Revised 4-2022

Connecticut WIC Program Manual

WIC 400-18 SECTION: Food Delivery

SUBJECT: Coordination between WIC and Medicaid (HUSKY) and Coordination between WIC and Private Insurance for Issuance of Special/Exempt Formulas and Medical Foods

Federal Regulations: § 246.10(c) 3 and § 246.10(e) 3(vi) POLICY Coordination between WIC and Medicaid (HUSKY) for Issuance of Special/Exempt Formulas and Medical Foods Beginning on April 1, 2022, Medicaid (HUSKY) Program will be the primary payor for special or exempt formula and/or medical foods for WIC participants that are dually enrolled in both WIC and HUSKY/Medicaid insurance. See CT-DSS Provider Bulletin Number 2021-99 for more details. For WIC participants not enrolled in HUSKY or with private insurance, the Connecticut WIC Program will provide special or exempt formulas in amounts consistent with the current federal WIC regulations. (WIC Policy 400-12 Retail Purchase of WIC Special Formula) When Medicaid (HUSKY) provides the formula, the local WIC nutritionist needs to communicate with the health care provider, participant/caregiver and if appropriate the Community Health Network of Connecticut (CHN-CT) Intensive Care Management program staff to ensure appropriate use of Medicaid (HUSKY) resources. • Determine if the participant is on Medicaid (HUSKY). If they are not, promptly refer them for eligibility review/enrollment. • For WIC participants enrolled in Medicaid (HUSKY), WIC staff must tell the participant to request their health care provider follow the process to have Medicaid (HUSKY) provide/cover the special/exempt formula. WIC staff can assist the participant in this process by connecting with the HCP as needed.

• Coordination of care and communication is expected among WIC staff, the health care provider, the parent/caregiver, and if appropriate, the CHN-CT Intensive Care Management program, to ensure proper assessment and monitoring of the medically fragile participant, limit under or oversupply of special/exempt formula and medical foods, with the common goal to improve health outcomes.

• If a WIC participant receives no formula or medical food benefits through the WIC Program, inform the participant/caregiver that WIC participation for the nutritional assessment and education can continue, even though they not receiving supplemental formula from the Program.

Revised 4-2022

• Emphasize the benefits of nutrition education and for infants, if appropriate, clarify that starting at 6 months there are additional supplemental foods i.e., infant cereal, fruits, and vegetables that they can receive through WIC. For other participant categories (child, women), remind participants that WIC provides nutrition education, referrals and additional supplemental foods and encourage continued participation.

• See below for how to document receipt of HUSKY/Medicaid special/exempt infant formula, in CT-WIC.

• Follow up with the health care provider and/or participant/caregiver to ensure that the formula was requested by the health care provider through Medicaid (HUSKY).

• For special/exempt formula or medical food provided through WIC, Contact the WIC State agency Vendor Unit if a participant asks for assistance with locating or obtaining the product or for ordering/availability issues. Contact the WIC State agency Nutrition Unit for clinical issues.

• If there is an issue obtaining the formula through HUSKY, an initial month supply can be provided by the WIC Program with a completed WIC Medical Documentation Form. See WIC Policy 400-12 Retail Purchase of WIC Special Formula

Frequently Asked Questions:

Q: How does a HUSKY member obtain their special/exempt formula (nutritional) under Husky insurance?

A: Prescriptions for nutritionals (as well as any medication or other covered over the counter (OTC) products) are sent to the pharmacy and not directly to HUSKY. The member can either take the handwritten script to the pharmacy or the prescriber can phone or fax the prescription in. The pharmacist will then submit a claim for payment to HUSKY (just like any other prescription). A valid diagnosis (ICD-10 code) needs to be submitted on the claim for Medicaid to pay for a nutritional supplement.

Q: How long is a HUSKY prescription for the nutritional valid?

A: Depending on how the prescriber writes the prescription will determine how long the script is valid for up to 1 year. For example, the prescriber may write the script for an original fill plus 3 refills or 6 refills or 9 refills, etc. In the State of CT, a prescription is only valid for 1 year no matter how many refills the prescriber writes for. Once the prescription is older than 1 year from the date it was written it is no longer valid and a new one will need to be obtained.

Q: Is there a Prior-Authorization (PA) requirement for special/exempt formula or nutritionals?

A: No, a PA is not required for nutritional supplements. Only a diagnosis (ICD-10) code is required.

Q: Is justification or additional documentation required for approval beyond the diagnosis/ ICD-10 code?

Revised 4-2022

A: No.

Q: Is there a contact person at DSS if there are any issues?

A: Members can call a Client Assistance Call Center if any issues with obtaining any prescription including nutritional supplement, Monday through Friday from 8:00am to 5:00pm., excluding holidays at 1-866-409-8430.

Q: Are the formulas/nutritionals mailed to members after the first month or do they pick up in person every month at the pharmacy

A: Mailing options are up to individual pharmacies.

Q: What happens if coverage is denied? Is the participant liable for payment to the pharmacy after the product has been obtained?

A: Members can call the Call Center Monday through Friday from 8:00am to 5:00pm., excluding holidays at 1-866-409-8430.

Q: Is there a listing of approved HUSKY pharmacies?

A: No. HUSKY doesn’t have a list of enrolled pharmacies, but basically every pharmacy in the state is able to bill Medicaid.

Coordination between WIC and Private Insurance for Issuance of Special Formula

If the participant has private insurance and some or all formula needs cannot be met through WIC, encourage the parent/caregiver to check with their private insurance carrier to pursue potential approval for exempt formula coverage. Potential coverage for formula coverage will vary among companies.

• Contact the health care provider or request that the participant/caregiver contact their health care provider to submit a prescription or request to their private insurance company for formula coverage.

• Inform the participant and health care provider the maximum amount needed (if known), the amount that WIC will provide and how much that the private insurance company would need to supply to meet the participant’s total needs.

• Provide appropriate follow-up to ensure the participant receives maximum amount of formula through WIC if it is not covered by private insurance. If private insurance covers some or all the formula adjust the amount of WIC formula provided.

Revised 4-2022

CT WIC Documentation for Participants Dually Enrolled in WIC and Medicaid (HUSKY) NO FORMULA – RECEIVING FROM MEDICAID 1. The following columns have been added to the Food Package grid on the Food Prescription screen: • Medicaid Cov’d (checkbox) – This will be selected when it is determined that a participant is receiving formula through Medicaid/HUSKY. • Medicaid Cov’d Formula (dropdown) – This dropdown contains ALL formulas, Contract and Special Formulas. A formula must be selected from this dropdown when the Medicaid Cov’d checkbox is selected.

2. A new report “Participants Receiving Formula from Medicaid” has been added under the Reports → Certification menu from the top blue toolbar of the Clinic module. This report will identify participants who have the “Medicaid Cov’d” checkbox selected and will be used by state and local agency management staff for QA purposes. The following information will be displayed on the report: • Participant Name • Participant ID • Cert Start Date • Last Medicaid VER Date • Food Package Name (for the date range that is entered) • Formula Issued (for the date range that is entered)

Revised 4-2022

• Medicaid Cov’d Formula – this is the name of the formula that is selected from the new dropdown on the food package row.