Member handbook

For more information on covered conditions, visit www. Your condition can be certified by the Program if:. The Program will certify your health condition if it finds that your health condition and exposure meet the above criteria. You can be certified for more than one condition. Please note: Your WTC Health Program doctor may only submit a request for certification to the Program when all of the criteria listed above are met. Requests for certification that do not meet these criteria will not be accepted by the Program and will not be eligible for appeal.

In some circumstances, a certified condition may be decertified. For more information see the decertification section. In addition to the health conditions on the List of WTC-Related Health Conditions, the Program may also certify health conditions that result from either the treatment of your certified WTC-related health condition or the progression of your certified WTC-related health condition.

These conditions are called medically associated health condition s. Your medically associated health condition will be eligible for treatment in the Program if the Program finds it is the direct result of the treatment or progression of your certified WTC-related health condition and the relationship between the two conditions is supported in the scientific literature.

Medically associated conditions must be certified. To certify a medically associated health condition, your CCE or NPN doctor must explain how the health condition results from either treatment or progression of the underlying certified WTC-related health condition.

View more information on decertification. For an aerodigestive disorder, an additional requirement known as maximum time intervals must be met for the health condition to be certified by the Program.

Your symptoms of the aerodigestive disorder must have started during that time frame in order for it to be certified by the Program. The Administrator divided aerodigestive disorders into 6 categories and set a maximum time interval for each category. If you have questions about maximum time interval for your aerodigestive disorder, speak to your Program doctor.

For more information about maximum time intervals, you can refer to the Program policies at www. The 6 categories of aerodigestive disorders and the maximum time interval for each are as follows:.

Minimum latency requirements must be met in order for your cancer to be certified by the Program. In most cases, cancer does not develop until some time has passed after exposure to a cancer-causing agent. As a result, the Program has set minimum latency requirements based on well-established scientific literature. The following table outlines the minimum latency requirements for cancers covered by the Program:. Members may not request a secondary medical review when their cancer does not meet the minimum latency period and may not appeal this decision.

If you have questions about latency requirements for certification of your cancer, speak to your Program doctor. For examples of acute traumatic injuries and musculoskeletal disorders, see the ATI section of this handbook. If your WTC Health Program provider does not submit your condition to the Program for certification, you may be eligible for a secondary medical review.

You may not request a secondary medical review when your health condition does not meet Program policy. Disagreement with Program policy is not a valid reason for secondary review. However, the Administrator may add new health conditions to the List through the rulemaking process. If this is the case, you may petition the Administrator to add a health condition to the List.

In order to be considered, a petition must be sent in writing to the Administrator, and include the following:. The petition form can be found at www. For more information on how the Program considers petitions to add health conditions to the List of WTC-Related Health Conditions, you may review the applicable three policies and procedures at www. The Program may decertify your WTC-related or medically associated health condition in the following circumstances:.

The Program will notify you in writing if the certification has been withdrawn and your health condition has been decertified. The letter will explain why your condition was decertified and provide you with information about how to appeal the decision if you would like to do so. For more information on how to appeal a decertification, see the appeals section. In order for your treatment to be covered by the Program, you must receive the treatment from a WTC Health Program affiliated provider.

The NPN is a network of affiliated providers that are located all over the country to serve Program members that reside outside of the New York NY metropolitan area. View CCE locations and contact information. View NPN contact information. The Program only provides treatment for your certified WTC-related health condition or medically associated health condition.

Treatment must follow Program guidelines and be medically necessary to treat your certified health condition. In order to access the treatment services for your certified WTC-related or medically associated health conditions, you will need your current Program identification ID number. Your Program ID number is included on your Program welcome letter from the time of your enrollment, your condition certification letter from the Program, and on your Optum or NPN treatment card, if applicable.

Your Program provider will help coordinate care of only your certified WTC-related health conditions. Members should always maintain their own primary care provider for health conditions not covered in the Program. If your Program provider thinks that you need to see a specialist to diagnose or treat a certified WTC-related health condition, she or he will refer you to a specialist that is affiliated with the Program.

For example, if you have asthma, your Program provider might refer you to a pulmonologist who is affiliated with the Program. Your Program provider and the specialist will communicate about medically necessary treatment for your certified WTC-related health condition s. Your WTC Health Program provider authorizes your treatment to ensure it is medically necessary for your condition and meets Program policy. This is called a Level 1 Authorization. If you need treatment services that require a Level 2 or Level 3 Prior Authorization, your Program provider will request the authorization for you.

