Medical Foods and Formulas Access Act

Summary#

This bill would require Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federal Employees Health Benefits Program (FEHBP) to cover "medically necessary food." That term is defined to include specially formulated products such as low-protein foods, amino acid preparations, modified fat products, nutritional formulas, vitamins, and individual amino acids when prescribed for people with certain digestive or inherited metabolic disorders. Coverage would also include the medical equipment and supplies needed to give these products, like tubes and feeding supplies.

The bill lists the types of conditions covered, including many inherited metabolic disorders (for example amino acid disorders, urea cycle disorders, fatty acid oxidation disorders, and others), malabsorption conditions (such as short bowel syndrome), food-protein allergies and related eosinophilic disorders, and inflammatory or immune-mediated gut diseases (such as Crohn’s disease and severe reflux). The Secretary of Health and Human Services may add other conditions.

The bill excludes foods taken as part of a general diet to reduce disease risk, weight-loss foods, foods marketed as gluten-free, and foods marketed for diabetes management. It also says states may keep or adopt laws that provide more coverage than this bill.

What it means for you#

  • If you are a Medicare beneficiary, a Medicaid or CHIP enrollee, or covered under FEHBP, prescribed medically necessary formulas, vitamins, or individual amino acids for a listed condition could be covered under your program if the bill becomes law. Coverage includes products for oral use or enteral (tube) feeding and the necessary supplies to administer them.
  • A health professional (physician, physician assistant, nurse practitioner, or other authorized practitioner) must prescribe or order the medically necessary food.
  • Private health plans are not required by this bill, but Congress expresses the view that private plans should provide similar coverage.
  • The bill names specific exclusions (for example, gluten-free marketed foods and diabetes management foods) and requires that the products be specially formulated, not ordinary unprocessed foods.

Expenses#

No publicly available information on total federal costs is included in the bill text or metadata.

  • The bill sets a Medicare payment rule: for medically necessary food, Medicare would pay 80 percent of the lesser of the actual charge or an amount in a Secretary-established fee schedule.
  • Effective dates in the bill: Medicare coverage changes would apply 3 years after enactment; Medicaid changes 2 years after enactment (with a delay allowed if state law is needed); CHIP changes 1 year after enactment (with a similar state-law delay exception); FEHBP changes would apply to contract years starting 1 year after enactment.

Proponents' View#

The bill text includes findings saying medically necessary foods are life-sustaining for people with certain digestive and inherited metabolic disorders. Supporters argue that access to these specialized foods prevents malnutrition, repeated hospitalizations, surgeries, developmental harm in children, and other severe medical consequences. The bill also cites the 2022 formula shortage as an example of harm when specialty formulas are inaccessible.

Opponents' View#

No publicly available information on opponents’ views or formal objections is included in the bill text or metadata.