[Federal Register Volume 81, Number 241 (Thursday, December 15, 2016)]
[Rules and Regulations]
[Pages 90926-90947]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-29957]



[[Page 90925]]

Vol. 81

Thursday,

No. 241

December 15, 2016

Part II





Department of Health and Human Services





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42 CFR Part 88





World Trade Center Health Program; Amendments to Definitions, Appeals, 
and Other Requirements; Final Rule

  Federal Register / Vol. 81 , No. 241 / Thursday, December 15, 2016 / 
Rules and Regulations  

[[Page 90926]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

42 CFR Part 88

[Docket No. CDC-2016-0072; NIOSH-291]
RIN 0920-AA56, 0920-AA44, 0920-AA48, 0920-AA50


World Trade Center Health Program; Amendments to Definitions, 
Appeals, and Other Requirements

AGENCY: Centers for Disease Control and Prevention, HHS.

ACTION: Final rule.

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SUMMARY: In 2011 and 2012, the Secretary, Department of Health and 
Human Services (HHS), promulgated regulations designed to govern the 
World Trade Center (WTC) Health Program (Program), including the 
processes by which eligible responders and survivors may apply for 
enrollment in the Program, obtain health monitoring and treatment for 
WTC-related health conditions, and appeal enrollment and treatment 
decisions, as well as a process to add new conditions to the List of 
WTC-Related Health Conditions (List). After using the regulations for a 
number of years, the Administrator of the WTC Health Program identified 
potential improvements to certain existing provisions, including, but 
not limited to, appeals of enrollment, certification, and treatment 
decisions, as well as the procedures for the addition of health 
conditions for WTC Health Program coverage. He also identified the need 
to add new regulatory provisions, including, but not limited to, 
standards for the disenrollment of a WTC Health Program member and 
decertification of a certified WTC-related health condition. A notice 
of proposed rulemaking was published on August 17, 2016; this action 
addresses public comments received on that proposed rulemaking, as well 
as three interim final rules promulgated since 2011, and finalizes the 
proposed rule and three interim final rules.

DATES: This rule is effective on January 17, 2017.

FOR FURTHER INFORMATION CONTACT: Rachel Weiss, Program Analyst; 1090 
Tusculum Ave., MS: C-46, Cincinnati, OH 45226; telephone (855) 818-1629 
(this is a toll-free number); email [email protected].

SUPPLEMENTARY INFORMATION: This preamble is organized as follows:

I. Executive Summary
    A. Purpose of Regulatory Action
    B. Summary of Major Provisions
    C. Costs
II. Public Participation
III. Background
IV. WTC Health Program Statutory Authority
V. Summary of Final Rule and Response to Comments
VI. Regulatory Assessment Requirements
    A. Executive Order 12866 and Executive Order 13563
    B. Regulatory Flexibility Act
    C. Paperwork Reduction Act
    D. Small Business Regulatory Enforcement Fairness Act
    E. Unfunded Mandates Reform Act of 1995
    F. Executive Order 12988 (Civil Justice)
    G. Executive Order 13132 (Federalism)
    H. Executive Order 13045 (Protection of Children From 
Environmental Health Risks and Safety Risks)
    I. Executive Order 13211 (Actions Concerning Regulations That 
Significantly Affect Energy Supply, Distribution, or Use)
    J. Plain Writing Act of 2010

I. Executive Summary

A. Purpose of Regulatory Action

    On August 17, 2016, the Secretary, HHS, and the Administrator of 
the WTC Health Program published a notice of proposed rulemaking 
proposing amendments to some provisions in part 88 in Title 42 and the 
addition of others (August 2016 NPRM).\1\ This final rule includes the 
Administrator's response to public comments received on the August 2016 
NPRM, as well as public comments received in response to three interim 
final rules establishing portions of 42 CFR part 88, published in 2011, 
2013, and 2014, respectively.\2\ The amendments to part 88 are intended 
to benefit both the WTC Health Program and its members by clarifying 
requirements and improving administrative processes.
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    \1\ 81 FR 55086 (Aug. 17, 2016).
    \2\ These include the July 2011 IFR (establishing part 88 and 
implementing the Program), 76 FR 38914 (July 1, 2011); the March 
2013 IFR (establishing eligibility criteria for Shanksville and 
Pentagon responders), 78 FR 18855 (Mar. 28, 2013); and the February 
2014 IFR (clarifying the definition of ``childhood cancers'' and 
revising the definition of ``rare cancers''), 79 FR 9100 (Feb. 18, 
2014).
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B. Summary of Major Provisions

    In this action, the Administrator finalizes amendments to a number 
of existing sections in part 88, including provisions for appeals of 
enrollment decisions, appeals of certification, decertification, or 
treatment authorization decisions, and the addition of health 
conditions to the List of WTC-Related Health Conditions. Some existing 
language is moved into new sections for clarity. Finally, new language 
on disenrollment, decertification, appeals of reimbursement denials, 
and coordination of benefits and recoupment is added to part 88.

C. Costs

    The revisions to part 88 proposed in the August 2016 NPRM and 
finalized in this action are expected to result in approximately 
$42,742 in costs to the WTC Health Program associated with updating 
existing Program policies and developing new policies. As explained 
below, the Program estimates that total costs of the WTC Health Program 
were $240.5 million in FY 2015 and may range from $265.5 to $388.6 
million in FY 2025. Cumulative costs associated with WTC Health Program 
administration and monitoring and treatment services for all health 
conditions for fiscal years (FY) 2016 through 2025 are projected to 
range from $2.9 billion (7% discount rate) to $3.6 billion (3% discount 
rate).\3\
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    \3\ Costs for FY 2016-2025 have been evaluated for all health 
conditions covered by the Program, both those conditions included in 
the PHS Act at sec. 3312(a)(3) and 3322(b) and those added to the 
List of WTC-Related Health Conditions in Sec.  88.15, including 
cancer, new-onset chronic obstructive pulmonary disease, and WTC-
related acute traumatic injury.
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II. Public Participation

    Interested persons or organizations were invited to participate in 
the August 2016 NPRM by submitting written views, opinions, 
recommendations, and/or data on any topic related to the proposed rule. 
All communications received on or before the closing date for comments 
were fully considered by the Administrator of the WTC Health Program. 
The August 2016 NPRM as well as public comments received are available 
in the docket for this rulemaking. Public comments received on the 
three interim final rules are available in those respective dockets.\4\
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    \4\ See infra note 9.
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    Submissions to the August 2016 NPRM docket were received from three 
commenters, including a labor organization, a joint labor/management 
trust fund, and the contractor providing care for survivors in the WTC 
Health Program.

III. Background

    This final rule includes the Administrator's response to public 
comments received on the August 2016 NPRM, as well as public comments 
received in response to three interim final rules (IFRs). The first IFR 
was published on July 1, 2011 to establish part 88 and implement the 
Program, and included all of the original sections establishing 
eligibility criteria and enrollment processes, health condition 
certification and treatment requirements, mechanisms to appeal Program 
decisions, and reimbursement

[[Page 90927]]

(July 2011 IFR).\5\ A second IFR was published on March 28, 2013 to 
establish new eligibility criteria for Pentagon and Shanksville, 
Pennsylvania responders (March 2013 IFR).\6\ A third IFR was published 
on February 18, 2014 to clarify the definition of ``childhood cancers'' 
and revise the definition of ``rare cancers,'' resulting in cancers of 
the brain, the pancreas, and the testes, and invasive cervical cancer 
becoming eligible for Program coverage (February 2014 IFR).\7\ The 
Administrator addressed some of the public comments submitted on the 
three IFRs in the August 2016 NPRM; this final rule includes the 
Administrator's responses to the remainder of public comments on the 
IFRs.
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    \5\ 76 FR 38914 (July 1, 2011).
    \6\ 78 FR 18855 (Mar. 28, 2013.
    \7\ 79 FR 9100 (Feb. 18. 2014).
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IV. WTC Health Program Statutory Authority

    Title I of the James Zadroga 9/11 Health and Compensation Act of 
2010 (Pub. L. 111-347, as amended by Pub. L. 114-113), added Title 
XXXIII to the Public Health Service Act (PHS Act), establishing the WTC 
Health Program within HHS. The WTC Health Program provides medical 
monitoring and treatment benefits to eligible firefighters and related 
personnel, law enforcement officers, and rescue, recovery, and cleanup 
workers who responded to the September 11, 2001, terrorist attacks in 
New York City, at the Pentagon, and in Shanksville, Pennsylvania 
(responders), and to eligible persons who were present in the dust or 
dust cloud on September 11, 2001, or who worked, resided, or attended 
school, childcare, or adult daycare in the New York City disaster area 
(survivors).
    All references to the Administrator of the WTC Health Program 
(Administrator) in this notice mean the WTC Program Administrator, the 
Director of the National Institute for Occupational Safety and Health 
(NIOSH), or his or her designee. Section 3301(j) of the PHS Act 
authorizes the Administrator to promulgate such regulations as are 
necessary to administer the WTC Health Program.

V. Summary of Final Rule and Response to Comments

    This rule adopts and finalizes all amendments to 42 CFR part 88 
promulgated by the July 2011, March 2013, and February 2014 IFRs and 
proposed in the August 2016 NPRM. Amendments to the regulatory text in 
part 88 are finalized in accordance with the discussion provided in the 
August 2016 NPRM \8\ and below, responding to public comments received 
on all four rulemakings. All public comments are available in the 
dockets for the four respective rulemakings.\9\
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    \8\ See 81 FR 55086 at 55087-96.
    \9\ See July 2011 IFR, docket CDC-2011-0009; March 2013 IFR, 
docket CDC-2013-0002; February 2014 IFR, docket CDC-2014-0004; and 
August 2016 NPRM, docket CDC-2016-0072.
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Section 88.1 Definitions

    The Administrator revised pre-existing definitions and established 
new definitions for terms commonly used in the WTC Health Program in 42 
CFR 88.1.
    Comment: One July 2011 IFR commenter asked the Program to amend 
three definitions. The commenter asked that the definition of 
``aggravating'' include any health condition that requires medical 
treatment ``more intensive than'' would have been required for such a 
condition in the absence of 9/11 exposure; that ``medically necessary 
treatment'' include treatment modalities and protocols developed 
specifically for children; and that ``New York City disaster area'' 
include 14th Street as the northern boundary.
    Administrator's response: The term ``aggravating'' is defined in 
sec. 3306(1) of the PHS Act and cannot be expanded in the regulatory 
definition.
    The Administrator also declines to amend ``medically necessary 
treatment'' because the medical treatment protocols developed by the 
Data Centers already include treatment modalities developed for 
children. The existing definition is sufficiently broad to include all 
types of patients treated by physicians affiliated with the Clinical 
Centers of Excellence (CCEs) or the Nationwide Provider Network (NPN). 
No changes are made to the regulatory text in response to these 
comments.
    Finally, ``New York City disaster area'' is also defined in the PHS 
Act, at sec. 3306(7), and cannot be expanded in the regulatory 
definitions. No change is made to the regulatory text in response to 
the public comments.
    The term ``designated representative'' is revised to clarify that 
an individual applying for enrollment in the WTC Health Program may 
designate a representative. A new definition of ``WTC,'' meaning 
``World Trade Center,'' is added to this section; all existing 
definitions beginning with ``World Trade Center'' are revised 
accordingly to streamline the regulatory text.

Section 88.2 General Provisions

    This section establishes the appointment process for an applicant's 
or WTC Health Program member's designated representative and the 
parameters of the representative's authority.
    Comment: One July 2011 IFR commenter asked that the Program allow a 
parent or guardian to be the designated representative for a mentally 
impaired screening- or certified-eligible survivor.
    Administrator's response: The Administrator agrees with the comment 
and has added a new paragraph (a)(7) to address the concern. In 
addition, paragraph (a)(6) has been revised to clarify that a parent or 
guardian of a minor applicant, as well as the parent or guardian of a 
screening-eligible or certified-eligible survivor who is a minor, may 
act on behalf of the minor.
    Comment: One July 2011 IFR commenter asked that the Program offer 
reimbursement to members in the NPN for whom the cost of travel to the 
provider is less than 250 miles but nevertheless poses a financial 
burden, which is a barrier to care.
    Administrator's response: PHS Act, sec. 3312(b)(4)(C) allows the 
Program to provide transportation expenses for medically necessary 
treatment through the NPN involving ``travel of more than 250 miles.'' 
The statutory language only authorizes reimbursement of travel expenses 
where travel exceeds 250 miles. No change is made to the regulatory 
text in response to this comment.

Section 88.3 Eligibility--Currently Identified Responders

    No public comment was received on this section. No revisions are 
made to this section, although it is included in the regulatory text, 
below, for completeness.

Section 88.4 Eligibility Criteria--WTC Responders

    This section establishes eligibility criteria for individuals who 
participated in response and recovery activities at the New York City 
area sites, at the Pentagon site, and at the Shanksville, Pennsylvania 
site.
    Comment: One July 2011 IFR commenter asked the Program to develop 
eligibility criteria for responders engaged in the cleanup or 
demolition of buildings at or near Ground Zero, including 130 Liberty 
Street (Deutsche Bank) and 245 Greenwich Street (Fiterman Hall), which 
were heavily contaminated with WTC dust. In the case of those buildings

[[Page 90928]]

and others across Lower Manhattan, cleanup took place years after 
September 11, 2001 (e.g., cleanup of the Deutsche Bank building began 
in 2007; Fiterman Hall in 2008). Workers exposed to the re-suspension 
of WTC dust caused by cleanup activities ``had the potential to become 
ill from those exposures and should be eligible under modified criteria 
for monitoring and treatment.''
    Administrator's response: Workers who engaged in cleanup or 
demolition of buildings contaminated by WTC dust outside of the 
eligibility criteria identified in PHS Act, sec. 3311(a)(2) cannot be 
included in the eligibility criteria for WTC responders in Sec.  88.4 
without promulgating modified eligibility criteria by rulemaking. At 
this time, the Administrator is not aware of any scientific evidence to 
support such a rulemaking. No change is made to the regulatory text in 
response to this comment.
    Comment: One March 2013 IFR commenter suggested that the addition 
of eligibility criteria for Pentagon and Shanksville responders is 
unnecessary because, the commenter believes, there were no real hazards 
at the Shanksville, Pennsylvania site, and the Pentagon site was 
quickly cleaned up.
    Administrator's response: The Administrator does not agree with the 
sentiments expressed by this commenter. The eligibility criteria for 
Pentagon and Shanksville responders were developed after consideration 
of a report produced by NIOSH that reviewed published literature and 
other authoritative sources and consultations with participating 
responders from both sites.\10\ The report summarized the results of 
environmental sampling at the Pentagon and Shanksville, Pennsylvania 
sites; estimated the length of time that each of the various responder 
groups participated in rescue, recovery, demolition, debris cleanup, 
and other related response activities; and identified the types of 
exposures potentially experienced by the site responders. Based on the 
report's findings, the Administrator found it reasonable to establish 
eligibility criteria for Pentagon and Shanksville responders.\11\ No 
change is made to the regulatory text in response to this comment.
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    \10\ Robert McCleery, Summary of Evidence for Establishing Dates 
on which Cleanup of the Pentagon and Shanksville, Pennsylvania Sites 
of the Terrorist-Related Aircraft Crashes of September 11, 2001 
Concluded, Prepared for the Administrator, WTC Health Program, 
February 8, 2012, http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-248/0248-041312-ShanksvilleResponse.pdf.
    \11\ See generally 78 FR 18855.
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Section 88.5 Application Process--WTC Responders

    This section describes the application process for individuals who 
participated in response and recovery activities at any of the three 
sites. Language from Sec.  88.6(b), concerning notification of 
deficient applications, is moved into a new Sec.  88.5(c). The word 
``shall'' is replaced with ``must'' throughout the section, and ``WTC 
Program Administrator'' is replaced with ``WTC Health Program.''
    Comment: One July 2011 IFR commenter asked that the Program contact 
an applicant by telephone to notify the individual of deficiencies in 
an application or supporting documentation.
    Administrator's response: The Program makes every effort to contact 
applicants to correct any deficiencies in the application and conducts 
follow-up by telephone, mail, and/or email. No change is made to the 
regulatory text in response to this comment.

