Modernizing and Streamlining WIC Eligibility Determination and Enrollment Processes
WIC ― the Special Supplemental Nutrition Program for Women, Infants, and Children ― serves low-income pregnant and postpartum women, infants, and children up to age 5 who are at nutritional risk and plays a crucial role in improving their lifetime health. While WIC effectively and efficiently provides nutritious foods, nutrition education, breastfeeding support, and referrals to health care and social services to millions of families, there is room to modernize and simplify enrollment.
WIC is well-known for extensive research showing that participation improves the nutrition and health of low-income families ― leading to healthier infants, more nutritious diets and better health care for children, and subsequently to higher academic achievement for students. WIC is also extremely cost-effective.
WIC programs across the country are exploring ways to update business processes and use technology to improve service delivery. For example, states are moving to providing food benefits electronically rather than using paper vouchers, and in some places WIC participants can use apps on their mobile phones to learn which products they may buy at the grocery store. While certain aspects of WIC’s enrollment process, like interviewing applicants about their eating habits, may not lend themselves to a technological approach, WIC has been slower to apply such innovations to aspects of its eligibility determination and enrollment processes that would allow for streamlining. In recent years other major means-tested public benefit programs, such as the Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) and Medicaid, have employed new technology and redesigned business processes to save time, simplify enrollment, and reduce breaks in receiving benefits experienced by families that remain eligible.
While some WIC programs have streamlined their procedures and embraced technology to simplify eligibility determinations, implementation across the country has been uneven. With limited administrative funds and the imperative to meet the needs of a highly vulnerable population, state and local WIC programs are naturally cautious about procuring new technology or experimenting with alternative business practices that may not deliver on their promise of improved service delivery at lower costs. Nevertheless, program operators are anxious for information about how to modernize and streamline their eligibility determinations and enrollment procedures to improve services and efficiency.
Over the last year, the Center on Budget and Policy Priorities, in cooperation with the National WIC Association, gathered information on WIC practices and procedures to examine how WIC clinics could simplify the processes of applying for and maintaining WIC eligibility. We conducted phone interviews with national WIC experts and state and/or local WIC staff in ten states and site visits to two WIC clinics in each of five states. We held a workshop with WIC staff from across the country to solicit feedback on our initial findings and we reviewed selected certification-related policies in state manuals. While we sought to speak with a diverse group of states and visit a variety of local clinics, we have not comprehensively documented state and local practices. For example, in order to devote our limited resources to WIC programs that serve the vast majority of participants, we did not attempt to gather information about WIC programs operated by tribal organizations or territories.
This report is designed to serve as a guide for state and local WIC staff who wish to comprehensively assess their policies and practices regarding eligibility determinations and enrollment to identify opportunities to streamline them. Streamlining these processes could free up staff time to devote to providing WIC’s core services and could make it easier for eligible families to enroll in WIC and continue receiving benefits as their babies become toddlers.
We identified five areas that offer opportunities for streamlining or simplification: 1) WIC clinic processes; 2) communicating with applicants and participants; 3) policy flexibility; 4) data and reports; and 5) collaboration and outreach. This report describes specific practices within each of those areas that state and local WIC staff may wish to explore and provides examples from states or local clinics that have implemented them. Appendix A summarizes these opportunities in a checklist. We also reviewed state policy manuals to ascertain the prevalence of selected certification policies, which we summarized in Appendix B.
Room to Reach More Eligible Low-Income Families
WIC reaches roughly half of all babies born in the United States, but participation tapers off for eligible toddlers despite the critical nature of adequate nutrition during the early years of brain development. WIC participation rates vary widely by state but young children aged 1 to 5 tend to be the group with the lowest rates of participation across the country. (See Figure 1.)
In recent years, WIC’s caseloads have fallen across the country from a peak of 9.2 million in fiscal year 2010 to approximately 7.7 million in fiscal year 2016. Participation declines since caseloads peaked during the recession vary by state, ranging from more than 20 percent in 16 states to less than 10 percent in six states. It’s appropriate that participation falls as the economy recovers. Meanwhile, births nationwide since 2010 have remained nearly flat and births to women under age 30 have fallen. Nonetheless, after increasing gradually during the recession, the share of eligible 1- to 4-year-olds participating in WIC declined from 53.6 percent in fiscal year 2011 to 49.8 percent in fiscal year 2013, the most recent year for which data are available. The U.S. Department of Agriculture (USDA), which oversees the WIC program, has provided resources and grants to help state WIC agencies improve participation and retention of young children in WIC.
While some eligible families may understand that they are eligible and choose not to seek WIC benefits, the decline in the WIC caseload raises questions about whether misunderstandings of program rules or burdensome administrative practices pose barriers for eligible low-income families that could benefit from participating.
Many factors play a role in low-income women’s decision about whether to participate in WIC, including how much they and their families value the specific foods WIC provides, the shopping experience, the perceived value of WIC’s breastfeeding support, and nutrition services. The time and effort involved in getting and staying enrolled is also a consideration.
The time and effort required to obtain and continue receiving benefits may play a larger role in the decision to participate by women who have to miss work or take children out of preschool for WIC appointments. A recent analysis by the California Department of Health about why eligible pregnant women don’t enroll in WIC found that barriers to participation included difficulty getting to the WIC clinic and challenges with the application process, such as getting through by phone or obtaining the necessary documents.
Simplifying certification policies and streamlining administrative procedures could make it easier for eligible low-income families to enroll in WIC and continue to receive benefits, while freeing up staff time. Simplification does not necessarily mean less in-person interaction. Instead, it can be about making that in-person interaction more focused, meaningful, and service-oriented. By streamlining the process, clinics can reserve the face-to-face time and participants’ energy for breastfeeding support, nutrition counseling, referrals, and other services WIC offers.
Over the last year, the Center on Budget and Policy Priorities, in cooperation with the National WIC Association, observed and documented applicants’ certification experiences and variations in certification processes to identify best practices, as well as areas that states and local agencies find challenging. This report provides a framework for state and local WIC programs that wish to comprehensively assess whether changes to their own policies and procedures could simplify eligibility determinations. This report is written for WIC program operators and state or local policymakers and assumes the reader is quite familiar with program details and rules.
We identified five areas that offer opportunities for streamlining or simplification. The remaining sections of this report describe each of these areas in more detail, highlighting effective practices and state and local examples.
