Health Insurance Requirement

When reevaluating your health insurance needs each year during open enrollment or when you have a qualifying life event, it is important to consider your overall health needs, including your World Trade Center (WTC) Health Program needs.

Unlike a health insurance program that covers all health conditions, the WTC Health Program is a limited health benefit program that provides medical monitoring and treatment for certified WTC-related health conditions only. Primary health insurance may provide coverage for non-WTC-related health conditions.

Under the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) , as amended, all members of the WTC Health Program are required to have primary health insurance, including pharmacy and medical coverage.  Primary health insurance may be public, like Medicare or Medicaid, or private, such as insurance received through an employer.

If you do not obtain primary health insurance, it will impact the Program’s ability to pay for your monitoring and treatment.

There are limited exceptions to this requirement and your benefits counselor at your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN) can help if you have questions about whether an exception to the requirement for primary health insurance applies to you.

Are there requirements for the type of Primary Health Insurance I get?

Your primary health insurance must cover the 10 essential health benefits as outlined by the Patient Protection and Affordable Care Act of 2010. This means you must have pharmacy and medical coverage.

Your benefits counselor at your CCE or the NPN can answer specific questions you may have and help you find and apply for health insurance.

What if I don’t have health insurance?

The Zadroga Act requires that all Program members have primary health insurance, including medical and pharmacy coverage, in order for the Program to pay for the member’s monitoring and treatment. The WTC Health Program is a limited health benefit program that provides monitoring and treatment for certified WTC-related health conditions  only. Primary health insurance may provide coverage for non-WTC-related health conditions, which is good for your overall health.

If you do not have primary health insurance and a limited exception does not apply, it will impact the Program’s ability to pay for monitoring and treatment.

You may be eligible for public or private health insurance, such as Medicaid, Medicare, health insurance offered through the  Marketplace , or other options. Your benefits counselor at your CCE or the NPN can help you find and apply for health insurance.

What if I have medical insurance but don’t have pharmacy coverage?

Under the Zadroga Act, as amended, all members of the WTC Health Program are required to have primary health insurance, including pharmacy and medical coverage, unless a limited exception applies.

If you have medical insurance, but don’t have pharmacy coverage, you will need to obtain pharmacy coverage as soon as possible or it will impact the Programs ability to pay for your prescriptions.

How does this affect me as a Survivor?

As a Survivor in the WTC Health Program, your primary health insurance plays a critical role in providing your benefits at no out-of-pocket cost. This is because of a process called coordination of benefits that is required by the Zadroga Act.

Coordination of benefits means a Survivor’s primary health insurance is billed first for treatment of a certified WTC-related health condition, for annual monitoring, and for WTC-related prescriptions. Once your primary health insurance and any other coverage pay their shares, the Program pays the rest. This leaves no out-of-pocket cost to you for your WTC Health Program benefits.

Learn more on the Coordination of Benefits page.

It is also important that you have primary health insurance for any healthcare services that are not covered by the WTC Health Program.

Provide your primary health insurance information

Because of this required process, as a Survivor you must share your primary health insurance information with your Clinical Center of Excellence or the Nationwide Provider Network.

You also must share the information with any other Program-affiliated provider you see for WTC-related care and any pharmacy where you fill prescriptions for your WTC-related health conditions.

Sharing your health insurance information ensures that your services are billed properly.

How does this affect me as a Responder?

As a Responder in the WTC Health Program, your Program benefits are covered in full by the WTC Health Program when received by a Program provider or pharmacy and authorized by the Program.

In general, coordination of benefits does not apply to a Responder’s monitoring and treatment of certified WTC-related health conditions.

As a Responder, your health insurance will not be billed for care for your certified WTC-related health conditions when care is authorized and received through the WTC Health Program and its providers.

Please note: In some cases where a Responder’s certified WTC-related health condition is part of an established workers’ compensation case that is not funded by New York City, the Program bills the workers’ compensation insurance carrier for the cost of the treatment. This is known as workers’ compensation recoupment.

Why health insurance is required for Responders

Although Responders’ care for certified WTC-related health conditions is not subject to coordination of benefits, the Zadroga Act still requires that all members, including Responders, have primary health insurance. This requirement ensures that you have minimum health coverage for any condition(s) or service(s) received that is:

• not for a certified WTC-related health condition,
• not approved for coverage by the WTC Health Program,
• not part of a monitoring exam, or
• not received from a Program-affiliated provider or pharmacy.

Remember that the Program is a limited health benefit program and does not replace primary health insurance. By law, the WTC Health Program is not allowed to pay for members’ healthcare services that do not meet all criteria for coverage, including maintaining primary health insurance.

Provide your primary health insurance information

As a Responder, your Clinical Center of Excellence or the Nationwide Provider Network may ask you to give them your primary health insurance information. This ensures that you meet the requirement for primary health insurance to receive benefits through the Program and that they have this information in case a service is not covered or authorized by the WTC Health Program.

Please give your primary health insurance information to your Clinical Center of Excellence or the Nationwide Provider Network when asked.