Comparison of the World Trade Center Medical Monitoring and Treatment Program and the World Trade Center Health Program Created by Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010

This report compares the current federally-supported medical screening and treatment program offered to various persons affected by the terrorist attacks of September 11, 2001, with the federal program established by Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010.

Comparison of the World Trade Center Medical Monitoring and Treatment Program and the World Trade Center Health Program Created by Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010 Scott Szymendera Analyst in Disability Policy Sarah A. Lister Specialist in Public Health and Epidemiology January 25, 2011 Congressional Research Service 7-5700 www.crs.gov R41292 CRS Report for Congress Prepared for Members and Committees of Congress Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Summary In the wake of the September 11, 2001, terrorist attacks, Congress passed appropriations to provide limited health screening and treatment services to persons involved in rescue, recovery, and cleanup operations around the former site of the World Trade Center. This program, now known as the World Trade Center (WTC) Medical Monitoring and Treatment Program (MMTP), is not authorized in statute but rather relies on discretionary appropriations to provide services to eligible individuals. Since its inception in FY2002, the MMTP has received approximately $475 million in federal funds, and over 57,000 responders and community members have met initial eligibility requirements for the program. On January 2, 2011, President Barack Obama signed into law P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010. Title I of P.L. 111-347 replaces the MMTP with a program authorized in statute and financed through mandatory federal spending, partially matched by New York City. This program, called the World Trade Center Health Program (WTCHP), will provide full medical screening and treatment benefits to eligible WTC responders and community members beginning in July 2011. In addition, Title I of P.L. 111-347 establishes formal eligibility requirements based on a person’s activities after September 11, 2001, and his or her current health conditions. Health benefits will be provided by Clinical Centers of Excellence, a national network of providers, and the program will be administered by the Department of Health and Human Services (HHS). The WTCHP will sunset at the end of FY2016 or FY2015 if a federal spending cap is met. Total federal spending on the program is capped at $1.556 billion over the life of the program. New York City will contribute 10% of the program’s costs through FY2015, after which its contribution would become equal to one-ninth of any federal spending in FY2016. In addition to persons already receiving services under the MMTP, the WTCHP will serve up to 25,000 new responders and 25,000 new community members, referred to as survivors. Congressional Research Service Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Contents Brief Descriptions of Programs ...................................................................................................1 World Trade Center Medical Monitoring and Treatment Program ..........................................1 World Trade Center Health Program......................................................................................2 Comparison of Program Elements ...............................................................................................2 Authority ..............................................................................................................................2 MMTP............................................................................................................................2 WTCHP.......................................................................................................................... 3 Financing..............................................................................................................................3 MMTP............................................................................................................................3 WTCHP.......................................................................................................................... 3 Eligibility for Benefits...........................................................................................................4 MMTP............................................................................................................................4 WTCHP.......................................................................................................................... 4 Covered Conditions ..............................................................................................................7 MMTP............................................................................................................................7 WTCHP.......................................................................................................................... 8 Benefits ................................................................................................................................9 MMTP............................................................................................................................9 WTCHP.......................................................................................................................... 