In the U.S., indigent children have access to medical foods and formulas through
government insurance programs like Medicaid and the Womens, Infants and
Childrens Program (WIC).
- Most employer sponsored health insurance plans do not include coverage for
medical formulas/foods. Children in the U.S. who are not indigent need access
to medical foods/formulas too. Same formula, different coverage.
- Some private health insurers will only cover the cost of medical formula when it is
delivered through a feeding tube. They will not cover the same formula if the
child can take it orally through a bottle or a cup. Same formula, different coverage.
- If a child with private insurance is admitted to the hospital and given the formula
while there, the insurance company will cover the cost of the formula as part of
the admission. The same formula is generally not covered when ordered by a
physician on an outpatient basis. Same formula, different coverage.
- For a child with seizures, some insurers will cover the cost of a hospital admission
to initiate the Ketogenic diet. They will not cover the cost for the child to remain
on the diet after discharge. Same formula, different coverage.
- Thirty-three states have laws that provide medical food coverage for patients
with inborn errors of metabolism (certain genetic diseases). Only 20 states have
laws that provide medical food coverage for patients with milk/food allergies.
- There are no state laws that provide coverage for children on the Ketogenic
medical food diet to control seizures. Some states are introducing laws allowing
the legal use of medical marijuana for children. Insurers are not covering the
cost of medical marijuana stating that it is not FDA approved. Medical foods
and formulas are FDA approved in the medical management of certain allergic
conditions yet employer sponsored health insurance plans in a majority of states
will not cover these foods and formulas. Although FDA approval exists, coverage
We are working, together with our sister organization Children’s MAGIC U.S., to bring awareness and put an end to coverage inequality. We strongly believe that no family should ever have to choose between paying their power bill and feeding their child. You can download a PDF version of this information to share with family, friends, and lawmakers.