- WIC clinic processes
- Communicating with applicants and participants
- Policy flexibility to help streamline processes
- Data and reports
- Collaboration and outreach
The practices we identify do not represent sweeping changes that will instantly increase participation and retention. Instead, they offer concrete steps squarely within the purview of state and local program leaders that could make the program more accessible to those not currently participating or could make it easier for current participants to continue receiving benefits. Taken together these steps could make a difference for WIC operations and clients.
A few overarching themes cut across those areas that are worth keeping in mind when considering streamlining opportunities.
- WIC has a strong customer service orientation. It is clear that WIC clinics work hard to provide an inviting environment for participants and that staff are widely perceived as friendly and courteous. In addition, staff seemed motivated to help people access the WIC services and benefits for which they are eligible. This is an important strength that provides a strong foundation for WIC.
- The shift to EBT creates an opportunity to streamline. WIC EBT (Electronic Benefits Transfer) is an electronic system that replaces paper vouchers with an EBT card for food benefit issuance and redemption at authorized WIC grocery stores. Some states have already made the shift to EBT, and all WIC programs must implement EBT by 2020. Though there are always challenges with implementing major new technology, overall the shift to EBT seems to bring positive changes to clinic processes for both staff and participants. In addition to saving time previously spent on printing WIC vouchers, EBT also allows clinics to shift away from in-person interaction solely for the purpose of providing food benefits because some EBT systems allow benefits to be issued remotely.
Physical presence must be balanced with other participant needs. In-person visits offer the opportunity to observe WIC participants and identify health concerns that might not otherwise become apparent. They also allow for more personalized service delivery. But in-person visits to WIC clinics can be burdensome for participants, especially those who lack transportation options or have to miss work for appointments.
WIC staff grapple with how to balance these competing goals. Federal WIC rules require that participants come in person to the clinic a minimum of every six months ― once for a certification and a second time for health measurements. In practice, though, the number of in-person appointments varies widely. Some clinics strive to limit in-person visits to twice per year by using tools and strategies including conducting nutrition education online, mailing food vouchers, remotely loading EBT cards, and allowing participants to mail or email missing documents. In other places, participants come into the clinic more than four times per year for various reasons. Staff recognize that many participants ― particularly younger mothers ― are accustomed to conducting many personal transactions electronically and may not want to come to the clinic that often. But some clinics seem hesitant to move away from in-person interactions even when such visits are burdensome to participants or involve solely administrative, rather than service-oriented, interactions (such as picking up WIC food vouchers). By offering participants more options, clinics can continue to provide more in-person services to those who need and value them while minimizing burdens for other WIC participants.
- WIC participants need (and want) choices. Beyond physical presence requirements, there are many different, sometimes conflicting, perspectives about what families need and want when participating in WIC. There is no one-size-fits-all approach that will meet the needs of all participants. One local clinic staff member we spoke with captured this well, saying that people have different needs and wants and the best thing that WIC clinics can do is offer participants choices and flexibility. By offering options, clinics can empower participants to do what works best for them and their family, increasing the likelihood that they will continue to participate in WIC. As more medical services offer options like online appointment requests and scheduling, video chats with health care professionals, and web-based counseling and education, WIC clients will also look for those options within WIC.
WIC Clinic Processes
Other benefit programs like Medicaid and SNAP have substantially streamlined eligibility determinations in recent years. Strategies such as relying on data from third-party sources or checking documentation only if a participant’s circumstances have changed take advantage of technology to make quick and accurate eligibility determinations. Adopting similar strategies in WIC can reduce the time that staff spend with participants on paperwork, freeing up more time for services.
Many WIC applicants begin their interaction with the WIC clinic through appointment scheduling. Scheduling is also an important aspect of a participant’s ongoing interaction with the clinic. Scheduling practices range from offering the flexibility of walk-in, same-day, or next-day appointments to a more fixed approach that relies on scheduling appointments one to three months in advance. Follow-up appointments may be scheduled at the conclusion of the clinic visit, sent out via mailed notice three to eight weeks before the appointment, or scheduled when the participant realizes they are due for an appointment and contacts the clinic.
Most local program leaders we spoke with expressed a commitment to serving clients who walked in without an appointment whenever possible. Yet in our observations, very few clinics promoted the availability of walk-in appointments, even if they regularly had the capacity.
By offering participants multiple options to plan their next clinic visit, WIC clinics can allow participants to select the approach and appointment time that works best for them and increase the likelihood that they will keep the appointment. Automated systems that provide participants with email, phone call, and/or text appointment reminders can also help reduce no-shows.
Offering WIC participants the ability to schedule their own appointments online could be a useful tool to reduce staff time spent scheduling, while also offering clients the ability to select a time that works best for their schedule. In the absence of a statewide system that offers this feature, local clinic staff could develop a self-serve appointment process that ensures clients are making the right type and length of appointment.
Shawnee County, Kansas: Next-Day Scheduling
Shawnee County implemented next-day scheduling to improve clients’ attendance at appointments and staff satisfaction. The County also added new opportunities for drop-in appointments. Following the changes, no-shows declined. Staff found that next-day scheduling made it easier to adjust the clinic schedule when needed and that the clinic was less chaotic.
Colorado: Flexible Scheduling
Some local WIC clinics in Colorado are experimenting with new approaches to appointment scheduling that shift away from scheduling appointments one to three months in advance and instead let the participant schedule same-day or next-day appointments. When combined with offering appointments scheduled further in advance if that works better for a participant, this approach shows promise in terms of reducing no-shows. Staff also appreciate no longer having to plan their schedules three months in advance. As a result of early experience, this approach is being rolled out at additional WIC sites.
To determine eligibility, staff review documents showing identity, residency, and income eligibility. By adopting flexible policies and helping clients find relevant documents, WIC clinics can reduce the number of times families need to visit and how much time they spend at appointments.
Local clinic staff could help brainstorm with applicants about different documents they may be able to use, including electronic documents like an online paystub or something at home that a family member could send an image of via smartphone. In addition, WIC clinics can offer alternatives to bringing documentation in person, which could include offering mail (ideally with a stamped envelope), fax, and/or email options. Staff would need to monitor these communication channels for incoming documents, which might necessitate a change to how staff spend their time, but need not disrupt clinic operations.
Greensboro, North Carolina: Helping Gather Documentation
The clinic works with applicants to find all the documents they need to enroll in WIC. If the applicant does not have a paper document at a certification appointment, staff ask whether the applicant has documents that can be seen on a smartphone, whether there might be something in the car with the necessary information, or if there is someone at home who could text or email a relevant document. North Carolina does not offer temporary certifications so this focused effort helps applicants enroll at their first appointment.
