The Member Handbook is also available for download in the following languages:

Welcome to the World Trade Center (WTC) Health Program

Dear WTC Health Program Member,

Welcome to the WTC Health Program! The Program offers high-quality, expert, and compassionate care to you and others like you who were exposed to toxins and psychological stressors related to the September 11, 2001, terrorist attacks at the WTC, the Pentagon, and Shanksville, Pennsylvania. We hope that the Program will provide you with the care and knowledge necessary to help you address and manage any health concerns you might have related to your 9/11 exposures.

This WTC Health Program Member Handbook describes your benefits in the Program through Clinical Centers of Excellence (CCEs) in the New York metropolitan area. We hope the information helps you better understand and get the most out of your benefits through the Program. It is important to us that you have a positive experience with the Program. Please feel free to contact us toll-free at 1-888-982-4748 if we can answer any questions or address concerns you may have.

Sincerely,

ID Card

John Howard, M.D.
Administrator, World Trade Center Health Program

Important Contact Information

If you are experiencing a medical emergency, call 911 immediately

WTC Health Program

Toll-Free Telephone Number:
888-982-4748 (M-F, 9 am-5pm EST)
Email Address:
Website:

Logistics Health Incorporated (LHI)

Mailing Address:
328 Front Street South
La Crosse, Wisconsin 45601
Toll Free Telephone Number:
877-498-2911
Fax Number:
866-252-6272

The James Zadroga 9/11 Health and Compensation Act

On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act (Public Law 111-247). The Zadroga Act modified the Public Health Service Act to extend and improve protections and services to individuals directly affected by the terrorist attacks that occurred on September 11, 2001. The Zadroga Act also:

WTC Health Program

The Program provides medical monitoring exams; medical and mental health treatment for certified WTC-related health conditions; and social services assistance to 9/11 rescue, recovery, restoration, and clean-up workers and volunteers at the WTC and related sites in New York City, Pentagon, and Shanksville, PA (WTC responders). The Program also provides an initial health evaluation to those individuals who lived, worked, or attended school or daycare in Manhattan south of Houston Street or within a 1.5 mile radius of the WTC site in Brooklyn (WTC survivors). The Program offers follow-up medical exams medical and mental health treatment, and social services assistance for WTC survivors with certified WTC-related health conditions.

This handbook will provide you with detailed information about these services as well as your benefits, rights, and responsibilities as a member of the Program.

September 11th Victim Compensation Fund (VCF)

The September 11th Victim Compensation Fund (VCF) is a compensation program administered by the United States Department of Justice. The VCF is not a medical treatment program. It provides compensation for economic and non-economic loss to individuals or relatives of deceased individuals who were killed or physically injured as a result of the terrorist-related aircraft crashes of September 11, 2001. WTC responders and WTC survivors who became physically ill due to 9/11 exposures may also be eligible for compensation through the VCF if all other VCF eligibility criteria are met. The Fund does not compensate for mental health conditions related to 9/11 exposures.

For more information about the VCF, including whether or not you might be eligible, please contact the VCF directly at 1-855-885-1555 or www.vcf.gov.

WTC Health Registry

The WTC Health Registry was developed to document and evaluate the long-term physical and mental health effects of 9/11. To date, the Registry is the largest effort in the U.S. to monitor the health of people exposed to a large-scale disaster. Enrollment in the Registry was open from September 2003 through November 2004, and is now closed. During that time, more than 71,000 people enrolled by completing a 20 to 30 minute telephone interview.

The results of these surveys will help determine to what extent physical and mental health conditions have persisted in 9/11-exposed populations, and whether any new symptoms and conditions have emerged. Another important goal is to identify and help address gaps in physical and mental health treatment in these groups.

The WTC Health Registry was planned by the New York City Department of Health and Mental Hygiene and the federal Agency for Toxic Substances and Disease Registry (ATSDR). It has been funded by the National Institute for Occupational Safety and Health (NIOSH) since May 2009.

For more information about the WTC Health Registry, please contact the WTC Health Registry directly at 1-866-692-9827 or wtchr@health.nyc.gov.

Overview of 9/11 Health Services

Since the terrorist attacks of September 11, 2001, the U.S. Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH) has funded health evaluations and screenings for WTC responders to identify any health issues resulting from their exposure to the environment created by the collapse of the WTC buildings. This program was called the WTC Medical Monitoring and Treatment Program. Federal funding for the WTC Environmental Health Center (for WTC survivors) began in 2008.

Following implementation of the James Zadroga 9/11 Health and Compensation Act, the current WTC Health Program was established. Administered by NIOSH, the Program now provides services to four 9/11-affected populations:

Fire Department City of New York (FDNY) Responders: Active and retired FDNY firefighters and EMS workers. FDNY Responders receive Program services through the "FDNY Clinical Centers of Excellence (CCE)". Retired FDNY responders can receive care through the FDNY or the Nationwide Provider Network (NPN).

General Responders: Non-FDNY rescue, recovery, restoration, or clean-up workers and volunteers who participated in the WTC rescue and recovery efforts at various sites involved in 9/11 events. General Responders receive Program services through the CCEs or the NPN.

Pentagon and Shanksville, PA Responders: Emergency responders, recovery, and cleanup workers, and volunteers who were directly involved in the response to the attacks on the Pentagon in Arlington, VA, and the passenger-jet crash site near Shanksville, PA, on September 11, 2001, and during set periods afterwards. Pentagon and Shanksville Responders receive Program services through the General Responder CCEs or the NPN.

Survivors: Individuals who were in the New York City Disaster Area in Lower Manhattan and northwest parts of Brooklyn on September 11, 2001, or that lived, worked, went to school or day care in the weeks and months that followed. WTC Survivors receive Program services through the Survivors' Program at the WTC Environmental Health Center CCE or the NPN.

Is the WTC Health Program a Health Insurance Plan?

No. The Program is not an insurance plan. For eligible members, the Program covers initial health evaluations, yearly medical monitoring exams, and medical and/or mental health treatment only for specific certified WTC-related health conditions. For a list of those conditions, see section entitled "List of WTC-Related Health Conditions Covered By the Program".

If your physician thinks you might have a health problem that is not covered by the Program, this will be documented on the exam forms and sent to the NPN. Your Case Manager will advise you about how to find care outside of the Program. You will have to pay for care received outside of the Program. If you do not have insurance, your Case Manager will refer you to a social worker who can help you determine if you might be eligible for public health insurance programs like Medicaid or Medicare. If not, the social worker can help you to get the care you need at a federally qualified health center, or other community health center, that offers more affordable care options for you.

WTC Health Program Handbook for NPN Members

This member handbook was written especially for WTC responders and WTC survivors who receive services through the NPN. The purpose of the handbook is to inform you about Program services, benefits, and your rights and responsibilities as a Program participant. In the handbook, you will find information about:

  • Medical monitoring exams and Initial health evaluations
  • Medical and mental health treatment services offered by the Program
  • How your WTC-related medical and mental health conditions can be certified so that your treatment can be paid for by the Program
  • Cancer care
  • How to get your prescriptions filled
  • Social services assistance available to you
  • Your appeals rights as a Program participant
  • Your rights and responsibilities as a Program participant

Program at a Glance

Convenient Care

The WTC Health Program NPN provides care for WTC responders and WTC survivors members who live anywhere in the United States outside of the NY metropolitan area. The Program was specifically set up this way so that it would be convenient for you to access care near your place of work or residence. If you live in an urban area, the NPN will try to find you care within 30 miles or less of your residence. If you live in a rural area, the NPN will try to find you care within 70 miles or less of your residence. If you would like to learn more about the location of local providers available to you through the NPN, feel free to contact the NPN toll-free at 1-877-498-2911

Competent Care

LHI has trained doctors, nurses, and case managers who understand the unique exposures and health concerns of WTC responders and WTC survivors. LHI trained specialists will review your medical records to process WTC Health Program certifications. Trained staff will help you understand the benefits you qualify for based on your certifications.