9 Provision of Medical Services ............................................................................................. 10 MMTP.......................................................................................................................... 10 WTCHP........................................................................................................................ 10 Oversight ............................................................................................................................ 10 MMTP.......................................................................................................................... 10 WTCHP........................................................................................................................ 11 Tables Table 1. Responders and Community Members Meeting Initial Eligibility Requirements of the WTC Medical Monitoring and Treatment Program (MMTP) ..........................................2 Table 2. Covered Conditions Under the MMTP and WTCHP ......................................................8 Table A-1. Funding for the WTC Medical Monitoring and Treatment Program .......................... 12 Table A-2. Maximum Federal Contributions to the WTC Health Fund ....................................... 12 Appendixes Appendix. Funding Data for the WTC Medical Monitoring and Treatment Program and the WTC Health Fund ............................................................................................................ 12 Contacts Author Contact Information ...................................................................................................... 12 Congressional Research Service Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Brief Descriptions of Programs This report compares the current federally supported medical screening and treatment program offered to various persons affected by the terrorist attacks of September 11, 2001, with the federal program established by Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010. The following specific programs are compared in this report: • The World Trade Center (WTC) Medical Monitoring and Treatment Program (MMTP), financed through discretionary appropriations to the Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH);1 and • The World Trade Center Health Program (WTCHP) established by Title I of P.L. 111-347. Related programs such as the World Trade Center Health Registry, administered by the CDC Agency for Toxic Substances and Disease Registry (ATSDR), and the September 11th Victim Compensation Fund of 2001, are not discussed in this report.2 World Trade Center Medical Monitoring and Treatment Program Following the September 11, 2001, terrorist attacks, Congress provided appropriations to furnish health care services for rescue, recovery, and cleanup workers and others, in what is now called the World Trade Center Medical Monitoring and Treatment Program (MMTP).3 The MMTP is not explicitly authorized, but has received discretionary appropriations to pay for medical monitoring and health care services for eligible individuals. The MMTP funds medical screening, monitoring, and treatment services for eligible paid workers and volunteers who were involved in the rescue, recovery, and cleanup activities following the attack (referred to as “responders”), and more limited services for some residents and others in the vicinity of the WTC during and after the attack (referred to as “community members”). Services are provided through a limited network of providers. As shown in Table 1, through the end of FY2010, a total of 52,978 responders and 4,936 community members applied for and met the initial eligibility requirements for the MMTP. 1 See CDC, NIOSH, “World Trade Center Health Programs,” http://www.cdc.gov/niosh/topics/wtc/. Additional information on the World Trade Center Health Registry can be found at http://nyc.gov/html/doh/wtc/html/ registry/registry.shtml. Additional information on the September 11th Victim Compensation Fund of 2001 can be found in CRS Report RL33927, Selected Federal Compensation Programs for Physical Injury or Death, coordinated by Sarah A. Lister and C. Stephen Redhead. 3 The MMTP is one of a number of federal, state, and local programs that have funded or provided certain health care services to various groups affected by the WTC disaster. Information about some other programs may be found in GAO, September 11: Problems Remain in Planning for and Providing Health Screening and Monitoring Services for Responders, GAO-07-1253T, September 20, 2007, p. 7 ff. 2 Congressional Research Service 1 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Table 1. Responders and Community Members Meeting Initial Eligibility Requirements of the WTC Medical Monitoring and Treatment Program (MMTP) (as of September 30, 2010) Category Met Initial Eligibility Requirements Fire Department (FDNY) responders 15,721 Responders living in New York City (NYC) area 33,578 Responders living outside of NYC area Total all responders Community members Total 3,679 52,978 4,936 57,914 Source: Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, “Number of Participants in the WTC Health Programs,” http://www.cdc.gov/niosh/topics/wtc/participants.html. Note: Includes all persons who have met the initial eligibility requirements of the program, whether or not they have received any program benefits. World Trade Center Health Program Title I of P.L. 111-347 establishes the World Trade Center Health Program (WTCHP). The WTCHP, unlike the MMTP, provides for the program’s entitlement authority and financing through mandatory annual appropriations through FY2015. The