The WTC Health Program and How it Works

• What is the James Zadroga 9/11 Health and Compensation Act of 2010?

  On January 2, 2011, the President signed the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) into law. This law amended the Public Health Service Act, establishing the WTC Health Program, to be administered by the Department of Health and Human Services. A second part of the Act reopened and modified the September 11th Victim Compensation Fund (VCF), initially operated from 2001 to 2004, under the administration of the Department of Justice. For more information on the VCF visit www.vcf.gov. To contact the WTC Health Program, please call the toll-free number at 1-888-982-4748.

• What does the WTC Health Program provide?

  The WTC Health Program provides medical monitoring and treatment for emergency responders, recovery, and cleanup workers, and volunteers who helped after the terrorist attacks on September 11, 2001, at the World Trade Center, the Pentagon, and the crash site near Shanksville, Pennsylvania.

  The WTC Health Program also provides health evaluations and treatment for eligible people who were present in the dust or dust cloud on 9/11 or who worked, resided, or attended school, childcare, or adult daycare in the New York City disaster area for a period of time on 9/11 and/or during the following months.

  In addition to providing medical monitoring and treatment the WTC Health Program also provides:

  • Education and outreach to people who may be eligible;
    
  • Collection and analysis of physical and mental health data with members' permission; and
    
  • Research to better understand health conditions related to the attacks.

• Does the Program cost me anything?

  There are no out-of-pocket costs for members who:

  • Use healthcare providers approved by the WTC Health Program for eligible medical evaluation, monitoring, and treatment; and
    
  • Use pharmacies that participate in the WTC Health Program to fill any prescriptions you are given for a WTC-related health condition by an approved WTC Health Program healthcare provider.
    

• Aren't I already enrolled in this Program?

  Yes, you are already enrolled in the WTC Health Program if:

  • You are a New York City responder or volunteer and were enrolled in the WTC Medical Monitoring and Treatment Program (MMTP). (The MMTP was replaced by the WTC Health Program in July 2011.);
    
  • You are a member of the Fire Department of New York (active or retired) and were enrolled in the MMTP. (The MMTP was replaced by the WTC Health Program in July 2011.);
    
  • You are a community member and were enrolled in the WTC Environmental Health Center Community Program on or before December 31, 2010. (The WTC Environmental Health Center Community Program was replaced by the WTC Health Program in July 2011.) Your category in the new Program is called "Survivor."
    

  The WTC Health Program worked with the previous programs (MMTP and WTC Environmental Health Center Community Program) to enroll you into the new WTC Health Program. – You do not need to do anything unless you were notified that you need to re-enroll (see FAQs "I am a survivor who enrolled in the earlier WTC Environmental Health Center Community Program on or after January 1, 2011. What do I do?" and "I enrolled in the WTC Health Program after January 1, 2011. Why do I need to re-enroll?"). You will continue to receive quality medical benefits for WTC-related health conditions, including inpatient and outpatient treatment and medications, under the new WTC Health Program.

  If you are not sure you are enrolled, call the WTC Health Program at 1-888-982-4748.

• I am a responder or survivor who isn't enrolled yet. What will the Program provide for me?

  Responders who enroll in the WTC Health Program receive annual medical monitoring. If you have a health condition(s) that is certified as a WTC-related health condition (i.e., an illness or health condition for which exposure to airborne toxins, other hazards, or other adverse conditions resulting from the September 11, 2001, terrorist attacks that was substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition), the WTC Health Program's healthcare providers will provide quality medical treatment for the WTC-related health condition.

  Survivors who enroll will receive an initial health evaluation. The evaluation is to find out if you have a health condition eligible for coverage by the WTC Health Program. If you have a health condition that is considered WTC-related, the doctor will request that the WTC Health Program certify your condition(s) as eligible for treatment under the Program. If you have a health condition(s) that is certified as a WTC-related health condition as defined by the Zadroga Act (i.e., an illness or health condition for which exposure to airborne toxins, other hazards, or other adverse conditions resulting from the September 11, 2001, terrorist attacks was substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition), the WTC Health Program's healthcare providers will provide quality medical treatment for the WTC-related health condition. For more information, see FAQ "What happens if I get sick after my initial health evaluation?"

• Will the WTC Health Program pay for inpatient care?

  Yes. As long as the reason you are hospitalized is for treatment of a strongly suspected or certified WTC-related health condition, the WTC Health Program will pay for inpatient care. You should speak to your Clinical Center of Excellence or the Nationwide Provider Network about your inpatient care needs.

• Will current members be issued new health cards from the WTC Health Program?

  In July 2013, the WTC Health Program began sending out member cards, but you do not need a card to receive coverage for certified WTC-related health conditions.

• Is this a research program?

  The main goal of this Program is to provide healthcare for eligible individuals with WTC-related health conditions. When you come in for an exam, you will be asked if the clinic can add your health information to the data which researchers are using to better understand health effects as a result of the 9/11 attacks.

  However, you are not required to disclose your health information. If you choose not to sign the consent form, you will still be able to receive your monitoring exam, as well as treatment for certified WTC-related health conditions. If you do consent to let researchers see your health information, your name and contact information will not be given to them. Only your health information will be a part of the research record—not your identity.

New York City, Pentagon, or Shanksville Responder Thinking About Enrolling in the WTC Health Program

• How do I find out if I am eligible for the WTC Health Program?

  Please visit www.cdc.gov/wtc/ or call us at 1-888-982-4748 to determine if you may be eligible for the WTC Health Program. You can also download the enrollment form that fits you best at: www.cdc.gov/wtc/apply.html. If you need a paper form mailed to you, call us toll-free at 1-888-982-4748.

• How do I apply to the WTC Health Program?

  To apply to the WTC Health Program please visit our How to Apply page. You may download an enrollment form www.cdc.gov/wtc/apply.html. The application can be completed online, printed, and then submitted via mail or fax. If you do not have access to a computer, you can ask for a copy of the application to be mailed to you by calling 1-888-982-4748. Approval times for each application will vary. Once you have been approved for enrollment in the WTC Health Program, you will receive an acceptance letter notifying you of your approval. You can check the status of your application by calling us at 1-888-982-4748.

• What type of information is in the application?

  There are three responder applications—FDNY responder, general responder, and Pentagon & Shanksville responder. The applications request:
  
  

  • applicant information (name, mailing address, phone number, and similar information),
    
  • a series of questions for you to answer about your 9/11 terrorist site experience,
    
  • an explanation of the required documentation of your work experience and what to do if you cannot provide the documentation,
    
  • an attestation and acknowledgment that you have completed the application truthfully and that you understand the notices provided in the application that must be signed to complete the application.
    

  All application forms and their instructions can be found at How to Apply. You can download the form and complete it electronically or you can print it and complete it manually. If you complete the form electronically, you will need to print the form and sign and date it before sending your application.

  If you have questions about the application process or about your individual application, please contact us at 1-888-982-4748 or by email at WTC@cdc.gov.

• What will I need for supporting documentation?

  You will need to provide copies of documents that show you worked at one of the 9/11 terrorist sites. An explanation of what specific information you need and what to do if you cannot locate that information can be found at Supporting Documentation.

• It's been over a decade, why should I see a doctor now?

  Though the September 11th attacks were over a decade ago, many first responders continue to experience physical and mental health symptoms as a result of their experience. Current or eligible responders may not recognize that some cancers, a chronic cough, difficulty sleeping, or frequent heartburn could be a WTC-related condition (although the term relates to the World Trade Center in New York City, the WTC Health Program identifies all covered conditions, including those that affect Pentagon or Shanksville responders, as "WTC-related"). Doctors with the WTC Health Program are experts in identifying these illnesses and providing the highest quality care.

• How would I know if my health problems are related to 9/11?

  Only a physician in the WTC Health Program can make that determination. By law, the WTC Health Program is limited to the coverage of certified WTC-related health conditions. If you believe you may be eligible for the Program, more information on the program and applications can be found on our How to Apply page.