Comprehensive Care

The Program offers services to help you with your medical, mental health, and benefits needs related to your certified WTC-related health conditions. We recognize that illness not only affects your body, but also your mind, your work, your relationships, and your finances. Our staff experts work together to deliver comprehensive care so that you can address all of these related needs.

Complementary Care

Through the James Zadroga 9/11 Health and Compensation Act, we are able to provide medical and mental health services at no cost to you. This means that you can access convenient, compassionate, and competent care without having to pay any co-payments, deductibles, or other out-of-pocket expenses for treatment of certified WTC-related health conditions.

Getting Medical Care

Clinical Centers of Excellence

The CCEs are located in the NY metropolitan area and provide care to WTC responders and WTC survivors. CCE providers specialize in diagnosing and treating certified WTC-related health conditions, and have provided these services to numerous WTC responders and survivors.

Even if you reside outside of the NY metropolitan area, you can choose to receive your care at a CCE if you prefer. The Program does not cover travel expenses for Program members who reside outside of the NY metropolitan area and receive their Program care at a CCE.

If you would like more information about receiving care through the CCEs, please consult the "WTC Health Program Member Handbook—Clinical Centers of Excellence."

Medical Care Transfer Policy and Procedure

Program members are allowed to change their CCE once a year. In some limited special circumstances, you can transfer your care to a new CCE, even if it has been less than a year since you began care at your current CCE. For example, if you move, you can transfer to a CCE that is closer to your new residence.

For General responders, Shanksville responders, and Pentagon responders, transfers can be made between the NPN and any General responder CCE.

For retired FDNY responders, transfers can be made between the NPN and any General responder CCE or the FDNY CCE.

For Survivors, transfers can be made between the NPN and the Survivors’ Program at the WTC Environmental Health Center CCE.

You can request a transfer by calling the NPN and informing them that you would like to go to a CCE.

If you need more information or assistance with the transfer process, you may either call the NPN toll-free at 1-877-498-2911 or the Program’s Call Center toll-free at 1-888-982-4748

Coordination of Benefits

The Program covers medically necessary treatment for certified WTC-related health conditions by healthcare providers affiliated with the Program at no cost to you.

For WTC responders, the Program is the first payer for your medical and mental health treatment services. This means that your health insurance will not be billed for any medical treatment service rendered by the Program to treat a certified WTC-related health condition.

For WTC survivors, if you have health insurance, your health insurance will be billed first for any medically necessary treatment services rendered by the Program to treat a certified WTC-related health condition. However, these services are still offered at no cost to you because you will not be responsible for paying any co-insurance charges, copayments, or deductibles for care of your certified WTC-related health conditions (so long as Program-affiliated healthcare providers are utilized).

For more discussion on certified WTC-related health conditions, see sections entitled "WTC-Related Health Conditions Covered by the Program” and "Certification of Your WTC-Related Health Condition(s).”

The Program and Workers' Compensation

For Program members whose certified WTC-related health conditions are also work-related conditions, you may be eligible to file for workers' compensation benefits. Even if you are a Program member and receiving medical treatment for your certified WTC-related health conditions at no cost to you, it can be beneficial to file a workers' compensation claim. This is because workers' compensation may also provide a financial award for lost wages related to your WTC-related health conditions. In addition, workers' compensation medical benefits can be permanent if your WTC-related health conditions are chronic. If funding for the Program was to end and you had an established workers' compensation case, you could then use your workers' compensation benefits to pay for care of your WTC-related health conditions in the future.

If you already have an established workers' compensation case for certified WTC-related health conditions that is not funded by New York City, the Program will bill your workers' compensation insurance carrier for services rendered to treat those conditions. While you are waiting for your case to be established, the Program will pay for any medically necessary services needed to treat your certified WTC-related health conditions.

Some workers decide to settle their workers' compensation claims. The worker enters into a settlement agreement, called a Section 32 waiver agreement, with the workers' compensation insurance carrier. The insurance carrier gives the worker a lump sum of money to close the case forever. Sometimes, Section 32 agreements release the insurance carrier from having to pay any future medical costs for the workers' injury or illness.

Any Section 32 agreement entered into between a Program member and an insurance carrier on or after October 1, 2013, must protect the WTC Health Program's interests. In some cases, the Program will require that money from a Section 32 agreement be set aside to cover future medical expenses that should have been paid by workers' compensation, like the costs of medical treatment and medications for certified WTC-related health conditions.

If you consider entering into a Section 32 agreement, you must ask the Program to review the proposed settlement. This review determines if the proposed settlement amount is enough to cover future medical costs for your certified WTC-related health conditions.

For more information about the Program's workers' compensation recoupment policy, refer to the policy online at https://www.cdc.gov/wtc/policies.html or the frequently asked questions about workers' compensation recoupment at https://www.cdc.gov/wtc/faq.html.

The Program and the September 11th Victim Compensation Fund

If you have a certified WTC-related health condition, your coverage for treatment costs by the Program becomes effective on the date that your the NPN physician signed and submitted your certification request to the Program (For more information on certification, see section entitled "Certification of Your WTC-Related Health Conditions").

The Program will not pay for any care you received for the certified condition before that date. If you have had out-of-pocket costs for healthcare to treat your certified condition(s), you might be eligible for reimbursement through the September 11th Victim Compensation Fund (VCF). For more information on the VCF, see section entitled "September 11th Victim Compensation Fund.”

Travel Expenses

Travel expenses are not typically a covered benefit under the Program. Transportation and lodging expenses for medical care within the U.S. may be allowed on a case by case basis and are usually limited to a Federal per diem rate. In order for reimbursement to be considered, certain criteria (such as the need to travel over 250 miles for necessary medical care), must be met. Please speak to your NPN case manager for additional information.

Making Your Monitoring Appointments with the NPN

Step 1: The NPN will contact you directly to schedule your three-part medical monitoring exams.

Step 2: Once the appointment is scheduled, you will be mailed an appointment summary and driving directions. Be sure to review all information and call the NPN toll-free at 1-877-498-2911 if you have any questions. If you need to cancel or reschedule an appointment, be sure to call the NPN within 24 hours of your scheduled appointment time so that the appointment can be offered to another member.

Tips for Getting the Most out of Your Appointment

  • Review this handbook and the Program website (www.cdc.gov/wtc) to learn about your program benefits, rights, and responsibilities.
  • Write down a list of symptoms you are experiencing, and when you started experiencing those symptoms, even those that you think might not be related to your 9/11 exposures.
  • Write down a list of questions you'd like to ask the doctor.
  • Write down a list of the medications you are currently taking.
  • Bring your medical records and any workers' compensation or line-of-duty injury paperwork with you.
  • Be prepared to talk about your work history, anything you've been exposed to at WTC or on other jobs, and how your current symptoms affect your ability to work.

