HR5684-119

What This Bill Does

The Medical Foods and Formulas Access Act of 2025 addresses patients whose digestive or inherited metabolic disorders require specialized nutrition as treatment. The findings describe children and adults who risk malnutrition, surgery, repeated hospitalizations, intellectual disability, abnormal development, cognitive impairment, behavioral disorders, and death without medically necessary food. The bill defines medically necessary food to include low-protein modified food products, amino acid preparation products, modified fat preparation products, nutritional formulas, vitamins, and individual amino acids prescribed or ordered for dietary management of covered diseases or conditions and used orally or by feeding tube under medical direction. It excludes naturally occurring foods, restaurants meals, nonprescription grocery items, and weight-loss products. Coverage is added across Medicare, Medicaid, CHIP, benchmark Medicaid coverage, FEHBP carriers, TRICARE, and the Veterans Community Care Program, including related equipment and supplies needed to administer the food.

Who Benefits and How

Patients with inherited metabolic disorders benefit because federal health programs must cover medically necessary formulas, vitamins, amino acids, and equipment. Children with digestive disorders benefit from coverage that can prevent feeding-tube placement, hospitalizations, growth problems, and developmental harm. Families buying specialty formulas benefit because coverage shifts medically necessary nutrition costs from household budgets to health programs. Clinicians treating metabolic conditions benefit because prescriptions and orders for medically necessary food become recognized coverage triggers.

Who Bears the Burden and How

CMS Medicare staff must add medically necessary food and administration equipment to covered medical and other health services. State Medicaid programs must cover medically necessary food in Medicaid, CHIP, and benchmark coverage. FEHBP carriers and TRICARE contractors must update plan benefits, claims systems, and coverage guidance. Federal health financing bears higher costs for nutrition products and supplies that were previously excluded or inconsistently covered.

Key Provisions

• Requires Medicare coverage of medically necessary food and necessary equipment and supplies.
• Defines medically necessary food around prescribed dietary management of covered digestive and inherited metabolic disorders.
• Requires Medicaid, CHIP, and benchmark Medicaid coverage of medically necessary food and administration supplies.
• Requires FEHBP, TRICARE, and Veterans Community Care Program coverage for medically necessary food.
• Provides coverage for oral formulas as well as tube-administered nutrition when medically appropriate.