Frequently Asked Questions (FAQs)

Enrollment in the WTC Health Program

• How do I know if I am enrolled in the WTC Health Program?

  You’re enrolled in the Program if:

  • You applied to the WTC Health Program and received an acceptance letter; and/or
  • You were previously enrolled in the WTC Medical Monitoring and Treatment Program (MMTP) as an FDNY member (active or retired), a New York City responder, or a New York City volunteer. The WTC Health Program replaced the MMTP in July 2011; or
  • You were enrolled in the WTC Environmental Health Center Community Program. The WTC Health Program replaced the WTC Environmental Health Center Community Program in July 2011.

  If you’re not sure if you are enrolled, you can call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

• How do I apply to the WTC Health Program?

  You can apply through the Program’s online application system, OASIS, or you can download an application form to print out and mail or fax. You also need to gather and send required supporting documentation with your application. We cannot process your application unless we also have your required supporting documentation.

  Application forms are available in English, Español, Polskie, and 中文. The OASIS online application is currently available only in English.

  You can also call the Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), and ask for an application to be mailed or faxed to you.

  You should apply only once, either online or by mail/fax.

  For more information, see the How to Apply page.

• What supporting documentation do I need when applying?

  If you are applying as a Responder, you need to provide documentation that shows you worked at one or more of the World Trade Center sites, the Pentagon, or the Shanksville, Pennsylvania site. The documents must show all of the following information:

  • The type of work you performed (activity);
  • The address and/or street name of where you worked (location);
  • The time period you worked at each location (date range); and
  • How many hours per day, week, or month you worked at each location.

  If you are applying as a Survivor, you need to provide documentation that shows one or more of the following:

  • Address of your home, workplace, school, daycare center, or adult daycare center and dates of residence or attendance;
  • Proof of presence within the NYC Disaster Area and confirmation of exposure to the dust or dust cloud on September 11, 2001; or
  • Proof of eligibility to receive a residential grant from Lower Manhattan Development Corporation (LMDC)
  • Residential Grant Program or proof of your employer receiving a LMDC grant.

  For examples of supporting documentation, see the Required Supporting Documentation page.

  If you have questions about your required supporting documentation, call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

• What if I can’t get copies of my supporting documentation?
  

  If you can’t get copies of your official supporting documentation, you can submit a letter written by someone who can confirm the details of your eligibility. This is called a third-party attestation.

  If you can’t find official supporting documentation or someone to write a third-party attestation, you can personally write a letter that includes the required eligibility information. This is known as a first-party attestation. Along with the first-party attestation, you must also include details about:

  • What you did to try to get documentation, and
  • Why you can't include it.

  Both types of attestations must contain the required specific information about your activities and location and be signed by the writer as truthful under penalty of law. You can find more information about attestations on the Required Supporting Documentation page.

• What if my name has changed from what is on my documentation?

  If your current name does not match what is on your supporting documentation, you must also send in documentation of your name change (such as a copy of your marriage certificate, divorce decree, adoption decree, or court order) with the rest of your supporting documentation.

• How long will it take to process my application?

  If you have included all the required information on your application and sent all the necessary supporting documentation with it, it will generally take a few weeks to review and process. Every application is different, however, and some reviews may take longer.

  If your application is missing information, your application review will be delayed or suspended. If that happens, a WTC Health Program enrollment specialist will contact you by phone, email, or mail to help you complete your application.

• How do I check the status of my application?

  Call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), to check the status of your application.

• What if my enrollment is denied?

  If your enrollment is denied, we will send you a letter explaining why it has been denied. You have the right to appeal this decision. Please see the Appeals section of this FAQ for more details.

• What if my enrollment classification is wrong and needs to be changed?

  Your enrollment classification is whether you are enrolled as a Responder or Survivor in the Program. If you receive your enrollment acceptance letter and you feel the classification is incorrect, call the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern). The helpline representative will tell you what you need to do to request a change in your classification.

• How do I update my member contact information?

  If your member contact information (such as your address or phone number) has changed, call both your Clinical Center of Excellence (CCE) or Nationwide Provider Network (NPN) clinic and the WTC Health Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern), as soon as possible to update your information.

  If you have moved away from your clinic and need to transfer to another clinic closer to your new residence, please see Can I change clinics? in this FAQ for information on how to transfer.