Program Services

Initial Health Evaluations - For WTC Survivors

New WTC survivor enrollees in the Program are called screening-eligible survivors. The Program offers a one-time, initial health evaluation to all screening-eligible survivors. Only one screening evaluation can be paid for by the Program. The purpose of the initial health evaluation is to find out if you have a condition(s) related to your 9/11 exposures that is covered under the Program. Only WTC Health Program physicians may conduct an initial health evaluation. The initial health evaluation consists of the following:

  • Blood tests
  • Breathing test
  • Chest x-ray
  • EKG
  • Questionnaires to evaluate your 9/11 exposures, health complaints, medical history, and mental health
  • Screening colonoscopy for members aged 50 and over
  • Screening mammogram for female members aged 40 and over
  • Urinalysis

Based on your initial health evaluation, there are three possible outcomes:

  1. The NPN reviews the medical records and determines that you don’t have any symptoms that are related to your 9/11 exposures. You will receive no additional services from the Program at this time. You will still be a members of the Program. If you develop symptoms in the future, you may request an additional health evaluation at your own expense.
  2. Your Case Manager tells you that you have symptoms that could be related to your 9/11 exposures, but that more information is needed to determine if you do have a WTC-related health condition. The Case Manager will then advise you as to the next steps in the process, find specialty providers and work on scheduling appointments in order to find out if you do have a WTC-related health condition.
  3. Your Case Manager tells you that you do have one or more WTC-related health conditions that are covered by the Program. The Program covers a specific list of health conditions (see section entitled " WTC-Related Health Conditions Covered by the Program”). If the NPN determines that your health condition is on the list of covered health conditions and that your 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing your health conditions, then the NPN will request certification of your health conditions from the WTC Health Program Administrator (the Administrator). For more information on certification, see section entitled "Certification of Your WTC-Related Health Condition(s)".

If your health condition is certified by the Administrator, you are then referred to as a certified-eligible survivor. As a certified-eligible survivor, you are also eligible to receive yearly follow-up exams from the Program as well as medically necessary treatment for your certified WTC-related health conditions.

Medical Monitoring Exams For WTC Responders

The Program offers yearly medical monitoring exams to WTC responders. The purpose of the monitoring exam is to find out if you have a condition(s) related to your 9/11 exposures that is covered by the Program.

Your first medical monitoring exam is called a baseline monitoring exam. Each yearly exam after the first one is called an annual, or follow-up, exam. The chart below outlines what happens during a base-line monitoring exam and at annual monitoring exams.

Exam Component Baseline Exam Annual Follow-up Exam
Medical History and Mental Health Questionnaires
9/11 Exposure Assessment
Vital Signs (blood pressure, pulse)
Spirometry/Pulmonary Function Testing (Breathing Test)
Blood Tests
Urinalysis
Chest X-ray Every 2 years
Physical Examination
EKG (for members ages 45 and up, or if needed for medical reasons)
Screening colonoscopy (for members ages 50 and up) How often you receive a colonoscopy depends on your health situation and recommendation of your healthcare provider
Screening mammogram (for female members ages 40 and up) How often you receive a mammogram depends on your health situation and recommendation of your healthcare provider

You will meet with a physician who will examine you to see if you might have any health conditions related to your 9/11 exposures. Based on that evaluation, there are three possible outcomes to your medical monitoring exam:

  1. Based on your monitoring exam, the NPN tells you that you don't have any symptoms that are related to your 9/11 exposures. These exams help you to track your health over time, and contribute to our understanding of how 9/11 affected WTC responders. As we learn more, we can develop better treatment approaches for you and your fellow WTC responders and improve future disaster response. The NPN will contact you to return in one year for your annual monitoring exam.
  2. The NPN tells you that you have symptoms that could be related to your 9/11 exposures, but that more information is needed to determine if you do have a health condition related to your 9/11 exposures. Your Case Manager will then advise you on the process, providers and scheduling of appointments in order to find out if you do have a health condition related to your 9/11 exposures. The NPN will contact you to return in one year for your annual medical monitoring exam.
  3. The NPN tells you that you do have one or more health conditions that are covered by the Program. The Program covers a specific list of health conditions (see section entitled "List of WTC-Related Health Conditions Covered by the Program”). If the NPN determines that your health condition is on the list of covered health conditions and that your 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing your health conditions, then the NPN will request certification of your conditions from the Administrator. For more information on certification, see section entitled "Certification of Your WTC-Related Health Condition(s)." The NPN will contact you to return in one year for your annual monitoring exam.

WTC-Related Health Conditions Covered by the Program

The Program covers a specific list of WTC-related physical and mental health conditions. If you are diagnosed with a health condition on the list and the NPN physician thinks that the health condition is related to your 9/11 exposures, then the NPN physician will request certification, or approval, of your condition(s) so that your treatment can be covered by the Program (see section entitled "Certification of Your WTC-Related Health Condition(s)”).

In addition to the health conditions listed, the Program also covers health conditions that result from the treatment of a certified WTC-related health condition or additional health conditions that result from the progression of a certified WTC-related health condition (these conditions are called medically associated health conditions).

Acute Traumatic Injury

Burn
Complex sprain
Eye Injury
Fracture
Head trauma
Other similar acute traumatic injuries
Tendon tear

Aerodigestive Disorders

Asthma
Chronic cough syndrome
Chronic laryngitis
Chronic nasopharyngitis
Chronic respiratory disorder due to fumes/vapors
Chronic rhinosinusitis
Gastroesophageal reflux disorder (GERD)
Interstitial lung diseases
Reactive airways dysfunction syndrome (RADS)
Sleep apnea exacerbated by or related to one of the above certified WTC-related health conditions
Upper airway hyperreactivity
WTC-exacerbated and new-onset chronic obstructive pulmonary disease (COPD)

Mental Health Conditions

Acute stress disorder
Adjustment disorder
Anxiety disorder (not otherwise specified)
Depression (not otherwise specified)
Dysthymic disorder
Generalized anxiety disorder
Major depressive disorder
Panic disorder
Posttraumatic stress disorder (PTSD)
Substance abuse

Musculoskeletal Disorders (only for WTC responders)

The Program covers the following specific WTC-related musculoskeletal disorders in certain situations if they were caused by your 9/11 work and you have proof that you received medical care for the injury on or before September 11, 2003:

Carpal tunnel syndrome (CTS)
Low back pain
Other musculoskeletal disorders

The following cancers have been added to the list of WTC-related health conditions by regulation:

Blood and Lymphoid Tissue

Diffuse non-Hodgkin lymphoma
Follicular [nodular] non-Hodgkin lymphoma
Hodgkin's disease
Leukemia of unspecified cell type
Lymphoid leukemia
Malignant immunoproliferative diseases
Monocytic leukemia
Multiple myeloma and malignant plasma cell neoplasms
Myeloid leukemia
Other and unspecified malignant neoplasms of lymphoid, hematopoietic and related tissue
Other and unspecified types of non-Hodgkin lymphoma
Other leukemias of specified cell type
Peripheral and cutaneous T-cell lymphomas

Childhood Cancers

Any type of cancer diagnosed in a person less than 20


Rare Cancers

Any type of cancer that occurs in less than 15 cases per 100,000 persons per year in the United States (based on 2005–2009 average annual data age-adjusted to the 2000 U.S. population).