Section 88.6 Enrollment Decision--WTC Responders

    This section describes the basis for enrollment and enrollment 
denial decisions and explains the Program's notification procedures. 
Language from Sec.  88.6(b), concerning notification of deficient 
applications, is moved into a new Sec.  88.5(c) where it is better 
placed. A sentence is added to paragraph (d) to clarify that the 60-day 
time period for Program enrollment decisions will be tolled during any 
days in which the applicant is correcting deficiencies, as in Sec.  
88.10(a).
    Comment: Two July 2011 IFR commenters expressed concerns about the 
requirement regarding use of the terrorist watch list. Specifically, 
the commenters asked about information sharing protections and redress 
procedures, and stated that the terrorist watch list must not be used 
to harass, jeopardize, and/or deport immigrants.
    Administrator's response: The Program is required to screen 
applicants against the terrorist watch list (see PHS Act, secs. 
3311(a)(5) and 3321(a)(4)). Program applications as well as the System 
of Records Notice (SORN) for the WTC Health Program \12\ state that 
information will only be disclosed to the Department of Justice (DOJ) 
and others for the limited purposes of ascertaining enrollment 
eligibility and qualification. HHS does not conduct terrorist watch 
list screening; the Program submits limited information collected from 
applications to DOJ, and DOJ's Terrorist Screening Center conducts the 
screening. DOJ is a signatory to the 2007 Memorandum of Understanding 
on Terrorist Watchlist Redress Procedures (MOU).\13\ There is no change 
to the regulatory language in response to these comments.
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    \12\ Occupational Health Epidemiological Studies and EEOICPA 
Program Records and WTC Health Program Records, HHS/CDC/NIOSH, 
Privacy Act System Notice 09-20-0147, https://www.gpo.gov/fdsys/pkg/FR-2011-06-14/html/2011-14807.htm.
    \13\ See DOJ press release, Federal Inter-Agency Partners Sign 
Government-wide Watchlisting Redress MOU, October 24, 2007, https://www.justice.gov/archive/opa/pr/2007/October/ustsc-102407.html.
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    Comment: One July 2011 IFR commenter asked that the Program notify 
the applicant of an enrollment decision within 30 calendar days of the 
Program's receipt of the application.
    Administrator's response: The Program is required by statute to 
respond to applications within 60 calendar days of receipt of the 
application and makes every effort to respond in less time; average 
response time is approximately 4 weeks. Applicants can impact the 
length of the eligibility review process by submitting a complete 
application. No change is made to the regulatory text in response to 
this comment.

Section 88.7 Eligibility--Currently-Identified Survivors

    No public comment was received on this section. No revisions are 
made to this section, although it is included in the regulatory text, 
below, for completeness.

Section 88.8 Eligibility Criteria--WTC Survivors

    This section establishes eligibility criteria for individuals who 
do not meet the eligibility criteria for WTC responders.
    Comment: One July 2011 IFR commenter asked that the language in 
Sec.  88.8(a)(1)(iii), regarding ``extensive exposure,'' be interpreted 
liberally because ``this population may be least likely to have 
employment related documents or the ability to obtain them.''
    Administrator's response: This eligibility criteria is based on 
section 3321(a)(1)(B)(iii) of the PHS Act, which requires extensive 
exposure to WTC dust for this specific population. However, the Program 
takes an applicant-favorable approach to eligibility criteria. There is 
no change made to the regulatory text in response to this comment.
    Comment: One July 2011 IFR commenter pointed out that the

[[Page 90929]]

regulatory language in Sec.  88.8(a)(1)(iv)(C) implies that the 
individual must have lived in the New York City disaster area residence 
from September 11, 2001 through May 31, 2003 but asserts that the Lower 
Manhattan Development Corporation Residential Grant Program did not 
begin until August 2002 and participation requirements state that 
``renters must have leases commencing on or after June 1, 2001 and on 
or prior to May 31, 2003. Owners must purchase apartments on or prior 
to May 31, 2003.'' The commenter requests that the text of the 
regulation indicate that the individual was in residence for part of 
that period.
    Administrator's response: The Administrator appreciates the 
comment, however, the language in this section mirrors the eligibility 
language in PHS Act, sec. 3321(a)(1)(B)(iv). No change is made to the 
regulatory text in response to this comment.
    Comment: Similar to comments made on Sec.  88.4, one July 2011 IFR 
commenter suggested that the section be amended to include survivors 
who conducted cleanup or demolition of buildings at or near Ground Zero 
which were heavily contaminated with WTC dust. In some cases, cleanup 
took place years after September 11, 2001 and workers were exposed to 
the re-suspension of WTC dust caused by cleanup activities.
    Administrator's response: As discussed above, workers who engaged 
in cleanup or demolition of buildings contaminated by WTC dust outside 
of the eligibility criteria identified in PHS Act, sec. 3321(a)(1)(B) 
cannot be included in the eligibility criteria for WTC survivors in 
Sec.  88.8 without promulgating modified eligibility criteria by 
rulemaking. At this time, the Administrator is not aware of any 
scientific evidence to support such a rulemaking. There is no change 
made to the regulatory text in response to this comment.
    Comment: One July 2011 IFR commenter asked the Program to establish 
modified eligibility criteria for the ``full cohort of affected 
children,'' including those who were exposed in utero (mothers who 
lived or worked in the New York City disaster area); those exposed to 
WTC dust brought home by responder parents; those born after September 
11, 2001, to responder or survivor parents and suffering mental health 
impacts due to the parents' WTC-related mental health condition; and 
those born to exposed responders or survivors if evidence of 
environmental reproductive health impacts is available.
    Administrator's response: Individuals who were children at the time 
of the terrorist attack in New York City or its aftermath may be 
enrolled WTC survivors if they meet the eligibility criteria for 
screening-eligible survivors. Children who were exposed in-utero, who 
experienced `take-home' exposures, who suffer from mental health 
conditions resulting from their parents' WTC-related mental health 
conditions, and who suffer from health effects resulting from parental 
exposures were not identified in the PHS Act's eligibility criteria for 
survivors. To the extent that language could be added to the 
eligibility criteria to permit some or all such cohorts of children to 
be enrolled as WTC survivors under Sec.  88.8, the Administrator would 
be required to promulgate modified eligibility criteria. The 
Administrator is not contemplating such modified criteria at this time. 
Developmental disorders cannot be added to the List without rulemaking 
supported by scientific or medical evidence, pursuant to the procedures 
established in Sec.  88.16 for adding new WTC-related health conditions 
to the List. There is no change made to the regulatory text in response 
to this comment.

Section 88.9 Application Process--WTC Survivors

    This section describes the application process for individuals in 
the New York City disaster area who did not participate in response and 
recovery activities.
    Comment: One July 2011 IFR commenter suggested that the application 
process should allow statements written under penalty of perjury from 
fellow workers, neighbors, and fellow students or teachers, and allow a 
sworn statement of facts by the applicant before a notary if no other 
documentation is available.
    Administrator's response: The Program accepts a wide range of 
documentation to verify an applicant's status. Statements from co-
workers and others used as evidence of an individual's presence in the 
New York City disaster area are contemplated by Sec.  88.9(a)(1), which 
has been slightly revised for clarity by replacing a comma with a semi-
colon, to state that ``[d]ocumentation may include but is not limited 
to: Proof of residence, such as a lease or utility bill; attendance 
roster at a school or daycare; or pay stub, other employment 
documentation, or written statement, under penalty of perjury, by an 
employer indicating employment location during the relevant time 
period; or similar documentation.'' ``Similar documentation'' could 
include written statements from co-workers and fellow students or 
neighbors. The types of written statements suggested by the commenter 
are among those that are routinely accepted by the Program. This 
section is not changed in response to this comment.
    A new paragraph (a)(3), comprising language concerning the 
notification of deficiencies in an application, is moved from Sec.  
88.10(a). ``Shall'' is replaced with ``must'' throughout the section, 
and ``WTC Program Administrator'' is replaced with ``WTC Health 
Program'' in paragraph (b).

Section 88.10 Enrollment Decision--Screening-Eligible Survivors

    This section describes the basis for enrollment as a screening-
eligible survivor and enrollment denial decisions, and explains the 
Program's notification procedures.
    Comment: One July 2011 IFR comment asked that the Program shorten 
the time frame for notifying applicants of screening-eligible status 
from 60 calendar days to no more than 30 days from NIOSH's receipt of 
the application. The commenter also asked that the Program use 
telephone outreach to follow up with applicants when documentation is 
absent or deficient.
    Administrator's response: The Program is required by statute to 
respond to applications within 60 calendar days of receipt of the 
application and makes every effort to respond in less time; the average 
response time is approximately 4 weeks. Applicants can impact the 
length of the eligibility review process by submitting a complete 
application. The Program makes every effort to contact applicants to 
correct any deficiencies in the application, and conducts follow-up by 
telephone, mail, and/or email. This section is not changed in response 
to this comment.
    Language in paragraph (a) concerning notification of deficiencies 
in an application is moved to Sec.  88.9(a)(3).

Section 88.11 Initial Health Evaluation for Screening-Eligible 
Survivors

    This section describes the initial health evaluation process for 
screening-eligible survivors.
    Comment: One August 2016 NPRM commenter shared a concern that the 
language may permit survivors to obtain an initial health evaluation 
and treatment from any CCE.
    Administrator's response: The language in this section is 
essentially unchanged from the original language of Sec.  88.10(d)(1), 
which reads ``A WTC Health Program Clinical Center of Excellence or a 
member of the nationwide network provider [sic] will provide the 
screening-eligible survivor

[[Page 90930]]

an initial health evaluation to determine if the individual has a WTC-
related health condition. . . .'' Although the names are changed to 
acronyms for the sake of brevity and clarity, the Administrator's 
intent is unchanged and the language in this section continues to mean 
that an initial health evaluation will be provided by the Program. No 
change is made to the regulatory text in response to this comment.

Section 88.12 Enrollment Decision--Certified-Eligible Survivors

    This section describes the basis for enrollment as a certified-
eligible survivor and enrollment denial decisions, and explains the 
Program's notification procedures.
    Comment: One July 2011 IFR commenter asked that the Program specify 
a time frame for notification of certified-eligible status, no more 
than 30 days from receipt by the Program of a physician determination.
    Administrator's response: Although the WTC Health Program makes 
every effort to provide certification decisions in a timely manner, the 
establishment of a deadline for notification of certified-eligible 
status or a deadline for the Program's decision whether to certify a 
WTC-related health condition (pursuant to Sec.  88.18) could impede the 
Program's ability to conduct a thorough analysis of the member's health 
condition and exposure history. This could especially be the case where 
the Administrator has added a health condition to the List but the 
Program has not yet established implementation guidelines. Moreover, a 
deadline may create confusion if stakeholders believe that a 
certification request not granted or denied within the period is deemed 
to be either granted or denied. No change is made to the regulatory 
text in response to this comment.

Section 88.13 Disenrollment

    This section clarifies the process for disenrolling a member from 
the WTC Health Program.
    Comment: One August 2016 NPRM commenter agreed that the 
disenrollment (and decertification, pursuant to Sec.  88.18) provisions 
are important to ``ensure program integrity.''
    Comment: One August 2016 NPRM commenter stated that there is no 
language included in this section to address grandfathered members 
(those enrolled pursuant to Sec. Sec.  88.3 and 88.7) and stated the 
opinion that such members should be ``immune from disenrollment.''
    Administrator's response: It is important to the integrity of the 
WTC Health Program to maintain the authority to disenroll any member if 
evidence indicates that the enrollment was based on incorrect or 
fraudulent information. The provisions in paragraph (a)(1) only apply 
to members enrolled under the eligibility criteria in Sec. Sec.  88.4 
or 88.8 (which do not include grandfathered members) and permit 
disenrollment where there is insufficient proof of meeting the 
eligibility criteria required by those sections. The provisions in 
paragraph (a)(2) apply to all members (including grandfathered members) 
and permit disenrollment where the enrollment was based on incorrect or 
fraudulent information. No change to the regulatory text is made in 
response to this comment.

Section 88.14 Appeal of Enrollment or Disenrollment Decision

    This section establishes procedures for the appeal of a WTC Health 
Program decision to deny enrollment of an applicant or disenroll a 
Program member.
    Comment: One August 2016 NPRM commenter agreed that the proposed 
extension of the deadline for filing an appeal, from 60 to 90 days, is 
an improvement but is still too short a time frame for obtaining 
necessary records. According to the commenter, the deadline for filing 
an appeal should be extended to at least 4 months (120 days).
    Administrator's response: The Administrator agrees and extends the 
deadline for appeal submission to 120 days. The regulatory text in 
paragraph (b)(1) is amended accordingly.
    Comment: One August 2016 NPRM commenter requested that the Program 
allow applicants and members to make an oral statement during the 
appeal, as is allowed in Sec.  88.21.
    Administrator's response: Although applicants and members are 
allowed to submit new information in support of Program enrollment 
denial or disenrollment appeals, the Administrator has determined that, 
in the context of enrollment and disenrollment appeals, the 
administrative burden associated with oral statements outweighs the 
benefits. The factual bases and documentation requirements for 
enrollment and disenrollment decisions can be more efficiently 
considered through a paper-based review. No changes to the regulatory 
text are made in response to this comment.
    Comment: One July 2011 IFR commenter asked that the Program 
indicate from where the Federal Official will be drawn and what 
expertise that individual may have with the monitoring and treatment of 
WTC-related health conditions.
    Administrator's response: The Federal Officials appointed to hear 
appeals are chosen from Centers, Institutes, or Offices within the 
Centers for Disease Control and Prevention. They have relevant 
knowledge but do not work within the WTC Health Program. No change is 
made to the regulatory text in response to this comment.
    Comment: One August 2016 NPRM commenter stated that the NPRM 
provides no justification for having the Administrator make final 
decisions on appeals and appears unfair to the claimant making the 
appeal.
    Administrator's response: To clarify the processes by which certain 
decisions are made within the Program, language throughout Part 88 is 
changed to indicate that some decisions are made directly by the 
Administrator, while he has designated WTC Health Program staff to make 
other Program decisions, such as certifications. In the case of 
enrollment or disenrollment appeals, the Administrator is reviewing 
decisions made by Program staff. The Program finds it important to 
shift the final appeal decision-making authority to the Administrator 
because the final decision on eligibility appeals (and the 
certification and treatment authorization appeals in Sec.  88.21) 
should be made by the Administrator, who has a thorough understanding 
of the WTC cohorts and matters related to eligibility and exposures and 
is best able to apply the laws, policies, and procedures governing the 
WTC Health Program. No change is made to the regulatory text in 
response to this comment.
    Comment: One August 2016 NPRM commenter expressed concern that some 
appeals may take longer than the average 45 days, and recommended a 
final decision deadline of 120 days, with a contingency for justifying 
longer delays based on specific circumstances.
    Administrator's response: As discussed above, the establishment of 
a deadline for notification of a decision such as a final appeal 
decision could impede the Program's ability to conduct a thorough 
review of the prospective member's application and documentation of 
eligibility. The section is not changed in response to this comment.

Section 88.15 List of WTC-Related Health Conditions

    This section contains the List previously placed in Sec.  88.1 
Definitions. No public comments were received on this section and no 
substantive revisions are made to the text. Some punctuation

[[Page 90931]]

is corrected and the names of two types of cancer are pluralized.

Section 88.16 Addition of Health Conditions to the List of WTC-Related 
Health Conditions

    This section establishes the process by which interested parties 
may petition the Administrator to add a health condition to the List. 
No public comments were received on this section and no revisions are 
made to the text.

Section 88.17 Physician's Determination of WTC-Related Health 
Conditions

    This section establishes the basis for a CCE or NPN-affiliated 
physician's determination that a member has a health condition that can 
be certified. No public comments were received on this section and no 
revisions are made to the text.

