VIII. CERTIFICATION, ELIGIBILITY & COORDINATION OF SERVICES

(Please indicate) State Agency: Wisconsin for FY 2025

The review of certification, eligibility and coordination of services involves the process of determining and documenting participant eligibility (income eligibility as well as nutritional risk determination, standards, and criteria), and the coordination of certification activities with other health services. During disasters, emergencies, public health emergencies, or a supply chain disruption, including infant formula recalls, the State agency may request to implement existing and allowable regulatory flexibilities or waivers to support the continuation of Program benefits and services. Waivers granted under Access to Baby Formula Act of 2022 (codified at 7 CFR 246.4a(30)) or temporary provision(s) authorized by Congress are not permanent amendments to the State Plan; however, State agencies should consider any historical amendments as the result of waivers granted under prior waiver authority to develop policies and procedures for current and future disasters.

A. Eligibility Determination and Documentation - 7 CFR 246.7(c)(1); 2(1); 246.7(d)(1); (2)(v)(B)): describe the policies and procedures for determining and documenting eligibility including the application process, residency requirements, identity requirements, documented physical presence or valid exception; proof of categorical eligibility, income limits, income eligibility documentation, determination of special populations and a definition of and policy toward the economic unit.

B. Nutrition Risk Determination, Documentation, and Priority Assignment - 7 CFR 246.4(a)(11)(i): describe the policies and procedures for determining and documenting nutritional risk and priority assignments. Include a copy of the nutritional risk criteria the State agency plans to use with the appropriate documentation.

C. Health Care Agreements, Referrals, and Coordination - 7 CFR 246.4(a)(6); (7); (8) and (19): describe the procedures for coordinating agreements and services with other health care providers at the State and local agency level including procedures to ensure that benefits are provided to persons with special needs.

D. Processing Standards - 7 CFR 246.4(a)(11)(i); 246.7(f)(2): describe the State agency's processing procedures to ensure that the required standards and timelines are met.

E. Certification Periods - 7 CFR 246.4(a)(11)(i); 246.7(g): describe the policies and procedures used to establish certification periods for participants and the autonomy (if applicable) granted to local agencies in determining eligibility time periods.

F. Transfer of Certification - 7 CFR 246.4(a)(6); (11)(i); and 246.7(k): describe the State

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agency's procedures for the transfer of certification and VOC cards ensuring that vital participant and program information is included.

G. Dual Participation, Participant Rights and Responsibilities, Fair Hearing Procedures, and Sanction System - 7CFR 246.4(a)(11)(i) (16); (17) and (18); 246.7(h); 246.7(i)(10); 246.7(j); 246.7(I): describe the procedures used to detect and prevent dual participation at the State and local level, the procedures for ensuring participants are notified of their rights and responsibilities, and the procedures regarding participant fair hearings and sanction system.

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A. Eligibility, Determination, and Documentation

1. Application Process a. The State agency requires all local agencies to use a standardized application process for all persons applying for the WIC Program ☒ Yes ☐ No

b. The State agency shares ☐ Statewide or ☐ at local agency (check one), a common income application or certification form with (check all that apply): ☒ No other benefit programs ☐ Medicaid ☐ TANF ☐ SNAP ☐ Maternal and Child Health (MCH) ☐ Other reduced-price health care program(s) ☐Other (specify): Click or tap here to enter text. ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

2. Residency, Identity and Physical Presence Requirements a. The State agency requires documentation of residency ☒ Yes ☒ Signed statement that documentation of residency information is not available and why (e.g., homeless, theft, fire) ☐No (Specify why, e.g., ITOs and Alaska natives who are exempt from this requirement): Click or tap here to enter text. b. The State agency has reciprocal agreements concerning residency with other State agencies ☐ Yes; list States: Click or tap here to enter text. ☒ No Describe any reciprocal agreements: Click or tap here to enter text.

c. The State agency has special residency policies and procedures for how the following special categories should be treated (check all that apply): ☒ Homeless applicants ☒ Institutionalized applicants ☒ Migrants ☐ Indian Tribal Organizations