Female Breast

Malignant neoplasm of breast

Female Reproductive Organs

Malignant neoplasm of ovary

Malignant Neoplasms of the Digestive System

Colon
Esophagus
Liver and intrahepatic bile ducts
Other and ill-defined digestive organs
Rectosigmoid junction
Rectum
Retroperitoneum and peritoneum
Stomach

Malignant Neoplasm of Eye and Orbit

Eye and adnexa

Malignant Neoplasms of the Head and Neck

Accessory sinuses
Base of tongue
Floor of mouth
Gum
Hypopharynx
Larynx
Lip
Nasal cavity
Nasopharynx
Oropharynx
Other and ill-defined conditions in the lip, oral cavity, and pharynx
Other and unspecified major salivary glands
Other and unspecified parts of mouth
Other and unspecified parts of tongue
Palate
Parotid gland
Piriform sinus
Tonsil

Malignant neoplasms of the Respiratory System

Bronchus and lung
Heart, mediastinum and pleura
Other and ill-defined sites in the respiratory system and intrathoracic organs
Trachea

Malignant Neoplasm of the Urinary System

Bladder
Kidney except renal pelvis
Other and unspecified urinary organs
Prostate
Renal pelvis
Ureter

Malignant neoplasm of Skin (non-Melanoma)

Scrotum
Other malignant neoplasm of skin

Malignant Neoplasm of the Soft Tissue

Peripheral nerves and autonomic nervous system
Other connective and soft tissue

Mesothelium

Mesothelioma

Melanoma

Malignant melanoma of skin

Thyroid

Malignant neoplasm of thyroid gland

Note: The list of WTC-related health conditions provided on the previous pages reflects the language found in the Federal laws and regulations that govern the WTC Health Program. It has been formatted for viewing and organized alphabetically for ease of use. If you are interested in seeing the laws and regulations in their original format, this and other information on the WTC Health Conditions Program can be found at www.cdc.gov/wtc/regulations.html.

Adding New Health Conditions to List of WTC-Related Health Conditions

The Administrator has the authority to add new health conditions to the list of WTC-related health conditions. For example, a condition may be added if the Administrator finds there is enough evidence to link a health condition to 9/11 exposures. This might happen if research shows that a health condition is more likely to occur in individuals with 9/11 exposure than in individuals without 9/11 exposure. You may have a condition you believe is the result of your 9/11 exposure but that is not included on the list of WTC-related health conditions. If this is the case, you or any interested party may petition the Administrator to add a medical condition to the list of WTC-related health conditions. In order to be considered, a petition must be sent in writing to the Administrator, state the intent to petition, and include the following:

  • Name and contact information of the interested party;
  • Name and description of the health conditions(s) to be added; and
  • Reasons for adding the health conditions (s), including the medical basis for the association between 9/11 exposure and the health condition(s) to be added.

A petition form has been developed and may be found at https://www.cdc.gov/wtc/petitions.html

Certification of Your WTC-Related Health Condition(s)

The Program will pay for treatment of your WTC-related health condition(s) if your condition(s) has been certified. The NPN physician will request that the Administrator certify your WTC-related health condition if:

  • The health condition is included on the list of WTC-related health conditions; or
  • The health condition is medically associated with a certified health condition included on the list of WTC-related health conditions; and
  • The NPN physician determines that your 9/11 exposures are sub-stantially likely to have been a significant factor in aggravating, contributing to, or causing the health condition.

The NPN will complete paperwork (called the WTC-3 Certification Package) to request that your health condition(s) be certified by the Administrator. The certification package includes information about you, your health conditions, and your 9/11 work and exposures. The Administrator and his medical staff will review the paperwork to decide if your health condition can be certified. The Administrator will certify your health condition if he finds that:

  • The health condition is included on the list of WTC-related health conditions; or
  • The health condition is medically associated with a certified health condition included on the list of WTC-related health conditions; and
  • Your 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing the health condition.

The Administrator's certification decision will be sent to both you and the NPN.

For some WTC-related health conditions, a fourth requirement must be met for the condition(s) to be certified by the Administrator. For cancers and aerodigestive disorders, the Administrator will also consider the date when you were first diagnosed with the condition when making a certification decision. For more information about time requirements for cancer, see section entitled "Latency” under "Cancer Care”.

Maximum Time Intervals for Aerodigestive Disorders

There are five categories, or groupings, of aerodigestive disorders. Each category includes WTC-related health conditions that can be certified if all certification requirements are met. The Administrator has decided on maximum time intervals for each of the five categories of aerodigestive disorders. The Administrator selected the time intervals based on the best available published science and the Program's clinical experience since 2001.

The maximum time interval is the maximum amount of time that could have gone by between the last date of your 9/11 exposure and the initial onset of an aerodigestive disorder. Your aerodigestive disorder must have started during that time frame in order for it to be certified and covered by the Program. The maximum time intervals for each of the five categories of aerodigestive disorders are as follows:

Category Types of Diseases Conditions Included Maximum Time Interval
1 Obstructive Airways Diseases Chronic respiratory disorder
Asthma
RADS
WTC-exacerbated COPD
Chronic cough syndrome
5 years
2 Upper Respiratory Diseases Upper airway hyperreactivity
Chronic rhinosinusitis
Chronic nasopharyngitis
Chronic laryngitis
5 years
3 Interstitial Lung Diseases All types of interstitial lung diseases No maximum time interval
4 Co-occurring GERD GERD in combination with a condition in Category 1, 2, or 3 5 years
5 Isolated GERD GERD with no other diagnosed 9/11-related health condition 1 year

Certification: Frequently Asked Questions

What happens if the NPN physician does not request certification of my health condition?

If you think you have a WTC-related health condition but the NPN determines that your condition is not related to your 9/11 exposures, you have a right to request a secondary review of this decision by the NPN Medical Director.

The NPN will provide you with instructions on how to request a review. This will involve a written letter to the NPN Medical Director explaining why you disagree with the determination not to request certification. The NPN Medical Director will arrange for a designated secondary reviewer to review your case. The reviewer will use your medical records and the information in your letter to conduct a review of this decision, and come to a final decision. You will receive a written letter from the NPN Medical Director with the results of this review and any actions taken.

If the designated secondary reviewer makes a positive determination, then the request for certification is submitted to the Program for consideration. If the designated secondary reviewer agrees with the negative determination, then the request for certification is not submitted to the Program.

Once you receive the results of your review from the NPN Medical Director, you do not have any further formal review rights from the Program. This decision constitutes the final action of the NPN on behalf of the Program. If at any point you have concerns about how the NPN has handled your case or care in the WTC Health Program, you may always send a letter to the WTC Health Program informing them of your concerns.

What happens if my health condition is certified?

If the Administrator certifies your health condition as WTC-related, then the Program will cover all medically necessary treatment of your health condition in accordance with WTC Health Program protocols. This could include doctor's visits, consultations with specialists, medical procedures or tests, medications, hospitalization, surgery, and other services.

What happens if my certification request is denied by the Administrator?

If the Administrator does not certify your health condition, then you have the right to appeal that decision.