The following treatments are examples of the medically necessary treatments you may receive for your certified WTC-related health condition s.

Please note: The WTC Health Program reserves the right to not cover any of the following services at any time if they are determined not to be medically necessary or do not meet Program policies or coverage guidelines. Program published medical policies are available at www.

Please refer to these links for the most current medical coverage guidelines, as guidelines may change based on the latest medical research and recommendations. The Program will cover all medically necessary cancer treatment for your certified WTC-related cancer. This includes doctor visits, medications, cancer therapies, surgeries, and other services. If DME is medically necessary to treat your certified WTC-related health condition s , then the rental or purchase of DME is covered by the Program and supplied by a preferred Program provider whenever possible.

Marital counseling for a member and his or her spouse may also be covered in certain circumstances. If you are interested in learning more about this, consult your Program provider or case manager. Home health services may be covered for a limited period of time for members who are homebound and require medically necessary home health care services.

The Program may cover hospice services when treatment for your certified WTC-related health condition is no longer controlling the illness and the member has a life expectancy of six months or less if the illness runs its normal course. Hospice care typically lasts 6 months but may be continued longer if your CCE or the NPN Clinical Director confirms care is needed for a longer period of time. The Program covers inpatient treatment and services if those services are medically necessary to treat your certified WTC-related health condition s.

Inpatient care covers hospital services, including semiprivate rooms, meals, general nursing, and prescription drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in acute care hospitals, critical access hospitals, and mental health care in a hospital setting.

In order for inpatient services to be covered, your CCE or the NPN Clinical Director must authorize the services before you are hospitalized or admitted to an inpatient facility. The Program may cover inpatient rehabilitation services for members with intensive physical rehabilitation needs due to their certified WTC-related health condition. Inpatient rehabilitation services may be covered when the member requires a team approach to care that cannot be provided in an outpatient setting.

These services must be authorized by the Program. A long-term care hospital provides care to members with medically complex problems that require an extended stay. In order for a stay at a long-term care hospital to be covered, the Program must confirm these services are medically necessary for your certified WTC-related health condition s and authorize your treatment.

The Program covers mental health treatment services for certified WTC-related mental health conditions. The Program does not cover residential treatment for mental health care. At some CCEs, the mental health treatment services are provided in-house by a mental health provider employed directly by the CCE. The NPN also includes affiliated and credentialed mental health care providers. Family members of deceased FDNY personnel may receive mental health treatment under the following conditions:.

Non-emergency medical transportation, such as via an ambulance or ambulette, may be provided to you if you are receiving medically necessary care for a certified WTC-related health condition and it is determined that such transportation is necessary.

Non-medical, general transportation is only available to NPN members who live a certain distance away from a Program provider. The Program may cover organ transplants if specific circumstances are met. If you are interested in learning more about coverage for organ transplants, speak to your Program doctor or NPN case manager. This facility provides outpatient services such as physical therapy, physician services, and social or psychological services.

The Program may cover medically necessary services in a skilled nursing facility that provides around-the-clock nursing or rehabilitation services after a member has been hospitalized for a certified WTC-related health condition s. If you are interested in learning more about skilled nursing facility services, consult your Program provider or NPN case manager. Examples of smoking cessation therapy include non-nicotine medications that reduce cravings and nicotine replacement products such as patches, gum, and lozenges.

In certain circumstances, the Program may cover substance use disorder treatment. This may include acute hospitalization services and specialty outpatient treatment to treat certified mental health and substance use disorders. Residential treatment for substance use disorder is not covered by the Program.

To learn more about available treatment for substance use disorder, speak to your WTC Health Program provider. The Program covers certain vaccines for all eligible enrolled members except for FDNY family members. Members may be eligible for vaccines recommended by the CDC Advisory Committee on Immunization Practices ACIP when the member meets requirements regarding age, timing of doses, and specific precautions.

The Program also covers the flu shot for all members. In the event of a medical emergency , call or go to the nearest emergency room. A medical crisis can occur unexpectedly and after normal office hours. As a member of the Program you have access to urgent care and emergency room services for your certified WTC-related health condition s in your local area and when travelling outside of your local area. You should seek immediate treatment for any illness or injury that would be considered an emergency.

This allows the Program to coordinate your ongoing care and ensure you receive proper authorization. When seeking emergency care, please note that the Program only covers emergency care services that are related to your certified WTC-related health condition s. Urgent care services are for medically necessary treatment of an urgent medical condition which is not considered to be an emergency, but is an illness or injury that must be addressed within 12 hours to avoid the likely onset of a medical emergency.

