WTC Health Program Requirements, Services, and Benefits

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Services provided under the World Trade Center (WTC) Health Program, a limited health care benefits program, include the following:

Enrolled Screening-Eligible Survivors receive:

• A one-time initial health evaluation
  • If the initial health evaluation does not result in a certified condition and a survivor wants an additional health evaluation in the future for a new condition possibly WTC-related, they may pay out of pocket or use primary health insurance to pay for an evaluation by a WTC Health Program doctor in the future.

Enrolled Responders and Certified-Eligible Survivors (Survivors with a certified WTC-related health condition) receive:

• Annual monitoring exams,
• Medical and mental health treatment for certified WTC-related health conditions, and
• Benefits counseling services.

Cancer screening is available to all WTC Health Program members (except FDNY family members) who meet the age and risk guidelines of the U.S. Preventive Services Task Force.

Services are provided through Clinical Centers of Excellence (CCEs) in the New York metropolitan area or through the Nationwide Provider Network (NPN). The Administrator of the WTC Health Program, designated as the Director of the National Institute for Occupational Safety and Health (NIOSH), determines eligibility for enrollment and certifies an enrolled member’s condition for treatment.

WTC-Related Health Conditions

The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), which established the WTC Health Program, designated the original List of WTC-Related Health Conditions (the List) covered for treatment (sections 3312(a)(3) and 3322(b) of the Public Health Service Act). Additional health conditions may be added to the List by the Administrator of the WTC Health Program through rulemaking. More information on covered conditions is available at www.cdc.gov/wtc/conditions.html.

Monitoring and Treatment

The WTC Health Program provides annual medical monitoring for enrolled Responders. Survivors receive annual medical monitoring if certified with a WTC-related health condition(s), referred to as a Certified-Eligible Survivor. Medical monitoring is intended to detect symptoms and illnesses that may be WTC-related, and include a physical exam, breathing tests, mental health assessment, exposure assessment, routine blood and urine tests that do not include drug or HIV testing, and referral for treatment if necessary. Eligible Responders and Certified-Eligible Survivors, including those eligible under prior programs, will receive these monitoring benefits and treatment that is medically necessary for both certified WTC-related health conditions and certain medically related conditions.

If a WTC Health Program doctor determines a member has a WTC-related health condition based on the initial health evaluation or medical monitoring examination, the Administrator of the WTC Health Program must first certify the condition for coverage and approve the treatment provided. Covered treatment is available for certified WTC-related health conditions and certain health conditions medically associated with a certified WTC-related health condition. Treatment for a certified WTC-related health condition must be provided by a WTC Health Program-affiliated provider.

These services and benefits are voluntary for members. Members may withdraw from participation in the WTC Health Program at any time, without any financial or other consequences other than loss of Program services.

Pharmacy Benefits

Members are entitled to pharmacy benefits for certified WTC-related or medically associated conditions. The WTC Health Program contracts with one or more pharmaceutical providers and has the discretion to change pharmaceutical provider(s) at any time.

Payment for Services

The WTC Health Program will cover the cost of medically necessary care from Program providers for certified WTC-related health conditions and coordinate payment with any other private or public healthcare plans (e.g., Medicare).

For Responders, the Program is the first payer for all monitoring and treatment, paying for all services received through the Program unless the Responder has an established workers’ compensation case for the certified health condition(s). If there is an established workers’ compensation case for the Responder’s certified WTC-related condition, a workers’ compensation fund will be the first payor. The WTC Health Program is required to reduce or recoup payment for treatment of a WTC-related health condition if such condition is covered by a workers’ compensation or similar work-related injury or illness plan. For Responders who are being treated within the Program for work-related certified WTC-related health conditions and who do not receive workers’ compensation for that condition, the WTC Health Program is the first payor.

For Survivors, the Program pays in full for the initial health evaluation and, if certified-eligible, annual monitoring exams. For treatment of a certified WTC-related health condition, the Program is the secondary payer. This means that the Program will bill the Survivor’s private health insurance first, then any public health insurance (e.g., Medicare or Medicaid). Once other health insurance providers have paid, the Program pays any remaining amount. If a Survivor has a certified WTC-related health condition that is work-related and has a workers’ compensation claim for the condition, the Program will pay initially and then seek recoupment from either the workers’ compensation carrier or the settlement, where applicable.

The Program may share a member’s protected health information and/or personally identifiable information (e.g., medical records) with these potential payers for reimbursement purposes. The WTC Health Program may also exchange protected health information and/or personally identifiable information with the Centers for Medicare and Medicaid Services and WTC Health Program contractors for payment purposes.

