89–006 

111TH CONGRESS REPT. 111–560 " ! HOUSE OF REPRESENTATIVES 2d Session Part 1 

JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT 

OF 2010 

JULY 22, 2010.—Committed to the Committee of the Whole House on the State of 

the Union and ordered to be printed 

Mr. WAXMAN, from the Committee on Energy and Commerce, 

submitted the following 

R E P O R T 

together with 

DISSENTING VIEWS 

[To accompany H.R. 847] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Energy and Commerce, to whom was referred 

the bill (H.R. 847) to amend the Public Health Service Act to extend and improve protections and services to individuals directly 

impacted by the terrorist attack in New York City on September 

11, 2001, and for other purposes, having considered the same, report favorably thereon with an amendment and recommend that 

the bill as amended do pass. 

CONTENTS 

Page 

Amendment .............................................................................................................. 2 

Purpose and Summary ............................................................................................ 28 

Background and Need for Legislation .................................................................... 28 

Legislative History .................................................................................................. 32 

Committee Consideration ........................................................................................ 32 

Committee Votes ...................................................................................................... 33 

Committee Oversight Findings and Recommendations ........................................ 46 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 46 

Statement of General Performance Goals and Objectives .................................... 46 

Constitutional Authority Statement ...................................................................... 46 

Earmarks and Tax and Tariff Benefits .................................................................. 46 

Advisory Committee Statement .............................................................................. 46 

Applicability of Law to the Legislative Branch ..................................................... 46 

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Federal Mandates Statement ................................................................................. 46 

Committee Cost Estimate ....................................................................................... 47 

Congressional Budget Office Estimate ................................................................... 47 

Section-by-Section Analysis of the Legislation ...................................................... 61 

Changes in Existing Law Made by the Bill, as Reported ..................................... 67 

Dissenting Views ..................................................................................................... 103 

AMENDMENT

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

(a) SHORT TITLE.—This Act may be cited as the ‘‘James Zadroga 

9/11 Health and Compensation Act of 2010’’. 

(b) TABLE OF CONTENTS.—The table of contents of this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—WORLD TRADE CENTER HEALTH PROGRAM 

Sec. 101. World Trade Center Health Program. 

‘‘TITLE XXXIII—WORLD TRADE CENTER HEALTH PROGRAM 

‘‘Subtitle A—Establishment of Program; Advisory Committee 

‘‘Sec. 3301. Establishment of World Trade Center Health Program. 

‘‘Sec. 3302. WTC Health Program Scientific/Technical Advisory Committee; WTC Health Program Steering 

Committees. 

‘‘Sec. 3303. Education and outreach. 

‘‘Sec. 3304. Uniform data collection and analysis. 

‘‘Sec. 3305. Clinical Centers of Excellence and Data Centers. 

‘‘Sec. 3306. Definitions. 

‘‘Subtitle B—Program of Monitoring, Initial Health Evaluations, and Treatment 

‘‘PART 1—WTC RESPONDERS

‘‘Sec. 3311. Identification of WTC responders and provision of WTC-related monitoring services. 

‘‘Sec. 3312. Treatment of enrolled WTC responders for WTC-related health conditions. 

‘‘Sec. 3313. National arrangement for benefits for eligible individuals outside New York. 

‘‘PART 2—WTC SURVIVORS

‘‘Sec. 3321. Identification and initial health evaluation of screening-eligible and certified-eligible WTC sur- vivors. 

‘‘Sec. 3322. Followup monitoring and treatment of certified-eligible WTC survivors for WTC-related health 

conditions. 

‘‘Sec. 3323. Followup monitoring and treatment of other individuals with WTC-related health conditions. 

‘‘PART 3—PAYOR PROVISIONS

‘‘Sec. 3331. Payment of claims. 

‘‘Sec. 3332. Administrative arrangement authority. 

‘‘Subtitle C—Research Into Conditions 

‘‘Sec. 3341. Research regarding certain health conditions related to September 11 terrorist attacks in New 

York City. 

‘‘Sec. 3342. World Trade Center Health Registry. 

‘‘Subtitle D—Funding 

‘‘Sec. 3351. World Trade Center Health Program Fund. 

TITLE II—SEPTEMBER 11TH VICTIM COMPENSATION FUND OF 2001 

Sec. 201. Definitions. 

Sec. 202. Extended and expanded eligibility for compensation. 

Sec. 203. Requirement to update regulations. 

Sec. 204. Limited liability for certain claims. 

TITLE I—WORLD TRADE CENTER HEALTH 

PROGRAM 

SEC. 101. WORLD TRADE CENTER HEALTH PROGRAM. 

The Public Health Service Act is amended by adding at the end the following new 

title: 

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‘‘TITLE XXXIII—WORLD TRADE CENTER 

HEALTH PROGRAM 

‘‘Subtitle A—Establishment of Program; Advisory 

Committee 

‘‘SEC. 3301. ESTABLISHMENT OF WORLD TRADE CENTER HEALTH PROGRAM. 

‘‘(a) IN GENERAL.—There is hereby established within the Department of Health 

and Human Services a program to be known as the World Trade Center Health Program, which shall be administered by the WTC Program Administrator, to provide 

beginning on July 1, 2011— 

‘‘(1) medical monitoring and treatment benefits to eligible emergency responders and recovery and cleanup workers (including those who are Federal employees) who responded to the September 11, 2001, terrorist attacks; and 

‘‘(2) initial health evaluation, monitoring, and treatment benefits to residents 

and other building occupants and area workers in New York City who were directly impacted and adversely affected by such attacks. 

‘‘(b) COMPONENTS OF PROGRAM.—The WTC Program includes the following components: 

‘‘(1) MEDICAL MONITORING FOR RESPONDERS.—Medical monitoring under section 3311, including clinical examinations and long-term health monitoring and 

analysis for enrolled WTC responders who were likely to have been exposed to 

airborne toxins that were released, or to other hazards, as a result of the September 11, 2001, terrorist attacks. 

‘‘(2) INITIAL HEALTH EVALUATION FOR SURVIVORS.—An initial health evaluation under section 3321, including an evaluation to determine eligibility for followup monitoring and treatment. 

‘‘(3) FOLLOWUP MONITORING AND TREATMENT FOR WTC-RELATED HEALTH CONDITIONS FOR RESPONDERS AND SURVIVORS.—Provision under sections 3312, 3322, 

and 3323 of followup monitoring and treatment and payment, subject to the 

provisions of subsection (d), for all medically necessary health and mental 

health care expenses of an individual with respect to a WTC-related health condition (including necessary prescription drugs). 

‘‘(4) OUTREACH.—Establishment under section 3303 of an education and outreach program to potentially eligible individuals concerning the benefits under 

this title. 

‘‘(5) CLINICAL DATA COLLECTION AND ANALYSIS.—Collection and analysis under 

section 3304 of health and mental health data relating to individuals receiving 

monitoring or treatment benefits in a uniform manner in collaboration with the 

collection of epidemiological data under section 3342. 

‘‘(6) RESEARCH ON HEALTH CONDITIONS.—Establishment under subtitle C of a 

research program on health conditions resulting from the September 11, 2001, 

terrorist attacks. 

‘‘(c) NO COST SHARING.—Monitoring and treatment benefits and initial health 

evaluation benefits are provided under subtitle B without any deductibles, copayments, or other cost sharing to an enrolled WTC responder or certified-eligible WTC 

survivor. Initial health evaluation benefits are provided under subtitle B without 

any deductibles, copayments, or other cost sharing to a screening-eligible WTC survivor. 

‘‘(d) PREVENTING FRAUD AND UNREASONABLE ADMINISTRATIVE COSTS.— 

‘‘(1) FRAUD.—The Inspector General of the Department of Health and Human 

Services shall develop and implement a program to review the WTC Program’s 

health care expenditures to detect fraudulent or duplicate billing and payment 

for inappropriate services. This title is a Federal health care program (as defined in section 1128B(f) of the Social Security Act) and is a health plan (as defined in section 1128C(c) of such Act) for purposes of applying sections 1128 

through 1128E of such Act. 

‘‘(2) UNREASONABLE ADMINISTRATIVE COSTS.—The Inspector General of the 

Department of Health and Human Services shall develop and implement a program to review the WTC Program for unreasonable administrative costs, including with respect to infrastructure, administration, and claims processing. 

‘‘(e) QUALITY ASSURANCE.—The WTC Program Administrator working with the 

Clinical Centers of Excellence shall develop and implement a quality assurance program for the monitoring and treatment delivered by such Centers of Excellence and 

any other participating health care providers. Such program shall include— 

‘‘(1) adherence to monitoring and treatment protocols; 

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‘‘(2) appropriate diagnostic and treatment referrals for participants; 

‘‘(3) prompt communication of test results to participants; and 

‘‘(4) such other elements as the Administrator specifies in consultation with 

the Clinical Centers of Excellence. 

‘‘(f) ANNUAL PROGRAM REPORT.— ‘‘(1) IN GENERAL.—Not later than 6 months after the end of each fiscal year 

in which the WTC Program is in operation, the WTC Program Administrator 

shall submit an annual report to the Congress on the operations of this title 

for such fiscal year and for the entire period of operation of the program. 

‘‘(2) CONTENTS INCLUDED IN REPORT.—Each annual report under paragraph 

(1) shall include at least the following: 

‘‘(A) ELIGIBLE INDIVIDUALS.—Information for each clinical program described in paragraph (3)— 

‘‘(i) on the number of individuals who applied for certification under 

subtitle B and the number of such individuals who were so certified; 

‘‘(ii) of the individuals who were certified, on the number who received monitoring under the program and the number of such individuals who received medical treatment under the program; 

‘‘(iii) with respect to individuals so certified who received such treatment, on the WTC-related health conditions for which they were treated; and 

‘‘(iv) on the projected number of individuals who will be certified 

under subtitle B in the succeeding fiscal year and the succeeding 10- 

year period. 

‘‘(B) MONITORING, INITIAL HEALTH EVALUATION, AND TREATMENT COSTS.— 

For each clinical program so described— 

‘‘(i) information on the costs of monitoring and initial health evaluation and the costs of treatment and on the estimated costs of such monitoring, evaluation, and treatment in the succeeding fiscal year; and 

‘‘(ii) an estimate of the cost of medical treatment for WTC-related 

health conditions that have been paid for or reimbursed by workers’ 

compensation, by public or private health plans, or by New York City 

under section 3331. 

‘‘(C) ADMINISTRATIVE COSTS.—Information on the cost of administering 

the program, including costs of program support, data collection and analysis, and research conducted under the program. 

‘‘(D) ADMINISTRATIVE EXPERIENCE.—Information on the administrative 

performance of the program, including— 

‘‘(i) the performance of the program in providing timely evaluation of 

and treatment to eligible individuals; and 

‘‘(ii) a list of the Clinical Centers of Excellence and other providers 

that are participating in the program. 

‘‘(E) SCIENTIFIC REPORTS.—A summary of the findings of any new scientific reports or studies on the health effects associated with exposure described in section 3306(1), including the findings of research conducted 

under section 3341(a). 

‘‘(F) ADVISORY COMMITTEE RECOMMENDATIONS.—A list of recommendations by the WTC Scientific/Technical Advisory Committee on additional 

WTC Program eligibility criteria and on additional WTC-related health conditions and the action of the WTC Program Administrator concerning each 

such recommendation. 

‘‘(3) SEPARATE CLINICAL PROGRAMS DESCRIBED.—In paragraph (2), each of the 

following shall be treated as a separate clinical program of the WTC Program: 

‘‘(A) FIREFIGHTERS AND RELATED PERSONNEL.—The benefits provided for 

enrolled WTC responders described in section 3311(a)(2)(A). 

‘‘(B) OTHER WTC RESPONDERS.—The benefits provided for enrolled WTC 

responders not described in subparagraph (A). 

‘‘(C) WTC SURVIVORS.—The benefits provided for screening-eligible WTC 

survivors and certified-eligible WTC survivors in section 3321(a). 

‘‘(g) NOTIFICATION TO CONGRESS UPON REACHING 80 PERCENT OF ELIGIBILITY NUMERICAL LIMITS.—The Secretary shall promptly notify the Congress of each of the 

following: 

‘‘(1) When the number of enrollments of WTC responders subject to the limit 

established under section 3311(a)(4) has reached 80 percent of such limit. 

‘‘(2) When the number of certifications for certified-eligible WTC survivors 

subject to the limit established under section 3321(a)(3) has reached 80 percent 

of such limit. 

‘‘(h) CONSULTATION.—The WTC Program Administrator shall engage in ongoing 

outreach and consultation with relevant stakeholders, including the WTC Health 

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Program Steering Committees and the Advisory Committee under section 3302, regarding the implementation and improvement of programs under this title. 

‘‘SEC. 3302. WTC HEALTH PROGRAM SCIENTIFIC/TECHNICAL ADVISORY COMMITTEE; WTC 

HEALTH PROGRAM STEERING COMMITTEES. 

‘‘(a) ADVISORY COMMITTEE.— 

‘‘(1) ESTABLISHMENT.—The WTC Program Administrator shall establish an 

advisory committee to be known as the WTC Health Program Scientific/Technical Advisory Committee (in this subsection referred to as the ‘Advisory Committee’) to review scientific and medical evidence and to make recommendations 

to the Administrator on additional WTC Program eligibility criteria and on additional WTC-related health conditions. 

‘‘(2) COMPOSITION.—The WTC Program Administrator shall appoint the members of the Advisory Committee and shall include at least— 

‘‘(A) 4 occupational physicians, at least 2 of whom have experience treating WTC rescue and recovery workers; 

‘‘(B) 1 physician with expertise in pulmonary medicine; 

‘‘(C) 2 environmental medicine or environmental health specialists; 

‘‘(D) 2 representatives of WTC responders; 

‘‘(E) 2 representatives of certified-eligible WTC survivors; 

‘‘(F) an industrial hygienist; 

‘‘(G) a toxicologist; 

‘‘(H) an epidemiologist; and 

‘‘(I) a mental health professional. 

‘‘(3) MEETINGS.—The Advisory Committee shall meet at such frequency as 

may be required to carry out its duties. 

‘‘(4) REPORTS.—The WTC Program Administrator shall provide for publication 

of recommendations of the Advisory Committee on the public Web site established for the WTC Program. 

‘‘(5) DURATION.—Notwithstanding any other provision of law, the Advisory 

Committee shall continue in operation during the period in which the WTC Program is in operation. 

‘‘(6) APPLICATION OF FACA.—Except as otherwise specifically provided, the Advisory Committee shall be subject to the Federal Advisory Committee Act. 

‘‘(b) WTC HEALTH PROGRAM STEERING COMMITTEES.— 

‘‘(1) CONSULTATION.—The WTC Program Administrator shall consult with 2 

steering committees (each in this section referred to as a ‘Steering Committee’) 

that are established as follows: 

‘‘(A) WTC RESPONDERS STEERING COMMITTEE.—One Steering Committee, 

to be known as the WTC Responders Steering Committee, for the purpose 

of receiving input from affected stakeholders and facilitating the coordination of monitoring and treatment programs for the enrolled WTC responders under part 1 of subtitle B. 

‘‘(B) WTC SURVIVORS STEERING COMMITTEE.—One Steering Committee, to 

be known as the WTC Survivors Steering Committee, for the purpose of receiving input from affected stakeholders and facilitating the coordination of 

initial health evaluations, monitoring, and treatment programs for screening-eligible and certified-eligible WTC survivors under part 2 of subtitle B. 

‘‘(2) MEMBERSHIP.— 

‘‘(A) WTC RESPONDERS STEERING COMMITTEE.— 

‘‘(i) REPRESENTATION.—The WTC Responders Steering Committee 

shall include— 

‘‘(I) representatives of the Centers of Excellence providing services to WTC responders; 

‘‘(II) representatives of labor organizations representing firefighters, police, other New York City employees, and recovery and 

cleanup workers who responded to the September 11, 2001, terrorist attacks; and 

‘‘(III) 3 representatives of New York City, 1 of whom will be selected by the police commissioner of New York City, 1 by the 

health commissioner of New York City, and 1 by the mayor of New 

York City. 

‘‘(ii) INITIAL MEMBERSHIP.—The WTC Responders Steering Committee 

shall initially be composed of members of the WTC Monitoring and 

Treatment Program Steering Committee (as in existence on the day before the date of the enactment of this title). 

‘‘(B) WTC SURVIVORS STEERING COMMITTEE.— 

‘‘(i) REPRESENTATION.—The WTC Survivors Steering Committee shall 

include representatives of— 

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‘‘(I) the Centers of Excellence providing services to screening-eligible and certified-eligible WTC survivors; 

‘‘(II) the population of residents, students, and area and other 

workers affected by the September 11, 2001, terrorist attacks; 

‘‘(III) screening-eligible and certified-eligible survivors receiving 

initial health evaluations, monitoring, or treatment under part 2 of 

subtitle B and organizations advocating on their behalf; and 

‘‘(IV) New York City. 

‘‘(ii) INITIAL MEMBERSHIP.—The WTC Survivors Steering Committee 

shall initially be composed of members of the WTC Environmental 

Health Center Survivor Advisory Committee (as in existence on the day 

before the date of the enactment of this title). 

‘‘(C) ADDITIONAL APPOINTMENTS.—Each Steering Committee may recommend, if approved by a majority of voting members of the Committee, 

additional members to the Committee. 

‘‘(D) VACANCIES.—A vacancy in a Steering Committee shall be filled by 

an individual recommended by the Steering Committee. 

‘‘SEC. 3303. EDUCATION AND OUTREACH. 

‘‘The WTC Program Administrator shall institute a program that provides education and outreach on the existence and availability of services under the WTC 

Program. The outreach and education program— 

‘‘(1) shall include— 

‘‘(A) the establishment of a public Web site with information about the 

WTC Program; 

‘‘(B) meetings with potentially eligible populations; 

‘‘(C) development and dissemination of outreach materials informing people about the program; and 

‘‘(D) the establishment of phone information services; and 

‘‘(2) shall be conducted in a manner intended— 

‘‘(A) to reach all affected populations; and 

‘‘(B) to include materials for culturally and linguistically diverse populations. 

‘‘SEC. 3304. UNIFORM DATA COLLECTION AND ANALYSIS. 

‘‘(a) IN GENERAL.—The WTC Program Administrator shall provide for the uniform 

collection of data (and analysis of data and regular reports to the Administrator) 

on the prevalence of WTC-related health conditions and the identification of new 

WTC-related health conditions. Such data shall be collected for all individuals provided monitoring or treatment benefits under subtitle B and regardless of their 

place of residence or Clinical Center of Excellence through which the benefits are 

provided. The WTC Program Administrator shall provide, through the Data Centers 

or otherwise, for the integration of such data into the monitoring and treatment program activities under this title. 

‘‘(b) COORDINATING THROUGH CENTERS OF EXCELLENCE.—Each Clinical Center of 

Excellence shall collect data described in subsection (a) and report such data to the 

corresponding Data Center for analysis by such Data Center. 

‘‘(c) COLLABORATION WITH WTC HEALTH REGISTRY.—The WTC Program Administrator shall provide for collaboration between the Data Centers and the World Trade 

Center Health Registry described in section 3342. 

‘‘(d) PRIVACY.—The data collection and analysis under this section shall be conducted and maintained in a manner that protects the confidentiality of individually 

identifiable health information consistent with applicable statutes and regulations, 

including, as applicable, HIPAA privacy and security law (as defined in section 

3009(a)(2)) and section 552a of title 5, United States Code. 

‘‘SEC. 3305. CLINICAL CENTERS OF EXCELLENCE AND DATA CENTERS. 

‘‘(a) IN GENERAL.— 

‘‘(1) CONTRACTS WITH CLINICAL CENTERS OF EXCELLENCE.—The WTC Program 

Administrator shall, subject to subsection (b)(1)(B), enter into contracts with 

Clinical Centers of Excellence (as defined in subsection (b)(1)(A))— 

‘‘(A) for the provision of monitoring and treatment benefits and initial 

health evaluation benefits under subtitle B; 

‘‘(B) for the provision of outreach activities to individuals eligible for such 

monitoring and treatment benefits, for initial health evaluation benefits, 

and for followup to individuals who are enrolled in the monitoring program; 

‘‘(C) for the provision of counseling for benefits under subtitle B, with respect to WTC-related health conditions, for individuals eligible for such benefits; 

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‘‘(D) for the provision of counseling for benefits for WTC-related health 

conditions that may be available under workers’ compensation or other benefit programs for work-related injuries or illnesses, health insurance, disability insurance, or other insurance plans or through public or private social service agencies and assisting eligible individuals in applying for such 

benefits; 

‘‘(E) for the provision of translational and interpretive services for program participants who are not English language proficient; and 

‘‘(F) for the collection and reporting of data in accordance with section 

3304. 

‘‘(2) CONTRACTS WITH DATA CENTERS.— 

‘‘(A) IN GENERAL.—The WTC Program Administrator shall enter into contracts with Data Centers (as defined in subsection (b)(2))— 

‘‘(i) for receiving, analyzing, and reporting to the WTC Program Administrator on data, in accordance with section 3304, that have been 

collected and reported to such Data Centers by the corresponding Clinical Centers of Excellence under subsection (b)(1)(B)(iii); 

‘‘(ii) for the development of monitoring, initial health evaluation, and 

treatment protocols, with respect to WTC-related health conditions; 

‘‘(iii) for coordinating the outreach activities conducted under paragraph (1)(B) by each corresponding Clinical Center of Excellence; 

‘‘(iv) for establishing criteria for the credentialing of medical providers participating in the nationwide network under section 3313; 

‘‘(v) for coordinating and administering the activities of the WTC 

Health Program Steering Committees established under section 

3002(b); and 

‘‘(vi) for meeting periodically with the corresponding Clinical Centers 

of Excellence to obtain input on the analysis and reporting of data collected under clause (i) and on the development of monitoring, initial 

health evaluation, and treatment protocols under clause (ii). 

‘‘(B) MEDICAL PROVIDER SELECTION.—The medical providers under subparagraph (A)(iv) shall be selected by the WTC Program Administrator on 

the basis of their experience treating or diagnosing the health conditions included in the list of WTC-related health conditions. 

‘‘(C) CLINICAL DISCUSSIONS.—In carrying out subparagraph (A)(ii), a Data 

Center shall engage in clinical discussions across the WTC Program to 

guide treatment approaches for individuals with a WTC-related health condition. 

‘‘(D) TRANSPARENCY OF DATA.—A contract entered into under this subsection with a Data Center shall require the Data Center to make any data 

collected and reported to such Center under subsection (b)(1)(B)(iii) available to health researchers and others as provided in the CDC/ATSDR Policy 

on Releasing and Sharing Data. 

‘‘(3) AUTHORITY FOR CONTRACTS TO BE CLASS SPECIFIC.—A contract entered 

into under this subsection with a Clinical Center of Excellence or a Data Center 

may be with respect to one or more class of enrolled WTC responders, screening-eligible WTC survivors, or certified-eligible WTC survivors. 

‘‘(4) USE OF COOPERATIVE AGREEMENTS.—Any contract under this title between the WTC Program Administrator and a Data Center or a Clinical Center 

of Excellence may be in the form of a cooperative agreement. 

‘‘(b) CENTERS OF EXCELLENCE.— 

‘‘(1) CLINICAL CENTERS OF EXCELLENCE.— 

‘‘(A) DEFINITION.—For purposes of this title, the term ‘Clinical Center of 

Excellence’ means a Center that demonstrates to the satisfaction of the Administrator that the Center— 

‘‘(i) uses an integrated, centralized health care provider approach to 

create a comprehensive suite of health services under this title that are 

accessible to enrolled WTC responders, screening-eligible WTC survivors, or certified-eligible WTC survivors; 

‘‘(ii) has experience in caring for WTC responders and screening-eligible WTC survivors or includes health care providers who have been 

trained pursuant to section 3313(c); 

‘‘(iii) 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 

‘‘(iv) meets such other requirements as specified by the Administrator. 

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‘‘(B) CONTRACT REQUIREMENTS.—The WTC Program Administrator shall 

not enter into a contract with a Clinical Center of Excellence under subsection (a)(1) unless the Center agrees to do each of the following: 

‘‘(i) Establish a formal mechanism for consulting with and receiving 

input from representatives of eligible populations receiving monitoring 

and treatment benefits under subtitle B from such Center. 

‘‘(ii) Coordinate monitoring and treatment benefits under subtitle B 

with routine medical care provided for the treatment of conditions other 

than WTC-related health conditions. 

‘‘(iii) Collect and report to the corresponding Data Center data in accordance with section 3304(b). 

‘‘(iv) Have in place safeguards against fraud that are satisfactory to 

the Administrator, in consultation with the Inspector General of the 

Department of Health and Human Services. 

‘‘(v) Treat or refer for treatment all individuals who are enrolled 

WTC responders or certified-eligible WTC survivors with respect to 

such Center who present themselves for treatment of a WTC-related 

health condition. 

‘‘(vi) Have in place safeguards, consistent with section 3304(c), to ensure the confidentiality of an individual’s individually identifiable 

health information, including requiring that such information not be 

disclosed to the individual’s employer without the authorization of the 

individual. 

‘‘(vii) Use amounts paid under subsection (c)(1) only for costs incurred 

in carrying out the activities described in subsection (a), other than 

those described in subsection (a)(1)(A). 

‘‘(viii) Utilize health care providers with occupational and environmental medicine expertise to conduct physical and mental health assessments, in accordance with protocols developed under subsection 

(a)(2)(A)(ii). 

‘‘(ix) Communicate with WTC responders and screening-eligible and 

certified-eligible WTC survivors in appropriate languages and conduct 

outreach activities with relevant stakeholder worker or community associations. 

‘‘(x) Meet all the other applicable requirements of this title, including 

regulations implementing such requirements. 

