View all text of Subpart 1 [§ 300mm-21 - § 300mm-23]
§ 300mm–22. Treatment of enrolled WTC responders for WTC-related health conditions
(a) WTC-related health condition defined
(1) In generalFor purposes of this subchapter, the term “WTC-related health condition” means a condition that—
(A)
(i) is 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 experience in treating or diagnosing the health conditions included in the applicable 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, as determined under paragraph (2); or
(ii) is a mental health condition for which such attacks, based on an examination by a medical professional with experience in treating or diagnosing the health conditions included in the applicable list of WTC-related health conditions, is substantially likely to be a significant factor in aggravating, contributing to, or causing the condition, as determined under paragraph (2); and
(B) is included in the applicable list of WTC-related health conditions or—
(i) with respect to a WTC responder, is provided certification of coverage under subsection (b)(2)(B)(iii); or
(ii) with respect to a screening-eligible WTC survivor or certified-eligible WTC survivor, is provided certification of coverage under subsection (b)(2)(B)(iii), as applied under section 300mm–32(a) of this title.
In the case of a WTC responder described in section 300mm–21(a)(2)(A)(ii) of this title (relating to a surviving immediate family member of a firefighter), such term does not include an illness or health condition described in subparagraph (A)(i).
(2) DeterminationThe determination under paragraph (1) or subsection (b) of whether the September 11, 2001, terrorist attacks were substantially likely to be a significant factor in aggravating, contributing to, or causing an individual’s illness or health condition shall be made based on an assessment of the following:
(A) The individual’s exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the terrorist attacks. Such exposure shall be—
(i) evaluated and characterized through the use of a standardized, population-appropriate questionnaire approved by the Director of the National Institute for Occupational Safety and Health; and
(ii) assessed and documented by a medical professional with experience in treating or diagnosing health conditions included on the list of WTC-related health conditions.
(B) The type of symptoms and temporal sequence of symptoms. Such symptoms shall be—
(i) assessed through the use of a standardized, population-appropriate medical questionnaire approved by the Director of the National Institute for Occupational Safety and Health and a medical examination; and
(ii) diagnosed and documented by a medical professional described in subparagraph (A)(ii).
(3) List of health conditions for WTC respondersThe list of health conditions for WTC responders consists of the following:
(A) Aerodigestive disorders
(i) Interstitial lung diseases.
(ii) Chronic respiratory disorder—fumes/vapors.
(iii) Asthma.
(iv) Reactive airways dysfunction syndrome (RADS).
(v) WTC-exacerbated chronic obstructive pulmonary disease (COPD).
(vi) Chronic cough syndrome.
(vii) Upper airway hyperreactivity.
(viii) Chronic rhinosinusitis.
(ix) Chronic nasopharyngitis.
(x) Chronic laryngitis.
(xi) Gastroesophageal reflux disorder (GERD).
(xii) Sleep apnea exacerbated by or related to a condition described in a previous clause.
(B) Mental health conditions
(i) Posttraumatic stress disorder (PTSD).
(ii) Major depressive disorder.
(iii) Panic disorder.
(iv) Generalized anxiety disorder.
(v) Anxiety disorder (not otherwise specified).
(vi) Depression (not otherwise specified).
(vii) Acute stress disorder.
(viii) Dysthymic disorder.
(ix) Adjustment disorder.
(x) Substance abuse.
(C) Musculoskeletal disorders for certain WTC responders
(D) Additional conditions
(4) Musculoskeletal disorders
(A) In generalFor purposes of this subchapter, in the case of a WTC responder who received any treatment for a WTC-related musculoskeletal disorder on or before September 11, 2003, the list of health conditions in paragraph (3) shall include:
(i) Low back pain.
(ii) Carpal tunnel syndrome (CTS).
(iii) Other musculoskeletal disorders.
(B) Definition
(5) Cancer
(A) In general
(B) Proposed regulations and rulemaking
(C) Final regulations
(D) Determinations not to add cancer or certain types of cancer
(6) Addition of health conditions to list for WTC responders
(A) In general
(B) Administrator’s options after receipt of petitionIn the case that the WTC Program Administrator receives a written petition by an interested party to add a health condition to the list of health conditions in paragraph (3), not later than 90 days after the date of receipt of such petition the Administrator shall—
(i) request a recommendation of the Advisory Committee;
(ii) publish a proposed rule in the Federal Register to add such health condition, in accordance with subparagraph (D);
(iii) publish in the Federal Register the Administrator’s determination not to publish such a proposed rule and the basis for such determination; or
(iv) publish in the Federal Register a determination that insufficient evidence exists to take action under clauses (i) through (iii).