Section 88.18 Certification

    This section establishes that the WTC Health Program will promptly 
assess physician determinations submitted by a CCE or NPN-affiliated 
physician and, if the Program concurs with the determination and 
decides that a health condition is a WTC-related health condition or a 
health condition medically associated with a WTC-related health 
condition, will certify the condition as eligible for coverage under 
the WTC Health Program.
    Comment: One August 2016 NPRM commenter recommended the 
establishment of a deadline for Program decisions concerning the 
certification of WTC-related health conditions.
    Administrator's response: As discussed above with regard to 
certified-eligible status notification, the establishment of a deadline 
for a final appeal decision could impede the Program's ability to 
conduct a thorough analysis of the member's health condition and 
exposure history. Certification decisions may be particularly time-
consuming to resolve if a condition has been added to the List but the 
Program has not yet established implementation guidelines. Moreover, a 
deadline may create confusion if stakeholders believe that a 
certification request not granted or denied within the period is deemed 
granted. The section is not changed in response to this comment.
    Comment: Four July 2011 IFR commenters stated their belief that PHS 
Act, sec. 3312(b)(2) permits certification of individual primary 
conditions determined to be WTC-related that are not on the List and 
the regulatory text should be revised accordingly.
    Administrator's response: The Administrator has reviewed PHS Act, 
sec. 3312(b)(2)(A)-(B) and finds that the meaning of the text 
``determination based on medically associated WTC-related health 
conditions'' and ``if a . . . WTC responder has a health condition 
described in subsection (a)(1)(A) that is not in the list in subsection 
(a)(3) but which is medically associated with a WTC-related health 
condition . . .'' is plain--the medically associated health condition 
must be related to a health condition listed in sec. 3312(a)(3). The 
language of the enacted statute does not permit physicians to recommend 
a health condition for certification that is not causally related to a 
listed WTC-related health condition. The Administrator finds the 
language of the Act is clear, and the legislative history is consistent 
with the Administrator's interpretation. While the language in the 
introduced bill did give physicians the authority requested by 
commenters, subsequent amendments to the bill changed the language and 
the intent of the enacted Act is different from that which was 
introduced. The regulatory text in this section is not changed in 
response to these comments.

Section 88.19 Decertification

    This section clarifies the process for decertification of a WTC-
related health condition or health condition medically associated with 
a WTC-related health condition.
    Comment: One August 2016 NPRM commenter asked that language be 
added to this section ``to clarify that a member whose health condition 
has been decertified retains the right to seek recertification'' in 
some circumstances. For example, where new information about the 
member's exposure or evidence of association between 9/11 exposure and 
the decertified condition was previously not considered by the Program.
    Administrator's response: In addition to a right to appeal a WTC 
Health Program decision to decertify a certified WTC-related health 
condition, a member who believes the decision was made in error may ask 
the CCE or NPN physician to resubmit the certification request; the 
physician may include new information to support the case for 
certification. The Administrator finds it unnecessary to revise the 
regulatory text in Sec.  88.19(b) and may address this matter 
administratively.
    Comment: Similar to a comment on Sec.  88.13, one August 2016 NPRM 
commenter expressed concern that there is no language in this section 
addressing grandfathered members (those enrolled pursuant to Sec. Sec.  
88.3 and 88.7), who should be ``immune from decertification.''
    Administrator's response: It is important to the integrity of WTC 
Health Program that any health condition may be decertified if the 
available evidence indicates that the certification is based on 
inadequate exposure or was otherwise certified in error. This includes 
grandfathered Program members. The section is not changed in response 
to this comment.

Section 88.20 Authorization of Treatment

    This section describes the provision of medically necessary 
treatment.
    Comment: One July 2011 IFR commenter asked the Program to use a 
variety of mental health modalities to treat mental health conditions. 
The commenter recommended that such treatment must be culturally 
sensitive and allow patients to be treated by private, community-based 
mental health professionals.
    Administrator's response: The Program allows a variety of treatment 
modalities to address various diagnoses, especially posttraumatic 
stress disorder (PTSD) and other mental health conditions. Many of the 
practitioners affiliated with CCEs or the NPN have community-based 
mental health practices where they see Program members and should be 
able to render culturally-sensitive care. No change is made to the 
regulatory text in response to this comment.
    Comment: One August 2016 NPRM commenter recommended the addition of 
flexibility to the regulatory text in paragraph (b) to ``accommodate 
complex care situations'' like cancer treatment or organ transplant in 
medical protocols developed by the Data Centers.
    Administrator's response: The Program finds that the regulatory 
text in paragraph (b) is sufficiently broad to allow for the 
development of medical protocols of any appropriate complexity. No 
change is made to the regulatory text in response to this comment.
    Comment: One August 2016 NPRM commenter expressed concern that a 
strict interpretation of the language in paragraph (c) requires the 
Administrator personally to authorize treatment pending certification 
before any treatment is provided (except for emergency care). According 
to the commenter, ``[g]iven the growing length of time between 
submission of certification requests and the receipt of decisions, a 
strict interpretation of this language would be detrimental to member 
wellbeing.''

[[Page 90932]]

    Administrator's response: The Administrator agrees with the 
commenter and changes the regulatory text to replace ``Administrator of 
the WTC Health Program'' with ``WTC Health Program.''

Section 88.21 Appeal of Certification, Decertification, or Treatment 
Authorization Decision

    This section establishes that a WTC Health Program member or the 
designated representative of such a member may appeal the Program's 
decision to deny certification of a health condition as WTC-related or 
medically associated with a WTC-related health condition, decertify a 
WTC-related health condition or medically associated health condition, 
or deny authorization of treatment for a certified health condition.
    In response to public comment on Sec.  88.14, concerning appeal of 
enrollment decisions, the Administrator agreed to extend enrollment 
appeal submission deadlines to 120 days. To maintain parity with that 
process, the deadline for the submission of appeals of certification, 
decertification, and treatment authorization decisions is also extended 
to 120 calendar days.

Section 88.24 Coordination of Benefits and Recoupment

    This section addresses the matter of coordination of benefits, 
including recoupment from workers' compensation settlements.
    Comment: One August 2016 NPRM commenter stated that the language in 
paragraph (e) ``does not address the growing use of restricted networks 
by health insurers which can make it very difficult for a participant 
to find a provider in their network for the complicated specialty 
treatment required for their medical condition. Would they be forced to 
go to an in-network provider which is not in the WTC program?''
    Administrator's response: The Program is aware of the concern 
raised by the commenter, especially in the cancer care context. In very 
rare circumstances, the Program may allow for members who require 
``specialty treatment,'' such as cancer care and transplants, to 
receive care from providers outside of their insurance networks. 
Otherwise, the CCE or NPN will coordinate care through providers within 
the members' insurance networks. The Program may provide more specific 
administrative guidance on this issue, as necessary. No changes are 
made to the regulatory text in response to this comment.

General Comments

    Comment: One July 2011 IFR commenter asked that the Part 88 
regulations address outreach, and include radio, TV, newspaper 
advertising, community meetings; fund effective, culturally competent 
outreach; partnership with community-based social service providers; 
re-fund de-funded outreach programs; and offer in-person assistance for 
completing application for non-English speakers and the mentally 
impaired.
    Administrator's response: Section 3303 of the PHS Act authorizes 
the Administrator to conduct the following outreach and education 
activities: establish a public Web site with information about the 
Program; hold meetings with potentially eligible populations; develop 
and disseminate outreach and education materials about the Program; and 
establish telephone information services. The Act further specifies 
that these activities will be conducted in a manner intended to reach 
all affected populations and include materials for culturally and 
linguistically diverse populations. The WTC Health Program meets these 
requirements by funding outreach and education activities (including 
culturally appropriate and diverse programs) to be conducted by the 
CCEs as well as community and labor groups. These groups are able to 
provide face-to-face enrollment assistance. Furthermore, the WTC Health 
Program has a New York Field Coordinator who also conducts outreach and 
provides application assistance. No change is made to Part 88 in 
response to this comment.

VI. Regulatory Assessment Requirements

A. Executive Order 12866 and Executive Order 13563

    Executive Orders 12866 and 13563 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, and public 
health and safety effects, distributive impacts, and equity). Executive 
Order 13563 emphasizes the importance of quantifying both costs and 
benefits, reducing costs, harmonizing rules, and promoting flexibility.
    This final rule has been determined to be a ``significant 
regulatory action'' under section 3(f) of Executive Order 12866.
    This final rule includes changes proposed in the August 2016 NPRM 
and final revisions made in response to public comment and to clarify 
the Program's intent; it also finalizes three IFRs issued in July 2011, 
March 2013, and February 2014, respectively. This final rule includes 
revisions to Sec. Sec.  88.14 and 88.21 (enrollment and medical 
appeals) and Sec.  88.16 (addition of health conditions) that will 
result in necessary updates to several existing WTC Health Program 
policies; novel regulatory provisions in Sec.  88.13 (disenrollment), 
Sec.  88.19 (decertification), and Sec.  88.23 (reimbursement appeals) 
will require the revision of existing policies or development of new 
policies. The Administrator estimates that amending the existing Policy 
and Procedures for Handling Submissions and Petitions to Add a Health 
Condition to the List of WTC-Related Health Conditions and the Web page 
containing frequently asked questions regarding appeals, and developing 
new disenrollment, decertification, and reimbursement appeal policies 
will require approximately 568 hours of staff time. The average WTC 
Health Program staff member responsible for updating these policies is 
a GS 14-5, earning $125,221 annually, pursuant to OPM's Salary Table 
2016-DCB (Washington DC), or $75.25 hourly, adjusted to include 
benefits. Accordingly, the revisions to Part 88 finalized in this final 
rule are expected to cost the WTC Health Program approximately $42,742 
and that amount is included in the administrative costs discussed 
below. This rulemaking is not expected to change the number of 
applicants or Program members; the Administrator has not identified any 
other potential impacts associated with this final rule.
    In addition to the costs associated with the August 2016 NPRM, this 
rule also updates the regulatory impact analyses for the July 2011, 
March 2013, and February 2014 IFRs, which are all finalized in this 
action. In the original cost analysis conducted for the Part 88 WTC 
Health Program regulations,\14\ HHS estimated the aggregate cost of 
medical monitoring and treatment to be provided and administrative 
expenses associated with implementing the WTC Health Program for a 
period of 5 years. HHS developed those estimates for the health 
conditions included for Program coverage in sections 3312 and 3321 of 
the PHS Act, using data from the health programs that were in place for 
WTC responders and survivors prior to the establishment of the WTC 
Health Program. Since that original July 2011 rulemaking and cost 
analysis, the WTC Health Program has expanded the list of

[[Page 90933]]

health conditions eligible to receive coverage in the Program through 
regulations, as permitted by section 3312(a)(6) of the PHS Act; in 
addition to the original statutory conditions of specified 
aerodigestive disorders, mental health conditions, and, for certain 
responders, musculoskeletal disorders, the WTC Health Program now also 
provides coverage for numerous types of cancer, new-onset chronic 
obstructive pulmonary disease (COPD), and WTC-related acute traumatic 
injury. Data used to update this regulatory impact analysis include 
data derived from WTC Health Program health services claims data as 
well as administrative and infrastructure cost data collected between 
FY 2012, the first full year for which data are available, and the end 
of FY 2015, the last full year for which data are available.
---------------------------------------------------------------------------

    \14\ July 2011 IFR, 76 FR 38914 at 38921.
---------------------------------------------------------------------------

    The Program estimates that total cumulative costs associated with 
the WTC Health Program over the next 10 years will be $4,223,209,653, 
undiscounted (from $2,874,481,628 at 7 percent discount rate to 
$3,553,658,528 at 3 percent discount rate). The cost of the rule in FY 
2025 is estimated to be $522,307,538 (present value between 
$265,514,667 and $388,645,860, at 7 percent and 3 percent discounts 
rates, respectively).\15\
---------------------------------------------------------------------------

    \15\ These estimates represent only a 60 percent increase over 
the cost estimates provided in the July 2011 IFR, where the Program 
found that costs in 2015 could range from $106,800,000 to 
$151,000,000. That estimate was based not on WTC Health Program 
experience, but on health programs that pre-dated the current WTC 
Health Program. The estimate in the July 2011 IFR was carried out 
until only FY 2015; the current analysis projects Program costs 
through FY 2025 based on WTC Health Program experience to date.

                                 Table 1--Summary of WTC Health Program Costs *
----------------------------------------------------------------------------------------------------------------
                                                                                             Cumulative FY 2016-
                                                       FY 2015               FY 2025                2025
----------------------------------------------------------------------------------------------------------------
                                                   Total Costs
----------------------------------------------------------------------------------------------------------------
    Undiscounted..............................          $240,571,579          $522,307,537        $4,223,209,653
    7% discount rate..........................  ....................           265,514,667         2,874,481,628
    3% discount rate..........................  ....................           388,645,860         3,553,658,528
----------------------------------------------------------------------------------------------------------------
                                             Program Administration
----------------------------------------------------------------------------------------------------------------
    Undiscounted..............................            96,414,964           134,485,132         1,194,966,221
    7% discount rate..........................  ....................            68,365,421           825,867,165
    3% discount rate..........................  ....................           100,069,568         1,012,191,361
----------------------------------------------------------------------------------------------------------------
                                        Medical Monitoring and Treatment
----------------------------------------------------------------------------------------------------------------
Initial health evaluation (survivors only):
    Undiscounted..............................               887,401             2,387,362            18,641,297
    7% discount rate..........................  ....................             1,213,614            12,610,885
    3% discount rate..........................  ....................             1,776,421            15,644,794
Annual medical monitoring:
    Undiscounted..............................            17,583,046            47,303,408           369,360,390
    7% discount rate..........................  ....................            24,046,654           249,873,253
    3% discount rate..........................  ....................            35,198,178           309,987,399
Diagnostic evaluation/cancer screening:
    Undiscounted..............................            13,131,585            35,327,709           275,850,234
    7% discount rate..........................  ....................            17,958,816           186,613,392
    3% discount rate..........................  ....................            26,287,133           231,508,572
Medical Treatment:
    Undiscounted..............................           112,554,583           302,803,927         2,364,391,511
    7% discount rate..........................  ....................           153,930,162         1,599,516,932
    3% discount rate..........................  ....................           225,314,560         1,984,326,403
----------------------------------------------------------------------------------------------------------------
                                      All Medical Monitoring and Treatment
----------------------------------------------------------------------------------------------------------------
    Undiscounted..............................           144,156,615           387,822,405         3,028,243,432
    7% discount rate..........................  ....................           197,149,246         2,048,614,463
    3% discount rate..........................  ....................           288,576,292         2,541,467,168
----------------------------------------------------------------------------------------------------------------
                                         Prior Rulemaking Cost Estimates
----------------------------------------------------------------------------------------------------------------
Cancer, September 2012 final rule (non-add).....Estimated cost per year FY 2013-2016
                                                                         ($mil)
                                                                     12.5-33.3.
Pentagon/Shanksville responders, March 2013 IFR Estimated cost per year FY 2013-2016
                                                                         ($mil)
                                                                        .9-3.2.
Prostate cancer, September 2013 final rule (non-Estimated cost per year FY 2014-2016
                                                                         ($mil)
                                                                       3.5-7.0.
Brain, invasive cervical pancreatic, testicular cancers, February
 2014 IFR (non-add).............................Estimated cost per year FY 2014-2016
                                                                         ($mil)
                                                                       2.2-5.0.
COPD and acute traumatic injury, July 2016 finalEstimated cost per year FY 2016-2019
                                                                         ($mil)
                                                                       4.6-5.7.
----------------------------------------------------------------------------------------------------------------
* Due to rounding, some totals may not correspond with the sum of the separate figures.


[[Page 90934]]

Enrollment
    As of the end of FY 2015, WTC Health Program membership included 
64,008 WTC responders and 9,144 screening- and certified-eligible 
survivors. Based on enrollment numbers since FY 2012, the first full 
year for which data are available, responders (including Pentagon and 
Shanksville responders) enroll at an approximate rate of 2,087 per 
year, screening- and certified-eligible survivors at an approximate 
rate of 1,077 per year. Table 2 displays the past annual enrollment of 
members, the projected enrollment over the 10 years between FY 2016 and 
FY 2025, and the projected total number of members by FY 2025.\16\
---------------------------------------------------------------------------

    \16\ These enrollment numbers do not include grandfathered 
members, the majority of whom were automatically enrolled in the 
Program in July 2011.

