42 U.S.C. § 300mm–41: Payment of claims

Summary

The WTC Health Program pays for monitoring, treatment, and initial health checks under subparts 1 and 2 from its special Funds. If a health condition is work-related and a workers’ compensation plan (federal, state, local, or employer) will pay or likely will pay, the Program’s payments will be cut or recovered. The same recovery rules in section 1862(b) of the Social Security Act apply here, but payment rates are those of the WTC Program. That rule does not apply for any quarter if New York City is required to pay and has made the full payment required under its contract for that quarter. If the condition is not work-related but the person has health insurance (including Medicare, Medicaid, or CHIP), the rules in section 1862(b) also apply to that plan. Any out-of-pocket costs the insurance leaves (deductibles, copays, coinsurance) are payable by the WTC Program if the costs are covered by the Program. A provider does not have to seek payment from an insurer it has no contract with. No Program payment can be made for any month (starting July 2014) if the person is subject to the individual mandate and is not covered by minimum essential coverage. No money from the WTC Fund can be paid out unless New York City signs a contract agreeing to make a required payment. For each calendar quarter in fiscal year 2016 and each fiscal year through fiscal year 2090, New York City must pay 10 percent of the Program’s expenditures for that quarter (excluding certain supplemental funds). Those payments cannot come from federal money, cannot be payments made before January 2, 2011, and cannot be settlement or judgment money from 9/11 cases. Payments are due by the last day of the second succeeding calendar quarter. Late payments accrue interest based on the average yield on New York City municipal bonds plus 1 percentage point, and the United States can sue to recover amounts owed. The Program Administrator will estimate, bill, and certify payments and will deposit amounts into the WTC Fund. A WTC-related condition counts as work-related if it is diagnosed in an enrolled responder or a certified-eligible survivor who worked rescue/recovery/cleanup, or if a workers’ compensation claim for the condition has been filed and established.

Title 42, §300mm–41

The Public Health and Welfare, Source: USLM XML via OLRC

(a)In general

Except as provided in subsections (b) and (c), the cost of monitoring and treatment benefits and initial health evaluation benefits provided under subparts 1 and 2 of this part shall be paid for by the WTC Program from (as applicable) the Funds established under section 300mm–61, 300mm–62, 300mm–63, and 300mm–64 of this title.

(b)Workers’ compensation payment

(1)In general

Subject to paragraph (2), payment for treatment under subparts 1 and 2 of this part of a WTC-related health condition of an individual that is work-related shall be reduced or recouped to the extent that the WTC Program Administrator determines that payment has been made, or can reasonably be expected to be made, under a workers’ compensation law or plan of the United States, a State, or a locality, or other work-related injury or illness benefit plan of the employer of such individual, for such treatment. The provisions of clauses (iii), (iv), (v), and (vi) of paragraph (2)(B) of section 1862(b) of the Social Security Act [42 U.S.C. 1395y(b)] and paragraphs (3) and (4) of such section shall apply to the recoupment under this subsection of a payment to the WTC Program (with respect to a workers’ compensation law or plan, or other work-related injury or illness plan of the employer involved, and such individual) in the same manner as such provisions apply to the reimbursement of a payment under section 1862(b)(2) of such Act [42 U.S.C. 1395y(b)(2)] to the Secretary (with respect to such a law or plan and an individual entitled to benefits under title XVIII of such Act [42 U.S.C. 1395 et seq.]) except that any reference in such paragraph (4) to payment rates under title XVIII of the Social Security Act shall be deemed a reference to payment rates under this subchapter.

(2)Exception

Paragraph (1) shall not apply for any quarter, with respect to any workers’ compensation law or plan, including line of duty compensation, to which New York City is obligated to make payments, if, in accordance with terms specified under the contract under subsection (d)(1)(A), New York City has made the full payment required under such contract for such quarter.

(3)Rules of construction

Nothing in this subchapter shall be construed to affect, modify, or relieve any obligations under a worker’s compensation law or plan, other work-related injury or illness benefit plan of an employer, or any health insurance plan.