If you would like to appeal the denial decision, you must mail or fax a written letter to the Program's appeals coordinator within 60 calendar days from the date of your denial letter from the Administrator.

Your appeal letter must include the following information:

  • The name, address, and contact information of the individual who is requesting the appeal; and
  • A clear statement of the reason(s) why you think the denial was wrong. For example, you can state that the denial was based on factually inaccurate information, the Program's policies and procedures were not applied correctly to the facts of your case, or the denial was not reasonable as applied to the facts of your case.

Your appeal letter can be mailed or faxed to:

Appeals Coordinator
WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144
Fax: 1-877-646-5308

Within 14 days of receiving an appeal request, the appeals coordinator will notify you by letter whether the appeal request is accepted or not. If an appeal request is accepted, the appeals coordinator's letter will also notify you of the name of the federal official who will review the appeal.

You can request the opportunity to make an oral statement to the federal official when you send your appeal request letter to the appeals coordinator, or within 14 calendar days of receiving the letter from the appeals coordinator notifying you that your appeal request was accepted and providing the name of the federal official who will review your appeal.

You can also designate someone to represent your interests during the appeal process. You can designate a representative by sending a letter to the appeals coordinator. For more information on designated representatives, please refer to the Program's website at www.cdc.gov/wtc/regulations2.html#reg42cfr88

Appeals will be reviewed by the federal official. If the appeal review is going to take longer than 60 calendar days from the date of the letter notifying you that the appeal request was accepted, the appeals coordinator will send a letter and provide a written explanation of the delay and the estimated date the review is expected to be completed.

For more information on the appeals process, including how to make an oral statement and how to designate a representative, please see the Program's website at www.cdc.gov/wtc.

Treatment Authorization

If the Administrator certifies your health condition(s), then the Program will cover your medically necessary treatment for that health condition(s). You will see a physician who will oversee treatment of your certified WTC-related health conditions. The Program has developed medical treatment guidelines for common WTC-related health conditions. The NPN uses those guidelines to determine whether or not a particular treatment for your health condition is medically necessary. If so, then that treatment is covered by the Program at no cost to you.

In order to access the treatment services for your certified WTC-related health conditions, you will need your current WTC Health Program identification number located on your member ID card. Member ID cards are only given to members with a certified WTC-related health condition. An example of a member ID card is pictured below.

All Program treatment services must be authorized, or approved, by the NPN. For example, if you are referred to a specialist and that specialist recommends medical testing or prescriptions for you, then the NPN medical staff will review the request and decide whether or not to authorize, or approve, the recommended testing or medications (Level 1 Authorization). In some cases, physician must seek authorization, or approval, from the NPN Medical Director (Level 2 Authorization) or the Program’s Medical Benefits Manager (Level 3 Authorization) in order for a medically necessary treatment service to be covered.

Level 1 Authorization

Most medically necessary treatment services require a Level 1 Authorization. A Level 1 authorization means that the NPN physician must authorize, or approve, the treatment service before it is rendered to you. The following treatment services require a Level 1 authorization:

  • Doctor's visits and specialty consults
  • Flu and pneumonia vaccines
  • Lab work, such as blood tests
  • Medical tests and procedures used to figure out if you might have WTC-related health condition or medically associated health condition
  • Most surgeries
  • MRIs, CT scans, other types of imaging studies
  • Pharmacy benefits (see section entitled Pharmacy Benefits: How To Get Medications Through The Program for more detailed information)

Level 2 and Level 3 Authorizations

Some medically necessary treatment services require authorization, or approval, by the NPN Medical Director (a Level 2 Authorization) or by the Program's Medical Benefits Manager (a Level 3 Authorization). If you need treatment services that require a Level 2 or Level 3 authorization, the NPN physician will request the authorization for you. The following services require a Level 2 or Level 3 authorization. A more detailed description of each of these services is provided below:

Vaccines for Herpes Zoster (Shingles) and Pertussis (Whooping Cough)

Shingles and whooping cough vaccines are covered for members who are at risk for these illnesses, and are certified for one of the following WTC-related health conditions:

  • Systemic cancer
  • Lower airway disease (obstructive airway and restrictive lung disease)
  • Lung transplant due to a WTC-related lung disease

Smoking Cessation Program

The Program covers smoking cessation counseling and/or drug therapy for members who are current smokers and are referred for smoking cessation counseling and/or drug therapy as part of the lung cancer screening program. The Program also covers these services for members who meet BOTH of the following criteria:

  1. Certified for a WTC-related aerodigestive disorder; mental health condition; or cancer; and
  2. Meet the requirements for and need smoking cessation therapy according to the member’s WTC Health Program physician.

Treatment Services

Inpatient Care Services

The Program covers inpatient treatment and services if those services are medically necessary to treat your certified WTC-related health condition(s). Inpatient care covers hospital services, including semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care, inpatient care as part of a qualifying clinical research study, and mental healthcare.

In order for inpatient services to be covered, the NPN Medical Director must authorize, or approve, the services before you are hospitalized or admitted to an inpatient facility. In some cases, if you need services such as an organ transplant or some types of surgery, the services must be approved by the Program's Medical Benefits Manager before they are rendered.

It is important to work closely with the NPN case management team if inpatient care is needed so that the services can be appropriately authorized, or approved, by the NPN Medical Director or the Program's Medical Benefits Manager.

What's not covered?

  • Personal care items, like razors or slipper socks
  • Private-duty nursing
  • Private room (unless medically necessary)
  • Television and phone in your room (if there's a separate charge for these items)

Organ Transplants

The Program will cover organ transplants if specific circumstances are met. If you are interested in learning more about this, speak to the Case Manager.

Mental Health Services

FDNY Family Members' Mental Health Treatment

Mental health treatment, including psychotherapy and medications, for FDNY family members can be covered under the following conditions:

  • The member is a surviving immediate family member of one of the FDNY responders who were killed at the WTC site on September 11, 2001; and
  • The member received treatment for a mental health condition included on the list of WTC-related health conditions on or before September 1, 2008; and
  • The member's mental health condition has been certified by the Administrator.

Family Therapy and/or Marital Counseling

In certain circumstances, psychotherapy services for a member's family may be covered as part of the treatment of the member's certified WTC-related health condition. Marital counseling for a member and his or her spouse may also be covered in certain circumstances. If you are interested in learning more about this, consult the NPN physician or mental health provider.

Substance Abuse Treatment Programs

The Program will cover substance abuse treatment programs if the following three conditions are met:

  • The member is certified for a WTC-related mental health condition; and
  • The services are authorized by the NPN physician or mental health provider; and
  • The provider or place providing your care is an affiliated provider/facility with the Program.

Other Services

Social Services

The NPN has a Social Worker on staff to help you complete workers' compensation, disability, and unemployment insurance forms. The Social Worker can also help you find housing resources, financial or food assistance, and medical care for non-WTC-related health conditions. It is important to remember that the ability to provide you with the social services you need is dependent on what is available in your community.

Case Management

If you need treatment, the NPN will connect you with a Nurse Case Manager. Your Nurse Case Manager will be the liaison between you, your healthcare providers, and social services resources. The overall goal of case management is that you receive the resources available in order for you to return to your maximum living, wellness, and functional capacity as much as possible.