• If my health conditions are found to be related to my WTC work and exposures, what can I do?
  

  Your WTC Health Program provider will meet with you individually, informing you of the treatment and services available through the WTC Health Program.

• What if during my exam a health condition is found that is not covered by the WTC Health Program?

  You will be referred to someone to talk to about healthcare that is available through other options outside of the WTC Health Program. There may be resources available for reduced cost or other socially funded healthcare programs.

• If I have work-related health issues that are not related to my WTC work and exposures, what can I do?

  The New York State Occupational Health Clinic Network can provide diagnosis and treatment of work-related health conditions.

Survivor Thinking About Enrolling in the WTC Health Program

• How do I find out if I am eligible for the WTC Health Program?

  Please visit www.cdc.gov/wtc/ or call us at 1-888-982-4748 to determine if you may be eligible for the WTC Health Program. You can also download the enrollment form that fits you best at: www.cdc.gov/wtc/apply.html. If you need a paper form mailed to you, call us toll-free at 1-888-982-4748.

• How do I apply to the WTC Health Program?

  To apply to the WTC Health Program please visit our How to Apply page. You may download an enrollment form www.cdc.gov/wtc/apply.html. The application can be completed online, printed, and then submitted via mail or fax. If you do not have access to a computer, you can ask for a copy of the application to be mailed to you by calling 1-888-982-4748. Approval times for each application will vary. Once you have been approved for enrollment in the WTC Health Program, you will receive an acceptance letter notifying you of your approval. You can check the status of your application by calling us at 1-888-982-4748.

• Does my family member need to enroll in the program to receive benefits?

  Yes. Although the two of you are related, your family member is considered a new member and must go through the enrollment process in order to be in the WTC Health Program.

• What type of information is in the application?

  The application contains:
  
  

  • applicant information (name, mailing address, phone number, and similar information),
    
  • a series of questions for you to answer about your 9/11 terrorist site experience,
    
  • an explanation of the required documentation of your work experience and what to do if you cannot provide the documentation,
    
  • an attestation and acknowledgment that you have completed the application truthfully and that you understand the notices provided in the application that must be signed to complete the application.
    

  All application forms and their instructions can be found at How to Apply. You can download the form and complete it electronically or you can print it and complete it manually. If you complete the form electronically, you will need to print the form and sign and date it before sending your application.

  If you have questions about the application process or about your individual application, please contact us at 1-888-982-4748 or by email at WTC@cdc.gov.

• What will I need for supporting documentation?

  You will need to provide copies of documents that show you were present at the 9/11 terrorist site. An explanation of what specific information you need and what to do if you cannot locate that information can be found at Supporting Documentation.

• It's been over a decade, why should I see a doctor now?

  Though the September 11th attacks were over a decade ago, many first responders continue to experience physical and mental health symptoms as a result of their experience. Current or eligible responders may not recognize that some cancers, a chronic cough, difficulty sleeping, or frequent heartburn could be a WTC-related condition (although the term relates to the World Trade Center in New York City, the WTC Health Program identifies all covered conditions, including those that affect Pentagon or Shanksville responders, as "WTC-related"). Doctors with the WTC Health Program are experts in identifying these illnesses and providing the highest quality care.

• What benefits do I have under the WTC Health Program?

  When you are accepted into the WTC Health Program, you are eligible for an initial health evaluation. The doctor will determine if you have a health condition related to your 9/11 terrorist site exposure. Your WTC Health Program provider will make this determination based on a clinical evaluation of your specific exposure situation and the type of health condition you develop (the diagnosis). Then the WTC Health Program must approve (certify) the evaluation and diagnosis to allow you to receive treatment for the specific health condition through your Clinical Center of Excellence or the Nationwide Provider Network.

• What happens if I get sick after my initial health evaluation?

  If you experience symptoms after your initial health evaluation, you have the option to pay for an additional appointment by a WTC Health Program provider. If the provider finds that you have a WTC-related health condition during this evaluation, the evidence will be submitted to the program and your eligibility for treatment benefits will be considered.

• I was in the New York City Disaster Area on 9/11 but I don't feel sick. Can I make an appointment and be monitored?

  To qualify for a medical evlaution as a Survivor, you must have symptoms that you suspect could be related to a condition that is covered by the WTC Health Program. Please see "What conditions are covered by this program?" above to see the list of conditions.

• If I have a work-related health condition that is not related to my WTC exposures, what can I do?

  The New York State Occupational Health Clinic Network can provide diagnosis and treatment of work-related health conditions.

  By law, the WTC Health Program is limited to the coverage of specified health conditions (WTC-related health conditions). If you are enrolled in the program and have received your initial health evaluation, or if you are enrolled and will receive your first examination, make sure to talk with the WTC Health Program provider about your health condition. It is important that you work with them to make a determination whether it is related to your 9/11 terrorist site exposures. Your WTC Health Program provider will make this determination based on a clinical evaluation of your specific exposure situation and the type of health condition you develop (the diagnosis). Then the WTC Health Program must approve (certify) the evaluation and diagnosis to allow you to receive treatment for the WTC-related health condition through your Clinical Center of Excellence or the Nationwide Provider Network.

• If I am found to have a health condition(s) related to my WTC exposures, what can I do?

  Your WTC Health Program provider will meet with you individually, informing you of the treatment and services available to you through the WTC Health Program.

• What if my WTC Health Program physician finds a health condition not covered by the WTC Health Program?

  You will be referred to someone to talk to about healthcare that is available through other options outside of the WTC Health Program. There may be resources available for reduced cost or other socially funded healthcare programs.

Health Conditions Covered by the WTC Health Program and How to Receive Benefits

• Does the WTC Health Program provide treatment for all health problems?

  No. The WTC Health Program provides medical monitoring and treatment only for conditions specified on the List of WTC-Related Health Conditions. If your healthcare physician in the WTC Health Program determines you have a health condition not on the List, he or she will advise you about seeking care outside the WTC Health Program.

• Which conditions are covered by the WTC Health Program?

  The list of health conditions eligible for coverage under the WTC Health Program (List of WTC-Related Health Conditions) is below. The List of WTC-Related Health Conditions may be amended by the WTC Program Administrator to include other health conditions as more information is learned about the relationship of 9/11 terrorist site exposures and those health conditions.

  Note: The information on this page reflects the language found in the Federal laws and regulations that govern the WTC Health Program. It has been formatted for viewing on the Web 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 Program can be found on our Law and Regulations page.

  • Acute Traumatic Injury
    
    • Burn
    • Complex sprain
    • Eye injury
    • Fracture
    • Head trauma
    • Other similar acute traumatic injuries
    • Tendon tear
    
    
  • Aerodigestive Disorders (Airways and Digestive Disorders)
    
    • Asthma
    • Chronic cough syndrome
    • Chronic laryngitis
    • Chronic nasopharyngitis
    • Chronic respiratory disorder—fumes/vapors
    • Chronic rhinosinusitis
    • Gastroesophageal reflux disorder (GERD)
    • Interstitial lung diseases
    • Reactive airways dysfunction syndrome (RADS)
    • Sleep apnea exacerbated by or related to another condition described in the list of aerodigestive disorders
    • Upper airway hyperreactivity
    • WTC-exacerbated and new-onset chronic obstructive pulmonary disease (COPD)
    
    
  • Cancer
    (Note: A list of the cancers covered by the WTC Health Program and included on the List of WTC-Related Health Conditions can be found on the Covered Cancers page.)
    
    
  • 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
    (Limited to responders who received any treatment for a WTC-related musculoskeletal disorder on or before September 11, 2003, and meaning chronic or recurrent disorder of the musculoskeletal system caused by heavy lifting or repetitive strain on the joints or musculoskeletal system occurring during rescue or recovery efforts in the New York City disaster area in the aftermath of the September 11, 2001, terrorist attacks.)
    
    • Carpal tunnel syndrome (CTS)
    • Low back pain
    • Other musculoskeletal disorders
    
    
  • Other
    Other health conditions determined to result from the treatment or progression of an underlying certified WTC-related health condition may be certified as "health conditions medically associated with a WTC-related health condition.

