Member Handbook

About Your Member Handbook

This Handbook will help you better understand the benefits and services available to you as a member of the World Trade Center (WTC) Health Program.

This Handbook has seven sections:

1. Important Information for Members
2. Benefits and Services
3. Covered Conditions and Certifications
4. Treatment in the WTC Health Program
5. Pharmacy Benefits
6. Program Policies, Privacy, and Support
7. Glossary

Each one of these sections will explore that area of the Program in more detail.

Throughout the Handbook you will see a few symbols to highlight important information we don’t want you to miss:

Important note

Who to contact for help

More info online

Key Program term

Terms that are highlighted in purple are key terms with definitions in the Glossary.

In this section we've included important information for new members and helpful contact information for various parts of the Program. There is also a handy section for you to write down key details about your membership.

New to the WTC Health Program

In This Section:

• Important Contact Information
• Fill Out This Page For Your Reference

If you are new to the WTC Health Program, welcome. We are dedicated to providing you with compassionate, expert care for WTC-related conditions. There are some important things to remember as you get familiar with the Program.

• We are a limited federal benefits program administered by the National Institute for Occupational Safety and Health (NIOSH) within the U.S. Centers for Disease Control and Prevention (CDC).
• We provide medical monitoring and treatment for certified WTC-related conditions only.
• We do not replace your primary health insurance, and are not a health insurance provider. You must maintain your other health insurance to receive treatment through the Program.
• WTC-related care must be authorized and provided by a WTC Health Program Participating Provider (e.g., doctor, specialist, clinician).
• We are a separate program from the September 11th Victim Compensation Fund (VCF), administered by the U.S. Department of Justice (DOJ), and the WTC Health Registry.

The first step for every new member is getting an initial health evaluation. This is the first medical exam within the Program and looks for potential WTC-related health condition(s). For Responder members, this is also your first monitoring exam. Your Program welcome letter will have more information about your Clinical Center of Excellence or the Nationwide Provider Network and next steps for scheduling this exam.

Here are some helpful tips to prepare for your initial health evaluation:

Important Contact Information

WTC Health Program Member Services

Enrollment, Program benefits and policies, appeals, or to update your contact info
Call 888-982-4748 (M-F 9a-5p ET) or email wtc@cdc.gov

Express Scripts, Inc.

Pharmacy benefits, home delivery services, or issues filling a prescription
Call 800-935-7179 or visit the

Clinical Centers of Excellence or Nationwide Provider Network

Scheduling appointments, care and treatment, medications, provider authorizations and denials, case management, clinic transfers, and certifications.

Responder Clinical Centers of Excellence

Survivor Clinical Centers of Excellence

Nationwide Provider Network

Program Feedback

or write to the Administrator at CDC/NIOSH, WTC Health Program, 400 7th Street SW, Suite 5W, Washington, DC 20024

Fill Out This Page For Your Reference

Print this page and write down your key membership details here for your quick reference.
Membership Details [PDF, 1 page, 46 KB]

Benefits and Services

In This Section:

• Where you get care
  • Clinical Centers of Excellence
  • Nationwide Provider Network
• Program Exams
  • Monitoring, Diagnostic, and Screening Services
• Benefits Counseling
  • Workers' Compensation Counseling
  • September 11th Victim Compensation Fund (VCF) Assistance
  • External Work-Related and Disability Benefits Counseling
  • Social Services Assistance
  • Cancer Care Assistance
  • Non-Covered Conditions Assistance

Through the Zadroga Act and its implementing regulations, the WTC Health Program is able to provide WTC-related medical and mental health services at no out-of-pocket cost.

This means access to high-quality, compassionate care without any copayments, deductibles, or other out-of-pocket expenses for medically necessary treatment of certified WTC-related health conditions.

The services available to you depend on what type of enrolled member you are:

* Screening-Eligible Survivors receive select cancer screenings for six months from the date of initial health evaluation.

Where you get care

The Program covers medically necessary healthcare services within the United States and its territories, including the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, American Samoa, and the Trust Territory of the Pacific Islands.

These benefits and services are provided through Clinical Centers of Excellence for members in the New York (NY) metropolitan area. Members outside of the NY metropolitan area receive care through the Nationwide Provider Network.

The WTC Health Program does not cover medical care, pharmacy products, or supplies received outside of the United States or its territories.

Clinical Centers of Excellence

Care for both Responders and Survivors in the New York (NY) metropolitan area is provided through designated WTC Health Program Clinical Centers of Excellence (CCEs). CCE providers specialize in diagnosing and treating certified WTC-related health conditions.

