Coordination of Benefits for WTC Survivors
What is Coordination of Benefits?
The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), as amended, requires the World Trade Center (WTC) Health Program medical and pharmacy claims for Survivor members go through a process called Coordination of Benefits (COB). COB sets the order in which different payors (e.g., private insurance, public insurance, the WTC Health Program) pay their share of costs for treatment of a Survivor’s certified WTC-related health condition.
What are the Steps for COB?
As a Survivor member of the WTC Health Program, you play an important role in helping us coordinate your benefits. All Survivors must follow these steps so the WTC Health Program can make payments for your medical treatment and/or prescriptions for your certified WTC-related health condition(s):
Sign up for primary health insurance.
If you already have primary health insurance, continue to step 2. If not, you must sign up for public or private health insurance, such as Medicaid, Medicare, private health insurance offered through your employer or the Marketplace , or other options.
All members of the WTC Health Program are required to have primary health insurance, including pharmacy and medical coverage. Your benefits counselor at your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN) can help you find and apply for health insurance. Learn more about the WTC Health Program health insurance requirement.
Share your current primary health insurance information with your Clinical Center of Excellence CCE or the NPN as soon as possible.
You will be asked to provide your primary insurance information during each visit or phone call with your CCE/NPN. If your insurance information changes, let your CCE/NPN know right away. If your CCE/NPN does not have up-to-date information, it may impact payment for your treatment or pharmacy claims.
Show your primary health insurance card at every treatment visit.
Once you begin your WTC-related care, your WTC Health Program provider must have up-to-date insurance information to process your claims and ensure that you do not receive a bill for WTC-related services.
Make sure that any WTC Health Program provider you see is also in your primary health insurance plan’s network.
In order for the Program to pay for any treatment of your certified WTC-related health condition, the treatment must be received through a Program-affiliated provider. In addition, Survivors must make sure that provider is also in their primary health insurance plan’s network.
Your CCE/NPN will confirm the provider is in network with your primary insurance prior to referring you for treatment. If the Program-affiliated provider is not in network with your primary health insurance, talk to your CCE or the NPN about your options.
Show your primary health insurance card at every pharmacy visit.
Your WTC Health Program pharmacy must have up-to-date insurance information to process your pharmacy claims and ensure that you do not receive a bill for WTC-related prescriptions. Survivors must get all WTC-related prescriptions filled at a pharmacy (home delivery, specialty, or retail) that is both in the Program’s Express Scripts network and your primary health insurance plan’s pharmacy network.
If you need help finding an in-network pharmacy, talk to your CCE or the NPN or call Express Scripts 1-800-935-7179.
Follow all requirements of your primary health insurance.
For example, if a medically necessary procedure or prescription to treat your certified WTC-related health condition requires a prior authorization from your primary health insurance, this prior authorization must be received before the WTC Health Program can pay for your treatment.
The following frequently asked questions describe more information you need to know about Coordination of Benefits for Survivors in the WTC Health Program. If you have any additional questions, contact your CCE or the NPN.
General COB Questions
Medical Benefits COB Questions
Pharmacy COB Questions
What if I have additional questions?
Contact the Program, your Clinical Center of Excellent, or the Nationwide Provider Network with any questions related to coordination of benefits or your WTC-related care.