Temporary certification is also a useful tool to ensure that benefits are not delayed because an applicant cannot provide all documentation at a certification appointment. But it is important not to let the option of a temporary certification substitute for working with an applicant to obtain documentation and complete a regular certification when possible. We observed that some clinics using temporary certifications defaulted to having most applicants come back within 30 days to bring additional documents without inquiring if they might have access to another document or explaining that they need to return solely to bring the document. Further explanation and exploration might save the participant an additional trip to the WIC clinic.
Checking for Adjunctive Eligibility
There are multiple approaches to confirming adjunctive eligibility, including a check that is built into the WIC Management Information System (MIS), logging onto a separate online portal to check eligibility, and/or calling a telephone number to confirm an applicant’s benefits status (see Table 3 in Appendix B). The more streamlined and simple the process for checking for adjunctive eligibility, the more likely that WIC clinic staff will utilize that process before asking an applicant or participant to provide documentation.
Checking for adjunctive eligibility during a certification appointment can shorten the appointment. Doing so even before the client is in the clinic could further reduce appointments’ duration. A few clinics mentioned doing this when staff had time. This check could be done either during the initial phone call or before the appointment. Either approach could save time and energy for WIC applicants as they would know before their appointment that this information has been confirmed. Some clinics ask about participation in programs that confer adjunctive eligibility (such as Medicaid or SNAP) as part of the pre-screening process when an individual calls the clinic. But few clinics that we interviewed regularly confirm adjunctive eligibility at pre-screening and indicate the confirmation in their MIS. Further, some clinics indicated that they instruct clients to bring in income documentation even if the applicant indicates that they are adjunctively eligible because the client’s eligibility may change before they come into the clinic or because they may not realize they are actually ineligible for the program that confers adjunctive income eligibility.
California: Adjunctive Eligibility Check Within MIS
Even with a relatively old WIC eligibility system, California has built the check for adjunctive eligibility into its management information system. With a simple click, staff can check participation in Medicaid, SNAP, and/or cash assistance. This capacity is of great value to both staff and participants, as it makes checking for adjunctive eligibility quick and seamless.
Woodburn Salud Clinic, Oregon:
Checking Adjunctive Eligibility Prior to Meeting with Client
At the four sites operated by Salud, staff check adjunctive eligibility before meeting with the applicant, which slightly reduces the time a client must spend in the clinic. Two sites check adjunctive eligibility after the client has checked in for her appointment at reception, but prior to the certifier calling the client from the waiting area. The other sites have reception staff spend time first thing in the morning checking who on the schedule for the day is adjunctively eligible. They note adjunctive eligibility on the schedule so that the certifier knows whether the applicant is adjunctively eligible before they meet.
The flow of clients through the clinic is defined by the certification requirements, how the clinic structures staffing, and the steps in the enrollment process. Clinic flow can have a significant impact on a participant’s experience with WIC, including how well they understand the enrollment process and what services and participation requirements follow certification.
There are two general approaches to managing clinic flow. Participants can move between different rooms within the clinic for various services such as checking documents, measuring heights and weights, and counseling, sometimes returning to a waiting area between each. Other clinics have the participants remain in one room while staff rotate into the room to provide the services. Each approach has advantages, but regardless which approach is implemented, it is important to provide participants a roadmap of the process, including when there will be opportunities to ask questions and what follow-up steps are needed. A roadmap helps participants better understand what will happen during their appointment and beyond. It can also help participants maximize the value of the time they spend with WIC staff in the clinic.
As a program integrity measure, there are federal requirements regarding “separation of duties,” which can impact the clinic flow design. These requirements are designed to prevent staff from issuing WIC benefits to families that do not qualify. Under recent guidance clarifying how to implement “separation of duties,” either the certification process must be divided between at least two staff people or the clinic must have a process for reviewing certification decisions. This requirement can result in duplicative staffing at very small sites that would otherwise be able to operate with a single staff person. It can also create a less streamlined process for participants who have to interact with different staff for different aspects of their visit. This is an area where further exploration could focus on identifying options for simplifying the process for staff and participants without compromising program integrity.
Communicating with Applicants and Participants
WIC clinics need to communicate with participants for several reasons, including scheduling appointments, sending reminders about upcoming appointments or available food vouchers, and providing breastfeeding support. There are many ways that states and local agencies communicate with WIC clients and that clinics can streamline communication with families. Improved communication could particularly improve the eligibility determination process, as well as other aspects of WIC services, like nutrition education.
In recent years, clinics have shifted toward using more electronic communication to increase access and to be more responsive to younger participants. Many low-income adults own smartphones and use them to find health information. WIC clinics are confronting many of the same challenges (such as funding, compatibility with other systems, and the functionality of the technology) that other programs have faced with implementing new technology, while meeting system and security requirements. Despite these challenges, widespread use of mobile devices by WIC participants offers promising avenues for connecting with clients.
Many clinics already provide appointment reminders and other basic communications to participants via text message and this has largely been well-received by both staff and participants. But communication usually flows only from the clinic to the client. There is an opportunity to expand texting to communicate back and forth with WIC participants via two-way text messaging. This could be used in a variety of ways, including to provide breastfeeding support, answer follow-up questions, and schedule appointments.
Oregon: New Electronic Messaging System
The state recently received an infrastructure grant from USDA for an Electronic Messaging System that is a two-way, HIPAA-compliant desktop text messaging service. It received enough funding for ten agencies to use this service for breastfeeding support.
Email Address for Participants
Many participants have access to email via their mobile phones. Offering email as an option for ongoing communication with the staff can be useful for sending follow-up documents or other messages to the clinic. Sending an email could save participants a trip to the clinic or having to make copies of documents and mailing them to the clinic. One approach is to create a centralized or shared email address that multiple staff members can monitor. Clinics may also have individual staff members share their email address with participants for needed communication. Regardless of the approach, it is important that email is checked and acted on regularly if it is provided as an option to participants.
Clackamas County, Oregon: Using Email to Gather Documents
The Clackamas County WIC clinic uses a central clinic email address to accept documents that were missing at the initial certification appointment and for participants to report completion of online nutrition education. Selected staff have access to the central email. They use a flag system to track which emails have been addressed and then tabulate how many are received before deleting them. Staff have also developed email response templates for the most frequent topics. Staff noted that it is important to work with information technology staff to ensure that appropriate security measures are in place. They also notify participants that email is not secure outside the clinic’s network.