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☐ None ☒ Other (specify): victims of theft, loss, or disaster

d. The State agency allows the following as proof of identity; please select all that apply. ☒ Driver’s license ☒ Passport ☒ State issued identification card ☒ Employer issued identity card ☐ Documentation from participation in a means-tested program. ☒ Other (please list all that are accepted) county/tribal/student/military ID, birth certificate, name change court order, alien card, U.S. immigration/naturalization doc. Infant/child only: adoption/hospital/WI Immunization Registry/electronic birth record. Adult only: social security card e. The State agency requires physical presence of the applicant or a valid exception to be documented: ☒ Yes except for the following condition(s): 7 CFR 246.7(o)(2) ☒ Applicant or parent/caretaker is an individual with disabilities which prevent him/her from being physically present at the WIC clinic (e.g., medical equipment, bedrest or serious illness exacerbated by coming into clinic). ☒ Applicant is an infant or child receiving documented ongoing health care from any health care provider, including the local agency; being physically present would pose an unreasonable barrier; and the infant or child was present at his/her initial WIC certification. ☐ Applicant is an infant under 8 weeks of age who cannot be present at the time of certification (for a reason determined appropriate by the local agency) and for whom all necessary certification information is provided. ☒ Applicant is an infant or child who was present at his/her initial certification; was present at certification within the one-year period of the most recent determination; and is under the care of one or more working parent, or under the care of primary working caretakers whose status presents a barrier to bringing the infant or child into the WIC clinic.

3. The State agency requires applicants to submit proof of categorical eligibility for (check all that apply): ☐ All pregnant women ☐ Pregnant women not visibly pregnant ☐ Postpartum women ☒ Children ☒ Infants ☐ Other (specify): Click or tap here to enter text.

4. Income Limits for Eligibility a. The State agency gross income limit for income eligibility is at or below 185% of the federal poverty income guidelines

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☒ Yes, with no local agency exceptions ☐ Yes, with local agency variation ☐ No, with no local agency exceptions (specify State maximum percent of poverty: Click or tap here to enter text. %)

☐ No, with local agency variation (specify State maximum percent of poverty: Click or tap here to enter text. %)

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

b. The State agency implements income eligibility guidelines concurrently with Medicaid ☐ Yes ☒ No

ADDITIONAL DETAIL: Please attach a copy of the income guidelines in the Appendix or the appropriate citation in the Procedure Manual. Certification and Eligibility Appendix and/or Procedure Manual (citation): Appendix VIII.A.4.a. WIC Income Eligibility Table

c. The State agency requires documentation of an applicant's, or certain family members' eligibility to receive benefits in the following means-tested programs that confer adjunctive income eligibility for WIC, as set forth in 7 CFR 246.7(d)(2)(vi): Poverty Level ☒ TANF (specify State "percent of poverty") 115% ☒ SNAP 130% ☒ Medicaid (specify State "percent of poverty" for each) Click or tap here to enter text.% ☒ Pregnant women and infants 306% ☒ Children 306% ☒ Other categorically eligible women 100% d. The State agency uses documented eligibility for participation in other means-tested programs to establish automatic WIC income eligibility (check all that apply, and the poverty levels used for each):

Poverty Level

☐ Free or Reduced-Price School Meals Click or tap here to enter text.% ☐ Supplemental Security Income (SSI) Click or tap here to enter text.%

☐ Other State-provided health insurance (specify State "percent of poverty" maximum Click or tap here to enter text. %)Click or tap here to enter text.%

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☒ Food Distribution Program on Indian Reservations (FDPIR) 130%

☐ Other (specify):

Click or tap here to enter text.%

e. Individuals are required to document that they or a family member are certified as eligible to receive TANF, Medicaid, or SNAP benefits or, under the State option, certified as eligible to receive benefits in State- administered programs by providing: ☒ Program ID card (only if it includes dates of eligibility) or notice of current eligibility ☐ Documentation of participation in State-administered programs (and such programs require documentation of income and have income guidelines at or below WIC's income guideline of 185% of poverty). (Program[s]: Click or tap here to enter text.)

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

5. Income Eligibility Documentation a. For WIC applicants whose income eligibility is not based on adjunctive or automatic income eligibility in another means-tested program, the State agency requires (check all that apply): ☒ Documentation of income information ☒ Signed statement that documentation of income information is not available and why ☐ Notation in the participant record if the applicant declares no income and why ☒ Other (specify): Notation in the record if the applicant declares no income b. Exceptions to income documentation are made for the following: 7 CFR 246.7(d)(2)(v)(C) ☒ The necessary information is not available ☒ The income documentation presents an unreasonable barrier to participation as determined by the State agency ☒ Those applicants with no income ☒ Those applicants who work for cash ☐ Other (specify): Click or tap here to enter text.

c. If the applicant does not supply the necessary documentation at the certification appointment, local agencies are generally instructed to do the following: ☐ Certification process is terminated, and no food instruments/cash-value vouchers are provided; appointment rescheduled. ☒ Temporary certification (not to exceed 30 days) for applicants that have one qualifying