(c)Health insurance coverage

(1)In general

In the case of an individual who has a WTC-related health condition that is not work-related and has health coverage for such condition through any public or private health plan (including health benefits under title XVIII, XIX, or XXI of the Social Security Act [42 U.S.C. 1395 et seq., 1396 et seq., 1397aa et seq.]) the provisions of section 1862(b) of the Social Security Act [42 U.S.C. 1395y(b)] shall apply to such a health plan and such individual in the same manner as they apply to group health plan and an individual entitled to benefits under title XVIII of such Act pursuant to section 226(a) of such Act [42 U.S.C. 426(a)]. Any costs for items and services covered under such plan that are not reimbursed by such health plan, due to the application of deductibles, copayments, coinsurance, other cost sharing, or otherwise, are reimbursable under this subchapter to the extent that they are covered under the WTC Program. The program under this subchapter shall not be treated as a legally liable party for purposes of applying section 1902(a)(25) of the Social Security Act [42 U.S.C. 1396a(a)(25)].

(2)Recovery by individual providers

Nothing in paragraph (1) shall be construed as requiring an entity providing monitoring and treatment under this subchapter to seek reimbursement under a health plan with which the entity has no contract for reimbursement.

(3)Maintenance of required minimum essential coverage

No payment may be made for monitoring and treatment under this subchapter for an individual for a month (beginning with July 2014) if with respect to such month the individual—

(A)is an applicable individual (as defined in subsection (d) of section 5000A of title 26) for whom the exemption under subsection (e) of such section does not apply; and

(B)is not covered under minimum essential coverage, as required under subsection (a) of such section.

(d)Required contribution by New York City in program costs

(1)Contract requirement

(A)In general

No funds may be disbursed from the World Trade Center Health Program Fund under section 300mm–61 of this title or the World Trade Center Health Program Special Fund under section 300mm–63 of this title unless New York City has entered into a contract with the WTC Program Administrator under which New York City agrees, in a form and manner specified by the Administrator, to pay the full contribution described in subparagraph (B) in accordance with this subsection on a timely basis, plus any interest owed pursuant to subparagraph (E)(i). Such contract shall specify the terms under which New York City shall be considered to have made the full payment required for a quarter for purposes of subsection (b)(2).

(B)Full contribution amount

Under such contract, with respect to each calendar quarter of fiscal year 2016 and of each subsequent fiscal year through fiscal year 2090, the full contribution amount under this subparagraph shall be equal to 10 percent of the expenditures in carrying out this subchapter for the respective quarter (excluding any expenditures from amounts in the World Trade Center Health Program Supplemental Fund under section 300mm–62 of this title or the World Trade Center Health Program Fund for Certain WTC Responders at the Pentagon and Shanksville, Pennsylvania under section 300mm–64 of this title).

(C)Satisfaction of payment obligation

The payment obligation under such contract may not be satisfied through any of the following:

(i)An amount derived from Federal sources.

(ii)An amount paid before January 2, 2011.

(iii)An amount paid to satisfy a judgment or as part of a settlement related to injuries or illnesses arising out of the September 11, 2001, terrorist attacks.

(D)Timing of contribution

The payment obligation under such contract for a calendar quarter in a fiscal year shall be paid not later than the last day of the second succeeding calendar quarter.

(E)Compliance

(i)Interest for late payment

If New York City fails to pay to the WTC Program Administrator pursuant to such contract the amount required for any calendar quarter by the day specified in subparagraph (D), interest shall accrue on the amount not so paid at the rate (determined by the Administrator) based on the average yield to maturity, plus 1 percentage point, on outstanding municipal bonds issued by New York City with a remaining maturity of at least 1 year.

(ii)Recovery of amounts owed

The amounts owed to the WTC Program Administrator under such contract shall be recoverable by the United States in an action in the same manner as payments made under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] may be recoverable in an action brought under section 1862(b)(2)(B)(iii) of such Act [42 U.S.C. 1395y(b)(2)(B)(iii)].

(F)Deposit in fund

The WTC Program Administer shall deposit amounts paid under such contract into the World Trade Center Health Program Fund under section 300mm–61 of this title.