WTCHP will provide medical monitoring and treatment services to WTC responders and community members (referred to as “survivors”) who meet statutory eligibility requirements. Services will be provided through Clinical Centers of Excellence in the New York area and a national network of approved providers. Comparison of Program Elements Authority MMTP The MMTP is not authorized in statute. Rather, the program’s authority comes from discretionary appropriations to the Department of Health and Human Services (HHS), CDC, NIOSH. The FY2010 appropriation for this program was $70.723 million.4 The President requested $150.137 million for this program in his FY2011 budget request.5 HHS is currently operating under a continuing resolution that provides temporary funding at FY2010 funding levels for most programs, through early March 2011.6 4 Consolidated Appropriations Act, 2010, P.L. 111-117, 123 Stat. 3241-3242. 5 Department of Health and Human Services, Centers for Disease Control and Prevention, Justification of Estimates for Appropriation Committees, FY2011, Washington, DC, February 2010, pp. 231 and 235. 6 CRS Report R41521, Labor, Health and Human Services, and Education: FY2011 Appropriations, coordinated by Pamela W. Smith. Congressional Research Service 2 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 WTCHP The WTCHP established by Title I of P.L. 111-347 is authorized as Title XXXIII of the Public Health Service Act. 7 The WTCHP will be administered by the Program Administrator. For the purposes of program enrollment and the payment for benefits, the Program Administrator will be an HHS official designated by the Secretary of HHS.8 For all other purposes, the Program Administrator will be the Director of NIOSH or his designee. The Program Administrator will consult with two steering committees, one for responders and one for survivors, made up of representatives of medical providers and affected populations. Financing MMTP The current MMTP is financed through discretionary appropriations to the CDC. Following the September 11, 2001, terrorist attacks, Congress appropriated funds to the Federal Emergency Management Agency (FEMA) for various response and recovery activities. FEMA entered into agreements with NIOSH and other CDC centers to establish and carry out medical monitoring programs for WTC responders and others. Appropriations were provided directly to CDC thereafter. In FY2006, Congress authorized the use of appropriated funds for treatment services, in addition to screening and monitoring. Table A-1, in the Appendix, provides a funding history for the MMTP. In total, the program has received approximately $475 million since its inception. WTCHP Benefits and administrative costs under the WTCHP will be paid out of the World Trade Center Health Fund (the Fund) established by the law. The Fund is authorized from the last quarter of FY2011 through the end of FY2015, or FY2016 if the federal spending cap has not yet been met. The Fund will be financed by capped mandatory federal spending and contributions from New York City. The federal government will deposit into the Fund for each specified fiscal year an amount equal to the lesser of 90% of the costs of carrying out the WTCHP in that fiscal year or annual spending limits provided in Table A-2 in the Appendix to this report. Title I of P.L. 111-347 also stipulates maximum amounts that may be spent each year on certain specified program activities. New York City is required to enter into a contract with the WTCHP to pay its required share of program costs. New York City will deposit into the Fund for each fiscal year through FY2015 an amount equal to 10% of the costs of carrying out the WTCHP. If the program continues into FY2016, New York City’s share for that fiscal year will be one-ninth of the federal expenditures for that fiscal year. No money may be released from the Fund unless New York City has entered into such a contract. New York City will be charged interest, in a manner specified in the law, if it fails to make its 7 8 The Public Health Service Act is codified at 42 U.S.C. § 201 et. seq. For the purposes of payment of benefits, this person may not be the Director of NIOSH or his designee. Congressional Research Service 3 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 contributions to the Fund on time. Provided New York City is making its required contributions to the Fund, the city will not be liable to pay for services provided by the WTCHP to its employees through city workers’ compensation or line-of-duty injury programs. Eligibility for Benefits MMTP The current MMTP is open to all workers and volunteers who participated in rescue, recovery, or other activities in response to the September 11, 2001, terrorist attack on the WTC as well as lower Manhattan and Brooklyn residents, students, and others who were affected by the WTC terrorist attacks. Because the MMTP is not authorized or established in statute, there are no formal requirements in the law regarding program eligibility and no formal definitions of the types or locations of activities that make a person eligible for the program. The application form for the responder component of the MMTP indicates that, to be eligible, a person must have provided “rescue, recovery, demolition, debris removal and related support services” in the aftermath of the WTC attack.9 In addition, the application form requires applicants to provide information on their work south of Canal Street in Manhattan, in the Port Authority Trans-Hudson (PATH) transit tunnel, at the Staten Island landfill, on the barge loading piers, or