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nutrition risk and are able to present at least two of the three required documents (identification, residency, and income) during a certification appointment is completed and food instruments are provided. However, if applicant does not provide documentation within 30 days, certification expires, and a new eligibility determination must be conducted. ☒ Other (specify): If two or three of the required proofs are not provided the cert process is terminated and appointment rescheduled; or in hardship cases appointment is conducted without proofs and when proofs are provided within 10 days the cert is processed & benefits issued at that time

d. The State agency requires ☐ State-wide, or ☐ at local agency discretion (check one), the verification of applicant income information, if determined necessary ☒ No ☐ Yes (check all sources required, as appropriate): ☐ Employer ☐ Public assistance offices ☐ State employment offices (wage match, unemployment) ☐ Social Security Administration ☐ School districts/offices ☐ Collateral contacts ☐ Other (specify): Click or tap here to enter text.

e. The State agency has specific policies that define actions to be taken at a mid-certification appointment if a participant’s income eligibility changes. ☒ Yes; Please specify: Policy 2.3 ☐ No

f. The State agency allows documentation of alternate income procedures for Indian or Indian Health Service (IHS) operated local agencies. ☐ Yes ☒ No ☐ Not Applicable g. The State agency has a specific policy that addresses income from benefits provided by a State- administered programs. ☒ Yes ☐ No h. The State agency has a specific policy to ensure that certain types of income, such as combat pay or Family Subsistence Supplemental Allowance (FSSA) payments for households that include service members, are excluded from consideration in the WIC income eligibility determination, as provided by law and regulation. ☒ Yes ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

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Policy 2.3B

6. In determining an applicant’s income eligibility for WIC, the State agency excludes basic allowance for housing received by military services personnel residing off military installations and in privatized housing, whether on- or off-base. ☒ Yes, State-wide ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.3B

7. The State agency excludes cost-of-living allowances for military personnel on duty outside of the contiguous 48 States (OCONUS COLA) from applicant income for purposes of WIC income determination. ☒ Yes, State-wide ☐ No

8. In determining an applicant’s income eligibility for WIC, the State agency excludes payments given to deployed military service members. These payments are in accordance with Chapter 5 of Title 37 of the U.S.C. ☒ Yes, State-wide ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

9. In determining an applicant’s income eligibility for WIC, the State agency calculates multiple income sources received by an applicant’s household at different frequencies in accordance with WIC Policy Memo 2011-7 and compares the sum to the established WIC IEGs. ☐ Yes, State-wide ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.3B

10. The State agency defines the economic unit in accordance with WIC Policy Memo 2013-3. ☒ Yes

☐ No (if no, why not): Click or tap here to enter text.

Provide the definition of an economic unit used by the State agency in the Appendix or the appropriate citation in the Procedure Manual.

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

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Policy 2.3

11. The State agency has specific policies or lists examples concerning the determination of the economic unit for (check all that apply): ☒ Foster children ☒ Divorced/legally separated parents; step parents ☒ Absentee spouse (military hardship tours, etc.) ☒ Cohabitation ☒ Institutionalized applicants (including incarcerated applicants) ☒ Homeless applicants ☒ Minors ("emancipated" minors) ☒ Separate economic units under the same roof ☒ Striker/unemployed ☒ Students away at school ☒ Self-employed applicants ☒ Other (specify): Kinship Care ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

12. Mid-Certification Disqualification a. The State agency ensures that local agencies are required to stipulate that an individual is not automatically disqualified mid-certification since she/he no longer participates in one or more of the Programs for which they were originally determined adjunctively/automatically income eligible. ☒ Yes ☐ No

b. WIC regulations specify that when income eligibility is reassessed mid-certification, State/local agencies are required to reevaluate the Programs for which the individual could be determined adjunctively/automatically income eligible. If the individual cannot qualify based on eligibility for one of these Programs, eligibility must be determined based on WIC income guidelines and disqualification made only after all options are exhausted. The State agency ensures its policy and procedures comply with this requirement: ☒ Yes ☐ No

B. Nutrition Risk Determination, Documentation and Priority Assignment

1. Nutrition Risk Determination and Documentation

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a. Professionals authorized by the State agency as Competent Professional Authorities (CPAs) to determine nutritional risk include (check all that apply): Can certify for: Qualification Priorities I-III All Priorities RD or Masters Level Nutritionist ☐