  
  

• Does the program also cover treatment for mental health problems?

  Yes, each participating Clinical Center of Excellence and the Nationwide Provider Network includes mental health professionals who are experienced in treating WTC-related psychological and substance abuse problems.

• Which diagnostic and treatment services are available?

  The WTC Health Program will cover medically necessary diagnostic evaluation and treatment costs for WTC-related health conditions as per program protocols, including inpatient and outpatient medical procedures and prescribed medications. During the diagnostic work-up, if your provider determines you do not have a covered health condition or the health condition is not related to your 9/11 terrorist site exposures, the Clinical Center of Excellence will assist you in finding medical care outside the WTC Health Program. However, the WTC Health Program will no longer pay for services related to those conditions.

• How do I get approved to receive healthcare?

  The first step for receiving care is to apply to the program. Once you apply and have been determined to be eligible, and you have enrolled in the WTC Health Program, you will choose a clinic for your initial appointment. At that appointment, and any subsequent appointments, a physician approved by the WTC Health Program will determine if you have any WTC-health related conditions.

  Your WTC Health Program provider will make a determination based on a clinical evaluation of your specific exposure situation and the type of health condition you develop (the diagnosis). Then the WTC Health Program must approve (certify) the evaluation and diagnosis to permit you to receive treatment for the specific health condition through your Clinical Center of Excellence or the Nationwide Provider Network at no cost to you. The WTC Health Program's decision will be shared with you by the Clinical Center of Excellence or Nationwide Provider Network via a letter from the program.

• How long does certification of a WTC-related health condition take?

  Before we can certify your condition, you must schedule an initial health evaluation with a WTC Health Program provider. During the evaluation, your doctor will determine if you have a condition that is related to your 9/11 terrorist site exposures. If you have a condition on the List of WTC-Related Health Conditions that your physician determines is related to your 9/11 terrorist site exposure, your doctor will request that your condition be certified by the WTC Health Program. Certifications are done on a case by case basis. Although there is no set timeframe for a health condition to be certified, the WTC Health Program will make certification decisions as promptly as possible.

• If my condition is not certified as a WTC-related health condition, do I have a right to appeal the decision?

  If you are denied certification, your cancer treatment will not be paid for by the WTC Health Program. You have a right to appeal a denial of certification. Information on how to appeal a denial will be included in the letter informing you of the WTC Health Program's denial decision. More detailed information about the appeal process is available in the FAQs below, as well as on the Appeals page.

• How soon after my condition is certified as a WTC-related health condition can I actually expect to begin treatment?

  As soon as your cancer has been certified by the WTC Health Program as a WTC-related health condition, you are eligible for treatment coverage for your cancer in the WTC Health Program. However, you and your doctor must make decisions about when you should begin treatment based on the type of cancer and your personal medical situation.

• If I have a health condition and I am already seeing a doctor for my care, can I still keep seeing my doctor?

  Although you may continue to see your personal physician, if he or she is not affiliated with the WTC Health Program, any treatment or services you receive from him or her will not be reimbursed by the WTC Health Program.
  
  In order for a WTC Health Program member to obtain coverage for treatment of any health condition on the List of WTC-Related Health Conditions, including any type of cancer on the List, the condition must first be certified by the WTC Health Program. All care for the WTC Health Program must be provided by a healthcare provider affiliated with the WTC Health Program. If your current provider is affiliated with the WTC Health Program, then you will be able to continue seeing your doctor. If your current provider is not affiliated, ask the provider to contact your Clinical Center of Excellence or the Nationwide Provider Network to see if it is possible to become a WTC Health Program provider.

• Will the WTC Health Program provide reimbursements to individuals for cancer treatment costs incurred before October 12, 2012?

  No. The WTC Health Program cannot, by law, reimburse members or healthcare providers for the costs of cancer treatments received before October 12, 2012 (the effective date of the final rule adding many types of cancer to the List of WTC-Related Health Conditions). Similarly, costs associated with prostate cancer treatment will not be reimbursed for treatment received before October 21, 2013.

• I have cancer now. What should I do?
  

  1. Your WTC Health Program healthcare provider must confirm that the type of cancer you have is one of the cancers on the List of WTC-Related Health Conditions and that the date of diagnosis meets minimum latency requirements. This means that the doctor will have to review your biopsy report and/or other medical records.
     
  2. The healthcare provider must then determine that your exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 11, 2001, terrorist attacks is substantially likely to be a significant factor in aggravating, contributing to, or causing your cancer. To do this the doctor must have the details of your exposure at the terrorist attack site in either New York City, Shanksville, or at the Pentagon, and your subsequent medical history.
     
     If your doctor confirms that you do have one of the cancers on the List of WTC-Related Health Conditions and determines that your exposure resulting from the September 11, 2001, terrorist attacks is substantially likely to be a significant factor in aggravating, contributing to, or causing your cancer, she or he will request certification of your cancer from the WTC Health Program.
     
  3. The WTC Health Program will then review your doctor's request for cancer certification. Your cancer will be certified for treatment coverage unless the WTC Health Program finds that your cancer is not a cancer on the List of WTC-Related Health Conditions, or your cancer diagnosis does not meet the minimum latency requirements, or that your exposure resulting from the September 11, 2001, terrorist attacks is not substantially likely to be a significant factor in aggravating, contributing to, or causing your cancer.
     

• What do I do if I am worried about cancer?

  If you are a member of the World Trade Center Health Program:
  Contact your Clinical Center of Excellence or your Nationwide Provider Network physician to schedule an appointment so that you can begin the cancer certification process as soon as possible. If you do not know which Clinical Center of Excellence you are with, please contact our call center at 1-888-982-4748.
  
  If you are not a member of the World Trade Center Health Program:
  Please visit our How to Apply page for information about the application process. You can also contact the WTC Health Program at 1-888-982-4748 for information on how to apply.

• Should I schedule a monitoring exam even if I am feeling fine now?

  Yes. Everyone who is eligible for medical monitoring within the WTC Health Program is strongly encouraged to participate in regular monitoring exams for the following two reasons:

  1. The exam may detect changes in body function that you are not aware of and that can be corrected or slowed with early intervention; and
     
  2. While the main focus of the WTC Health Program is to assess your health, the information that is learned about 9/11 responders will be extremely valuable in understanding how to protect workers in future emergency or disaster operations.
     

• What if I want to be screened for cancer?

  Screening for some types of cancer may be available to you as part of the annual monitoring exam benefit. Although you are not required to have a certified WTC-related health condition to receive a cancer screening, other requirements, such as age, may have to be met. Cancer screening will be offered to eligible WTC Health Program members in accordance with the U.S. Preventive Services Task Force Guidelines.

• What should I do if I am not a member of the WTC Health Program?

  If you believe you may be eligible for the program, please visit the WTC Health Program website for information about the application process, www.cdc.gov/wtc or contact the WTC Health Program at 1-888-982-4748.

• What if my health condition is not on the List of WTC-Related Health Conditions?

  Only those health conditions on the List of WTC-Related Health Conditions will be covered by the program. Even if you think your health condition is not on the List, you should contact your Clinical Center of Excellence or your Nationwide Provider Network to inform your doctor about your health condition and find out if it is covered by the WTC Health Program.
  
  If you find out that your health condition is not on the List, the WTC Health Program will not cover the costs of your treatment, drugs, or services. However, if needed, your doctor may work with you to help you identify a place to get your care.
  
  In addition, the Administrator may propose the addition of other types of health conditions to the List of WTC-Related Health Conditions if he determines that there is new scientific evidence of a relationship between WTC exposures and a specific type of health condition. If your health condition is added to the List of WTC-Related Health Conditions in the future, the WTC Health Program will make every effort to inform you of this change. Any interested party may petition the Administrator to add health conditions to the List of WTC-Related Health Conditions. Additional information about the petition process is available on our Petitions page.

• Who decided which conditions are considered WTC-related health conditions?