‘‘(C) TRANSITION RULE TO ENSURE CONTINUITY OF CARE.—The WTC Program Administrator shall to the maximum extent feasible ensure continuity 

of care in any period of transition from monitoring and treatment of an enrolled WTC responder or certified-eligible WTC survivor by a provider to a 

Clinical Center of Excellence or a health care provider participating in the 

nationwide network under section 3313. 

‘‘(2) DATA CENTERS.—For purposes of this title, the term ‘Data Center’ means 

a Center that the WTC Program Administrator determines has the capacity to 

carry out the responsibilities for a Data Center under subsection (a)(2). 

‘‘(3) CORRESPONDING CENTERS.—For purposes of this title, a Clinical Center 

of Excellence and a Data Center shall be treated as ‘corresponding’ to the extent 

that such Clinical Center and Data Center serve the same population group. 

‘‘(c) PAYMENT FOR INFRASTRUCTURE COSTS.— 

‘‘(1) IN GENERAL.—The WTC Program Administrator shall reimburse a Clinical Center of Excellence for the fixed infrastructure costs of such Center in carrying out the activities described in subtitle B at a rate negotiated by the Administrator and such Centers. Such negotiated rate shall be fair and appropriate and take into account the number of enrolled WTC responders receiving 

services from such Center under this title. 

‘‘(2) FIXED INFRASTRUCTURE COSTS.—For purposes of paragraph (1), the term 

‘fixed infrastructure costs’ means, with respect to a Clinical Center of Excellence, the costs incurred by such Center that are not reimbursable by the WTC 

Program Administrator under section 3312(c). 

‘‘SEC. 3306. DEFINITIONS. 

‘‘In this title: 

‘‘(1) The term ‘aggravating’ means, with respect to a health condition, 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. 

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‘‘(2) The term ‘certified-eligible WTC survivor’ has the meaning given such 

term in section 3321(a)(2). 

‘‘(3) The terms ‘Clinical Center of Excellence’ and ‘Data Center’ have the 

meanings given such terms in section 3305. 

‘‘(4) The term ‘enrolled WTC responder’ means a WTC responder enrolled 

under section 3311(a)(3). 

‘‘(5) The term ‘initial health evaluation’ includes, with respect to an individual, 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 Program. 

‘‘(6) The term ‘list of WTC-related health conditions’ means— 

‘‘(A) for WTC responders, the health conditions listed in section 

3312(a)(3); and 

‘‘(B) for screening-eligible and certified-eligible WTC survivors, the health 

conditions listed in section 3322(b). 

‘‘(7) The term ‘New York City disaster area’ means the area within New York 

City that is— 

‘‘(A) the area of Manhattan that is south of Houston Street; and 

‘‘(B) any block in Brooklyn that is wholly or partially contained within a 

1.5-mile radius of the former World Trade Center site. 

‘‘(8) The term ‘New York metropolitan area’ means an area, specified by the 

WTC Program Administrator, within which WTC responders and eligible WTC 

screening-eligible survivors who reside in such area are reasonably able to access monitoring and treatment benefits and initial health evaluation benefits 

under this title through a Clinical Center of Excellence described in subparagraphs (A), (B), or (C) of section 3305(b)(1). 

‘‘(9) The term ‘screening-eligible WTC survivor’ has the meaning given such 

term in section 3321(a)(1). 

‘‘(10) Any reference to ‘September 11, 2001’ shall be deemed a reference to the 

period on such date subsequent to the terrorist attacks at the World Trade Center, Shanksville, Pennsylvania, or the Pentagon, as applicable, on such date. 

‘‘(11) The term ‘September 11, 2001, terrorist attacks’ means the terrorist attacks that occurred on September 11, 2001, in New York City, in Shanksville, 

Pennsylvania, and at the Pentagon, and includes the aftermath of such attacks. 

‘‘(12) The term ‘WTC Health Program Steering Committee’ means such a 

Steering Committee established under section 3302(b). 

‘‘(13) The term ‘WTC Program’ means the Word Trade Center Health Program established under section 3301(a). 

‘‘(14) The term ‘WTC Program Administrator’ means— 

‘‘(A) with respect to paragraphs (3) and (4) of section 3311(a) (relating to 

enrollment of WTC responders), section 3312(c) and the corresponding provisions of section 3322 (relating to payment for initial health evaluation, 

monitoring, and treatment), paragraphs (1)(C), (2)(B), and (3) of section 

3321(a) (relating to determination or certification of screening-eligible or 

certified-eligible WTC responders), and part 3 of subtitle B (relating to 

payor provisions), an official in the Department of Health and Human Services, to be designated by the Secretary; and 

‘‘(B) with respect to any other provision of this title, the Director of the 

National Institute for Occupational Safety and Health, or a designee of such 

Director. 

‘‘(15) The term ‘WTC-related health condition’ is defined in section 3312(a). 

‘‘(16) The term ‘WTC responder’ is defined in section 3311(a). 

‘‘(17) The term ‘WTC Scientific/Technical Advisory Committee’ means such 

Committee established under section 3302(a). 

‘‘Subtitle B—Program of Monitoring, Initial 

Health Evaluations, and Treatment 

‘‘PART 1—WTC RESPONDERS 

‘‘SEC. 3311. IDENTIFICATION OF WTC RESPONDERS AND PROVISION OF WTC-RELATED MONITORING SERVICES. 

‘‘(a) WTC RESPONDER DEFINED.— 

‘‘(1) IN GENERAL.—For purposes of this title, the term ‘WTC responder’ means 

any of the following individuals, subject to paragraph (4): 

‘‘(A) CURRENTLY IDENTIFIED RESPONDER.—An individual who has been 

identified as eligible for monitoring under the arrangements as in effect on 

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the date of the enactment of this title between the National Institute for 

Occupational Safety and Health and— 

‘‘(i) the consortium coordinated by Mt. Sinai Hospital in New York 

City that coordinates the monitoring and treatment for enrolled WTC 

responders other than with respect to those covered under the arrangement with the Fire Department of New York City; or 

‘‘(ii) the Fire Department of New York City. 

‘‘(B) RESPONDER WHO MEETS CURRENT ELIGIBILITY CRITERIA.—An individual who meets the current eligibility criteria described in paragraph (2). 

‘‘(C) RESPONDER WHO MEETS MODIFIED ELIGIBILITY CRITERIA.—An individual who— 

‘‘(i) performed rescue, recovery, demolition, debris cleanup, or other 

related services in the New York City disaster area in response to the 

September 11, 2001, terrorist attacks, regardless of whether such services were performed by a State or Federal employee or member of the 

National Guard or otherwise; and 

‘‘(ii) meets such eligibility criteria relating to exposure to airborne 

toxins, other hazards, or adverse conditions resulting from the September 11, 2001, terrorist attacks as the WTC Program Administrator, 

after consultation with the WTC Scientific/Technical Advisory Committee, determines appropriate. 

The WTC Program Administrator shall not modify such eligibility criteria 

on or after the date that the number of enrollments of WTC responders has 

reached 80 percent of the limit described in paragraph (4) or on or after 

the date that the number of certifications for certified-eligible WTC survivors under section 3321(a)(2)(B) has reached 80 percent of the limit described in section 3321(a)(3). 

‘‘(2) CURRENT ELIGIBILITY CRITERIA.—The eligibility criteria described in this 

paragraph for an individual is that the individual is described in any of the following categories: 

‘‘(A) FIREFIGHTERS AND RELATED PERSONNEL.—The individual— 

‘‘(i) was a member of the Fire Department of New York City (whether 

fire or emergency personnel, active or retired) who participated at least 

one day in the rescue and recovery effort at any of the former World 

Trade Center sites (including Ground Zero, Staten Island Landfill, and 

the New York City Chief Medical Examiner’s Office) for any time during the period beginning on September 11, 2001, and ending on July 

31, 2002; or 

‘‘(ii)(I) is a surviving immediate family member of an individual who 

was a member of the Fire Department of New York City (whether fire 

or emergency personnel, active or retired) and was killed at the World 

Trade site on September 11, 2001; and 

‘‘(II) received any treatment for a WTC-related health condition described in section 3312(a)(1)(A)(ii) (relating to mental health conditions) 

on or before September 1, 2008. 

‘‘(B) LAW ENFORCEMENT OFFICERS AND WTC RESCUE, RECOVERY, AND

CLEANUP WORKERS.—The individual— 

‘‘(i) worked or volunteered onsite in rescue, recovery, debris cleanup, 

or related support services in lower Manhattan (south of Canal St.), the 

Staten Island Landfill, or the barge loading piers, for at least 4 hours 

during the period beginning on September 11, 2001, and ending on September 14, 2001, for at least 24 hours during the period beginning on 

September 11, 2001, and ending on September 30, 2001, or for at least 

80 hours during the period beginning on September 11, 2001, and ending on July 31, 2002; 

‘‘(ii)(I) was a member of the Police Department of New York City 

(whether active or retired) or a member of the Port Authority Police of 

the Port Authority of New York and New Jersey (whether active or retired) who participated onsite in rescue, recovery, debris cleanup, or related services in lower Manhattan (south of Canal St.), including 

Ground Zero, the Staten Island Landfill, or the barge loading piers, for 

at least 4 hours during the period beginning September 11, 2001, and 

ending on September 14, 2001; 

‘‘(II) participated onsite in rescue, recovery, debris cleanup, or related 

services in at Ground Zero, the Staten Island Landfill, or the barge 

loading piers, for at least one day during the period beginning on September 11, 2001, and ending on July 31, 2002; 

‘‘(III) participated onsite in rescue, recovery, debris cleanup, or related services in lower Manhattan (south of Canal St.) for at least 24 

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hours during the period beginning on September 11, 2001, and ending 

on September 30, 2001; or 

‘‘(IV) participated onsite in rescue, recovery, debris cleanup, or related services in lower Manhattan (south of Canal St.) for at least 80 

hours during the period beginning on September 11, 2001, and ending 

on July 31, 2002; 

‘‘(iii) 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 World Trade Center 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; 

‘‘(iv) 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; or 

‘‘(v) 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 during a duration and 

period described in subparagraph (A). 

‘‘(C) RESPONDERS TO THE SEPTEMBER 11 ATTACKS AT THE PENTAGON AND

SHANKSVILLE, PENNSYLVANIA.—The individual— 

‘‘(i)(I) was a member of a fire or police department (whether fire or 

emergency personnel, active or retired), worked for a recovery or cleanup contractor, or was a volunteer; and performed rescue, recovery, demolition, debris cleanup, or other related services at the Pentagon site of 

the terrorist-related aircraft crash of September 11, 2001, during the 

period beginning on September 11, 2001, and ending on the date on 

which the cleanup of the site was concluded, as determined by the WTC 

Program Administrator; or 

‘‘(II) was a member of a fire or police department (whether fire or 

emergency personnel, active or retired), worked for a recovery or cleanup contractor, or was a volunteer; and performed rescue, recovery, demolition, debris cleanup, or other related services at the Shanksville, 

Pennsylvania, site of the terrorist-related aircraft crash of September 

11, 2001, during the period beginning on September 11, 2001, and ending on the date on which the cleanup of the site was concluded, as determined by the WTC Program Administrator; and 

‘‘(ii) is determined by the WTC Program Administrator to be at an 

increased risk of developing a WTC-related health condition as a result 

of exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 11, 2001, terrorist attacks, and meets such 

eligibility criteria related to such exposures, as the WTC Program Administrator determines are appropriate, after consultation with the 

WTC Scientific/Technical Advisory Committee. 

‘‘(3) ENROLLMENT PROCESS.— 

‘‘(A) IN GENERAL.—The WTC Program Administrator shall establish a 

process for enrolling WTC responders in the WTC Program. Under such 

process— 

‘‘(i) WTC responders described in paragraph (1)(A) shall be deemed 

to be enrolled in such Program; 

‘‘(ii) subject to clause (iii), the Administrator shall enroll in such program individuals who are determined to be WTC responders; 

‘‘(iii) the Administrator shall deny such enrollment to an individual 

if the Administrator determines that the numerical limitation in paragraph (4) on enrollment of WTC responders has been met; 

‘‘(iv) there shall be no fee charged to the applicant for making an application for such enrollment; 

‘‘(v) the Administrator shall make a determination on such an application not later than 60 days after the date of filing the application; 

and 

‘‘(vi) an individual who is denied enrollment in such Program shall 

have an opportunity to appeal such determination in a manner established under such process. 

‘‘(B) TIMING.— 

‘‘(i) CURRENTLY IDENTIFIED RESPONDERS.—In accordance with subparagraph (A)(i), the WTC Program Administrator shall enroll an individual described in paragraph (1)(A) in the WTC Program not later 

than July 1, 2011. 

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‘‘(ii) OTHER RESPONDERS.—In accordance with subparagraph (A)(ii) 

and consistent with paragraph (4), the WTC Program Administrator 

shall enroll any other individual who is determined to be a WTC responder in the WTC Program at the time of such determination. 

‘‘(4) NUMERICAL LIMITATION ON ELIGIBLE WTC RESPONDERS.— 

‘‘(A) IN GENERAL.—The total number of individuals not described in paragraph (1)(A) or (2)(A)(ii) who may be enrolled under paragraph (3)(A)(ii) 

shall not exceed 25,000 at any time, of which no more than 2,500 may be 

individuals enrolled based on modified eligibility criteria established under 

paragraph (1)(C). 

‘‘(B) PROCESS.—In implementing subparagraph (A), the WTC Program 

Administrator shall— 

‘‘(i) limit the number of enrollments made under paragraph (3)— 

‘‘(I) in accordance with such subparagraph; and 

‘‘(II) to such number, as determined by the Administrator based 

on the best available information and subject to amounts available 

under section 3351, that will ensure sufficient funds will be available to provide treatment and monitoring benefits under this title, 

with respect to all individuals who are enrolled through the end of 

fiscal year 2020; and 

‘‘(ii) provide priority (subject to paragraph (3)(A)(i)) in such enrollments in the order in which individuals apply for enrollment under 

paragraph (3). 

‘‘(5) DISQUALIFICATION OF INDIVIDUALS ON TERRORIST WATCH LIST.—No individual who is on the terrorist watch list maintained by the Department of 

Homeland Security shall qualify as an eligible WTC responder. Before enrolling 

any individual as a WTC responder in the WTC Program under paragraph (3), 

the Administrator, in consultation with the Secretary of Homeland Security, 

shall determine whether the individual is on such list. 

‘‘(b) MONITORING BENEFITS.— 

‘‘(1) IN GENERAL.—In the case of an enrolled WTC responder (other than one 

described in subsection (a)(2)(A)(ii)), the WTC Program shall provide for monitoring benefits that include monitoring consistent with protocols approved by 

the WTC Program Administrator and including clinical examinations and longterm health monitoring and analysis. In the case of an enrolled WTC responder 

who is an active member of the Fire Department of New York City, the responder shall receive such benefits as part of the individual’s periodic company 

medical exams. 

‘‘(2) PROVISION OF MONITORING BENEFITS.—The monitoring benefits under 

paragraph (1) shall be provided through the Clinical Center of Excellence for 

the type of individual involved or, in the case of an individual residing outside 

the New York metropolitan area, under an arrangement under section 3313. 

‘‘SEC. 3312. TREATMENT OF ENROLLED WTC RESPONDERS FOR WTC-RELATED HEALTH CONDITIONS. 

‘‘(a) WTC-RELATED HEALTH CONDITION DEFINED.— 

‘‘(1) IN GENERAL.—For purposes of this title, 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 3322(a). 

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In the case of a WTC responder described in section 3311(a)(2)(A)(ii) (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) DETERMINATION.—The 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 RESPONDERS.—The 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.—In 

the case of a WTC responder described in paragraph (4), a condition described in such paragraph. 

‘‘(D) ADDITIONAL CONDITIONS.—Any cancer (or type of cancer) or other 

condition added, pursuant to paragraph (5) or (6), to the list under this 

paragraph. 

‘‘(4) MUSCULOSKELETAL DISORDERS.— 

‘‘(A) IN GENERAL.—For purposes of this title, 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.—The term ‘WTC-related musculoskeletal disorder’ 

means a chronic or recurrent disorder of the musculoskeletal system caused 

by heavy lifting or repetitive strain on the joints or musculoskeletal system 

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occurring during rescue or recovery efforts in the New York City disaster 

area in the aftermath of the September 11, 2001, terrorist attacks. 

‘‘(5) CANCER.— 

‘‘(A) IN GENERAL.—The WTC Program Administrator shall periodically 

conduct a review of all available scientific and medical evidence, including 

findings and recommendations of Clinical Centers of Excellence, published 

in peer-reviewed journals to determine if, based on such evidence, cancer 

or a certain type of cancer should be added to the applicable list of WTCrelated health conditions. The WTC Program Administrator shall conduct 

the first review under this subparagraph not later than 180 days after the 

date of the enactment of this title. 

‘‘(B) PROPOSED REGULATIONS AND RULEMAKING.—Based on the periodic reviews under subparagraph (A), if the WTC Program Administrator determines that cancer or a certain type of cancer should be added to such list 

of WTC-related health conditions, the WTC Program Administrator shall 

propose regulations, through rulemaking, to add cancer or the certain type 

of cancer to such list. 

‘‘(C) FINAL REGULATIONS.—Based on all the available evidence in the rulemaking record, the WTC Program Administrator shall make a final determination of whether cancer or a certain type of cancer should be added to 

such list of WTC-related health conditions. If such a determination is made 

to make such an addition, the WTC Program Administrator shall by regulation add cancer or the certain type of cancer to such list. 

‘‘(D) DETERMINATIONS NOT TO ADD CANCER OR CERTAIN TYPES OF CANCER.—In the case that the WTC Program Administrator determines under 

subparagraph (B) or (C) that cancer or a certain type of cancer should not 

be added to such list of WTC-related health conditions, the WTC Program 

Administrator shall publish an explanation for such determination in the 

Federal Register. Any such determination to not make such an addition 

shall not preclude the addition of cancer or the certain type of cancer to 

such list at a later date. 

‘‘(6) ADDITION OF HEALTH CONDITIONS TO LIST FOR WTC RESPONDERS.— 

‘‘(A) IN GENERAL.—Whenever the WTC Program Administrator determines that a proposed rule should be promulgated to add a health condition 

to the list of health conditions in paragraph (3), the Administrator may request a recommendation of the Advisory Committee or may publish such 

a proposed rule in the Federal Register in accordance with subparagraph 

(D). 

‘‘(B) ADMINISTRATOR’S OPTIONS AFTER RECEIPT OF PETITION.—In 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 60 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.—In the case that the Administrator requests a recommendation of the Advisory Committee under this 

paragraph, with respect to adding a health condition to the list in paragraph (3), the Advisory Committee shall submit to the Administrator such 

recommendation not later than 60 days after the date of such request or 

by such date (not to exceed 180 days after such date of request) as specified 

by the Administrator. Not later than 60 days after the date of receipt of 

such recommendation, the Administrator shall, in accordance with subparagraph (D), publish in the Federal Register a proposed rule with respect to 

such recommendation or a determination not to propose such a proposed 

rule and the basis for such determination. 

‘‘(D) PUBLICATION.—The 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, United States Code; and 

‘‘(ii) provide interested parties a period of 30 days after such publication to submit written comments on the proposed rule. 

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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.—For purposes of this paragraph, the 

term ‘interested party’ includes a representative of any organization representing WTC responders, a nationally recognized medical association, a 

Clinical or Data Center, a State or political subdivision, or any other interested person. 

‘‘(b) COVERAGE OF TREATMENT FOR WTC-RELATED HEALTH CONDITIONS.— ‘‘(1) DETERMINATION FOR ENROLLED WTC RESPONDERS BASED ON A WTC-RE- LATED HEALTH CONDITION.— ‘‘(A) IN GENERAL.—If a physician at a Clinical Center of Excellence that 

is providing monitoring benefits under section 3311 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.—A Federal employee designated by the WTC Program 

Administrator shall review determinations made under subparagraph 

(A). 

‘‘(ii) CERTIFICATION.—The Administrator shall provide a certification 

of such condition based upon reviews conducted under clause (i). Such 

a certification shall be provided unless the Administrator determines 

that the responder’s condition is not a WTC-related health condition in 

the list in subsection (a)(3) or that exposure to airborne toxins, other 

hazards, or adverse conditions resulting from the September 1, 2001, 

terrorist attacks is not substantially likely to be a significant factor in 

aggravating, contributing to, or causing the condition. 

‘‘(iii) APPEAL PROCESS.—The Administrator shall establish, by rule, a 

process for the appeal of determinations under clause (ii). 

‘‘(2) DETERMINATION BASED ON MEDICALLY ASSOCIATED WTC-RELATED HEALTH

CONDITIONS.— 

‘‘(A) IN GENERAL.—If 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 APPEAL.—The 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.—If the WTC Program Administrator provides certification under subparagraph (B)(iii) for coverage 

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of a condition, the Administrator may, pursuant to subsection (a)(6), add 

the condition to the list in subsection (a)(3). 

‘‘(D) CONDITIONS ALREADY DECLINED FOR INCLUSION IN LIST.—If the WTC 

Program Administrator publishes a determination under subsection 

(a)(6)(B) not to include a condition in the list in subsection (a)(3), the WTC 

Program Administrator shall not provide certification under subparagraph 

(B)(iii) for coverage of the condition. In the case of an individual who is certified under subparagraph (B)(iii) with respect to such condition before the 

date of the publication of such determination the previous sentence shall 

not apply. 

‘‘(3) REQUIREMENT OF MEDICAL NECESSITY.— 

‘‘(A) IN GENERAL.—In providing treatment for a WTC-related health condition, a physician or other provider shall provide treatment that is medically necessary and in accordance with medical treatment protocols established under subsection (d). 

‘‘(B) REGULATIONS RELATING TO MEDICAL NECESSITY.—For the purpose of 

this title, the WTC Program Administrator shall issue regulations specifying a standard for determining medical necessity with respect to health 

care services and prescription pharmaceuticals, a process for determining 

whether treatment furnished and pharmaceuticals prescribed under this 

title meet such standard (including any prior authorization requirement), 

and a process for appeal of a determination under subsection (c)(3). 

‘‘(4) SCOPE OF TREATMENT COVERED.— 

‘‘(A) IN GENERAL.—The scope of treatment covered under this subsection 

includes services of physicians and other health care providers, diagnostic 

and laboratory tests, prescription drugs, inpatient and outpatient hospital 

services, and other medically necessary treatment. 

‘‘(B) PHARMACEUTICAL COVERAGE.—With respect to ensuring coverage of 

medically necessary outpatient prescription drugs, such drugs shall be provided, under arrangements made by the WTC Program Administrator, directly through participating Clinical Centers of Excellence or through one 

or more outside vendors. 

‘‘(C) TRANSPORTATION EXPENSES FOR NATIONWIDE NETWORK.—The WTC 

Program Administrator may provide for necessary and reasonable transportation and expenses incident to the securing of medically necessary treatment through the nationwide network under section 3313 involving travel 

of more than 250 miles and for which payment is made under this section 

in the same manner in which individuals may be furnished necessary and 

reasonable transportation and expenses incident to services involving travel 

of more than 250 miles under regulations implementing section 3629(c) of 

the Energy Employees Occupational Illness Compensation Program Act of 

2000 (title XXXVI of Public Law 106–398; 42 U.S.C. 7384t(c)). 

‘‘(5) PROVISION OF TREATMENT PENDING CERTIFICATION.—With respect to an 

enrolled WTC responder for whom a determination is made by an examining 

physician under paragraph (1) or (2), but for whom the WTC Program Administrator has not yet determined whether to certify the determination, the WTC 

Program Administrator may establish by rule a process through which the Administrator may approve the provision of medical treatment under this subsection (and payment under subsection (c)) with respect to such responder and 

such responder’s WTC-related health condition (under such terms and conditions as the Administrator may provide) until the Administrator makes a decision on whether to certify the determination. 

‘‘(c) PAYMENT FOR INITIAL HEALTH EVALUATION, MONITORING, AND TREATMENT OF

WTC-RELATED HEALTH CONDITIONS.— 

‘‘(1) MEDICAL TREATMENT.— 

‘‘(A) USE OF FECA PAYMENT RATES.—Subject to subparagraphs (B) and (C), 

the WTC Program Administrator shall reimburse costs for medically necessary treatment under this title 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. For treatment not covered under the previous sentence or subparagraph (B), the WTC Program Administrator shall establish by regulation a reimbursement rate for such treatment. 

‘‘(B) PHARMACEUTICALS.— 

‘‘(i) IN GENERAL.—The WTC Program Administrator shall establish a 

program for paying for the medically necessary outpatient prescription 

pharmaceuticals prescribed under this title for WTC-related health conditions through one or more contracts with outside vendors. 

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‘‘(ii) COMPETITIVE BIDDING.—Under 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.—Under such program the 

Administrator may enter into an agreement with a separate vendor to 

provide pharmaceutical benefits to enrolled WTC responders for whom 

the Clinical Center of Excellence is described in section 3305 if such an 

arrangement is deemed necessary and beneficial to the program by the 

WTC Program Administrator. 

‘‘(C) IMPROVING QUALITY AND EFFICIENCY THROUGH MODIFICATION OF PAYMENT AMOUNTS AND METHODOLOGIES.—The WTC Program Administrator 

may modify the amounts and methodologies for making payments for initial 

health evaluations, monitoring, or treatment, if, taking into account utilization and quality data furnished by the Clinical Centers of Excellence under 

section 3305(b)(1)(B)(iii), the Administrator determines that a bundling, 

capitation, pay for performance, or other payment methodology would better ensure high quality and efficient delivery of initial health evaluations, 

monitoring, or treatment to an enrolled WTC responder, screening-eligible 

WTC survivor, or certified-eligible WTC survivor. 

‘‘(2) MONITORING AND INITIAL HEALTH EVALUATION.—The WTC Program Administrator shall reimburse the costs of monitoring and the costs of an initial 

health evaluation provided under this title at a rate set by the Administrator 

by regulation. 