☒ Bachelor's Level Nutritionist ☐

☒ Physician ☐

☒ Physician Assistant ☐

☒ Registered Nurse ☐

☒ Licensed Practical Nurse ☐

☐ Home Economist ☐

☐ Paraprofessional ☐

☐ Other (Specify): Dietetic Technician Registered b. The State agency authorizes local agencies to (check all that apply): ☒ Conduct ☒ Anthropometric and ☒ Hematological measurements ☒ Use medical referral data for ☒ Anthropometric and ☒ Hematological measurements ☐ Use data from a state Health Information Exchange (including access to medical referral data via a participant/physician portal) ☐ Use data from a trusted partner trained in taking accurate measurements. Please list or attach partners the state agency accepts data from (list doesn’t need to be all-inclusive): c. The State agency uses only FNS-approved nutrition risk criteria, as referenced in Policy Memorandum #2011-5, WIC Nutrition Risk Criteria, and transmittal memorandum (dated December 17, 2020) that list the revised risk criteria requiring implementation by 10/1/2022, published on the FNS PartnerWeb, to document nutrition risk. (Note: A more recent transmittal memorandum was issued on November 17, 2022, however, the revised risk criteria included in this memorandum are not scheduled to be implemented until October 1, 2024) ☒ Yes ☐ No Please append a list of the nutrition risk criteria used by the State agency in its entirety to this State Agency Plan.

d. The State agency modifies nutrition risk criteria such that criteria definitions are more restrictive than nationally established definitions.

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☐ Yes (list criteria): Click or tap here to enter text. ☒ No e. Hematological risk determination: CFR 246.7(e)1(i)(A) The State agency requires (check one of the following): ☐ Bloodwork data to be collected at the time of certification (Statewide). ☒ Bloodwork data to be collected within 90 days of certification, so long as the participant is determined to have at least one qualifying nutritional risk at the time of certification (Statewide), and the State has implemented procedures to ensure receipt of data. ☐ A shorter (less than 90 days) timeframe for collection of data past certification. Please specify the shorter timeframe Click or tap here to enter text. The State agency ensures that hematological assessment data are current and reflective of participant status, to include a bloodwork periodicity schedule that conforms to the requirements as described in 7 CFR 246.7(e)(1)(ii)(B). ☒ Yes ☐ No The State agency allows local agencies the option of obtaining bloodwork on children ages 2-5 annually if prior certification results were normal. ☒ Yes ☐ No

f. Anthropometric risk determination: The State agency allows (check one): ☒ Anthropometric data for certification to be no older than 60 days (Statewide)

☐ A shorter (less than 60 days) limit on age of anthropometric data or certification

g. Nutrition assessment: (i) Local agencies are required to perform a complete nutrition assessment (as described in the Value Enhanced Nutrition Assessment [VENA] Guidance) for all participants. ☒ Yes ☐ No (explain): Click or tap here to enter text.

(ii) Local agencies are required to perform a mid-certification nutrition assessment (as described in the Guidance for Providing Quality Nutrition Services during Extended Certification Periods) for all participants with and extended certification period.

☒ Yes ☐ Not Applicable: (The State agency does not utilize the extended certification option for any participant category)

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(iii) The State agency policy requires that nutrition assessment intake information be collected on a State agency mandated form or Management Information System (MIS). ☒ Yes ☐ No If yes, attach mandated forms (or MIS screen shots) or specify location in the procedure manual and reference below. If no, the State agency assures quality of nutrition assessment by: ☐ Requiring local agencies to submit forms for approval ☐ Annually monitoring the locally developed forms during local agency review ☐ Other (specify): Click or tap here to enter text.

(iv) Dietary assessment is based on professionally recognized guidelines (e.g., Dietary Guidelines for Americans, My Plate Food Guide, American Academy of Pediatrics) ☒ Yes (specify): USDA’s risk criteria ☐ No (explain): Click or tap here to enter text. ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite):

Appendix VIII.B.1.c. Nutrition Risk Criteria, Policy 3.10 Value Enhanced Nutrition Assessment

2. Documentation a. The State agency requires documentation in the applicant’s case file for all nutrition risk criteria used to establish WIC eligibility (check one) (as described in FNS Policy Memorandum #2008-4, WIC Nutrition Services Documentation): ☒ Yes, supported by a written "exceptions" policy (e.g., policies to direct clinic staff in situations in which documentation is unavailable) ☐ Yes, with CPA discretion when to waive documentation requirement (no written policy) ☐ No (explain): Click or tap here to enter text. b. As a matter of policy, the State agency requires the documentation of nutritional risk criteria on a participant's certification form in the following manner: ☒ All identified risk criteria are recorded ☐ A set number of criteria Click or tap here to enter text. is recorded (maximum number is 10 criteria) ☐ Local agency personnel decide how many and which criteria are recorded ☐ Other (specify): Click or tap here to enter text.