  The James Zadroga 9/11 Health and Compensation Act of 2010 specified a number of health conditions covered by the WTC Health Program. The list was developed using existing knowledge of the health effects related to the toxins, contaminants, and other hazards that responders and survivors experienced at the three 9/11 terrorist attack sites. This list of health conditions, codified by regulation as the List of WTC-Related Health Conditions, may be amended by the WTC Program Administrator to include other health conditions as more information is learned about the relationship of 9/11 terrorist site exposures and those health conditions. For instance, in October 2012, the WTC Health Program amended the List to include certain types of cancer.

• I believe another medical condition should be covered by the WTC Health Program. What can I do?

  You (or any interested party) may petition the Administrator of WTC Health Program to add a recognized medical condition to the List of WTC-Related Health Conditions found in the WTC Health Program regulations. Please use this form. More information about the process for adding a health condition to the List of WTC-Related Health Conditions is available on our Petitions page.

Medically Necessary Dental Care Covered by the Program for Members with Head and Neck Cancers

• Does the WTC Health Program provide dental health benefits?

  In some cases, yes. The Program will pay for medically necessary dental care for members who have certified WTC-related head and neck cancers. To see the list of covered head and neck cancers, please visit our Covered Conditions page.

• What does medically necessary mean?

  It means that the treatment has been shown to manage, cure, or improve a WTC-related health condition or a sickness that was caused by a WTC-related condition (known as a medically associated condition).

• When will the Program pay for dental care?

  The Program may approve dental care for two reasons:

  1. dental care is needed before head and neck cancer treatment to make the treatment safer and/or more effective; or
  2. dental care is needed after head or neck cancer care to help recover from any harmful effects of the cancer treatment.

• What types of dental treatments may be covered by the Program?

  If approved, the Program may cover: initial dental exams to identify the treatment plans, visits to diagnose problems caused by the radiation or chemotherapy, some dental x-rays, and in some cases surgery to remove an erupted tooth prior to radiation and chemotherapy.

• What dental care is not covered?

  In most cases dental care that is routine is not covered.

• How do I get dental care if I have a certified WTC-related head and neck cancer?

  Your dental care first must be approved by the Medical Director at your Clinical Center of Excellence or the Nationwide Provider Network. Any follow-up dental care must be approved by the Program’s Medical Benefits Manager at NIOSH. Speak with your Program doctor if you have questions or concerns about getting approval for dental care.

• What happens if my request for dental treatment is denied?

  As with all treatment in the WTC Health Program you have the right to appeal a denial.

Where to Receive WTC Health Program Monitoring and Treatment Services

General Information

• What are the locations of the medical providers?

  There are seven Clinical Centers of Excellence in the New York metropolitan area. Many of these clinics have multiple locations throughout New York and New Jersey (see www.cdc.gov/wtc/clinics.html). For responders living outside this NYC/NJ area, the Nationwide Provider Network has physicians across the country that are able to provide care.

  Current and retired FDNY employees are seen at the Bureau of Health Services office in Brooklyn or may be referred to satellite locations. For FDNY members living outside this NYC/NJ area, the Nationwide Provider Network has physicians across the country that are able to provide care.

  For newly enrolled survivors in the New York metropolitan area, you will go to the Bellevue Hospital Center for your initial health evaluation. For follow-up treatment, you may go to Bellevue Hospital, Elmhurst Hospital, or Gouverneur Hospital. For survivors living outside this NYC/NJ area, the Nationwide Provider Network has physicians across the country that are able to provide care.

• How do I make an appointment?

  You should not make an appointment until you have applied to the WTC Health Program and are notified that you are enrolled. Once you are enrolled, you will be given instructions on how to make an appointment or you will be contacted by the program or Clinical Center of Excellence or Nationwide Provider Network.

Clinical Centers of Excellence

• What are the Clinical Centers of Excellence?

  The Clinical Centers of Excellence are a network of healthcare professionals in New York City and New Jersey with experience in caring for responders and survivors of the September 11, 2001, terrorist attacks. A listing of the Clinical Centers of Excellence can be found at Find a Clinic.

• Can I be seen at more than one Clinical Center of Excellence?

  No. To maintain continuity of care, you must receive your WTC Health Program health benefits through one Clinical Center of Excellence, or through the Nationwide Provider Network.

• Can I switch to a different Clinical Centers of Excellence?

  If you would like to switch your Clinical Center of Excellence, you may elect another participating Clinical Center of Excellence to provide your benefits. If you move out of the New York metropolitan area, you may transfer into the Nationwide Provider Network.

  Before making any change, you must first notify your current Clinical Center of Excellence or the Nationwide Provider Network and have your medical records transferred to the new location to arrange an appointment. Only one transfer per year will be allowed, except in special situations.

Nationwide Provider Network

• What is the Nationwide Provider Network?

  The WTC Health Program has a nationwide network of clinics with providers across the country for responders and survivors who live outside the New York metropolitan area. For information about the Nationwide Provider Network, call 1-888-982-4748.

• How is the Nationwide Provider Network different than the New York City and New Jersey clinics?

  The Nationwide Provider Network is able to find the providers you need close to where you live so that you do not have to pay the expense to travel to the New York metropolitan area. If you are currently a patient at one of the Clinical Centers of Excellence in the New York metropolitan area, you can continue to be a patient there if you choose. However, if you live outside the New York metropolitan area and choose to continue your care at one of the Clinical Centers of Excellence locations in the New York metropolitan area, you will be responsible for your travel expenses.

  The Nationwide Provider Network conducts the initial health evaluation and monitoring exams differently than is done at the Clinical Centers of Excellence. The exam is conducted in a three-part process: a medical history questionnaire, testing, and a clinical evaluation. The medical history questionnaire will be conducted over the phone by a member of the Nationwide Provider Network's Case Management team. During the call you will be scheduled for an appointment with a provider for the appropriate testing services. Upon completion of these two parts of the process, you will be scheduled for a clinical evaluation in order to complete your exam.

• I am a survivor and I was told that I could not join the Nationwide Provider Network and had to go to a clinic in the New York metropolitan area. Is this still true?

  Starting October 1, 2012, the Nationwide Provider Network began accepting survivors. If you are a survivor who is enrolled in the WTC Health Program, live outside the New York metropolitan area, and would like to receive your care through the Nationwide Provider Network, call 1-888-982-4748.

• Do I have to enroll in the Nationwide Provider Network if I am a survivor who lives outside the New York metropolitan area?

  No. If you are a survivor who lives outside the New York metropolitan area then you can choose to either get care at one of the NYC Health + Hospitals Corporation WTC Environmental Health Center clinics at Bellevue, Gouverneur, or Elmhurst or you can enroll in the Nationwide Provider Network. If you choose to visit a clinic in the New York metropolitan area, you are responsible for your travel costs for your clinic visits.

• Do I have to reapply to the program if I want to receive services from the Nationwide Provider Network?

  If you have already enrolled in the WTC Health Program and have been determined to be eligible for treatment and monitoring services, you do not need to reapply. If you are already receiving care at a Clinical Center of Excellence in the New York metropolitan area and you want to receive services from the Nationwide Provider Network, then you should call your clinic and ask them to transfer you. If you are enrolled in the WTC Health Program but you are not a patient at a clinic in the New York metropolitan area then you should call the WTC Health Program at 1-888-982-4748 and tell us you would like to receive your health benefits through the Nationwide Provider Network.

Your Medications are Generic Brands and You are Asking Why and are They Effective

• What does “generic first” mean for filling my prescriptions?

  Starting March 1, 2016, prescriptions for medications that come in generic form must be filled using the generic medication. This practice is common in many government and private insurance companies. In fact, nearly 8 in 10 prescriptions filled in the U.S. are for generic drugs.

• Are generic drugs as safe and effective as brand name drugs?

  Yes. The United States Food and Drug Administration (FDA) says that generic drugs must be equally safe and effective as the brand name version. Generic drugs contain the same active ingredients as brand name drugs so they have the same risks and benefits. A generic drug is the same as a brand drug in its:

  • Dosage
  • Safety
  • Stability
  • Strength
  • Purity
  • Quality
  • The way it works
  • The way it is taken
  • The way it should be used

• Why are generic drugs cheaper?