Online and Mobile Tools
States have developed both online and mobile tools to provide participants additional options for managing their WIC experience, particularly in the areas of nutrition education and grocery shopping, with sites like WIChealth.org or the WIC Shopper mobile phone app. Web and mobile tools specific to WIC eligibility and enrollment are more limited. Other public benefit programs, such as Medicaid and SNAP, have begun to offer more robust online and mobile tools for participants that allow them to easily view the status of their benefits, submit documents, and/or communicate with program staff. This type of tool could help participants respond more rapidly and easily to requests for information and more easily manage their appointments.
Lifeline: Connectivity for Low-Income Families
The Federal Communications Commission’s “Lifeline” program provides low-income households with monthly subsidies to help cover basic telephone services, including mobile phones.a A new rule expands its subsidies to cover broadband services on home computers or mobile devices.
a More information on the Lifeline Program is available at http://www.lifelinesupport.org/ls/.
Some WIC eligibility systems have the capacity for a participant portal but it appears that states have not yet fully implemented them. The existing capacity to set up such portals offers an important opportunity to facilitate communication with clients and make program participation easier for families.
Michigan: WIC Client Connect
Michigan implemented its WIC Client Connect website in 2014. It allows participants to schedule appointments, see upcoming appointments, find a local clinic or store, check remaining food benefits, and more. Each local agency decides whether to allow clients to request or schedule appointments. For example, a local agency could allow participants to request an appointment but not schedule it.
Video conferencing services can allow WIC staff to interact with clients “face-to-face” without being in the same physical location. Some clinics have begun to use this communication tool to provide nutrition counseling or breastfeeding support in areas with a large geographic area to cover but limited staff available. Such technology is becoming more widely available and can offer participants an option for receiving vital WIC services even if they are not able to travel to a clinic location.
Applications and Referrals
One of the notable differences between WIC and other programs that serve low-income families is that the WIC application process often does not begin with a paper or online application. Instead an applicant either calls or visits a local WIC clinic to begin the process, which typically involves completing a pre-screening and then scheduling an initial appointment to enroll. This process works well for some participants but may be challenging for others if they have trouble getting through to the clinic on the phone or if getting to the clinic is challenging.
USDA has an online WIC Prescreening Tool that helps someone determine if they may be eligible for WIC. The tool is available in English and eight other languages. If it indicates eligibility, it instructs families to contact their local WIC agency.
A few state or local areas have their own online screening tools and applications available for WIC. The application typically collects basic contact information for the individual or household with which the WIC clinic can then follow up. In addition, Colorado and California are exploring the possibility of incorporating WIC into existing multi-program online applications for Medicaid, SNAP, and other programs. Information from the online application would be provided to the WIC clinic so staff could follow up to schedule a certification appointment. This area is ripe for further testing and development as the WIC staff we spoke with expressed strong interest in making online applications more available to potential participants.
In some areas, clinics use referral forms to facilitate partner organizations referring individuals and families for WIC participation. These forms can help WIC clinics capture key contact and/or health information for potentially eligible participants, upon which they can then follow up.
New York: Online Screening and Referral Tool
A collaborative of local agencies in Central New York has developed a WIC outreach website that includes a screening and referral tool.a The tool screens potential participants for eligibility and collects demographic information. Once an applicant provides information, the tool sends a referral via email to the local agency closest to their residence. The agency then contacts the applicant to schedule a certification appointment and answer any questions.
Ingham County, Michigan: Partner Referral Form
The Ingham County WIC clinic uses a paper application as a referral form to help partners initiate and facilitate a WIC eligibility determination. Referring agencies, including physicians and other health care providers, use the form to transmit information about potential WIC participants to the WIC clinic. The application includes basic information about household members, income, and participation in Medicaid or other programs. The form also includes a section where providers can note information like height and weight measurements or bloodwork results. Staff have found this an effective way to encourage partner organizations to refer people to WIC and provide information that allows staff to streamline the eligibility determination at the certification appointment.
Using Policy Flexibility to Streamline the Process
During the course of our interviews and site visits, it became apparent that the federal rules allow for some simplification of the eligibility determination process, but there may be some confusion among states about what is allowable. In this section we highlight several areas where states already have flexibility that can be used to streamline the eligibility and enrollment process.
In addition, to better understand how policy areas that allow for streamlining are being implemented across states, we reviewed all available WIC state policy manuals and compiled information about how different states approach key policy areas. That information is summarized in Appendix B.
Some WIC clinics accept electronic documents to offer more options to applicants when providing proof of identity, residency, or income. Electronic documents could include an online pay stub or a photo of a document on a smartphone. States vary significantly, however, in whether and how they accept electronic documents provided by the applicant (see Table 2 in Appendix B). Some generally accept electronic documents while others limit their use, such as using online pay stubs only and not allowing an online utility bill to document residency. Federal policy does not prohibit the use of electronic documents and allowing individuals to use them can help participants more easily document their WIC eligibility.
Single Document or Source Covering Multiple Requirements
Allowing one document to meet multiple eligibility requirements can also make it easier for applicants to provide necessary documents. For example, a clinic could use a pay stub to document both income and residency if the current address is clearly listed on the pay stub. This is a simple yet effective strategy that clinics can employ to help participants through the certification process.
Further, adjunctive eligibility may be used to document residency in addition to income eligibility. If the address provided by the applicant is consistent with the address in the source the clinic checks for adjunctive eligibility, residency has been documented.
California: Using Adjunctive Eligibility to Prove Residency
California recently issued a policy memo clarifying that Medicaid, SNAP, or Temporary Assistance for Needy Families (TANF) participation makes applicants adjunctively eligible and documents residence. Staff still attempt to view other residency documentation, but if it is not available they can certify an applicant based on documentation of participation in Medicaid, SNAP, or TANF.
WIC applicants and participants can transmit or deliver documents to the local WIC agency in multiple ways. But some local clinics require participants to provide documentation in person even if there is no other need for a visit to the clinic. Federal rules do not require this practice. Instead, offering participants a range of options for transmitting documents can help ease the burden on participants and increase the likelihood they will follow up with requested documents. This simplification will become even more important as more states move to electronic delivery of WIC food benefits and participants will not need to visit the clinic to pick up food vouchers (though they might still need to visit to receive services like nutrition education or breastfeeding support).
The federal policy that permits temporary certifications allows clinics to provide WIC food benefits immediately to an applicant who reports meeting eligibility criteria but has not yet provided full documentation. The applicant must provide appropriate documentation within 30 days to continue receiving benefits. This option can help more eligible WIC participants gain initial access to the program, and most states are employing this strategy, though their interpretation of it varies (see Table 1 in Appendix B).
