS should retain beneficiary consent, confidentiality, and individualized documentation requirements, particularly because weight bias and stigma may affect a beneficiary’s willingness to discuss obesity-related health information in a group setting.

II. Health and Well-Being Coaching Services

TOS supports CMS’ proposal to establish national payment for health and well-being coaching services described by CPT codes 0591T, 0592T, and 0593T.

CMS describes health and well-being coaching as a patient-centered, goal-directed process that uses self-discovery, active learning, content education, and strategies to support behavior change. The proposed codes address an initial individual assessment, individual follow-up services, and group coaching involving two or more individuals. CMS also proposes that these services may be furnished by appropriately qualified auxiliary personnel under the required level of supervision.

Health and well-being coaching can support people receiving obesity treatment by helping them establish individualized goals, identify barriers, implement treatment plans, sustain health-related behaviors, and remain engaged in longitudinal care. TOS supports national payment for these services when they are incorporated into a comprehensive, evidence-based plan of care.

However, coaching should complement, not replace, clinical obesity treatment. CMS should clarify that health and well-being coaching is not a substitute for medical evaluation, diagnosis, Medical Nutrition Therapy, behavioral health treatment, pharmacotherapy management, metabolic and bariatric surgery evaluation, or other services that require a separately qualified or licensed health professional.

TOS recommends that CMS:

• Explicitly recognize obesity and obesity-related complications as conditions for which health and well-being coaching may be reasonable and necessary when furnished as part of an individualized care plan.
• Permit coaching services to address patient-selected goals related to nutrition, physical activity, sleep, stress, treatment engagement, self-monitoring, physical function, and management of obesity-related complications.
• Require use of people-first, nonstigmatizing, and evidence-based communication.
• Clarify that health coaching must not be used to substitute lower-cost personnel for covered services that require the expertise of a qualified health professional.
• Assess whether the proposed valuation, particularly for group coaching, is sufficient to support high-quality services for Medicare beneficiaries with multiple chronic conditions and complex care needs.
• Preserve telehealth access to these services where clinically appropriate.

III. Registered Dietitian Nutritionists Should Be Permitted to Furnish Health and Well-Being Coaching Services Without Additional Certification

TOS strongly recommends that CMS recognize registered dietitian nutritionists as qualified to furnish and bill, or furnish under applicable Medicare billing arrangements, the proposed health and well-being coaching services without requiring an RDN to obtain an additional health coaching certification.

CMS identifies several possible qualifications for individuals furnishing these services, including credentials or training associated with health and wellness coaching, health education, nurse coaching, and certain evidence-based programs. TOS supports reasonable qualification standards. However, requiring an RDN to obtain a separate coaching certification would create an unnecessary and duplicative barrier to the delivery of care.

The RDN credential reflects specialized education and supervised practice related to nutrition assessment, counseling, behavior change, communication, chronic disease management, and the development and implementation of individualized nutrition-care plans. These competencies are directly relevant to the patient-centered, goal-oriented, and behavior-change functions described in the proposed health and well-being coaching codes.

Accordingly, TOS recommends that CMS:

• Expressly include registered dietitian nutritionists among the professionals qualified to furnish health and well-being coaching services.
• Recognize the current RDN credential as sufficient evidence of the relevant education, training, and professional competency, without requiring an additional health coaching certification.
• Permit RDNs to furnish the services within applicable state scope-of-practice requirements and Medicare enrollment and billing rules.
• Clarify that an RDN furnishing a covered and separately identifiable MNT service may bill the appropriate MNT code rather than being required to report the service as health coaching.
• Prevent duplicative payment while preserving the distinction between health and well-being coaching and MNT. Coaching may support general patient-directed goals and behavior change, while MNT is a specialized clinical service involving nutrition assessment, diagnosis, intervention, monitoring, and evaluation.
• Avoid policies that would narrow access by requiring RDNs to obtain an external credential that duplicates competencies already demonstrated through the RDN credential.

Imposing an additional certification requirement could increase costs for practitioners, delay implementation, limit the available workforce, and disproportionately affect small, independent, and rural practices. It could also unintentionally discourage RDN participation in interdisciplinary obesity-care programs.

TOS therefore urges CMS to revise the proposed qualification framework to state clearly that an individual holding an active RDN credential is qualified to furnish the health and well-being coaching services without an additional coaching certification.

IV. Medical Nutrition Therapy and Diabetes Self-Management Training in Rural Health Clinics

TOS supports CMS’ proposal to recognize Medical Nutrition Therapy and Diabetes Self-Management Training as stand-alone billable visits in Rural Health Clinics.

CMS explains that RHCs historically could include the cost of these services in their cost reports but could not generate a separately billable RHC visit when DSMT or MNT was furnished alone. The proposed policy would recognize the services as qualified preventive services covered and paid under the RHC payment methodology as stand-alone visits when applicable requirements are met.

This proposal could improve access to nutrition services for rural Medicare beneficiaries, including many people with obesity and diabetes. TOS recommends that CMS finalize the proposal and monitor its effect on access, workforce participation, utilization, and beneficiary outcomes.

