Coverage States

Stemming from our mission, Children's MAGIC U.S. is working to expand insurance coverage and reimbursement for all amino acid-based elemental formulas, regardless of delivery method.

Its sister organization – Children’s Medical Nutrition Alliance (CMNuA) – a 501©(3) nonprofit supports Children’s MAGIC U.S. with experts and public outreach to improve their efforts to change legislation in states not offering coverage for sometimes life-saving formulas.

Children’s MAGIC U.S. and a passionate coalition of parents, doctors and other nonprofits has been on the front lines in fourteen of the twenty states (in bold below) with elemental formula coverage. Children's MAGIC U.S. is proud to have been leading the charge for medical nutrition coverage and working with our partners to make medical nutrition coverage a reality in many of the states listed below.

 

Download our State Coverage guide

Alabama – No mandated coverage. Learn more and join the fight for coverage equity!

Alaska – No mandated coverage. Learn more and join the fight for coverage equity!


Arizona

Statutes ARS §§ 20-826.03, 20-1057-10, 20-1342.05, 20-1402.02, 20-2332

  • Coverage:
    • Requires insurance coverage for amino-acid based formula where insured has been diagnosed with the following:
      • Eosinophilic gastrointestinal disorder.
  • Limitations:
    • The accountable health plan may limit the maximum annual benefit for formula under this section to twenty thousand dollars.
    • An accountable health plan will cover at least seventy‑five per cent (25%) of the cost of the formula.

ArkansasNo mandated coverage. Learn more and join the fight for coverage equity!

CaliforniaNo mandated coverage. Learn more and join the fight for coverage equity!


Colorado

House Bill 16-1387

  • Coverage:
    • Insurance covers amino acid-based formula for children with the following:
      • ANY MEDICALLY NECESSARY DIAGNOSIS
    • Insurance covers formula administered orally or by a feeding.
  • Limitations:
    • Takes effect January 1, 2018.

Connecticut

Statute–Connecticut General Statutes § 38a‑492c

  • Coverage:
    • Includes mandated coverage for the following:
      • Medically necessary for the treatment of “Inherited metabolic disease” defined as a disease for which newborn screening is required under section 19a-55;
      • Cystic fibrosis.
    • Provides coverage on the same basis as outpatient prescription drugs for:
      • “Low protein modified food product” (defined as a product formulated to have less than one gram of protein per serving and intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.)
      • “Amino acid modified preparation” (defined as a product intended for the dietary treatment of an inherited metabolic disease under the direction of a physician.)
      • “Specialized formula” (defined as a nutritional formula for children up to age twelve that is exempt from the general requirements for nutritional labeling under the statutory and regulatory guidelines of the federal Food and Drug Administration and is intended for use solely under medical supervision in the dietary management of specific diseases.)
  • Limitations:
    • No coverage for food allergies, Eosiniphilic disorders, FPIES or short bowel
    • Age: Only requires insurance coverage for children up to the age of twelve (12)
    • Must be administered under the direction of a physician
    • Requires  coverage applicable to policies delivered, issued for delivery or renewed in this state on or after October 1, 2007

DelawareNo mandated coverage. Learn more and join the fight for coverage equity!

District of ColumbiaNo mandated coverage. Learn more and join the fight for coverage equity!

FloridaNo mandated coverage. Learn more and join the fight for coverage equity!

GeorgiaNo mandated coverage. Learn more and join the fight for coverage equity!

HawaiiNo mandated coverage. Learn more and join the fight for coverage equity!

IdahoNo mandated coverage. Learn more and join the fight for coverage equity!


Illinois

Statute– 215 ILCS 5/356z.10

  • Coverage:
    • Insurance policies must provide coverage and reimbursement for; amino acid‑based elemental formulas, regardless of delivery method, for the diagnosis and treatment of:
      • Eosinophilic disorders;
      • Short bowel syndrome.
    • Limitations: The prescribing physician must issue a written order stating that the amino acid‑based elemental formula is medically necessary.

IndianaNo mandated coverage. Learn more and join the fight for coverage equity!

IowaNo mandated coverage. Learn more and join the fight for coverage equity!

KansasNo mandated coverage. Learn more and join the fight for coverage equity!