Participation in the WTC Health Program does not prevent members from seeing their personal physician or obtaining any medical evaluation or treatment from any other provider at their own expense. Responders and Survivors are responsible for obtaining necessary follow-up evaluations and treatment at their own expense for any health conditions that are not determined to be WTC-related conditions or are not pre-authorized by the member’s WTC Health Program provider and the WTC Health Program.

Affordable Care Act

The Affordable Care Act (ACA), sometimes known as Obamacare, was effective on January 1, 2014. The ACA requires everyone to maintain minimum essential health care coverage, absent an approved exemption. The Zadroga Act requires that Program members meet the ACA requirements as of July 1, 2014.

Please contact a specially trained ACA counselor (or navigator) for direct help to select and act on the option that is right for you:

1. Federal ACA counselors can be reached at 1-800-318-2596 (TTY: 1-855-889-4325) 24 hours a day, 7 days a week (except holidays); or
2. New York State ACA counselors can be reached at 1-855-355-5777 (TTY: 1-800-662-1220) Monday-Friday (8 a.m.-8 p.m. and Saturday 9 a.m.-1 p.m.); or
3. Find local help/agent-broker help on demand at localhelp.healthcare.gov

You can also get information on the Federal ACA website at www.healthcare.gov and on the New York State ACA website at nystateofhealth.ny.gov

Applications

The WTC Health Program will evaluate applications on a first-come, first-served basis.

Terrorist Watch List

The Zadroga Act requires that the Administrator of the WTC Health Program determine whether a Program applicant is in the Terrorist Screening Database (commonly known as the “terrorist watch list”) prior to enrollment. The Administrator of the WTC Health Program will consult with the Department of Justice to determine whether an applicant is on the terrorist watch list. Individuals determined to be on this list are not qualified for enrollment in the WTC Health Program. This also applies to Responders and Survivors who were eligible for treatment and benefits under prior WTC programs. More information on the terrorist watch list is available at www.fbi.gov/about/leadership-and-structure/national-security-branch/tsc .

Any disclosure of personally identifiable information to the Department of Justice will be limited to what is necessary to determine terrorist watch list status. Personally identifiable information will be destroyed or returned to the WTC Health Program once it is determined that the individual is not on the terrorist watch list.

Appeals Process

Members are entitled to appeal decisions made by the Administrator of the WTC Health Program (the Administrator) regarding enrollment, certification of health conditions, and provision of treatment and benefits. An individual or their designated representative may appeal the decision in writing within 120 days of the date on the enrollment decision letter. The appeal must state the reason(s) why the member believes the Administrator’s decision is incorrect, among other requirements. Appeals of Program policy, regulations, or law are invalid appeals. Please note: Members are not entitled to appeal a determination by a Program provider that a condition does not satisfy certification criteria and a certification request will not be submitted.

Upon receiving a valid appeal request, the Administrator will designate a Federal Official who is independent of the Program to review the case and make a recommendation. The Federal Official may consider new information that was not previously submitted with the application and considered by the WTC Health Program. The Administrator will review the Federal Official’s recommendation and make a final decision on the appeal.

The Administrator may reopen and reconsider a denial at any time. An appeal related to an enrollment denial based on information from the terrorist watch list will be delegated to the appropriate Federal agency.

September 11th Victim Compensation Fund

The September 11th Victim Compensation Fund (VCF) provides financial compensation to individuals (or a personal representative of a deceased individual) who were present at the World Trade Center or in the VCF’s NYC Exposure Zone (www.vcf.gov/nyc-map-exposure-zone ); the Pentagon crash site; or the Shanksville, Pennsylvania, crash site, at some point between September 11, 2001, and May 30, 2002, and who have been diagnosed with a 9/11-related physical illness. The VCF does not compensate for mental health conditions and does not distinguish between responders and survivors.

The VCF is administered by the Department of Justice and is a separate federal program under the Zadroga Act. Enrollment in the WTC Health Program does not automatically register you with the VCF. Please visit the VCF website for more information at www.vcf.gov or call 1-855-885-1555.

Responders or Survivors who have applied for benefits from the WTC Health Program may also apply for benefits from the VCF. The VCF requires applicants to sign an authorization form permitting the Department of Justice to share protected health information and/or personally identifiable information (including medical records) with other entities such as the WTC Health Program. Therefore, the WTC Health Program may disclose protected health information and/or personally identifiable information to the VCF if a VCF applicant is also a member of the WTC Health Program.