                                                      Table 2--WTC Health Program Annual Enrollment
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                           Total members
                                                              FY 2012         FY 2013         FY 2014         FY 2015      FY 2016-2025       by 2025
--------------------------------------------------------------------------------------------------------------------------------------------------------
WTC responders..........................................             886           1,539           3,096           2,205          20,873          84,545
Screening- and certified-eligible survivors.............           1,017             736           1,451           1,170          10,770          19,809
    Total...............................................           1,903           2,275           4,547           3,375          31,643         104,354
--------------------------------------------------------------------------------------------------------------------------------------------------------

Administrative Costs
    The annual cost to the WTC Health Program of conducting 
administrative functions was approximately $96,414,964 in FY 2015. 
Given the aggregate rate of enrollment of WTC responders and screening- 
and certified-eligible survivors, a rise in operations costs by 1.7 
percent and a rise in infrastructure costs of 3.3 percent, annual 
administrative costs for FY 2025 are expected to be $134,485,132. Such 
costs include program management, enrollment, certification of health 
conditions, pre-authorization of medical care, payment services, 
administration of appeals, education and outreach, administration of 
the advisory and steering committees, and infrastructure costs for the 
CCEs/NPN.
    Infrastructure costs for the CCEs/NPN include the retention of 
participants, case management, medical review, benefits counseling, 
quality management, data transfer, interpreter services, and assisting 
with the development of treatment protocols.

            Table 3--WTC Health Program Administrative Costs
                             [Undiscounted]
------------------------------------------------------------------------
                                              FY 2015         FY 2025
------------------------------------------------------------------------
Administrative costs (not including CCE/     $39,672,004     $57,193,270
 NPN infrastructure--see below).........
CCE/NPN infrastructure cost.............      56,742,690      77,291,862
                                         -------------------------------
    Total...............................      96,414,694     134,485,132
------------------------------------------------------------------------

Costs of Medical Monitoring and Treatment
    In FY 2015, the total cost to the WTC Health Program for medical 
monitoring and treatment was $144,156,615, and the breakdown by type of 
service is shown in Table 1. Initial health evaluations are for WTC 
screening-eligible survivors only. Diagnostic evaluation and cancer 
screening is for WTC screening- and certified-eligible survivors and 
WTC responders. The other two categories of services are for WTC 
certified-eligible survivors and WTC responders. These costs are based 
on claims paid during FY 2015. The FY 2015 costs do not include costs 
associated with monitoring and treatment of new-onset COPD and WTC-
related acute traumatic injury because the rulemaking adding those 
conditions to the List was not completed until July 2016.\17\
---------------------------------------------------------------------------

    \17\ 81 FR 43510 (July 5, 2016).
---------------------------------------------------------------------------

    For FY 2025, the WTC Health Program estimated the total cost for 
all health care service categories based on linear cost projections 
from prior fiscal years, with an adjustment (increase) to account 
conservatively for statistical uncertainty in the estimate. Also 
included in the estimate are increases for the treatment and monitoring 
of new-onset COPD and WTC-related acute traumatic injury, added to the 
List in July 2016. The FY 2025 total for all health care service 
categories is $387,822,406. This estimate accounts for an increase in 
enrollment, more members receiving health care benefits, higher-cost 
care related to cancer and complications of other illnesses, and 
general medical care cost increases. In order to determine the breakout 
by health care service category for FY 2025, the WTC Health Program 
calculated the percentage of the total cost in FY 2015 for each 
category and applied those percentages to the total estimate for FY 
2025.
Examination of Benefits
    Through FY 2015, the last full year for which Program data are 
available, 35,523 members (49 percent) have been certified for at least 
one WTC-related health condition. The number of certifications of WTC-
related health conditions identified in the categories of health 
conditions included in the List of WTC-Related Health Conditions is in 
Table 4, below. Based on the projected FY 2025 enrollment number of 
104,354 and an increase of 3 percent annually of the number of members 
who are estimated to be certified, there would be 158,415 
certifications for 68,103 Program members in FY 2025.

[[Page 90935]]



  Table 4--Number of Certified WTC-Related Health Conditions Among WTC
                         Health Program Members
------------------------------------------------------------------------
        Health condition category             FY 2015         FY 2025
------------------------------------------------------------------------
Aerodigestive disorders.................          58,782         112,694
Mental health conditions................          18,868          36,173
Musculoskeletal disorders...............             535           1,026
Cancers.................................           4,445           8,522
                                         -------------------------------
    1Total certifications...............          82,630         158,415
------------------------------------------------------------------------

    An evaluation of the health and quality of life improvements 
associated with medical treatment of several of the most commonly-
certified health conditions is based on the prevalence of certified 
WTC-related health conditions. Quality-adjusted life year (QALY) is a 
common metric of expected treatment effectiveness for the health 
conditions evaluated. For the purpose of this evaluation, the 
Administrator assumes that each health condition will continue to be 
represented among new Program members at the same rate at which it 
occurs in current members. The health benefits provided by the WTC 
Health Program are compared with the effect of no Program at all.
    The Administrator assumes that WTC Health Program members receive 
the best care available, as CCE and NPN providers are experts in 
treating the types of health conditions on the List eligible for 
certification. In order to compare the benefits provided by the WTC 
Health Program to a scenario with no WTC Health Program, the 
Administrator further assumes that the 9/11-exposed population of 
responders and survivors would instead receive some but not optimal 
treatment for their health conditions. Accordingly, the estimated 
benefits (QALYs) represent the incremental improvement in health that 
WTC Health Program members can expect from receiving the optimal 
treatment provided by the CCEs and NPN versus standard treatments that 
are commonly received outside of the Program.
    Below are summarized QALY estimates for morbidity improvements for 
aero-digestive conditions, PTSD and depression, and cancer.\18\
---------------------------------------------------------------------------

    \18\ Estimates for mental disorders other than PTSD and 
depression and for musculoskeletal disorders are not provided 
because these conditions only account for approximately 9 percent of 
the total certifications; estimates for WTC-related acute traumatic 
injuries are not included because the FY 2015 data used to conduct 
this analysis pre-dates the July 2016 rulemaking that added WTC-
related acute traumatic injuries to the List.
---------------------------------------------------------------------------

Aerodigestive Disorders
 Gastroesophageal Reflux Disorder (GERD)

    In the July 2011 IFR, an estimated 0.012 QALYs were gained per year 
per patient under treatment for GERD in the Program compared with 
patients treated outside the Program. Multiplying the WTC Health 
Program's GERD population for each year during FY 2016-2025 by 0.012 
results in 3,311 total undiscounted QALYs gained. Discounting future 
health benefits at 3 and 7 percent results in 2,781 and 2,244 total 
QALYs gained, respectively.

 Chronic Rhinosinusitis and other Upper Respiratory Diseases

    In the July 2011 IFR, an estimated 0.0145 QALYs were gained per 
year per patient under treatment for chronic rhinosinusitis and other 
upper respiratory diseases in the Program compared with patients 
treated outside the Program. Assuming the same gain is achieved for 
patients treated for other upper respiratory diseases, treating 
patients for all upper respiratory diseases would result in 4,877 total 
undiscounted QALYs gained. Discounting future health benefits at 3 and 
7 percent results in 4,095 and 3,304 total QALYs gained, respectively.

 Asthma

    In the July 2011 IFR, an estimated 0.029 QALYs were gained per year 
per patient under treatment for asthma in the Program resulting in 
6,002 total undiscounted QALYs gained. Discounting future benefits at a 
rate of 3 percent and 7 percent results in 5,040 and 4,066 total QALYs, 
respectively.

 Chronic Obstructive Pulmonary Disease (COPD) \19\
---------------------------------------------------------------------------

    \19\ Data used to develop QALYs for COPD were derived from FY 
2015 Program data regarding WTC-exacerbated COPD; estimates for new-
onset COPD are not included because the FY 2015 data pre-dates the 
addition of new-onset COPD to the List in the July 2016 rulemaking.

    In the July 2011 IFR, an estimated 0.077 QALYs were gained per year 
per patient under treatment in the program for WTC-exacerbated COPD in 
the Program resulting in 3,320 total undiscounted QALYs gained. 
Discounting future health benefits at 3 and 7 percent results in 2,788 
---------------------------------------------------------------------------
and 2,249 total QALYs gained, respectively.

 Reactive Airways Dysfunction Syndrome (RADS) and other 
Aerodigestive Conditions

    In the July 2011 IFR, an estimated medical treatment similar to 
that for asthma was discussed for patients suffering from RADS. 
Assuming that treating one patient results in 0.029 QALYs gained and 
that treating all other aerodigestive conditions not examined above 
would also result in 0.029 QALYs gained would result in a total of 
4,877 undiscounted QALYs gained. Discounting future health benefits at 
3 and 7 percent, results in 4,094 and 3,204 total QALYs gained, 
respectively.
Posttraumatic Stress Disorder (PTSD) and Depression
    In the July 2011 IFR, an estimated 0.013 QALYs were gained per year 
per patient under treatment for PTSD and depression in the Program 
resulting in a total of 3,598 undiscounted QALYs gained. Discounting 
future health benefits at 3 and 7 percent results in 3,022 and 2,438 
total QALYs gained, respectively.
Cancer
    It was assumed that all patients in FY 2016-2025 will live at a 
health-related quality of life level similar overall to that reported 
in Cutler and Richardson \20\ and Tengs and Wallace \21\ for patients 
with cancer. A QALY for a person living with cancer, without specifying 
treatment, stage of disease, or other specifics is approximately 0.7, 
with 1 representing perfect health and 0 death. For comparison, 
Sullivan and Ghushchyan \22\ estimated the health-related quality of 
life for the age group 50-69 in the general U.S. population at 0.827.
---------------------------------------------------------------------------

    \20\ David Cutler and Elizabeth Richardson, Your Money and Your 
Life: The Value of Health and What Affects It, in Frontiers in 
Health Policy Research, vol. 2, 99-132 (National Bureau of Economic 
Research, 1999).
    \21\ Tammy Tengs and Amy Wallace, One-Thousand Health-Related 
Quality of Life Estimates, Med Care 2000;38(6):583-637.
    \22\ Patrick Sullivan and Vahram Ghushchyan, Preference-Based 
EQ-5D Index Scores for Chronic Conditions in the United States, Med 
Decis Making 2006;26:410-420.

---------------------------------------------------------------------------

[[Page 90936]]

    Using the expected number of prevalent cancer cases for FY 2016-
2025 and published information in Tengs and Wallace on the health-
related quality of life of cancer patients who respond to treatment for 
their cancer, a rough estimate of 0.06 for the increase in patients' 
quality of life was estimated for cancers treated in the WTC Health 
Program compared to those not treated in the Program.\23\ Using the 
prevalence of cancers and an assumed difference in health-related 
quality of life of 0.06 among patients treated in the Program and those 
not treated in the Program for the years FY 2016-2025 results in a 
total of 3,913 undiscounted QALYs gained. Discounting future benefits 
at 3 percent and 7 percent, results in 3,285 and 2,651 total QALYs 
gained, respectively.
---------------------------------------------------------------------------

    \23\ Tengs and Wallace, supra note 15, reports ranges of 
differences in QALYs according to different treatments for ovarian 
cancer patients and whether these patients responded to these 
treatments. The ranges of these differences varied from 0.06 to 
0.17. We used the low end of the range as a conservative estimate. 
We are not aware of data available with which to estimate the 
possible effect more reliably.
---------------------------------------------------------------------------

    In summary, available information indicates the WTC Health Program 
is likely to provide substantial improvements in health to responders 
and survivors. The QALY estimates discussed above and summarized and 
annualized in Table 5 below are illustrative of these benefits.

 Table 5--Potential QALYs Gained From the WTC Health Program Treatment of Select WTC-Related Health Conditions:
                                              FY 2016-2025 Summary
----------------------------------------------------------------------------------------------------------------
                                                                                  Present  value  Present  value
                                                                       Total         of  QALYs       of  QALYs
                                                                   undiscounted     gained  by      gained  by
                        Health condition                           QALYs gained      treatment       treatment
                                                                   by treatment   discounted  at  discounted  at
                                                                                        7%              3%
----------------------------------------------------------------------------------------------------------------
Aerodigestive disorders.........................................          17,510          11,863          14,704
PTSD & Depression...............................................           3,598           2,438           3,022
Cancers.........................................................           3,913           2,651           3,285
                                                                 -----------------------------------------------
    Total.......................................................          25,021          16,952          21,011
        Annualized..............................................           2,502           2,414           2,463
----------------------------------------------------------------------------------------------------------------

    The cost analysis above is subject to a number of limitations, some 
but not all of which have been identified by the Program. The 
enrollment, administrative, and medical monitoring and treatment cost 
estimates are based on historical cost experience from the first full 
year of the WTC Health Program (FY 2012) to the end of FY 2015 and do 
not anticipate the costs of WTC-related health conditions added to the 
List in the future. The annual rate of increase takes into account the 
growth of the Program's membership based on enrollment data from the 
start of the Program to present and does not consider natural 
population mortality and mortality due to the WTC-related health 
conditions. The medical monitoring and treatment cost estimates are 
based on a combination of linear regression analysis of aggregate 
medical costs and adjustments for factors described above.
    The Program has also identified some, but not all, limitations in 
deriving the health benefits estimate. Some new Program members, if 
they have not received treatment for a certified WTC-related health 
condition prior to enrollment, may present in worse health and may 
benefit less from medical treatment than members who received more 
timely treatment in the Program. Furthermore, many Program members may 
have more than one concurrent certified WTC-related health condition 
for which they are receiving treatment in the Program, which can impact 
the effectiveness of medical treatment for any given condition.
    This rule does not interfere with State, local, or Tribal 
governments in the exercise of their governmental functions.

B. Regulatory Flexibility Act

    The Regulatory Flexibility Act (RFA), 5 U.S.C. 601 et seq., 
requires each agency to consider the potential impact of its 
regulations on small entities including small businesses, small 
governmental units, and small not-for-profit organizations. The 
Administrator certifies that this proposed rule has ``no significant 
economic impact upon a substantial number of small entities'' within 
the meaning of the RFA.