Kentucky

Bill– 16 RS SB 193/GA (no direct link, must search by bill number)

  • Coverage:
    • Insurance covers amino acid-based formula for children with any medically necessary diagnosis, including but not limited to:
      • Eosinophilic disorders
      • Food protein allergies
      • Food protein-induced enterocolitis syndrome ( FPIES )
      • Short-bowel syndrome.
    • Insurance covers formula administered orally or by a feeding tube.
  • Limitations: Coverage is subject to:
    • A cap of $25,000 for therapeutic food, formulas, and supplements;
    • A separate cap of $4,000 on low-protein modified foods each plan year.

LouisianaNo mandated coverage. Learn more and join the fight for coverage equity!


Maine

Statutes–24 A M.R.S.A. § 2764, 24-A M.R.S.A. § 2847-P, 24‑A M.R.S.A. § 4256

  • Coverage:
    • Amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula.
    • Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:
      • A history of anaphylaxis;
      • Allergic gastroenteritis (must be laboratory- or biopsy-proven);
      • Eosinophilic gastroenteritis (must be laboratory- or biopsy-proven);
      • Gastroesophageal reflux disease (GERD) that is nonresponsive to standard medical therapies;
      • Malabsorption of cow milk-based or soy milk-based infant formula;
      • Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider;
      • Symptomatic allergic colitis or proctitis;
      • Symptomatic allergic proctitis.

Maryland

Statute–Md. Code, Insurance § 15-843

  • Coverage:
    • A policy or plan subject to this section shall include, under the family member coverage, coverage for amino acid‑based elemental formula,
    • Regardless of delivery method, for the diagnosis and treatment of:
      • Immunoglobulin E and non‑Immunoglobulin E mediated allergies to multiple food proteins;
      • Eosinophilic disorders, as evidenced by the results of a biopsy;
      • Food protein induced enterocolitis syndrome (FPIES) Must be noted as "severe";
      • Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.

Massachusetts

Statues–M.G.L.A. 32A  § 17A, M.G.L.A. 176G § 4D, M.G.L.A. 176B § 4K, M.G.L.A. 176A § 8L, M.G.L.A. 175 § 47I,


Minnesota

  • Statute–NONE, however, after discussions with lawmakers and the introduction of legislation insurers in Minnesota voluntarily agreed to add coverage for amino acid-based elemental formulas to their medical policies. Coverage is extended by policy with language that mirrors the legislative mandate that was introduced in Senate File 504. A letter confirming the agreement can be found here. Letters from participating insurers can be found here. It maybe a good idea to include your insurers letter of commitment with your claim form.
  • Coverage:
    • Per amended senate file 504, the agreement provides for coverage of amino acid based elemental formulas when ordered by a physician when the following conditions that have been diagnosed by an allergist, gastroenterologist, or pediatrician.
    • Amino acid, organic acid, and fatty acid metabolic and malabsorption disorders
    • Cystic fibrosis
    • Eosinophilic colitis
    • Eosinophilic esophagitis (EOE)
    • Eosinophilic gastroenteritis
    • Food protein induced enterocolitis syndrome (FPIES)
    • IgE mediated allergies to food proteins (Coverage of amino acid based elemental formulas for enrollees diagnosed with an IgE mediated condition is limited to enrollees age five years and under.)
    • Inborn errors of metabolism.
  • Limitations:
    • Conditions must have been diagnosed by an allergist, gastroenterologist, or pediatrician.

MississippiNo mandated coverage. Learn more and join the fight for coverage equity!


Missouri

Statute–SB354

  • Coverage: The department will provide coverage, subject to state and federal appropriations, for the full cost of amino acid-based elemental formulas, meaning formulas made from single non-allergenic amino acids, for children under nineteen years of age with a medical diagnosis of:
    • Eosinophilic disorders, (EOE, Eosinophilic colitis, eosinophilic gastroenteritis, etc);
    • Food proteins food protein-induced enterocolitis syndrome (FPIES),
    • Immunoglobulin E mediated allergies to multiple food proteins,
    • Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract (Such as short bowel syndrome),
    • Non-immunoglobulin E mediated allergies to multiple food proteins.