The VCF may also request information from the WTC Health Program related to a member’s certified WTC-related health condition and treatment, about any WTC Health Program certification or requested certification of the WTC Health Program member’s WTC-related health condition, and the member’s eligibility for treatment.

Information regarding costs and payment for treatment of a WTC Health Program member may also be shared with VCF. VCF compensation awards may be reduced by the cost of the treatment the individual receives or is entitled to receive, including through the WTC Health Program.

Clinical Centers of Excellence

The WTC Health Program contracts with Clinical Centers of Excellence (CCEs) to provide eligible members with initial health evaluations, monitoring, treatment, and other services. In compliance with the Zadroga Act, the CCEs also collect and report data, including data about medical claims, to the WTC Health Program Data Centers.

Data Centers

In accordance with the Zadroga Act, the WTC Health Program contracts with Data Centers to do the following:

1. Receive, analyze, and report data collected from the CCEs and the Nationwide Provider Network (NPN) to the WTC Health Program;
2. Develop initial health evaluation, monitoring, and treatment protocols with respect to WTC-related health conditions;
3. Coordinate the outreach activities of the CCEs;
4. Establish criteria for credentialing of medical providers participating in the NPN (see below);
5. Coordinate and administer the activities of the WTC Health Program Steering Committees; and
6. Meet periodically with the CCEs to obtain input on the analysis and reporting of data and on development of monitoring, initial health evaluation, and treatment protocols.

Nationwide Provider Network

The WTC Health Program contracts with a Nationwide Provider Network (NPN) to provide initial health evaluation, monitoring, treatment, and benefits to eligible members who reside in areas outside of the New York metropolitan area. These individuals may choose to receive WTC Health Program benefits from a CCE. NPN providers must meet qualifications established by Data Centers. Like the CCEs, the NPN collects and reports data, including data about claims, to the Data Centers.

Designated Representatives

Responders and Survivors may designate a person to act on their behalf and represent their administrative interests in the WTC Health Program. A designated representative may provide and obtain personal information regarding your application to the WTC Health Program, your benefits, and your membership in the Program. A designated representative can also make a request or give direction to the Program regarding your eligibility, certification, or any other administrative issue under the WTC Health Program, including appeals.

A designated representative can be any individual (not a group or firm) if their service as a designated representative does not violate any applicable provision of law. Members can only have one (1) designated representative at a given time. A parent or a legal guardian may act on behalf of a minor seeking monitoring or treatment services under the WTC Health Program.

By designating a representative, you are authorizing the WTC Health Program to disclose your personal information to the individual and authorizing that individual to serve as your representative in all matters pertaining to your membership in the WTC Health Program; and receive and/or provide information pertaining to your membership and participation in the WTC Health Program, including copies of factual and medical evidence contained in your records for the Program. However, this person may not make medical care (e.g., treatment) decisions on your behalf.

To designate a representative, a member must fill out and submit a Designated Representative form and a Designated Representative HIPAA Authorization form to the Program. More information and the forms are available at www.cdc.gov/wtc/designated_representative.html or by calling 1-888-982-4748.

Disruptive and Abusive Behavior

The WTC Health Program believes that all individuals have a right to a safe working environment. Disruptive or abusive behavior by a WTC Health Program applicant or member at or directed towards a facility or personnel affiliated with the Program (e.g., a CCE, the NPN, providers, or staff) will not be tolerated.

These types of behavior include, but are not limited to, acts of violence or threats against staff or other patients (including verbal or physical abuse), rude or vulgar language (including cursing or shouting), throwing and striking objects, harassing or stalking, concealing or using a weapon, and engaging in criminal behavior.

Depending on the particular circumstances, members who engage in such behaviors may have their care suspended by their CCE or NPN provider, be required to sign a behavioral agreement outlining what will be expected of them in order to receive care from their provider, be required to transfer to another CCE or NPN provider, or be subject to other appropriate actions, including involvement of law enforcement authorities as necessary.

The Program strives to provide high-quality, compassionate care for members’ WTC-related health needs. Disruptive or abusive behavior, however, may impact the Program’s ability to provide benefits in a timely manner.

Penalties

If a Responder or Survivor knowingly and willfully provides false information to the WTC Health Program, including on the application for enrollment, they may be subject to a fine and/or imprisonment of not more than five years.

For more information about the WTC Health Program, please refer to the authorizing statute and federal regulations (see Title XXXIII of the Public Health Service Act, 42 U.S.C. §§ 300mm - 300mm-61; 42 C.F.R. Part 88). Links to the statute and federal regulations are available at www.cdc.gov/wtc/laws.html.