Clinics that offer temporary certifications can still streamline the certification process for applicants by fully exploring whether the documentation is available immediately, rather than defaulting to a temporary certification. It creates less work for both the clinic and participants if a certification is completed at the initial appointment, so striving to collect all necessary documents is preferable.
Local agencies can track how well the temporary certification process is working by examining what portion of those temporarily certified complete certification for ongoing WIC benefits. Tracking this share can help clinics assess how effectively the temporary certification process is for enrolling participants on an ongoing basis.
Under federal rules, states can allow local WIC agencies to certify breastfeeding women, infants, and children for up to a full year. Year-long certifications reduce the amount of time participants and staff must spend on eligibility determinations, which frees up time for nutrition counseling or other services. While states have generally allowed this flexibility for breastfeeding women and infants, some states have not elected this option for children (see Table 4 in Appendix B). These states have an opportunity to streamline operations and increase retention of participating children by allowing year-long certifications for children.
Our interviews and site visits also revealed federal policies that create barriers to access or simplification. Because these are federal policies, state and local WIC programs are not in a position to change them. The most common policy challenges we identified include:
- Certification alignment: It can be difficult or impossible to align the certification periods of multiple WIC participants in a household, as participants may have certification periods of different durations and/or may have begun receiving benefits at different times. As a result, family members may have different WIC certification end dates and thus separate certification appointments. Federal rules allow for the certification period to be shortened or lengthened by 30 days but this flexibility is often insufficient to bring all household members into alignment.
- Streamlining subsequent certification (recertification): WIC recertification is typically viewed as simply doing certification again. The primary difference from the initial certification is that some information is already in the eligibility system and does not need to be re-entered. Otherwise, the steps of the certification process remain the same. There are likely opportunities to simplify the WIC recertification process for both participants and staff. Other programs may offer useful approaches. For example, SNAP requires less documentation at recertification than at initial certification.
- Proof of residency: One of the WIC certification requirements is documenting residency, but the importance of this requirement across all WIC sites is unclear. Documenting residency may be used locally to assign participants to a specific local WIC agency or site. It also may be used in areas that border other states to prevent participating in more than one location, though some clinics with nearby borders rely on other systems to prevent dual participation. In many communities, documenting residency seems to serve little purpose. As such, there could be flexibility offered in this area to allow for a policy approach that is most locally relevant and removes documentation requirements that are not used for program integrity or management purposes.
Data and Reports
WIC clinics can use data to guide efforts to improve enrollment and retention or to assess the effectiveness of a newly implemented policy or process. The level of data that WIC clinics have access to varies depending on their management information system and how well the associated reporting functionality is working. Clinics that have access to several data and operational reports are able to track what is happening in the clinics and can pinpoint opportunities or challenges.
We found that there is generally a strong focus on tracking caseload levels and trends, as well as appointments, while other operational reports and data may get less review. This section describes the mostly commonly used reports, additional reports that clinics find useful, and promising reports that are generally not used but could be helpful in increasing participation and retention.
Commonly Used Reports
- Caseload Measures: Caseload reports typically provide the number of WIC participants for a given agency broken down by eligibility categories over a given time period. They sometimes indicate whether the participant is picking up or redeeming food vouchers. These reports are used to monitor trends in caseload and participation over time and to manage funding and staff assignments.
- No-Show/Show Rates: No-show reports offer data on how frequently appointments are missed. Staff often use this information to determine how many appointments can be scheduled at the same time, knowing that some clients will likely miss their appointment. Staff can also use this report following the implementation of a new scheduling approach or reminders to assess the effectiveness of the change.
- Participant Surveys: Many state and local agencies conduct surveys of their WIC participants at least periodically. The focus and format of these surveys vary depending on the state or local agency and whether the staff is trying to better understand particular issues or questions. Participant surveys can also specifically target former WIC participants to learn why they are no longer participating.
Alamance Health Department, NC: Regular Participant Surveys
The Alamance clinic conducts an ongoing customer service survey. Staff send the survey to a small number of participants each month to receive regular feedback. They consider responses carefully and develop plans to respond to any issues raised in the surveys.
Additional Reports in Use
- Eligibility Pending: This kind of report indicates participants who are missing a document following a temporary certification. Staff can use it to make follow-up calls to participants to remind them what they need to provide to continue to receive WIC benefits.
- Certification Status Report: This type of report identifies participants who missed appointments in prior months and/or do not have future appointments scheduled when they should. Staff can use this kind of report to follow up with participants to re-engage them and prevent them from losing WIC benefits.
- Unissued Benefits: Reports on unissued benefits identify people who are certified but are not currently receiving food benefits and can include the reason they are not receiving benefits. These include individuals who were eligible to receive WIC food benefits but did not receive them, likely because they missed a nutrition education contact, missed a mid-certification appointment, or did not pick up food vouchers. Staff can reach out to these participants in various ways to encourage them to take the steps necessary to receive their food benefits again.
- Termination Reasons: A report that outlines the reasons why someone is no longer participating in WIC can be used to identify trends and former participants who could be re-engaged. These reports might describe whether the former participant is no longer categorically eligible, didn’t bring in required documents, did not schedule a recertification appointment, no longer meets income requirements, moved out of state, etc. Staff can use this report to contact former participants who may still be eligible for WIC benefits.
- Temporary Certification Outcome: Assessing the portion of those temporarily certified that are able to complete certification for ongoing WIC benefits can help staff assess how the temporary certification policy is working.
- Retention at One Year: Many clinics are trying to improve retention when infants turn 1. A report that examines the share of infant participants who are recertified could help staff determine the extent to which they are losing participants at this point and if retention efforts are having an effect.
Jackson County, Michigan: Using Reports to Retain Participants
Jackson County WIC staff use several different reports to proactively reach out to participants on a daily and weekly basis to remind them to make appointments, if a document is due, or if some other action is needed. For example, they use a report on pending eligibility to help them target outreach to participants who may be missing a document following temporary certification.
Public Health Foundation WIC Program, California: Retention Reports
The Public Health Foundation WIC Program’s data system generates several reports that allow staff to assess participant retention. For example, one report shows the number and percentage of infants who were not recertified at 13 and 14 months of age.
- Number of Clinic Visits per Year: A report that provides a basic indicator of how frequently participants come to the clinic for visits and appointments could be used in multiple ways. If clinic visits are burdensome for participants, the number of visits in a year may affect the likelihood that they will continue participating. Assessing the number of visits can help staff consider whether they are necessary and how they relate to program impact, client satisfaction, and participant retention. Such a report would also allow staff to assess whether higher-risk participants are receiving more intensive services. In addition, as more states transition to EBT and have the option to remotely load an EBT card, such a report could assess if implementation reduces the number of clinic visits.