MontanaNo mandated coverage. Learn more and join the fight for coverage equity!


Nebraska Elemental Formula Reimbursement Program

  • Statute–LB 254
  • Coverage:
  • Statute directs The Department of Health and Human Services to establish a program (see Nebraska Elemental Formula Reimbursement Program below) to provide amino acid-based elemental formulas for the diagnosis and treatment of the following conditions:
    • Eosinophilic disorders (EOE, Eosinophilic colitis, eosinophilic gastroenteritis, etc.);
    • Food protein-induced enterocolitis syndrome (FPIES);
    • Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract;
    • Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins.
  • Limitations: The ordering physician must have issued a written order stating that the amino acid-based elemental formula is medically necessary for the treatment of a disease or disorder.

NevadaNo mandated coverage. Learn more and join the fight for coverage equity!


New Hampshire

Statute–N.H. Rev. Stat. Ann. § 415:6‑c, 415:18‑e, 420‑A:17, 420‑B:8‑ff

  • Coverage:
    • Requires coverage for formula for:
      • Inherited diseases of amino acids and organic acids (Specifically notes that coverage is for  enteral formula, including food products modified to be low protein*.)
      • Treatment of impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, or motility of the gastrointestinal tract.
  • Limitations:
    • The prescribing physician must issued a written order stating that the enteral formula is needed to:
      • Sustain life;
      • Is medically necessary;
      • Is the least restrictive and;
      • Is the most cost effective means for meeting the needs of the patient.
    • Regarding coverage for inherited diseases of amino acids and organic acids:
      • The enteral formula, and food products modified to be low protein only have mandated coverage in an amount not to exceed $1,800 annually for any insured individual.

New Jersey

Statute – N.J. Stat. Ann. §§ 17:48‑6z, 17:48A‑7y, 17:48E‑35.24. 17B:26‑2.1v, 17B:27‑46.1z

  • Coverage:
    • Requires hospital service corporation, medical service corporation, group and individual health insurers to cover medically necessary non-standard infant formulas for infants diagnosed as having:
      • Multiple food protein intolerance,
  • Limitations:
    • Coverage is limited to infants.
    • The covered infant must not have not been responsive to trials of standard non‑cow milk‑based formulas, including soybean and goat milk.

New MexicoNo mandated coverage. Learn more and join the fight for coverage equity!


New York

New York Insurance Law §§ 3216, 3221, 4303,4322

  • Requires coverage for enteral formulas whether administered orally or via feeding tube that are medically necessary.
  • Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease‑specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic physical disability, mental retardation or death.
  • Specific diseases for which enteral formulas have been proven effective shall include, but are not limited to:
    • Inherited diseases of amino acid or organic acid metabolism;
    • Crohn’s Disease;
    • Gastroesophageal reflux with failure to thrive;
    • Disorders of gastrointestinal motility such as chronic intestinal pseudo‑obstruction;
    • And multiple, severe food allergies which if left untreated will cause malnourishment, chronic physical disability, mental retardation or death.

North CarolinaNo mandated coverage. Learn more and join the fight for coverage equity!

North DakotaNo mandated coverage. Learn more and join the fight for coverage equity!

OhioNo mandated coverage. Learn more and join the fight for coverage equity!

OklahomaNo mandated coverage. Learn more and join the fight for coverage equity!


Oregon

Or. Rev. Stat. § 743A.070

  • Coverage:
    • All policies providing health insurance, as defined in ORS 731.162, except those policies whose coverage is limited to expenses from accidents or specific diseases that are unrelated to the coverage required by this section, must include coverage for a nonprescription elemental enteral formula for home use.
  • Limitations:
    • Coverage limited to "medically necessary treatment of "severe intestinal malabsorption"
    • A physician must have issued a written order for the formula
    • Formula must comprises the sole source, or an essential source, of nutrition.