How often you interact with your Nurse Case Manager will depend on your treatment needs. It is very important that you work closely with your Nurse Case Manager because he/she will be coordinating your care and should be your first level of contact if an issue arises. To better serve you, the case management team is available by telephone toll-free at 1-877-498-2911, Monday-Friday, 7a-5p CST.

Hospice Care

The Program will pay for hospice services when therapies for a certified WTC-related health condition are no longer controlling the illness and the member's life expectancy is 6 months or less. Hospice care can be continued if the member lives longer than 6 months, as long as the NPN Medical Director reconfirms the member's condition.

The following hospice services can be provided when needed to care for a member's terminal certified WTC-related health condition:

  • Dietary counseling
  • Drugs for symptom control or pain relief
  • Durable Medical Equipment (such as wheelchairs or walkers)
  • Grief and loss counseling for member and family
  • Hospice aide and homemaker services
  • Medical supplies (such as bandages and catheters)
  • Nursing care
  • Other services needed to manage pain and other symptoms related to the member’s terminal certified WTC-Related Health Conditions, as recommended by hospice.
  • Physical and occupational therapy
  • Physician services
  • Short-term inpatient care (for pain and symptom management)
  • Short-term respite care
  • Speech-language pathology services
  • Social worker services

Home Health Services

Home health services are personal care and related support services that enable Program members to live at home while receiving medically necessary treatment for a certified WTC-related health condition(s). These services must be authorized by the NPN medical director, and can only be authorized for 60 days at a time. Additional authorization is required if care is needed for a longer period of time.

The following hospice services can be provided when needed to care for a member's terminal certified WTC-related health condition:

Home health services may be covered if the services provided are necessary to treat your certified WTC-related health condition and you require the skilled services of at least one of the following:

  • Medical social services under the direction of a physician
  • Part-time or occasional services of a home health aide
  • Part-time or occasional skilled nursing care provided by or under the supervision of a registered professional nurse
  • Physical/occupational, or speech-language pathology services
  • Routine and non-routine medical supplies

Skilled Nursing Facility/Extended Care Services

The Program will cover extended care services if you require skilled nursing or rehabilitation staff to manage, observe, and evaluate your care for a certified WTC-related health condition(s). Multiple circumstances must be met in order for these services to be covered. If you are interested in learning more about skilled nursing facility/extended care coverage, consult the Case Manager.

Durable Medical Equipment

Durable Medical Equipment (DME) is medical equipment used in the home, such as nebulizers, CPAP machines, hospital beds, wheelchairs, and other types of equipment. DME rental or purchase is a covered health service of the Program.

In order to be covered, the DME must be necessary and reasonable to treat your certified WTC-related health condition(s). In addition, the DME must be ordered by prescription by the NPN physician or a specialist affiliated with the Program, and authorized, or approved, by the NPN Medical Director.

Medical Transport/Ambulance Services

Ambulance services may be provided to you if you are receiving medically necessary treatment for a certified WTC-related health condition and this method of transportation is needed. Examples of when ambulance services may be covered are as follows:

  • Air ambulance or boat ambulance transport when the pickup point is not accessible by a land vehicle, or when great distance or other obstacles are involved in transporting you to the nearest hospital with appropriate facilities. Your medical condition must require a rapid admission or show you are not able to be transferred by other means.
  • Ambulance transfers from a hospital-based emergency room to a hospital more capable of providing the care you need for your certified WTC-related health conditions
  • Emergency transfers to or from your home (or other location) to a hospital and transfers between hospitals
  • Transfers between a hospital or skilled nursing facility and another hospital-based or freestanding outpatient therapeutic or diagnostic department/facility

Non-emergency ambulance services must be authorized, or approved, by the NPN Medical Director before the service is rendered. Emergency ambulance services require review and approval by the NPN Medical Director as soon as is practicable after the service is rendered.

The Program Does Not Cover:

  • Ambulance service used instead of taxi service when the condition is not an emergency and private transportation is available
  • Transport or transfer in order for you to be closer to home, family, friends, or personal physician
  • Use of medicabs or ambicabs as a form of transportation to and from medical appointments

Cancer Care

As of October 12, 2012, the Program added many types of cancer to the list of WTC-related health conditions covered by the Program (for a full list, see section entitled "List of WTC-Related Health Conditions Covered by the Program”).

Cancer care benefits include:

Cancer Screening

Breast Cancer Screening/Mammograms:

If you are between the ages of 40 and 74, you may receive a mammogram once every other year. The Program may cover earlier or more frequent screening if you have a higher risk for breast cancer, such as having a family history or a previous cancer diagnosis. The Program will also cover an additional mammogram if you receive a positive result from a mammogram.

For more information on breast cancer screening, consult the Program fact sheets at www.cdc.gov/wtc/cancerfactsheets.html.

Colon Cancer Screening:

In most cases, the Program provides colon cancer screening for members between the ages of 50 and 75. The Program may cover earlier or more frequent screening if you have a higher risk for colon cancer, such as having a family history, a previous cancer diagnosis, or a condition that suggests a higher risk for colon cancer.

For more information on colon cancer screening, consult the Program fact sheets at www.cdc.gov/wtc/cancerfactsheets.html

If additional types of cancer are added to the list of covered conditions, the Program may offer additional screening tests in the future.

Cancer Diagnostic Services

The Program covers diagnostic services, such as blood work, imaging studies, biopsies, and specialty consults that the NPN physician needs to determine whether you have a cancer that is covered by the Program.

Cancer Treatment Services

The Program will cover all medically necessary cancer treatment, including doctors' visits, medications, cancer therapies, surgeries, and other services, if all of the following conditions are met:

  1. The NPN physician determines that you have a type of cancer that is on the list of WTC-related health conditions (for a full list, see section entitled "List of WTC-Related Health Conditions Covered by the Program”); and
  2. The NPN physician determines that your 9/11 exposures are substantially likely to be a significant factor in aggravating, contributing to, or causing your cancer; and
  3. Your cancer is certified by the Administrator (for a description of certification, see section entitled "Certification of Your WTC-Related Health Conditions”); and
  4. Your cancer specialist has been approved by the Program to provide services to our members ; and
  5. The cancer treatment you receive follows the National Comprehensive Cancer Network guidelines on treatment for your type of cancer.

Cancer Certification

The cancer certification process is very similar to the Program's certification process for other WTC-related health conditions (for a description of certification, see section entitled "Certification of Your WTC-Related Health Condition(s)”). The Administrator has determined that an additional factor, Latency, must be considered when certifying a member's cancer.

Latency

Latency is the amount of time that has passed between your initial 9/11 exposures and the date you were first diagnosed with cancer. In most cases, cancer does not develop until some time has passed after exposure to a cancer-causing agent.

The Program has developed minimum latency requirements for cancer. Minimum latency requirements must be met in order for your cancer to be certified by the Program.

The table below outlines the minimum latency requirements for cancers covered by the Program.

