FOOD DELIVERY SYSTEM WPPM #390-20 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Coordinating with Medi-Cal

Revised May 22, 2023 California WIC Policy and Procedure Manual Page 1 of 4 PURPOSE: To provide requirements for referring WIC participants to Medi-Cal for the provision of prescribed therapeutic formula (TF) and WIC-eligible nutritionals (WEN). Medi-Cal is the primary payer for TF and WEN for WIC participants who are also Medi-Cal beneficiaries. POLICY: I. Local agency (LA) staff must provide TF/WEN in the following situations when the participant: A. Does not have healthcare coverage. B. Has private or military insurance. C. Has pending application for Medi-Cal health coverage. D. Is required to pay a share of cost to Medi-Cal. E. Is waiting for Medi-Cal to process coverage for TF/WEN. F. Is denied TF/WEN coverage or only partially covered by Medi-Cal. G. Has been prescribed standard non-contract formula that can be issued on the WIC Card as TF. II. Before providing the prescribed TF/WEN, LA staff must verify that the participant has valid medical documentation and meets all the requirements for TF/WEN issuance. Refer to WPPM 390-10 and WPPM 330-10. III. If the participant does not have health coverage, the LA must refer the participant to Medi-Cal and must issue the prescribed TF/WEN while the Medi-Cal application is being processed. IV. LA staff must inform participants that they cannot receive TF/WEN from both Medi-Cal and WIC, with the exception being if Medi-Cal provides less than the WIC federal maximum monthly amount. Refer to Formula Job Aid with WIC Card Benefits. PROCEDURES: I. Referral to Medi-Cal for Health Care Coverage A. If the participant does not have healthcare coverage, LA staff must: 1. Refer the participant to apply for Medi-Cal. Refer to WPPM 700-02.

FOOD DELIVERY SYSTEM WPPM #390-20 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Coordinating with Medi-Cal

Revised California WIC Policy and Procedure Manual Page 2 of 4 May 22, 2023 2. Issue the prescribed TF/WEN for up to two months if all food benefit issuance requirements are met. LA staff may double-issue food benefits if appropriate. Refer to WPPM 390-10 and 330-10. 3. If healthcare coverage with Medi-Cal has not been established after two months, LA staff must: a. Document this information in the WIC Web Information System Exchange (WIC WISE) “General Notes”. b. Single-issue the TF/WEN until the participant’s Medi-Cal status is determined. c. Request updates on the status of the participant’s Medi-Cal application at each appointment. 4. If Medi-Cal denies healthcare coverage for the participant, LA staff must: a. Document the denial in WIC WISE “General Notes”. b. Continue to issue the prescribed TF/WEN to the participant as long as all food benefit issuance requirements are met. LA staff may double or triple-issue benefits if appropriate. 5. If Medi-Cal approves healthcare coverage for the participant and the participant does not have to pay a share of cost, LA staff must: a. Document the approval in WIC WISE “General Notes”. b. Direct the participant to coordinate with their HCP/pharmacy to request the prescribed TF/WEN from Medi-Cal. c. Single-issue the TF/WEN while waiting for Medi-Cal to initiate coverage of the TF/WEN. II. Referral to Medi-Cal for TF and WEN Coverage A. If the participant is a Medi-Cal beneficiary, LA staff must ask the participant if they are required to pay a share of cost to Medi-Cal. 1. If yes, LA staff must issue the prescribed TF/WEN to the participant. No coordination with Medi-Cal for TF/WEN coverage is required. 2. If no, LA staff must instruct the participant to coordinate with their HCP/pharmacy to request the prescribed TF/WEN from Medi-Cal. The LA must single-issue the TF/WEN while waiting for Medi-Cal to initiate coverage of the TF/WEN. If Medi-Cal has not initiated coverage of the TF/WEN after two months, LA staff must:

FOOD DELIVERY SYSTEM WPPM #390-20 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Coordinating with Medi-Cal

Revised California WIC Policy and Procedure Manual Page 3 of 4 May 22, 2023 a. Document this information in WIC WISE “General Notes”. b. Request updates on the status of TF/WEN coverage at each appointment. c. Continue to single-issue the TF/WEN until denial is received or Medi-Cal provides coverage of the TF/WEN. B. If Medi-Cal denies coverage of TF or WEN, LA staff must: 1. Document the receipt of the Medi-Cal denial in WIC WISE “General Notes”. Verbal or written denial is accepted. 2. Scan the following documents into WIC WISE: a. Denial letter, if written denial received. b. Consent form. c. WIC Pediatric Referral Form/medical documentation. 3. Notify CDPH/WIC of the denial and provide contact information including local agency and site number by: a. Email Formula@cdph.ca.gov or, b. Fax (916) 636-6238 C. CDPH/WIC will contact the LA if it is determined that Medi-Cal may have incorrectly denied coverage for the TF/WEN. In this situation, LA staff must: 1. Ask the participant or the family representative/caretaker to appeal the denial with the CA Department of Social Services’ State Hearing Division at 855-795-0634. 2. Request updates on the status of the appeal and document in WIC WISE “General Notes” at each appointment. 3. Continue to issue the TF/WEN until Medi-Cal provides a decision on the appeal. LA staff must stop issuing the TF/WEN if the appeal is successful. AUTHORITY: 7 CFR §246.10(d) 7 CFR §246.10(e)(3) 22 CCR §51313.3(e)(2) WIC Policy Memorandum #2015-07

FOOD DELIVERY SYSTEM WPPM #390-20 Subject: Therapeutic Formula and WIC-Eligible Nutritionals Item: Coordinating with Medi-Cal

Revised California WIC Policy and Procedure Manual Page 4 of 4 May 22, 2023 RESOURCE: Formula Job Aid with WIC Card Benefits (on Local Agency SharePoint Site (LASS)) California Children’s Services California Department of Developmental Services Regional Centers Child Health and Disability Prevention (CHDP) CROSS REFERENCE: WPPM 330-10 Single/Double/Triple Food Benefit Issuance WPPM 390-10 Provision of Therapeutic Formulas and WIC Eligible Nutritionals WPPM 700-02 Outreach and Referrals