Summary of WTC Health Program Covered Health Benefits

Appendix OO

Summary of Covered Health Benefits, Health Conditions,

Treatments, and Payments

I. Covered Health Benefits

A. Medical Monitoring Exams for WTC Responders:

The Program offers yearly medical monitoring exams to WTC responders. The purpose of the monitoring exam is to monitor the responder’s health, whether he/she is sick or not. If the responder has a medical condition(s) related to his/her 9/11 exposures, medically necessary treatment is covered by the Program.

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

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

During the medical monitoring exam, the responder will meet with a WTC Health Program physician who will examine the responder to see if he/she might have any health conditions related to his/her 9/11 exposures. Based on the medical monitoring exam, there are three possible outcomes:

1. The WTC Health Program physician does not find any symptoms that are related to the responder’s 9/11 exposures. These exams help track the responder’s health over time, and contribute to our understanding of how 9/11 affected WTC responders. As we learn more, we can develop better treatment approaches for WTC responders and improve future disaster response. The WTC Health Program physician will encourage the responder to return in one year for an annual medical monitoring exam.

2. The WTC Health Program physician determines the responder has symptoms that could be related to 9/11 exposures, but more information is needed to determine if the responder has a health condition related to 9/11 exposures. The WTC Health Program physician will advise the responder on any follow-up medical appointments, testing, or procedures that are needed in order to find out if the responder has a health condition related to 9/11 exposures. The WTC Health Program physician will also encourage the responder to return in one year for an annual medical monitoring exam.

3. The WTC Health Program physician determines the responder has one or more health conditions that are covered by the Program. The Program covers a specific list of health conditions (see section entitled "WTC-Related Health Conditions Covered by the Program”). If the WTC Health Program physician determines that a responder has a health condition on the list of covered health conditions and that 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing the health conditions, then the WTC Health Program physician will request certification of the member’s condition(s) from the WTC Health Program Administrator. The WTC Health Program covers treatment for certified health conditions. The WTC Health Program physician will also encourage the responder to return in one year for an annual medical monitoring exam.

B. Initial Health Evaluations for WTC Survivors:

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

• Blood tests

• Breathing test

• Chest x-ray

• EKG

• Questionnaires to evaluate 9/11 exposures, health complaints, medical history, and mental health

• Screening colonoscopy for members aged 50 and over

• Screening mammogram for female members aged 40 and over

• Urinalysis

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

1. The WTC Health Program physician does not find any symptoms that are related to the survivor’s 9/11 exposures. The survivor will receive no additional services from the Program at this time. The survivor will still be a member of the Program. If the survivor develop symptoms in the future, he/she may request an additional health evaluation at their own expense.

2. The WTC Health Program physician determines the survivor has symptoms that could be related to 9/11 exposures, but more information is needed to determine if the responder has a health condition related to 9/11 exposures. The WTC Health Program physician will then advise the survivor on any follow-up medical appointments, testing, or procedures that might be needed in order to determine if the survivor has a WTC-related health condition.

3. The WTC Health Program physician determines the survivor has one or more health conditions that are covered by the Program. The Program covers a specific list of health conditions (see section entitled "List of WTC-Related Health Conditions Covered by the Program”). If the WTC Health Program physician determines that the survivor’s health condition is on the list of covered health conditions and that 9/11 exposures are substantially likely to have been a significant factor in aggravating, contributing to, or causing the health condition, then the WTC Health Program physician will request certification of the health conditions from the WTC Health Program Administrator. If the survivor’s health condition is certified by the Administrator, the survivor is then referred to as a certified-eligible survivor. Certified-eligible survivors are eligible to receive yearly follow-up exams from the Program as well as medically necessary treatment for certified WTC-related health conditions.

C. Benefits Counseling

The Program offers benefits counseling to members. Members might be eligible for benefits from the September 11th Victim Compensation Fund, workers' compensation, line-of-duty injury, disability pensions, Social Security, or other benefits programs. These benefits may provide more medical coverage for members and financial compensation for the member and their family. At each CCE, there are staff members who can assist members in identifying the benefits they may be eligible for and explain how to apply for them. These staff members can also refer members to external experts in a specific benefits system if needed.

D. Pharmacy Benefits

The Program covers prescription drugs used to treat a certified WTC-Related Health Condition(s). The CCE/NPN physician will prescribe medication using the Program's formulary. The drugs on the Program's formulary are covered by the Program. The list includes drugs that are safe and effective for the treatment of certified WTC-related health conditions.