The Program provides payment for certain types of urgent care visits for your certified WTC-related health condition s. The Program defines a medical emergency as a serious medical condition with symptoms so severe that the health of the member would be at risk without immediate medical attention.

The Program may cover emergency care services that are necessary to prevent death or serious impairment to the member as a result of a certified WTC-related health condition s. The Program does not cover non-emergency visits to the emergency department. This national pharmacy network includes 65, retail pharmacy network locations. If you have a certified condition, you may also use the home delivery option to have your medications mailed directly to your home.

Members with certified conditions will receive an Optum pharmacy card. If you did not receive an Optum card, or have questions about your pharmacy benefits, please call Optum at or contact your CCE. The Program covers prescription drugs used to treat a certified WTC-related health condition. On occasion, you may need a medication that is not on the approved formulary. Program medical staff will review the request from your Program doctor and decide if the drug should be approved.

If the drug is approved, the medication will be covered by the Program at no cost to you. Non-formulary drugs can be approved for up to 1 year. If the drug is not approved but you would like to continue using it, you will have to use a different form of payment such as your primary insurance or pay out of pocket for the drug. The Program requires that WTC-related prescriptions for medications that come in generic form must be filled using the generic medication.

Generic drugs contain the same active ingredients as brand name drugs, and are the same in dosage, safety, stability, strength, purity, quality, and administration. However, the cost of a generic drug is significantly lower than brand name drugs. For some drugs, there are no approved generics. In these cases, the Program reviews the available medications to compare effectiveness and cost. The Program then decides to cover a specific medication based on the one that provides a reasonable treatment at the best cost.

This practice is known as preferred medications and is common with government health programs and private insurance companies. Effective October , the WTC Health Program only allows up to a day supply of medication for each fill at a retail or community pharmacy. All members receiving medications taken on a regular or on-going basis are encouraged to enroll in home delivery when possible. Please note: The day supply limit at retail and community-based pharmacy policy was suspended in April in response to the COVID pandemic.

This suspension was temporary. The day limit is reinstated on August 1, If a retail pharmacy is having trouble filling a prescription, please ask the pharmacist to call Optum at to resolve the issue.

This is known as Coordination of Benefits and is a process required by the Zadroga Act. Learn more about this process in the Coordination of Benefits section of this handbook. For more information on how to ensure your prescriptions are billed correctly at a retail pharmacy, visit www.

More Program pharmacy benefit information is available at www. As a member of the Program, you are eligible for benefits counseling from a case manager, social worker, benefits counselor, or other designated staff person at your CCE or the NPN. Benefits counselors can help identify benefits you may be eligible for and explain how you can apply for those benefits.

Benefits counselors may also refer you to external benefits experts to help you access benefits available outside the Program, if needed. The questionnaire helps the Program representative identify specific benefits for which you might be eligible.

More information on how Workers' Compensation works with the Program is available here. More information about the VCF is available here. Helps you identify external non-WTC Health Program benefits you might be eligible for and educating you on how to access them i. Helps you access needed social services, such as food, utility, housing, transportation, or other basic needs assistance.

Coordinates with oncology social workers as needed. Helps you identify appropriate care for medical and mental health conditions or medications not covered by the Program. The goal of case management is to share resources that allow you to return to your maximum health and well-being.

Case managers can help you understand your available care options while developing a plan of care specific to your individual needs. This may include helping identify providers, locate healthcare facilities, address pharmacy concerns, assist with billing inquiries, and obtain authorizations for specialty care. This could include doctors, nurse practitioners, nurses, social workers, care coordinators, and CCE support staff. This team will coordinate with you, your health care providers, and social services resources.

How often you interact with your nurse case manager and the care coordinator will depend on your treatment needs. It is very important that you work closely with the case management team because they will be coordinating your care and should be your first level of contact if an issue arises.

For any questions, call the NPN case management helpline at A designated representative is someone you appoint and authorize to act on your behalf and represent your administrative interests in the World Trade Center WTC Health Program. However, this person may not make medical care e. The designated representative will then be authorized to do the following:. Please note: Any requirement of the WTC Health Program to notify you in writing is fully satisfied if sent to the designated representative.

You may only have one designated representative at a time. An entire organization or group of people—such as a law firm or multiple family members—is not permitted. To designate a representative, you must notify the Program in writing using the Designated Representative forms available at www.