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3. Priority Assignments a. Participants certified for regression ☒ Remain in the same priority in which they were previously assigned ☐ Are assigned to Priority VII, regardless of their initial priority at first certification ☐ Other (specify): Click or tap here to enter text. b. The State agency requires verification for all nutrition risk criteria that require a physician’s diagnosis. ☐ Yes ☒ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite): Click or tap here to enter text.

c. Participants may be certified for regression (check all that apply): ☐ A single six-month period ☒ One time following a certification period ☐ No policy, local agency discretion d. High risk postpartum women are assigned to the following priority: ☐ Priority III ☐ Priority IV ☒ Priority V ☒ Priority VI e. Participants certified solely due to homelessness/migrancy are assigned to the following priority:

IV V VI VII Pregnant Women ☐ ☐ Breastfeeding Women ☒ ☐ Postpartum Women ☒ ☐ Infants ☒ ☐ Children

☐ ☐ f. Attach a copy of any nutrition risk criteria that will be added, modified, or deleted during the coming fiscal year. For each criterion, indicate: Applicable participant category

Applicable priority level(s)

Whether a physician’s diagnosis is required SA code number which conforms to list of codes provided by USDA for Participant Characteristics

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data collection ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 3.10 and ROSIE, Wisconsin WIC Program Risk Criteria

C. Health Care Agreements, Referrals, and Coordination 1. State Agency Referral Agreements and Coordination of Services a. The State agency has written formal agreements that permit the sharing of participant information with the following programs/providers (indicate whether information is shared manually (M) or through ADP (A) by placing either an M or A in front of the appropriate service): Click or tap here to enter text. SNAP Click or tap here to enter text. Rural/migrant health centers Click or tap here to enter text. TANF Click or tap here to enter text. Hospitals Click or tap here to enter text. Medicaid Click or tap here to enter text. Childhood immunization Click or tap here to enter text. SSI A Immunization registries Click or tap here to enter text. EPSDT Click or tap here to enter text. Well-child programs Click or tap here to enter text. MCH programs Click or tap here to enter text. Child protective services Click or tap here to enter text. Family planning Click or tap here to enter text. IHS facilities Click or tap here to enter text. Private physicians Click or tap here to enter text. Children with special health care needs program(s) Click or tap here to enter text.Other (specify): A Lead Program, M Fit Families, M Mortality Review b. Formal agreements for coordination of services include: ☒ Responsibilities of each party ☐ Assurance that information is used only for program eligibility and/or outreach ☐ Assurance that information will remain confidential and not be shared with a third party c. The State agency requires local agencies to coordinate services with, and/or develop referral systems for, the following (check all that apply):

☒ SNAP ☐ Children with special health care needs ☐TANF ☐ Schools ☐ SSI ☐ Expanded Food and Nutrition Education Program

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(EFNEP) ☒ Medicaid ☐ Other food assistance program (TEFAP, FDPIR,

CSFP, etc.) ☐ CHIP

☐ Breastfeeding promotion ☐ IHS facilities ☐Child protective services ☐ MCH (clinics/facilities) ☐Head Start ☐ Early and Periodic Screening, Diagnostic and Treatment (EPSDT) ☐ Early Head Start ☐ Family planning ☐ Healthy Start ☐ Prenatal care ☒ Substance abuse program ☐ Postnatal care ☐ Child abuse counseling ☐ Immunization ☐ Foster care agencies ☐ Dental services ☐ Homeless facilities ☐ Private physicians ☐ Mental health services ☐ Hospitals ☐ Rural/migrant health centers ☒ Well-child programs ☒ Lead Screening ☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

2. Local Agency Referral Procedures a. The State agency ensures that local agencies make available to all adults applying or re-applying for the WIC Program for themselves or on behalf of others the following types of information: ☒ State Medicaid Program, including presumptive eligibility determinations, where available ☐Child support services ☒ SNAP ☒ Substance abuse counseling/treatment programs ☐ TANF, including presumptive eligibility determinations, where available ☐Other State-funded medical insurance programs (specify): Click or tap here to enter text. ☐ Other nutrition services (specify): Click or tap here to enter text. ☐ EPSDT Program ☐ Children’s Health Insurance programs (s) ☐ Other (specify): Click or tap here to enter text.