Cancer in the WTC Health Program

• What cancers are covered by the WTC Health Program?

  The Program covers a wide variety of cancers. Further description of the cancers covered by the Program may be found on the Program’s Covered Conditions webpage. The official list of WTC-related cancers can be found in the Program’s regulation at 42 C.F.R. § 88.15, List of WTC-Related Health Conditions in the cancer section. If you have cancer, speak to your CCE or NPN doctor to find out if your cancer may be related to your 9/11 exposure. In order for your cancer to be certified it must meet certain criteria like cancer latency periods. Visit the cancer latency section of the member handbook to learn more about cancer latency periods.

  To learn more about certification visit the Certification section of this FAQ.

• If I have one of the cancers on the list, am I automatically eligible for treatment coverage in the WTC Health Program?

  No. The inclusion of your cancer on the List of WTC-Related Health Conditions does not mean that your cancer will automatically be covered by the Program. Your Program doctor must also find that your 9/11 exposures are substantially likely to have been a significant factor in causing or contributing to your cancer and request certification of your cancer from the Program. If your cancer is certified, then you are eligible for treatment coverage in the Program.

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

  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 (List), including any type of cancer added to the List, the condition must first be certified by the Program.

  Once certified, all care must be rendered by a provider affiliated with the Program. If your current doctor is affiliated with the Program, then you will be able to continue seeing your doctor. If your current provider is not affiliated, ask the provider to contact your CCE or the NPN to discuss becoming a WTC Health Program provider.

• Will the WTC Health Program provide reimbursements to individuals for cancer treatment costs incurred before coverage began in the Program (October 2012) or before certification?

  No. The Program will not reimburse members or healthcare providers for the costs of cancer treatments received before cancer coverage began in the Program (October 2012) or before certification.

  However, you may be able to receive compensation through the September 11th Victim Compensation Fund (VCF) for past cancer treatment costs. The VCF is administered by the Department of Justice, and enrollment in that program is separate from the WTC Health Program.

  For information regarding the VCF, please visit https://www.vcf.gov/ or call the VCF toll-free at 1-855-885-1555.

• I have cancer now. What should I do?

  If you are a member of the WTC Health Program:

  Contact your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN) to schedule an appointment so that you can begin the cancer certification process as soon as possible. If you do not know which CCE/NPN you are with, please contact the Program helpline at 1-888-982-4748, Monday through Friday, 9 a.m. to 5 p.m. (Eastern).

  If you are not a member of the WTC Health Program:

  Please visit our How to Apply page for information about the application process. You can also contact the Program at 1-888-982-4748 for information on how to apply.

• I don’t have cancer now, but I have had cancer since September 11, 2001. What should I do?

  If you are a member of the WTC Health Program:

  Contact your CCE or NPN to schedule an appointment to review your medical history. Your doctor will determine if the cancer certification process should be started in case you need treatment again in the future. If you do not know which CCE/NPN you are with, please contact the Program helpline at 1-888-982-4748.

  If you are not a member of the WTC Health Program:

  Please visit our How to Apply page for information about the application process. You can also contact the Program at 1-888-982-4748 for information on how to apply.

• I don’t have cancer now, but what if I get it in the future? What should I do then?

  If you are a member of the WTC Health Program:

  It is important that you continue to go to your annual monitoring exams so that your health can be checked. If a doctor finds that you have cancer, or any other listed WTC-related health condition, during your annual monitoring exam, the doctor will determine whether your health condition may be related to your 9/11 exposure. If your Program provider determines your cancer is related to your 9/11 exposures, your provider will request certification of that condition(s) as soon as possible so that you can get the treatment you need.

  At any point in time, if you find out you have cancer from another healthcare provider, contact your CCE or NPN as soon as possible so that your doctor can determine if the certification process should be started.

  If you are not a member of the WTC Health Program:

  If you are eligible as a Responder, you should apply and begin your annual monitoring exams so that your health can be checked yearly to see if you develop any WTC-related health conditions, including cancer.

  If you are eligible as a Survivor and develop a condition (or symptoms of a condition) on the List of WTC-Related Health Conditions, including cancer, you should then apply to the WTC Health Program.

  For more information, see the How to Apply page.

• What if I want to be screened for cancer?