Even if you reside outside of the NY metropolitan area, you can choose to receive your care at a CCE. However, the Program does not cover travel expenses for you to get to a CCE appointment.

For clinic contact information, see Important Contact Information.

General Responder CCEs

There are five General Responder CCEs in the NY metropolitan area:

FDNY Responder CCEs

The Fire Department of the City of New York (FDNY) has several clinic locations throughout the NY metropolitan area that serve FDNY Responders:

Survivor CCEs

There are two Survivor CCEs in the NY metropolitan area:

Nationwide Provider Network

Members who live outside the New York metropolitan area receive their WTC Health Program benefits through the Nationwide Provider Network (NPN). The NPN is a network of WTC Health Program Participating Providers throughout the country who provide WTC-related services. Members in the NPN get the same Program benefits as members who go to the CCEs.

Network: The health care providers, facilities, and pharmacies the Program has contracted with to provide you with health care services covered by the Program.

The NPN is different than the CCEs based in the New York metropolitan area. Unlike the CCEs, the NPN has no central clinic. Instead, a healthcare delivery company provides a network of individual providers or provider groups nationwide. Managed Care Advisors (MCA)-Sedgwick administers the NPN.

MCA-Sedgwick oversees the day-to-day operations of the NPN by:

• Building and expanding the available provider network
• Scheduling initial health evaluations, annual monitoring exams, and diagnostic appointments
• Submitting WTC-related health condition certification requests to the WTC Health Program
• Maintaining medical records for NPN members
• Operating an NPN-specific call center and online member portal

Since individual doctors and clinicians with their own specialties make up the NPN, you may need to go to more than one participating provider to receive care for each of your certified WTC-related health conditions.

If you live in an urban area, the NPN will try to find you care within 30 miles of your residence. If you live in a rural area, the NPN will try to find you care within 75 miles of your residence. If you would like to learn more about the location of local participating providers available to you through the NPN, please contact the NPN directly.

Program Exams

Monitoring, Diagnostic, and Screening Services

Initial Health Evaluations

Initial health evaluations are given to each new member of the World Trade Center (WTC) Health Program at no cost to you.

The purpose of the initial health evaluation is to find out if you have any conditions related to your 9/11 exposures that are covered by the Program. Only doctors who are WTC Health Program Participating Providers may conduct an initial health evaluation.

For more information on covered conditions, see the Covered Conditions section.

An initial health evaluation may include the following services:

• 9/11 exposure assessment;
• Blood tests;
• Medical history and mental health questionnaires;
• Physical examination;
• Urinalysis (urine test);
• Vital signs (blood pressure, pulse);
• Chest X-ray, if medically necessary;
• EKG (heart test), if medically necessary; and
• Spirometry/Pulmonary function testing (breathing test).

9/11 Exposure Assessment: A questionnaire used to gather a comprehensive and medically relevant exposure history that helps physicians determine if 9/11 exposures are substantially likely to be a significant factor in aggravating, contributing to, or causing conditions that may be submitted to the Program for a certification request.

Responders

When you first enroll, the Program provides an initial health evaluation to all members, Responders included. The Program provides Responders yearly follow-up exams called annual monitoring exams, whether you are sick or not.

Survivors

New Survivor enrollees in the Program are called Screening-Eligible Survivors. The Program offers a one-time initial health evaluation to all Screening-Eligible Survivors at no cost. The Zadroga Act allows only one initial health evaluation to be paid for by the Program. Therefore, Survivors should have symptoms of a WTC-related health condition before scheduling their initial health evaluation.

Until you have an initial health evaluation, most Program benefits are not available to you. If you receive your initial health evaluation and are not diagnosed with a certified WTC-related condition, you can receive selected cancer screenings covered by the Program for six (6) months.

As a Survivor, if you are certified as having a WTC-related health condition, then your status is changed to a Certified-Eligible Survivor. You are then eligible for Program benefits, such as yearly follow-up exams called annual monitoring exams, medical and mental health treatment for certified WTC-related health conditions, and benefits counseling.

Annual Monitoring Exams

Responders and Certified-Eligible Survivors receive annual monitoring exams in the Program. Annual monitoring exams help track your health over time and allow participating doctors to evaluate any new symptoms to determine if any WTC-related health condition(s) or health condition medically associated to your WTC-related health condition(s) have developed.