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b. The referral methods used by local agencies to other health and social service programs include (check all that apply, and indicate whether the method selected is the primary method of referral):

Primary ☒ State agency-developed referral forms ☒ ☒ Local agency-developed referral form ☐ ☒Telephone call to referring agency ☐ ☒ Verbal referral to participants ☐ ☐ Automated client/participant information exchange ☐ ☒ Written literature on referral programs ☐ ☒ Follow-ups by staff to monitor ☐ ☒ Maintain a list of local resources for drug and other harmful substance abuse ☐ ☐Counseling ☐ ☐ Other (specify): Click or tap here to enter text. ☐

c. Methods used by other health and social service programs to refer clients to the WIC Program include (check all that apply, and indicate whether the method selected is the primary method of referral):

Primary

☒ WIC Program referral form

☐

☐ Health/social program referral form

☐

☒ Telephone call

☐

☒ Verbal referral

☒

☐ Automated client/participant information exchange

☐

☒ Written literature on the WIC Program

☐

☐ Other (specify): Click or tap here to enter text. d. The State agency has a system in place to monitor the extent to which WIC participants are using other health or social services (check all that apply): ☒ Yes (check): ☒ Medicaid ☒ TANF ☐ MCH ☒ SNAP ☐ Yes, other (specify): Click or tap here to enter text. ☐ No e. The State agency requires local agencies to monitor referrals to determine the extent of health or social services utilization in addition to State monitoring systems. ☐Yes ☒ No

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ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policies 5.1, 5.2, 5.3, 5.4

f. To facilitate referrals to the Medicaid Program, the State agency provides each local agency a chart showing the maximum income limits, according to family size, applicable to pregnant women, infants, and children up to age 5 under the Medicaid Program. ☐ Yes ☒ No

g. The State agency assures that each local agency operating the Program within a hospital, and/or that has a cooperative arrangement with a hospital, advises potentially eligible individuals that receive inpatient or outpatient prenatal, maternity, or postpartum services, or that accompany a child under the age of 5 who receives well-child services, of the availability of Program services. ☒ Yes ☐No

h. The State agency ensures that, to the extent possible, local agencies provide an opportunity for individuals who may be eligible to be certified within the hospital for participation in WIC. ☐ Yes ☒ No

i. The State agency ensures that when WIC is at maximum caseload, local agencies make referrals to:

☐ Food banks ☒ Food pantries ☒ Soup kitchens or other emergency meal providers ☒ SNAP ☒ The Emergency Food Assistance Program (TEFAP) ☒ Food Distribution Program on Indian Reservations (FDPIR)☐ Other (specify): Click or tap here to enter text.

j. The State agency ensures that when WIC is at maximum caseload, local agencies notify the State agency of any waiting lists established. ☒ Yes ☐ No k. The State agency ensures that when WIC is at maximum caseload, the State agency notifies FNS of any waiting lists established. ☒ Yes ☐ No l. The State agency ensures that when the WIC participant's family has immediate needs for food

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beyond what WIC might provide, local agencies make referrals to: ☐ Food banks ☒ Food pantries ☒ Soup kitchens ☒ SNAP ☒ The Emergency Food Assistance Program (TEFAP) ☐ Food Distribution Program on Indian Reservations (FDPIR) ☐ Other (specify): Click or tap here to enter text.

m. Immunization Screening and Referral The State agency assures that each local agency is meeting the requirements of WIC Policy Memorandum #2001-7, August 30, 2001: Immunization Screening and Referral, as follows: ☒ Screening children under the age of two using a documented immunization history: ☐Using the minimum screening protocol; or ☒ Using a more comprehensive means, (specify): Click or tap here to enter text.

☒ Using another program or entity to screen and refer WIC children using a documented immunization history; (specify):Click or tap here to enter text.; or

☐ Implementing the minimum screening protocol is unnecessary because immunization coverage rates of WIC children by 24 months are 90% or greater; or ☐ The State agency has been unable to formalize a coordination agreement with the State Immunization Program. Provide explanation of extenuating circumstances: Click or tap here to enter text.