C. Paperwork Reduction Act

    The Paperwork Reduction Act, 44 U.S.C. 3501 et seq., requires an 
agency to invite public comment on, and to obtain OMB approval of, any 
regulation that requires 10 or more people to report information to the 
agency or to keep certain records. This final action continues to 
impose the same information collection requirements as under the July 
2011, March 2013, and February 2014 IFRs, including the submission of 
the following forms and other information listed in the table below.
    Data collection and recordkeeping requirements for the WTC Health 
Program are approved by OMB under ``World Trade Center Health Program 
Enrollment, Appeals & Reimbursement'' (OMB Control No. 0920-0891, exp. 
September 30, 2018). HHS has determined that substantive changes are 
needed to the information collection already approved by OMB. 
Accordingly, HHS has published a notice of the proposed changes to the 
existing approved information collection and invites comment from the 
public during the 60-day comment period. The 60-day notice, published 
in the Federal Register on October 24, 2016, is open for comment 
through December 23, 2016 (see 81 FR 73108); the 60-day notice will be 
followed by a 30-day notice, after which the revised information 
collection request will be finalized and approved by OMB. Revisions to 
the approved information collection include the following:

     Disenrollment Letter and Appeal Notification--
Eligibility: Of the over 70,000 Program members, we expect that 
0.014 percent (10) will be subsequently disenrolled from the 
Program. Of those, we expect that 30 percent (3) will appeal the 
disenrollment decisions. We estimate that the appeal requests will 
take no more than 0.5 hours per respondent. The annual burden 
estimate is 1.5 hours.
     Decertification Letter and Appeal Notification--Health 
Condition: Of the projected 51,472 enrollees who have at least

[[Page 90937]]

one health condition certification, it is estimated that 0.02 
percent (10) will be decertified, and 50 percent (5) of those will 
appeal a decertification. We estimate that the appeal request will 
take no more than 0.5 hours per respondent and providing additional 
information and/or an oral statement will take no more than 1 hour 
per respondent. The annual burden estimate is 7.5 hours.
     Denial Letter and Appeal Notification--Health Condition 
Certification: This information collection, including the submission 
of appeal requests, is currently approved by OMB for 60 respondents 
(0.5 hours per respondent) and is expanded by this final rule to 
include the provision of new information and/or an oral statement. 
We do not expect the OMB-approved estimated number of respondents to 
change. We estimate that the additional burden will be no more than 
1 hour per respondent. The total burden estimate (1.5 hours) 
includes both 0.5 hours per respondent for the submission of an 
appeal request (currently approved by OMB) as well as 1 hour per 
respondent for new information and/or an oral statement. The annual 
burden estimate is 90 hours.
     Denial Letter and Appeal Notification--Treatment 
Authorization: This information collection, including the submission 
of appeal requests, is currently approved by OMB for 26 respondents 
(0.5 hours per respondent) and is expanded by this final rule to 
include the provision of new information and/or an oral statement. 
We do not expect the OMB-approved estimated number of respondents to 
change. We estimate that the additional burden will be no more than 
1 hour per respondent. The total burden estimate (1.5 hours) 
includes both 0.5 hours per respondent for the submission of an 
appeal request (currently approved by OMB) as well as 1 hour per 
respondent for new information and/or an oral statement. The annual 
burden estimate is 39 hours.
     Reimbursement Denial Letter and Appeal Notification--
Providers: Of the nearly 52,000 providers affiliated with the 
Program, it is estimated that 1.15 percent (600) annually will 
appeal a denial of reimbursement for treatment found to be not 
medically necessary or in accordance with treatment protocols. We 
estimate that the appeal request will take no more than 0.5 hours 
per respondent to compile. The annual burden estimate is 300 hours.
     Designated Representative HIPAA Authorization: The 
Program also finds it necessary to add a new form to allow 
applicants and Program members to grant permission to share 
protected health information with an individual who has been 
properly appointed the applicant's or member's designated 
representative pursuant to 42 CFR 88.2. We estimate that 10 
applicants and members will submit the Designated Representative 
Health Insurance Portability and Accountability Act (HIPAA) 
Authorization form annually. The form is expected to take no longer 
than 0.25 hours to complete. The burden estimate for the HIPAA 
Authorization form is 2.5 hours.

    The Program estimates that the total annual paperwork burden 
associated with this rulemaking, including the revised and new burden 
hour estimates, is 14,178.95 hours.\24\
---------------------------------------------------------------------------

    \24\ The burden estimates provided here are subject to change in 
the final approved information collection revision request, pending 
the collection and review of public comments.

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                              Average
                                                                                             Number of        Number        burden per     Total burden
              Type of  respondent                               Form name                   respondents   responses  per   response  (in       hours
                                                                                                             respondent       hours)
--------------------------------------------------------------------------------------------------------------------------------------------------------
FDNY Responder.................................  World Trade Center Health Program FDNY               45               1             0.5            22.5
                                                  Responder Eligibility Application.
General Responder..............................  World Trade Center Health Program                 2,475               1             0.5         1,237.5
                                                  Responder Eligibility Application
                                                  (Other than FDNY).
Pentagon/Shanksville Responder.................  World Trade Center Health Program                   630               1             0.5             315
                                                  Pentagon/Shanksville Responder.
WTC Survivor...................................  World Trade Center Health Program                 1,350               1             0.5             675
                                                  Survivor Eligibility Application.
General Responder..............................  Postcard for new general responders in            2,475               1            0.25          618.75
                                                  NY/NJ to select a clinic.
Program Medical Provider.......................  WTC-3 Request for Certification........          20,000               1             0.5          10,000
Responder/Survivor.............................  Denial Letter and Appeal Notification--              45               1             0.5            22.5
                                                  Enrollment.
Responder/Survivor.............................  Disenrollment Letter and Appeal                       3               1             0.5             1.5
                                                  Notification--Eligibility.
Responder/Survivor.............................  Decertification Letter and Appeal                     5               1             1.5             7.5
                                                  Notification.
Responder/Survivor.............................  Denial Letter and Appeal Notification--              60               1             1.5              90
                                                  Health Condition Certification.
Responder/Survivor.............................  Denial Letter and Appeal Notification--              26               1             1.5              39
                                                  Treatment Authorization.
Responder/Survivor.............................  WTC Health Program Medical Travel                    10               1            0.17             1.7
                                                  Refund Request.
Responder/Survivor.............................  Designated Representative form.........              10               1            0.25             2.5
Pharmacy.......................................  Outpatient prescription pharmaceuticals             150             261            0.02             783
Program Medical Provider.......................  Reimbursement Denial Letter and Appeal              600               1             0.5             300
                                                  Notification.
Responder/Survivor.............................  Designated Representative HIPAA                      10               1            0.25             2.5
                                                  Authorization.
Responder/Survivor/Advocate (physician)........  Petition for the addition of health                  60               1               1              60
                                                  conditions.
                                                                                         ---------------------------------------------------------------
    Total......................................  .......................................  ..............  ..............  ..............       14,178.95
--------------------------------------------------------------------------------------------------------------------------------------------------------

D. Small Business Regulatory Enforcement Fairness Act

    As required by Congress under the Small Business Regulatory 
Enforcement Fairness Act of 1996, 5 U.S.C. 801 et seq., HHS will report 
the promulgation of this rule to Congress prior to its effective date.

E. Unfunded Mandates Reform Act of 1995

    Title II of the Unfunded Mandates Reform Act of 1995, 2 U.S.C. 1531 
et

[[Page 90938]]

seq., directs agencies to assess the effects of Federal regulatory 
actions on State, local, and Tribal governments, and the private sector 
``other than to the extent that such regulations incorporate 
requirements specifically set forth in law.'' For purposes of the 
Unfunded Mandates Reform Act, this final rule does not include any 
Federal mandate that may result in increased annual expenditures in 
excess of $100 million by State, local, or Tribal governments in the 
aggregate, or by the private sector.

F. Executive Order 12988 (Civil Justice)

    This final rule has been drafted and reviewed in accordance with 
Executive Order 12988, ``Civil Justice Reform,'' and will not unduly 
burden the Federal court system. This rule has been reviewed carefully 
to eliminate drafting errors and ambiguities.

G. Executive Order 13132 (Federalism)

    The Administrator has reviewed this final rule in accordance with 
Executive Order 13132 regarding Federalism, and has determined that it 
does not have ``Federalism implications.'' The rule does not ``have 
substantial direct effects on the States, on the relationship between 
the national government and the States, or on the distribution of power 
and responsibilities among the various levels of government.''

H. Executive Order 13045 (Protection of Children From Environmental 
Health Risks and Safety Risks)

    In accordance with Executive Order 13045, the Administrator has 
evaluated the environmental health and safety effects of this final 
rule on children. The Administrator has determined that the rule would 
have no environmental health and safety effect on children.

I. Executive Order 13211 (Actions Concerning Regulations That 
Significantly Affect Energy Supply, Distribution, or Use)

    In accordance with Executive Order 13211, the Administrator has 
evaluated the effects of this final rule on energy supply, distribution 
or use, and has determined that the rule will not have a significant 
adverse effect.

J. Plain Writing Act of 2010

    Under Public Law 111-274 (October 13, 2010), executive Departments 
and Agencies are required to use plain language in documents that 
explain to the public how to comply with a requirement the Federal 
government administers or enforces. The Administrator has attempted to 
use plain language in promulgating the final rule consistent with the 
Federal Plain Writing Act guidelines and requests public comment on 
this effort.

List of Subjects in 42 CFR Part 88

    Aerodigestive disorders, Appeal procedures, Health care, Mental 
health conditions, Musculoskeletal disorders, Respiratory and pulmonary 
diseases.

Final rule

0
For the reasons discussed in the preamble, the Administrator revises 42 
CFR part 88 to read as follows:

PART 88--WORLD TRADE CENTER HEALTH PROGRAM

Sec.
88.1 Definitions.
88.2 General provisions.
88.3 Eligibility--currently-identified responders.
88.4 Eligibility criteria--WTC responders.
88.5 Application process--WTC responders.
88.6 Enrollment decision--WTC responders.
88.7 Eligibility--currently-identified survivors.
88.8 Eligibility criteria--WTC survivors.
88.9 Application process--WTC survivors.
88.10 Enrollment decision--screening-eligible survivors.
88.11 Initial health evaluation for screening-eligible survivors.
88.12 Enrollment decision--certified-eligible survivors.
88.13 Disenrollment.
88.14 Appeal of enrollment or disenrollment decision.
88.15 List of WTC-Related Health Conditions.
88.16 Addition of health conditions to the List of WTC-Related 
Health Conditions.
88.17 Physician's determination of WTC-related health conditions.
88.18 Certification.
88.19 Decertification.
88.20 Authorization of treatment.
88.21 Appeal of certification, decertification, or treatment 
authorization decision.
88.22 Reimbursement for medical treatment and services.
88.23 Appeal of reimbursement denial.
88.24 Coordination of benefits and recoupment.
88.25 Reopening of WTC Health Program final decisions.

    Authority:  42 U.S.C. 300mm to 300mm-61, Pub. L. 111-347, 124 
Stat. 3623, as amended by Pub. L. 114-113, 129 Stat. 2242.


Sec.  88.1  Definitions.

    Act means Title XXXIII of the Public Health Service Act, as 
amended, 42 U.S.C. 300mm through 300mm-61 (codifying Title I of the 
James Zadroga 9/11 Health and Compensation Act of 2010, Pub. L. 111-
347, as amended by Pub. L. 114-113), which created the World Trade 
Center (WTC) Health Program.
    Aggravating means a health condition that existed on September 11, 
2001, and that, as a result of exposure to airborne toxins, any other 
hazard, or any other adverse condition resulting from the September 11, 
2001, terrorist attacks, requires medical treatment that is (or will 
be) in addition to, more frequent than, or of longer duration than the 
medical treatment that would have been required for such condition in 
the absence of such exposure.
    Certification means WTC Health Program review of a health condition 
in a particular WTC Health Program member for the purpose of 
identification and approval of a WTC-related health condition, as 
defined in this section and included on the List of WTC-Related Health 
Conditions in 42 CFR 88.15, or a health condition medically associated 
with a WTC-related health condition.
    Certified-eligible survivor means (1) an individual who has been 
identified as eligible for medical monitoring and treatment as of 
January 2, 2011; or (2) a screening-eligible survivor who is eligible 
for follow-up monitoring and treatment pursuant to Sec.  88.12(b).
    Clinical Center of Excellence (CCE) means a center or centers under 
contract with the WTC Health Program. A CCE:
    (1) Uses an integrated, centralized health care provider approach 
to create a comprehensive suite of health services that are accessible 
to enrolled WTC responders, screening-eligible survivors, or certified-
eligible survivors;
    (2) Has experience in caring for WTC responders and screening-
eligible survivors, or includes health care providers who have received 
WTC Health Program training;
    (3) Employs health care provider staff with expertise that 
includes, at a minimum, occupational medicine, environmental medicine, 
trauma-related psychiatry and psychology, and social services 
counseling; and
    (4) Meets such other requirements as specified by the Administrator 
of the WTC Health Program.
    Data Center means a center or centers under contract with the WTC 
Health Program to:
    (1) Receive, analyze, and report to the Administrator of the WTC 
Health Program on data that have been collected and reported to the 
Data Center by the corresponding CCE(s);
    (2) Develop monitoring, initial health evaluation, and treatment 
protocols with respect to WTC-related health conditions;
    (3) Coordinate the outreach activities of the corresponding CCE;
    (4) Establish criteria for credentialing of medical providers 
participating in the Nationwide Provider Network;

[[Page 90939]]

    (5) Coordinate and administer the activities of the WTC Health 
Program Steering Committees; and
    (6) Meet periodically with the corresponding CCE(s) to obtain input 
on the analysis and reporting of data and on development of monitoring, 
initial health evaluation, and treatment protocols.
    Designated representative means an individual selected by an 
applicant, WTC responder, or a screening-eligible or certified-eligible 
survivor to represent his or her interests to the WTC Health Program.
    Ground Zero means a site in Lower Manhattan bounded by Vesey Street 
to the north, the West Side Highway to the west, Liberty Street to the 
south, and Church Street to the east in which stood the former World 
Trade Center complex.
    Health condition medically associated with a WTC-related health 
condition means a condition that results from treatment of a WTC-
related health condition or results from progression of a WTC-related 
health condition.
    Initial health evaluation means assessment of one or more symptoms 
that may be associated with a WTC-related health condition and includes 
a medical and exposure history, a physical examination, and additional 
medical testing as needed to evaluate whether the individual has a WTC-
related health condition and is eligible for treatment under the WTC 
Health Program.
    Interested party means a representative of any organization 
representing WTC responders, a nationally recognized medical 
association, a WTC Health Program CCE or Data Center, a State or 
political subdivision, or any other interested person.
    List of WTC-Related Health Conditions means those conditions 
eligible for coverage in the WTC Health Program as identified in Sec.  
88.15 of this part.
    Medical emergency means a physical or mental health condition for 
which immediate treatment is necessary.
    Medically necessary treatment means the provision of services to a 
WTC Health Program member by physicians and other health care 
providers, including diagnostic and laboratory tests, prescription 
drugs, inpatient and outpatient hospital services, and other care that 
is appropriate, to manage, ameliorate, or cure a WTC-related health 
condition or a health condition medically associated with a WTC-related 
health condition, and which conforms to medical treatment protocols 
developed by the Data Centers, with input from the CCEs, and approved 
by the Administrator of the WTC Health Program.
    Monitoring means periodic physical and mental health assessment of 
a WTC responder or certified-eligible survivor in relation to exposure 
to airborne toxins, any other hazard, or any other adverse condition 
resulting from the September 11, 2001, terrorist attacks and which 
includes a medical and exposure history, a physical examination and 
additional medical testing as needed for surveillance or to evaluate 
symptom(s) to determine whether the individual has a WTC-related health 
condition.
    Nationwide Provider Network (NPN) means a network of providers 
throughout the United States under contract with the WTC Health Program 
to provide an initial health evaluation, monitoring, and treatment to 
enrolled WTC responders, screening-eligible survivors, or certified-
eligible survivors who live outside the New York metropolitan area.
    New York City disaster area means an area within New York City that 
is the area of Manhattan that is south of Houston Street and any block 
in Brooklyn that is wholly or partially contained within a 1.5-mile 
radius of the former World Trade Center complex.
    New York metropolitan area means the combined statistical areas 
comprising the Bridgeport-Stamford-Norwalk, CT Metropolitan Statistical 
Area; Kingston, NY Metropolitan Statistical Area; New Haven-Milford, CT 
Metropolitan Statistical Area; New York-Northern New Jersey-Long 
Island, NY-NJ-PA Metropolitan Statistical Area; Poughkeepsie-Newburgh-
Middletown, NY Metropolitan Statistical Area; Torrington, CT 
Micropolitan Statistical Area; Trenton-Ewing, NJ Metropolitan 
Statistical Area, as defined in OMB Bulletin 10-02, December 1, 2009.
    NIOSH means the National Institute for Occupational Safety and 
Health, Centers for Disease Control and Prevention, U.S. Department of 
Health and Human Services.
    One (1) day means the length of a standard work shift, or at least 
4 hours but less than 24 hours.
    Pentagon site means any area of the land (consisting of 
approximately 280 acres) and improvements thereon, located in 
Arlington, Virginia, on which the Pentagon Office Building, Federal 
Building Number 2, the Pentagon heating and sewage treatment plants, 
and other related facilities are located, including various areas 
designated for the parking of vehicles, vehicle access, and other areas 
immediately adjacent to the land or improvements previously described 
that were affected by the terrorist-related aircraft crash on September 
11, 2001; and those areas at Fort Belvoir in Fairfax County, Virginia 
and at the Dover Port Mortuary at Dover Air Force Base in Delaware 
involved in the recovery, identification, and transportation of human 
remains for the incident.
    Police department means any law enforcement department or agency, 
whether under Federal, state, or local jurisdiction, responsible for 
general police duties, such as maintenance of public order, safety, or 
health, enforcement of laws, or otherwise charged with prevention, 
detection, investigation, or prosecution of crimes.
    Scientific/Technical Advisory Committee means the WTC Health 
Program Scientific/Technical Advisory Committee whose members are 
appointed by the Administrator of the WTC Health Program to review 
scientific and medical evidence and to make recommendations to the 
Administrator on additional WTC Health Program eligibility criteria and 
on additional WTC-related health conditions.
    Screening-eligible survivor means an individual who is not a WTC 
responder and who claims symptoms of a WTC-related health condition and 
meets the eligibility criteria for a survivor specified in Sec.  
[thinsp]88.8 of this part.
    September 11, 2001, terrorist attacks means the terrorist attacks 
that occurred on September 11, 2001, in New York City, at Shanksville, 
Pennsylvania, and at the Pentagon, and includes the aftermath of such 
attacks.
    Shanksville, Pennsylvania site means the property in Stonycreek 
Township, Somerset County, Pennsylvania, which is bounded by Route 30 
(Lincoln Highway), State Route 1019 (Buckstown Road), and State Route 
1007 (Lambertsville Road); and those areas at the Pennsylvania National 
Guard Armory in Friedens, Pennsylvania involved in the recovery, 
identification, and transportation of human remains for the incident.
    Staten Island Landfill means the landfill in Staten Island, NY 
called ``Fresh Kills.''
    Terrorist watch list means the lists maintained by the Federal 
government that will be utilized to screen for known terrorists.
    WTC means World Trade Center.
    WTC Health Program means the program established by Title XXXIII of 
the Public Health Service Act as amended, 42 U.S.C. 300mm to 300mm-61 
(codifying Title I of the James Zadroga 9/11 Health and Compensation 
Act of 2010, Pub. L. 111-347, as amended by Pub. L. 114-113) to provide