- Share of Medicaid Families Reached: A report that focuses on the share of eligible populations who are receiving WIC benefits would help staff identify gaps in coverage. For example, a report on the share of families with pregnant women or children under 5 who receive Medicaid and WIC could be used in multiple ways. It could provide a rough estimate of the number of WIC-eligible families not being served, identify local areas where collaboration with health care providers around referrals could be fruitful, and identify individual families for outreach.
Colorado: Using Medicaid Data to Identify Potential Participants
WIC staff are working with the state’s Medicaid agency to identify Medicaid recipients who are eligible for WIC but not participating so those families can receive direct mail referring them to WIC. WIC staff are also working to include WIC as a program option in the Colorado Program Eligibility and Application Kit universal benefits application, so anyone applying for Medicaid or SNAP online can opt to receive a phone call from a local WIC clinic to schedule an appointment. Initial data indicate that only 44 percent of mothers of young children receiving Medicaid are receiving WIC, which suggests there is a significant opportunity to enroll additional eligible families.
California: Local Coverage Estimates
USDA has estimated coverage rates by state and category.a California took this kind of analysis a step further by developing county and regional-level estimates, by participant category, of the number of people eligible for WIC, and what share of them were being served. State staff also developed state, county, and regional profiles of WIC eligibility and participation.b
a “National and State-Level Estimates of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Eligibles and Program Reach, 2013” USDA, December 2015, http://www.fns.usda.gov/national-and-state-level-estimates-special-supplemental-nutrition-program-women-infants-and-childr-2.
b “State, County and Regional-Level Estimates of WIC Eligibles and Program Reach, California 2011, California Department of Public Health, March 2016, http://www.cdph.ca.gov/programs/wicworks/Documents/Research-Evaluation/StateCountyandRegional-LevelEstimatesofWICEligiblesandProgramReachCalifornia2011(March%202016).pdf.
Collaboration and Outreach
Many states and local clinics are developing or strengthening collaborations with other programs in response to declining caseloads. The most recent National Survey of WIC Participants found that first-time program participants (who were previously eligible for WIC) most often cited a lack of awareness about the WIC program as the reason they had not previously participated. This lack of awareness highlights the importance of outreach and collaboration with other programs and partners to reach eligible participants who may not know about WIC or do not realize they may be eligible.
Medicaid and SNAP
Because all Medicaid and SNAP participants are adjunctively income-eligible for WIC, there are significant opportunities to strengthen collaborations between WIC and Medicaid and/or SNAP at both the state and local levels. Individuals and families could be offered the opportunity to be connected to WIC when they apply for SNAP and Medicaid benefits. This can be done by encouraging the local offices that administer Medicaid and SNAP to refer applicants to WIC. It is particularly helpful if the referral goes beyond providing the applicant with a flyer or number to call; for example Medicaid or SNAP staff could call a WIC clinic to schedule an appointment, walk the applicant to the WIC office if they are located in the same building, or gather contact information and share it with WIC staff so that they can follow up. These kind of referrals are sometimes referred to as “warm referrals.” In addition, online applications for these programs could be leveraged to screen potentially eligible households for WIC eligibility and share their information with WIC staff.
States and clinics can also use data from programs like Medicaid to identify and reach out to potentially eligible WIC recipients or to identify geographic areas where there are large numbers of potential participants who are not yet enrolled. Finally, data sharing could also allow for an automated process that eases enrollment for adjunctively eligible participants.
California: Enhancing WIC-SNAP-Medicaid Connections
The state legislature recently approved funding for new staff members to focus specifically on increasing data and information sharing among these programs with the goal of increasing participation in both WIC and SNAP. For example, the new staff will develop maps based on participation data that identify underserved hot spots for targeted outreach activities.
Medicaid Coordinated Care Organizations
For those states that use Medicaid Coordinated Care Organizations (CCOs), there may be opportunities to further collaborate to identify and reach out to potential WIC participants, particularly newly pregnant women. States can also pursue adding a performance measure to CCOs’ state contracts regarding the level of WIC participation to help incentivize CCOs to connect more of their customers with WIC services.
Oregon: Information Sharing with Medicaid CCOs
Many local clinics in Oregon are working to establish collaborations with Medicaid CCOs. One clinic has developed a memorandum of understanding with a coordinated care organization; when the CCO enrolls new pregnant women into Medicaid, they obtain permission from the women and send the list of the pregnant women to the WIC clinic so the clinic can reach out to them.
Head Start is a federal program that promotes school readiness for low-income children from birth to age 5. Many Head Start programs also provide Early Head Start, which serves infants, toddlers, and pregnant women and their families. Head Start serves a very similar population to WIC and is a promising potential partner for WIC outreach and collaboration. Activities can include cross-referrals, allowing WIC staff to provide program information at Head Start meetings, or merging some of the Head Start programming with WIC nutritional contacts and requirements. USDA is working with the Department of Health and Human Services to update an existing Memorandum of Understanding to improve program coordination and service delivery for low-income families participating in WIC, Head Start, child care, and child care feeding programs.
Oregon: Focus on Head Start Partnerships
State and local Oregon WIC staff have worked for several years developing partnerships with Head Start programs to generate more referrals to WIC and to allow Head Start participants to incorporate some of the WIC nutrition education requirements into Head Start activities so that participants have fewer appointments at WIC clinics.
211 is a three-digit telephone number assigned by the Federal Communications Commission for the purpose of providing quick and easy access to information about health and human services in local areas. While 211 is not available in all areas, it is an important resource in many communities. In 2013, 211 services in the United States answered more than 15.6 million calls. WIC clinics can develop relationships with their local 211 service, to provide referral information to potentially eligible callers and possibly screen them for program eligibility. 211 staff could also capture information via an online referral form to initiate a WIC application for individuals and ensure that the WIC clinic has contact information for applicants so they can follow up.
Oregon: 211 Screening and Referral Partnership
Oregon WIC and four other public health programs have a joint contract with 211info, the state information and referral call center, to provide information and referrals to any caller searching for services such as pregnancy, food assistance, and nutrition assistance. Individuals can call or text 211info and information and referral specialists can screen for eligibility and provide information about their closest WIC clinic and other services that they might need. 211info also has a smartphone app that individuals are increasingly using to access referral information in lieu of calling.
Co-Location and Offsite Enrollment
WIC clinics can reach more eligible families if they are in locations where potential participants already go for other services or that are part of their normal routine. This can be accomplished by permanently co-locating a WIC clinic in a community health center or a hospital. Another approach is to enroll people offsite (outside of the regular clinic setting) in other locations like a Head Start center, a food bank, or a military base.