(C) Action by Advisory Committee
(D) PublicationThe WTC Program Administrator shall, with respect to any proposed rule under this paragraph—
(i) publish such proposed rule in accordance with section 553 of title 5; and
(ii) provide interested parties a period of 30 days after such publication to submit written comments on the proposed rule.
The WTC Program Administrator may extend the period described in clause (ii) upon a finding of good cause. In the case of such an extension, the Administrator shall publish such extension in the Federal Register.
(E) Interested party defined
(F) Independent peer reviews
(G) Additional advisory committee recommendations
(i) Program policies(I) Existing policies(II) Subsequent policies
(ii) Identification of individuals conducting independent peer reviews
(b) Coverage of treatment for WTC-related health conditions
(1) Determination for enrolled WTC responders based on a WTC-related health condition
(A) In generalIf a physician at a Clinical Center of Excellence that is providing monitoring benefits under section 300mm–21 of this title for an enrolled WTC responder makes a determination that the responder has a WTC-related health condition that is in the list in subsection (a)(3) and that exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 1, 2001, terrorist attacks is substantially likely to be a significant factor in aggravating, contributing to, or causing the condition—
(i) the physician shall promptly transmit such determination to the WTC Program Administrator and provide the Administrator with the medical facts supporting such determination; and
(ii) on and after the date of such transmittal and subject to subparagraph (B), the WTC Program shall provide for payment under subsection (c) for medically necessary treatment for such condition.
(B) Review; certification; appeals
(i) Review
(ii) Certification
(iii) Appeal process
(2) Determination based on medically associated WTC-related health conditions
(A) In generalIf a physician at a Clinical Center of Excellence determines pursuant to subsection (a) that the enrolled 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—
(i) the physician shall promptly transmit such determination to the WTC Program Administrator and provide the Administrator with the facts supporting such determination; and
(ii) the Administrator shall make a determination under subparagraph (B) with respect to such physician’s determination.
(B) Procedures for review, certification, and appealThe WTC Program Administrator shall, by rule, establish procedures for the review and certification of physician determinations under subparagraph (A). Such rule shall provide for—
(i) the timely review of such a determination by a physician panel with appropriate expertise for the condition and recommendations to the WTC Program Administrator;
(ii) not later than 60 days after the date of the transmittal under subparagraph (A)(i), a determination by the WTC Program Administrator on whether or not the condition involved is described in subsection (a)(1)(A) and is medically associated with a WTC-related health condition;
(iii) certification in accordance with paragraph (1)(B)(ii) of coverage of such condition if determined to be described in subsection (a)(1)(A) and medically associated with a WTC-related health condition; and
(iv) a process for appeals of determinations relating to such conditions.
(C) Inclusion in list of health conditions
(D) Conditions already declined for inclusion in list
(3) Requirement of medical necessity
(A) In general
(B) Regulations relating to medical necessity
(4) Scope of treatment covered
(A) In general
(B) Pharmaceutical coverage
(C) Transportation expenses for nationwide network
(5) Provision of treatment pending certification
(c) Payment for initial health evaluation, monitoring, and treatment of WTC-related health conditions
(1) Medical treatment
(A) Use of FECA payment rates
(i) In generalSubject to clause (ii):(I) Subject to subparagraphs (B) and (C), the WTC Program Administrator shall reimburse costs for medically necessary treatment under this subchapter for WTC-related health conditions according to the payment rates that would apply to the provision of such treatment and services by the facility under the Federal Employees Compensation Act.(II) For treatment not covered under subclause (i) or subparagraph (B), the WTC Program Administrator shall establish by regulation a reimbursement rate for such treatment.
(ii) Exception
(B) Pharmaceuticals
(i) In general
(ii) Competitive biddingUnder such program the Administrator shall—(I) select one or more appropriate vendors through a Federal competitive bid process; and(II) select the lowest bidder (or bidders) meeting the requirements for providing pharmaceutical benefits for participants in the WTC Program.
(iii) Treatment of FDNY participants
(iv) Pharmaceuticals
(C) Improving quality and efficiency through modification of payment amounts and methodologies
(2) Monitoring and initial health evaluation
(3) Determination of medical necessity
(A) Review of medical necessity and protocols
(B) Withholding of payment for medically unnecessary treatment
(d) Medical treatment protocols
(1) Development
(2) Approval
(July 1, 1944, ch. 373, title XXXIII, § 3312, as added Pub. L. 111–347, title I, § 101, Jan. 2, 2011, 124 Stat. 3639; amended Pub. L. 114–113, div. O, title III, § 302(e), Dec. 18, 2015, 129 Stat. 2999.)