[[Page 90940]]

medical monitoring and treatment benefits for eligible responders to 
the September 11, 2001, terrorist attacks and initial health 
evaluation, monitoring, and treatment benefits for residents and other 
building occupants and area workers in New York City who were directly 
impacted and adversely affected by such attacks.
    WTC Health Program member means any responder, screening-eligible 
survivor, or certified-eligible survivor enrolled in the WTC Health 
Program.
    WTC Program Administrator (Administrator of the WTC Health Program, 
or Administrator) means, for the purposes of this part, the Director of 
the National Institute for Occupational Safety and Health, Centers for 
Disease Control and Prevention, Department of Health and Human 
Services, or his or her designee.
    WTC-related acute traumatic injury means a health condition 
eligible for coverage in the WTC Health Program as described in Sec.  
88.15(e)(1) of this part.
    WTC-related health condition means an illness or health condition 
for which exposure to airborne toxins, any other hazard, or any other 
adverse condition resulting from the September 11, 2001, terrorist 
attacks, based on an examination by a medical professional with 
expertise in treating or diagnosing the health conditions in the List 
of WTC-Related Health Conditions, is substantially likely to be a 
significant factor in aggravating, contributing to, or causing the 
illness or health condition, including a mental health condition. Only 
those conditions on the List of WTC-Related Health Conditions codified 
in 42 CFR 88.15 may be considered WTC-related health conditions.
    WTC-related musculoskeletal disorder means a health condition 
eligible for coverage in the WTC Health Program as described in Sec.  
88.15(c)(1) of this part.
    WTC responder means an individual who has been identified as 
eligible for monitoring and treatment as described in Sec.  88.3 or who 
meets the eligibility criteria in Sec.  88.4.


Sec.  88.2  General provisions.

    (a) Designated representative. (1) An applicant or WTC Health 
Program member may appoint one individual to represent his or her 
interests under the WTC Health Program. The appointment must be made in 
writing and consistent with all relevant Federal laws and regulations 
in order for the designated representative to receive personal health 
information.
    (2) There may be only one designated representative at any time. 
After one designated representative has been properly appointed, the 
WTC Health Program will not recognize another individual as the 
designated representative until the appointment of the previously 
designated representative is withdrawn in a signed writing.
    (3) A properly appointed designated representative who is 
recognized by the WTC Health Program may make a request or give 
direction to the WTC Health Program regarding the eligibility, 
certification, or any other administrative issue pertaining to the 
applicant or WTC Health Program member under the WTC Health Program, 
including appeals. Any notice requirement contained in this part or in 
the Act is fully satisfied if sent to the designated representative.
    (4) An applicant or WTC Health Program member may authorize any 
individual to represent him or her in regard to the WTC Health Program, 
unless that individual's service as a representative would violate any 
applicable provision of law (such as 18 U.S.C. 205 or 18 U.S.C. 208) or 
is otherwise prohibited by WTC Health Program policies and procedures 
or contract provisions.
    (5) A Federal employee may act as a representative only on behalf 
of the individuals specified in, and in the manner permitted by, 18 
U.S.C. 203 and 18 U.S.C. 205.
    (6) If an applicant or screening-eligible or certified-eligible 
survivor is a minor, a parent or guardian may act on his or her behalf.
    (7) If an applicant or WTC Health Program member is a mentally 
incompetent adult, an individual authorized under state or other 
applicable law to act on the applicant's or member's behalf may act as 
his or her designated representative as described in this section.
    (b) Transportation and travel expenses. The WTC Health Program may 
provide for necessary and reasonable transportation and expenses 
incident to the securing of medically necessary treatment through the 
NPN, involving travel of more than 250 miles.


Sec.  [thinsp]88.3  Eligibility--currently identified responders.

    (a) Responders who were identified as eligible for monitoring and 
treatment under the arrangements as in effect on January 2, 2011, 
between NIOSH and the consortium administered by Mount Sinai School of 
Medicine in New York City and the Fire Department, City of New York, 
are enrolled in the WTC Health Program.
    (1) No individual who is determined to be a positive match to the 
terrorist watch list maintained by the Federal government will be 
considered to be enrolled in the WTC Health Program.
    (2) [Reserved]
    (b) WTC responders identified as enrolled under this section are 
not required to submit an application to the WTC Health Program.


Sec.  88.4  Eligibility criteria--WTC responders.

    (a) Responders to the New York City disaster area who have not been 
previously identified as eligible as provided for under Sec.  88.3 of 
this part may apply for enrollment in the WTC Health Program on or 
after July 1, 2011. Such individuals must meet the criteria in one of 
the following categories to be considered eligible for enrollment:
    (1) Firefighters and related personnel must meet the criteria 
specified in paragraph (a)(1)(i) or (ii) of this section:
    (i) The individual was an active or retired member of the Fire 
Department, City of New York (whether firefighter or emergency 
personnel), and participated at least 1 day in the rescue and recovery 
effort at any of the former World Trade Center sites (including Ground 
Zero, the Staten Island Landfill, or the New York City Chief Medical 
Examiner's Office), during the period beginning on September 11, 2001, 
and ending on July 31, 2002; or
    (ii) The individual is:
    (A) A surviving immediate family member of an individual who was an 
active or retired member of the Fire Department, City of New York 
(whether firefighter or emergency personnel), who was killed at Ground 
Zero on September 11, 2001, and
    (B) Received any treatment for a WTC-related mental health 
condition on or before September 1, 2008.
    (2) Law enforcement officers and WTC rescue, recovery, and cleanup 
workers must meet the criteria specified in paragraph (a)(2)(i) or (ii) 
of this section:
    (i) The individual worked or volunteered onsite in rescue, 
recovery, debris cleanup, or related support services in lower 
Manhattan (south of Canal Street), the Staten Island Landfill, or the 
barge loading piers, for at least:
    (A) 4 hours during the period beginning on September 11, 2001, and 
ending on September 14, 2001; or
    (B) 24 hours during the period beginning on September 11, 2001, and 
ending on September 30, 2001; or
    (C) 80 hours during the period beginning on September 11, 2001, and 
ending on July 31, 2002.
    (ii) The individual was an active or retired member of the New York 
City Police Department or an active or retired member of the Port 
Authority Police of the Port Authority of New York and

[[Page 90941]]

New Jersey who participated onsite in rescue, recovery, debris cleanup, 
or related support services, for at least:
    (A) 4 hours during the period beginning September 11, 2001, and 
ending on September 14, 2001, in lower Manhattan (south of Canal 
Street), including Ground Zero, the Staten Island Landfill, or the 
barge loading piers; or
    (B) 1 day beginning on September 11, 2001, and ending on July 31, 
2002, at Ground Zero, the Staten Island Landfill, or the barge loading 
piers; or
    (C) 24 hours during the period beginning on September 11, 2001, and 
ending on September 30, 2001, in lower Manhattan (south of Canal 
Street); or
    (D) 80 hours during the period beginning on September 11, 2001, and 
ending on July 31, 2002, in lower Manhattan (south of Canal Street).
    (3) Office of the Chief Medical Examiner of New York City employee. 
The individual 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 post-September 11 functions for such Office staff, 
during the period beginning on September 11, 2001, and ending on July 
31, 2002.
    (4) Port Authority Trans-Hudson Corporation Tunnel worker. The 
individual was a worker in the Port Authority Trans-Hudson Corporation 
Tunnel for at least 24 hours during the period beginning on February 1, 
2002, and ending on July 1, 2002.
    (5) Vehicle-maintenance worker. The individual was a vehicle-
maintenance worker who was exposed to debris from the former World 
Trade Center while retrieving, driving, cleaning, repairing, and 
maintaining vehicles contaminated by airborne toxins from the September 
11, 2001, terrorist attacks; and conducted such work for at least 1 day 
during the period beginning on September 11, 2001, and ending on July 
31, 2002.
    (b) Responders to the Pentagon site of the September 11, 2001, 
terrorist attacks, may apply for enrollment in the WTC Health Program 
on or after April 29, 2013. Individuals must meet the criteria below to 
be considered eligible for enrollment:
    (1) The individual was an active or retired member of a fire or 
police department (fire or emergency personnel), worked for a recovery 
or cleanup contractor, or was a volunteer; and
    (2) Performed rescue, recovery, demolition, debris cleanup, or 
other related services at the Pentagon site of the September 11, 2001, 
terrorist attacks, for at least 1 day beginning September 11, 2001, and 
ending on November 19, 2001.
    (c) Responders to the Shanksville, Pennsylvania site of the 
September 11, 2001, terrorist attacks, may apply for enrollment in the 
WTC Health Program on or after April 29, 2013. Individuals must meet 
the criteria below to be considered eligible for enrollment:
    (1) The individual was an active or retired member of a fire or 
police department (fire or emergency personnel), worked for a recovery 
or cleanup contractor, or was a volunteer; and
    (2) Performed rescue, recovery, demolition, debris cleanup, or 
other related services at the Shanksville, Pennsylvania site of the 
September 11, 2001, terrorist attacks, for at least 1 day beginning 
September 11, 2001, and ending on October 3, 2001.
    (d) [Reserved]
    (e) The WTC Health Program will maintain a list of WTC responders.


Sec.  88.5  Application process--WTC responders.

    (a) An application to the WTC Health Program based on the criteria 
in Sec.  88.4 must be submitted with documentation of the applicant's 
employment affiliation (if relevant) and work activity during the 
dates, times, and locations specified in Sec.  88.4
    (1) Documentation may include but is not limited to a pay stub; 
official personnel roster; a written statement, under penalty of 
perjury by an employer; site credentials; or similar documentation.
    (2) An applicant who is unable to submit the required documentation 
must instead offer a written explanation of how he or she tried to 
obtain proof of presence, residence, or work activity and why the 
attempt was unsuccessful. The applicant must attest, under penalty of 
perjury, that he or she meets the criteria specified in Sec.  88.4.
    (b) The application and supporting documentation must be submitted 
to the WTC Health Program for consideration.
    (c) The WTC Health Program will notify the applicant in writing (or 
by email if an email address is provided by the applicant) of any 
deficiencies in the application or the supporting documentation.


Sec.  88.6  Enrollment decision--WTC responders.

    (a) Enrollment priority. The WTC Health Program will prioritize 
applications in the order in which they are received.
    (b) Enrollment eligibility. The WTC Health Program will decide if 
the applicant meets the eligibility criteria provided in Sec.  88.4.
    (c) Denial of enrollment. (1) The WTC Health Program will deny 
enrollment if the applicant fails to meet the applicable eligibility 
requirements.
    (2) The WTC Health Program may deny enrollment of a responder who 
is otherwise eligible and qualified if the Act's numerical limitations 
for newly enrolled responders have been met.
    (i) No more than 25,000 WTC responders, other than those enrolled 
pursuant to Sec. Sec.  88.3 and 88.4(a)(1)(ii), may be enrolled at any 
time. The Administrator of the WTC Health Program may decide, based on 
the best available evidence, that sufficient funds are available under 
the WTC Health Program Fund to provide treatment and monitoring only 
for individuals who are already enrolled as WTC responders at that 
time.
    (ii) [Reserved]
    (3) No individual who is determined to be a positive match to the 
terrorist watch list maintained by the Federal government may qualify 
to be enrolled or be determined to be eligible for the WTC Health 
Program.
    (d) Notification of enrollment decision. (1) The WTC Health Program 
will decide if the applicant meets the current eligibility criteria for 
WTC responders in Sec.  88.4 and is qualified, and notify the applicant 
of the enrollment decision in writing within 60 calendar days of the 
date of receipt of the application. The 60-day time period will not 
include any days during which the applicant is correcting deficiencies 
in the application or supporting documentation.
    (2) If the WTC Health Program decides that an applicant is denied 
enrollment, the written notification will include an explanation, as 
appropriate, for the decision to deny enrollment and inform the 
applicant of the right to appeal the initial denial of eligibility and 
provide instructions on how to file an appeal.


Sec.  [thinsp]88.7  Eligibility--currently identified survivors.

    (a) Survivors who have been identified as eligible for medical 
treatment and monitoring as of January 2, 2011, are considered 
certified-eligible in the WTC Health Program.
    (1) No individual who is determined to be a positive match to the 
terrorist watch list maintained by the Federal government will be 
considered to be a certified-eligible survivor in the WTC Health 
Program.
    (2) [Reserved]
    (b) Survivors identified as certified-eligible under this section 
are not

[[Page 90942]]

required to submit an application to the WTC Health Program.


Sec.  88.8  Eligibility criteria--WTC survivors.

    (a) Criteria for status as a screening-eligible survivor. An 
individual who is not a WTC responder, claims symptoms of a WTC-related 
health condition, and who has not been previously identified as 
eligible under Sec.  88.7 may apply to the WTC Health Program on or 
after July 1, 2011, for a determination of eligibility for an initial 
health evaluation.
    (1) The WTC Health Program will determine an applicant's 
eligibility for an initial health evaluation based on one of the 
following criteria:
    (i) The screening applicant was present in the dust or dust cloud 
in the New York City disaster area on September 11, 2001.
    (ii) The screening applicant worked, resided, or attended school, 
childcare, or adult daycare in the New York City disaster area, for at 
least:
    (A) 4 days during the period beginning on September 11, 2001, and 
ending on January 10, 2002; or
    (B) 30 days during the period beginning on September 11, 2001, and 
ending on July 31, 2002.
    (iii) The screening applicant worked as a cleanup worker or 
performed maintenance work in the New York City disaster area during 
the period beginning on September 11, 2001, and ending on January 10, 
2002, and had extensive exposure to WTC dust as a result of such work.
    (iv) The screening applicant:
    (A) Was deemed eligible to receive a grant from the Lower Manhattan 
Development Corporation Residential Grant Program;
    (B) Possessed a lease for a residence or purchased a residence in 
the New York City disaster area; and
    (C) Resided in such residence during the period beginning on 
September 11, 2001, and ending on May 31, 2003.
    (v) The screening applicant is an individual whose place of 
employment--
    (A) At any time during the period beginning on September 11, 2001, 
and ending on May 31, 2003, was in the New York City disaster area; and
    (B) Was deemed eligible to receive a grant from the Lower Manhattan 
Development Corporation WTC Small Firms Attraction and Retention Act 
program or other government incentive program designed to revitalize 
the lower Manhattan economy after the September 11, 2001, terrorist 
attacks.
    (2) [Reserved]
    (b) Criteria for status as a certified-eligible survivor. Survivors 
who have been determined to have screening-eligible status under Sec.  
88.10(a), may seek status as a certified-eligible survivor. Status as a 
certified-eligible survivor is based on a certification by the WTC 
Health Program that, pursuant to an initial health evaluation, the 
screening-eligible survivor has a WTC-related health condition and is 
eligible for follow-up monitoring and treatment.
    (c) The WTC Health Program will maintain a list of screening-
eligible and certified-eligible survivors.