  Responders and certified-eligible survivors are eligible for breast, cervical, colon, and lung cancer screening as necessary according to the U.S. Preventive Services Task Force (USPSTF) guidelines. Screening may have to comply with frequency limits and age requirements.

Pharmacy Benefits

• If I need medications for my certified health condition, how can I get them?

  You can either have your prescription medications delivered to your home by mail order or pick them up from your local in-network pharmacy.

  Optum, the Pharmacy Benefits Manager for the WTC Health Program, has two home-delivery (mail-order) services:

  • The OptumRx service fills non-specialty prescriptions.
  • The OptumRx Specialty Pharmacy (formerly known as BrivoaRx) service fills specialty prescriptions that need special handling (like refrigerated shipping) or administration (like infusion).

  If you want to enroll in home delivery, or if you need help getting home-delivery refills, you can call Optum at the number on your pharmacy card (1-855-640-0005, option #2) to speak with a customer service representative. You can also visit enroll or request refills on Optum’s WTC Health Program Home Delivery website.

  To find a local in-network pharmacy, you can use Optum’s Pharmacy Locator.

  For more information, visit the Pharmacy Benefits page.

• Do I have to pay anything for prescriptions or home delivery?

  No, the Program pays for medications approved for your certified WTC-related health condition(s), whether you get them from your local in-network pharmacy or by home delivery.

• If I pay out-of-pocket for my prescription, can the WTC Health Program reimburse me?

  No, the Program can’t make payments to individual members, so it is important to use your Program pharmacy benefits when you get your prescriptions.

  For Survivors, your primary, individual health insurance (private and/or public) must pay their share of the prescription cost first, then the Program pays the rest. This is known as Coordination of Benefits and is a process required by the Zadroga Act. Learn more about this process in the Coordination of Benefits section of the member handbook. For more information on how to ensure your prescriptions are billed correctly at a retail pharmacy, visit the Coordination of Benefits page.

• How do I know which medications are covered by the Program?

  The Program covers medically necessary prescription drugs used to treat a certified WTC-related health condition. Your Program doctor or specialist will prescribe medication for you using the Program’s formulary, a list of drugs approved by the Program.

  On occasion, you may need a medication that is not on the approved formulary. Your Program doctor can submit a request to the Program for approval to prescribe a drug for you that is not on the Program’s formulary.

  Program medical staff will review the request from your Program doctor and decide if the drug should be approved. If the drug is approved, the medication will be covered by the Program at no cost to you. Non-formulary drugs can be approved for up to 1 year.

  If the drug is not approved but you would like to continue using it, you will have to use a different form of payment such as your primary insurance or pay out of pocket for the drug.

• Will I get a pharmacy card from the Program?

  Members with certified health conditions will receive an Optum pharmacy card. If you did not receive an Optum card, or have questions about your pharmacy benefits, please call Optum at 1-855- 640-0005 or contact your CCE.

  For members in the NPN, pharmacy information is printed on the NPN cards sent by LHI. However, only those NPN members with a certified WTC-related health condition(s) receive NPN cards. If you have questions about NPN member cards, please call LHI at 1-877-498-2911 or contact them through the LHI.Care Member Portal.

Appeals

• When can I file an appeal?

  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 a medically associated health condition, or decertification of a WTC-related health condition.
  • Treatment denial - includes denial of treatment authorization for a certified health condition based on a finding that the treatment is not medically necessary.

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

  • Enrollment criteria established by the James Zadroga 9/11 Health and Compensation Act (Zadroga Act) or WTC Health Program regulations;
  • Certification requirements established by the Zadroga Act;
  • A WTC Health Program policy that has been established by the Administrator and is applicable to all Program applications and/or members; or
  • 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. More information on how to add a condition available on the Petitions page.

  Your appeal may, however, challenge the Program’s application of enrollment, certification, or treatment authorization criteria to your individual enrollment, certification, or treatment decision. 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.

  More information on what may and may not be appealed is available on the Appeals page.

• How do I file an appeal?

  If you would like to appeal an enrollment, certification, or treatment denial, 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/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; or
  • A request to designate a representative.

  Your appeal letter should be mailed or faxed to:

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

  For certification denial, decertification, or treatment authorization denial appeals, your appeal request may also include a request for you or your designated representative to make a 15-minute oral statement by telephone.