Your annual monitoring exam may include:

• Blood tests;
• Medical history and mental health questionnaires;
• Physical examination;
• Urinalysis (urine test);
• Vital signs (blood pressure, pulse);
• Chest X-ray, if medically necessary;
• EKG (heart test), if medically necessary; and
• Spirometry/Pulmonary function testing (breathing test).

Program members should contact their Clinical Center of Excellence (CCE) or Nationwide Provider Network (NPN) participating provider directly to schedule an annual monitoring exam.

Cancer Diagnostic and Screening Services

The Program covers diagnostic services, such as blood work, imaging studies, biopsies, and specialty consults that your WTC Health Program Participating Provider needs to determine if you have a cancer that is covered by the Program.

The Program covers cancer screenings for all members (except FDNY family members) who meet the age and risk-factor guidelines set forth by the U.S. Preventive Services Task Force (USPSTF). The criteria for each type of screening are listed below. Cancer screenings for Screening-Eligible Survivors are only covered by the Program from the date of their initial health evaluation until six (6) months after.

Cancer screening benefits may change based on new guidelines issued by USPSTF. The Program may offer additional screening tests in the future based on the recommendations for cancer screenings by the USPSTF.

Breast Cancer Screening/Mammograms

Eligible members between the ages of 40 and 74 can receive a mammogram once every other year. The Program will also cover an additional mammogram if you receive a positive test result from a mammogram.

Cervical Cancer Screening

Most members between the ages of 21 and 65 are eligible to receive cervical cancer screening covered by the Program. Members between the ages of 21 and 65 may receive a Pap smear every three years. Members between the ages of 30 and 65 who wish to lengthen the screening interval may choose to receive a Pap smear in combination with HPV testing every five years.

Colon Cancer Screening

In most cases, the Program provides colon cancer screening for members between the ages of 45 and 75. The frequency and type of screenings can be determined by your Program provider.

Lung Cancer Screening

Lung cancer screening once a year is available to eligible members aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. A pack year is the equivalent of smoking an average of 20 cigarettes, or one full pack, per day for a year.

Benefits Counseling

As a member of the Program, you may be eligible for benefits counseling from a case manager, social worker, benefits counselor, or other designated staff person at your CCE or the NPN. Benefits counselors can help identify benefits you may be eligible for and explain how you can apply for those benefits. Benefits counselors may also refer you to external benefits experts to help you access benefits available outside the Program, if needed.

As part of each visit, a CCE or NPN Program representative will work with you to complete a short benefits assessment questionnaire. The questionnaire helps the Program representative identify specific benefits for which you might be eligible. Then, you can work with your Program representative to learn more about those benefits, seek assistance applying for benefits, and/or be referred to a benefits expert for help.

Benefits Counseling: A service available to eligible members where a CCE or NPN WTC Health Program representative informs you about various benefits outside of the Program that you might be eligible for and assists you in applying for those benefits.

The WTC Health Program offers various types of benefits counseling, including:

Workers’ Compensation Counseling

Educates you about available workers’ compensation benefits, how to access them, and how they interact with WTC Health Program benefits.

More information on how Workers’ Compensation works with the Program.

September 11th Victim Compensation Fund (VCF) Assistance

Informs you about the September 11th Victim Compensation Fund (VCF), how to register and file a claim, and the relationship between the VCF and the WTC Health Program. Your WTC Health Program provider may conduct a VCF disability evaluation as needed and appropriate.

More information about the VCF is available.

External Work-Related and Disability Benefits Counseling

Helps you identify external (non-WTC Health Program) benefits you might be eligible for and educating you on how to access them.

Social Services Assistance

Helps you access needed social services, such as food, utility, housing, transportation, or other basic needs assistance.

Cancer Care Assistance

Helps members with cancer identify and access Program cancer-related benefits and services, as well as other resources needed for cancer treatment and/or in response to the financial, psychosocial, legal, or occupational impact of cancer on the member and the member’s family. Coordinates with oncology social workers as needed.

Non-Covered Conditions Assistance

Helps you identify appropriate care for medical and mental health conditions or medications not covered by the Program.

Contact information for CCEs and the NPN.