at the Office of the Chief Medical Examiner (OCME) during the period between September 11, 2001, and July 2002. The website of the community member component of the MMTP states that a person is eligible if he or she lived, worked, commuted to, or was a student in lower Manhattan or “areas of Brooklyn” on September 11, 2001, or participated in the cleanup of buildings in the “affected area.”10 WTCHP The WTCHP has eligibility requirements established by Title I of P.L. 111-347. No person on a terrorist watch list maintained by the Department of Homeland Security is eligible to participate in the WTCHP as a responder or survivor. Title I of H.R. 847 establishes the following groups of responders and community members, referred to as survivors, that are eligible for the WTCHP:11 Responders A currently identified responder is an individual who has been identified as eligible for medical monitoring under the MMTP. 9 A copy of this application form is available online at http://www.wtcexams.org/pdfs/wtc_saef_v08.pdf. 10 The community member component of the MMTP is administered by the NYC Health and Hospitals Corporation. See “WTC Environmental Health Center,” http://www.nyc.gov/html/hhc/html/services/wtc-qualifies.shtml. 11 The law uses the term “survivors” to refer to community members affected by the attack on the WTC but not involved in rescue or other operations. Congressional Research Service 4 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 A responder who meets current eligibility criteria is an individual who meets one of the following conditions: For members of the Fire Department of the City of New York (FDNY) and related persons: • was a member, active or retired, of the FDNY who participated for at least one day in the rescue or recovery effort at Ground Zero, the Staten Island Landfill, or the New York City Chief Medical Examiner’s Office during the period between September 11, 2001, and July 31, 2002; or • is a surviving immediate family member of an FDNY member, retired or active, who was killed at the WTC on September 11, 2001, and who received any treatment for a WTC-related mental health condition on or before September 1, 2008. For law enforcement, rescue, recovery, and clean-up workers: • worked or volunteered in rescue, recovery, or debris cleanup or related support services in lower Manhattan below Canal Street, the Staten Island Landfill, or the barge loading piers, for at least 4 hours between September 11 and September 14, 2001; for at least 24 hours between September 11, 2001, and September 30, 2001; or for at least 80 hours between September 11, 2001 and July 31, 2002; • was a member, active or retired, of the Police Department of New York City (NYPD) or the Port Authority of New York and New Jersey Police, and participated in rescue, recovery, debris cleanup, or related services in lower Manhattan below Canal Street, the Staten Island Landfill, or the barge loading piers, for at least 4 hours between September 11, 2001, and September 14, 2001; • was a member, active or retired, of the NYPD or the Port Authority of New York and New Jersey Police, and participated in rescue, recovery, debris cleanup, or related services at Ground Zero, the Staten Island Landfill, or the barge loading piers for at least one day between September 11, 2001, and July 31, 2002; • was a member, active or retired, of the NYPD or the Port Authority of New York and New Jersey Police, and participated on-site in rescue, recovery, debris cleanup, or related services in lower Manhattan below Canal Street for at least 24 hours between September 11, 2001, and September 30, 2001; • was a member, active or retired, of the NYPD or the Port Authority of New York and New Jersey Police, and participated in rescue, recovery, debris cleanup, or related services in lower Manhattan below Canal Street for at least 24 hours between September 11, 2001, and September 30, 2001, or for at least 80 hours between September 11, 2001, and July 31, 2002; • was an employee of the Office of the Chief Medical Examiner of New York City involved in the examination and handling of human remains from the WTC attacks, or other morgue worker who performed similar functions, between September 11, 2001, and July 31, 2002; Congressional Research Service 5 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 • was a worker in the Port Authority Trans-Hudson Corporation (PATH) tunnel for at least 24 hours between February 1, 2002, and July 1, 2002; or • was a vehicle maintenance worker who was exposed to debris from the former WTC while working on vehicles contaminated by airborne toxins from the September 11, 2001, attacks during work between September 11, 2001 and July 31, 2002. For responders to the Pentagon and Shanksville, PA, aircraft crash sites: • was an active member of a fire or police department, or performed rescue, recovery, demolition, debris cleanup, or other related services at the terroristrelated aircraft crash site at the Pentagon or in Shanksville, PA, beginning on September 11, 2001, and ending on a date established by the Administrator; and is determined by the Administrator to be at an increased risk of developing a WTC-related condition as a result of exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 11, 2001, terrorist attacks, and meets such eligibility criteria related to such exposures, as the Administrator determines are appropriate, after consultation with the WTC Scientific/Technical Advisory Committee. A responder who meets modified eligibility criteria is an individual who performed rescue, recovery, or cleanup services in the “New York