  On average, the cost of a generic drug is 80 – 85% lower than brand name drugs. Generic manufacturers are able to sell their products for lower prices because they are not required to repeat the costly clinical trials of new drugs and generally do not pay for advertising, marketing, and promotion. In addition, multiple generic companies are often approved to market a single product; this creates competition in the market place, often resulting in lower prices.

• How do I switch my prescription to a generic drug?

  If you are on a brand name drug, and need to be switched to a generic, your WTC Health Program doctor will either provide you with a new prescription or will contact your pharmacy directly. When you receive prescriptions for new medications, they will automatically be filled with the generic drug.

• What happens if there is no generic version of the medicine I take?

  For some drugs, there are no approved generics. In these cases, the WTC Health Program will review the available medications to compare effectiveness and cost. The Program will then decide to cover a specific medication based on the one that provides the best treatment at the best cost. This practice is known as “preferred medications,” and is common with all major government and private insurance companies.

• Why does it matter which brand name medication is used if there is no generic?

  When approved generic medications are available, they will always be preferred. When a generic is not available, the Program is required to make sure that money is still spent responsibly. In order to make sure this happens, healthcare experts review the available brand name drugs and choose the medications that are the most effective in treating your condition at the lowest cost. This is why sometimes a brand medication may be “preferred.”

• Do preferred medications change?

  Yes. The Program will periodically conduct reviews of medications. In most cases, we will notify members of changes in the preferred medications every year. There may be times we notify you sooner than every 12-months if there is a reason the Program needs to make a change sooner.

• Why do preferred medications change?

  There are several reasons why the Program will change the medications that are covered. Some of these factors include:

  • If the FDA approves a new generic drug, the preferred drug will change to the new generic.
  • A new drug may become available to treat your condition that has the same effectiveness and is less expensive than the current preferred medication.
  • A new over-the-counter medication may become available that the Program will cover at a lower cost.
  • As the market changes, drug costs may change. This could lead to a change in the preferred drug available to members.

• Why do some drugs say “OTC”?

  OTC means over-the-counter. If your doctor prescribes you an OTC medication, it will be filled by the pharmacist the same as any other prescription and the WTC Health Program will pay all costs. The Program will not reimburse you for any OTC medications you purchase on your own.

You Disagree with an Enrollment or Disenrollment Decision Made by the WTC Health Program

Appeal Request

• Who may request an appeal?

  Any applicant denied eligibility for enrollment in the WTC Health Program or a WTC Health Program member disenrolled has the right to appeal the denial decision.

• When can I request an appeal?

  If you are denied enrollment or have been disenrolled from the WTC Health Program, you will receive a letter from the Program notifying you of the denial or disenrollment. You have 120 calendar days from the date of the denial or disenrollment letter to appeal the decision. Please note, the 120 calendar days is counted from the date on the top of the denial or disenrollment letter; it is not counted from the postmarked date or from the date you receive the letter.

• How do I request an appeal?

  You must mail or electronically transmit a scanned of a written and signed letter to the WTC Health Program's appeal coordinator. The request must be postmarked or, if sent electronically, transmitted within 120 calendar days of the date of the denial or disenrollment letter. If your appeal request is not postmarked or transmitted electronically within 120 calendar days of the date of the denial or disenrollment letter, your request will not be considered further.

  Use the following mailing address or fax number to send your request to the appeal coordinator:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• What is required to be included in my appeal letter request?

  The following information is required to be included in an appeal letter request:

  1. The name, address, and contact information of the denied applicant or disenrolled WTC Health Program member, as well as the member’s designated representative, if applicable, who is requesting the appeal; and
  2. A clear statement of the reason(s) why the applicant, disenrolled WTC Health Program member, or designated representative believes the denial of enrollment or disenrollment is incorrect and should be reversed. The appeal request may include relevant new information not previously considered by the WTC Health Program.
• What else can I include in my appeal request letter?

  If you wish to designate a representative to act on your behalf, you may include your request in your appeal request letter (see Using a Representative).

• What happens when my appeal request is received?

  When your letter or electronic request for an appeal is received by the WTC Health Program, the appeal coordinator will examine your appeal request to ensure that it meets all of the requirements. (See What is required to be included in my appeal letter request?)

• If my appeal request is accepted for review, what happens next?

  The appeal coordinator will notify you by letter if your appeal is accepted and provide a brief statement about next steps. Upon the receipt of a valid appeal, the Administrator will appoint a Federal Official independent of the WTC Health Program who will review your appeal.

• What happens if my appeal is not accepted for review?

  If your appeal request is not accepted, the appeal coordinator will notify you by letter. The appeal coordinator will inform you of the specific reason(s) why your appeal request was not accepted. No further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued outside the administrative appeal process of the WTC Health Program.

Appeal Review

• How will the Federal Official review my appeal?

  The Federal Official will review any information relevant to the denial of enrollment or disenrollment from the WTC Health Program that is available in your Program member file, including the information you provided with your appeal request and, if applicable, medical record.

• Who makes the final decision on my appeal?

  The Administrator makes the final decision on your appeal. A Federal Official independent of the WTC Health Program is appointed by the Administrator to review your appeal and make a recommendation to the Administrator. The Federal Official will review all available records and may consider additional relevant new information submitted. The Federal Official evaluates all the information and provides a recommendation on whether to grant your appeal to the Administrator. After receipt of the Federal Official’s recommendation, the Administrator will make a final decision on your appeal.

• How will I be informed of the final decision on my appeal?

  The Administrator will notify the WTC Health Program member and/or the member’s designated representative in writing of the decision and provide an explanation of the reason(s) for the decision, as well as any actions taken by the WTC Health Program as a result of the Administrator’s decision. For example, if your appeal of the disenrollment is granted, these actions could include re-enrollment in the WTC Health Program.

• What happens if my appeal is denied by the Administrator?

  If your appeal is denied, no further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued legally outside the administrative appeal process of the WTC Health Program.

Using a Representative

• Can I designate someone to represent me during the appeal process?

  Yes. You can designate one representative to act on your behalf in the WTC Health Program, including representing your interests during the appeal process. Your designated representative can mail or electronically transmit a request for an appeal on your behalf and represent you during the appeal process.

• When can I designate a representative for my appeal?

  You can designate a representative for the WTC Health Program anytime, including anytime during the appeal process.

• How do I designate a representative for my appeal?

  You can designate a representative by sending a letter to the appeal coordinator. In your letter, include the name, address, and contact information for the individual you designate as your representative. Mail or electronically transmit a letter to the appeal coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• How will my representative be recognized by the WTC Health Program?

  The WTC Health Program will review your designation to ensure that the individual's service does not violate any applicable laws. The appeal coordinator will send you a letter notifying you whether or not your designated representative can be recognized by the Program and providing any additional materials necessary to effect the designation. If you designate a representative for the appeal process, and that representative is recognized by the Program, then all communications sent to you concerning the appeal process will also be sent to your representative.

• Can I have more than one designated representative at a time?

  No. You may only have one designated representative at a time. If you choose to request a different designated representative, you must first withdraw the appointment of the previously designated representative by sending a written and signed request to the Appeal Coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• Who is my representative if I am less than 18 years old?

  If you are a WTC Health Program member and are a minor (less than 18 years of age in most states), your parent or guardian may act on your behalf. If a parent or guardian will act on behalf of a minor, mail or electronically transmit a letter notifying the Program of the name, address, and contact information of the person who will act for the minor to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

Making an Oral Statement

• Can I make an oral statement during my appeal?

  No. The WTC Health Program does not allow oral statements during the appeal process for denial of an enrollment decision or a disenrollment decision.

Getting Help

• Where can I get help if I have questions about the appeal process?