Sec.  88.9  Application process--WTC survivors.

    (a) Application for status as a screening-eligible survivor. An 
application to the WTC Health Program based on the criteria in Sec.  
88.8(a) must be submitted with documentation of the applicant's 
location, presence or residence, and/or work activity during the 
relevant time period.
    (1) Documentation may include but is not limited to: Proof of 
residence, such as a lease or utility bill; attendance roster at a 
school or daycare; or pay stub, other employment documentation, or 
written statement, under penalty of perjury, by an employer indicating 
employment location during the relevant time period; or similar 
documentation. The applicant must also attest to symptoms of a WTC-
related health condition.
    (2) An applicant who is unable to submit the required documentation 
must instead offer a written explanation of how he or she tried to 
obtain proof of location, presence, or residence, and/or work activity 
and why the attempt was unsuccessful. The applicant must attest, under 
penalty of perjury, that he or she meets the criteria specified in 
Sec.  88.8.
    (3) The applicant will be notified of any deficiencies in the 
application or the supporting documentation.
    (b) Status as a certified-eligible survivor. No additional 
application is required for status as a certified-eligible survivor. 
If, based upon the screening-eligible survivor's initial health 
evaluation (see Sec.  88.11), the WTC Health Program certifies the 
diagnosis of a WTC-related health condition, then the survivor will 
automatically receive the status of a certified-eligible survivor.


Sec.  88.10  Enrollment decision--screening-eligible survivors.

    (a) The WTC Health Program will decide if the applicant meets the 
screening-eligible survivor criteria pursuant to Sec.  88.8(a) and is 
qualified, and notify the applicant of the enrollment decision in 
writing within 60 calendar days of the date of receipt of the 
application. The 60-day time period will not include any days during 
which the applicant is correcting deficiencies in the application or 
supporting documentation.
    (b) If the WTC Health Program decides that an applicant is denied 
enrollment, the written notification will include an explanation for 
the decision to deny enrollment and inform the applicant of the right 
to appeal the enrollment denial and provide instructions on how to file 
an appeal.
    (1) The WTC Health Program may deny screening-eligible survivor 
status if the applicant is ineligible under the criteria specified in 
Sec.  88.8(a).
    (2) The WTC Health Program may deny screening-eligible survivor 
status if the numerical limitation on certified-eligible survivors in 
Sec.  88.12(b)(3)(i) has been met.
    (3) No individual who is determined to be a positive match to the 
terrorist watch list maintained by the Federal government may qualify 
to be a screening-eligible survivor in the WTC Health Program.


Sec.  88.11  Initial health evaluation for screening-eligible 
survivors.

    (a) A CCE or an NPN-affiliated physician will provide the 
screening-eligible survivor an initial health evaluation to determine 
if the individual has a WTC-related health condition.
    (b) The WTC Health Program will provide only one initial health 
evaluation per screening-eligible survivor. The individual may request 
additional health evaluations at his or her own expense.
    (c) If the physician determines that the screening-eligible 
survivor has a WTC-related health condition, the physician will 
promptly transmit to the WTC Health Program his or her determination, 
consistent with the requirements of Sec.  88.17(a).


Sec.  88.12  Enrollment decision--certified-eligible survivors.

    (a) The WTC Health Program will prioritize certification requests 
in the order in which they are received.
    (b) The WTC Health Program will review the physician's 
determination, render a decision regarding certification of the 
individual's WTC-related health condition, and notify the individual of 
the decision and the reason for the decision in writing, pursuant to 
Sec. Sec.  88.17 and 88.18.
    (1) If the individual is a screening-eligible survivor and the 
individual's condition is certified as a WTC-related health condition, 
the individual will automatically receive the status of a certified-
eligible survivor.

[[Page 90943]]

    (2) If a screening-eligible survivor's condition is not certified 
as a WTC-related health condition pursuant to Sec. Sec.  88.17 and 
88.18, the WTC Health Program will deny certified-eligible status. The 
screening-eligible survivor may appeal the decision to deny 
certification, as provided under Sec.  88.21.
    (3) The WTC Health Program may deny certified-eligible survivor 
status of an otherwise eligible and qualified screening-eligible 
survivor if the Act's numerical limitations for certified-eligible 
survivors have been met.
    (i) No more than 25,000 individuals, other than those described in 
Sec.  88.7, may be determined to be certified-eligible survivors at any 
time. The Administrator of the WTC Health Program may decide, based on 
the best available evidence, that sufficient funds are available under 
the WTC Health Program Fund to provide treatment and monitoring only 
for individuals who have already been certified as certified-eligible 
survivors at that time.
    (ii) [Reserved]
    (4) No individual who is determined to be a positive match to the 
terrorist watch list maintained by the Federal government may qualify 
to be a certified-eligible survivor in the WTC Health Program.


Sec.  88.13  Disenrollment.

    (a) The disenrollment of a WTC Health Program member may be 
initiated by the WTC Health Program in the following circumstances:
    (1) The WTC Health Program mistakenly enrolled an individual under 
Sec.  88.4 (WTC responders) or Sec.  88.8 (screening-eligible 
survivors) who did not provide sufficient proof of eligibility 
consistent with the required eligibility criteria; or
    (2) The WTC Health Program member's enrollment was based on 
incorrect or fraudulent information.
    (b) The disenrollment of a WTC Health Program member may be 
initiated by the enrollee for any reason.
    (c) A disenrolled WTC Health Program member will be notified in 
writing by the WTC Health Program of a disenrollment decision, provided 
an explanation, as appropriate, for the decision, and provided 
information on how to appeal the decision. A disenrolled WTC Health 
Program member disenrolled pursuant to paragraph (a) may appeal the 
disenrollment decision in accordance with Sec.  88.14.
    (d) A disenrolled WTC Health Program member who has been 
disenrolled in accordance with paragraphs (a) or (b) of this section 
may seek to re-enroll in the WTC Health Program using the application 
and enrollment procedures, provided that the application is supported 
by new information.


Sec.  88.14  Appeal of enrollment or disenrollment decision.

    (a) Right to appeal. An applicant denied WTC Health Program 
enrollment, a disenrolled WTC Health Program member, or the applicant's 
or member's designated representative (appointed pursuant to Sec.  
88.2(a)) may appeal the enrollment denial or disenrollment decision.
    (b) Appeal request. (1) A letter requesting an appeal must be 
postmarked within 120 calendar days of the date of the letter from the 
Administrator notifying the denied applicant or disenrolled WTC Health 
Program member of the adverse decision. Electronic versions of a signed 
letter will be accepted if transmitted within 120 calendar days of the 
date of the Administrator's notification letter.
    (2) A valid request for an appeal must:
    (i) Be made in writing and signed;
    (ii) Identify the denied applicant or disenrolled WTC Health 
Program member and designated representative (if applicable);
    (iii) Describe the decision being appealed and state the reasons 
why the denied applicant, disenrolled WTC Health Program member, or 
designated representative believes the enrollment denial or 
disenrollment was incorrect and should be reversed. The appeal request 
may include relevant new information not previously considered by the 
WTC Health Program; and
    (iv) Be sent to the WTC Health Program at the address specified in 
the notice of denial or disenrollment.
    (3) Where the denial or disenrollment is based on information from 
the terrorist watch list, the appeal will be forwarded to the 
appropriate Federal agency.
    (c) Appeal process. Upon receipt of a valid appeal, the 
Administrator will appoint a Federal Official independent of the WTC 
Health Program to review the case. The Federal Official will review all 
available records relevant to the WTC Health Program's decision not to 
enroll the applicant or to disenroll the WTC Health Program member and 
assess whether the appeal should be granted. In conducting the review, 
the Federal Official's consideration will include the following: 
Whether the WTC Health Program substantially complied with all relevant 
WTC Health Program policies and procedures; whether the information 
supporting the WTC Health Program's decision was factually accurate; 
and whether the WTC Health Program's decision was reasonable as applied 
to the facts of the case.
    (1) The Federal Official may consider additional relevant new 
information submitted by the denied applicant, disenrolled WTC Health 
Program member, or designated representative.
    (2) The Federal Official will provide his or her recommendation 
regarding the disposition of the appeal, including his or her findings 
and any supporting materials, to the Administrator.
    (d) Final decision and notification. The Administrator will review 
the Federal Official's recommendation and any relevant information and 
make a final decision on the appeal. The Administrator will notify the 
denied applicant or disenrolled WTC Health Program member and/or 
designated representative of the following in writing:
    (1) The recommendation and findings made by the Federal Official as 
a result of the review;
    (2) The Administrator's final decision on the appeal;
    (3) An explanation of the reason(s) for the Administrator's final 
decision on the appeal; and
    (4) Any administrative actions taken by the WTC Health Program in 
response to the Administrator's final decision.


Sec.  88.15  List of WTC-Related Health Conditions.

    WTC-related health conditions include the following disorders and 
conditions:
    (a) Aerodigestive disorders:
    (1) Interstitial lung diseases.
    (2) Chronic respiratory disorder--fumes/vapors.
    (3) Asthma.
    (4) Reactive airways dysfunction syndrome (RADS).
    (5) WTC-exacerbated and new-onset 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).
    (12) Sleep apnea exacerbated by or related to a condition described 
in preceding paragraphs (a)(1) through (11) of this section.
    (b) Mental health conditions:
    (1) Posttraumatic stress disorder (PTSD).
    (2) Major depressive disorder.
    (3) Panic disorder.
    (4) Generalized anxiety disorder.
    (5) Anxiety disorder (not otherwise specified).

[[Page 90944]]

    (6) Depression (not otherwise specified).
    (7) Acute stress disorder.
    (8) Dysthymic disorder.
    (9) Adjustment disorder.
    (10) Substance abuse.
    (c) Musculoskeletal disorders:
    (1) WTC-related musculoskeletal disorder is a chronic or recurrent 
disorder of the musculoskeletal system caused by heavy lifting or 
repetitive strain on the joints or musculoskeletal system occurring 
during rescue or recovery efforts in the New York City disaster area in 
the aftermath of the September 11, 2001, terrorist attacks. For a WTC 
responder who received any treatment for a WTC-related musculoskeletal 
disorder on or before September 11, 2003, such a health condition 
includes:
    (i) Low back pain.
    (ii) Carpal tunnel syndrome (CTS).
    (iii) Other musculoskeletal disorders.
    (2) [Reserved].
    (d) Cancers:
    (1) Malignant neoplasms of the lip; tongue; salivary gland; floor 
of mouth; gum and other mouth; tonsil; oropharynx; hypopharynx; and 
other oral cavity and pharynx.
    (2) Malignant neoplasm of the nasopharynx.
    (3) Malignant neoplasms of the nose; nasal cavity; middle ear; and 
accessory sinuses.
    (4) Malignant neoplasm of the larynx.
    (5) Malignant neoplasm of the esophagus.
    (6) Malignant neoplasm of the stomach.
    (7) Malignant neoplasms of the colon and rectum.
    (8) Malignant neoplasms of the liver and intrahepatic bile duct.
    (9) Malignant neoplasms of the retroperitoneum and peritoneum; 
omentum; and mesentery.
    (10) Malignant neoplasms of the trachea; bronchus and lung; heart, 
mediastinum and pleura; and other ill-defined sites in the respiratory 
system and intrathoracic organs.
    (11) Mesothelioma.
    (12) Malignant neoplasms of the peripheral nerves and autonomic 
nervous system; and other connective and soft tissue.
    (13) Malignant neoplasms of the skin (melanoma and non-melanoma), 
including scrotal cancer.
    (14) Malignant neoplasm of the female breast.
    (15) Malignant neoplasm of the ovary.
    (16) Malignant neoplasm of the prostate.
    (17) Malignant neoplasm of the urinary bladder.
    (18) Malignant neoplasm of the kidney.
    (19) Malignant neoplasms of the renal pelvis; ureter; and other 
urinary organs.
    (20) Malignant neoplasms of the eye and orbit.
    (21) Malignant neoplasm of the thyroid.
    (22) Malignant neoplasms of the blood and lymphoid tissues 
(including, but not limited to, lymphoma, leukemia, and myeloma).
    (23) Childhood cancers: any type of cancer diagnosed in a person 
less than 20 years of age.
    (24) Rare cancers: any type of cancer \1\ that occurs in less than 
15 cases per 100,000 persons per year in the United States.
---------------------------------------------------------------------------

    \1\ Based on 2005-2009 average annual data age-adjusted to the 
2000 U.S. population. See Glenn Copeland, Andrew Lake, Rick Firth, 
et al. (eds), Cancer in North America: 2005-2009. Volume One: 
Combined Cancer Incidence for the United States, Canada and North 
America, Springfield, IL: North American Association of Central 
Cancer Registries, Inc., June 2012.
---------------------------------------------------------------------------

    (e) Acute traumatic injuries:
    (1) WTC-related acute traumatic injury is physical damage to the 
body caused by and occurring immediately after a one-time exposure to 
energy, such as heat, electricity, or impact from a crash or fall, 
resulting from a specific event or incident. For a WTC responder or 
screening-eligible or certified-eligible survivors who received any 
medical treatment for a WTC-related acute traumatic injury on or before 
September 11, 2003, such a health condition includes:
    (i) Eye injury.
    (ii) Burn.
    (iii) Head trauma.
    (iv) Fracture.
    (v) Tendon tear.
    (vi) Complex sprain.
    (vii) Other similar acute traumatic injuries.
    (2) [Reserved]


Sec.  88.16  Addition of health conditions to the List of WTC-Related 
Health Conditions.

    (a) Any interested party may submit a request to the Administrator 
of the WTC Health Program to add a condition to the List of WTC-Related 
Health Conditions in Sec.  88.15. The Administrator will evaluate the 
submission to decide whether it is a valid petition.
    (1) Each valid petition must include the following:
    (i) An explicit statement of an intent to petition the 
Administrator to add a health condition to the List of WTC-Related 
Health Conditions;
    (ii) Name, contact information, and signature of the interested 
party petitioning for the addition;
    (iii) Name and/or description of the condition(s) to be added;
    (iv) Reasons for adding the condition(s), including the medical 
basis for the association between the September 11, 2001, terrorist 
attacks and the condition(s) to be added.
    (2) Not later than 90 calendar days after the receipt of a valid 
petition, the Administrator will take one of the following actions:
    (i) Request a recommendation of the WTC Health Program Scientific/
Technical Advisory Committee;
    (ii) Publish in the Federal Register a proposed rule to add such 
health condition;
    (iii) Publish in the Federal Register the Administrator's decision 
not to publish a proposed rule and the basis for that decision; or
    (iv) Publish in the Federal Register a decision that insufficient 
evidence exists to take action under paragraph (a)(2)(i) through (iii) 
of this section.
    (3) The 90-day time period will not include any days during which 
the Administrator is consulting with the interested party to clarify 
the submission.
    (4) The Administrator may consider more than one petition 
simultaneously when the petitions propose the addition of the same 
health condition. Scientific/Technical Advisory Committee 
recommendations and Federal Register notices initiated by the 
Administrator pursuant to paragraph (a)(2) of this section may respond 
to more than one petition.
    (5) The Administrator will be required to consider a submission for 
a health condition previously reviewed by the Administrator and found 
not to qualify for addition to the List of WTC-Related Health 
Conditions as a valid new petition only if the submission presents a 
new medical basis (i.e., a basis not previously reviewed) for the 
association between the September 11, 2001, terrorist attacks and the 
condition to be added. A submission that provides no new medical basis 
and is received after the publication of a response in the Federal 
Register to a petition requesting the addition of the same health 
condition will not be considered a valid petition and will not be 
answered in a Federal Register notice pursuant to paragraph (a)(2), 
above. The interested party will be informed of the WTC Health 
Program's decision in writing.
    (b) The Administrator may propose to add a condition to the List of 
WTC-Related Health Conditions in Sec.  88.15 of this part by publishing 
a proposed rule in the Federal Register and providing interested 
parties a period of 30 calendar days to submit written comments. The 
Administrator may

[[Page 90945]]

extend the comment period for good cause.
    (1) If the Administrator requests a recommendation from the WTC 
Health Program Scientific/Technical Advisory Committee, the Advisory 
Committee will submit its recommendation to the Administrator no later 
than 90 calendar days after the date of the transmission of the request 
or no later than a date specified by the Administrator (but not more 
than 180 calendar days after the request). The Administrator will 
publish a proposed rule or a decision not to publish a proposed rule in 
the Federal Register no later than 90 calendar days after the date of 
transmission of the Advisory Committee recommendation.
    (2) Before issuing a final rule to add a health condition to the 
List of WTC-Related Health Conditions, the Administrator will provide 
for an independent peer review of the scientific and technical evidence 
that would be the basis for issuing such final rule.