‘‘(3) DETERMINATION OF MEDICAL NECESSITY.— 

‘‘(A) REVIEW OF MEDICAL NECESSITY AND PROTOCOLS.—As part of the process for reimbursement or payment under this subsection, the WTC Program 

Administrator shall provide for the review of claims for reimbursement or 

payment for the provision of medical treatment to determine if such treatment is medically necessary and in accordance with medical treatment protocols established under subsection (d). 

‘‘(B) WITHHOLDING OF PAYMENT FOR MEDICALLY UNNECESSARY TREATMENT.—The Administrator shall withhold such reimbursement or payment 

for treatment that the Administrator determines is not medically necessary 

or is not in accordance with such medical treatment protocols. 

‘‘(d) MEDICAL TREATMENT PROTOCOLS.— 

‘‘(1) DEVELOPMENT.—The Data Centers shall develop medical treatment protocols for the treatment of enrolled WTC responders and certified-eligible WTC 

survivors for health conditions included in the applicable list of WTC-related 

health conditions. 

‘‘(2) APPROVAL.—The medical treatment protocols developed under paragraph 

(1) shall be subject to approval by the WTC Program Administrator. 

‘‘SEC. 3313. NATIONAL ARRANGEMENT FOR BENEFITS FOR ELIGIBLE INDIVIDUALS OUTSIDE 

NEW YORK. 

‘‘(a) IN GENERAL.—In order to ensure reasonable access to benefits under this subtitle for individuals who are enrolled WTC responders, screening-eligible WTC survivors, or certified-eligible WTC survivors and who reside in any State, as defined 

in section 2(f), outside the New York metropolitan area, the WTC Program Administrator shall establish a nationwide network of health care providers to provide monitoring and treatment benefits and initial health evaluations near such individuals’ 

areas of residence in such States. Nothing in this subsection shall be construed as 

preventing such individuals from being provided such monitoring and treatment 

benefits or initial health evaluation through any Clinical Center of Excellence. 

‘‘(b) NETWORK REQUIREMENTS.—Any health care provider participating in the network under subsection (a) shall— 

‘‘(1) meet criteria for credentialing established by the Data Centers; 

‘‘(2) follow the monitoring, initial health evaluation, and treatment protocols 

developed under section 3305(a)(2)(A)(ii); 

‘‘(3) collect and report data in accordance with section 3304; and 

‘‘(4) meet such fraud, quality assurance, and other requirements as the WTC 

Program Administrator establishes, including sections 1128 through 1128E of 

the Social Security Act, as applied by section 3301(d). 

‘‘(c) TRAINING AND TECHNICAL ASSISTANCE.—The WTC Program Administer may 

provide, including through contract, for the provision of training and technical assistance to health care providers participating in the network under subsection (a). 

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‘‘PART 2—WTC SURVIVORS 

‘‘SEC. 3321. IDENTIFICATION AND INITIAL HEALTH EVALUATION OF SCREENING-ELIGIBLE 

AND CERTIFIED-ELIGIBLE WTC SURVIVORS. 

‘‘(a) IDENTIFICATION OF SCREENING-ELIGIBLE WTC SURVIVORS AND CERTIFIED-ELIGIBLE WTC SURVIVORS.— 

‘‘(1) SCREENING-ELIGIBLE WTC SURVIVORS.— 

‘‘(A) DEFINITION.—In this title, the term ‘screening-eligible WTC survivor’ 

means, subject to subparagraph (C) and paragraph (3), an individual who 

is described in any of the following clauses: 

‘‘(i) CURRENTLY IDENTIFIED SURVIVOR.—An individual, including a 

WTC responder, who has been identified as eligible for medical treatment and monitoring by the WTC Environmental Health Center as of 

the date of enactment of this title. 

‘‘(ii) SURVIVOR WHO MEETS CURRENT ELIGIBILITY CRITERIA.—An individual who is not a WTC responder, for purposes of the initial health 

evaluation under subsection (b), claims symptoms of a WTC-related 

health condition and meets any of the current eligibility criteria described in subparagraph (B). 

‘‘(iii) SURVIVOR WHO MEETS MODIFIED ELIGIBILITY CRITERIA.—An individual who is not a WTC responder, for purposes of the initial health 

evaluation under subsection (b), claims symptoms of a WTC-related 

health condition and meets such eligibility criteria relating to exposure 

to airborne toxins, other hazards, or adverse conditions resulting from 

the September 11, 2001, terrorist attacks as the WTC Administrator 

determines, after consultation with the Data Centers described in section 3305 and the WTC Scientific/Technical Advisory Committee and 

WTC Health Program Steering Committees under section 3302. 

The Administrator shall not modify such criteria under clause (iii) on or 

after the date that the number of certifications for certified-eligible WTC 

survivors under paragraph (2)(B) has reached 80 percent of the limit described in paragraph (3) or on or after the date that the number of enrollments of WTC responders has reached 80 percent of the limit described in 

section 3311(a)(4). 

‘‘(B) CURRENT ELIGIBILITY CRITERIA.—The eligibility criteria described in 

this subparagraph for an individual are that the individual is described in 

any of the following clauses: 

‘‘(i) A person who was present in the New York City disaster area 

in the dust or dust cloud on September 11, 2001. 

‘‘(ii) A person who worked, resided, or attended school, childcare, or 

adult daycare in the New York City disaster area for— 

‘‘(I) at least 4 days during the 4-month period beginning on September 11, 2001, and ending on January 10, 2002; or 

‘‘(II) at least 30 days during the period beginning on September 

11, 2001, and ending on July 31, 2002. 

‘‘(iii) Any person who worked as a cleanup worker or performed maintenance work in the New York City disaster area during the 4-month 

period described in subparagraph (B)(i) and had extensive exposure to 

WTC dust as a result of such work. 

‘‘(iv) A person who was deemed eligible to receive a grant from the 

Lower Manhattan Development Corporation Residential Grant Program, who possessed a lease for a residence or purchased a residence 

in the New York City disaster area, and who resided in such residence 

during the period beginning on September 11, 2001, and ending on May 

31, 2003. 

‘‘(v) A person whose place of employment— 

‘‘(I) 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 

‘‘(II) 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. 

‘‘(C) APPLICATION AND DETERMINATION PROCESS FOR SCREENING ELIGIBILITY.— 

‘‘(i) IN GENERAL.—The WTC Program Administrator in consultation 

with the Data Centers shall establish a process for individuals, other 

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than individuals described in subparagraph (A)(i), to be determined to 

be screening-eligible WTC survivors. Under such process— 

‘‘(I) there shall be no fee charged to the applicant for making an 

application for such determination; 

‘‘(II) the Administrator shall make a determination on such an 

application not later than 60 days after the date of filing the application; 

‘‘(III) the Administrator shall make such a determination relating to an applicant’s compliance with this title and shall not determine that an individual is not so eligible or deny written documentation under clause (ii) to such individual unless the Administrator determines that— 

‘‘(aa) based on the application submitted, the individual does 

not meet the eligibility criteria; or 

‘‘(bb) the numerical limitation on certifications of certified-eligible WTC survivors set forth in paragraph (3) has been met; 

and 

‘‘(IV) an individual who is determined not to be a screening-eligible WTC survivor shall have an opportunity to appeal such determination in a manner established under such process. 

‘‘(ii) WRITTEN DOCUMENTATION OF SCREENING-ELIGIBILITY.— 

‘‘(I) IN GENERAL.—In the case of an individual who is described 

in subparagraph (A)(i) or who is determined under clause (i) (consistent with paragraph (3)) to be a screening-eligible WTC survivor, 

the WTC Program Administrator shall provide an appropriate written documentation of such fact. 

‘‘(II) TIMING.— 

‘‘(aa) CURRENTLY IDENTIFIED SURVIVORS.—In the case of an 

individual who is described in subparagraph (A)(i), the WTC 

Program Administrator shall provide the written documentation under subclause (I) not later than July 1, 2011. 

‘‘(bb) OTHER MEMBERS.—In the case of another individual 

who is determined under clause (i) and consistent with paragraph (3) to be a screening-eligible WTC survivor, the WTC 

Program Administrator shall provide the written documentation under subclause (I) at the time of such determination. 

‘‘(2) CERTIFIED-ELIGIBLE WTC SURVIVORS.— 

‘‘(A) DEFINITION.—The term ‘certified-eligible WTC survivor’ means, subject to paragraph (3), a screening-eligible WTC survivor who the WTC Program Administrator certifies under subparagraph (B) to be eligible for followup monitoring and treatment under this part. 

‘‘(B) CERTIFICATION OF ELIGIBILITY FOR MONITORING AND TREATMENT.— 

‘‘(i) IN GENERAL.—The WTC Program Administrator shall establish a 

certification process under which the Administrator shall provide appropriate certification to screening-eligible WTC survivors who, pursuant to the initial health evaluation under subsection (b), are determined to be eligible for followup monitoring and treatment under this 

part. 

‘‘(ii) TIMING.— 

‘‘(I) CURRENTLY IDENTIFIED SURVIVORS.—In the case of an individual who is described in paragraph (1)(A)(i), the WTC Program 

Administrator shall provide the certification under clause (i) not 

later than July 1, 2011. 

‘‘(II) OTHER MEMBERS.—In the case of another individual who is 

determined under clause (i) to be eligible for followup monitoring 

and treatment, the WTC Program Administrator shall provide the 

certification under such clause at the time of such determination. 

‘‘(3) NUMERICAL LIMITATION ON CERTIFIED-ELIGIBLE WTC SURVIVORS.— 

‘‘(A) IN GENERAL.—The total number of individuals not described in paragraph (1)(A)(i) who may be certified as certified-eligible WTC survivors 

under paragraph (2)(B) shall not exceed 25,000 at any time. 

‘‘(B) PROCESS.—In implementing subparagraph (A), the WTC Program 

Administrator shall— 

‘‘(i) limit the number of certifications provided under paragraph 

(2)(B)— 

‘‘(I) in accordance with such subparagraph; and 

‘‘(II) to such number, as determined by the Administrator based 

on the best available information and subject to amounts made 

available under section 3351, that will ensure sufficient funds will 

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be available to provide treatment and monitoring benefits under 

this title, with respect to all individuals receiving such certifications through the end of fiscal year 2020; and 

‘‘(ii) provide priority in such certifications in the order in which individuals apply for a determination under paragraph (2)(B). 

‘‘(4) DISQUALIFICATION OF INDIVIDUALS ON TERRORIST WATCH LIST.—No individual who is on the terrorist watch list maintained by the Department of 

Homeland Security shall qualify as a screening-eligible WTC survivor or a certified-eligible WTC survivor. Before determining any individual to be a screening-eligible WTC survivor under paragraph (1) or certifying any individual as 

a certified eligible WTC survivor under paragraph (2), the Administrator, in 

consultation with the Secretary of Homeland Security, shall determine whether 

the individual is on such list. 

‘‘(b) INITIAL HEALTH EVALUATION TO DETERMINE ELIGIBILITY FOR FOLLOWUP MON- ITORING OR TREATMENT.— ‘‘(1) IN GENERAL.—In the case of a screening-eligible WTC survivor, the WTC 

Program shall provide for an initial health evaluation to determine if the survivor has a WTC-related health condition and is eligible for followup monitoring 

and treatment benefits under the WTC Program. Initial health evaluation protocols under section 3305(a)(2)(A)(ii) shall be subject to approval by the WTC 

Program Administrator. 

‘‘(2) INITIAL HEALTH EVALUATION PROVIDERS.—The initial health evaluation 

described in paragraph (1) shall be provided through a Clinical Center of Excellence with respect to the individual involved. 

‘‘(3) LIMITATION ON INITIAL HEALTH EVALUATION BENEFITS.—Benefits for an 

initial health evaluation under this part for a screening-eligible WTC survivor 

shall consist only of a single medical initial health evaluation consistent with 

initial health evaluation protocols described in paragraph (1). Nothing in this 

paragraph shall be construed as preventing such an individual from seeking additional medical initial health evaluations at the expense of the individual. 

‘‘SEC. 3322. FOLLOWUP MONITORING AND TREATMENT OF CERTIFIED-ELIGIBLE WTC SURVIVORS FOR WTC-RELATED HEALTH CONDITIONS. 

‘‘(a) IN GENERAL.—Subject to subsection (b), the provisions of sections 3311 and 

3312 shall apply to followup monitoring and treatment of WTC-related health conditions for certified-eligible WTC survivors in the same manner as such provisions 

apply to the monitoring and treatment of WTC-related health conditions for enrolled 

WTC responders. 

‘‘(b) LIST OF WTC-RELATED HEALTH CONDITIONS FOR SURVIVORS.—The list of 

health conditions for screening-eligible WTC survivors and certified-eligible WTC 

survivors consists of the following: 

‘‘(1) AERODIGESTIVE DISORDERS.— ‘‘(A) Interstitial lung diseases. 

‘‘(B) Chronic respiratory disorder—fumes/vapors. 

‘‘(C) Asthma. 

‘‘(D) Reactive airways dysfunction syndrome (RADS). 

‘‘(E) WTC-exacerbated chronic obstructive pulmonary disease (COPD). 

‘‘(F) Chronic cough syndrome. 

‘‘(G) Upper airway hyperreactivity. 

‘‘(H) Chronic rhinosinusitis. 

‘‘(I) Chronic nasopharyngitis. 

‘‘(J) Chronic laryngitis. 

‘‘(K) Gastroesophageal reflux disorder (GERD). 

‘‘(L) Sleep apnea exacerbated by or related to a condition described in a 

previous clause. 

‘‘(2) MENTAL HEALTH CONDITIONS.— ‘‘(A) Posttraumatic stress disorder (PTSD). 

‘‘(B) Major depressive disorder. 

‘‘(C) Panic disorder. 

‘‘(D) Generalized anxiety disorder. 

‘‘(E) Anxiety disorder (not otherwise specified). 

‘‘(F) Depression (not otherwise specified). 

‘‘(G) Acute stress disorder. 

‘‘(H) Dysthymic disorder. 

‘‘(I) Adjustment disorder. 

‘‘(J) Substance abuse. 

‘‘(3) ADDITIONAL CONDITIONS.—Any cancer (or type of cancer) or other condition added to the list in section 3312(a)(3) pursuant to paragraph (5) or (6) of 

section 3312(a), as such provisions are applied under subsection (a) with respect 

to certified-eligible WTC survivors. 

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‘‘SEC. 3323. FOLLOWUP MONITORING AND TREATMENT OF OTHER INDIVIDUALS WITH WTCRELATED HEALTH CONDITIONS. 

‘‘(a) IN GENERAL.—Subject to subsection (c), the provisions of section 3322 shall 

apply to the followup monitoring and treatment of WTC-related health conditions 

in the case of individuals described in subsection (b) in the same manner as such 

provisions apply to the followup monitoring and treatment of WTC-related health 

conditions for certified-eligible WTC survivors. 

‘‘(b) INDIVIDUALS DESCRIBED.—An individual described in this subsection is an individual who, regardless of location of residence— 

‘‘(1) is not an enrolled WTC responder or a certified-eligible WTC survivor; 

and 

‘‘(2) is diagnosed at a Clinical Center of Excellence with a WTC-related health 

condition for certified-eligible WTC survivors. 

‘‘(c) LIMITATION.— 

‘‘(1) IN GENERAL.—The WTC Program Administrator shall limit benefits for 

any fiscal year under subsection (a) in a manner so that payments under this 

section for such fiscal year do not exceed the amount specified in paragraph (2) 

for such fiscal year. 

‘‘(2) LIMITATION.—The amount specified in this paragraph for— 

‘‘(A) the last calendar quarter of fiscal year 2011 is $5,000,000; 

‘‘(B) fiscal year 2012 is $20,000,000; or 

‘‘(C) a succeeding fiscal year is the amount specified in this paragraph for 

the previous fiscal year increased by the annual percentage increase in the 

medical care component of the consumer price index for all urban consumers. 

‘‘PART 3—PAYOR PROVISIONS 

‘‘SEC. 3331. PAYMENT OF CLAIMS. 

‘‘(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 

parts 1 and 2 of this subtitle shall be paid for by the WTC Program from the World 

Trade Center Health Program Fund. 

‘‘(b) WORKERS’ COMPENSATION PAYMENT.— 

‘‘(1) IN GENERAL.—Subject to paragraph (2), payment for treatment under 

parts 1 and 2 of this subtitle 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 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 to the Secretary (with respect to such a law or plan and 

an individual entitled to benefits under title XVIII of such Act) 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 title. 

‘‘(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 title 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) the provisions of section 1862(b) 

of the Social Security Act 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 

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Act. 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 title 

to the extent that they are covered under the WTC Program. The program 

under this title shall not be treated as a legally liable party for purposes of applying section 1902(a)(25) of the Social Security Act. 

‘‘(2) RECOVERY BY INDIVIDUAL PROVIDERS.—Nothing in paragraph (1) shall be 

construed as requiring an entity providing monitoring and treatment under this 

title 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 title 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 Internal Revenue Code of 1986) 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 3351 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 

the last calendar quarter of fiscal year 2011 and each calendar quarter in 

fiscal years 2012 through 2020 the full contribution amount under this subparagraph shall be equal to 10 percent of the expenditures in carrying out 

this title for the respective quarter. 

‘‘(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 the date of the enactment of this title. 

‘‘(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 may be recoverable in an 

action brought under section 1862(b)(2)(B)(iii) of such Act. 

‘‘(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 3351. 

‘‘(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; 

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‘‘(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 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 3311(a)(4) or 3321(a)(3) 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. 

‘‘SEC. 3332. ADMINISTRATIVE ARRANGEMENT AUTHORITY. 

‘‘The WTC Program Administrator may enter into arrangements with other government agencies, insurance companies, or other third-party administrators to provide for timely and accurate processing of claims under sections 3312, 3313, 3322, 

and 3323. 

‘‘Subtitle C—Research Into Conditions 

‘‘SEC. 3341. RESEARCH REGARDING CERTAIN HEALTH CONDITIONS RELATED TO SEPTEMBER 

11 TERRORIST ATTACKS. 

‘‘(a) IN GENERAL.—With respect to individuals, including enrolled WTC responders 

and certified-eligible WTC survivors, receiving monitoring or treatment under subtitle B, the WTC Program Administrator shall conduct or support— 

‘‘(1) research on physical and mental health conditions that may be related 

to the September 11, 2001, terrorist attacks; 

‘‘(2) research on diagnosing WTC-related health conditions of such individuals, in the case of conditions for which there has been diagnostic uncertainty; 

and 

‘‘(3) research on treating WTC-related health conditions of such individuals, 

in the case of conditions for which there has been treatment uncertainty. 

The Administrator may provide such support through continuation and expansion 

of research that was initiated before the date of the enactment of this title and 

through the World Trade Center Health Registry (referred to in section 3342), 

through a Clinical Center of Excellence, or through a Data Center. 

‘‘(b) TYPES OF RESEARCH.—The research under subsection (a)(1) shall include epidemiologic and other research studies on WTC-related health conditions or emerging 

conditions— 

‘‘(1) among enrolled WTC responders and certified-eligible WTC survivors 

under treatment; and 

‘‘(2) in sampled populations outside the New York City disaster area in Manhattan as far north as 14th Street and in Brooklyn, along with control populations, to identify potential for long-term adverse health effects in less exposed 

populations. 

‘‘(c) CONSULTATION.—The WTC Program Administrator shall carry out this section 

in consultation with the WTC Scientific/Technical Advisory Committee. 

‘‘(d) APPLICATION OF PRIVACY AND HUMAN SUBJECT PROTECTIONS.—The privacy 

and human subject protections applicable to research conducted under this section 

shall not be less than such protections applicable to research conducted or funded 

by the Department of Health and Human Services. 

‘‘SEC. 3342. WORLD TRADE CENTER HEALTH REGISTRY. 

‘‘For the purpose of ensuring ongoing data collection relating to victims of the September 11, 2001, terrorist attacks, the WTC Program Administrator shall ensure 

that a registry of such victims is maintained that is at least as comprehensive as 

the World Trade Center Health Registry maintained under the arrangements in effect as of April 20, 2009, with the New York City Department of Health and Mental 

Hygiene. 

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‘‘Subtitle D—Funding 

‘‘SEC. 3351. WORLD TRADE CENTER HEALTH PROGRAM FUND. 

‘‘(a) ESTABLISHMENT OF FUND.— 

‘‘(1) IN GENERAL.—There is established a fund to be known as the World 

Trade Center Health Program Fund (referred to in this section as the ‘Fund’). 

‘‘(2) FUNDING.—Out of any money in the Treasury not otherwise appropriated, 

there shall be deposited into the Fund for each of fiscal years 2012 through 

2020 (and the last calendar quarter of fiscal year 2011)— 

‘‘(A) the Federal share, consisting of an amount equal to the lesser of— 

‘‘(i) 90 percent of the expenditures in carrying out this title for the 

respective fiscal year (initially based on estimates, subject to subsequent reconciliation based on actual expenditures); or 

‘‘(ii) $71,000,000 for the last calendar quarter of fiscal year 2011, 

$318,000,000 for fiscal year 2012, $354,000,000 for fiscal year 2013, 

$382,000,000 for fiscal year 2014, $431,000,000 for fiscal year 2015, 

$481,000,000 for fiscal year 2016, $537,000,000 for fiscal year 2017, 

$601,000,000 for fiscal year 2018, $672,000,000 for fiscal year 2019, and 

$743,000,000 for fiscal year 2020; plus 

‘‘(B) the New York City share, consisting of the amount contributed under 

the contract under section 3331(d). 

‘‘(3) CONTRACT REQUIREMENT.— 

‘‘(A) IN GENERAL.—No funds may be disbursed from the Fund unless New 

York City has entered into a contract with the WTC Program Administrator 

under section 3331(d)(1). 

‘‘(B) BREACH OF CONTRACT.— In the case of a failure to pay the amount 

so required under the contract— 

‘‘(i) the amount is recoverable under subparagraph (E)(ii) of such section; 

‘‘(ii) such failure shall not affect the disbursement of amounts from 

the Fund; and 

‘‘(iii) the Federal share described in paragraph (2)(A) shall not be increased by the amount so unpaid. 

‘‘(b) MANDATORY FUNDS FOR MONITORING, INITIAL HEALTH EVALUATIONS, TREATMENT, AND CLAIMS PROCESSING.— 

‘‘(1) IN GENERAL.—The amounts deposited into the Fund under subsection 

(a)(2) shall be available, without further appropriation, consistent with paragraph (2) and subsection (c), to carry out subtitle B and sections 3302(a), 3303, 

3304, 3305(a)(2), 3305(c), 3341, and 3342. 

‘‘(2) LIMITATION ON MANDATORY FUNDING.—This title does not establish any 

Federal obligation for payment of amounts in excess of the amounts available 

from the Fund for such purpose. 

‘‘(3) LIMITATION ON AUTHORIZATION FOR FURTHER APPROPRIATIONS.—This title 

does not establish any authorization for appropriation of amounts in excess of 

the amounts available from the Fund under paragraph (1). 

‘‘(c) LIMITS ON SPENDING FOR CERTAIN PURPOSES.—Of the amounts made available under subsection (b)(1), not more than each of the following amounts may be 

available for each of the following purposes: 

‘‘(1) SURVIVING IMMEDIATE FAMILY MEMBERS OF FIREFIGHTERS.—For the purposes of carrying out subtitle B with respect to WTC responders described in 

section 3311(a)(2)(A)(ii)— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $100,000; 

‘‘(B) for fiscal year 2012, $400,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year. 

‘‘(2) WTC HEALTH PROGRAM SCIENTIFIC/TECHNICAL ADVISORY COMMITTEE.—For 

the purpose of carrying out section 3302(a)— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $25,000; 

‘‘(B) for fiscal year 2012, $100,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year. 

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25 

‘‘(3) EDUCATION AND OUTREACH.—For the purpose of carrying out section 

3303— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $500,000; 

‘‘(B) for fiscal year 2012, $2,000,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year. 

‘‘(4) UNIFORM DATA COLLECTION.—For the purpose of carrying out section 

3304 and for reimbursing Data Centers (as defined in section 3305(b)(2)) for the 

costs incurred by such Centers in carrying out activities under contracts entered 

into under section 3305(a)(2)— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $2,500,000; 

‘‘(B) for fiscal year 2012, $10,000,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year. 

‘‘(5) RESEARCH REGARDING CERTAIN HEALTH CONDITIONS.—For the purpose of 

carrying out section 3341— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $3,750,000; 

‘‘(B) for fiscal year 2012, $15,000,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year. 

‘‘(6) WORLD TRADE CENTER HEALTH REGISTRY.—For the purpose of carrying 

out section 3342— 

‘‘(A) for the last calendar quarter of fiscal year 2011, $1,750,000; 

‘‘(B) for fiscal year 2012, $7,000,000; and 

‘‘(C) for each subsequent fiscal year, the amount specified under this 

paragraph for the previous fiscal year increased by the percentage increase 

in the consumer price index for all urban consumers (all items; United 

States city average) as estimated by the Secretary for the 12-month period 

ending with March of the previous year.’’. 

TITLE II—SEPTEMBER 11TH VICTIM 

COMPENSATION FUND OF 2001 

SEC. 201. DEFINITIONS. 

Section 402 of the Air Transportation Safety and System Stabilization Act (49 

U.S.C. 40101 note) is amended— 

(1) in paragraph (6) by inserting ‘‘, or debris removal, including under the 

World Trade Center Health Program established under section 3001 of the Public Health Service Act,’’ after ‘‘September 11, 2001’’; 

(2) by inserting after paragraph (6) the following new paragraphs and redesignating subsequent paragraphs accordingly: 

‘‘(7) CONTRACTOR AND SUBCONTRACTOR.—The term ‘contractor and subcontractor’ means any contractor or subcontractor (at any tier of a subcontracting 

relationship), including any general contractor, construction manager, prime 

contractor, consultant, or any parent, subsidiary, associated or allied company, 

affiliated company, corporation, firm, organization, or joint venture thereof that 

participated in debris removal at any 9/11 crash site. Such term shall not include any entity, including the Port Authority of New York and New Jersey, 

with a property interest in the World Trade Center, on September 11, 2001, 

whether fee simple, leasehold or easement, direct or indirect. 