  If you need help understanding the appeal process, you can call the WTC Health Program Call Center at 1.888.982.4748 Monday through Friday, 9 a.m. to 5 p.m. Eastern Time Zone. The Call Center will refer you to the appeal coordinator who can explain the appeal process and answer any questions you may have.

You Disagree with a Health Condition Certification or Decertification Decision Made by the WTC Health Program

Appeal Request

• Who may request an appeal?

  Enrolled members of the WTC Health Program have the right to appeal the following types of decisions:

  • Denial of certification of a health condition as a WTC-related health condition;
  • Denial of certification of a health condition as a health condition medically associated with a WTC-related health condition;
  • Decertification of a WTC-related health condition; or
  • Decertification of a health condition medically associated with a WTC-related health condition.

• When can I request an appeal?

  If you are denied certification of a health condition or your health condition is decertified, you will receive a letter from the WTC Health Program notifying you of the denial or decertification. You have 120 calendar days from the date of the denial or decertification letter to appeal the decision. Please note, the 120 calendar days to request an appeal is counted from the date on the top of the denial letter; it is not counted from the postmarked date or from the date you receive the letter.

• How do I request an appeal?

  You must mail or electronically transmit a scanned copy of a written and signed letter to the WTC Health Program's appeal coordinator. The request must be postmarked or, if sent electronically, transmitted, within 120 calendar days of the date of the denial or decertification letter. If your appeal request is not postmarked or transmitted electronically within 120 calendar days of the date of the denial or decertification letter, your request will not be considered further.

  Use the following mailing address or fax number to send your request to the appeal coordinator:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• What is required to be included in my appeal request letter?

  The following information is required to be included in an appeal request letter:

  1. The name, address, and contact information of the WTC Health Program member as well as the member’s designated representative, if applicable, who is requesting the appeal; and
  2. A clear statement of the reason(s) why you think the denial was wrong. For example, you can state that the denial or decertification 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 or decertification was not reasonable as applied to the facts of your case.

  If needed, contact your Clinical Center of Excellence (CCE)/Nationwide Provider Network (NPN) for information and assistance.

• What else can I include in my appeal request letter?

  Members who are denied certification of a health condition or have a health condition decertified may request the following in their appeal request letter:

  1. Request An Oral Statement. If you wish to make an oral statement to the Federal Official who will review your appeal, you may ask for an opportunity to do so in writing in your appeal request letter (see Making an Oral Statement).
  2. Designate A Representative. If you wish to designate a representative to act on your behalf, you may include your request in your appeal request letter (see Using a Representative).

• Are there any limitations on what I can include in my appeal request letter?

  An appeal request that objects to the rationale or methodology upon which the WTC Health Program’s policies and procedures are based is considered to be outside the scope of the Program’s administrative appeal process. For example, the WTC Health Program will not accept for review an appeal request for the denial of certification of a health condition that is not on the List of WTC-Related Health Conditions (List) at 42 C.F.R. § 88.15, or medically associated with a health condition on the List. However, the WTC Health Program will consider an appeal if the member argues that the CCE or NPN physician incorrectly characterized the member’s health condition as a condition not on the List. (See What happens if my appeal request is not accepted for review?)

• What happens when my appeal request is received?

  When your letter or electronic request for an appeal is received by the WTC Health Program, the appeal coordinator will examine your appeal request to ensure that it meets all of the requirements (see What is required to be included in my appeal request letter?).

• If my appeal request is accepted for review, what happens next?

  The appeal coordinator will notify you by letter if your appeal request is accepted or not. If your appeal request is accepted, the letter from the appeal coordinator will also inform you of the name of the Federal Official who will review your appeal.

• What happens if my appeal request is not accepted for review?
  

  If your appeal request is not accepted, the appeal coordinator will notify you by letter. The appeal coordinator will inform you of the specific reason(s) why your appeal request was not accepted. No further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued outside the administrative appeal process of the WTC Health Program.

Appeal Review

• How will the Federal official review my appeal?

  The Federal Official will review any information relevant to the denial certification of a health condition or the decertification of a health condition that is available in your WTC Health Program member file and medical record and the information you provided with your appeal request, as well as information presented in your oral statement, if you choose to make one.

• Who makes the final decision on my appeal?

  The Administrator makes the final decision on your appeal. A Federal Official independent of the WTC Health Program is appointed by the Administrator to review your appeal and make a recommendation on it to the Administrator. The Federal Official will review all available records and may consider additional relevant new information submitted, including your oral statement if you choose to make one. The Federal Official evaluates all of the information and provides a recommendation on whether to grant your appeal, including any findings or supporting materials (including the transcript of any oral statement and any expert reviewers’ findings), to the Administrator. After receipt of the Federal Official’s recommendation, the Administrator will make a final decision on your appeal.

• How will I be informed of the final decision on my appeal?

  The Administrator will notify the WTC Health Program member and/or the member’s designated representative in writing of the decision and provide an explanation of the reason(s) for the decision, as well as any actions taken by the WTC Health Program as a result of the Administrator’s decision. For example, if your appeal of the health condition certification denial is granted, these actions could include certifying a health condition as a WTC-related health condition and recognizing a member’s status as a certified-eligible survivor.

• What happens if my appeal is denied by the Administrator?

  If your appeal is denied, no further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued legally outside the administrative appeal process of the WTC Health Program.

  
  

Using a Representative

• Can I designate someone to represent me during the appeal process?

  Yes. You can designate one representative to act on your behalf in the WTC Health Program, including representing your interests during the appeal process. Your designated representative can mail or electronically transmit a request an appeal on your behalf and represent you during the appeal process.

• When can I designate a representative for my appeal?

  You can designate a representative for the WTC Health Program anytime, including anytime during the appeal process.

• How do I designate a representative for my appeal?

  You can designate a representative by sending a letter to the appeal coordinator. In your letter, include the name, address, and contact information for the individual you designate as your representative. Mail or electronically transmit a letter to the appeal coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

• How will my representative be recognized by the WTC Health Program?

  The WTC Health Program will review your designation to ensure that the individual's service does not violate any applicable laws. The appeal coordinator will send you a letter notifying you whether or not your designated representative can be recognized by the Program and providing any additional materials necessary to effect the designation. If you designate a representative for the appeal process, and that representative is recognized by the Program, then all communications sent to you concerning the appeal process will also be sent to your representative.

• Can I have more than one designated representative at a time?

  No. You may only have one designated representative at a time. If you choose to request a different designated representative, you must first withdraw the appointment of the previously designated representative by sending a written and signed request to the Appeal Coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• Who is my representative if I am less than 18 years old?
  
  

  If you are a WTC Health Program member and are a minor (less than 18 years of age in most states), your parent or guardian may act on your behalf. If a parent or guardian will act on behalf of a minor, mail or electronically transmit a letter notifying the Program of the name, address, and contact information of the person who will act for the minor to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

Making an Oral Statement

• Can I make an oral statement during my appeal?

  Yes. You can request an opportunity to make an oral statement to the Federal Official by telephone during the appeal review. See "When and how can I request to make an oral statement during my appeal?" below.

• When and how can I request to make an oral statement during my appeal?

  You can request the opportunity to make an oral statement during the appeal review at the time you send your appeal request letter to the WTC Health Program. Or, you can request to make an oral statement within 14 calendar days of receiving the letter from the appeal coordinator accepting your appeal for review and notifying you of the name of the Federal Official who will review your appeal. Mail or electronically transmit your request to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• How will my oral statement be scheduled?

  Following the WTC Health Program's receipt of your request to make an oral statement, the appeal coordinator will contact you by telephone to discuss and set a convenient date and time for you to make an oral statement to the Federal Official. After three unsuccessful attempts by the appeal coordinator to contact you, the appeal coordinator will send you a letter explaining that the coordinator has not been able to contact you to schedule the oral statement and that your review will occur without your oral statement. The oral statement with the Federal Official will be allowed by telephone conference only. If you want to allow a representative to make an oral statement either in your place or with you, you must designate the representative prior to the scheduling of the oral statement with the Federal Official (see Using a Representative).

• What can I say to the Federal official during my oral statement?

