Coordination of Benefits
Coordination of benefits is a process that helps determine who pays a medical bill first when there is more than one potential payer. A payer can be an insurance plan or health benefits program.
The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) sets the order in which these payers are responsible for paying for monitoring and treatment of a certified WTC-related health condition. The World Trade Center (WTC) Program is required by law to follow this process.
Coordination of benefits in the WTC Health Program applies to Survivor members only.
For Responders, the Program directly pays for all monitoring, treatment, and medication costs of a certified WTC-related health condition, except if a Responder has a workers’ compensation claim for the certified condition.
Learn more about workers’ compensation and Coordination of Benefits in the Member Handbook.
How does Coordination of Benefits apply to my WTC-related care as a Survivor?
For treatment and medication costs of a certified WTC-related health condition, the Program covers what is left after your primary health insurance pays its share.
The Program bills your private health insurance first, then bills any public health insurance like Medicare or Medicaid you may have. Once your other health insurance providers have paid, the Program pays any remaining amount.
This includes any co-insurance charges, copayments, or deductibles for care of your certified WTC-related health conditions if that care is from a Program provider. This leaves no out-of-pocket cost to you.
Please note: For initial health evaluations and annual monitoring exams, the Program pays in full. If your certified condition is work-related and you have 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. Learn more about workers’ compensation and Coordination of Benefits in the Member Handbook.
What do I need to do?
As a Survivor, you must provide your primary health insurance information when receiving services from the WTC Health Program.
This means you need to give it to:
- Your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN).
- Any specialist or external provider you see for your certified WTC-related health condition. Tell the provider’s staff your visit is for a WTC-related condition. This will help make sure that they bill your visit properly.
- A retail, community, or Program-affiliated mail order pharmacy when filling a WTC-related prescription. Also give them your WTC Health Program/Optum pharmacy card and tell them to bill the WTC Health Program last.
What if I don’t have health insurance?
The WTC Health Program is a limited health benefit plan that provides monitoring and treatment for certified WTC-related health conditions only. The Zadroga Act requires that Program members have primary health insurance in order to coordinate benefits and to cover costs for conditions that are not certified by the Program.
If you do not have health insurance, you might be eligible for public or private health insurance, such as Medicaid, Medicare, health insurance offered through the Marketplace or other options. Your benefits counselor or case manager at your CCE or the NPN can help you find and apply for health insurance.
How does Coordination of Benefits work for prescription drugs?
The WTC Health Program covers prescription drugs to treat certified WTC-related health conditions. Optum is the company that manages the WTC Health Program pharmacy benefits.
Same as with WTC-related medical care for Survivors, your primary health insurance will be billed first for WTC-related prescription medicines. Primary insurance may be a type of private insurance, group health, or government program such as Medicare or Medicaid.
Any remaining costs will be covered by the Program. Covered prescriptions will have no copayments.
How do I get my prescriptions filled?
Your WTC Health Program doctor or specialist will write the prescription for your WTC-related certified condition.
Step 1: You may fill your prescriptions in a retail pharmacy or through a Program-affiliated mail order pharmacy.
Step 2: In both cases, you will always need to present your primary insurance and Program pharmacy card to the pharmacy.
Step 3: Tell the pharmacist that the WTC Health Program is the secondary payer.
Step 4: The pharmacy will bill your primary insurance first, and then bill any remaining costs to the WTC Health Program.
What happens if there is a problem filling my prescription?
If there is a problem billing your prescription to your primary insurance, you or the pharmacy will need to contact that insurance company to resolve the issue. Your pharmacy should notify you when there is a problem.
If there is a problem billing the WTC Health Program, you or the pharmacy must contact Optum at 1-855-640-0005 to resolve the issue. Note: If you pay for the prescription out-of-pocket before resolving the issue with Optum, the Program cannot guarantee you will be reimbursed.
How do I find a pharmacy that works with the WTC Health Program?
Find a retail pharmacy near you through Optum's Pharmacy Locator or by calling 1-855-640-0005, option 2.
Mail order offers convenience, privacy, and the security of never missing a refill. You can register for mail order through Optum's WTC Health Program Home Delivery site or calling 1-855-640-0005, option 2.
What if I have additional questions?
Contact the Program, your CCE, or the NPN with any questions related to coordination of benefits or your WTC-related care.