Program Policies, Privacy, and Support

In This Section:

• Designated Representatives
  • Who Can be a Designated Representative
  • How to Designate a Representative
• Appeals
  • What Can Be Appealed
  • What Cannot Be Appealed
  • Requesting an Appeal
  • Appeal Process
• HIPAA Privacy Practices in the WTC Health Program
  • How Do We Use and Share Your Personal Health Information?
  • How Else Do We Use and Share Your Personal Health Information?
  • What Are Your Rights When It Comes To Your Personal Health Information?
  • When Do We Require Your Written Permission?
  • What Are the Responsibilities of the WTC Health Program?
  • How Can You Contact the WTC Health Program?
  • How Can You File a Complaint?
• Complaint Procedure
  • Fraud and Abuse
• Other September 11th Programs
  • September 11th Victim Compensation Fund
  • WTC Health Registry
  • Workers' Compensation Benefits
  • New York State Workers' Compensation Law

Designated Representatives

A designated representative is someone you appoint and authorize to act on your behalf and represent your administrative interests in the World Trade Center (WTC) Health Program. However, this person may not make medical care (e.g., treatment) decisions for you.

When you designate a representative, you must also authorize the WTC Health Program to disclose your personal health information to the representative under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Once you designate a representative and complete a HIPAA authorization for them, the designated representative may then:

• Serve as your representative in all matters pertaining to your membership in the WTC Health Program, including enrollment, certification, and any other administrative issues; and
• Receive and/or provide information pertaining to your membership and participation in the WTC Health Program, including copies of factual and medical evidence contained in your records for the Program.

Please note: Any requirement of the WTC Health Program to notify you in writing is fully satisfied if sent to the designated representative.

Who Can be a Designated Representative

A designated representative in the WTC Health Program can be someone such as a family member, friend, attorney, or advocate, unless that individual’s service as a representative would violate any applicable provision of law.

Only a single individual may serve as your designated representative. An entire organization or group of people—such as multiple family members or a law firm —is not permitted to be a designated representative.

If a member is a minor, a parent or guardian may act on the member’s behalf. If a member is a mentally incompetent adult, the person authorized under state or other applicable law to act on the member’s behalf may act as their designated representative in the Program.

How to Designate a Representative

To designate a representative, you must notify the Program in writing using the Designated Representative forms available on the Designated Representative page.

Appeals

An appeal in the WTC Health Program is a formal process requesting reconsideration of certain Program decisions.

What Can Be Appealed

You or your designated representative may appeal the following three types of decisions made by the Program:

• Enrollment denial – includes denial of enrollment in the Program or disenrollment.
• Certification denial – includes denial of certification of a health condition as a WTC-related health condition, denial of certification of a health condition as medically associated health condition, or decertification of a WTC-related health condition.
• Treatment denial - includes denial of treatment authorization for a certified WTC-related health condition based on a finding that the treatment is not medically necessary.

An appeal can be submitted when you believe the Program incorrectly determined you don’t meet Program criteria as described above. For example, an appeal request could argue that the Program incorrectly determined the number of hours the individual worked or volunteered during a covered time period.

What Cannot Be Appealed

Not all appeal requests can be considered. An appeal is invalid if it challenges:

• Enrollment criteria established by the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) or WTC Health Program regulations;
• Certification requirements established by the Zadroga Act and WTC Health Program regulations;
• A determination by a WTC Health Program Participating Provider that a condition does not meet the criteria for certification;
• A WTC Health Program policy that has been established by the Administrator and is applicable to all Program applicants and/or members;
• The exclusion or absence of a health condition from the List of WTC-Related Health Conditions (List);

Criteria and requirements in the Zadroga Act are established by law and may only be changed by the U.S. Congress amending the Act.

Criteria within the WTC Health Program’s regulations are established through rulemaking and may only be changed by the Program revising the regulations.

Health conditions may only be added to the List through a petition process. See the How to Add a Condition section of this handbook for more information.

Valid Appeals in a Nutshell

Requesting an Appeal

To request an appeal, you must mail or fax a written letter requesting an appeal to the Program’s appeals coordinator postmarked within 120 calendar days from the date of your denial, disenrollment, or decertification letter from the Administrator.

Your appeal letter must:

• Be made in writing and signed;
• Identify the name, address, and contact information of the member and designated representative (if applicable);
• Describe the decision being appealed and state the reasons why you believe the decision was incorrect and should be reversed; and
• Provide a basis for the appeal that is sufficiently detailed and supported by information to permit a review of the appeal. An appeal request may include relevant new information not previously considered by the WTC Health Program.

The description may include:

• Scientific or medical information correcting factual errors that may have been submitted to the Program by the CCE or NPN;
• Information showing that the Program did not correctly follow or apply relevant Program policies or procedures;
• Any information showing that the Program’s decision was not reasonable given the facts of the case; and/or
• A request to designate a representative.