You or your designated representative may appeal the following 3 types of decisions made by the Program:. Box Rensselaer, NY Fax: For certification denial, decertification, or treatment authorization denial appeals, your appeal request may also include a request for you or your designated representative to make a minute oral statement by telephone.

Not all appeal requests can be considered. An appeal will be considered invalid if it challenges:. Criteria and requirements in the Zadroga Act are established by law and may only be changed by the U. Congress amending the Act. Health conditions may only be added to the List through a petition process. See How to Add a Condition section of this handbook.

For example, an appeal request could argue that the Program incorrectly determined the number of hours the individual worked or volunteered during a covered time period. More information on what may and may not be appealed is available at www.

When the Program receives your appeal, the Administrator will appoint a Federal Official independent of the Program to review your appeal.

This review would include any relevant new information submitted by you. Based on the review, the Federal Official makes a recommendation to the Administrator regarding whether or not your appeal should be granted. More information on the appeal process is available at www. You will be notified in writing of the following:. Once the Administrator has made a decision on your appeal, it is final. Disruptive or abusive behavior by a WTC Health Program applicant or member at or directed towards a facility or personnel affiliated with the Program e.

Depending on the particular circumstances, members who engage in such behaviors: May have their care suspended by their CCE or NPN provider; May be required to sign a behavioral agreement outlining what will be expected of them in order to receive care from their provider; May be required to transfer to another CCE or NPN provider; or May be subject to other appropriate actions, including involvement of law enforcement authorities as necessary. For example, the WTC Health Program may use or share your personal health information in the following ways:.

Under limited circumstances, the WTC Health Program may use or share your personal health information for the following purposes:. When it comes to your personal health information, you have certain rights. By law, you have the right to:. By law, the WTC Health Program must have your written permission authorization to use or share your personal health information for any purpose that is not set out in this notice, including certain uses or disclosures of psychotherapy notes.

In addition, the WTC Health Program will not sell or market your personal health information without your written permission. You may take back revoke your written permission anytime, except in cases where the WTC Health Program has already acted on your permission. The WTC Health Program is prohibited from using or sharing your personal genetic health information i.

The WTC Health Program has the right to change this privacy notice and the changes will apply to all the information that we have about you. If we make any significant changes to this notice, a copy of the revised notice will be made electronically available on the WTC Health Program website and you will receive the new notice by mail or email within 60 days.

You may also request to receive a copy of the notice at any time. You can call to get further information about matters covered by this notice. If you believe that your privacy rights have been violated, you may file a complaint with the WTC Health Program by calling or by sending a letter to P. Filing a complaint will not affect your coverage under the Program. TTY users should call All Program health care providers and staff share responsibility for assuring member satisfaction.

If you have a problem or concern about the services you receive, please ask for help. If you have a problem with any aspect of the service you have received at your CCE, call or visit the administrative office at that facility. The NPN has an administrator or director who is responsible for addressing concerns involving the facility or provider network.

A Member Services Associate will assist you in addressing your concern as best as possible. Be sure to provide complete information regarding the nature of your complaint, including names, dates, and any other specific information.

The Member Services Associate will forward the complaint to the appropriate Program staff. Amounts you contribute to buy a leave period Tooltip or past service may also lower your taxable income. Your employer deducts these contributions from your gross income, which reduces your taxable income — the amount of income on which you pay taxes. As a result, over the course of the year, the income on which you pay taxes has been reduced by the amount of your pension contributions.

Your employer also contributes an equal amount. These contributions are not a taxable benefit — you do not count them as income. Once you retire and begin collecting your OMERS pension, income tax will be applied to your payments.

However, in most cases, it will be at a lower marginal tax rate than when you were employed. There are two caps on contributory earnings:. Additional cap — total annual contributory earnings are limited to seven times the CPP earnings limit effective:. The disability waiver begins on the later of:.

The disability pension continues until:. If, because of an illness or other condition, your life expectancy is less than two years, you may be able to withdraw the cash value of your pension.

Once you receive this shortened life expectancy benefit, no further benefit is payable from the OMERS Plan to you, your survivors, beneficiary Tooltip or estate. If you have an eligible spouse, they must provide their written consent for you to withdraw the funds. Starting January 1, , benefit calculation changes affect you if your employment ends and you are not yet eligible for an early retirement Tooltip pension.