City disaster area” in response to the September 11, 2001, attacks on the WTC, regardless of whether such services were performed by a state or federal employee or member of the National Guard; and who meets eligibility criteria established by the WTCHP administrator in consultation with the WTC Scientific/Technical Advisory Committee established by the legislation.12 There is a limit of 25,000 responders, not counting currently identified responders, that may participate in the WTCHP, of which no more than 2,500 may be responders who meet modified eligibility criteria. Survivors A currently identified survivor is a person, including a responder, who has been identified as eligible for treatment and monitoring by the community component of the MMTP. A survivor who meets current eligibility criteria is an individual who is not a WTC responder, who claims symptoms of a WTC-related health condition, and who meets one of the following criteria: • was present in the New York City disaster area, defined as Lower Manhattan south of Houston Street and any block in Brooklyn within a 1.5 mile radius of the WTC site, in the dust or dust cloud on September 11, 2001; • worked; resided; or attended school, child care, or adult day care in the New York City disaster area for at least 4 days between September 11, 2001 and January 10, 2002; or at least 30 days between September 11, 2001 and July 31, 2002; 12 Title I of the law defines the “New York City disaster area” as the area of Manhattan that is south of Houston Street and the area of Brooklyn that is wholly or partially contained within a 1.5 mile radius of the former WTC site. Congressional Research Service 6 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 • worked as a clean-up worker in the New York City disaster area between September 11, 2001, and January 10, 2002, and had extensive exposure to WTC dust as a result of such work; • was deemed eligible to receive a grant from the Lower Manhattan Development Corporation Residential Grant Program, who possessed a lease for a residence or purchased a residence in the New York City disaster area, and who resided in such residence during the period between September 11, 2001, and May 31, 2003; or • worked at a place of employment that at any time between September 11, 2001, and May 31, 2003, was in the New York City disaster area, and that place of employment was deemed eligible for a grant from the Lower Manhattan Development Corporation WTC Small Firms Attraction and Retention Act program, or similar program to revitalize the lower Manhattan economy. A survivor who meets modified eligibility criteria is an individual who is not an eligible WTC responder and who meets such eligibility criteria as determined by the WTCHP administrator in consultation with the Data Centers, Advisory Committee, and steering committees established by the law. A certified-eligible WTC survivor is an eligible survivor who is certified by the Program Administrator to be eligible for follow-up monitoring and treatment. There is a limit of 25,000 certified-eligible WTC survivors. This limit does not include currently identified survivors. The Program Administrator will also limit certifications to ensure sufficient funds are available to provide treatment and monitoring, and will prioritize certifications based on the order in which a person applies. Covered Conditions MMTP Responders The current MMTP provides benefits to eligible responders with covered medical conditions. The list of covered medical conditions for responders is established by NIOSH and shown in Table 2. Community Members There is no formal list of covered medical conditions for eligible community members. However, the website of the community member component of the MMTP provides the following list of “common symptoms” for community members: (1) coughing, (2) wheezing, (3) shortness of breath, (4) sinus congestion, (5) stomach problems, (6) depression, (7) anxiety, and (8) other symptoms. 13 13 New York City Health and Hospitals Corporation, WTC Environmental Health Center: Common Symptoms, http://www.nyc.gov/html/hhc/html/services/wtc-symptoms.shtml. Congressional Research Service 7 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Table 2. Covered Conditions Under the MMTP and WTCHP Category MMTP, Covered Conditions for Respondersa WTCHP, Covered Conditions for Responders WTCHP, Covered Conditions for Survivors Aerodigestive disorders (1) Interstitial lung diseases; (2) Chronic Respiratory Disorder –Fumes/Vapors; (3) Asthma; (4) Reactive Airways Dysfunction Syndrome (RADS); (5) WTCexacerbated chronic obstructive pulmonary disease (COPD); (6) Chronic Cough Syndrome; (7) Upper airway hyperreactivity; (8) Chronic rhinosinusitis; (9) Chronic nasopharyngitis; (10) Chronic laryngitis; (11) Gastroesophageal Reflux Disorder (GERD); and (12) Sleep apnea exacerbated by or related to the above conditions. All conditions under MMTP, at left. All conditions under MMTP, at left. Mental health conditions (1) Post Traumatic Stress Disorder (PTSD); (2) Major Depressive Disorder; (3) Panic Disorder; (4) Generalized Anxiety Disorder; (5) Anxiety Disorder (not otherwise specified); (6) Depression (not otherwise specified); (7) Acute Stress Disorder; (8) Dysthymic Disorder; (9) Adjustment Disorder; (10) Substance Abuse; and (11) “V codes” (treatments not specifically related to psychiatric disorders, such as marital problems, parenting problems etc.). All conditions under MMTP, at left, except that WTCHP does not cover “V codes.” All conditions under MMTP, at left, except that WTCHP does not cover “V codes.” Musculoskeletal