Benefits Package and Supporting Documentation

Health Systems Bureau

5600 Fishers Lane

Rockville, MD 20857

[Current Date]

[Requester name]

[Requester home address]

[Requester City, State, Zip code]

Case Number: CICP [Case number]

Dear [Requester name]:

The Countermeasures Injury Compensation Program (CICP or the Program) has determined that [Requester name] is medically eligible for benefits, as stated in our [Eligibility letter date] decision letter to you. Please review your decision letter, which identifies the injuries that are eligible for CICP benefits. The Program will now proceed to calculate reimbursement or payment for eligible past, current, and/or future medical expenses and/or lost employment income resulting from [Injured Countermeasure Recipient’s name] covered injury. The description of documentation required by the CICP to calculate benefits is attached (see Attachment 1). See 42 C.F.R. §§ 110.60-110.61.

Within 60 calendar days from the date of this letter, you must submit additional documentation to the CICP. If insufficient documentation is submitted in response to this letter, the CICP may disapprove the Request for Benefits. 42 C.F.R. § 110.71. If you are unable to provide the required additional documentation, you may provide, within 60 calendar days from the date of this letter, a written explanation of the reason(s) that the requested documentation is unavailable and the efforts you have made to obtain the documentation. 42 C.F.R. §§110.50(c); 110.71. The CICP may accept such a statement in place of the required documentation or disapprove the portion of the Request for Benefits for which insufficient documentation was submitted.

Please submit the requested documents online at injurycompensation.hrsa.gov (preferred). If you are unable to submit the documents electronically, please send them to the following address:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

The information provided below explains the types of Program benefits available, and their limitations.

Benefits for Unreimbursed Medical Expenses

The CICP may reimburse or pay reasonable costs for past, current, and future medical services and/or items that are reasonable and necessary to diagnose or treat [Injured Countermeasure Recipient’s name] covered injury and to diagnose, treat, or prevent its health complications. See 42 C.F.R. §§ 110.31 and 110.80. With respect to future medical services or items, the CICP may make such payments or reimbursements if they are likely to be needed in the future. In making determinations about which medical services and items are reasonable and necessary, the CICP may consider whether those medical services and items were prescribed or recommended by a healthcare provider and may consider whether the applicable service or item is within the standard of care for that condition.

If [Injured Countermeasure Recipient’s name] continues to receive medical care for a covered injury or its health complications and plans to request payment for current and future services or items, you must submit information to support this request. The original Authorization to Disclose Health Information Form(s) you submitted with your Request Package may have expired. Therefore, the Program may ask you to complete and sign a new set of forms for each of his healthcare providers so that the CICP can communicate directly with them, as necessary.

Lost Employment Income Benefits

The CICP may also pay for lost employment income resulting from a covered injury. See C.F.R. §§ 110.32 and 110.81. The period requested for lost employment income benefits must be supported by the severity of the covered injury as demonstrated by medical and employment records. In order to qualify for lost employment income benefits, [Injured Countermeasure Recipient’s name] must have been absent from work for more than five (5) days in an unpaid status. The days of lost income do not have to be consecutive, and partial days may be added together. Please also note the following:

• [Injured Countermeasure Recipient’s name] may be compensated for ten or more days of work lost if they lost employment income for those days as a result of the covered injury (or its health complications). If the number of days of lost employment income due to the covered injury (or its health complications) is fewer than ten, the number of lost workdays will be reduced by five days. If [Injured Countermeasure Recipient’s name] lost employment income for a period of five days or fewer, no benefits for lost employment income will be paid. In other words, if [Injured Countermeasure Recipient’s name] lost five days or less of income, there would be no reimbursement; if [Injured Countermeasure Recipient’s name] lost six to nine days of income, the calculation would be based on the number of days lost minus five; and if [Injured Countermeasure Recipient’s name ] lost ten or more days of income, the lost employment benefit would be calculated based on the entire number of days.

• If [Injured Countermeasure Recipient’s name] used days of paid leave, those days will be considered days of work for which employment income was received. Therefore, [Injured Countermeasure Recipient’s name] would not qualify for lost employment income for those days. The Program can only pay for lost employment income for unpaid leave. However, if [Injured Countermeasure Recipient’s name] reimburses his employer for the paid leave taken and the employer restores that leave, then they may be eligible for lost employment income benefits for those days that have been changed to unpaid leave. It is your responsibility to follow [Injured Countermeasure Recipient’s name]’s employers’ procedures to change paid leave to unpaid leave.

• Benefits for employment income lost as a result of his covered injury or its health complications are paid as a percentage of the amount of gross employment income (including income from self-employment, if applicable) earned at the time of [Injured Countermeasure Recipient’s name]’s injury. If they had no dependents at the time their covered injury was sustained, the lost employment benefits are 66²/₃ percent of their gross employment income. If they had one or more dependents (as defined by the Internal Revenue Service) at the time that [Injured Countermeasure Recipient’s name]’s covered injury was sustained, the benefits are 75 percent of their gross employment income. CICP’s lost employment income benefit has a maximum of $50,000 per year, and cannot be paid after the injured countermeasure recipient reaches the age of 65, with a lifetime cap. If [Injured Countermeasure Recipient’s name] is fully disabled (as defined by the Social Security Act) by the covered injury, then there is no lifetime cap on the amount of lost employment income they can receive.

• The CICP may not consider projected future earnings in the calculation of lost employment income, except for injured countermeasure recipients who are minors.

Payer of Last Resort

The CICP is the payer of last resort and can only reimburse or pay for medical services, items, or lost employment income that other third-party payers have not paid and/or are not obligated to pay.

Third-party payers are organizations are responsible for paying some or all of [Injured Countermeasure Recipient’s name]’s medical expenses or lost employment income, such as a private insurance company (e.g., health

or disability insurance plans), their employer (e.g., Workers’ Compensation), or a government program (e.g., Medicaid, Medicare, Veteran’s benefits).

If you become aware that a third-party payer may have an obligation to pay for or provide any medical services or items and/or lost employment income for injuries that are eligible for compensation under the CICP, you must inform the Program within ten business days of obtaining this information, even after benefits have been paid by the CICP.

If you have questions, please call 1-855-266-2427, email [email protected], or mail them to the address above.

Sincerely,

_________________________________ __________________

CDR George Reed Grimes, M.D., M.P.H. Date

Director

Enclosures:

Attachment 1 – Documentation Required to Reimburse or Pay for Medical Expenses and/or Lost Employment Income

Attachment 2 – Certification of Status: Unreimbursed Medical Expenses

Attachment 3 – Certification of Status: Lost Employment Income Benefits

Health Resources and Services Administration

www.hrsa.gov