  You can make an oral statement to the Federal Official about the reason(s) why you think the denial or decertification was wrong. For example, you can explain why you think the denial or decertification was based on factually inaccurate information, why you think that the Program's policies and procedures were not applied correctly to the facts of your case, or why you think the denial or decertification was not reasonable given the facts of your case.

• How do I make my oral statement?

  You and/or your designated representative will have a total of 15 uninterrupted minutes to make an oral statement to the Federal Official by telephone. You can share the 15 minutes with your representative, or either you or your representative can use the entire 15 minutes. After the oral statement, the Federal Official may engage you and/or your representative in questions, but for no longer than 45 additional minutes. The maximum commitment of time for the oral statement, including questions from the Federal Official, is 1 hour.

• Can I make an oral statement in a language other than English?

  Yes. Inform the appeal coordinator at the time you make your request to make an oral statement that you wish to request translation services for your oral statement. The WTC Health Program will provide translation services to you at no cost. Family members may not serve as translators.

• Will the Federal official decide my appeal when I finish my oral statement?

  No. The Federal Official will review all the information provided during the appeal, including the oral statement, and make a recommendation to the Administrator. You will receive a final decision on your appeal in writing from the Administrator at a later time.

• What happens if I am unable to make my oral statement at the scheduled date and time?

  A second opportunity to make an oral statement to the Federal Official will be provided only if you can show that a medical emergency (or similarly serious situation) prevented you or your designated representative from being available when the oral statement was originally scheduled.

• Will there be a transcript of my oral statement to the Federal official for me to review?

  Yes. A written transcript of the oral statement (including any questions asked by the Federal Official and responses provided to those questions) will be prepared and provided to you as soon as feasible following completion of the oral statement.

• Can I correct any errors I find in the transcript?

  Yes. You can correct any errors you find in the transcript. Mail or electronically transmit the corrected transcript to the following address or fa number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

  The transcript containing your corrections must be postmarked or electronically transmitted within 14 calendar days of the date of the appeal coordinator's letter accompanying the transcript. The corrected transcript will be provided to the Federal Official reviewing your appeal.

  
  

Getting Help

• Where can I get help if I have questions about the appeal process?

  If you need help understanding the appeal process, you can call the WTC Health Program Call Center at 1.888.982.4748 Monday through Friday, 9 a.m. to 5 p.m. Eastern Time Zone. The Call Center will refer you to the appeal coordinator who can explain the appeal process and answer any questions you may have.

You Disagree with a Denial for Authorization of Treatment for a Certified Health Condition Decision Made by the WTC Health Program

Appeal Request

• Who may request an appeal?

  Enrolled members of the WTC Health Program have the right to appeal a Program’s decision to deny authorization of treatment for a certified health condition.

• When can I request an appeal?

  If you are denied authorization of treatment of a certified health condition, you will receive a letter from the WTC Health Program notifying you of the denial. You have 120 calendar days from the date of the denial letter to appeal the decision. Please note that 120 calendar days to request an appeal is counted from the date on the top of the denial letter; it is not counted from the postmarked date or from the date you receive the letter.

• How do I request an appeal?

  You must mail or electronically transmit a scanned copy of a written and signed letter to the WTC Health Program's appeal coordinator. The request must be postmarked or, if sent electronically, transmitted within 120 calendar days of the date of the denial letter. If your appeal request is not postmarked or transmitted electronically within 120 calendar days of the date of the denial letter, your request will not be considered further.

  Use the following mailing address or fax number to send your request to the appeal coordinator:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

• What is required to be included in my appeal request letter?

  The following information is required to be included in an appeal request letter:

  • The name, address, and contact information of the WTC Health Program member, as well as the member’s designated representative, if applicable, 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.

  If needed, contact your Clinical Center of Excellence of Nationwide Provider Network for information and assistance.

• What else can I include in my appeal request letter?

  Members who are denied authorization of treatment for a certified health condition may request the following in their appeal request letter:

  • Request An Oral Statement. If you wish to make an oral statement to the Federal Official who will review your appeal, you may ask for an opportunity to do so in writing in your appeal request letter (see Making an Oral Statement)
  • Designate A Representative. If you wish to designate a representative to act on your behalf, you may include your request in your appeal request letter (see Using a Representative)

• Are there any limitations on what I can include in my appeal request letter?

  An appeal request that objects to the rationale or methodology upon which the WTC Health Program’s policies and procedures are based is considered to be outside the scope of the Program’s administrative appeal process. (See What happens if my appeal request is not accepted for review?)

• What happens when my appeal request is received?

  When your letter or electronic request for an appeal is received by the WTC Health Program, the appeal coordinator will examine your appeal request to ensure that it meets all of the requirements (see What is required to be included in my appeal request letter?)

• If my appeal request is accepted for review, what happens next?

  The appeal coordinator will notify you by letter if your appeal request is accepted or not. If your appeal request is accepted, the letter from the appeal coordinator will also inform you of the name of the Federal Official who will review your appeal.

• What happens if my appeal request is not accepted for review?
  

  If your appeal request is not accepted, the appeal coordinator will notify you by letter. The appeal coordinator will inform you of the specific reason(s) why your appeal request was not accepted. No further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued outside the administrative appeal process of the WTC Health Program.

Appeal Review

• How will the Federal Official review my appeal?

  The Federal Official will review any information relevant to the denial of authorization of treatment for a certified health condition that is available in your WTC Health Program member file and medical record and the information you provided with your appeal request as well as information presented in your oral statement, if you choose to make one.

• Who makes the final decision on my appeal?

  The Administrator makes the final decision on your appeal. A Federal Official independent of the WTC Health Program is appointed by the Administrator to review your appeal and make a recommendation on it to the Administrator. The Federal Official will review all available records and may consider additional relevant new information submitted, including your oral statement if you choose to make one. The Federal Official evaluates all of the information and provides a recommendation on whether to grant your appeal, including any findings or supporting materials (including the transcript of any oral statement and any expert reviewers’ findings), to the Administrator. After receipt of the Federal Official’s recommendation, the Administrator will make a final decision on your appeal.

• How will I be informed of the final decision on my appeal?

  The Administrator will notify the WTC Health Program member and/or the member’s designated representative in writing of the decision and provide an explanation of the reason(s) for the decision, as well as any actions taken by the WTC Health Program as a result of the Administrator's decision. If your appeal of the denial of authorization of treatment for a certified health condition is granted, the Program will authorize treatment for the certified health condition.

• What happens if my appeal is denied by the Administrator?

  If your appeal is denied, no further consideration will be given to your appeal request by the WTC Health Program. Further consideration of your appeal request would have to be pursued legally outside the administrative appeal process of the WTC Health Program.

  
  

Using a Representative

• Can I designate someone to represent me during the appeal process?

  Yes. You can designate one representative to act on your behalf in the WTC Health Program, including representing your interests during the appeal process. Your designated representative can mail or electronically transmit a request for an appeal on your behalf and represent you during the appeal process.

• When can I designate a representative for my appeal?

  You can designate a representative for the WTC Health Program anytime, including anytime during the appeal process.

• How do I designate a representative for my appeal?

  You can designate a representative by sending a letter to the appeal coordinator. In your letter, include the name, address, and contact information for the individual you designate as your representative. Mail or electronically transmit a letter to the appeal coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

• How will my representative be recognized by the WTC Health Program?

  The WTC Health Program will review your designation to ensure that the individual's service does not violate any applicable laws. The appeal coordinator will send you a letter notifying you whether or not your designated representative can be recognized by the Program and providing any additional materials necessary to effect the designation. If you designate a representative for the appeal process, and that representative is recognized by the Program, then all communications sent to you concerning the appeal process will also be sent to your representative.

• Can I have more than one designated representative at a time?

  No. You may only have one designated representative at a time. If you choose to request a different designated representative, you must first withdraw the appointment of the previously designated representative by sending a written and signed request to the Appeal Coordinator at the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• Who is my representative if I am less than 18 years old?
  