Sec.  88.17  Physician's determination of WTC-related health 
conditions.

    (a) A physician affiliated with either a CCE or NPN will promptly 
transmit to the WTC Health Program a determination that a member's 
exposure to airborne toxins, any other hazard, or any other adverse 
condition resulting from the September 11, 2001, terrorist attacks is 
substantially likely to be a significant factor in aggravating, 
contributing to, or causing the illness or health condition, including 
a mental health condition. The transmission will also include the basis 
for such determination. The physician's determination will be made 
based on an assessment of the following:
    (1) The individual's exposure to airborne toxins, any other hazard, 
or any other adverse condition resulting from the September 11, 2001, 
terrorist attacks.
    (2) The type of symptoms experienced by the individual and the 
temporal sequence of those symptoms.
    (b) For a health condition medically associated with a WTC-related 
health condition, the physician's determination must contain 
information establishing how the health condition has resulted from 
treatment of a previously certified WTC-related health condition or how 
it has resulted from progression of the certified WTC-related health 
condition.


Sec.  88.18  Certification.

    (a) WTC-related health condition. The WTC Health Program will 
review each physician determination and render a decision regarding 
certification of the condition as a WTC-related health condition. The 
WTC Health Program will notify the WTC Health Program member of the 
decision and the reason for the decision in writing.
    (b) Health condition medically associated with a WTC-related health 
condition. The WTC Health Program will review each physician 
determination and render a decision regarding certification of the 
condition as a health condition medically associated with a WTC-related 
health condition. The WTC Health Program will notify the WTC Health 
Program member in writing of the decision and the reason for the 
decision within 60 calendar days after the date the physician's 
determination is received.
    (1) In the course of review, the WTC Health Program may seek a 
recommendation about certification from a physician panel with 
appropriate expertise for the condition.
    (2) [Reserved]
    (c) Appeal right. If certification of a condition as a WTC-related 
health condition or a health condition medically associated with a WTC-
related health condition is denied, the WTC Health Program member may 
appeal the WTC Health Program's decision to deny certification, as 
provided under Sec.  88.21.


Sec.  88.19  Decertification.

    (a) The decertification of a WTC Health Program member's certified 
WTC-related health condition or health condition medically associated 
with a WTC-related health condition may be initiated by the WTC Health 
Program in the following circumstances:
    (1) The WTC Health Program finds that the member's exposure is 
inadequate or is otherwise not covered;
    (2) The WTC Health Program finds that the member's certified WTC-
related health condition was certified in error or erroneously 
considered to have been aggravated, contributed to, or caused by 
exposure to airborne toxins, any other hazard, or any other adverse 
condition resulting from the September 11, 2001, terrorist attacks, 
pursuant to Sec.  88.17(a); or
    (3) The WTC Health Program finds that the member's health condition 
was erroneously determined to be medically associated with a WTC-
related health condition, pursuant to Sec.  88.17(b).
    (b) A WTC Health Program member will be notified in writing by the 
WTC Health Program of a decertification decision, provided an 
explanation, as appropriate, for the decision, and provided information 
on how to appeal the decision. A WTC Health Program member whose WTC-
related health condition or health condition medically associated with 
a WTC-related health condition is decertified may appeal the 
decertification decision in accordance with Sec.  88.21 of this part.


Sec.  88.20  Authorization of treatment.

    (a) Generally. Medically necessary treatment of certified WTC-
related health conditions and certified health conditions medically 
associated with WTC-related health conditions will be provided through 
the CCEs or the NPN as permitted under WTC Health Program treatment 
protocols and in accordance with all applicable WTC Health Program 
policies and procedures.
    (b) Standard for determining medical necessity. All treatment 
provided under the WTC Health Program will adhere to a standard which 
is reasonable and appropriate; based on scientific evidence, 
professional standards of care, expert opinion or any other relevant 
information; and which has been included in the medical treatment 
protocols developed by the Data Centers, with input from the CCEs, and 
approved by the Administrator of the WTC Health Program.
    (c) Treatment pending certification. While certification of a 
condition is pending, authorization for treatment of a WTC-related 
health condition or a health condition medically associated with a WTC-
related health condition must be obtained from the WTC Health Program 
before treatment is provided, except for the provision of treatment for 
a medical emergency.


Sec.  88.21  Appeal of certification, decertification, or treatment 
authorization decision.

    (a) Right to appeal. A WTC Health Program member or the member's 
designated representative (appointed pursuant to Sec.  88.2(a)) may 
appeal the following four types of decisions made by the WTC Health 
Program:
    (1) To deny certification of a health condition as a WTC-related 
health condition;
    (2) To deny certification of a health condition as medically 
associated with a WTC-related health condition;
    (3) To decertify a WTC-related health condition or a health 
condition medically associated with a WTC-related health condition; or
    (4) To deny authorization of treatment for a certified health 
condition based on a finding that the treatment is not medically 
necessary.
    (b) Appeal request. (1) A letter requesting an appeal must be 
postmarked within 120 calendar days of the date of the letter from the

[[Page 90946]]

Administrator of the WTC Health Program notifying the member of the 
adverse decision. Electronic versions of a signed letter will be 
accepted if transmitted within 120 calendar days of the date of the 
Administrator's notification letter.
    (2) A valid request for an appeal must:
    (i) Be made in writing and signed;
    (ii) Identify the member and designated representative (if 
applicable);
    (iii) Describe the decision being appealed and the reason(s) why 
the member or designated representative believes the decision is 
incorrect and should be reversed. The description may include, but is 
not limited to, the following: Scientific or medical information 
correcting factual errors that may have been submitted to the WTC 
Health Program by the CCE or NPN; information demonstrating that the 
WTC Health Program did not correctly follow or apply relevant WTC 
Health Program policies or procedures; or any information demonstrating 
that the WTC Health Program's decision was not reasonable given the 
facts of the case. The basis provided in the appeal request must be 
sufficiently detailed and supported by information to permit a review 
of the appeal. Any new information not previously considered by the WTC 
Health Program must be included with the appeal request, unless later 
requested by the WTC Health Program; and
    (iv) Be sent to the WTC Health Program at the address specified in 
the notice of denial.
    (3) The appeal request may also state an intent to make a 15-minute 
oral statement by telephone. The WTC Health Program member or 
designated representative will have a second opportunity to schedule an 
oral statement after being contacted by the WTC Health Program 
regarding the appeal.
    (c) Appeal process. Upon receipt of a valid appeal, the 
Administrator will appoint a Federal Official independent of the WTC 
Health Program to review the case. The Federal Official will review all 
available records relevant to the WTC Health Program's decision to deny 
certification of a health condition as a WTC-related health condition, 
deny certification of a health condition as medically associated with a 
WTC-related health condition, decertify the WTC-related health 
condition or health condition medically associated with a WTC-related 
health condition, or deny treatment authorization, and assess whether 
the appeal should be granted. The Federal Official's consideration will 
include the following: Whether the WTC Health Program substantially 
complied with all relevant WTC Health Program policies and procedures; 
whether the information supporting the WTC Health Program's decision 
was factually accurate; and whether the WTC Health Program's decision 
was reasonable as applied to the facts of the case.
    (1) In conducting his or her review, the Federal Official will 
review the case record, including any oral statement made by the WTC 
Health Program member or the member's designated representative, as 
well as additional relevant new information submitted with the appeal 
request or provided by the WTC Health Program member or the member's 
designated representative at the request of the WTC Health Program.
    (2) The Federal Official may consult one or more qualified experts 
to review the WTC Health Program's decision and any additional 
information provided by the WTC Health Program member or the member's 
designated representative. The expert reviewer(s) will submit their 
findings to the Federal Official.
    (3) The Federal Official will provide his or her recommendation 
regarding the disposition of the appeal, including his or her findings 
and any supporting materials (including the transcript of any oral 
statement and any expert reviewers' findings), to the Administrator.
    (d) Final decision and notification. The Administrator will review 
the Federal Official's recommendation and any relevant information and 
make a final decision on the appeal. The Administrator will notify the 
WTC Health Program member and/or the member's designated representative 
of the following in writing:
    (1) The recommendation and findings made by the Federal Official as 
a result of the review;
    (2) The Administrator's final decision on the appeal;
    (3) An explanation of the reason(s) for the Administrator's final 
decision on the appeal; and
    (4) Any administrative actions taken by the WTC Health Program in 
response to the Administrator's final decision.


Sec.  88.22  Reimbursement for medical treatment and services.

    (a) Review of claims. Each claim for reimbursement for treatment 
will be reviewed by the WTC Health Program. Claims that cannot be 
validated by that process will be further assessed by the Administrator 
of the WTC Health Program.
    (b) Initial health evaluations, medical monitoring, and medically 
necessary treatment. (1) The costs incurred by a CCE or NPN-affiliated 
provider for providing a WTC Health Program member an initial health 
evaluation, medical monitoring, and/or medically necessary treatment or 
services for a WTC-related health condition or a health condition 
medically associated with a WTC-related health condition will be 
reimbursed according to the payment rates that apply to the provision 
of such treatment and services under the Federal Employees Compensation 
Act (FECA), 5 U.S.C. 8101 et seq., 20 CFR part 10.
    (i) The Administrator will reimburse a CCE or NPN-affiliated 
provider for treatment for which FECA rates have not been established 
pursuant to the applicable Medicare fee for service rate, as determined 
appropriate by the Administrator.
    (ii) The Administrator will reimburse a CCE or NPN-affiliated 
provider for treatment for which neither FECA nor Medicare fee for 
service rates have been established, at rates as determined appropriate 
by the Administrator.
    (2) If the treatment is determined not to be medically necessary or 
is inconsistent with WTC Health Program protocols, the Administrator 
will withhold reimbursement.
    (c) Outpatient prescription pharmaceuticals. Payment for costs of 
medically necessary outpatient prescription pharmaceuticals for a WTC-
related health condition or health condition medically associated with 
a WTC-related health condition will be reimbursed by the WTC Health 
Program under a contract with one or more pharmaceutical benefit 
management services.


Sec.  88.23  Appeal of reimbursement denial.

    After exhausting procedural and/or contractual administrative 
remedies, a CCE or NPN medical director or affiliated provider may 
submit a written appeal of a WTC Health Program decision to withhold 
reimbursement or payment for treatment found to be not medically 
necessary or not in accordance with approved WTC Health Program medical 
treatment protocols pursuant to Sec.  88.20 of this part. Appeal 
procedures are published on the WTC Health Program Web site.


Sec.  88.24  Coordination of benefits and recoupment.

    The WTC Health Program will attempt to recover the cost of payment 
for treatment, including pharmacy benefits, for a WTC Health Program 
member's certified WTC-related health condition or health condition 
medically associated with a WTC-related health condition by 
coordinating benefits with any workers' compensation insurance

[[Page 90947]]

available \2\ for members' work-related health conditions, and with any 
public or private health insurance available \3\ for members' non-work-
related health conditions.
---------------------------------------------------------------------------

    \2\ As described in PHS Act, sec. 3331(b). To the extent that 
payment for treatment of the member's work-related condition has 
been made, or can reasonably be expected to be made, under any other 
work-related injury or illness benefit plan of the member's 
employer, the WTC Health Program will also attempt to recover the 
costs associated with treatment, including pharmacy benefits, for 
the member's certified WTC-related health condition or health 
condition medically associated with a WTC-related health condition. 
See PHS Act, sec. 3331(b)(1). For purposes of this regulation, 
``workers' compensation law or plan'' or ``workers' compensation 
insurance'' includes any other work-related injury or illness 
benefit plan of the WTC Health Program member's employer.
    \3\ As described in PHS Act, sec. 3331(c).
---------------------------------------------------------------------------

    (a) Where a WTC Health Program member's WTC-related health 
condition or health condition medically associated with a WTC-related 
health condition is eligible for workers' compensation or another 
illness or injury benefit plan to which New York City is obligated to 
pay, the WTC Health Program is the primary payer.
    (b) Where a WTC Health Program member has filed a workers' 
compensation claim for a WTC-related health condition or health 
condition medically associated with a WTC-related health condition and 
the claim is pending, the WTC Health Program is the primary payer; 
however, if the claim is ultimately accepted by the workers' 
compensation board, the workers' compensation insurer in question is 
responsible for reimbursing the WTC Health Program for any treatment 
provided and/or paid for during the pendency of the claim.
    (c) Where a WTC Health Program member has filed a workers' 
compensation claim for a WTC-related health condition or health 
condition medically associated with a WTC-related health condition, but 
a final decision is issued denying the compensation for the claim, the 
WTC Health Program is the primary payer.
    (d) Where a WTC Health Program member has filed a workers' 
compensation claim for a WTC-related health condition or health 
condition medically associated with a WTC-related health condition with 
a workers' compensation plan to which New York City is not obligated to 
pay, the workers' compensation insurer is the primary payer. The WTC 
Health Program is the secondary payer.
    (1) If a WTC Health Program member settles a workers' compensation 
claim by entering into a settlement agreement that releases the 
employer or insurance carrier from paying for future medical care, the 
settlement must protect the interests of the WTC Health Program. This 
may include setting aside adequate funds to pay for future medical 
expenses, as required by the WTC Health Program, which would otherwise 
have been paid by workers' compensation. In such situations, the WTC 
Health Program may require reimbursement for treatment services of a 
WTC-related health condition or health condition medically associated 
with a WTC-related health condition directly from the member.
    (2) The WTC Health Program will pay providers for treatment in 
accordance with Sec.  88.22(b); to the extent that the workers' 
compensation insurance pays for treatment at a lower rate, the WTC 
Health Program will recoup treatment costs at the workers' compensation 
insurance rate.
    (e) Where a WTC Health Program member's WTC-related health 
condition or health condition medically associated with a WTC-related 
health condition is not work-related, the WTC Health Program member's 
public or private health insurance plan is the primary payer. The WTC 
Health Program will pay costs not reimbursed by the public or private 
health insurance plan due to the application of deductibles, co-
payments, co-insurance, other cost sharing arrangements, or payment 
caps up to and in accordance with the rates described in Sec.  
88.22(b).
    (f) Any coordination of benefits or recoupment situation not 
described in paragraphs (a) through (e) of this section will be handled 
pursuant to WTC Health Program policies and procedures, as found on the 
WTC Health Program Web site.


Sec.  88.25  Reopening of WTC Health Program final decisions.

    At any time, and without regard to whether new evidence or 
information is provided or obtained, the Administrator of the WTC 
Health Program may reopen any final decision made by the WTC Health 
Program pursuant to the provisions of this part. The Administrator may 
affirm, vacate, or modify such decision, or take any other action he or 
she deems appropriate.

    Dated: November 22, 2016.
John Howard,
Administrator, World Trade Center Health Program and Director, National 
Institute for Occupational Safety and Health, Centers for Disease 
Control and Prevention, Department of Health and Human Services.

    Dated: November 28, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-29957 Filed 12-12-16; 11:15 am]
 BILLING CODE 4163-18-P