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

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

• Dental prescriptions (unless prescribed for a certified WTC-related health condition)

• Drugs for cosmetic uses

• Drugs used for reasons not approved by the United States Food and Drug Administration

• Most nonprescription or over-the-counter medicines

Filling Prescriptions

The WTC Health Program allows members to obtain their medications from mail order or retail.

E. Medical Emergencies:

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

Urgent Care (After Hours)

Urgent care services are medically necessary treatment required for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. The Program provides payment for urgent care visits for certified WTC-related health condition(s). Members are required to contact their CCE/NPN as soon as possible to let them know that they have received urgent care services.

Emergency Care Services

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

Examples of conditions where emergency care may be needed:

• Persistent suicidal or homicidal ideation

• Severe or persistent bleeding

• Severe shortness of breath

• Sudden onset of severe abdominal pain

In the event of a medical emergency, members are instructed to call 911 or go to the nearest emergency room. However, in all emergencies, members must notify their CCE/NPN within 24 hours or on the next business day following admission to coordinate ongoing care and to ensure they receive proper authorization.

When the Program Member Travels Outside of His/Her Local Area

Urgent and emergency care for certified WTC-related health condition(s) is available even when a Program member is traveling outside of his/her local area. Members are encouraged to seek immediate treatment for any illness or injury that would be considered an emergency. If the member is admitted to an inpatient facility, he/she must immediately notify the CCE/NPN. In other cases, the member is required to notify the CCE/NPN within 48 hours of an emergency. The Program does not cover emergency care services that are not related to the member’s certified WTC-related health conditions.

The Program Does Not Cover:

• Ambulance service used instead of taxi service when the condition is not an emergency and private transportation is available

• Transport or transfer in order for the Program member to be closer to home, family, friends, or personal physician

• Use of medicabs or ambicabs as a form of transportation to and from medical appointments

II. WTC-Related Health Conditions Covered by the Program

The Program covers a specific list of WTC-related physical and mental health conditions. If a Program member is diagnosed with a health condition on the list and the WTC Health Program physician thinks that the health condition is related to 9/11 exposures, then the WTC Health Program physician will request certification, or approval, of the condition(s) so that treatment can be covered by the.

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

Acute Traumatic Injury

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

Aerodigestive Disorders (see Maximum Time Intervals for Aerodigestive Disorders)

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

Mental Health Conditions

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

Musculoskeletal Disorders (only for WTC responders)

The Program covers the following specific WTC-related musculoskeletal disorders in certain situations if they were caused by the member’s 9/11 work and the responder has proof that he/she received medical care for the injury on or before September 11, 2003:

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

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

Blood and Lymphoid Tissue

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

Childhood Cancers

Any type of cancer diagnosed in a person less than 20

Rare Cancers

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

Female Breast

Malignant neoplasm of breast

Female Reproductive Organs

Malignant neoplasm of ovary

Malignant Neoplasms of the Digestive System

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

Malignant Neoplasm of Eye and Orbit

Eye and adnexa

Malignant Neoplasms of the Head and Neck

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

Malignant neoplasms of the Respiratory System

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

Malignant Neoplasm of the Urinary System

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

Malignant neoplasm of Skin (non-Melanoma)

Scrotum
Other malignant neoplasm of skin

Malignant Neoplasm of the Soft Tissue

Peripheral nerves and autonomic nervous system
Other connective and soft tissue

Mesothelium

Mesothelioma

Melanoma

Malignant melanoma of skin

Thyroid

Malignant neoplasm of thyroid gland

Maximum Time Intervals for Aerodigestive Disorders

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

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

III. Treatments

The Program has developed medical treatment guidelines for common WTC-related health conditions. The WTC Health Program physician uses those guidelines to determine whether or not a particular treatment for a covered health condition is medically necessary. There are three levels of treatment authorizations:

Level 1 Authorization

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

• Doctors' visits and specialty consults

• Flu and pneumonia vaccines

• Lab work, such as blood tests

• Medical tests and procedures used to determine if the member might have a WTC-related health condition(s) or medically associated health condition(s)

• Most surgeries

• MRIs, CT scans, other types of imaging studies

• Pharmacy benefits (see section entitled "Pharmacy Benefits" for more detailed information).