Appeal Process

When the Program receives your appeal, the Administrator will appoint a federal official independent of the Program to review your appeal.

The federal official will review all available records, including any oral statement made by you or your designated representative, that are relevant to the Program’s decision to assess whether your appeal should be granted. This review would include any relevant new information submitted by you.

For certification and treatment denial appeals, the federal official may also consult one or more qualified experts to review the Program’s decision and any additional information provided by you.

Based on the review, the federal official makes a recommendation to the Administrator regarding whether or not your appeal should be granted.

Final Appeal Decision and Notification of the Outcome

The Administrator reviews the federal official’s recommendation and any relevant information and makes a final decision on your appeal. You will be notified in writing of the following:

1. The recommendation and findings made by the federal official;
2. The Administrator’s final decision on your appeal;
3. An explanation of the Administrator’s final decision; and
4. Any actions taken by the Program in response to the Administrator’s final decision.

Once the Administrator has made a decision on your appeal, it is final. The Administrator’s decision may not be appealed further.

HIPAA Privacy Practices in the WTC Health Program

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the World Trade Center (WTC) Health Program 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 is held, used, and disclosed by the WTC Health Program.

How Do We Use and Share Your Personal Health Information?

The WTC Health Program must use and share your personal health information to provide information:

• To you, someone you name to receive your personal health information, or someone who has the legal right to act for you (the WTC Health Program will make sure that the person has the proper authority before taking any action);
• To the Secretary of the Department of Health and Human Services (HHS), if necessary, to make sure your privacy is protected and that the HIPAA requirements are being followed; and
• Where required by law.

How Else Do We Use and Share Your Personal Health Information?

The WTC Health Program may use and share your personal health information to provide you with treatment, to pay for your health care, and to operate the WTC Health Program. For example, the WTC Health Program may use or share your personal health information in the following ways:

• The WTC Health Program will collect and use your personal health information to decide if you meet the necessary requirements for coverage of your health condition(s) under the WTC Health Program. Conditions which meet these requirements are then “certified” by the WTC Health Program.
• The WTC Health Program will collect and use your personal health information to determine your diagnosis and any medically necessary treatment for your “certified” health conditions.
• The WTC Health Program will disclose your personal health information to the Centers for Medicare and Medicaid Services (CMS) Office of Financial Management to pay providers for eligible health care services you received.
• The WTC Health Program will review and use your personal health information to make sure you are receiving quality healthcare.

Under limited circumstances, the WTC Health Program may use or share your personal health information for the following purposes:

• 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 conducted by public health authorities (such as reporting disease outbreaks);
• For health care 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 to a government authority about victims of abuse, neglect, or domestic violence;
• To report information about deceased individuals to a coroner, medical examiner, or funeral director;
• To organ procurement organizations for organ or tissue donation and transplantation purposes;
• For research purposes, under certain conditions;
• For worker’s compensation purposes; or
• To contact you about new or changed coverage under the WTC Health Program.

What Are Your Rights When It Comes To Your Personal Health Information?

When it comes to your personal health information, you have certain rights. By law, you have the right to:

• Receive a paper copy of this privacy notice. You can ask for a paper copy of this notice even if you have already received an electronic copy (for example, by email). We will provide you with a paper copy promptly upon request.
• Receive a list that shows with whom we have shared your personal health information. You can ask for a list (accounting) of the times we have shared your personal health information for six years prior to the date you ask. The list shows whom we shared it with, when, and why. The list does not include information about treatment, payment, health care operations, and certain other disclosures (such as any you asked us to make). We will provide one free accounting a year but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Receive a 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. You can contact us by using the information included in the How Can You Contact the WTC Health Program? section. We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee to send your health and claims records.
• Ask us to change (“amend”) your personal health information. You can request to change your records if you believe that your personal health information is wrong or that information is missing. Please note that we may deny your request to change your personal health information if we believe the information in your records is accurate and complete. If your request is denied, we will provide you with a written explanation of the denial within 60 days of the date we received your request. You may have a statement added to your personal health records to reflect your disagreement.
• Request confidential communications. You may request that we communicate your personal health information in a private (“confidential”) way. You may ask that we contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• Ask us to limit how we use and share your personal health information. You can ask us not to use or share certain health information. We are not required to agree to the limits you request, except under certain circumstances.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your personal health information. We will make sure the person has this authority and can act for you before we take any action.
• Receive breach notification. You can expect to be informed of and receive notification if a breach occurs that may have compromised the privacy or security of your information.