disorders (1) Low back pain; (2) Carpal Tunnel Syndrome (CTS); and (3) Other musculoskeletal disorders. Musculoskeletal disorders only if manifested on or before Sept. 11, 2003. Musculoskeletal disorders are not covered. Other conditions None. Any additional condition (including types of cancer) listed pursuant to the process specified in the law. Any additional condition (including types of cancer) listed pursuant to the process specified in the law. Source: Congressional Research Service (CRS). Information taken from the website of the MMTP at http://www.wtcexams.org/ and Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010. Note: Clinical findings or other information must suggest that conditions are related to injury or exposure due to the WTC attacks to be covered by the MMTP or WTCHP. P.L. 111-347 provides a process to add additional conditions for coverage, including but not limited to types of cancer. a. Under the MMTP, there is no formal list of covered medical conditions for eligible community members. WTCHP Title I of P.L. 111-347 provides lists of conditions covered by the responder and survivor components of the WTCHP. For all eligible responders and survivors, the list of covered conditions includes all of the aerodigestive and mental health conditions currently covered by the MMTP and listed in Table 2, except that the WTCHP does not cover mental health conditions indentified by “V codes,” either for responders or survivors.14 In addition, only those eligible 14 “V codes” include treatments not specifically related to psychiatric disorders, such as marital problems and parenting (continued...) Congressional Research Service 8 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 responders who received any treatment for a WTC-related musculoskeletal condition on or before September 11, 2003 are eligible to have such condition covered by the WTCHP, and musculoskeletal conditions are not covered for survivors. Title I of P.L. 111-347 also provides administrative procedures for the Program Administrator to add to the list of covered conditions for responders and survivors and provide coverage in the case of a responder who has a WTC-related medical condition that is not on the list of covered conditions. The Program Administrator is also required to periodically review scientific and medical evidence to determine if any type of cancer should be added to the list of covered conditions for responders or survivors. Benefits MMTP The current MMTP provides medical monitoring to all eligible responders and community members, and medical treatment for covered conditions for eligible responders. Medical monitoring includes initial screenings and annual exams. Medical treatment for covered conditions is provided at no cost to the responder and includes in-patient and out-patient services, medical procedures, and pharmaceuticals. For eligible community members, the MMTP provides medical screening; however, medical care for covered conditions is not necessarily provided. Rather, the MMTP provides assistance in filling gaps when an eligible community member’s private or public insurance or other benefits are not able to fully cover the costs of medical care for WTC-related conditions. WTCHP The WTCHP will provide medical monitoring for eligible responders, initial health evaluations for eligible survivors, and medical treatment for covered conditions for all eligible responders and survivors. Medical treatment includes in-patient and out-patient services, medical procedures, pharmaceuticals, and transportation to distant medical appointments. For conditions that are work-related, the WTCHP will seek recoupment of its costs from workers’ compensation programs. For conditions that are not work-related, the WTCHP will be a secondary payer to any medical insurance, Medicaid, or the State Children’s Health Insurance Program (SCHIP) that covers the participant. However, the WTCHP is the primary payer for individuals covered by Medicare. Eligible responders and survivors will not have any out-of-pocket costs for covered medical monitoring or treatment services. Beginning in July 2014, responders and survivors will be required to have the minimum health insurance coverage required under Section 5000A of the Internal Revenue Code of 1986 as established by the Patient Protection and Affordable Care Act (PPACA).15 (...continued) problems. 15 26 U.S.C. § 5000A. For more information, see CRS Report R41331, Individual Mandate and Related Information Requirements under PPACA, by Hinda Chaikind. Congressional Research Service 9 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Provision of Medical Services MMTP The current MMTP uses four systems to provide medical services to eligible program participants. For FDNY members and retired members, medical services are provided by the FDNY Bureau of Health Services. For responders in the New York area, medical services are provided by a network of clinics in New York City, Long Island, and New Jersey. 