That is, if you have not reached your early retirement birthday 55th birthday for normal retirement age Tooltip 65, or 50th birthday for normal retirement age 60 , your benefit will be calculated in two parts:. The benefit based on pre credited service Tooltip includes preretirement indexing inflation protection and early retirement subsidies including the OMERS Plan bridge benefit Tooltip. The benefit based on post credited service does not include pre-retirement indexing or early retirement subsidies including the OMERS Plan bridge benefit.

Inflation protection pre-retirement indexing Pre-retirement indexing is the inflation protection we apply to your benefit from the date you leave your OMERS employer to the date your pension begins. The pre portion of your benefit will include inflation protection, whether you leave your benefit in the OMERS Plan or transfer the commuted value out.

The post portion of your benefit will not include pre-retirement inflation protection. Early retirement subsidies Early retirement subsidies affect your benefit calculation for service earned after and the amount of the OMERS Plan bridge benefit. As of January 1, , your benefit will be calculated in two portions: pre and post The pre portion:. This portion no longer includes a possible unreduced early retirement pension.

If your normal retirement age is 60, a five-year portion of the bridge benefit from age 60 to 65 will be included in the post- portion. Generally, if you take a leave of absence that has been authorized by your employer, you may buy the service for the time you are away and convert it into credited service Tooltip. This includes both leaves protected by employment standards legislation, for example, pregnancy and parental leaves, and family medical and personal emergency leaves, and non-protected leaves authorized by your employer.

The cost of buying the service depends on the type of leave. For more information on purchasing a leave, including the cost and purchase deadline, visit omers. Depending on your age and the amount of your pension, options when you leave your OMERS employer include:. You are eligible to transfer the CV of your pension if you leave an OMERS employer and you have not yet reached your early retirement birthday.

But there is a limit to the amount of time you have to transfer your CV after you leave your employer. If you rejoin the OMERS Plan after making this transfer, you have to wait five years from when you transferred out your CV before you can buy back the associated service.

However, your OMERS Plan pension must begin on December 1 of the year in which you reach 71, whether or not you are still working, and you will no longer make contributions. There are two types of early retirement pensions: unreduced and reduced.

Unreduced early retirement pension An unreduced early retirement pension is calculated without a reduction. You qualify for an unreduced early retirement pension if you have:. The reduction factor is pro-rated for part years.

If you go back to work for an OMERS employer in a position that requires that you enrol, you will be re-enrolled in the OMERS Plan and your pension will stop unless you specifically elect to continue receiving your pension and not re-enrol. If you re-enrol in the OMERS Plan, your pension will stop and you will resume as a continuing member so long as your credited service Tooltip was less than 35 years as of December 31, When you subsequently retire, all your credited service and earnings are combined and your pension is recalculated.

Effective January 1, , OMERS and other registered pension plan administrators in Ontario were required to comply with updated rules related to the valuation and division of the pension benefit in the event of a member's separation and divorce. More information on the rules is available on the Separation and Divorce section of omers. This order cannot be changed, for example, by a will. Spouse — Your pre-retirement spouse Tooltip can choose a survivor pension or cash refund.

Designated beneficiary — If there is no pre-retirement spouse or eligible dependent child ren , your designated beneficiary ies on file may be entitled to a cash refund. Estate — If there is no pre-retirement spouse, eligible dependent child ren , or designated beneficiaries, a cash refund may be paid to your estate.

In addition to the OMERS Plan survivor benefits, the following refunds may be payable in the event of death before retirement. Any excess contributions will be refunded to you, your beneficiary or your estate. It is paid to your living designated beneficiaries on file or, if none, to your estate. Spouse — Your retirement-date spouse Tooltip or post-retirement-date spouse Tooltip if there is no eligible retirement-date spouse will receive a survivor pension.

Designated beneficiary — If there is no retirement-date spouse, post-retirement-date spouse or eligible dependent child ren , your designated beneficiary ies on file may be entitled to a residual refund. Estate — If there is no retirement-date spouse, post-retirement date spouse, eligible dependent child ren or designated beneficiaries, any residual refund may be paid to your estate.

The survivor pension is guaranteed for life it does not stop if your spouse remarries and is indexed for inflation. When a child is no longer eligible, the benefit is redistributed among the remaining eligible children. A spouse can transfer the cash refund to a non-locked-in registered retirement savings arrangement. Note: After about five years of retirement, most members have received pension payments equal to their contributions plus interest, so there may not be a residual refund.

An executor, estate trustee, power of attorney for property or survivor cannot name or change your designated beneficiary ies.