Bronx, New York: Co-location Supports Comprehensive Service Delivery
Two sites of the Morrisania WIC program in the Bronx are co-located with other services. One is co-located with a Head Start and family daycare center. Another is part of a comprehensive health center and is integrated into the health center environment. The WIC staff work closely with health staff, including obstetrics, pediatrics, and social services. A breastfeeding education room is also located on the pediatrics floor of the health center. The WIC staff have found that physically integrating services allows them to serve WIC participants more effectively.
Piedmont Health Services, North Carolina:
Reaching Participants in the Local Medicaid/SNAP Office
Piedmont Health Services serves two counties and partners with both of their local Medicaid/SNAP offices to reach more potential WIC participants. WIC staff are on site in one of the local Medicaid/SNAP offices weekly to talk with clients about WIC, provide informal nutrition assessments, and help set up WIC appointments. In addition, WIC staff regularly engage with the local Medicaid/SNAP staff ― meeting at least quarterly ― to be sure they understand how WIC works and the benefits it can offer their clients. Local Medicaid/SNAP staff can use a referral form to capture contact information for potential participants, upon which the WIC clinic follows up. In the coming months, WIC is planning to open a permanent satellite location at one of the local Medicaid/SNAP offices, allowing them to fully complete the WIC eligibility determination process and issue benefits on site.
This report can serve as a guide for state and local WIC staff who wish to comprehensively assess their policies and practices regarding eligibility determinations to identify opportunities to streamline them. Longstanding concerns about retaining children and recent concerns about declining caseloads have led many state and local WIC staff to consider how they can increase participation by eligible families and make it easier for eligible families to continue receiving WIC benefits as their babies become toddlers. Whether eligible families continue to seek out WIC benefits depends on many factors, including how much time and effort is required. Streamlining eligibility determinations could also free up staff time to devote to providing WIC’s core services.
State or local staff could, for example, convene a small group to meet regularly to discuss WIC eligibility and enrollment issues and where there might be opportunities for improvement or innovation. The steps identified in this report are all feasible and do not require changes in program rules or additional funding.
The checklist in Appendix A can guide such work by summarizing key areas for consideration. WIC is already known as effective and inviting. By reconsidering certification practices and procedures, staff have an opportunity to modernize the program and make it more accessible to low-income families with young children who can benefit in the short and long term from WIC’s foods and services.
Appendix A: Streamlining WIC Eligibility Determinations Checklist
This checklist can serve as a guide for state and local WIC staff who wish to comprehensively assess their policies and practices regarding eligibility determinations to reduce the time that low-income families spend maintaining their WIC certification. It poses a few key questions in each area for WIC staff to consider.
WIC Clinic Processes
- Scheduling Approaches
- Could next-day or same-day appointments, or more flexible scheduling, be implemented to be more responsive to client needs?
- Would reminders (text, email, and/or phone) help participants keep appointments?
- Reviewing Documents
- Would allowing electronic documents (such as an online pay stub or an image on a smartphone) help more clients meet documentation requirements?
- Could clients be offered email or fax information to return documents instead of returning to the clinic?
- Checking for Adjunctive Eligibility
- Is the current process for checking adjunctive eligibility difficult or cumbersome for staff?
- Could staff confirm adjunctive eligibility during the prescreening or in advance of appointments?
- Clinic Flow
- How often do clients have to move to different spaces or rooms during the clinic process? Does this affect how long the appointment takes?
- Is the clinic process clear to participants? How do participants know what to expect and who can answer their questions?
Communicating with Applicants and Participants
- Text Messaging
- Could two-way text messaging be used for breastfeeding support or ongoing communication with clients?
- Email Address for Participants
- Could clients be offered an email address to return documents, ask questions, or change their appointment (once a plan has been developed to protect confidentiality and respond to incoming messages)?
- Online and Mobile Tools
- Does your WIC eligibility system have an available client portal?
- Could an online client portal be used to help participants respond to requests for information or manage their appointments?
- Video Chat
- Could you use video chats for breastfeeding support or other interactions to help clients for whom it may be difficult to get to the clinic?
- Applications and Referrals
- Is there a way for partners to refer potential participants to WIC and provide relevant information to WIC staff (such as a referral form)?
- How does someone apply for WIC if they cannot get through on the phone or get to the clinic?
Policy Flexibility to Help Streamline Certification Process
- Electronic Documents
- Could using electronic documents like an online pay stub or image from smartphone help more participants provide required documentation?
- Single Source for Multiple Documentation Requirements
- Is there an opportunity to encourage staff to use pay stubs or adjunctive eligibility to document both income and address?
- Transmitting Documents
- Could offering clients a way to return documents without visiting the clinic help ease burden on participants and increase the likelihood of follow up?
- Temporary Certification
- Does the state allow for temporary certifications? If so, do staff probe and explore all documentation options or before doing a temporary certification?
- Year-Long Certification
- Does the state allow certifications of up to a full year for children as well as breastfeeding women and infants?
Data and Reports
- No-Show Rates
- Could this report be used to help manage the schedule or to assess how a new scheduling approach is working?
- Participant Surveys
- Could the state or local agency conduct ongoing participant surveys?
- How can the state or local agency respond to and act on feedback from participants?
- Reports Indicating Participants at Risk of Losing Benefits
- Are there reports that could help staff follow up with participants to re-engage and them and prevent them from losing WIC benefits because they have missed an appointment or need to provide documentation?
- Number of Clinic Visits per Year
- Could monitoring the number of clinics visits per year (by different participant groups) help assess the balance between providing in-person services and offering convenience?
- Temporary Certification Outcome
- Are there data that indicate how often people successfully complete full certification after a temporary certification period?
- Retention at One Year
- Are there data on how many participants do not get recertified at their first birthday? How could this information be used to evaluate retention efforts?
Collaboration and Outreach
- Medicaid and SNAP
- Are there opportunities to work with the Medicaid/SNAP agency on data sharing, local office referrals, and/or incorporating WIC into the online Medicaid/SNAP application?
- Medicaid Coordinated Care Organizations (CCOs)
- If CCOs are present, could they refer pregnant women and other potentially eligible families or help promote WIC in other ways?
- Head Start
- Could a partnership be established to provide cross-referrals, present information at Head Start meetings, or even combine nutrition education programming?
- Can the local 2-1-1 screen for WIC and make referrals? Could referral information be sent to WIC clinics?