Level 2 and Level 3 Authorizations

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

• Vaccines for shingles and whooping cough

• Smoking cessation therapy

• Inpatient care services

• Organ transplants

• FDNY family members' mental health treatment

• Family therapy and/or mental health counseling

• Substance abuse treatment programs

• Hospice care

• Home health services

• Skilled nursing facility/extended care services

• Durable medical equipment (DME)

• Medical transport/ambulance services

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

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

• Systemic cancer

• Lower airway disease (obstructive airway and restrictive lung disease)

• Lung transplant due to a WTC-related lung disease

B. Smoking Cessation Program

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

1. Certified for a WTC-related aerodigestive disorder; mental health condition; or cancer; AND

2. Meet the requirements for and need smoking cessation therapy according to the member’s WTC Health Program physician.

C. Inpatient Care Services

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

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

What's not covered?

• Personal care items, like razors or slipper socks

• Private-duty nursing

• Private room (unless medically necessary)

• Television and phone in the room (if there's a separate charge for these items)

D. Organ Transplants

The Program will cover organ transplants if specific circumstances are met.

E. Mental Health Services

• FDNY Family Members' Mental Health Treatment

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

• The member is a surviving immediate family member of one of the FDNY responders who were killed at the WTC site on September 11, 2001; and

• The member received treatment for a mental health condition included on the list of WTC-related health conditions on or before September 1, 2008; and

• The member's mental health condition has been certified by the Administrator.

• Family Therapy and/or Marital Counseling

In certain circumstances, psychotherapy services for a member's family may be covered as part of the treatment of the member's certified WTC-related health condition. Marital counseling for a member and his or her spouse may also be covered in certain circumstances.

F. Substance Abuse Treatment Programs

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

• The member is certified for a WTC-related mental health condition; and

• The services are authorized by the WTC Health Program physician or mental health provider; and

• The provider or place providing care is an affiliated provider/facility with the Program.

G. Hospice Care

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

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

• Physician Services

• Dietary counseling

• Drugs for symptom control or pain relief

• Durable medical equipment (such as wheelchairs or walkers)

• Grief and loss counseling for member and family

• Hospice aide and homemaker services

• Medical supplies (such as bandages and catheters)

• Nursing care

• Physical and occupational therapy

• Short-term inpatient care (for pain and symptom management)

• Short-term respite care

• Social worker services

• Speech-language pathology services

• Other services needed to manage pain and other symptoms related to the member’s terminal certified WTC-related health condition, as recommended by hospice

H. Home Health Services

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

Home health services may be covered if the services provided are necessary to treat the member’s certified WTC-related health condition and the member requires the skilled services of at least one of the following:

• Medical social services under the direction of a physician

• Part-time or occasional services of a home health aide

• Part-time or occasional skilled nursing care provided by or under the supervision of a registered professional nurse

• Physical/occupational, or speech-language pathology services

• Routine and non-routine medical supplies

I. Skilled Nursing Facility/Extended Care Services

The Program will cover extended care services if the Program member requires skilled nursing or rehabilitation staff to manage, observe, and evaluate care for a certified WTC-related health condition(s). Multiple circumstances must be met in order for these services to be covered.

J. Durable Medical Equipment

Durable Medical Equipment (DME) is medical equipment used in the home, such as nebulizers, CPAP machines, hospital beds, wheelchairs, and other types of equipment. DME rental or purchase is a covered health service of the Program. In order to be covered, the DME must be necessary and reasonable to treat a certified WTC-related health condition(s). In addition, the DME must be ordered by prescription by the WTC Health Program physician or a specialist affiliated with the Program, and authorized, or approved, by the CCE/NPN Medical Director.

K. Medical Transport/Ambulance Service

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

• Air ambulance or boat ambulance transport when the pickup point is not accessible by a land vehicle, or when great distance or other obstacles are involved in transporting the member to the nearest hospital with appropriate facilities. The Program member’s medical condition must require a rapid admission or show he/she is not able to be transferred by other means.

• Ambulance transfers from a hospital-based emergency room to a hospital more capable of providing the care needed for certified WTC-related health conditions

• Emergency transfers to or from Program member’s home (or other location) to a hospital and transfers between hospitals

• Transfers between a hospital or skilled nursing facility and another hospital-based or freestanding outpatient therapeutic or diagnostic department/facility

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

IV. Payments

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

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

For WTC survivors, the Program is the payer of last resort. The member’s health insurance will be billed first for any medically necessary treatment services rendered by the Program to treat a certified WTC-related health condition. At that point, the WTC Health Program is responsible for paying any co-insurance charges, copayments, or deductibles for care of a certified WTC-related health conditions (as long as Program-affiliated healthcare providers are utilized).