Type of Cancer Minimum Latency Requirement
All types of leukemia (including childhood leukemia) 0.4 years (146 days)
All types of childhood cancers 1 year
All types of thyroid cancer 2.5 years
All types of mesothelioma 11 years
All other types of covered cancers4 years

If you have questions about latency requirements for certification of your cancer, speak to your WTC Health Program physician. For more information about latency requirements, you can refer to the Program website at www.cdc.gov/wtc/pdfs/wtchpminlatcancer2013-05-01.pdf

Getting Medical Care for Cancer

The Program covers cancer treatment if the cancer specialist caring for you has been approved by the NPN to provide medical services to our members. The NPN maintains a network of healthcare providers that are affiliated with the Program. The network includes healthcare providers that treat cancer. If you do not already have a cancer specialist, the NPN can help you find one that is affiliated with the Program.

If you already have a cancer specialist, ask the NPN if the cancer specialist is affiliated with the Program. If they are not affiliated with the Program, speak to your Case Manager about how your cancer specialist could become affiliated with the Program so that your cancer care can be covered by the Program.

National Comprehensive Cancer Network (NCCN) Guidelines

The Program covers medically necessary cancer treatment services that fall within the National Comprehensive Cancer Network (NCCN) guidelines for treating your type of cancer. NCCN, a not-for-profit alliance of 23 of the world's leading cancer centers is dedicated to improving the quality and effectiveness of care provided to patients with cancer. NCCN develops guidelines for treating various types of cancer. For more information about NCCN, including guidelines for treating your cancer, see the NCCN website at www.nccn.org.

Other Program Services

Cancer affects peoples' lives in many ways. It can affect your physical health, your emotional well-being, your relationships with family and friends, your work, and your finances. The mental health and social services staff at the NPN can help you to address some of these concerns.

Pharmacy Benefits

The Program covers prescription drugs used to treat a certified WTC-related health condition. The NPN physician will prescribe medication for you using the Program's formulary, a list of drugs approved to treat certified WTC-related health conditions. The drugs on the Program's list are covered by the Program. The list includes drugs that are safe and effective for the treatment of certified WTC-related health conditions.

If your physician would like to prescribe a drug for you that is not on the Program's formulary, then your Case Manager can request that the Program approve coverage of the drug for you. The Case Manager will send the name of the drug, your certified health condition that the drug would treat, and the reasons why that specific drug should be added to the Program's list of drugs used to treat certified WTC-related health conditions to the Program for approval. Program medical staff will review the request from your Case Manager and decide if the drug your physician would like to prescribe for your certified WTC-related health condition should be added to the Program's list of drugs. If the Program medical staff decides to add it to the list, then the Program would cover the cost of the drug for you. If they decide not to add it, the Program would not cover the cost of the drug for you. Then, your physician would have to prescribe a drug that is on the Program's list of drugs, or you would have to pay out of pocket (or use your own health insurance) to pay for the drug.

Some types of drugs are not covered by the Program, including:

  • Nonprescription or over-the-counter medicines
  • Drugs for cosmetic uses
  • Dental prescriptions (unless prescribed for a certified WTC-related health condition)
  • Drugs used for reasons not approved by the United States Food and Drug Administration

Filling Prescriptions

You may obtain covered prescriptions in 2 ways:

  1. Mail order is a convenient way to get prescriptions. You can get up to a 90 day supply of drugs through the WTC Health Program's OptumRX mail order service.

    To get your prescriptions through the mail, you will first need to register with OptumRX mail order service at www.optumrx.com.

  2. Retail – You can get up to a 30 day supply of drugs through a pharmacy of your choice. To fill prescriptions at a retail pharmacy, you will need your current WTC Health Program identification number located on your Member ID card. Member ID cards are only given to members with a WTC-related certified health condition. An example of a Member ID card is pictured below.

Only members who are in treatment will get a card. The member ID card will allow you to fill prescriptions at a pharmacy. Some medications will require preauthorization in order to be filled. Your pharmacy will need to call 1-877-498-2911 for approval.

If you are having a problem filling a prescription, you should ask the pharmacist to call the NPN Case Management department toll-free at 1-877-498-2911, Monday - Friday, 7am-5pm.

Medical Emergencies

A medical crisis can occur unexpectedly and after normal office hours. When that happens, the Program provides services for your certified WTC-related health conditions.

Urgent Care (After Hours)

Urgent care services are medically necessary treatment required for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. The Program provides payment for urgent care visits for your certified WTC-related health condition(s). If you need to go to an urgent care facility, be sure to contact the NPN at 1-877-498-2911 as soon as possible to let them know.

Emergency Care Services

The Program defines a medical emergency as a serious medical or psychiatric condition that would result in a threat to life, limb or sight, or when a person is an immediate risk to self or others.

Examples of conditions where emergency care may be needed:

  • Severe shortness of breath
  • Severe or persistent bleeding
  • Sudden onset of severe abdominal pain
  • Persistent suicidal or homicidal ideation

In the event of a medical emergency, call 911 or go to the nearest emergency room.

You do not need to call the NPN before receiving emergency medical care. However, in all emergencies, you must notify the NPN within 24 hours or on the next business day following admission to coordinate ongoing care and to ensure you receive proper authorization.

When Traveling Outside Your Local Area

Urgent and emergency care for your certified WTC-related health condition(s) is available even when you are traveling outside of your local area. You should seek immediate treatment for any illness or injury that would be considered an emergency. If you are admitted to an inpatient facility, you must immediately notify the NPN. In other cases, you should notify the NPN within 48 hours of an emergency.

When seeking emergency care, please note that:

The Program does not cover emergency care services that are not related to your certified WTC related health conditions.

Member Rights and Responsibilities

Your Rights as a WTC Health Program Member

You have the right to:

Be assured of privacy and confidentiality: Your personal and medical information will be handled in a manner that preserves and protects your confidentiality. This includes, but is not limited to, the maintenance of medical records in a secure environment and the education of Program staff regarding confidentiality. The Program will not release medical information without authorization, except as required or permitted by law to administer benefits, comply with government requirements, or if you consent to participate in research or education.

Have access to treatment: You have the right to receive medically necessary treatment for a certified WTC-related health condition(s) if those conditions are certified by the Administrator. In addition, you have the right to be informed about the risks and benefits of treatment and to refuse care.

You also have the right to appeal the following decisions:

  • A decision made by the Administrator not to certify a WTC-related health condition
  • A decision made by the Administrator not to certify a health condition as medically associated with a WTC-related health condition
  • A decision made by the Administrator not to authorize treatment due to a determination that the treatment is not medically necessary to treat a certified WTC-related health condition.

Voice complaints/grievances related to the Program: You have the right to voice your concerns and receive a prompt and fair review of any complaints you may have about the Program. For more information about the complaints procedure, please see section entitled "Complaints Procedure.”

Receive considerate, respectful care: In the Program, we strive to treat all members equally and with respect and dignity, regardless of race, religion, sex, sexual orientation, national origin, age, disability, or income. If you have any concerns about how you are being treated, please contact the Program's Member Services Department at 1-888-982-4748.

Your Responsibilities as a WTC Health Program Member

You are responsible for:

Knowing the extent and limitations of the Program's services: This handbook provides information about the Program. You are encouraged to contact the Program's Call Center toll-free at 1-888-982-4748 if you have questions.

Keeping appointments: You have a responsibility to keep your appointments. If you are unable to keep your appointment, notify your NPN Case Manager within 24 hours of your appointment so that your slot can be given to another member.

Providing accurate and complete information: You are responsible for providing accurate and complete information about your present and past medical conditions to the Program. You are also responsible for submitting appropriate signed medical release forms so that the Program can obtain medical records as needed.