‘‘(8) DEBRIS REMOVAL.—The term ‘debris removal’ means rescue and recovery 

efforts, removal of debris, cleanup, remediation, and response during the immediate aftermath of the terrorist-related aircraft crashes of September 11, 2001, 

with respect to a 9/11 crash site.’’; 

(3) by inserting after paragraph (10), as so redesignated, the following new 

paragraph and redesignating the subsequent paragraphs accordingly: 

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26 

‘‘(11) IMMEDIATE AFTERMATH.—The term ‘immediate aftermath’ means any period beginning with the terrorist-related aircraft crashes of September 11, 2001, 

and ending on August 30, 2002.’’; and 

(4) by adding at the end the following new paragraph: 

‘‘(14) 9/11 CRASH SITE.—The term ‘9/11 crash site’ means— 

‘‘(A) the World Trade Center site, Pentagon site, and Shanksville, Pennsylvania site; 

‘‘(B) the buildings or portions of buildings that were destroyed as a result 

of the terrorist-related aircraft crashes of September 11, 2001; 

‘‘(C) any area contiguous to a site of such crashes that the Special Master 

determines was sufficiently close to the site that there was a demonstrable 

risk of physical harm resulting from the impact of the aircraft or any subsequent fire, explosions, or building collapses (including the immediate area 

in which the impact occurred, fire occurred, portions of buildings fell, or debris fell upon and injured individuals); and 

‘‘(D) any area related to, or along, routes of debris removal, such as 

barges and Fresh Kills.’’. 

SEC. 202. EXTENDED AND EXPANDED ELIGIBILITY FOR COMPENSATION. 

(a) INFORMATION ON LOSSES RESULTING FROM DEBRIS REMOVAL INCLUDED IN

CONTENTS OF CLAIM FORM.—Section 405(a)(2)(B) of the Air Transportation Safety 

and System Stabilization Act (49 U.S.C. 40101 note) is amended— 

(1) in clause (i), by inserting ‘‘, or debris removal during the immediate aftermath’’ after ‘‘September 11, 2001’’; 

(2) in clause (ii), by inserting ‘‘or debris removal during the immediate aftermath’’ after ‘‘crashes’’; and 

(3) in clause (iii), by inserting ‘‘or debris removal during the immediate aftermath’’ after ‘‘crashes’’. 

(b) EXTENSION OF DEADLINE FOR CLAIMS UNDER SEPTEMBER 11TH VICTIM COMPENSATION FUND OF 2001.—Section 405(a)(3) of such Act is amended to read as follows: 

‘‘(3) LIMITATION.— 

‘‘(A) IN GENERAL.—Except as provided by subparagraph (B), no claim may 

be filed under paragraph (1) after the date that is 2 years after the date 

on which regulations are promulgated under section 407(a). 

‘‘(B) EXCEPTION.—A claim may be filed under paragraph (1), in accordance with subsection (c)(3)(A)(i), by an individual (or by a personal representative on behalf of a deceased individual) during the period beginning 

on the date on which the regulations are updated under section 407(b) and 

ending on December 22, 2031.’’. 

(c) REQUIREMENTS FOR FILING CLAIMS DURING EXTENDED FILING PERIOD.—Section 405(c)(3) of such Act is amended— 

(1) by redesignating subparagraphs (A) and (B) as subparagraphs (B) and (C), 

respectively; and 

(2) by inserting before subparagraph (B), as so redesignated, the following 

new subparagraph: 

‘‘(A) REQUIREMENTS FOR FILING CLAIMS DURING EXTENDED FILING PERIOD.— 

‘‘(i) TIMING REQUIREMENTS FOR FILING CLAIMS.—An individual (or a 

personal representative on behalf of a deceased individual) may file a 

claim during the period described in subsection (a)(3)(B) as follows: 

‘‘(I) In the case that the Special Master determines the individual 

knew (or reasonably should have known) before the date specified 

in clause (iii) that the individual suffered a physical harm at a 9/ 

11 crash site as a result of the terrorist-related aircraft crashes of 

September 11, 2001, or as a result of debris removal, and that the 

individual knew (or should have known) before such specified date 

that the individual was eligible to file a claim under this title, the 

individual may file a claim not later than the date that is 2 years 

after such specified date. 

‘‘(II) In the case that the Special Master determines the individual first knew (or reasonably should have known) on or after the 

date specified in clause (iii) that the individual suffered such a 

physical harm or that the individual first knew (or should have 

known) on or after such specified date that the individual was eligible to file a claim under this title, the individual may file a claim 

not later than the last day of the 2-year period beginning on the 

date the Special Master determines the individual first knew (or 

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27 

should have known) that the individual both suffered from such 

harm and was eligible to file a claim under this title. 

‘‘(ii) OTHER ELIGIBILITY REQUIREMENTS FOR FILING CLAIMS.—An individual may file a claim during the period described in subsection 

(a)(3)(B) only if— 

‘‘(I) the individual was treated by a medical professional for suffering from a physical harm described in clause (i)(I) within a reasonable time from the date of discovering such harm; and 

‘‘(II) the individual’s physical harm is verified by contemporaneous medical records created by or at the direction of the medical 

professional who provided the medical care. 

‘‘(iii) DATE SPECIFIED.—The date specified in this clause is the date 

on which the regulations are updated under section 407(a).’’. 

(d) CLARIFYING APPLICABILITY TO ALL 9/11 CRASH SITES.—Section 405(c)(2)(A)(i) 

of such Act is amended by striking ‘‘or the site of the aircraft crash at Shanksville, 

Pennsylvania’’ and inserting ‘‘the site of the aircraft crash at Shanksville, Pennsylvania, or any other 9/11 crash site’’. 

(e) INCLUSION OF PHYSICAL HARM RESULTING FROM DEBRIS REMOVAL.—Section 

405(c) of such Act is amended in paragraph (2)(A)(ii), by inserting ‘‘or debris removal’’ after ‘‘air crash’’. 

(f) LIMITATIONS ON CIVIL ACTIONS.— (1) APPLICATION TO DAMAGES RELATED TO DEBRIS REMOVAL.—Clause (i) of section 405(c)(3)(C) of such Act, as redesignated by subsection (c), is amended by 

inserting ‘‘, or for damages arising from or related to debris removal’’ after ‘‘September 11, 2001’’. 

(2) PENDING ACTIONS.—Clause (ii) of such section, as so redesignated, is 

amended to read as follows: 

‘‘(ii) PENDING ACTIONS.—In the case of an individual who is a party 

to a civil action described in clause (i), such individual may not submit 

a claim under this title— 

‘‘(I) during the period described in subsection (a)(3)(A) unless 

such individual withdraws from such action by the date that is 90 

days after the date on which regulations are promulgated under 

section 407(a); and 

‘‘(II) during the period described in subsection (a)(3)(B) unless 

such individual withdraws from such action by the date that is 90 

days after the date on which the regulations are updated under 

section 407(b).’’. 

(3) AUTHORITY TO REINSTITUTE CERTAIN LAWSUITS.—Such section, as so redesignated, is further amended by adding at the end the following new clause: 

‘‘(iii) AUTHORITY TO REINSTITUTE CERTAIN LAWSUITS.—In the case of 

a claimant who was a party to a civil action described in clause (i), who 

withdrew from such action pursuant to clause (ii), and who is subsequently determined to not be an eligible individual for purposes of this 

subsection, such claimant may reinstitute such action without prejudice 

during the 90-day period beginning after the date of such ineligibility 

determination.’’. 

SEC. 203. REQUIREMENT TO UPDATE REGULATIONS. 

Section 407 of the Air Transportation Safety and System Stabilization Act (49 

U.S.C. 40101 note) is amended— 

(1) by striking ‘‘Not later than’’ and inserting ‘‘(a) IN GENERAL.—Not later 

than’’; and 

(2) by adding at the end the following new subsection: 

‘‘(b) UPDATED REGULATIONS.—Not later than 90 days after the date of the enactment of the James Zadroga 9/11 Health and Compensation Act of 2008, the Special 

Master shall update the regulations promulgated under subsection (a) to the extent 

necessary to comply with the provisions of title II of such Act.’’. 

SEC. 204. LIMITED LIABILITY FOR CERTAIN CLAIMS. 

Section 408(a) of the Air Transportation Safety and System Stabilization Act (49 

U.S.C. 40101 note) is amended by adding at the end the following new paragraphs: 

‘‘(4) LIABILITY FOR CERTAIN CLAIMS.— 

‘‘(A) IN GENERAL.—Notwithstanding any other provision of law, subject to 

subparagraph (B), liability for all claims and actions (including claims or 

actions that have been previously resolved, that are currently pending, and 

that may be filed through December 22, 2031) for compensatory damages, 

contribution or indemnity, or any other form or type of relief, arising from 

or related to debris removal, against New York City, any entity (including 

the Port Authority of New York and New Jersey) with a property interest 

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28 

in the World Trade Center on September 11, 2001 (whether fee simple, 

leasehold or easement, or direct or indirect) and any contractors and subcontractors thereof, shall not be in an amount that exceeds the sum of the 

following: 

‘‘(i) The amount of funds of the WTC Captive Insurance Company, including the cumulative interest. 

‘‘(ii) The amount of all available insurance identified in schedule 2 of 

the WTC Captive Insurance Company insurance policy. 

‘‘(iii) The amount that is the greater of New York City’s insurance 

coverage or $350,000,000. In determining the amount of the City’s insurance coverage for purposes of the previous sentence, any amount described in clauses (i) and (ii) shall not be included. 

‘‘(iv) The amount of all available liability insurance coverage maintained by any entity, including the Port Authority of New York and 

New Jersey, with a property interest in the World Trade Center, on 

September 11, 2001, whether fee simple, leasehold or easement, or direct or indirect. 

‘‘(v) The amount of all available liability insurance coverage maintained by contractors and subcontractors. 

‘‘(B) EXCEPTION.—Subparagraph (A) shall not apply to claims or actions 

based upon conduct held to be intentionally tortious in nature or to acts of 

gross negligence or other such acts to the extent to which punitive damages 

are awarded as a result of such conduct or acts. 

‘‘(5) PRIORITY OF CLAIMS PAYMENTS.—Payments to plaintiffs who obtain a settlement or judgment with respect to a claim or action to which paragraph (4)(A) 

applies, shall be paid solely from the following funds in the following order: 

‘‘(A) The funds described in clause (i) or (ii) of paragraph (4)(A). 

‘‘(B) If there are no funds available as described in clause (i) or (ii) of 

paragraph (4)(A), the funds described in clause (iii) of such paragraph. 

‘‘(C) If there are no funds available as described in clause (i), (ii), or (iii) 

of paragraph (4)(A), the funds described in clause (iv) of such paragraph. 

‘‘(D) If there are no funds available as described in clause (i), (ii), (iii), 

or (iv) of paragraph (4)(A), the funds described in clause (v) of such paragraph. 

‘‘(6) DECLARATORY JUDGMENT ACTIONS AND DIRECT ACTION.—Any party to a 

claim or action to which paragraph (4)(A) applies may, with respect to such 

claim or action, either file an action for a declaratory judgment for insurance 

coverage or bring a direct action against the insurance company involved.’’. 

PURPOSE AND SUMMARY

Title I of H.R. 847, the James Zadroga 9/11 Health and Compensation Act of 2010, amends the Public Health Service Act to 

provide monitoring and treatment services to individuals with 

health conditions resulting from the September 11, 2001, terrorist 

attacks at the World Trade Center (WTC), the Pentagon, and 

Shanksville, Pennsylvania, including rescue personnel, workers 

who participated in clean-up, and residents and others present in 

the area near the World Trade Center. Title II of H.R. 847 amends 

the Air Transportation Safety and System Stabilization Act to reopen the September 11 Victim Compensation Fund of 2001 to provide monetary compensation to eligible individuals for physical 

harm resulting from the terrorist attacks. 

BACKGROUND AND NEED FOR LEGISLATION

THE TERRORIST ATTACKS OF SEPTEMBER 11, 2001

On September 11, 2001, terrorists flying four airplanes attacked 

the United States. One plane flew into the Pentagon, one crashed 

in a field in Shanksville, Pennsylvania, en route to Washington, 

D.C., and two planes were crashed into the World Trade Center 

Twin Towers in New York City. 

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1Testimony of Jacqueline Moline, M.D. M. Sc., Director, World Trade Center Medical Monitoring and Treatment Program at Mount Sinai School of Medicine, before the House Committee 

on Energy and Commerce Subcommittee on Health, Hearing on H.R. 847 (Apr. 22, 2009). 2Landrigan et al., Health and Environmental Consequences of the World Trade Center Disaster, Environ Health Perspect, pp. 731–739 (2004). 3 Aldrich et al., Lung Function in Rescue Workers at the World Trade Center after 7 Years, 

New England Journal of Medicine (April 8, 2010), pp. 1263–1272. 4 Banauch et al., Pulmonary Function after Exposure to the World Trade Center in the New 

York City Fire Department, Am J Respir Crit Care Med, pp. 312–319 (2006). 

The resulting collapse of the Twin Towers (and a third building) 

killed more than 2,751 people, including 343 firefighters and rescue 

workers. It also produced ‘‘a complex and unprecedented mix of 

toxic chemicals.’’ 1 Burning jet fuel resulted in a plume of black 

smoke containing benzene, metals, and polycyclic aromatic hydrocarbons. From the wreckage of the Twin Towers arose an enormous 

dust cloud consisting of pulverized cement, microscopic glass fibers 

and shards, asbestos, lead, hydrochloric acid, polychlorinated 

biphenyls (PCBs), organochlorine pesticides, furans, and dioxins. 

The pulverized cement accounted for 60% to 65% of the total dust 

mass, making it extremely caustic, with a pH between 9 and 11 

similar to lye.2

An estimated 60,000 to 70,000 first responders and volunteers 

from all 50 states converged on the World Trade Center site to help 

in the rescue and recovery and debris removal and clean-up efforts. 

Some of these responders worked at the site for days, weeks, and 

even months. Fires burned above and below ground until December 

2001. The debris removal and cleanup continued until May 2002. 

During much of this time, the air around the site remained toxic. 

Exposure to the dust and toxic chemicals, and to the death and 

devastation at the site, had long-term health effects on the responders and on those who returned to the area around the site to 

live and to work. The Subcommittee on Health heard testimony 

from the Director of the World Trade Center Medical Monitoring 

and Treatment Program at the Mount Sinai School of Medicine 

that the following conditions were common among the responders 

being treated there: sinus disorders, asthma, gastro-esophageal 

reflux disorder, post-traumatic stress disorder (PTSD), and major 

depression. A study recently published in the New England Journal of Medicine reported that firefighters and EMS workers who 

were at the World Trade Center site during the first two weeks 

after the attacks lost about 10% of their lung function in the first 

year, and that this loss persisted during the subsequent 6 years.3

This decrease in ventilatory function is equivalent to 12 years of 

age-related decline.4

THE WORLD TRADE CENTER HEALTH PROGRAMS

The World Trade Center Health Programs provide medical 

screening, monitoring, and treatment services for responders as 

well as for non-responders who resided, worked, or went to school 

in the community directly affected by the September 11, 2001, attacks. The programs are administered by the National Institute for 

Occupational Safety and Health (NIOSH), an agency of the Centers 

for Disease Control and Prevention (CDC) within the Department 

of Health and Human Services (HHS). NIOSH supports six clinical 

centers and two data coordination centers as well as the WTC 

Health Registry. A total of $71 million is appropriated in FY2010 

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30 

5http://www.cdc.gov/niosh/topics/wtc/SciSumAllByYear.html. 

to support these activities. The President’s budget requests $150 

million in FY2011. Since FY2003, a total of $326 million has been 

obligated for these purposes. 

There are three WTC Responder programs: a program operated 

by the Fire Department of New York (FDNY); a consortium coordinated by Mt. Sinai School of Medicine; and a national program for 

responders outside of the New York City/New Jersey metropolitan 

area managed by Logistics Health, Inc., under contract to NIOSH. 

As of March 31, 2010, a total of 52,700 individuals were enrolled 

in the WTC Responders programs (about 4,500 of these were enrolled in the national program). During the previous year, 24,100 

of these enrolled responders received monitoring exams, and 13,300 

received treatment through five clinical centers of excellence: Bellevue Hospital/New York University School of Medicine; City University of New York/Queens College; Mount Sinai School of Medicine; 

State University of New York at Stony Brook; and the University 

of Medicine and Dentistry of New Jersey/Robert Wood Johnson 

Medical School. These clinical centers are supported by two data 

and coordination centers: one located at the FDNY, the other at 

Mt. Sinai. The Responder programs have been funded by the federal government since FY2003; in FY2009, $104 million was obligated for this purpose. 

Federal funding for the WTC Community Program began in September 2008. The program is operated by the New York City 

Health and Hospitals Corporation through three locations: Bellevue 

Hospital Center on the East Side of Manhattan; Gouverneur 

Healthcare Services in Lower Manhattan; and Elmhurst Hospital 

in Queens. About 4,600 individuals were enrolled in the WTC Community Program as of March 31, 2010. Of these, 1,200 received 

monitoring exams and 2,600 received treatment during the previous year. In FY2009, $10 million was obligated for the Community Program. 

In addition to providing initial screening, monitoring, and treatment services, the WTC Health Programs have supported research 

on the health effects of exposure to the toxic dust cloud by rescue 

workers and others at the World Trade Center site. This developing 

science is used to inform the treatment of enrollees in the Responder and Community programs and is posted on the NIOSH 

website.5 In addition, the New York City Department of Health 

and Mental Hygiene established the WTC Health Registry, which 

includes individuals at risk for possible near and long term physical and mental health effects from the attacks. Before it closed to 

new registrants in 2004, the WTC Health Registry had enrolled 

more than 70,000 residents, workers, students, and responders. 

NIOSH funding helps to support the Registry. 

NEED FOR LEGISLATION

The WTC Health Programs currently funded by the federal government are not authorized in statute. That is, there is no legislation authorizing the appropriation of funds to NIOSH to support 

these programs. The absence of such legislation has not precluded—and should not preclude—the funding of these programs. 

It is far preferable, however, for Congress to set forth in an authormstockstill on DSKH9S0YB1PROD with HEARINGS

31 

izing statute the purpose and scope of the programs needed, the individuals intended to be assisted, and the resources necessary. An 

authorizing statute can improve accountability of the agency responsible for administering the programs, transparency in operation, and stability of funding over time. 

In the case of the September 11, 2001, terrorist attacks, the need 

for monitoring and treatment will not end this fiscal year or anytime in the near future. The evidence from the current WTC 

Health Program is overwhelming: many responders and non-responders in the affected communities have developed complex 

health conditions resulting from exposures at the sites of the attacks that require specialized treatment, and more health conditions requiring such treatment are likely to emerge among these 

populations in the future. 

The September 11, 2001, terrorist attacks at the Pentagon, the 

World Trade Center, and Shanksville were an attack on this nation. The Committee believes the federal government has a moral 

obligation to ensure that those who participated in the rescue and 

recovery and debris removal and clean-up operations at these sites 

receive the services necessary to treat the health conditions resulting from their participation. In the case of the World Trade Center 

site, this obligation extends to those who returned to the affected 

neighborhoods shortly after the attack to live, work, and go to 

school and, as a result, were exposed to the toxic dust. 

To fulfill this moral obligation, the federal government must 

make a long-term commitment to the monitoring and treatment of 

health and mental health conditions resulting from the terrorist attacks. The Committee bill represents that commitment. 

The bill would amend the Public Health Service Act to establish 

a new World Trade Center Health Program to monitor and treat 

the health conditions developed by responders and community residents as the result of the September 11, 2001, attacks. The new 

WTC Program, to be administered primarily by NIOSH, would 

build upon and improve the existing WTC health programs. The 

federal government would provide funding on a mandatory basis 

over the next 10 years for 90% of the costs of operating the new 

program. The remaining 10% of the costs of the program would be 

the responsibility of New York City. 

The federal government’s contribution to the new program would 

not be open-ended. Federal funds would be capped at the lower of 

90% of the costs or a specified amount each fiscal year beginning 

in FY2011 and ending in FY2020. Over this 10-year period, federal 

outlays for all aspects of the new program—education and outreach, initial evaluation, monitoring, treatment, data collection, 

and research—could not exceed $4.59 billion. No federal funds 

would be available for the program after FY2020. The bill prohibits 

the disbursement of any federal funds for the program unless New 

York City has entered into an enforceable contract with the WTC 

Program Administrator in which it agrees to pay its share of program costs on a timely basis. 

The bill contains a number of provisions designed to ensure that 

federal funds committed to the WTC Program are spent efficiently 

and effectively. Payment may not be made for treatment services 

unless they are medically necessary as determined under regulations issued by the WTC Program Administrator. In addition, treatmstockstill on DSKH9S0YB1PROD with HEARINGS

32 

ment services must be consistent with protocols developed by the 

Data Centers and approved by the Administrator. Monitoring services must also be consistent with protocols approved by the Administrator in order to qualify for payment. The bill also authorizes the 

WTC Program Administrator, based on utilization and quality data 

furnished by the Clinical Centers of Excellence, to modify amounts 

and methodologies for payments to providers in order to improve 

quality and efficient delivery of services. To ensure accountability, 

the bill directs the Inspector General of HHS to review the program’s expenditures to detect fraudulent or duplicate billing, payment for inappropriate services, or unreasonable administrative 

costs. 

Finally, the bill strengthens the federal government’s commitment to uniform data collection through Data Centers designated 

by the Program Administrator, epidemiological surveillance 

through the WTC Registry, and ongoing research into health conditions that may be related to exposures to the toxic dust at the 

World Trade Center site. The bill sets aside mandatory funding, up 

to specified amounts, for these activities for each fiscal year 

through FY2020. This clinical and epidemiological data, and the research on WTC-related health conditions, will provide information 

about medical trends, patterns of disease, outcomes, and efficacy of 

treatments essential to improving the treatment of responders and 

survivors and their health outcomes. 

The September 11, 2001, attacks at the Pentagon and 

Shanksville, Pennsylvania sites have been less well documented 

than the World Trade Center site. The Office of the Secretary of 

Defense estimates that there were less than 1,000 responders in 

the first few days following the attack at the Pentagon site and approximately 3,500 individuals who participated in the cleanup of 

that site in the year after it occurred. 

LEGISLATIVE HISTORY

On February 4, 2009, Reps. Carolyn B. Maloney (D–NY) and 

Jerrold Nadler (D–NY) and other members of the New York delegation introduced H.R. 847, the ‘‘James Zadroga 9/11 Health and 

Compensation Act of 2009’’. The bill was referred to the Committee 

on Energy and Commerce, and in addition to the Committee on the 

Judiciary, for a period to be subsequently determined by the Speaker. H.R. 847 is a revision of H.R. 7174, the bill from the 110th Congress that was introduced on September 27, 2008. 

H.R. 847 was referred to the Subcommittee on Health on February 9, 2010, and a legislative hearing on the bill was held April 

22, 2009. Testimony was heard from sponsors of the legislation; a 

construction worker who volunteered to help with debris removal 

in the immediate aftermath of the attack on the World Trade Center; the Directors of the WTC Environmental Health Center at 

Bellevue Hospital and the WTC Medical Monitoring and Treatment 

Center at Mt. Sinai Medical School; and a representative from the 

City of New York. 

COMMITTEE CONSIDERATION

On March 16, 2010, the Subcommittee on Health met in open 

markup session to consider H.R. 847. Subcommittee Chairman 

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33 

Pallone offered a manager’s amendment in the form of an amendment in the nature of a substitute, which was approved by a voice 

vote. Subsequently, the Subcommittee approved a motion to forward H.R. 847, amended, favorably to the full Committee by a roll 

call vote: 25–8. 

On May 25, 2010, the Committee on Energy and Commerce met 

in open markup session to consider H.R. 847 as approved by the 

Subcommittee on Health. Chairman Waxman offered a manager’s 

amendment in the form of an amendment in the nature of a substitute. The Committee agreed to four amendments offered to the 

substitute amendment. The Committee adopted the Waxman manager’s amendment, as amended, by a voice vote. Subsequently, the 

Committee ordered H.R. 847 favorably reported to the House, 

amended, by a roll call vote: 33–12. 

COMMITTEE VOTES

Clause 3(b) of rule XIII of the Rules of the House of Representatives requires the Committee to list each record vote on the motion 

to report legislation and amendments thereto. A motion by Mr. 

Waxman to order H.R. 847 favorably reported to the House, 

amended, was approved by a record vote of 33 yeas and 12 nays. 

The following is the record vote taken during Committee consideration, including the names of those members voting for and 

against: 

mstockstill on DSKH9S0YB1PROD with HEARINGS

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mstockstill on DSKH9S0YB1PROD with HEARINGSInsert graphic folio 37 here HR560.001
35 


mstockstill on DSKH9S0YB1PROD with HEARINGSInsert graphic folio 38 here HR560.002
36 


mstockstill on DSKH9S0YB1PROD with HEARINGSInsert graphic folio 39 here HR560.003
37 


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COMMITTEE OVERSIGHT FINDINGS AND RECOMMENDATIONS

In compliance with clause 3(c)(1) of rule XIII of the Rules of the 

House of Representatives, the findings and recommendations of the 

Committee are reflected in the descriptive portions of this report. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

Regarding compliance with clause 3(c)(2) of rule XIII of the Rules 

of the House of Representatives, the Committee adopts as its own 

the estimate prepared by the Director of the Congressional Budget 

Office pursuant to section 402 of the Congressional Budget Act of 

1974. 

STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

In accordance with clause 3(c)(4) of rule XIII of the Rules of the 

House of Representatives, the performance goals and objectives of 

H.R. 847 are reflected in the descriptive portions of this report. 