  For more information on filing an appeal visit the Appeals page.

Workers' Compensation Lump-Sum Settlements

• How do workers’ compensation lump-sum settlements work with the WTC Health Program?

  Where your health condition it work-related, the James Zadroga 9/11 Health and Compensation Act requires the WTC Health Program to recoup (recover) costs from workers’ compensation insurers since these insurers have primary responsibility for your healthcare expenses.

  If you receive a lump-sum settlement from workers’ compensation for a health condition that would be covered by the Program, you will need to set some of that money aside for future medical expenses in the Program. The Program must approve the amount of this set-aside. The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

• Does the WTC Health Program have to approve my lump-sum settlement agreement from workers’ compensation?

  The Program has to approve all lump-sum workers’ compensation agreements settled on or after October 1, 2013.

  If your settlement agreement releases your employer or insurer from future payments towards health conditions that are covered by the Program, and workers’ compensation would otherwise have paid for those conditions, then the Program must approve the amount of money you set aside to pay for future medical expenses before you agree to the settlement. The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

  You do not need Program approval for any settlements filed with workers’ compensation before October 1, 2013, even if workers’ compensation approved the settlement after that date.

• How much of my settlement do I have to set aside for future medical expenses?

  You need to set aside enough to pay for the reasonably anticipated costs of medical treatment and medications for your covered conditions. Since Congress has funded the WTC Health Program through 2090, you should set aside enough to pay for future medical expenses for your health conditions covered by the Program through 2090, taking into account your anticipated lifetime. You should use the reimbursement rates under your state’s workers’ compensation law to calculate those costs.

  You do not have to set aside money for screenings, monitoring exams, or diagnostic testing provided by the Program.

  The Centers for Medicare and Medicaid Services (CMS) have their own requirements for lump-sum settlements. To find out if you have comply with CMS requirements as well as WTC Health Program requirements, visit the Workers’ Compensation Medicare Set Aside Arrangements page on CMS’ website.

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

  You or your designated representative need to submit a copy of the proposed settlement agreement to the Program. The proposed agreement has to show:

  • Your (the claimant’s) name, address, and date of birth;
  • The Workers’ Compensation Board claim number;
  • A description of the conditions covered by workers’ compensation, and whether the Workers’ Compensation Board has ordered the carrier (the insurance company) to pay medical benefits (or whether the carrier’s responsibility for medical benefits is still in dispute);
  • A statement about any proposals to set aside money from your lump-sum settlement, including the amount you plan to set aside;
  • An explanation of how you calculated your future medical and pharmaceutical expenses. If the amount is based on an actuarial estimate from an outside expert, send the expert’s report too;
  • A copy of the CMS approval of any Medicare set-aside, if CMS has reviewed the settlement; and
  • The name and address of the custodian for the set-aside funds. The custodian is the individual or entity who will pay any medical expenses on your (the claimant’s) behalf. You can be the custodian for your own fund, or you can choose someone else to manage the account.

  Send all the information above to the WTC Health Program at wtchp.recoup@cdc.gov.

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

  The Program will send a letter telling you whether the Program agrees that the amount set aside for future medical expenses is reasonable, or whether you do not have to set aside any money from your lump-sum settlement.

  The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved.

• What happens if the WTC Health Program doesn’t approve my proposed set-aside?

  If you don’t get the Program’s approval for a set-aside amount to pay for a health condition covered by the WTC Health Program from your lump-sum settlement, you may be legally responsible for future medical expenses in the Program. The Zadroga Act requires the Program to recoup (recover) costs for conditions that are covered under other programs, like Workers’ Compensation. If you receive a settlement that releases your workers’ compensation insurer or employer from legal responsibility for future medical expenses, and the Program has not approved the settlement, the Program may need to recoup those costs directly from you.

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

  You will not have to pay for any medical expenses within the WTC Health Program beyond the set-aside amount, as long as the Program approved the amount of money set aside for future medical expenses and you created a set-aside account with the approved amount.

  The Program will bill the set-aside account periodically, to recoup the costs of your treatment. It will not bill the set-aside account more than the total amount approved. If your medical expenses are more than the amount in your approved set-aside agreement, the Program will pay those extra expenses.