When Do We Require Your Written Permission?

By law, the WTC Health Program must have your written permission (authorization) to use or share 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 WTC Health Program will not sell or market your personal health information without your written permission.

You may take back (revoke) your written permission anytime, except in cases where the WTC Health Program has already acted on your permission. If you take back your written permission, please provide that to the WTC Health Program in writing.

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

What Are the Responsibilities of the WTC Health Program?

The WTC Health Program is required by law to abide by the terms of this privacy notice. The WTC Health Program has the right to change this privacy notice and the changes will apply to all the information that we have about you. If we make any significant changes to this notice, a copy of the revised notice will be made electronically available on the WTC Health Program website and you will receive the new notice by mail or email within 60 days. You may also request to receive a copy of the notice at any time.

How Can You 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 member of the WTC Health Program’s HIPAA Team. To view an electronic copy of the WTC Health Program’s HIPAA privacy notice, you can visit the WTC Health Program’s website.

How Can You File a Complaint?

If you believe that your privacy rights have been violated, you may file a complaint with the WTC Health 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 HHS Office for Civil Rights by sending a letter to
200 Independence Avenue, SW, Washington, DC 20201, calling 1-800-368-1019, or visiting the . TTY users should call 1-800-537-7697.

Complaint Procedure

All Program health care providers and staff share responsibility for ensuring member satisfaction. If you have a problem or concern about the services you receive, please ask for help. Each CCE and the NPN has an administrator who is able to assist you with your concerns and complaints.

If you have a problem with any aspect of the service you have received at your CCE, call or visit the administrative office at that facility.

If you have a problem with the service you have received through the NPN, you may call MCA-Sedgwick, who administers the NPN, at 1-800-416-2898. The NPN has an administrator or director who is responsible for addressing concerns involving the provider network.

If you are not satisfied with the way your complaint was handled, Member Services Representatives who work directly for the Program are available to address your concerns. Be sure to provide complete information regarding the nature of your complaint, including names, dates, and any other specific information. We will make every effort to respond to your request as quickly and effectively as possible. You can contact the Program’s call center at 1-888-982-4748.

If you have comments and feedback for the WTC Health Program about our performance, you can use our .

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 health care 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, health care providers, or individual recipients should be reported to the U.S. Department of Health and Human Services, Office of Inspector General by phone at 1-800-HHS-TIPS (1-800-447-8477), online at , 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

Other September 11th Programs

The following programs are not part of the WTC Health Program. However, a Program member may also be eligible for these programs.

September 11th Victim Compensation Fund

The September 11th Victim Compensation Fund (VCF) is a separate program from the WTC Health Program and is administered by the U.S. Department of Justice. The VCF provides financial compensation for physical injuries, illnesses, or deaths that happened as the result of the 9/11 attacks. The VCF does not compensate for mental health conditions and does not distinguish between responders and survivors.

The VCF has a different process to sign up than the WTC Health Program. You need to register with them before filing a claim. You do not have to be sick or injured to register. Registration preserves your right to file a VCF claim in the future.

WTC Health Registry

The Zadroga Act also extended the WTC Health Registry. The Registry was developed to document and evaluate the long-term physical and mental health effects of the 9/11 attacks. To date, the Registry is the largest effort in the U.S. to monitor the health of people exposed to a large-scale disaster.

This is done through regular surveys of the enrolled participants. Enrollment in the Registry occurred in 2003-2004 through voluntary responses to an initial survey and is now closed.

Workers’ Compensation Benefits

WTC Health Program members whose certified WTC-related health condition(s) are also work-related 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 condition(s) through the Program, it can be beneficial to file a workers’ compensation claim if eligible. It may also provide a financial award for lost wages related to your WTC-related health condition(s).

New York State Workers’ Compensation Law

Workers and volunteers who performed rescue, recovery, and clean-up of the World Trade Center and other impacted sites can register with the New York State (NYS) Workers’ Compensation Board. This registration preserves the right to file for workers’ compensation benefits through the State of New York should you need them in the future.

NYS passed legislation (Senate Bill S9294A) on September 9, 2022, extending the deadline until September 11, 2026, for filing the Registration of Participation in World Trade Center Rescue, Recovery and/or Clean-up Operations form (Form WTC-12).

Workers can also pick up Form WTC-12 in-person from any New York State Workers’ Compensation Board office.