CONSTITUTIONAL AUTHORITY STATEMENT

Pursuant to clause 3(d)(1) of rule XIII of the Rules of the House 

of Representatives, the Committee finds that the constitutional authority for H.R. 847 is provided in Article I, section 8, clauses 1, 

3, and 18 of the Constitution of the United States. 

EARMARKS AND TAX AND TARIFF BENEFITS

H.R. 847 does not contain any congressional earmarks, limited 

tax benefits, or limited tariff benefits as defined in clause 9 of rule 

XXI of the Rules of the House of Representatives. 

ADVISORY COMMITTEE STATEMENT

The Committee finds that the legislation establishes or authorizes the establishment of an advisory committee within the meaning of section 5 U.S.C. App., 5(b) of the Federal Advisory Committee Act. Title I of H.R. 847 provides for the creation of the WTC 

Health Program Scientific Technical Advisory Committee to review 

scientific and medical evidence and make recommendations to the 

Administrator of the WTC Health Program. The Committee finds 

that this Advisory Committee is needed to assist the Administrator 

in evaluating WTC Program eligibility criteria and whether there 

are additional WTC-related health conditions. 

APPLICABILITY OF LAW TO THE LEGISLATIVE BRANCH

The Committee finds that Title I of H.R. 847 does not relate to 

the terms and conditions of employment or access to public services 

or accommodations within the meaning of section 102(b)(3) of the 

Congressional Accountability Act of 1985. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimates of federal mandates relating to Title I of H.R. 847 prepared by the Director of the 

Congressional Budget Office pursuant to section 423 of the Unfunded Mandate Reform Act. 

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COMMITTEE COST ESTIMATE

Pursuant to clause 3(d) of rule XIII of the Rules of the House of 

Representatives, the Committee adopts as its own the cost estimate 

of Title I of H.R. 847 prepared by the Director of the Congressional 

Budget Office pursuant to section 402 of the Congressional Budget 

Act. 

CONGRESSIONAL BUDGET OFFICE ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate on H.R. 847 

provided by the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, June 25, 2010. 

Hon. HENRY A. WAXMAN, Chairman, Committee on Energy and Commerce, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 847, the James Zadroga 

9/11 Health and Compensation Act of 2010. As you requested, CBO 

has completed an estimate that reflects Title I of the bill as ordered 

reported by the Committee on Energy and Commerce and Title II 

as ordered reported by the Committee on the Judiciary. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contacts are Stephanie Cameron 

(Title I), and Leigh Angres (Title II). 

Sincerely, 

ROBERT A. SUNSHINE

(For Douglas W. Elmendorf, Director). 

Enclosure. 

H.R. 847—James Zadroga 9/11 Health and Compensation Act of 

2010 

Summary: H.R. 847 would establish the World Trade Center 

(WTC) Health Program and extend and expand eligibility for compensation under the September 11th Victim Compensation Fund 

(VCF) of 2001. Specifically, H.R. 847 would provide: 

• Health care benefits for eligible emergency personnel who 

responded to the September 11, 2001, terrorist attacks (the terrorist attacks) in New York City, the Pentagon, and 

Shanksville, Pennsylvania, and for workers who participated in 

recovery and cleanup following the attacks (collectively referred to as responders in this estimate); 

• Health care benefits for eligible residents and others 

present in the area of New York City near the World Trade 

Center (defined as survivors under the bill); and 

• Monetary compensation to individuals eligible under the 

bill to submit claims for death and physical injury claims resulting from the attacks. 

CBO estimates that enacting H.R. 847 would increase direct 

spending by $7.2 billion over the 2011–2015 period and $10.5 bilmstockstill on DSKH9S0YB1PROD with HEARINGS

48 

lion over the 2011–2020 period. Pay-as-you-go procedures apply because enacting the legislation would affect direct spending. 

In addition, we estimate that, subject to appropriation of the necessary amounts, administering the VCF awards process would cost 

$514 million over the next 10 years. However, assuming appropriation actions consistent with title I of the bill, CBO estimates a $688 

million reduction in discretionary outlays over the 2011–2020 period because some spending that is currently funded by annual appropriations would become direct spending under the bill. On balance, CBO estimates that discretionary spending would decrease by 

$174 million over 10 years. 

H.R. 847 contains no intergovernmental mandates as defined in 

the Unfunded Mandates Reform Act (UMRA). 

H.R. 847 would impose a private-sector mandate as defined in 

UMRA. The bill would impose a mandate on individuals seeking 

compensatory damages or other relief arising from or related to debris removal from sites of the terrorist attacks by limiting the liability of entities from which individuals might win compensation. 

CBO cannot determine whether the aggregate cost of complying 

with that mandate would exceed the threshold established by 

UMRA for private-sector mandates in 2011 ($141 million in 2010, 

adjusted annually for inflation). 

Estimated cost to the Federal Government: The estimated budgetary impact of H.R. 847 is shown in the following table. The costs 

of this legislation fall within budget functions 550 (health), 570 

(Medicare), and 750 (administration of justice). 

Basis of estimate: For this estimate, CBO assumes that H.R. 847 

will be enacted by the end of fiscal year 2010. H.R. 847 would provide health benefits and compensation to those who qualify based 

on a combination of factors, including where they were exposed to 

hazardous conditions following the terrorist attacks, and their current and expected future health conditions. CBO’s estimate is 

based on an analysis of the size of the potentially affected populations, the prevalence of certain health conditions in those populations, the propensity to seek health services or compensation 

from the program, and the monetary damages previously awarded 

by the VCF through 2004. 

Under H.R. 847, spending for the WTC Health Program and VCF 

awards would increase direct spending, while the administrative 

costs associated with the VCF would be subject to future appropriations. Expenditures related to the WTC Health Program would be 

subject to annual spending caps totaling about $4.6 billion through 

2020, when the program would sunset. Award payments under the 

VCF would be subject to a lifetime spending cap of $8.4 billion 

through 2032, when the program would cease operation. 

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49 

ESTIMATED BUDGETARY EFFECTS OF H.R. 847, THE JAMES ZADROGA 9/11 HEALTH AND COMPENSATION ACT OF 2010 

By fiscal year, in millions of dollars— 

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2011– 2015 2011– 2020 

CHANGES IN DIRECT SPENDING 

Title I: World Trade Center Health Program WTC Health Program: 

Estimated Budget Authority .......................................................................................................... 70 318 349 380 424 469 521 578 639 706 1,541 4,454 Estimated Outlays ......................................................................................................................... 63 306 345 376 418 464 515 571 632 698 1,508 4,388 

Medicare and Medicaid: 

Estimated Budget Authority .......................................................................................................... 0 ¥5 ¥10 ¥10 ¥10 ¥20 ¥20 ¥30 ¥40 ¥40 ¥35 ¥185 

Estimated Outlays ......................................................................................................................... 0 ¥5 ¥10 ¥10 ¥10 ¥20 ¥20 ¥30 ¥40 ¥40 ¥35 ¥185 

Subtotal, Title I: 

Estimated Budget Authority .......................................................................................................... 70 313 339 370 414 449 501 548 599 666 1,506 4,269 Estimated Outlays ......................................................................................................................... 63 301 335 366 408 444 495 541 592 658 1,473 4,203 

Title II: September 11th Victim Compensation Fund 

Estimated Budget Authority .......................................................................................................... 500 1,000 3,500 500 200 150 150 100 100 100 5,700 6,300 Estimated Outlays ......................................................................................................................... 450 950 3,250 800 230 155 150 105 100 100 5,680 6,290 

Total Changes in Direct Spending: Titles I and II 

Estimated Budget Authority .......................................................................................................... 570 1,313 3,839 870 614 599 651 648 699 766 7,206 10,569 Estimated Outlays ......................................................................................................................... 513 1,251 3,585 1,166 638 599 645 646 692 763 7,153 10,498 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Administration of the September 11th Victim Compensation Fund: 

Estimated Authorization Level ...................................................................................................... 75 100 200 100 10 10 5 5 5 5 485 515 Estimated Outlays ......................................................................................................................... 56 94 175 125 33 10 6 5 5 5 483 514 

Appropriation for NIOSH World Trade Center Health Program: 

Estimated Authorization Level ...................................................................................................... ¥71 ¥72 ¥73 ¥74 ¥75 ¥77 ¥78 ¥80 ¥81 ¥83 ¥365 ¥764 

Estimated Outlays ......................................................................................................................... ¥26 ¥60 ¥69 ¥71 ¥73 ¥75 ¥76 ¥78 ¥79 ¥81 ¥299 ¥688 

Total Changes in Discretionary Spending 

Estimated Authorization Level ...................................................................................................... 4 28 127 26 ¥65 ¥67 ¥73 ¥75 ¥76 ¥78 120 ¥249 

Estimated Outlays ......................................................................................................................... 30 34 106 54 ¥40 ¥65 70 ¥73 ¥74 ¥76 184 ¥174 

Note: NIOSH = National Institute of Occupational Safety and Health. 

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50 

On June 10, 2010, a federal district court judge approved a settlement between firefighters, police, contractors, and others who 

worked at the World Trade Center site, and New York City and its 

contractors for claims of injuries associated with their rescue and 

cleanup work. To become final, the settlement requires the participation of 95 percent of the plaintiffs, who have yet to agree to the 

terms. Should that settlement become final, CBO expects that the 

number and value of compensation awards provided through the 

VCF would be lower than presented in this cost estimate for H.R. 

847. 

Eligible Population 

CBO’s analysis focused on two populations—responders and survivors. The responder population includes those who were involved 

in the rescue, recovery, and cleanup efforts following the terrorist 

attacks in 2001. Survivors include commuters, residents, ‘‘passersby,’’ and students who were in the New York City (NYC) disaster 

area around the time of the attacks and in the months following. 

Under H.R. 847, CBO estimates that roughly 650,000 individuals 

from the NYC disaster area—approximately 75,000 responders and 

575,000 survivors—would meet the exposure requirements specified in the legislation, along with potentially another 10,000 responders from the Pentagon and Shanksville, Pennsylvania, sites. 

Although many of those individuals may have or develop health 

conditions related to the terrorist attacks, CBO estimates that only 

a portion would participate in the WTC Health Program and apply 

for an award under the VCF. Overall, CBO expects that of the total 

population that meets the exposure requirements, slightly less than 

15 percent would enroll in the WTC Health Program by 2020 and 

slightly more than 5 percent would receive awards from the VCF. 

Those estimated participation rates reflect people’s willingness to 

enroll in government programs as well as additional requirements 

that would have to be met to receive a VCF award. 

Geographic and Time-Period Requirements. Title I specifies that 

individuals must have been present in the following locations following the terrorist attacks to be eligible for the new health program: NYC disaster area, the Pentagon site, and the Shanksville, 

Pennsylvania, site. Title II would give discretion to the VCF Special Master (appointed by the U.S. Attorney General to administer 

the fund) to define the geographic area for awards from that fund; 

for this estimate, CBO assumes that the geographic areas of exposure specified in title I would also be used as the criteria for compensation payments under title II. Title I defines the NYC disaster 

area as the part 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 site. H.R. 847 

would also base eligibility on the amount of time an individual 

spent in the specified region. Based on those requirements, CBO 

estimates that about 75,000 responders and 575,000 survivors from 

the NYC disaster area would meet the geographic-eligibility and 

time-period requirements specified in H.R. 847, as well as potentially another 10,000 responders from the Pentagon and 

Shanksville, Pensylvania, sites. 

Those estimates are based on information collected by certain 

hospitals (known as the Centers of Excellence) in the NYC area 

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51 

that are treating responders, New York City’s Department of 

Health and Mental Hygiene, the U.S. Department of Health and 

Human Services, Research Triangle International, and New York 

State Laborers’ Tri-Fund. In particular, CBO’s analysis relies heavily on the WTC Health Registry which was developed by New York 

City’s Department of Health and Mental Hygiene and the U.S. Department of Health and Human Services (HHS) to document and 

evaluate the short- and long-term physical and mental health 

issues associated with the terrorist attacks and recovery efforts. 

The Registry established eligibility criteria that considered an individual’s residence, location at the time of attacks, and intensity and 

duration of exposure to hazardous conditions. About 71,000 individuals enrolled voluntarily in this Registry before it closed in November 2004. 

Diseases. The bill would require a determination that the terrorist attacks were substantially likely to be a significant factor in 

aggravating, contributing to, or causing the condition or illness 

prior to receiving treatment through the WTC Health Program. 

Title I would specify certain physical and mental health conditions 

deemed WTC-related for both responders and survivors. Title II 

would give discretion to the Special Master to determine what 

physical conditions would be eligible for an award; for this estimate, CBO assumes that the diseases specified in title I would also 

be used as criteria for compensation payments. 

In general, individuals whose health conditions developed or 

were aggravated as a result of the terrorist attacks cannot easily 

be distinguished from individuals whose conditions would have developed or worsened in the absence of those attacks. Therefore, 

CBO considered the entire population that may develop and seek 

treatment for eligible physical and mental health conditions that 

might be associated with the aftermath of the terrorist attacks. The 

existence of a causal relationship between the attacks and specific 

diseases generally would be difficult to establish or disprove. 

CBO analyzed more than a dozen studies on the incidence and 

prevalence of the WTC-related health conditions in both responders 

and survivors. We also analyzed data collected in the Morbidity 

and Mortality Weekly Report (MMWR) and population level data 

collected by the Medical Expenditure Panel Survey (MEPS). The 

MEPS collects annual data pertaining to the use of health care 

services, sources of payment for those services, and health insurance coverage. Based on those analyses, CBO estimates that about 

280,000 of the individuals (about 40 percent) who meet the exposure criteria defined in the legislation have or will develop a health 

condition that meets the criteria set in the bill. 

Responders who meet the geographic-eligibility criteria and survivors who both meet the geographic-eligibility criteria and develop 

a qualifying physical or mental health condition, as defined in the 

bill, would be eligible to enroll in the WTC Health Program. 

CBO estimates that about 50,000 responders and 230,000 survivors would develop at least one qualifying physical or mental 

health condition. That estimate reflects the prevalence of the eligible conditions among the general population as well as the increase 

in prevalence attributable to the attacks themselves. 

Eligibility for an award under the VCF would differ from that for 

the WTC Health Program. The VCF would only compensate indimstockstill on DSKH9S0YB1PROD with HEARINGS

52 

viduals with physical health conditions who have received treatment. CBO estimates that about 100,000 responders and survivors 

would meet those criteria. 

Direct Spending 

CBO estimates that enacting H.R. 847 would increase direct spending by $10.5 billion over the 2011–2020 period. About $4.2 

billion of that amount would result from spending for health care 

benefits provided under title I. The remaining $6.3 billion would be 

spent on compensation payments provided under title II. 

Title I: Health Care Benefits. Under current law, the National 

Institute of Occupational Safety and Health (NIOSH) provides 

funding to several programs that offer medical monitoring and 

treatment to responders and survivors with conditions associated 

with the September 11, 2001, terrorist attacks under the umbrella 

of the WTC Medical Monitoring and Treatment Program. Those 

programs treat or have enrolled approximately 60,000 individuals: 

about 40,000 in the Mt. Sinai Coordinated Consortium Responder 

Health Program and the National Responder Program; about 

16,000 in the Fire Department City of New York Responder Health 

Program; and about 4,600 survivors in the WTC Environmental 

Health Center Program. Funding for those programs is subject to 

annual appropriation. For 2010, $70 million was appropriated to 

NIOSH through the Centers for Disease Control and Prevention 

(CDC) to support those programs. 

H.R. 847 would establish the WTC Health Program within HHS 

to replace and expand the NIOSH programs. The WTC Health Program would provide monitoring and treatment benefits for qualifying health conditions to individuals who were engaged in emergency response, recovery, and cleanup operations related to the terrorist attacks. It also would provide monitoring and treatment benefits to certain residents and others with a qualifying health condition who were working, visiting, or residing near the WTC during 

the year following the attacks. H.R. 847 would replace annual appropriations for the NIOSH programs with mandatory funding for 

the WTC Health Program. (An estimated reduction in authorized 

discretionary spending is discussed below under ‘‘Spending Subject 

to Appropriation.’’) 

CBO estimates that, if unconstrained, the WTC Health Program 

would cost between $5 billion and $6 billion over the 2011–2020 period. In contrast, the cap on federal spending specified in H.R. 847 

is about $4.6 billion over that same period. Taking that spending 

cap into consideration, CBO estimates that gross spending would 

total $4.4 billion over the 2011–2020 period. The WTC Health Program also would result in some savings for Medicare and Medicaid, 

yielding a net increase in direct spending of $4.2 billion over the 

2011–2020 period, as shown in the table on page 3. CBO also estimates that New York City would contribute $0.5 billion to the 

WTC Health Program over the 2011–2020 period. 

Program Participation. The WTC Health Program would cover 

individuals enrolled in the existing programs as of the date of enactment and would allow up to an additional 25,000 responders 

and 25,000 survivors to enroll in the program. H.R. 847 defines exposure and health criteria for an eligible WTC responder and an 

eligible WTC survivor. The program’s administrator would be almstockstill on DSKH9S0YB1PROD with HEARINGS

53 

lowed to expand those eligibility criteria until 80 percent of the numerical limitation is reached. 

CBO estimates that about 65,000 of the approximately 85,000 responders at the various sites who would meet the exposure criteria 

would enroll in the WTC Health Program and that about 20 percent of those enrollees would receive treatment through the program in a given year. We estimate that about 250,000 individuals, 

or roughly 40 percent of the approximately 575,000 survivors who 

would meet those criteria, would also meet the health condition criteria specified in title I of H.R. 847. CBO expects that less than 10 

percent of those individuals would enroll in the WTC Health Program by 2020. In part, this estimate reflects the expectation that 

most individuals will continue to receive care from providers who 

are not affiliated with a Center of Excellence or the WTC Health 

Program. CBO further expects that, in a given year, slightly less 

than half of the enrolled survivors would receive treatment through 

the WTC Health Program. 

Survivor and Responder Health Benefits. H.R. 847 would provide 

for health benefits, including monitoring and medically necessary 

follow-up treatment for enrolled responders. Survivors would receive an initial health evaluation to determine program eligibility. 

Once eligibility is determined, H.R. 847 would provide for monitoring and medically necessary follow-up treatment for survivors. 

Monitoring, initial health evaluations, and medically necessary follow-up would only be covered when provided by Centers of Excellence or by providers who participate in the nationwide network established by the WTC program administrator. The WTC Health 

Program would also provide funding for coordination and administrative expenses for the Centers of Excellence. CBO estimates that 

the cost of the health benefits program (including initial health 

evaluations, monitoring, treatment, and administration) would 

total up to $4.5 billion over the 2011–2020 period. That amount 

comprises about $4.2 billion for monitoring and medically necessary treatment and $0.3 billion for administrative costs. 

The WTC Health Program would pay for the monitoring and 

medically necessary treatment costs associated with a qualifying 

health condition that are not covered by a patient’s primary insurer, including deductibles, copayments, coinsurance, and other 

cost-sharing requirements. (As a practical matter, the WTC Health 

Program would be the primary insurer for individuals covered by 

Medicare.) H.R. 847 specifies a series of WTC-related health conditions; however, H.R. 847 would authorize the administrator to approve conditions and illnesses not specified in the legislation but 

deemed to be a WTC-related health condition for treatment. The 

administrator could also add illnesses and conditions to the list of 

WTC-related health conditions through the rulemaking process, 

which might include requesting a recommendation of the Advisory 

Panel. In addition, for an individual, a condition not on the list 

would be deemed to be WTC-related if a physician determines that 

it was likely to have been caused or aggravated by exposure to the 

terrorist attacks. 

CBO estimated the cost of treatment for WTC-related health conditions using data from MEPS, Medicare, and the Federal Employees Compensation Act (FECA) program. CBO analyzed MEPS data 

to estimate the national average cost of treating qualifying condimstockstill on DSKH9S0YB1PROD with HEARINGS

54 

1For responders employed by New York City, all WTC-related conditions would be considered 

work-related. The legislation would relieve the city’s worker’s compensation program or other 

work-related injury or illness benefit plan of the obligation to pay for those conditions in return 

for the city’s participation in the financing of the WTC Health Program. 

tions. Those costs were then adjusted to reflect the relative costs 

in New York City—spending per Medicare enrollee is about 20 percent higher in New York City than the national average—and to 

account for differences between payment rates in the FECA program and those underlying our estimate of national average cost. 

Those costs were then projected based on CBO’s estimates of 

growth in per capita health spending. The administrator would be 

required to establish a program for necessary outpatient prescription pharmaceuticals prescribed under this title through contracts 

with one or more vendors. Separately, CBO estimated the cost of 

outpatient prescription drugs and assumed that those payment 

amounts would be comparable to prices paid in the private market. 

The WTC Health Program would be the secondary payer for survivors with private insurance or Medicaid coverage and for responders receiving benefits from a non-NYC worker’s compensation 

or other work-related injury or illness benefit plan. For those individuals, the program would pay the difference between FECA payment rates and the amounts paid by the primary insurer; the individual would have no out-of-pocket obligation.1 CBO estimates that 

primary insurers would cover about 60 percent of the cost of treating WTC-related health conditions for those individuals, with the 

WTC Health Program paying the rest. 

CBO estimates that federal spending for Medicaid would be re- duced by about $30 million over the 2011–2020 period. Those savings would occur largely because, in some cases, providers would 

bill the WTC Health Program instead of Medicaid to avoid the administrative cost of dealing with two payers. 

The WTC Health Program would reduce Medicare spending because it would replace Medicare as the primary payer for individuals enrolled in Medicare. CBO estimates that Medicare savings 

would total about $155 million over the 2011–2020 period. 

CBO estimates that costs incurred to administer health evaluations, monitor, and provide treatment would total up to $0.3 billion 

over the 2011–2020 period. H.R. 847 would direct the administrator to enter into contracts with Clinical Centers of Excellence to 

provide monitoring and treatment benefits and initial health evaluations, counseling, outreach, translational and interpretive services, and to collect and report on utilization, incidence, and prevalence data. 

Other Health Benefits and Program Funding. H.R. 847 would 

provide funding for: 

• Mental health benefits for surviving family members of responders who died at the WTC site on September 11, 2001; 

• Creation of a scientific committee and technical advisory 

committee; 

• Education and outreach; 

• Uniform data collection; 

• Research pertaining to conditions related to the September 

11, 2001, terrorist attacks; and 

• Maintaining ongoing data collection through the WTC 

health registry. 

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55 

The bill specifies a maximum amount for each of those activities. 

CBO estimates that the costs of those activities would total up to 

$0.5 billion over the 2011–2020 period. In addition, H.R. 847 would 

provide funding for training and technical assistance, transportation expenses, and claims processing. CBO estimates that the 

costs of those activities would total an additional $0.2 billion over 

the 2011–2020 period. Thus, the total cost of other activities would 

total up to $0.7 billion over the 2011–2020 period. 

World Trade Center Health Program Fund. H.R. 847 would establish the WTC Health Program Fund to pay for the benefits included under title I. New York City and the federal government 

would contribute to the fund based on percentages and amounts 

provided in the legislation. 

The legislation would authorize implementation of the WTC 

Health Program only if New York City enters into a contract with 

the WTC program administrator in which the city agrees to pay 10 

percent of program costs. This estimate assumes that the city 

would enter into that contract and that the city would reimburse 

the WTC Health Program within six to nine months. (Alternatively, if the city would not enter into a contract with the administrator, CBO expects that no payments would be made from the 

WTC Health Program Fund, resulting in no increase in direct 

spending over the 2011–2020 period.) 

The federal government would be required to contribute the lesser of 90 percent of the program expenditures or an annual amount 

specified in the legislation. That cap on federal spending would rise 

from $71 million in 2011 to $743 million in 2020 and would total 

about $4.6 billion over the 2011–2020 period. 

In the absence of a cap, CBO estimates that the federal share of 

annual expenditures for the WTC Health Program would probably 

be about 1 percent to 5 percent higher than the annual caps. However, CBO’s cost estimate targets the midpoint of a distribution of 

likely spending outcomes. Establishing a cap on annual spending 

truncates that distribution of likely outcomes by eliminating the 

potential for spending above the cap. Therefore, the middle of the 

truncated range of likely spending outcomes would be slightly 

below the cap. As a result, CBO estimates that federal spending 

would total about $4.4 billion over the 2011–2020 period. 

H.R. 847 would require New York City to cover 10 percent of the 

expenditures for carrying out title I. If the city pays its share, the 

WTC Health Program would assume responsibility for treatment 

costs for responders that would under current law be the responsibility of the city’s worker’s compensation or other work-related injury or illness benefit plan. Late payments from the city would accrue interest on the unpaid amount. For the purpose of our estimate, we assume that New York City would make payments on 

time. If the city fails to pay pursuant to its contract with the administrator and interest accrues on the unpaid amount, the federal 

expenditures would reach the cap more quickly. 

CBO estimates that the city of New York would contribute about 

$0.5 billion over the 2011–2020 period. 

Title II: Compensation Payments. Title II would reopen the September 11, 2001, Victim Compensation Fund, which provided compensation to any individual (or relatives of a deceased individual) 

who was physically injured or killed as a result of the terrorist atmstockstill on DSKH9S0YB1PROD with HEARINGS

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tacks. The VCF, which terminated operations in 2004, was established by the Air Transportation Safety and System Stabilization 

Act (Public Law 107–42) as an administrative alternative to litigation. That act created a Special Master, who determined the compensation levels based on specified eligibility criteria and subsequent regulations. Through 2004, the VCF made 2,880 death and 

2,680 injury awards, totaling more than $7 billion (about $6 billion 

was for death awards). Public Law 107–42 did not cap the number 

or amount of awards that could be issued by the Special Master. 

H.R. 847 would establish broader eligibility rules for compensation than those established for the VCF under Public Law 107–42. 

