Benefits Package and Supporting Documentation

Date

Full Name

Address

Address

Case Number:

Dear Mr./Ms. Last Name:

The Countermeasures Injury Compensation Program (CICP or the Program) determined that [Deceased Countermeasure Recipient name] is medically eligible for benefits as stated in our [date of decision letter] decision letter. The benefits available to the estate of a deceased injured countermeasure recipient are medical and/or lost employment income benefits accrued during [Injured Countermeasure Recipient name]’s lifetime but were not paid in full by the Program before their death.

The Program would now like to proceed with calculating reimbursement or payment for eligible medical expenses and/or lost employment income resulting from [Deceased Countermeasure Recipient name]’s covered injuries. Since you are filing for benefits as the executor or administrator of the estate of an injured countermeasure recipient, please submit legal proof that you are the executor or administrator of the estate (and eligible to receive Program payments on the estate’s behalf), such as a court-issued Letter of Administration. 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 for medical services and/or items that were reasonable and necessary to diagnose or treat the covered injury and to diagnose, treat, or prevent its health complications.

Lost Employment Income Benefits

The CICP may also reimburse or pay for lost employment income resulting from a covered injury. In order to qualify for lost employment income benefits, [Deceased Countermeasure Recipient 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:

• The CICP cannot pay for the first five days of lost employment income resulting from a covered injury or its health complications, unless employment income was lost for ten or more workdays (in which case, all of the lost workdays – starting from day one – will be included in the calculation). If the number of days of lost employment income is more than five days, but less than ten days, then five days will be subtracted in calculating benefits. In other words, if [Deceased Countermeasure Recipient name] lost five days or less of wages, there would be no reimbursement; if they lost six to nine days of pay, the calculation would be based on the number of days lost minus five; and, if they lost ten or more days of wages, benefits would be calculated based on the entire number of days.

• If [Deceased Countermeasure Recipient name] used days of paid leave, those days will be considered days of work for which employment income was received. Therefore, the estate would not qualify to receive lost employment income for those days. The Program can only pay for lost employment income for unpaid leave, such as leave without pay (LWOP).

• Benefits for employment income lost as a result of the 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 the injury. If [Deceased Countermeasure Recipient name] had no dependents at the time the 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 the 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, cannot be paid after the injured countermeasure recipient reaches the age of 65, and is subject to a lifetime cap.

• No lost employment income may be paid after the receipt, by the survivor(s) of a deceased injured countermeasure recipient, of death benefits.

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 is not covered by other third-party payers.

Third-party payers are organizations that are responsible for paying some or all of the medical expenses or lost employment income, such as a private insurance company (e.g., health

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

If you become aware of a third-party payer who reimburses or pays for medical expenses and/or lost employment income for injuries that are eligible 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.

Required Documentation

The description of additional documentation required by the CICP to calculate benefits is attached (see Attachment 1). Please use these materials to help you submit the appropriate documentation to complete this case. Please submit the requested forms online at injurycompensation.hrsa.gov (preferred). If you cannot submit the form electronically, please send the required documentation to the address below.

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, Room 8W-25A

Rockville, MD 20857

The Program requests that you send all requested materials within 60 calendar days of the date of the enclosed letter. Please inform the Program if you need more time.

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

Sincerely,

________________________________ __________________

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

Director, Division of Injury Compensation Programs

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