- Co-Location or Offsite Enrollment
- Are there opportunities to outstation WIC staff or permanently co-locate with an organization that serves WIC-eligible families?
Appendix B: State Certification Policies
The Center on Budget and Policy Priorities reviewed states’ WIC policy manuals to ascertain selected certification policies and practices, which are summarized in the following tables.
|Selected State Policies on Temporary Certifications and Income Documentation|
|Does the state allow 30-day temporary approvals for applicants who do not have income, identity, or residency documentation?||If so, which documents can be missing?||Does the state allow applicants to self-declare income in extraordinary circumstances (outside of temporary certifications)?a||Does the state routinely require a third-party statement for zero-income households?|
Res = Documentation of Residency — Inc = Documentation of Income — NA = Not found in manual
|California||Yes||Res and/or Inc||Yes||No|
|Colorado||Yes||Res and/or Inc||Yes||No|
|Connecticut||Yes||Res and/or Inc||Yes||Yes|
|Hawaii||Yes||Res and/or Inc||Yes||Yes|
|Iowa||Yes||Only 1 of 3||No||No|
|Missouri||Yes||Only 1 of 3||Yes||No|
|New York||Yes||Only 1 of 3||Yes||No|
|North Dakota||Yes||Only 1 of 3||Yes||No|
|South Dakota||Yes||Only 1 of 3||Yes||No|
|Utah||Yes||Only 1 of 3||Yes||No|
|Wyoming||Yes||Only 1 of 3||Yes||No|
|Selected State Policies on Documentation, Clinic Hours, and Physical Presence|
|Does the state provide any direction regarding whether clinics may accept electronic documents?||Are states keeping copies, either electronic or paper, of residency, identity, and income documents?||Does the state have any requirements about providing clinic hours outside regular business hours?||Does the state exempt infants/ children of working parents from the physical presence requirement?|
|Legend||Yes = Provides direction and accepts documents||Yes(E)= Keep electronic copies
Yes(P) = Keep paper copies
Yes(E&P) = Keep electronic & paper copies
No = Explicitly states not to make copies
NA= Not found in manual
|GG = General guidelines
SR = Specific requirements
NA = Not found in manual
|NA = Not found in manual|
|New York||Yesd||Yes (P)||GG||Yes|
|South Dakota||Yes||Yes (E)c||GG||Yes|
|How Does the State Direct Local Agencies to Check Adjunctive Eligibility?|
|Approval notice from agency that administers SNAP, TANF, Medicaid or other applicable program||Phone call to automatically check SNAP, TANF, or Medicaid||Online access to Medicaid portal/data||Online access to SNAP or TANF program portal(s)/data||Interface built into WIC eligibility system that checks Medicaid, SNAP, or TANF eligibility|
|South Carolina||X||X||X||Medicaid only|
|South Dakota||X||X||SNAP only|
|Does the State Permit Certifications of up to a Full Year?|
|Breastfeeding women||Infants under 6 months||Children 1 to 4 years old|
 This report and the underlying research was developed with support from Koné Consulting. Kathy Wroblewska, a Center on Budget and Policy Priorities intern, conducted key underlying research reflected in this report. The Center on Budget and Policy Priorities greatly appreciates the time that state and local WIC staff spent speaking with us about WIC eligibility determination and enrollment processes.
 For more information on how WIC operates, see “Policy Basics: Special Supplemental Nutrition Program for Women, Infants, and Children,” Center on Budget and Policy Priorities, February 9, 2015, http://www.cbpp.org/cms/index.cfm?fa=view&id=5268.
 For more information on the health and nutrition benefits associated with WIC participation, see “WIC Works: Addressing the Nutrition and Health Needs of Low-Income Families for 40 Years,” Steven Carlson and Zoë Neuberger, Center on Budget and Policy Priorities, May 4, 2015, http://www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-health-needs-of-low-income-families.
 For more information on WIC’s cost-containment mechanisms, see “WIC’s Competitive Bidding Process for Infant Formula Is Highly Cost-Effective,” Steven Carlson, Robert Greenstein, and Zoë Neuberger, Center on Budget and Policy Priorities, updated September 14, 2015, http://www.cbpp.org/research/food-assistance/wics-competitive-bidding-process-for-infant-formula-is-highly-cost.
 See, for example, “State Innovations in Horizontal Integration: Leveraging Technology for Health and Human Services,” Terri Shaw, Lucy Streett, Shelby Gonzales, and Dottie Rosenbaum, Social Interest Solutions and Center on Budget and Policy Priorities, updated March 24, 2015, http://www.cbpp.org/research/state-innovations-in-horizontal-integration-leveraging-technology-for-health-and-human.
 We describe our approaches to gathering information in the “Streamlining Opportunities” section below.
 Center on Budget and Policy Priorities analysis of USDA administrative data comparing participation at its peak month during the recession to participation during fiscal year 2015.
 See “Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Eligibles and Coverage ―2013: National and State-Level Estimates (Summary),” USDA, December 2015, http://www.fns.usda.gov/sites/default/files/ops/WICEligibles2013-Summary.pdf, “Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Eligibles and Coverage ―2011: National and State-Level Estimates Summary,” USDA, March 2014, http://www.fns.usda.gov/sites/default/files/WICEligibles2011_Summary.pdf, and earlier similar USDA reports.
 For more information on USDA’s support for improving child retention see http://www.fns.usda.gov/pressrelease/2016/fns-001516 and https://wicworks.fns.usda.gov/sites/default/files/uploads/ChildRetentionStrategiesReport.pdf.
 “Making Connections: Understanding Women’s Reasons for Not Enrolling in WIC during Pregnancy, California 2010-2012,” California Department of Public Health, Center for Family Health, 2016, https://www.cdph.ca.gov/programs/wicworks/Documents/Research-Evaluation/Making-Connections-WIC-Reasons-2010-2012.pdf.
 See “WIC Policy Memorandum #2016-5: Separation of Duties at WIC Local Agencies,” USDA, August 19, 2016, http://www.fns.usda.gov/sites/default/files/wic/WPM-2016-5-Separation-of-Duties.pdf.
 About half of adults with annual income below $30,000 own smartphones and nearly two-thirds of them (63 percent) use their smartphones to get health information. See “U.S. Smartphone Use in 2015,” Aaron Smith, Pew Research Center, April 1, 2015, http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
 See 7 C.F.R. § 246.7 (g)(3).
 “National Survey of WIC Participants II ― Volume 1: Participant Characteristics,” USDA, April 2012, Exhibit 3.7, http://www.fns.usda.gov/sites/default/files/NSWP-II.pdf.