The State agency's policy and procedure manual has been updated to include the above immunization screening and referral protocol. ☒ Yes ☐ No D. Processing Standards

1. Notification Standards a. The State agency defines special nutritional risk applicants who are to be notified of their

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eligibility within 10 days of the date of the first request (at the local agency) for program benefits as the following (check all that apply): ☒ Pregnant women eligible as Priority I ☐High-risk infants (optional) ☒ Migrant farmworkers/family members ☐Homeless (optional) ☒ Optional; please specify: all infants under 6 months

b. The State agency requires local agencies to follow special policies and procedures to ensure timely certification of: ☒ Rural applicants ☒ Employed applicants ☐ No special policies/procedures

c. The State agency's policy allows it to authorize an extension of the notification period up to 15 days for special nutritional risk applicants when local agencies provide a written request with justification. ☐ Yes ☒ No

d. Policies and procedures are in place to assure all other applicants are notified of eligibility within 20 days of first request (at the local agency) for Program benefits. ☒ Yes ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.2 and 10.14

2. Processing Standards a. Processing standards begin when the applicant (check all that apply): ☒ Calls the local agency to request benefits ☒ Visits the local agency in person ☒ Makes a written request for benefits ☐ Makes a request for benefits via an application portal

b. The State agency requires the local agency to have a monitoring system in place to ensure processing standards are being met for all categories of applicants. ☒ Yes ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.2

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E. Certification Periods

1. Certification Period Standards a. (i) The State agency authorizes local agencies to certify infants under six months of age for a period extending up to the first birthday provided the quality and accessibility of health care services are not diminished: ☒ Yes, at all local agencies ☐ Yes, at selected local agencies ☐ No (ii) The State agency authorizes local agencies to certify children for a period of up to one year provided that participant children receive required health and nutrition services: ☒ Yes, at all local agencies ☐ Yes, at selected local agencies ☐ No (iii) The State agency authorizes local agencies to certify breastfeeding mothers for a period extending up to the infant's first birthday or until breastfeeding is discontinued (whichever comes first), if there is no decrease in health and nutrition services that the participant would otherwise receive during a shorter certification period: ☒ Yes, at all local agencies ☐ Yes, at selected local agencies ☐ No

(iv) The State agency ensures that health care and nutrition services are not diminished for participants certified for longer than six months: ☐ No ☒Yes (describe): Policy 3.34 b. Extended certification is an option for the following (check all that apply): ☒ Priority I infants ☒ Priority II infants ☒ Priority IV infants ☒ Priority III Children ☒ Priority V Children ☒ Priority I Breastfeeding Women ☒ Priority IV Breastfeeding Women c. The State agency authorizes local agencies to shorten or extend the certification period up to 30 days in certain circumstances. ☒ Yes (If yes, provide citation indicating circumstances): ☐ No Policy 2.10 and 10.61

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.10

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2. The State agency authorizes local agencies to disqualify an individual in the middle of a certification period for the following reasons (check all that apply): ☒ Participant volunteers the information that they are over income ☒ Participant abuse ☒ Family member found income ineligible at recertification ☐ Failure to pick up food instruments/cash-value vouchers for Click or tap here to enter text. consecutive issuances ☐ Other (specify): Click or tap here to enter text. ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policies 2.3 and 2.11

F. Transfer of Certification

1. Procedures for Transfer of Certification and Verification of Certification (VOC) a. The State agency has procedures in place that are used by all local agencies for transfers of certification within the State agency (intra-State), between State agencies (inter-State), and to the WIC Overseas Program (WICO): Intra-State Inter-State WIC Overseas ☒ ☒ ☒ Yes ☐ ☐ ☐ No b. A participant ID card/folder/documentation is provided which also serves as a VOC: ☐ Yes ☒ No

c. The State agency requires all local agencies to use a standardized VOC: ☒ Yes ☐ No d. VOCs are issued to the following (check all that apply): ☐ All participants ☒ Migrants ☐ Homeless ☐ Participants relocating during certification period ☒ Persons affiliated with the military who are transferred overseas ☒ Other (specify): all transferring out of state ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

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2. The State agency requires all local agencies to include the following information on the VOC (check all that apply): ☒ Name of participant ☒ Date certification performed ☒ Date income eligibility last determined ☒ Nutritional risk condition of the participant ☒ Date certification period expires ☒ Signature/printed or typed name of certifying local agency official ☒ Name/address/phone number of certifying local agency ☒ Identification number or some other means of accountability ☐ Other (specify): Click or tap here to enter text.