Pennsylvania

House Bill 1436

  • Coverage:
    • Provides for certain health insurance policies to cover the cost of formulas necessary for the therapeutic treatment of:
      • Branched-chain ketonuria,
      • Galactosemia;
      • Homocystinuria and;
      • Phenylketonuria,
    • Provides that the health insurance benefits applicable under the policy include coverage for infants and children for the usual and customary cost of amino acid-based elemental medical formula prescribed and ordered by a physician as medically necessary and administered orally or enterally for
      • Eosinophilic disorders (EOE, Eosinophilic colitis, eosinophilic gastroenteritis, etc.);
      • Food protein allergies;
      • Food protein-induced enterocolitis syndrome (FPIES);
      • Short-bowel syndrome (SBS)
    • Defines an amino acid based elemental formula covered under the section is a formula made of 100% free amino acids as the protein source.
    • Benefits for nutritional supplements (formulas) as medically necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a physician are exempt from deductible provisions in a health insurance policy.
  • Limitations:
    • Coverage for amino-acid-based elemental medical formulas for Eosiniphilic disorders, FPIES, food protein allergies and SBS are  subject to copayment and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the policy are subject to those provisions.

Rhode Island

Gen. Laws 1956, § 27‑18‑70

  • Coverage:
    • Requires insurance coverage for medically necessary enteral formula for the treatment of malabsorption caused by:
      • Chronic intestinal pseudo‑obstruction;
      • Crohn’s disease;
      • Gastroesophageal reflux ( GERD );
      • Inherited diseases of amino acids and organic acids
      • Ulcerative colitis;
  • Limitations:
    • No specified coverage for food protein allergies, Eosinophilic disorders or FPIES
    • For those conditions which are covered, coverage shall not exceed an amount of two thousand five hundred dollars ($2,500) per covered member per year.

South CarolinaNo mandated coverage. Learn more and join the fight for coverage equity!


South Dakota

No applicable statute. However, several insurance plans have agreed to reimburse families for amino acid based formula.

  • Coverage:
    • HealthPartners – Coverage for the following conditions, for children 5 years and younger:
      • Amino acid, organic acid and fatty acid metabolic and malabsorption disorders
      • Cystic fibrosis
      • Eosinophilic esophagitis (EE)
      • Eosinophilic gastroenteritis (EG)
      • Eosinophilic colitis
      • Food protein induced enterocolitis syndrome
      • IgE mediated allergies to food proteins
    • Medica – Coverage for the following conditions, for children 5 years and younger:
      • Amino acid, organic acid, and fatty acid metabolic and malabsorption disorders;
      • Cystic fibrosis;
      • eosinophilic colitis;
      • eosinophilic esophagitis ( EOE );
      • eosinophilic gastroenteritis;
      • food protein-induced entercolitis syndrome;
      • IgE mediated allergies to food proteins;
    • WellMark Blue Cross/Blue Shield – Coverage for
      • inborn errors of metabolism only.

TennesseeNo mandated coverage. Learn more and join the fight for coverage equity!


Texas

Tx. Ins. Code § 1377.051

  • Coverage:
    • A health benefit plan must provide coverage as provided by this chapter for amino acid‑based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of:
      • Immunoglobulin E and non‑immunoglobulin E mediated allergies to multiple food proteins;
      • Eosinophilic disorders, as evidenced by the results of a biopsy;
      • Food protein‑induced enterocolitis syndrome (FPIES ) - documented as severe;
      • Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.
  • Limitations:
    • The treating physician must issue a written order stating that the amino acid‑based elemental formula is medically necessary for the treatment of an enrollee who is diagnosed with a disease or disorder listed.

UtahNo mandated coverage. Learn more and join the fight for coverage equity!

VermontNo mandated coverage. Learn more and join the fight for coverage equity!

VirginiaNo mandated coverage. Learn more and join the fight for coverage equity!


Washington

Statute – SHB 2153

  • Coverage:
    • Each health benefit plan offered to public employees and their covered dependents under this chapter must offer benefits or coverage for medically necessary elemental formula, regardless of delivery method, when a licensed physician or other health care provider with prescriptive authority:
      • Diagnoses a patient with an eosinophilic gastrointestinal associated disorder; and
      • Orders and supervises the use of the elemental formula.

West VirginiaNo mandated coverage. Learn more and join the fight for coverage equity!

WisconsinNo mandated coverage. Learn more and join the fight for coverage equity!

WyomingNo mandated coverage. Learn more and join the fight for coverage equity!

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