Under the bill, total payments would be capped at $8.4 billion 

through 2032. CBO estimates that compensation payments would 

total $6.3 billion over the 2011–2020 period, with about 90 percent 

($5.7 billion) of those payments made in the first five years following enactment. Most of the awards would be for physical injuries associated with the attacks or with debris removal and response activities following the attacks. CBO estimates that the 

VCF would make additional payments totalling about $300 million 

after 2020. 

CBO’s estimate of those payments is based on a number of assumptions and projections regarding eligibility, average award 

amounts, and attorneys’ fees. 

Changes in Eligibility. Title II would make many more individuals who were involved in the rescue, recovery, and cleanup efforts 

potentially eligible for compensation. Based on information provided by the previous Special Master of the VCF, CBO assumes 

that the VCF would be administered in the same manner as it was 

previously but would reflect new regulations written after the bill’s 

enactment. Those regulations would reflect the following changes 

made by the bill: • Time Present at Site: Eligibility would be determined in part 

based on the time an individual was present or near the sites of 

the terrorist attacks. Specifically, the bill would require that an eligible individual must have been at those sites some time during 

the period beginning on September 11, 2001, and ending on August 

30, 2002. Prior to the sunset of the original VCF, the implementing 

regulations required that an individual had to have been present 

at those sites during the 12 hours immediately following the attacks, or for responders, 96 hours after the attacks. 

• Geographical Expansion: Based on regulations promulgated 

under Public Law 107–42, the Special Master originally defined the 

crash site as a zone bounded by specific streets very close to the 

WTC area. H.R. 847 would expand the definition of the crash site 

to include routes related to debris removal (such as barges and 

landfills). Although the bill does not specify other changes to the 

site definition, the Special Master would have discretion to expand 

the site if it is determined that there was demonstrable risk of 

physical harm in adjacent areas. For this estimate, CBO assumes 

that the new regulations would extend the boundaries to be the 

same as those defined for eligibility for the health care benefits authorized in title I of the bill. 

• Extended Claims Filing Deadlines: Generally, the filing deadline under the bill would depend primarily on when the Special 

Master determines that a claimant realizes that he or she suffered 

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57 

some form of physical harm resulting from the terrorist attacks or 

associated debris removal. If the Special Master determines that a 

claimant was aware (or should have been aware) of such an injury 

by the time the regulations are promulgated, the claimant would 

have two years to file from that time (roughly by the end of December 2012). For all others, if a claimant realizes such an injury after 

the new regulations are finalized, the claimant would have two 

years from when the Special Master determines that the claimant 

should have been aware of such injury. All claims would have to 

be filed by December 22, 2031. 

Awards and Average Award Amount. CBO expects that the bill’s 

expanded eligibility criteria would significantly increase the number of individuals who could seek compensation from the VCF. 

CBO expects that most of the awards would be for injuries associated with the attacks, and therefore our analysis focused on those 

claims. Further, the bill would not provide compensation for mental 

health conditions although it would provide treatment for mental 

illnesses under title I. Over the next 10 years, CBO estimates that 

about 35,000 awards would be made, with an average award 

amount of about $180,000. • Number of Awards: CBO expects that the number of awards 

would depend largely on the estimated number of responders and 

survivors who have or will have health conditions or symptoms associated with the terrorist attacks and recovery efforts, and are 

being treated for such conditions. Under H.R. 847, the VCF would 

require that all claimants prove they were treated by medical professionals and provide contemporaneous medical records to verify 

that treatment. CBO estimates that about 100,000 individuals— 

nearly 25,000 responders and more than 75,000 survivors—would 

meet that additional eligibility requirement. 

CBO estimated the proportion of those individuals who would file 

a claim by reviewing studies on the propensity of individuals to 

seek legal remedy for injuries. Although CBO estimates that the 

overall claim rate would be a bit under 50 percent, we expect that 

responders would have a much higher filing rate than survivors because of their involvement in the existing treatment programs at 

the Centers of Excellence and because of the efforts by certain 

union organizations to publicize the possible health issues associated with the cleanup efforts. 

Taking into account the VCF’s previous approval rate and the 

approval rates of other compensation programs, CBO estimates 

that about 35,000 awards would be made, including payments to 

nearly 20,000 responders and 15,000 survivors. CBO expects that 

the number of death claims would be very small because there is 

little evidence that many individuals have died from injuries 

caused by the 2001 terrorist attacks after compensation benefits 

were first awarded. 

• Average Award Amount: Under the bill, award amounts would 

be determined in the same way as they were before the sunset of 

the original VCF. Awards would comprise two parts—economic and 

noneconomic loss—adjusted for collateral offsets such as pensions. 

For injury victims, economic loss would reflect the actual lost income or expenses incurred as a direct result of the injury and future lost income and costs due to those injuries. Noneconomic loss 

would reflect compensation for pain and suffering due to injuries 

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associated with the attacks. Awards, which would be provided in 

one payment, would be determined within 120 days of filing the 

claim and paid within 20 days of such determination. 

Based on information provided by administrators of the previous 

VCF program, CBO estimates that the average injury award would 

be about $180,000. (For death claims, the average award would be 

about $2 million, the same amount provided under the original 

VCF.) CBO estimated the average injury award by considering the 

characteristics of the current population enrolled in WTC Medical 

Monitoring and Treatment Programs, including average age, extent 

of disability, estimated income, and employer-provided benefits 

such as pensions and health insurance. CBO estimates that the average award would be higher for responders—about $240,000 per 

claim—because we expect that a greater proportion of responders 

have more serious injuries. In contrast, we estimate that awards 

for survivors would average about $100,000. The award estimates 

also were adjusted to account for certain health care benefits provided under title I. 

Attorneys’ Fees. This estimate does not include any significant 

additional costs for attorneys’ compensation that the Special Master could award under the bill. The bill would give the Special Master discretion to provide compensation to attorneys for services rendered on cases filed in district court for injuries associated with the 

terrorist attacks, but CBO expects that this authority would be 

used sparingly, based on the historical experience of the VCF. Previously, attorneys provided free legal assistance to claimants. 

Spending subject to appropriation 

CBO estimates that implementing H.R. 847 would decrease dis- cretionary spending by $174 million over the 2011–2020 period. 

Administering VCF Awards. Under H.R. 847, additional funding 

would be required to administer the VCF. The original compensation program was administered by the Department of Justice’s 

(DOJ’s) Civil Division. About $87 million was spent to process 

about 7,400 claims, and the average administrative cost per claim 

was about $11,500. Under the bill, CBO assumes that DOJ would 

again administer and oversee the program. 

Based on information provided by DOJ, CBO estimates that the 

average cost to process a claim under H.R. 847 would be about 

$10,000. CBO expects that the average cost would be lower than 

under the original program because the administrative infrastructure already exists and because we assume that certain efficiencies 

would be achieved with a larger number of claims. In total, CBO 

estimates that, assuming appropriation of the necessary amounts, 

administrative costs for the program would total $483 million over 

2011–2015 period and $514 million over the 2011–2020 period to 

process an estimated 50,000 claims, including many from individuals who would not qualify for an award. Most of that amount 

would be for salaries of hundreds of individuals to process millions 

of documents, operate a claims management system, and manage 

20 to 30 claims-assistance sites around the country. Compensation 

also would be provided for DOJ attorneys, administrative law 

judges, and support staff. 

NIOSH World Trade Center Health Program. As discussed 

above, the enactment of H.R. 847 would replace annual appropriamstockstill on DSKH9S0YB1PROD with HEARINGS

59 

tions with mandatory funding for NIOSH through CDC. Under the 

current-law baseline, CBO projects that discretionary appropriations will continue at the current level of funding adjusted annually for anticipated inflation. Assuming appropriation actions consistent with the bill, CBO estimates that appropriations for NIOSH 

would be reduced by $71 million in 2011 and increasing amounts 

in subsequent years because that baseline spending would be replaced by new direct spending under H.R. 847. We estimate that 

the reduction in appropriations would total $764 million over the 

2011–2020 period, resulting in a corresponding reduction in outlays 

of $688 million over the same period. 

Pay-As-You-Go considerations: The Statutory Pay-As-You-Go Act 

of 2010 establishes budget reporting and enforcement procedures 

for legislation affecting direct spending or revenues. The net 

changes in outlays that are subject to those pay-as-you-go procedures are shown in the following table. 

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CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR TITLE I OF H.R. 847 AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON MAY 25, 

2010, AND TITLE II OF H.R. 847 AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON THE JUDICIARY ON JULY 29, 2009 

By fiscal year, in millions of dollars— 

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2010– 2015 2010– 2020 

NET INCREASE OR DECREASE (¥) IN THE DEFICIT 

Statutory Pay-As-You-Go Impact ................................................................................................. 0 513 1,251 3,585 1,166 638 599 645 646 692 763 7,153 10,498 

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Estimated impact on state, local, and tribal governments: H.R. 

847 contains no intergovernmental mandates as defined in UMRA. 

The bill would place conditions on the city of New York for participating in the health program authorized by the bill, but those conditions would not be intergovernmental mandates as defined in 

UMRA. 

Estimated impact on the private sector: H.R. 847 would impose 

a private-sector mandate as defined in UMRA by limiting the liability of New York City, any entity with a property interest in the 

World Trade Center on September 11, 2001, and any contractors 

and subcontractors thereof. Liability would be limited to the total 

amount of available insurance coverage of those entities for compensatory damages or other relief arising from or related to debris 

removal from sites of the terrorist attacks. By limiting the liability 

of those entities, the bill would impose a mandate on individuals 

seeking compensatory damages or other relief. Because of uncertainty about the potential amount of the awards and the ability of 

the city of New York and other entities whose liability would be 

limited to pay for any awards in excess of the liability limit, CBO 

cannot determine the costs the mandate would impose on the affected individuals. 

Estimate prepared by: Federal Costs: Stephanie Cameron, Leigh 

Angres, and Chapin White; Impact on State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: 

Sarah Axeen. 

Estimate approved by: Holly Harvey, Deputy Assistant Director 

for Budget Analysis. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

The following section-by-section analysis describes the provisions 

in Title I of the legislation (World Trade Center Health Program). 

For the section-by-section analysis of Title II of the legislation (September 11th Victim Compensation Fund of 2001), see Part II of this 

Report. 

Section 1. Short title; table of contents 

Section 1(a) designates the short title as the ‘‘James Zadroga 

9/11 Health and Compensation Act of 2010’’. 

Section 1(b) sets forth the table of contents. 

Title I—World Trade Center Health Program 

Section 101. World Trade Center Health Program 

Section 101 amends the Public Health Service Act by adding a 

new Title XXXIII that contains the following sections: 

Title XXXIII of the Public Health Service Act—World Trade Center 

Health Program 

SUBTITLE A—ESTABLISHMENT OF PROGRAM ADVISORY COMMITTEE

Section 3301. Establishment of World Trade Center Health Program. Establishes, effective July 1, 2011, a World Trade Center 

Health Program (the WTC Program) within the Department of 

Health and Human Services (HHS) to be administered by the WTC 

Program Administrator. The WTC Program includes the following 

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components: (1) medical monitoring for responders to the September 11, 2001, terrorist attacks on the WTC in New York City, 

at the Pentagon and in Shanksville, Pennsylvania; (2) initial health 

evaluation for survivors (i.e., residents and other building occupants and area workers in the area affected by the terrorist attack 

on the World Trade Center); (3) followup monitoring and treatment 

for WTC-related health conditions for eligible responders and survivors; (4) outreach and education to potentially eligible individuals; (5) clinical data collection and analysis; and (6) research on 

WTC-related health conditions. Prohibits the imposition of costsharing with respect to initial health evaluations, monitoring, or 

treatment benefits. Directs the Inspector General of HHS to develop and implement a program to review expenditures by the 

WTC Program to detect fraudulent billing and unreasonable administrative costs. Directs the WTC Program Administrator to establish a quality assurance program for services delivered by Centers of Excellence and other participating providers. Requires the 

WTC Program Administrator to submit an annual report to Congress on the operation of the program. 

Section 3302. WTC Health Program Scientific/Technical Advisory 

Committee; WTC Health Program Steering Committees. Requires 

the WTC Program Administrator to establish the WTC Health Program Scientific/Technical Advisory Committee to review scientific 

and medical evidence and make recommendations on additional 

WTC Program eligibility criteria and additional WTC-related 

health conditions. Requires the Administrator to consult with the 

WTC Responders Steering Committee and the WTC Survivors 

Steering Committee. 

Section 3303. Education and Outreach. Requires the WTC Program Administrator to institute a program to provide education 

and outreach to potentially eligible individuals regarding the existence of and services available under the WTC Health Program. 

Section 3304. Uniform Data Collection and Analysis. Requires 

the WTC Program Administrator to provide for the collection, analysis, and reporting of data, consistent with applicable privacy requirements, on the prevalence of WTC-related health conditions, 

and the identification of new WTC-related health conditions. Directs Clinical Centers of Excellence to collect and report data to a 

Data Center for analysis. Requires the Administrator to ensure collaboration between Data Centers and World Trade Center Health 

Registry. 

Section 3305. Clinical Centers of Excellence and Data Centers. 

Requires the WTC Program Administrator to enter into contracts 

or cooperative agreements with the Clinical Centers of Excellence 

and Data Centers. Requires Clinical Centers of Excellence to provide monitoring, initial health evaluation, and treatment benefits; 

conduct outreach activities; provide counseling for benefits for eligible individuals; provide translational and interpretive services for 

eligible individuals who are not English language proficient; and 

collect and report data to the Data Centers for analysis. Requires 

Data Centers to receive and analyze data for the purposes of developing protocols for monitoring, initial health evaluation, and treatment of WTC-related health conditions; conducting outreach activities; and establishing criteria for credentialing providers in the nationwide network. Sets forth contract requirements for Clinical 

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Centers of Excellence. Requires the Administrator to reimburse 

Clinical Centers of Excellence for fixed infrastructure costs using a 

fair and appropriate negotiated rate. 

Section 3306. Definitions. Sets forth definitions for certain terms 

used in Title I. In the case of the term ‘‘WTC Program Administrator,’’ authorizes the Secretary of HHS to designate one or more 

officials in the Department to carry the following responsibilities: 

enrollment of WTC responders; processing claims for reimbursement for initial health evaluations, monitoring and treatment; determination of eligibility of WTC responders; and administering 

secondary payor provisions. Specifies that the Director of the National Institute for Occupational Safety and Health (NIOSH), or a 

designee, is responsible for all other activities of the WTC Health 

Program. 

SUBTITLE B—PROGRAM OF MONITORING, INITIAL HEALTH

EVALUATIONS, AND TREATMENT

PART 1—WTC RESPONDERS

Section 3311. Identification of WTC Responders and Provision of 

WTC-Related Monitoring Services. Defines the term ‘‘WTC responder’’ as any of the following: (1) a responder who is identified 

as eligible for monitoring on the date of enactment; (2) a responder 

who meets current eligibility criteria; and (3) a responder who 

meets eligibility criteria modified by the WTC Program Administrator after consultation with the WTC Scientific/Technical Advisory Committee. Specifies that current eligibility criteria include 

firefighters and emergency personnel; law enforcement officers; rescue, recovery, and cleanup workers; and the surviving immediate 

family members of firefighters or emergency personnel who were 

killed as a result of the September 11, 2001, terrorist attacks on 

the World Trade Center. Further specifies that current eligibility 

criteria include members of fire or police departments, recovery or 

cleanup workers, or volunteers who performed rescue, recovery, debris cleanup, or related services at the Pentagon and in 

Shanksville, Pennsylvania, in the aftermath of the September 11, 

2001, terrorist attacks. Directs the WTC Program Administrator to 

establish an enrollment process for WTC responders. Limits enrollment in the WTC responder program at any time to 25,000 responders in addition to those identified as eligible for monitoring 

on the day of enactment and the surviving immediate family members of firefighters or emergency personnel killed at the World 

Trade Center site. (Of these 25,000, no more than 2,500 may qualify based on eligibility criteria modified by the Administrator). Disqualifies individuals on the Department of Homeland Security’s 

terrorist watch list from receiving benefits as WTC responders. Requires the WTC Program to provide monitoring consistent with 

protocols approved by the Administrator to enrolled WTC responders (other than surviving immediate family members of firefighters 

or emergency personnel). 

Section 3312. Treatment of Enrolled WTC Responders for WTCRelated Health Conditions. Sets forth a list of WTC-related health 

conditions, including aerodigestive disorders and mental health 

conditions, for which treatment is to be furnished to WTC responders through Centers of Excellence and the national program. Estabmstockstill on DSKH9S0YB1PROD with HEARINGS

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lishes a process for the addition of conditions to the list that includes an option for interested parties to submit written petitions, 

recommendations from the WTC Health Program Scientific/Technical Advisory Committee, and formal notice and comment rulemaking by the WTC Program Administrator. Requires the Administrator to periodically review all available scientific and medical 

evidence related to cancer to determine if particular types of cancers should be added to the list of WTC-related health conditions. 

Establishes a process for a physician at a Clinical Center of Excellence to be paid for treating an enrolled WTC responder for a condition that is not on the list of WTC-related health conditions but 

that the treating physician determines is medically associated with 

a WTC-related health condition. Requires physicians and other providers treating enrolled WTC responders to provide treatment that 

is medically necessary and in accordance with medical treatment 

protocols approved by the WTC Program Administrator; requires 

the Administrator to issue regulations specifying a standard for determining medical necessity; and prohibits the Administrator from 

paying for treatment that the Administrator determines is not 

medically necessary or not in accordance with such medical treatment protocols. Requires the Administrator to reimburse costs for 

medically necessary treatment for WTC-related health conditions 

at rates applicable under the Federal Employees Compensation Act 

(FECA). Authorizes the Administrator to modify the payment 

amounts and methodologies if, based on utilization and quality 

data furnished by the Clinical Centers of Excellence, the Administrator determines that another payment methodology would better 

ensure high quality and efficient delivery. In the case of outpatient 

prescription drugs, directs the Administrator to establish a program to use outside vendors selected through a competitive bidding 

process. 

Section 3313. National Arrangement for Benefits for Eligible Individuals Outside New York. Requires the WTC Program Administrator to establish a nationwide network of health care providers 

to furnish monitoring and treatment benefits and initial health 

evaluations to enrolled WTC responders and eligible WTC survivors who reside outside of the New York City metropolitan area. 

Requires that health care providers participating in this network 

meet credentialing criteria specified by the Data Centers, follow the 

approved protocols, collect and report data, and comply with program integrity, quality assurance, and other requirements established by the Administrator. 

PART 2—WTC SURVIVORS

Section 3321. Identification and Initial Health Evaluation of 

Screening-Eligible and Certified-Eligible WTC Survivors. Defines a 

‘‘screening-eligible WTC survivor’’ as an individual who (1) has 

been identified as eligible for medical monitoring and treatment by 

the WTC Environmental Health Center as of the date of enactment, (2) claims symptoms of a WTC-related health condition and 

meets current eligibility criteria, or (3) claims symptoms of a WTCrelated health condition and meets eligibility criteria modified by 

the WTC Program Administrator after consultation with the WTC 

Scientific/Technical Advisory Committee. Specifies that current eligibility criteria include individuals present in the New York City 

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disaster area in the dust or dust cloud on September 11, 2001, and 

individuals who worked, resided, or attended school or childcare 

during the 4-month period beginning on September 11, 2001. Directs the Administrator to establish a process for individuals to be 

determined to be screening-eligible WTC survivors. Requires the 

WTC Program to provide for a single initial health evaluation for 

each screening-eligible WTC survivor to determine if the survivor 

has a WTC-related health condition and is eligible for follow-up 

monitoring and treatment benefits. The initial health evaluation 

must be conducted through a Clinical Center of Excellence consistent with protocols approved by the Administrator. Defines ‘‘certified-eligible WTC survivor’’ as a screening-eligible WTC survivor 

who, based on an initial health evaluation, has been determined to 

be eligible for follow-up monitoring and treatment. Directs the Administration to establish a process for certification of this determination. Limits to 25,000 at any time the number of certifiedeligible WTC survivors in addition to those who were identified as 

eligible for medical monitoring and treatment as of enactment. Disqualifies individuals on the Department of Homeland Security’s 

terrorist watch list from receiving benefits as WTC survivors. 

Section 3322. Followup Monitoring and Treatment of CertifiedEligible WTC Survivors for WTC-Related Health Conditions. Sets 

forth a list of WTC-related health conditions, including 

aerodigestive disorders and mental health conditions, for which the 

WTC Program provides followup monitoring and treatment to certified-eligible WTC survivors. Provides that any cancers or other 

conditions added to the list of WTC-related health conditions for 

enrolled WTC responders under section 3312(a) are included in the 

list of WTC-related health conditions applicable to certified-eligible 

WTC survivors. Specifies that the provisions applicable to the monitoring and treatment of WTC-related health conditions for enrolled 

WTC responders, including those relating to the use of protocols 

and a standard of medical necessity approved by the WTC Program 

Administrator, also apply with respect to followup monitoring and 

treatment of WTC-related health conditions for certified-eligible 

WTC survivors. 

Section 3323. Followup Monitoring and Treatment of CertifiedEligible WTC Survivors for WTC-Related Health Conditions. Authorizes the provision of monitoring and treatment services to individuals who are not enrolled WTC responders or certified-eligible 

WTC survivors in certain circumstances but who are diagnosed at 

a Clinical Center of Excellence with a WTC-related health condition for certified-eligible WTC survivors. Limits the funds available 

for this purpose to $5 million in FY2011 and $20 million in 

FY2012, adjusted by the consumer price index every year thereafter through FY2020. 

PART 3—PAYOR PROVISIONS

Section 3331. Payment of Claims. Establishes the general rule 

that the WTC Health Program pays the costs of furnishing monitoring and treatment benefits and initial health evaluations from 

the WTC Health Program Fund, subject to certain exceptions. In 

the case of treatment for a WTC-related health condition that is 

work-related, the bill requires the WTC Program Administrator to 

reduce or recoup payment for the treatment using the Medicare 

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secondary payor procedures if the Administrator determines that 

payment for the treatment has been made or can reasonably be expected to be made under a worker’s compensation law or plan. In 

the case of treatment for a WTC-related health condition that is 

not work-related, the bill requires the Administrator to apply the 

Medicare secondary payor rules. For this purpose, treats Medicaid 

as primary to the WTC Program. Effective July 2014, it allows the 

WTC Program to make payment for monitoring or treatment only 

on behalf of individuals who have minimum essential coverage, unless the individual is exempt from the requirement to obtain such 

coverage. Provides that no funds may be disbursed from the WTC 

Health Program Fund until New York City enters into a contract 

with the WTC Program Administrator under which it agrees to 

contribute 10% of WTC Health Program expenditures in each calendar quarter. Specifies limits totaling $510 million on the amount 

of this 10% contribution owed in each fiscal year through FY 2020. 

Specifies interest penalties for late payments and provides that 

amounts owed to the WTC Administrator under the contract are 

recoverable by the United States. Specifies that New York City 

may not satisfy this 10% contribution using federal funds, payments made prior to enactment, or payments to satisfy a judgment 

or as part of a settlement related to injuries or illnesses related to 

the September 11, 2001, terrorist attacks. Provides that, in any 

quarter in which New York City makes the full payment it is obligated to make under the contract, the City is not required to make 

worker’s compensation or line-of-duty payments toward the treatment of WTC-related health conditions that are work-related. 

Section 3332. Administrative Arrangement Authority. Authorizes 

the WTC Program Administrator to enter into arrangements with 

government agencies, insurance companies, or other third-party administrators for processing of provider claims for payment for monitoring and treatment services furnished under the WTC Health 

Program to eligible WTC responders or survivors. 

SUBTITLE C—RESEARCH INTO CONDITIONS

Section 3341. Research Regarding Certain Health Conditions Related to September 11 Terrorist Attacks in New York City. Directs 

the WTC Program Administrator, in consultation with the WTC 

Scientific/Technical Advisory Committee, to conduct or support research on physical and mental health conditions that may be related to the September 11, 2001, terrorist attacks, including research on diagnosing and treating WTC-related health conditions 

on which there has been treatment uncertainty. 

Section 3342. World Trade Center Health Registry. Directs the 

WTC Program Administrator to ensure the maintenance of a registry of victims of the September 11 terrorist attacks at least as 

comprehensive as the WTC Health Registry in effect as of April 20, 

2009, under arrangements with the New York City Department of 

Health and Mental Hygiene. 

SUBTITLE D—FUNDING

Section 3351. World Trade Center Health Program Fund. Establishes the World Trade Center Health Program Fund for payment 

of costs of carrying out the WTC Health Program beginning in the 

last calendar quarter of FY2011 and continuing through FY2020. 

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Provides mandatory funding for the federal contribution to the 

Fund in amount equal to the lesser of (1) 90% of the expenditures 

in carrying out the WTC Program in each fiscal year or (2) a specified annual cap amount for each fiscal year ($71 million in FY2011, 

$318 million in FY2012, $354 million in FY2013, $382 million in 

FY2014, $431 million in FY2015, $481 million in FY2016, $537 

million in FY2017, $601 million in FY2018, $672 million in 

FY2019, and $743 million in FY2020). Provides that no federal dollars be disbursed from the Fund unless New York City has entered 

into the contract with the WTC Program Administrator required 

under section 3331. Directs that the City’s 10% contribution be deposited into the Fund, and specifies that any failure of the City to 

make its full contribution shall not increase the federal deposit into 

the Fund. Makes amounts deposited into the Fund available for 

carrying out the WTC Health Program, including payment of the 

costs of identification, initial health evaluations, monitoring, and 

treatment of WTC-related health conditions of WTC responders 

and WTC survivors. Also makes amounts deposited into the Fund 

available, subject to specified limits, to support the WTC Health 

Program Scientific/Technical Advisory Committee, education and 

outreach activities, data collection and analysis, Data Centers, infrastructure costs of Clinical Centers of Excellence, research on 

WTC-related health conditions, and the WTC Health Registry. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

The bill was referred to this committee for consideration of such 

provisions of the bill as fall within the jurisdiction of this committee pursuant to clause 2 of rule XII of the Rules of the House 

of Representatives. In compliance with clause 3(e) of rule XIII of 

the Rules of the House of Representatives, changes in existing law 

made by such provisions of the bill, as reported, are shown as follows (new matter is printed in italic and existing law in which no 

change is proposed is shown in roman): 

PUBLIC HEALTH SERVICE ACT 

* * * * * * * 

TITLE XXXIII—WORLD TRADE CENTER 

HEALTH PROGRAM 

Subtitle A—Establishment of Program; 

Advisory Committee 

SEC. 3301. ESTABLISHMENT OF WORLD TRADE CENTER HEALTH PROGRAM. 