(2)Payment of New York City share of monitoring and treatment costs

With respect to each calendar quarter for which a contribution is required by New York City under the contract under paragraph (1), the WTC Program Administrator shall—

(A)provide New York City with an estimate of such amount of the required contribution at the beginning of such quarter and with an updated estimate of such amount at the beginning of each of the subsequent 2 quarters;

(B)bill such amount directly to New York City; and

(C)certify periodically, for purposes of this subsection, whether or not New York City has paid the amount so billed.

Such amount shall initially be estimated by the WTC Program Administrator and shall be subject to adjustment and reconciliation based upon actual expenditures in carrying out this subchapter (excluding any expenditures from amounts in the World Trade Center Health Program Supplemental Fund under section 300mm–62 of this title or the World Trade Center Health Program Fund for Certain WTC Responders at the Pentagon and Shanksville, Pennsylvania under section 300mm–64 of this title).

(3)Rule of construction

Nothing in this subsection shall be construed as authorizing the WTC Administrator, with respect to a fiscal year, to reduce the numerical limitation under section 300mm–21(a)(4) or 300mm–31(a)(3) of this title for such fiscal year if New York City fails to comply with paragraph (1) for a calendar quarter in such fiscal year.

(e)Work-related described

For the purposes of this section, a WTC-related health condition shall be treated as a condition that is work-related if—

(1)the condition is diagnosed in an enrolled WTC responder, or in an individual who qualifies as a certified-eligible WTC survivor on the basis of being a rescue, recovery, or cleanup worker; or

(2)with respect to the condition the individual has filed and had established a claim under a workers’ compensation law or plan of the United States or a State, or other work-related injury or illness benefit plan of the employer of such individual.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsecs. (b)(1), (c)(1), and (d)(1)(E)(ii), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII, XIX, and XXI of the Act are classified generally to subchapters XVIII (§ 1395 et seq.), XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.), respectively, of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables.

Amendments

2023—Subsec. (a). Pub. L. 118–31, § 1851(c)(3)(A), substituted “(as applicable) the Funds established under section 300mm–61, 300mm–62, 300mm–63, and 300mm–64 of this title” for “the World Trade Center Health Program Fund and the World Trade Center Health Program Supplemental Fund”. Subsec. (d)(1)(A). Pub. L. 118–31, § 1851(c)(3)(B)(i), inserted “or the World Trade Center Health Program Special Fund under section 300mm–63 of this title” after “section 300mm–61 of this title”. Subsec. (d)(1)(B). Pub. L. 118–31, § 1851(c)(3)(B)(ii), inserted “or the World Trade Center Health Program Fund for Certain WTC Responders at the Pentagon and Shanksville, Pennsylvania under section 300mm–64 of this title” after “section 300mm–62 of this title”. Subsec. (d)(2). Pub. L. 118–31, § 1851(c)(3)(B)(iii), in concluding provisions, inserted “or the World Trade Center Health Program Fund for Certain WTC Responders at the Pentagon and Shanksville, Pennsylvania under section 300mm–64 of this title” after “section 300mm–62 of this title”. 2022—Subsec. (a). Pub. L. 117–328, § 7701(b)(3)(A), inserted “and the World Trade Center Health Program Supplemental Fund” before period at end. Subsec. (d)(1)(B). Pub. L. 117–328, § 7701(b)(3)(B)(i), inserted “(excluding any expenditures from amounts in the World Trade Center Health Program Supplemental Fund under section 300mm–62 of this title)” before period at end. Subsec. (d)(2). Pub. L. 117–328, § 7701(b)(3)(B)(ii), in concluding provisions, inserted “(excluding any expenditures from amounts in the World Trade Center Health Program Supplemental Fund under section 300mm–62 of this title)” before period at end. 2015—Subsec. (d)(1)(B). Pub. L. 114–113 substituted “each calendar quarter of fiscal year 2016 and of each subsequent fiscal year through fiscal year 2090,” for “the last calendar quarter of fiscal year 2011 and each calendar quarter in fiscal years 2012 through 2015” and struck out “and with respect to calendar quarters in fiscal year 2016, such full contribution amount shall be equal to ⅑ of the Federal expenditures in carrying out this subchapter for the respective quarter” before period at end.

§300mm–41 Payment of Claims