Congress·In Committee·S. 3304

Sen. Wicker Introduces Bipartisan Bill to Require Insurance Coverage for Medical Foods

Medical Foods and Formulas Access Act of 2025

4 months ago·View on Congress.gov

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Key Points

This bill requires Medicare, Medicaid, CHIP, and the Federal Employee Health Benefits Program to cover 'medically necessary food'—special formulas, low-protein products, vitamins, and amino acids—for people with digestive and inherited metabolic disorders whose bodies cannot process normal food.
From policy text
“To provide for the coverage of medical food and vitamins and individual amino acids for digestive and inherited metabolic disorders under Federal health programs, to ensure State and Federal protection for existing coverage, and for other purposes.”
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Without these specialized foods, patients—especially children—face severe consequences including malnutrition, intellectual disability, repeated hospitalizations, and even death. About 2,000 babies per year are diagnosed with inherited metabolic disorders requiring this treatment.
From policy text
“Without medically necessary food, these patients risk malnutrition, surgery, and repeated hospitalizations. They may suffer intellectual disability or even death.”
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The bill eliminates the requirement that formula must be given through a feeding tube to qualify for insurance coverage, allowing patients who can drink formula orally to receive coverage too. This avoids unnecessary surgeries and reduces costs.
From policy text
“Even when insurance does cover medically necessary food, it can come with the stipulation the formula be administered through a feeding tube, placed through the nose into the stomach or surgically placed directly into the stomach or jejunum, even if a patient is capable of taking the formula orally without these devices.”
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Covered conditions include inherited metabolic disorders, inflammatory bowel disease (like Crohn's), severe food allergies, and malabsorption conditions like short bowel syndrome. The bill explicitly excludes weight-loss products, standard gluten-free foods, and foods marketed for diabetes.
From policy text
“Foods, including vitamins and amino acids, taken as part of an overall diet designed to reduce the risk of a disease or medical condition or as weight loss products, even if they are recommended by a physician or other health professional.”
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Coverage timelines are staggered: CHIP and federal employee plans must comply 1 year after enactment, Medicaid within 2 years, and Medicare within 3 years. Medicare will pay 80% of the cost under a fee schedule set by HHS.
From policy text
“with respect to medically necessary food (as defined in section 1861(nnn)), the amount paid shall be an amount equal to 80 percent of the lesser of the actual charge for the services or the amount determined under a fee schedule established by the Secretary for purposes of this subparagraph.”
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The bill encourages but does not require private insurers to also cover medical foods. It also preserves existing state laws that already provide broader coverage, so no state loses ground on protections they've already enacted.
From policy text
“Nothing in the provisions of, or the amendments made by, this section shall preempt a State law that requires coverage of medically necessary food (as defined in subsection (nnn) of section 1861 of the Social Security Act, as added by subsection (a)) that exceeds the requirements for coverage under such provisions and amendments.”
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Healthcare

Impact Analysis

Personal Impact

Who is affectedScoreImpactCertaintyScopeDurationSentiment

Scores: 1 = low, 5 = highSentiment: -5 to +5 (net benefit)

Milestones

2 milestones2 actions

Dec 2, 2025Senate

Read twice and referred to the Committee on Finance.

Dec 2, 2025

Introduced in Senate

What Happens Next

Projected impacts based on AI analysis

1 year after enactment

CHIP and federal employee health plans must begin covering medically necessary food

Children on CHIP and federal workers with qualifying conditions can start getting their specialty formulas covered by insurance, reducing out-of-pocket costs for families

2 years after enactment

Medicaid must cover medically necessary food in all states

Low-income families with children or adults who have metabolic or digestive disorders gain guaranteed coverage for specialty formulas through Medicaid, ending the current patchwork of state-by-state rules

3 years after enactment

Medicare begins covering medically necessary food

Seniors and disabled adults on Medicare with qualifying conditions like Crohn's disease or inherited metabolic disorders can get specialty formulas covered at 80%, with patients responsible for the remaining 20%

Related News

2 articles

HomeCare Magazine·3 months ago

Rep. McGovern Introduces Medical Foods Access Act for Patients

Congressman Jim McGovern introduced the Medical Foods and Formulas Access Act to ensure Medicare, Medicaid, CHIP, and the Federal Employee Health Benefit Program cover specialized formulas, vitamins, and other medically necessary foods prescribed for gastrointestinal and metabolic disorders.

HME News·3 months ago

Sen. Jim McGovern seeks coverage for medical foods, formulas

The Medical Foods and Formulas Access Act requires federal health programs to cover specialized nutrition prescribed by physicians. Rep. McGovern stated the bill aims to break down barriers for families struggling to access prescribed foods that insurance companies often refuse to cover.

Related Bills

1 bill

H.R. 5684Identical bill

Medical Foods and Formulas Access Act of 2025

Oct 3 — Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Oversight and Government Reform, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.