TOS also encourages CMS to consider future pathways for broader Medicare coverage of MNT for obesity itself. Access to MNT should not depend solely on the presence of diabetes or renal disease when nutrition therapy is medically necessary as part of evidence-based obesity treatment.

V. Obesity Quality Measurement and BMI Screening

TOS supports continued inclusion of Quality Measure 128, “Preventive Care and Screening: BMI Screening and Follow-Up Plan,” within applicable MIPS Value Pathways. CMS indicates that the measure remains available for MVP use, with no substantive changes proposed.

BMI screening and documentation can help identify patients who may benefit from additional clinical assessment. However, BMI screening alone does not constitute obesity care, and BMI should not be used as the sole basis for diagnosis, risk assessment, or treatment decisions.

TOS recommends that CMS work with clinicians, patients, measure developers, and professional organizations to develop next-generation obesity outcome quality measures addressing:

• Appropriate clinical assessment following identification of obesity
• Documentation of obesity as a chronic disease when clinically appropriate
• Shared decision-making
• Referral to qualified obesity care professionals
• Access to evidence-based nutrition and behavioral interventions
• Assessment of obesity-related complications
• Longitudinal treatment and follow-up
• Patient-reported outcomes, physical function, and quality of life
• Use of people-first language and reduction of weight bias in health care.

These measures should evaluate whether beneficiaries receive clinically appropriate care rather than merely whether their BMI was recorded.

VI. Nutrition, Lifestyle, and Health-Related Improvement Activities

TOS supports CMS’ focus on improvement activities involving systematic nutrition screening, nonclinical factors affecting health, evidence-based lifestyle interventions, chronic disease management, and responsible use of artificial intelligence.

TOS recommends that CMS explicitly include obesity care in examples and implementation guidance for these activities. Relevant activities could include structured referral pathways to obesity medicine clinicians and RDNs, identification of food and transportation barriers, support for longitudinal treatment, and care coordination among primary care clinicians, specialists, and other qualified health professionals.

CMS should also require organizations using artificial intelligence for risk stratification, clinical decision support, population health, or care-gap identification to monitor and evaluate those systems for weight bias when possible. AI systems should not perpetuate stigmatizing assumptions, treat body size as a proxy for behavior or personal responsibility, or fail to recommend evidence-based obesity treatment.

VII. Primary Care Redesign and Annual Wellness Visits

TOS supports CMS’ examination of primary care payment, longitudinal care management, Annual Wellness Visits, technology-enabled prevention, and outcomes-based payment. Future primary care models should appropriately recognize the work required to identify, assess, and manage obesity over time. This includes evaluation of obesity-related complications, individualized treatment planning, coordination with RDNs, psychologists, and other healthcare professionals, monitoring treatment response, medication management when clinically appropriate and covered, and referral for metabolic and bariatric surgery evaluation when indicated.

The Annual Wellness Visit may provide an important opportunity to identify obesity, assess associated health risks, and initiate a pathway to evidence-based treatment. CMS should ensure that obesity care is not reduced to generic nutrition or physical activity advice. When obesity is identified, beneficiaries should receive appropriate assessment, shared decision-making, and referral or treatment options.

VIII. People-First Language and Protection From Weight Bias

TOS urges CMS to use people-first, nonstigmatizing language consistently throughout the final rule, subregulatory guidance, billing materials, measure specifications, and educational resources.

CMS should use terms such as “people with obesity,” “patients with obesity,” and “obesity treatment.” Language that labels individuals by body size or implies that obesity results solely from personal choices should be avoided.

CMS should also encourage participating clinicians and organizations to address weight bias in staff training, patient communications, clinical decision support, artificial intelligence governance, and program evaluation. Beneficiaries must be able to seek obesity care without experiencing stigma, shame, or discrimination.

Conclusion

TOS appreciates CMS’ efforts to strengthen chronic disease care, establish payment for shared medical appointments and health and well-being coaching, expand access to nutrition services in Rural Health Clinics, and preserve telehealth options.

We urge CMS to finalize these proposals with refinements that explicitly recognize obesity as a chronic disease and support comprehensive, evidence-based, and multidisciplinary obesity care. In particular, TOS recommends that CMS:

• Finalize HCPCS code GSMAS and explicitly recognize evidence-based obesity treatment as an appropriate use.
• Ensure that the valuation and billing rules for shared medical appointments appropriately recognize services furnished by RDNs and other qualified professionals.
• Finalize national payment for health and well-being coaching.
• Recognize RDNs as qualified to furnish the proposed health and well-being coaching services without requiring an additional certification.
• Preserve the distinction between health coaching and MNT.
• Finalize stand-alone RHC payment for MNT and DSMT.
• Develop obesity quality measures that extend beyond BMI screening.
• Integrate obesity care into primary care, Annual Wellness Visit, nutrition, lifestyle, and technology-enabled care policies.
• Require people-first language and protections against weight bias.

Thank you for considering our comments. TOS would welcome the opportunity to serve as a resource to CMS as the agency finalizes and implements these policies.  If you have questions regarding this comment submission, please contact Jeanne Blankenship, MS, RDN at [email protected].

Sincerely,
Kathleen Robinson,  MD PhD
Chair, Policy and Advocacy Committee
The Obesity Society