  

  If you are a WTC Health Program member and are a minor (less than 18 years of age in most states), your parent or guardian may act on your behalf. If a parent or guardian will act on behalf of a minor, mail or electronically transmit a letter notifying the Program of the name, address, and contact information of the person who will act for the minor to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

Making an Oral Statement

• Can I make an oral statement during my appeal?

  Yes. You can request an opportunity to make an oral statement to the Federal Official by telephone during the appeal review. See "When and how can I request to make an oral statement during my appeal?" below.

• When and how can I request to make an oral statement during my appeal?

  You can request the opportunity to make an oral statement during the appeal review at the time you send your appeal request letter to the WTC Health Program. Or, you can request to make an oral statement within 14 calendar days of receiving the letter from the appeal coordinator accepting your appeal for review and notifying you of the name of the Federal Official who will review your appeal. Mail or electronically transmit your request to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338

• How will my oral statement be scheduled?

  Following the WTC Health Program's receipt of your request to make an oral statement, the appeal coordinator will contact you by telephone to discuss and set a convenient date and time for you to make an oral statement to the Federal Official. After three unsuccessful attempts by the appeal coordinator to contact you, the appeal coordinator will send you a letter explaining that the coordinator has not been able to contact you to schedule the oral statement and that your review will occur without your oral statement. The oral statement with the Federal official will be allowed by telephone conference only. If you want to allow a representative to make an oral statement either in your place or with you, you must designate the representative prior to the scheduling of the oral statement with the Federal Official (see Using a Representative).

• What can I say to the Federal Official during my oral statement?

  You can make an oral statement to the Federal official about the reason(s) why you think the denial was wrong. For example, you can explain why you think the denial was based on factually inaccurate information, why you think that the program's policies and procedures were not applied correctly to the facts of your case, or why you think the denial was not reasonable given the facts of your case.

• How do I make my oral statement?

  You and/or your designated representative will have a total of 15 uninterrupted minutes to make an oral statement to the Federal Official by telephone. You can share the 15 minutes with your representative, or either you or your representative can use the entire 15 minutes. After the oral statement, the Federal Official may engage you and/or your representative in questions, but for no longer than 45 additional minutes. The maximum commitment of time for the oral statement, including questions from the Federal Official, is 1 hour.

• Can I make an oral statement in a language other than English?

  Yes. Inform the appeal coordinator at the time you make your request to make an oral statement that you wish to request translation services for your oral statement. The WTC Health Program will provide translation services to you at no cost. Family members may not serve as translators.

• Will the Federal Official decide my appeal when I finish my oral statement?

  No. The Federal Official will review all the information provided during the appeal, including the oral statement, and make a recommendation to the Administrator. You will receive a final decision on your appeal in writing from the Administrator at a later time.

• What happens if I am unable to make my oral statement at the scheduled date and time?

  A second opportunity to make an oral statement to the Federal Official will be provided only if you can show that a medical emergency (or similarly serious situation) prevented you or your designated representative from being available when the oral statement was originally scheduled.

• Will there be a transcript of my oral statement to the Federal Official for me to review?

  Yes. A written transcript of the oral statement (including any questions asked by the Federal Official and responses provided to those questions) will be prepared and provided to you as soon as feasible following completion of the oral statement

• Can I correct any errors I find in the transcript?

  Yes. You can correct any errors you find in the transcript. Mail or electronically transmit the corrected transcript to the following address or fax number:

  Appeal Coordinator
  WTC Health Program
  P.O. Box 7000
  Rensselaer, NY 12144
  Fax: 1.404.471.8338
  
  

  The transcript containing your corrections must be postmarked or electronically transmitted within 14 calendar days of the date of the appeal coordinator's letter accompanying the transcript. The corrected transcript will be provided to the Federal Official reviewing your appeal.

  
  

Getting Help

• Where can I get help if I have questions about the appeal process?

  If you need help understanding the appeal process, you can call the WTC Health Program Call Center at 1.888.982.4748 Monday through Friday, 9 a.m. to 5 p.m. Eastern Time Zone. The Call Center will refer you to the appeal coordinator who can explain the appeal process and answer any questions you may have.

Recoupment & Coordination of Benefits regarding Workers' Compensation Payment

• Am I required to get World Trade Center (WTC) Health Program approval of a lump sum settlement agreement?

  Yes. Any proposed settlement agreement entered into on or after October 1, 2013, that will pay a lump sum to a workers’ compensation (WC) claimant and that will release all or part of an employer or insurer's obligation to pay future medical expenses for certified WTC-related and medically associated health conditions must protect the WTC Health Program’s interests. That means that, where appropriate, money from the settlement should be set aside to cover future medical expenses for WTC-related and medically associated health conditions that would otherwise have been paid by WC. These set aside amounts must be approved by the WTC Health Program prior to settlement. The WTC Health Program will not require its approval for any proposed settlement agreement filed with WC before October 1, 2013, even if not approved by WC before October 1, 2013.

• How much money must be allocated to future medical expenses in a lump sum settlement?

  The WTC Health Program expects the parties to allocate a reasonable amount toward future medical expenses for certified WTC-related or medically associated conditions in a lump sum settlement. Currently, Congress has funded the WTC Health Program through 2090, so the WTC Health Program will require a WC claimant to set aside funds for future medical expenses through 2090 or the life of the claimant. Future medical expenses should be calculated based on reimbursement rates under state WC law.

• What expenses must be considered when deciding how much money to set aside for future medical expenses?

  The WTC Health Program will require that money be set aside to cover reasonably anticipated costs of medical treatment and medications for certified WTC-related or medically associated health conditions. WC claimants are not required to set aside money to cover the cost of screening or monitoring exams or diagnostic testing provided by the WTC Health Program.
  
  Note: The Centers for Medicare and Medicaid Services (CMS) may impose separate and additional requirements relating to lump sum settlements. Additional information regarding CMS policies on lump sum settlements for future medical expenses can be found at www.cms.gov/Medicare/Coordination-of-Benefits/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSAP-Overview.html

• How do I get approval from the WTC Health Program for a set aside arrangement from a lump sum settlement?

  The claimant, or the claimant's authorized representative, must submit the following information to the WTC Health Program at wtchp.recoup@cdc.gov

  1. A copy of the proposed settlement agreement showing the amount allocated for future medical expenses.
  2. An explanation of how the amount allocated for future medical expenses was calculated.
     If the amount is based on the actuarial estimate of an outside expert, attach the expert's report.
  3. An indication of whether the settlement represents a compromise of a WC claim or a commutation to present value of an established claim.
  4. The name and address of the custodian of the funds to be set aside for future medical expenses. This custodian must be the person or entity that will pay any medical expenses on behalf of the WC claimant.

• How do I know whether the WTC Health Program has approved the set-aside?

  If the WTC Health Program agrees that the amount set aside for future medical expenses is reasonable, or that no set aside is required, it will send a letter to the party submitting the proposal indicating its approval.
  
  Approval by the WTC Health Program of a set aside arrangement satisfies the requirements for recoupment under the Zadroga Act. CMS may impose separate and additional requirements under the Social Security Act.

• What happens if the money set aside is not adequate to cover all future medical expenses?

  If the WTC Health Program approves the amount of money for future medical expenses, and the WC claimant establishes a set-aside account funded with the agreed-upon amount, the parties to the settlement agreement have a safe harbor that protects them from having to pay the WTC Health Program for any medical expenses in excess of the approved amount for future medical expenses. The WTC Health Program will bill the set-aside account periodically, up to the agreed-upon amount. If medical expenses exceed the amount in the WTC Health Program-approved set-aside account, the parties are not responsible for those future medical expenses and they will be paid by the WTC Health Program.

• What happens if the WTC Health Program does not approve my proposed set aside?

  If a WC claimant receives a settlement that releases the WC insurer or employer from legal responsibility for future medical expenses, and does not obtain WTC Health Program approval of the amount of that settlement to be set aside for future medical expenses, the WC claimant may be legally responsible for future medical expenses. These expenses are susceptible to recoupment from the WTC Health Program.