16 Responders who live outside of the New York area are provided services through a national network of providers managed by Logistic Health Incorporated. Medical benefits for community members are provided by the New York City Health and Hospitals Corporation. WTCHP Medical benefits under the WTCHP will be provided to all eligible responders and survivors in the New York area through a network of Clinical Centers of Excellence determined by the Program Administrator to meet requirements provided in the legislation. Eligible responders and survivors living outside of the New York area would receive medical services through a national network of providers determined by the Program Administrator to meet statutory requirements. Oversight MMTP The MMTP is not authorized in statute, but rather has drawn its authority from of a series of federal appropriations to the CDC for grants to health care providers in the New York area. There are no program regulations. As a result, outside of the normal requirements that accompany federal grants, there are no specific requirements for program management, such as the collection of claims-level data on program participants or the reporting of this data to Congress or other bodies. In FY2008 appropriations, Congress asked HHS to produce a comprehensive plan for management of the program.17 Such plan has not been published. Appropriations acts have not tasked the Government Accountability Office (GAO) or similar agencies with responsibility to audit the MMTP or its grantees, although GAO has conducted numerous audits of various aspects of the program at the request of Members of Congress. GAO reports that NIOSH has taken various actions to improve data collection and other aspects of program oversight.18 The HHS 16 These clinics are located in Manhattan (Mt. Sinai Medical Center and New York University School of MedicineBellevue Hospital Center); Queens (Queens College); Staten Island (Richmond University Medical Center); Nassau County, New York (State University of New York (SUNY)-Stony Brook); Suffolk County, New York (SUNY-Stony Brook); and Piscataway, New Jersey (University of Medicine and Dentistry of New Jersey). 17 House Appropriations Committee Print, Consolidated Appropriations Act, 2008, (H.R. 2764; P.L. 110-110–161), Division G, Departments of Labor, Health and Human Services, and Education, and Related Agencies, p. 1559. 18 For additional information on data collection under the MMTP see U.S. Government Accountability Office (GAO), September 11: HHS Needs to Ensure the Availability of Health Screening and Monitoring for All Responders, GAO07-892, July 2007. In 2007 NIOSH proposed establishing a business process center to, among other things, improve data collection under the MMTP. However, in December 2007 the solicitation for the proposed BPC was cancelled and the BPC was never established. For additional information on the proposed BPC see GAO, September 11: World Trade Center Health Programs Business Process Center Proposal and Subsequent Data Collection, GAO-11-243R, December 3, 2010. Congressional Research Service 10 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Inspector General has not published any audit or evaluation/inspection reports regarding the program. WTCHP Title I of P.L. 111-347 tasks the HHS Inspector General with overseeing the WTCHP to prevent and detect fraudulent and duplicate billing, inappropriate payments, and unreasonable administrative costs. The Program Administrator, working through a network of Data Centers established by the law, is responsible for establishing and maintaining a system of data collection, including the collection of claims-level data, on the WTCHP. Clinical Centers of Excellence established to provide services under the WTCHP will be required to collect and report such data. The Program Administrator is also responsible for monitoring and assuring the quality of services provided under the program. The Program Administrator must submit an annual report on the WTCHP to Congress. This report must include program data and information on program effectiveness and efficiency. In addition, the GAO is required to prepare a series of reports on the effectiveness and efficiency of several aspects of the WTCHP, including a report on whether the selected Clinical Centers of Excellence have financial systems in place that will allow for the collection of claims-level data. Congressional Research Service 11 Comparison of the WTC MMTP and the WTCHP Created by P.L. 111-347 Appendix. Funding Data for the WTC Medical Monitoring and Treatment Program and the WTC Health Fund Table A-1. Funding for the WTC Medical Monitoring and Treatment Program (dollars in millions) FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 request 12.0 90.0 a a 75.0 50.0 108.1 70.0 70.7 150.1 Source: Compiled by CRS. Appropriations acts that provided the funding amounts are provided in CRS Report RL33927, Selected Federal Compensation Programs for Physical Injury or Death, coordinated by Sarah A. Lister and C. Stephen Redhead, section on “World Trade Center Medical Monitoring and Treatment Program.” Note: HHS is currently operating under a continuing resolution that provides temporary funding at FY2010 funding levels for most programs, through early March 2011. a. Funding for the WTC MMTP was not provided in FY2004 or FY2005. During these FYs, the program was financed with appropriations from previous fiscal years. Table A-2. Maximum Federal Contributions to the WTC Health Fund (dollars in millions) FY2011a FY2012 FY2013 FY2014 FY2015 FY2016 Total May Not Exceed 71 318 354 382 431 b 1,556 Source: CRS analysis of Title I of P.L. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010. Note: Numbers may not add due to rounding. a. Amount is for the last calendar quarter of FY2011 only. b. For FY2016: an amount equal to any unexpended amounts in the previous fiscal years, provided that the total amount for FY2011 through FY2016 does not exceed $1.556 billion. Author Contact Information Scott Szymendera Analyst in Disability Policy sszymendera@crs.loc.gov, 7-0014 Congressional Research Service Sarah A. Lister Specialist in Public Health and Epidemiology slister@crs.loc.gov, 7-7320 12