(a) IN GENERAL.—There is hereby established within the Department of Health and Human Services a program to be known as the 

World Trade Center Health Program, which shall be administered 

by the WTC Program Administrator, to provide beginning on July 

1, 2011— 

(1) medical monitoring and treatment benefits to eligible 

emergency responders and recovery and cleanup workers (inmstockstill on DSKH9S0YB1PROD with HEARINGS

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cluding those who are Federal employees) who responded to the 

September 11, 2001, terrorist attacks; and 

(2) initial health evaluation, monitoring, and treatment benefits to residents and other building occupants and area workers 

in New York City who were directly impacted and adversely affected by such attacks. 

(b) COMPONENTS OF PROGRAM.—The WTC Program includes the 

following components: 

(1) MEDICAL MONITORING FOR RESPONDERS.—Medical monitoring under section 3311, including clinical examinations and 

long-term health monitoring and analysis for enrolled WTC responders who were likely to have been exposed to airborne toxins that were released, or to other hazards, as a result of the 

September 11, 2001, terrorist attacks. 

(2) INITIAL HEALTH EVALUATION FOR SURVIVORS.—An initial 

health evaluation under section 3321, including an evaluation 

to determine eligibility for followup monitoring and treatment. 

(3) FOLLOWUP MONITORING AND TREATMENT FOR WTC-RE- LATED HEALTH CONDITIONS FOR RESPONDERS AND SURVIVORS.— Provision under sections 3312, 3322, and 3323 of followup monitoring and treatment and payment, subject to the provisions of 

subsection (d), for all medically necessary health and mental 

health care expenses of an individual with respect to a WTCrelated health condition (including necessary prescription 

drugs). 

(4) OUTREACH.—Establishment under section 3303 of an education and outreach program to potentially eligible individuals 

concerning the benefits under this title. 

(5) CLINICAL DATA COLLECTION AND ANALYSIS.—Collection 

and analysis under section 3304 of health and mental health 

data relating to individuals receiving monitoring or treatment 

benefits in a uniform manner in collaboration with the collection of epidemiological data under section 3342. 

(6) RESEARCH ON HEALTH CONDITIONS.—Establishment under 

subtitle C of a research program on health conditions resulting 

from the September 11, 2001, terrorist attacks. 

(c) NO COST SHARING.—Monitoring and treatment benefits and 

initial health evaluation benefits are provided under subtitle B 

without any deductibles, copayments, or other cost sharing to an enrolled WTC responder or certified-eligible WTC survivor. Initial 

health evaluation benefits are provided under subtitle B without 

any deductibles, copayments, or other cost sharing to a screeningeligible WTC survivor. 

(d) PREVENTING FRAUD AND UNREASONABLE ADMINISTRATIVE

COSTS.— 

(1) FRAUD.—The Inspector General of the Department of 

Health and Human Services shall develop and implement a 

program to review the WTC Program’s health care expenditures 

to detect fraudulent or duplicate billing and payment for inappropriate services. This title is a Federal health care program 

(as defined in section 1128B(f) of the Social Security Act) and 

is a health plan (as defined in section 1128C(c) of such Act) for 

purposes of applying sections 1128 through 1128E of such Act. 

(2) UNREASONABLE ADMINISTRATIVE COSTS.—The Inspector 

General of the Department of Health and Human Services shall 

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develop and implement a program to review the WTC Program 

for unreasonable administrative costs, including with respect to 

infrastructure, administration, and claims processing. 

(e) QUALITY ASSURANCE.—The WTC Program Administrator 

working with the Clinical Centers of Excellence shall develop and 

implement a quality assurance program for the monitoring and 

treatment delivered by such Centers of Excellence and any other 

participating health care providers. Such program shall include— 

(1) adherence to monitoring and treatment protocols; 

(2) appropriate diagnostic and treatment referrals for participants; 

(3) prompt communication of test results to participants; and 

(4) such other elements as the Administrator specifies in consultation with the Clinical Centers of Excellence. 

(f) ANNUAL PROGRAM REPORT.— (1) IN GENERAL.—Not later than 6 months after the end of 

each fiscal year in which the WTC Program is in operation, the 

WTC Program Administrator shall submit an annual report to 

the Congress on the operations of this title for such fiscal year 

and for the entire period of operation of the program. 

(2) CONTENTS INCLUDED IN REPORT.—Each annual report 

under paragraph (1) shall include at least the following: 

(A) ELIGIBLE INDIVIDUALS.—Information for each clinical 

program described in paragraph (3)— 

(i) on the number of individuals who applied for certification under subtitle B and the number of such individuals who were so certified; 

(ii) of the individuals who were certified, on the 

number who received monitoring under the program 

and the number of such individuals who received medical treatment under the program; 

(iii) with respect to individuals so certified who received such treatment, on the WTC-related health conditions for which they were treated; and 

(iv) on the projected number of individuals who will 

be certified under subtitle B in the succeeding fiscal 

year and the succeeding 10-year period. 

(B) MONITORING, INITIAL HEALTH EVALUATION, AND

TREATMENT COSTS.—For each clinical program so described— 

(i) information on the costs of monitoring and initial 

health evaluation and the costs of treatment and on the 

estimated costs of such monitoring, evaluation, and 

treatment in the succeeding fiscal year; and 

(ii) an estimate of the cost of medical treatment for 

WTC-related health conditions that have been paid for 

or reimbursed by workers’ compensation, by public or 

private health plans, or by New York City under section 3331. 

(C) ADMINISTRATIVE COSTS.—Information on the cost of 

administering the program, including costs of program 

support, data collection and analysis, and research conducted under the program. 

(D) ADMINISTRATIVE EXPERIENCE.—Information on the 

administrative performance of the program, including— 

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(i) the performance of the program in providing timely evaluation of and treatment to eligible individuals; 

and 

(ii) a list of the Clinical Centers of Excellence and 

other providers that are participating in the program. 

(E) SCIENTIFIC REPORTS.—A summary of the findings of 

any new scientific reports or studies on the health effects 

associated with exposure described in section 3306(1), including the findings of research conducted under section 

3341(a). 

(F) ADVISORY COMMITTEE RECOMMENDATIONS.—A list of 

recommendations by the WTC Scientific/Technical Advisory Committee on additional WTC Program eligibility criteria and on additional WTC-related health conditions and 

the action of the WTC Program Administrator concerning 

each such recommendation. 

(3) SEPARATE CLINICAL PROGRAMS DESCRIBED.—In paragraph 

(2), each of the following shall be treated as a separate clinical 

program of the WTC Program: 

(A) FIREFIGHTERS AND RELATED PERSONNEL.—The benefits provided for enrolled WTC responders described in section 3311(a)(2)(A). 

(B) OTHER WTC RESPONDERS.—The benefits provided for 

enrolled WTC responders not described in subparagraph 

(A). 

(C) WTC SURVIVORS.—The benefits provided for screening-eligible WTC survivors and certified-eligible WTC survivors in section 3321(a). 

(g) NOTIFICATION TO CONGRESS UPON REACHING 80 PERCENT OF

ELIGIBILITY NUMERICAL LIMITS.—The Secretary shall promptly notify the Congress of each of the following: 

(1) When the number of enrollments of WTC responders subject to the limit established under section 3311(a)(4) has 

reached 80 percent of such limit. 

(2) When the number of certifications for certified-eligible 

WTC survivors subject to the limit established under section 

3321(a)(3) has reached 80 percent of such limit. 

(h) CONSULTATION.—The WTC Program Administrator shall engage in ongoing outreach and consultation with relevant stakeholders, including the WTC Health Program Steering Committees 

and the Advisory Committee under section 3302, regarding the implementation and improvement of programs under this title. 

SEC. 3302. WTC HEALTH PROGRAM SCIENTIFIC/TECHNICAL ADVISORY 

COMMITTEE; WTC HEALTH PROGRAM STEERING COMMITTEES. 

(a) ADVISORY COMMITTEE.— 

(1) ESTABLISHMENT.—The WTC Program Administrator shall 

establish an advisory committee to be known as the WTC 

Health Program Scientific/Technical Advisory Committee (in 

this subsection referred to as the ‘‘Advisory Committee’’) to review scientific and medical evidence and to make recommendations to the Administrator on additional WTC Program eligibility criteria and on additional WTC-related health conditions. 

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(2) COMPOSITION.—The WTC Program Administrator shall 

appoint the members of the Advisory Committee and shall include at least— 

(A) 4 occupational physicians, at least 2 of whom have 

experience treating WTC rescue and recovery workers; 

(B) 1 physician with expertise in pulmonary medicine; 

(C) 2 environmental medicine or environmental health 

specialists; 

(D) 2 representatives of WTC responders; 

(E) 2 representatives of certified-eligible WTC survivors; 

(F) an industrial hygienist; 

(G) a toxicologist; 

(H) an epidemiologist; and 

(I) a mental health professional. 

(3) MEETINGS.—The Advisory Committee shall meet at such 

frequency as may be required to carry out its duties. 

(4) REPORTS.—The WTC Program Administrator shall provide for publication of recommendations of the Advisory Committee on the public Web site established for the WTC Program. 

(5) DURATION.—Notwithstanding any other provision of law, 

the Advisory Committee shall continue in operation during the 

period in which the WTC Program is in operation. 

(6) APPLICATION OF FACA.—Except as otherwise specifically 

provided, the Advisory Committee shall be subject to the Federal Advisory Committee Act. 

(b) WTC HEALTH PROGRAM STEERING COMMITTEES.— (1) CONSULTATION.—The WTC Program Administrator shall 

consult with 2 steering committees (each in this section referred 

to as a ‘‘Steering Committee’’) that are established as follows: 

(A) WTC RESPONDERS STEERING COMMITTEE.—One Steering Committee, to be known as the WTC Responders Steering Committee, for the purpose of receiving input from affected stakeholders and facilitating the coordination of 

monitoring and treatment programs for the enrolled WTC 

responders under part 1 of subtitle B. 

(B) WTC SURVIVORS STEERING COMMITTEE.—One Steering Committee, to be known as the WTC Survivors Steering 

Committee, for the purpose of receiving input from affected 

stakeholders and facilitating the coordination of initial 

health evaluations, monitoring, and treatment programs 

for screening-eligible and certified-eligible WTC survivors 

under part 2 of subtitle B. 

(2) MEMBERSHIP.— 

(A) WTC RESPONDERS STEERING COMMITTEE.— 

(i) REPRESENTATION.—The WTC Responders Steering Committee shall include— 

(I) representatives of the Centers of Excellence 

providing services to WTC responders; 

(II) representatives of labor organizations representing firefighters, police, other New York City 

employees, and recovery and cleanup workers who 

responded to the September 11, 2001, terrorist attacks; and 

(III) 3 representatives of New York City, 1 of 

whom will be selected by the police commissioner 

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of New York City, 1 by the health commissioner of 

New York City, and 1 by the mayor of New York 

City. 

(ii) INITIAL MEMBERSHIP.—The WTC Responders 

Steering Committee shall initially be composed of 

members of the WTC Monitoring and Treatment Program Steering Committee (as in existence on the day 

before the date of the enactment of this title). 

(B) WTC SURVIVORS STEERING COMMITTEE.— 

(i) REPRESENTATION.—The WTC Survivors Steering 

Committee shall include representatives of— 

(I) the Centers of Excellence providing services to 

screening-eligible and certified-eligible WTC survivors; 

(II) the population of residents, students, and 

area and other workers affected by the September 

11, 2001, terrorist attacks; 

(III) screening-eligible and certified-eligible survivors receiving initial health evaluations, monitoring, or treatment under part 2 of subtitle B and 

organizations advocating on their behalf; and 

(IV) New York City. 

(ii) INITIAL MEMBERSHIP.—The WTC Survivors Steering Committee shall initially be composed of members 

of the WTC Environmental Health Center Survivor Advisory Committee (as in existence on the day before the 

date of the enactment of this title). 

(C) ADDITIONAL APPOINTMENTS.—Each Steering Committee may recommend, if approved by a majority of voting 

members of the Committee, additional members to the 

Committee. 

(D) VACANCIES.—A vacancy in a Steering Committee 

shall be filled by an individual recommended by the Steering Committee. 

SEC. 3303. EDUCATION AND OUTREACH. 

The WTC Program Administrator shall institute a program that 

provides education and outreach on the existence and availability of 

services under the WTC Program. The outreach and education program— 

(1) shall include— 

(A) the establishment of a public Web site with information about the WTC Program; 

(B) meetings with potentially eligible populations; 

(C) development and dissemination of outreach materials 

informing people about the program; and 

(D) the establishment of phone information services; and 

(2) shall be conducted in a manner intended— 

(A) to reach all affected populations; and 

(B) to include materials for culturally and linguistically 

diverse populations. 

SEC. 3304. UNIFORM DATA COLLECTION AND ANALYSIS. 

(a) IN GENERAL.—The WTC Program Administrator shall provide 

for the uniform collection of data (and analysis of data and regular 

reports to the Administrator) on the prevalence of WTC-related 

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health conditions and the identification of new WTC-related health 

conditions. Such data shall be collected for all individuals provided 

monitoring or treatment benefits under subtitle B and regardless of 

their place of residence or Clinical Center of Excellence through 

which the benefits are provided. The WTC Program Administrator 

shall provide, through the Data Centers or otherwise, for the integration of such data into the monitoring and treatment program activities under this title. 

(b) COORDINATING THROUGH CENTERS OF EXCELLENCE.—Each 

Clinical Center of Excellence shall collect data described in subsection (a) and report such data to the corresponding Data Center 

for analysis by such Data Center. 

(c) COLLABORATION WITH WTC HEALTH REGISTRY.—The WTC 

Program Administrator shall provide for collaboration between the 

Data Centers and the World Trade Center Health Registry described 

in section 3342. 

(d) PRIVACY.—The data collection and analysis under this section 

shall be conducted and maintained in a manner that protects the 

confidentiality of individually identifiable health information consistent with applicable statutes and regulations, including, as applicable, HIPAA privacy and security law (as defined in section 

3009(a)(2)) and section 552a of title 5, United States Code. 

SEC. 3305. CLINICAL CENTERS OF EXCELLENCE AND DATA CENTERS. 

(a) IN GENERAL.— (1) CONTRACTS WITH CLINICAL CENTERS OF EXCELLENCE.— The WTC Program Administrator shall, subject to subsection 

(b)(1)(B), enter into contracts with Clinical Centers of Excellence 

(as defined in subsection (b)(1)(A))— 

(A) for the provision of monitoring and treatment benefits 

and initial health evaluation benefits under subtitle B; 

(B) for the provision of outreach activities to individuals 

eligible for such monitoring and treatment benefits, for initial health evaluation benefits, and for followup to individuals who are enrolled in the monitoring program; 

(C) for the provision of counseling for benefits under subtitle B, with respect to WTC-related health conditions, for 

individuals eligible for such benefits; 

(D) for the provision of counseling for benefits for WTCrelated health conditions that may be available under 

workers’ compensation or other benefit programs for workrelated injuries or illnesses, health insurance, disability insurance, or other insurance plans or through public or private social service agencies and assisting eligible individuals in applying for such benefits; 

(E) for the provision of translational and interpretive 

services for program participants who are not English language proficient; and 

(F) for the collection and reporting of data in accordance 

with section 3304. 

(2) CONTRACTS WITH DATA CENTERS.— 

(A) IN GENERAL.—The WTC Program Administrator 

shall enter into contracts with Data Centers (as defined in 

subsection (b)(2))— 

(i) for receiving, analyzing, and reporting to the WTC 

Program Administrator on data, in accordance with 

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section 3304, that have been collected and reported to 

such Data Centers by the corresponding Clinical Centers of Excellence under subsection (b)(1)(B)(iii); 

(ii) for the development of monitoring, initial health 

evaluation, and treatment protocols, with respect to 

WTC-related health conditions; 

(iii) for coordinating the outreach activities conducted under paragraph (1)(B) by each corresponding 

Clinical Center of Excellence; 

(iv) for establishing criteria for the credentialing of 

medical providers participating in the nationwide network under section 3313; 

(v) for coordinating and administering the activities 

of the WTC Health Program Steering Committees established under section 3002(b); and 

(vi) for meeting periodically with the corresponding 

Clinical Centers of Excellence to obtain input on the 

analysis and reporting of data collected under clause 

(i) and on the development of monitoring, initial health 

evaluation, and treatment protocols under clause (ii). 

(B) MEDICAL PROVIDER SELECTION.—The medical providers under subparagraph (A)(iv) shall be selected by the 

WTC Program Administrator on the basis of their experience treating or diagnosing the health conditions included 

in the list of WTC-related health conditions. 

(C) CLINICAL DISCUSSIONS.—In carrying out subparagraph (A)(ii), a Data Center shall engage in clinical discussions across the WTC Program to guide treatment approaches for individuals with a WTC-related health condition. 

(D) TRANSPARENCY OF DATA.—A contract entered into 

under this subsection with a Data Center shall require the 

Data Center to make any data collected and reported to 

such Center under subsection (b)(1)(B)(iii) available to 

health researchers and others as provided in the CDC/ 

ATSDR Policy on Releasing and Sharing Data. 

(3) AUTHORITY FOR CONTRACTS TO BE CLASS SPECIFIC.—A 

contract entered into under this subsection with a Clinical Center of Excellence or a Data Center may be with respect to one 

or more class of enrolled WTC responders, screening-eligible 

WTC survivors, or certified-eligible WTC survivors. 

(4) USE OF COOPERATIVE AGREEMENTS.—Any contract under 

this title between the WTC Program Administrator and a Data 

Center or a Clinical Center of Excellence may be in the form of 

a cooperative agreement. 

(b) CENTERS OF EXCELLENCE.— 

(1) CLINICAL CENTERS OF EXCELLENCE.— 

(A) DEFINITION.—For purposes of this title, the term 

‘‘Clinical Center of Excellence’’ means a Center that demonstrates to the satisfaction of the Administrator that the 

Center— 

(i) uses an integrated, centralized health care provider approach to create a comprehensive suite of 

health services under this title that are accessible to enmstockstill on DSKH9S0YB1PROD with HEARINGS

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rolled WTC responders, screening-eligible WTC survivors, or certified-eligible WTC survivors; 

(ii) has experience in caring for WTC responders and 

screening-eligible WTC survivors or includes health 

care providers who have been trained pursuant to section 3313(c); 

(iii) 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 

(iv) meets such other requirements as specified by the 

Administrator. 

(B) CONTRACT REQUIREMENTS.—The WTC Program Administrator shall not enter into a contract with a Clinical 

Center of Excellence under subsection (a)(1) unless the Center agrees to do each of the following: 

(i) Establish a formal mechanism for consulting with 

and receiving input from representatives of eligible 

populations receiving monitoring and treatment benefits under subtitle B from such Center. 

(ii) Coordinate monitoring and treatment benefits 

under subtitle B with routine medical care provided for 

the treatment of conditions other than WTC-related 

health conditions. 

(iii) Collect and report to the corresponding Data 

Center data in accordance with section 3304(b). 

(iv) Have in place safeguards against fraud that are 

satisfactory to the Administrator, in consultation with 

the Inspector General of the Department of Health and 

Human Services. 

(v) Treat or refer for treatment all individuals who 

are enrolled WTC responders or certified-eligible WTC 

survivors with respect to such Center who present 

themselves for treatment of a WTC-related health condition. 

(vi) Have in place safeguards, consistent with section 

3304(c), to ensure the confidentiality of an individual’s 

individually identifiable health information, including 

requiring that such information not be disclosed to the 

individual’s employer without the authorization of the 

individual. 

(vii) Use amounts paid under subsection (c)(1) only 

for costs incurred in carrying out the activities described in subsection (a), other than those described in 

subsection (a)(1)(A). 

(viii) Utilize health care providers with occupational 

and environmental medicine expertise to conduct physical and mental health assessments, in accordance 

with protocols developed under subsection (a)(2)(A)(ii). 

(ix) Communicate with WTC responders and screening-eligible and certified-eligible WTC survivors in appropriate languages and conduct outreach activities 

with relevant stakeholder worker or community associations. 

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(x) Meet all the other applicable requirements of this 

title, including regulations implementing such requirements. 

(C) TRANSITION RULE TO ENSURE CONTINUITY OF CARE.— The WTC Program Administrator shall to the maximum 

extent feasible ensure continuity of care in any period of 

transition from monitoring and treatment of an enrolled 

WTC responder or certified-eligible WTC survivor by a provider to a Clinical Center of Excellence or a health care 

provider participating in the nationwide network under section 3313. 

(2) DATA CENTERS.—For purposes of this title, the term ‘‘Data 

Center’’ means a Center that the WTC Program Administrator 

determines has the capacity to carry out the responsibilities for 

a Data Center under subsection (a)(2). 

(3) CORRESPONDING CENTERS.—For purposes of this title, a 

Clinical Center of Excellence and a Data Center shall be treated 

as ‘‘corresponding’’ to the extent that such Clinical Center and 

Data Center serve the same population group. 

(c) PAYMENT FOR INFRASTRUCTURE COSTS.— (1) IN GENERAL.—The WTC Program Administrator shall reimburse a Clinical Center of Excellence for the fixed infrastructure costs of such Center in carrying out the activities described 

in subtitle B at a rate negotiated by the Administrator and such 

Centers. Such negotiated rate shall be fair and appropriate and 

take into account the number of enrolled WTC responders receiving services from such Center under this title. 

(2) FIXED INFRASTRUCTURE COSTS.—For purposes of paragraph (1), the term ‘‘fixed infrastructure costs’’ means, with respect to a Clinical Center of Excellence, the costs incurred by 

such Center that are not reimbursable by the WTC Program 

Administrator under section 3312(c). 

SEC. 3306. DEFINITIONS. 

In this title: 

(1) The term ‘‘aggravating’’ means, with respect to a health 

condition, 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. 

(2) The term ‘‘certified-eligible WTC survivor’’ has the meaning given such term in section 3321(a)(2). 

(3) The terms ‘‘Clinical Center of Excellence’’ and ‘‘Data Center’’ have the meanings given such terms in section 3305. 

(4) The term ‘‘enrolled WTC responder’’ means a WTC responder enrolled under section 3311(a)(3). 

(5) The term ‘‘initial health evaluation’’ includes, with respect 

to an individual, 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 Program. 

(6) The term ‘‘list of WTC-related health conditions’’ means— 

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(A) for WTC responders, the health conditions listed in 

section 3312(a)(3); and 

(B) for screening-eligible and certified-eligible WTC survivors, the health conditions listed in section 3322(b). 

(7) The term ‘‘New York City disaster area’’ means the area 

within New York City that is— 

(A) the area of Manhattan that is south of Houston 

Street; and 

(B) any block in Brooklyn that is wholly or partially contained within a 1.5-mile radius of the former World Trade 

Center site. 

(8) The term ‘‘New York metropolitan area’’ means an area, 

specified by the WTC Program Administrator, within which 

WTC responders and eligible WTC screening-eligible survivors 

who reside in such area are reasonably able to access monitoring and treatment benefits and initial health evaluation benefits under this title through a Clinical Center of Excellence described in subparagraphs (A), (B), or (C) of section 3305(b)(1). 

(9) The term ‘‘screening-eligible WTC survivor’’ has the meaning given such term in section 3321(a)(1). 

(10) Any reference to ‘‘September 11, 2001’’ shall be deemed 

a reference to the period on such date subsequent to the terrorist 

attacks at the World Trade Center, Shanksville, Pennsylvania, 

or the Pentagon, as applicable, on such date. 

(11) The term ‘‘September 11, 2001, terrorist attacks’’ means 

the terrorist attacks that occurred on September 11, 2001, in 

New York City, in Shanksville, Pennsylvania, and at the Pentagon, and includes the aftermath of such attacks. 

(12) The term ‘‘WTC Health Program Steering Committee’’ 

means such a Steering Committee established under section 

3302(b). 

(13) The term ‘‘WTC Program’’ means the Word Trade Center 

Health Program established under section 3301(a). 

(14) The term ‘‘WTC Program Administrator’’ means— 

(A) with respect to paragraphs (3) and (4) of section 

3311(a) (relating to enrollment of WTC responders), section 

3312(c) and the corresponding provisions of section 3322 

(relating to payment for initial health evaluation, monitoring, and treatment), paragraphs (1)(C), (2)(B), and (3) of 

section 3321(a) (relating to determination or certification of 

screening-eligible or certified-eligible WTC responders), and 

part 3 of subtitle B (relating to payor provisions), an official in the Department of Health and Human Services, to 

be designated by the Secretary; and 

(B) with respect to any other provision of this title, the 

Director of the National Institute for Occupational Safety 

and Health, or a designee of such Director. 

(15) The term ‘‘WTC-related health condition’’ is defined in 

section 3312(a). 

(16) The term ‘‘WTC responder’’ is defined in section 3311(a). 

(17) The term ‘‘WTC Scientific/Technical Advisory Committee’’ means such Committee established under section 

3302(a). 

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Subtitle B—Program of Monitoring, Initial 

Health Evaluations, and Treatment 

PART 1—WTC RESPONDERS 

SEC. 3311. IDENTIFICATION OF WTC RESPONDERS AND PROVISION OF 

WTC-RELATED MONITORING SERVICES. 