3. The State agency requires all local agencies to accept as valid all VOCs from both the domestic WIC Program and the WIC Overseas Program that contain the following essential elements: ☒ Participant name ☒ Name and address of the certifying agency ☒ Date the current certification period expires 4. The State agency honors the one-year certification period for transferring participants (infants, children, and breastfeeding women) even if it certifies participants every six months. ☒ Yes ☐ No ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 2.6

G. Dual Participation, Rights and Responsibilities, Fair Hearings, Sanctions

1. Dual Participation a. The State agency has written procedures to prevent and detect dual participation within each local agency and between local agencies: ☐ Yes (Please attach any descriptions of policy in Appendix or cite appropriate

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section(s) of the Procedure Manual): Policy 8.1, 8.2, 8.4 ☐ No

b. The State agency has a written agreement with the Indian State agency(ies) or other geographic State agencies in proximity for the detection and prevention of dual participation (attach a copy of each applicable agreement or provide a citation of where a copy is located): ☒ Yes ☐ No

☐ Not applicable

c. The State agency has established procedures to handle participants found in violation due to dual participation: ☒ Yes (Please attach any descriptions of policy in Appendix or cite appropriate section(s) of the Procedure Manual): Policy 8.2 ☐ No ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Appendix VIII.G.1.a. Participant Integrity Guidance; Appendix VIII.G.1.b. State Dual Participation Agreements; Policy 8.2

2. Participant Rights and Responsibilities a. The State agency has uniform notification procedures that are used by all local agencies statewide: ☒ Yes ☐ No b. The State agency requires all local agencies to inform applicant/participant of his/her rights and responsibilities in written form, and must be read by or to the applicant, parent, or caretaker: ☒ Yes ☐ No c. The State agency has implemented a policy of disqualifying participants for not picking up food instruments: ☐ Yes

☒ No ☐ Not applicable

If yes, the policy is communicated to participants in the participant rights and responsibilities materials: ☐ Yes

☐ No ☐ Not applicable

d. The State agency has implemented a policy to specifically inform participants that they are not allowed to sell WIC food benefits, including online: ☒ Yes ☐ No; explain: Click or tap here to enter text. e. The State agency has policies and procedures to identify attempted sales of WIC food benefits in their WIC State Plan:

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☒ Yes ☐ No; explain: Click or tap here to enter text.

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Appendix VIII.G.2.b. WIC Rights and Responsibilities

f. The State agency has developed special notification policies and procedures for the following: ☒ Applicant/participant who cannot read ☒ Applicant/participant who speaks in a language other than English ☐ Homeless ☐ Migrants ☐ Persons with disabilities ☐ Other (specify): Click or tap here to enter text. g. The State agency requires all local agencies to provide notification of participant rights and responsibilities in the following situations: ☒ Eligibility at each certification ☒ Ineligibility at initial certification ☒ Mid-certification disqualification ☐ Expiration of a certification period ☒ Waiting list status ☒ Other (specify): copy is provided in the WIC Shopping Guide and the MyWIC app

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Appendix VIII.G.2.b. WIC Rights and Responsibilities; Policies 2.11, 3.21

3. Fair Hearing and Sanction System a. The State has a law or regulation governing participant appeals: ☒ Yes ☐ No b. The State agency has established statewide fair hearing procedures: ☒ Yes; attach fair hearing procedures for participants or specify the location in the Procedure Manual and reference in additional detail section below. ☐ No c. State or local agency actions against participants include (check all that apply):

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☒ Reclaiming the value of improperly received benefits ☒ Disqualification from the Program for up to one year ☒ Suspension from the Program mid-certification ☒ Other (specify): to allow children to stay on the Program, selection of a different cardholder d. Appeal hearings are held at: ☐ WIC State agency parent agency ☐ Other State agency or hearing board (specify): Click or tap here to enter text.

☒ Local WIC agency ☐ Other (specify): Click or tap here to enter text. e. Statewide fair hearing procedures include (check all that apply): ☒ Request for hearing ☒ Local agency responsibilities ☒ Denial or dismissal of request ☒ Continuation of benefits ☒ Rules of procedure ☒ Responsibilities of hearing official ☒ Fair hearing decision ☐ Other (specify): Click or tap here to enter text. ☒ Judicial review

f. State agency procedures require written notification for (check all that apply): ☒ Appeal rights ☒ Request for hearing ☐ Denial or dismissal of request ☒ Notice of hearing ☒ Termination within certification period ☒ Fair hearing decision ☐ Judicial review ☐ Other (specify): Click or tap here to enter text. g. The State agency has established timeframes to govern each step of the hearing process: ☒ Yes ☐ No h. The State agency requires all local agencies to document any notification/correspondence in the participant's file: ☒ Yes ☐ No

i. The State agency has a written sanction policy for participants:

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☒ Yes (If yes, provide appropriate citation below) ☐ No j. The State agency has established procedures which determine the type and levels of sanctions to be applied against participants: ☒ Yes ☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation): Policy 10.52 Fair Hearing; Chapter 8 Policies Participant Fraud and Abuse