Active participation in your care: You have a responsibility to participate in your care by asking questions to understand your certified WTC-related health condition(s), follow the recommended treatment plan, and make healthy lifestyle choices to try to maintain your health and prevent illness.

Fulfilling financial obligations: Treatment of your certified WTC-related health conditions will be provided at no cost to you as long as the provider and the services are appropriately authorized. Depending on the type of treatment services you need, services must be authorized by the NPN case manager, the NPN Medical Director, or the Program's Medical Benefits Manager.

Showing consideration and respect: You have a responsibility to show consideration and respect to Program providers and staff. Disruptive or abusive behavior may impact the Program's ability to provide benefits to you in a timely manner.

Privacy Practices in the WTC Health Program

The Program is required, by law, to maintain the privacy and security of your personal health information and to provide you with notice of its legal duties and privacy practices with respect to how your personal health information held by the Program will be used and disclosed ("given out”) by the Program.

Program Uses and Disclosures of Your Personal Health Information

The Program must use and disclose your personal health information to provide information:

  • To you, someone you name, or someone who has the legal right to act for you. The Program will make sure that person has this authority and can act for you before we take any action.
  • To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected; and
  • Where required by law

The Program has the right to use and disclose your personal health information to provide you with treatment, to pay for your healthcare, and to operate the Program. Examples include:

  • The Program will collect and use your personal health information to decide if the necessary requirements are met for coverage of your health condition(s) under the Program (conditions which meet these requirements are "certified” by the Program).
  • The Program will collect and use your personal health information for the purposes of determining diagnosis and medically necessary treatment of "certified” health conditions.
  • The Program will disclose your personal health information to the Centers for Medicare and Medicaid Services (CMS) in order for CMS to pay providers for eligible healthcare benefits you received.
  • The Program will review and use your personal health information to make sure you are receiving quality healthcare.

The Program may use or disclose your personal health information for the following purposes under limited circumstances:

  • To other federal and state agencies, where allowed by federal law, that need WTC Health Program health data for their program operations
  • For public health activities (such as reporting disease outbreaks)
  • For healthcare oversight activities (such as fraud and abuse investigations)
  • For judicial and administrative proceedings (such as in response to a court order)
  • For law enforcement purposes
  • To avoid a serious and imminent threat to health or safety
  • For purposes of reporting information about victims of abuse, neglect, or domestic violence
  • To report information about deceased individuals to a coroner, medical examiner, or funeral director, or for organ or tissue donation purposes
  • For research purposes, under certain conditions
  • For workers compensation purposes
  • To contact you about new or changed coverage under the Program

By law, the Program must have your written permission (an "authorization”) to use or disclose your personal health information for any purpose that is not set out in this notice including certain uses or disclosures of psychotherapy notes. In addition, the Program will not sell or market your personal health information without your written permission. You may take back ("revoke”) your written permission anytime, except to the extent that the Program has already acted based on your permission. If you take back your written permission, please provide that to the program in writing.

The Program is prohibited from using or disclosing your personal genetic health information (i.e., your genetic tests, the genetic tests of your family members and your family medical history) for purposes of determining your eligibility and enrollment into the WTC Health Program (i.e. underwriting).

Your Rights

By law, you have the right to:

  • Receive a paper copy of this notice, upon request to the Program, even if you have received an electronic copy of this notice (i.e. email). The Program will provide you with a paper copy promptly.
  • Receive an accounting (who and where) the Program has disclosed (given out) your personal health information for six years prior to the date you ask, who we shared it with and why. The Program will include all disclosures except for those about treatment, payment, and healthcare operation, and certain other disclosures (such as any you asked the Program to make). The Program will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
  • Inspect (review) and copy your personal health information. You can ask to see or get a copy of your health and claims records and other health information that we have about you. Please contact the program about how to do this. The Program will provide a copy or a summary of your health and claims records, usually within 30 days of your request. The Program may charge a reasonable, cost-based fee.
  • Amend your personal health information if you believe that it is wrong or if information is missing from your personal health records. Please note that the Program may deny your request to amend your personal health information if it believes the information in your records is accurate and complete. The Program will provide you with an explanation of the denial in writing within 60 days. If the Program declines to amend your records, you may have a statement added to your personal health records to reflect your disagreement.
  • Receive confidential (private) communications from the Program when you are contacted regarding your personal health information. You may ask the Program to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • Request limitations on certain uses and disclosures of your personal health information by the Program. Please note that the Program is not required to agree to this requested limitation except under certain circumstances.
  • Be informed of and receive notification if a breach occurs that may have compromised the privacy or security of your information.

WTC Health Program Responsibilities

The Program is required by law to abide by the terms of this privacy notice. The Program has the right to change this privacy notice and the changes will apply to all of the information that we have about you. If the Program makes any changes to this notice, a copy of the revised notice will be made electronically available on the Program website and it will be mailed to you in the Program's next annual mailing. You may also request to receive a copy of the notice.

How to Contact the WTC Health Program

You can call 1-888-982-4748 to get further information about matters covered by this notice. Ask to speak to a customer service representative about the Program's privacy notice. To view an electronic copy of the Program's privacy notice, you can visit the Program's website at: www.cdc.gov/wtc.

How to File a Complaint

If you believe that your privacy rights have been violated, you may file a complaint with the Program by calling 1-888-982-4748, or by sending a letter to P.O. Box 7000 Rensselaer, NY 12144 ATTN: WTC Health Program, HIPAA Complaint. Filing a complaint will not affect your coverage under the Program.

You may also file a complaint with the Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. TTY users should call 1-800-537-7697.

Complaints Procedure

All Program healthcare providers and staff share responsibility for assuring member satisfaction. If you have a problem or concern about the services you receive, please do not hesitate to ask for help. Each department has a supervisor or manager who is able to assist you. If you have a problem with any aspect of the service you've received at the NPN, call or visit the administrative office at that facility.

If you are not satisfied with the way your complaint was handled, you can contact the Program's Member Services Department at 1-888-982-4748. A Member Services Associate will assist you in addressing your concern as best as possible. Be sure to provide complete information regarding the nature of your complaint, including names, dates and any other specific information so that the person with whom you speak can work with you to resolve your concern. If the complaint cannot be resolved by the Member Services Associate, it will be forwarded to the appropriate Program staff. We will make every effort to respond to your request as quickly and effectively as possible.

Fraud and Abuse

Fraud is the intentional deception or misrepresentation that an individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other third party. The Program will closely monitor any fraudulent activity including the submission of fraudulent information in support of a claim of eligibility or for necessary and covered services, fraudulent misuse of the Program by healthcare providers participating in the program, and submission of claims for services not provided or needed as claimed. The Program will report fraudulent conduct to federal law enforcement agencies and violators may be subject to criminal, civil, or administrative penalties. Information concerning suspected fraud related to the Program by contractors, grantees, healthcare providers, or individual recipients should be reported to the Department of Health and Human Services Office of Inspector General by phone at 1-800-HHS-TIPS (1-800-447-8477); online at https://oig.hhs.gov/fraud/report-fraud/index.asp; or in writing to the following address:

U.S. Department of Health and Human Services, Office of Inspector General, ATTN: OIG HOTLINE OPERATIONS, P.O. Box 23489, Washington, DC 20026.

Glossary