(a) WTC RESPONDER DEFINED.— 

(1) IN GENERAL.—For purposes of this title, the term ‘‘WTC responder’’ means any of the following individuals, subject to 

paragraph (4): 

(A) CURRENTLY IDENTIFIED RESPONDER.—An individual 

who has been identified as eligible for monitoring under the 

arrangements as in effect on the date of the enactment of 

this title between the National Institute for Occupational 

Safety and Health and— 

(i) the consortium coordinated by Mt. Sinai Hospital 

in New York City that coordinates the monitoring and 

treatment for enrolled WTC responders other than with 

respect to those covered under the arrangement with 

the Fire Department of New York City; or 

(ii) the Fire Department of New York City. 

(B) RESPONDER WHO MEETS CURRENT ELIGIBILITY CRI- TERIA.—An individual who meets the current eligibility criteria described in paragraph (2). 

(C) RESPONDER WHO MEETS MODIFIED ELIGIBILITY CRITERIA.—An individual who— 

(i) performed rescue, recovery, demolition, debris 

cleanup, or other related services in the New York City 

disaster area in response to the September 11, 2001, 

terrorist attacks, regardless of whether such services 

were performed by a State or Federal employee or 

member of the National Guard or otherwise; and 

(ii) meets such eligibility criteria relating to exposure 

to airborne toxins, other hazards, or adverse conditions 

resulting from the September 11, 2001, terrorist attacks 

as the WTC Program Administrator, after consultation 

with the WTC Scientific/Technical Advisory Committee, determines appropriate. 

The WTC Program Administrator shall not modify such 

eligibility criteria on or after the date that the number of 

enrollments of WTC responders has reached 80 percent of 

the limit described in paragraph (4) or on or after the date 

that the number of certifications for certified-eligible WTC 

survivors under section 3321(a)(2)(B) has reached 80 percent of the limit described in section 3321(a)(3). 

(2) CURRENT ELIGIBILITY CRITERIA.—The eligibility criteria 

described in this paragraph for an individual is that the individual is described in any of the following categories: 

(A) FIREFIGHTERS AND RELATED PERSONNEL.—The individual— 

(i) was a member of the Fire Department of New 

York City (whether fire or emergency personnel, active 

or retired) who participated at least one day in the resmstockstill on DSKH9S0YB1PROD with HEARINGS

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cue and recovery effort at any of the former World 

Trade Center sites (including Ground Zero, Staten Island Landfill, and the New York City Chief Medical 

Examiner’s Office) for any time during the period beginning on September 11, 2001, and ending on July 

31, 2002; or 

(ii)(I) is a surviving immediate family member of an 

individual who was a member of the Fire Department 

of New York City (whether fire or emergency personnel, 

active or retired) and was killed at the World Trade 

site on September 11, 2001; and 

(II) received any treatment for a WTC-related health 

condition described in section 3312(a)(1)(A)(ii) (relating 

to mental health conditions) on or before September 1, 

2008. 

(B) LAW ENFORCEMENT OFFICERS AND WTC RESCUE, RE- COVERY, AND CLEANUP WORKERS.—The individual— 

(i) worked or volunteered onsite in rescue, recovery, 

debris cleanup, or related support services in lower 

Manhattan (south of Canal St.), the Staten Island 

Landfill, or the barge loading piers, for at least 4 

hours during the period beginning on September 11, 

2001, and ending on September 14, 2001, for at least 

24 hours during the period beginning on September 11, 

2001, and ending on September 30, 2001, or for at 

least 80 hours during the period beginning on September 11, 2001, and ending on July 31, 2002; 

(ii)(I) was a member of the Police Department of New 

York City (whether active or retired) or a member of 

the Port Authority Police of the Port Authority of New 

York and New Jersey (whether active or retired) who 

participated onsite in rescue, recovery, debris cleanup, 

or related services in lower Manhattan (south of Canal 

St.), including Ground Zero, the Staten Island Landfill, or the barge loading piers, for at least 4 hours during the period beginning September 11, 2001, and ending on September 14, 2001; 

(II) participated onsite in rescue, recovery, debris 

cleanup, or related services in at Ground Zero, the 

Staten Island Landfill, or the barge loading piers, for 

at least one day during the period beginning on September 11, 2001, and ending on July 31, 2002; 

(III) participated onsite in rescue, recovery, debris 

cleanup, or related services in lower Manhattan (south 

of Canal St.) for at least 24 hours during the period beginning on September 11, 2001, and ending on September 30, 2001; or 

(IV) participated onsite in rescue, recovery, debris 

cleanup, or related services in lower Manhattan (south 

of Canal St.) for at least 80 hours during the period beginning on September 11, 2001, and ending on July 

31, 2002; 

(iii) 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 

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World Trade Center 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; 

(iv) 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; or 

(v) 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 during 

a duration and period described in subparagraph (A). 

(C) RESPONDERS TO THE SEPTEMBER 11 ATTACKS AT THE

PENTAGON AND SHANKSVILLE, PENNSYLVANIA.—The individual— 

(i)(I) was a member of a fire or police department 

(whether fire or emergency personnel, active or retired), 

worked for a recovery or cleanup contractor, or was a 

volunteer; and performed rescue, recovery, demolition, 

debris cleanup, or other related services at the Pentagon site of the terrorist-related aircraft crash of September 11, 2001, during the period beginning on September 11, 2001, and ending on the date on which the 

cleanup of the site was concluded, as determined by the 

WTC Program Administrator; or 

(II) was a member of a fire or police department 

(whether fire or emergency personnel, active or retired), 

worked for a recovery or cleanup contractor, or was a 

volunteer; and performed rescue, recovery, demolition, 

debris cleanup, or other related services at the 

Shanksville, Pennsylvania, site of the terrorist-related 

aircraft crash of September 11, 2001, during the period 

beginning on September 11, 2001, and ending on the 

date on which the cleanup of the site was concluded, 

as determined by the WTC Program Administrator; 

and 

(ii) is determined by the WTC Program Administrator to be at an increased risk of developing a WTCrelated health condition as a result of exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 11, 2001, terrorist attacks, 

and meets such eligibility criteria related to such exposures, as the WTC Program Administrator determines 

are appropriate, after consultation with the WTC Scientific/Technical Advisory Committee. 

(3) ENROLLMENT PROCESS.— 

(A) IN GENERAL.—The WTC Program Administrator 

shall establish a process for enrolling WTC responders in 

the WTC Program. Under such process— 

(i) WTC responders described in paragraph (1)(A) 

shall be deemed to be enrolled in such Program; 

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(ii) subject to clause (iii), the Administrator shall enroll in such program individuals who are determined 

to be WTC responders; 

(iii) the Administrator shall deny such enrollment to 

an individual if the Administrator determines that the 

numerical limitation in paragraph (4) on enrollment of 

WTC responders has been met; 

(iv) there shall be no fee charged to the applicant for 

making an application for such enrollment; 

(v) the Administrator shall make a determination on 

such an application not later than 60 days after the 

date of filing the application; and 

(vi) an individual who is denied enrollment in such 

Program shall have an opportunity to appeal such determination in a manner established under such process. 

(B) TIMING.— (i) CURRENTLY IDENTIFIED RESPONDERS.—In accordance with subparagraph (A)(i), the WTC Program Administrator shall enroll an individual described in 

paragraph (1)(A) in the WTC Program not later than 

July 1, 2011. 

(ii) OTHER RESPONDERS.—In accordance with subparagraph (A)(ii) and consistent with paragraph (4), 

the WTC Program Administrator shall enroll any other 

individual who is determined to be a WTC responder 

in the WTC Program at the time of such determination. 

(4) NUMERICAL LIMITATION ON ELIGIBLE WTC RESPONDERS.— (A) IN GENERAL.—The total number of individuals not 

described in paragraph (1)(A) or (2)(A)(ii) who may be enrolled under paragraph (3)(A)(ii) shall not exceed 25,000 at 

any time, of which no more than 2,500 may be individuals 

enrolled based on modified eligibility criteria established 

under paragraph (1)(C). 

(B) PROCESS.—In implementing subparagraph (A), the 

WTC Program Administrator shall— 

(i) limit the number of enrollments made under 

paragraph (3)— 

(I) in accordance with such subparagraph; and 

(II) to such number, as determined by the Administrator based on the best available information and subject to amounts available under section 3351, that will ensure sufficient funds will be 

available to provide treatment and monitoring 

benefits under this title, with respect to all individuals who are enrolled through the end of fiscal 

year 2020; and 

(ii) provide priority (subject to paragraph (3)(A)(i)) in 

such enrollments in the order in which individuals 

apply for enrollment under paragraph (3). 

(5) DISQUALIFICATION OF INDIVIDUALS ON TERRORIST WATCH

LIST.—No individual who is on the terrorist watch list maintained by the Department of Homeland Security shall qualify as 

an eligible WTC responder. Before enrolling any individual as 

a WTC responder in the WTC Program under paragraph (3), 

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the Administrator, in consultation with the Secretary of Homeland Security, shall determine whether the individual is on 

such list. 

(b) MONITORING BENEFITS.— (1) IN GENERAL.—In the case of an enrolled WTC responder 

(other than one described in subsection (a)(2)(A)(ii)), the WTC 

Program shall provide for monitoring benefits that include 

monitoring consistent with protocols approved by the WTC Program Administrator and including clinical examinations and 

long-term health monitoring and analysis. In the case of an enrolled WTC responder who is an active member of the Fire Department of New York City, the responder shall receive such 

benefits as part of the individual’s periodic company medical 

exams. 

(2) PROVISION OF MONITORING BENEFITS.—The monitoring 

benefits under paragraph (1) shall be provided through the 

Clinical Center of Excellence for the type of individual involved 

or, in the case of an individual residing outside the New York 

metropolitan area, under an arrangement under section 3313. 

SEC. 3312. TREATMENT OF ENROLLED WTC RESPONDERS FOR WTC-RELATED HEALTH CONDITIONS. 

(a) WTC-RELATED HEALTH CONDITION DEFINED.— (1) IN GENERAL.—For purposes of this title, the term ‘‘WTCrelated 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 3322(a). 

In the case of a WTC responder described in section 

3311(a)(2)(A)(ii) (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) DETERMINATION.—The determination under paragraph (1) 

or subsection (b) of whether the September 11, 2001, terrorist 

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gravating, 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 RESPONDERS.—The 

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.—In the case of a WTC responder described in 

paragraph (4), a condition described in such paragraph. 

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(D) ADDITIONAL CONDITIONS.—Any cancer (or type of cancer) or other condition added, pursuant to paragraph (5) or 

(6), to the list under this paragraph. 

(4) MUSCULOSKELETAL DISORDERS.— (A) IN GENERAL.—For purposes of this title, in the case 

of a WTC responder who received any treatment for a WTCrelated 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.—The term ‘‘WTC-related musculoskeletal 

disorder’’ means 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. 

(5) CANCER.— (A) IN GENERAL.—The WTC Program Administrator 

shall periodically conduct a review of all available scientific and medical evidence, including findings and recommendations of Clinical Centers of Excellence, published 

in peer-reviewed journals to determine if, based on such 

evidence, cancer or a certain type of cancer should be added 

to the applicable list of WTC-related health conditions. The 

WTC Program Administrator shall conduct the first review 

under this subparagraph not later than 180 days after the 

date of the enactment of this title. 

(B) PROPOSED REGULATIONS AND RULEMAKING.—Based 

on the periodic reviews under subparagraph (A), if the 

WTC Program Administrator determines that cancer or a 

certain type of cancer should be added to such list of WTCrelated health conditions, the WTC Program Administrator 

shall propose regulations, through rulemaking, to add cancer or the certain type of cancer to such list. 

(C) FINAL REGULATIONS.—Based on all the available evidence in the rulemaking record, the WTC Program Administrator shall make a final determination of whether cancer 

or a certain type of cancer should be added to such list of 

WTC-related health conditions. If such a determination is 

made to make such an addition, the WTC Program Administrator shall by regulation add cancer or the certain type 

of cancer to such list. 

(D) DETERMINATIONS NOT TO ADD CANCER OR CERTAIN

TYPES OF CANCER.—In the case that the WTC Program Administrator determines under subparagraph (B) or (C) that 

cancer or a certain type of cancer should not be added to 

such list of WTC-related health conditions, the WTC Program Administrator shall publish an explanation for such 

determination in the Federal Register. Any such determination to not make such an addition shall not preclude the 

addition of cancer or the certain type of cancer to such list 

at a later date. 

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(6) ADDITION OF HEALTH CONDITIONS TO LIST FOR WTC RE- SPONDERS.— (A) IN GENERAL.—Whenever the WTC Program Administrator determines that a proposed rule should be promulgated to add a health condition to the list of health conditions in paragraph (3), the Administrator may request a 

recommendation of the Advisory Committee or may publish 

such a proposed rule in the Federal Register in accordance 

with subparagraph (D). 

(B) ADMINISTRATOR’S OPTIONS AFTER RECEIPT OF PETI- TION.—In 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 60 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.—In the case that 

the Administrator requests a recommendation of the Advisory Committee under this paragraph, with respect to adding a health condition to the list in paragraph (3), the Advisory Committee shall submit to the Administrator such 

recommendation not later than 60 days after the date of 

such request or by such date (not to exceed 180 days after 

such date of request) as specified by the Administrator. Not 

later than 60 days after the date of receipt of such recommendation, the Administrator shall, in accordance with 

subparagraph (D), publish in the Federal Register a proposed rule with respect to such recommendation or a determination not to propose such a proposed rule and the basis 

for such determination. 

(D) PUBLICATION.—The 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, United States Code; 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.—For purposes of this 

paragraph, the term ‘‘interested party’’ includes a representative of any organization representing WTC responders, a 

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nationally recognized medical association, a Clinical or 

Data Center, a State or political subdivision, or any other 

interested person. 

(b) COVERAGE OF TREATMENT FOR WTC-RELATED HEALTH CONDITIONS.— 

(1) DETERMINATION FOR ENROLLED WTC RESPONDERS BASED

ON A WTC-RELATED HEALTH CONDITION.— 

(A) IN GENERAL.—If a physician at a Clinical Center of 

Excellence that is providing monitoring benefits under section 3311 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.—A Federal employee designated by the 

WTC Program Administrator shall review determinations made under subparagraph (A). 

(ii) CERTIFICATION.—The Administrator shall provide a certification of such condition based upon reviews conducted under clause (i). Such a certification 

shall be provided unless the Administrator determines 

that the responder’s condition is not a WTC-related 

health condition in the list in subsection (a)(3) or that 

exposure to airborne toxins, other hazards, or adverse 

conditions resulting from the September 1, 2001, terrorist attacks is not substantially likely to be a significant factor in aggravating, contributing to, or causing 

the condition. 

(iii) APPEAL PROCESS.—The Administrator shall establish, by rule, a process for the appeal of determinations under clause (ii). 

(2) DETERMINATION BASED ON MEDICALLY ASSOCIATED WTCRELATED HEALTH CONDITIONS.— 

(A) IN GENERAL.—If 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 

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(ii) the Administrator shall make a determination 

under subparagraph (B) with respect to such physician’s determination. 

(B) PROCEDURES FOR REVIEW, CERTIFICATION, AND AP- PEAL.—The 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.—If the 

WTC Program Administrator provides certification under 

subparagraph (B)(iii) for coverage of a condition, the Administrator may, pursuant to subsection (a)(6), add the condition to the list in subsection (a)(3). 

(D) CONDITIONS ALREADY DECLINED FOR INCLUSION IN

LIST.—If the WTC Program Administrator publishes a determination under subsection (a)(6)(B) not to include a condition in the list in subsection (a)(3), the WTC Program Administrator shall not provide certification under subparagraph (B)(iii) for coverage of the condition. In the case of 

an individual who is certified under subparagraph (B)(iii) 

with respect to such condition before the date of the publication of such determination the previous sentence shall not 

apply. 

(3) REQUIREMENT OF MEDICAL NECESSITY.— 

(A) IN GENERAL.—In providing treatment for a WTC-related health condition, a physician or other provider shall 

provide treatment that is medically necessary and in accordance with medical treatment protocols established 

under subsection (d). 

(B) REGULATIONS RELATING TO MEDICAL NECESSITY.—For 

the purpose of this title, the WTC Program Administrator 

shall issue regulations specifying a standard for determining medical necessity with respect to health care services and prescription pharmaceuticals, a process for determining whether treatment furnished and pharmaceuticals 

prescribed under this title meet such standard (including 

any prior authorization requirement), and a process for appeal of a determination under subsection (c)(3). 

(4) SCOPE OF TREATMENT COVERED.— 

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(A) IN GENERAL.—The scope of treatment covered under 

this subsection includes services of physicians and other 

health care providers, diagnostic and laboratory tests, prescription drugs, inpatient and outpatient hospital services, 

and other medically necessary treatment. 

(B) PHARMACEUTICAL COVERAGE.—With respect to ensuring coverage of medically necessary outpatient prescription 

drugs, such drugs shall be provided, under arrangements 

made by the WTC Program Administrator, directly through 

participating Clinical Centers of Excellence or through one 

or more outside vendors. 

(C) TRANSPORTATION EXPENSES FOR NATIONWIDE NETWORK.—The WTC Program Administrator may provide for 

necessary and reasonable transportation and expenses incident to the securing of medically necessary treatment 

through the nationwide network under section 3313 involving travel of more than 250 miles and for which payment 

is made under this section in the same manner in which 

individuals may be furnished necessary and reasonable 

transportation and expenses incident to services involving 

travel of more than 250 miles under regulations implementing section 3629(c) of the Energy Employees Occupational Illness Compensation Program Act of 2000 (title 

XXXVI of Public Law 106–398; 42 U.S.C. 7384t(c)). 

(5) PROVISION OF TREATMENT PENDING CERTIFICATION.—With 

respect to an enrolled WTC responder for whom a determination is made by an examining physician under paragraph (1) 

or (2), but for whom the WTC Program Administrator has not 

yet determined whether to certify the determination, the WTC 

Program Administrator may establish by rule a process through 

which the Administrator may approve the provision of medical 

treatment under this subsection (and payment under subsection 

(c)) with respect to such responder and such responder’s WTCrelated health condition (under such terms and conditions as 

the Administrator may provide) until the Administrator makes 

a decision on whether to certify the determination. 

(c) PAYMENT FOR INITIAL HEALTH EVALUATION, MONITORING, AND

TREATMENT OF WTC-RELATED HEALTH CONDITIONS.— 

(1) MEDICAL TREATMENT.— 

(A) USE OF FECA PAYMENT RATES.—Subject to subparagraphs (B) and (C), the WTC Program Administrator shall 

reimburse costs for medically necessary treatment under 

this title 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. For treatment not covered 

under the previous sentence or subparagraph (B), the WTC 

Program Administrator shall establish by regulation a reimbursement rate for such treatment. 

(B) PHARMACEUTICALS.— 

(i) IN GENERAL.—The WTC Program Administrator 

shall establish a program for paying for the medically 

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tions through one or more contracts with outside vendors. 

(ii) COMPETITIVE BIDDING.—Under 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.—Under 

such program the Administrator may enter into an 

agreement with a separate vendor to provide pharmaceutical benefits to enrolled WTC responders for whom 

the Clinical Center of Excellence is described in section 

3305 if such an arrangement is deemed necessary and 

beneficial to the program by the WTC Program Administrator. 

(C) IMPROVING QUALITY AND EFFICIENCY THROUGH MODIFICATION OF PAYMENT AMOUNTS AND METHODOLOGIES.— 

The WTC Program Administrator may modify the amounts 

and methodologies for making payments for initial health 

evaluations, monitoring, or treatment, if, taking into account utilization and quality data furnished by the Clinical 

Centers of Excellence under section 3305(b)(1)(B)(iii), the 

Administrator determines that a bundling, capitation, pay 

for performance, or other payment methodology would better ensure high quality and efficient delivery of initial 

health evaluations, monitoring, or treatment to an enrolled 

WTC responder, screening-eligible WTC survivor, or certified-eligible WTC survivor. 

(2) MONITORING AND INITIAL HEALTH EVALUATION.—The WTC 

Program Administrator shall reimburse the costs of monitoring 

and the costs of an initial health evaluation provided under 

this title at a rate set by the Administrator by regulation. 

(3) DETERMINATION OF MEDICAL NECESSITY.— 

(A) REVIEW OF MEDICAL NECESSITY AND PROTOCOLS.—As 

part of the process for reimbursement or payment under 

this subsection, the WTC Program Administrator shall provide for the review of claims for reimbursement or payment 

for the provision of medical treatment to determine if such 

treatment is medically necessary and in accordance with 

medical treatment protocols established under subsection 

(d). 

(B) WITHHOLDING OF PAYMENT FOR MEDICALLY UNNECESSARY TREATMENT.—The Administrator shall withhold such 

reimbursement or payment for treatment that the Administrator determines is not medically necessary or is not in accordance with such medical treatment protocols. 

(d) MEDICAL TREATMENT PROTOCOLS.— 

(1) DEVELOPMENT.—The Data Centers shall develop medical 

treatment protocols for the treatment of enrolled WTC responders and certified-eligible WTC survivors for health conditions 

included in the applicable list of WTC-related health conditions. 

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(2) APPROVAL.—The medical treatment protocols developed 

under paragraph (1) shall be subject to approval by the WTC 

Program Administrator. 

SEC. 3313. NATIONAL ARRANGEMENT FOR BENEFITS FOR ELIGIBLE INDIVIDUALS OUTSIDE NEW YORK. 

(a) IN GENERAL.—In order to ensure reasonable access to benefits 

under this subtitle for individuals who are enrolled WTC responders, screening-eligible WTC survivors, or certified-eligible WTC survivors and who reside in any State, as defined in section 2(f), outside the New York metropolitan area, the WTC Program Administrator shall establish a nationwide network of health care providers 

to provide monitoring and treatment benefits and initial health 

evaluations near such individuals’ areas of residence in such States. 

Nothing in this subsection shall be construed as preventing such individuals from being provided such monitoring and treatment benefits or initial health evaluation through any Clinical Center of Excellence. 

(b) NETWORK REQUIREMENTS.—Any health care provider participating in the network under subsection (a) shall— 

(1) meet criteria for credentialing established by the Data 

Centers; 

(2) follow the monitoring, initial health evaluation, and treatment protocols developed under section 3305(a)(2)(A)(ii); 

(3) collect and report data in accordance with section 3304; 

and 

(4) meet such fraud, quality assurance, and other requirements as the WTC Program Administrator establishes, including sections 1128 through 1128E of the Social Security Act, as 

applied by section 3301(d). 

(c) TRAINING AND TECHNICAL ASSISTANCE.—The WTC Program 

Administer may provide, including through contract, for the provision of training and technical assistance to health care providers 

participating in the network under subsection (a). 

PART 2—WTC SURVIVORS 

SEC. 3321. IDENTIFICATION AND INITIAL HEALTH EVALUATION OF 

SCREENING-ELIGIBLE AND CERTIFIED-ELIGIBLE WTC 

SURVIVORS. 

(a) IDENTIFICATION OF SCREENING-ELIGIBLE WTC SURVIVORS AND

CERTIFIED-ELIGIBLE WTC SURVIVORS.— 

(1) SCREENING-ELIGIBLE WTC SURVIVORS.— 

(A) DEFINITION.—In this title, the term ‘‘screening-eligible 

WTC survivor’’ means, subject to subparagraph (C) and 

paragraph (3), an individual who is described in any of the 

following clauses: 

(i) CURRENTLY IDENTIFIED SURVIVOR.—An individual, including a WTC responder, who has been 

identified as eligible for medical treatment and monitoring by the WTC Environmental Health Center as of 

the date of enactment of this title. 

(ii) SURVIVOR WHO MEETS CURRENT ELIGIBILITY CRITERIA.—An individual who is not a WTC responder, 

for purposes of the initial health evaluation under subsection (b), claims symptoms of a WTC-related health 

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condition and meets any of the current eligibility criteria described in subparagraph (B). 

(iii) SURVIVOR WHO MEETS MODIFIED ELIGIBILITY CRI- TERIA.—An individual who is not a WTC responder, 

for purposes of the initial health evaluation under subsection (b), claims symptoms of a WTC-related health 

condition and meets such eligibility criteria relating to 

exposure to airborne toxins, other hazards, or adverse 

conditions resulting from the September 11, 2001, terrorist attacks as the WTC Administrator determines, 

after consultation with the Data Centers described in 

section 3305 and the WTC Scientific/Technical Advisory Committee and WTC Health Program Steering 

Committees under section 3302. 

The Administrator shall not modify such criteria under 

clause (iii) on or after the date that the number of certifications for certified-eligible WTC survivors under paragraph (2)(B) has reached 80 percent of the limit described 

in paragraph (3) or on or after the date that the number 

of enrollments of WTC responders has reached 80 percent 

of the limit described in section 3311(a)(4). 

(B) CURRENT ELIGIBILITY CRITERIA.—The eligibility criteria described in this subparagraph for an individual are 

that the individual is described in any of the following 

clauses: 

(i) A person who was present in the New York City 

disaster area in the dust or dust cloud on September 

11, 2001. 

(ii) A person who worked, resided, or attended 

school, childcare, or adult daycare in the New York 

City disaster area for— 

(I) at least 4 days during the 4-month period beginning on September 11, 2001, and ending on 

January 10, 2002; or 

(II) at least 30 days during the period beginning 

on September 11, 2001, and ending on July 31, 

2002. 

(iii) Any person who worked as a cleanup worker or 

performed maintenance work in the New York City disaster area during the 4-month period described in subparagraph (B)(i) and had extensive exposure to WTC 

dust as a result of such work. 

(iv) A person who was deemed eligible to receive a 

grant from the Lower Manhattan Development Corporation Residential Grant Program, who possessed a 

lease for a residence or purchased a residence in the 

New York City disaster area, and who resided in such 

residence during the period beginning on September 

11, 2001, and ending on May 31, 2003. 

(v) A person whose place of employment— 

(I) 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 

(II) was deemed eligible to receive a grant from 

the Lower Manhattan Development Corporation 

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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. 

(C) APPLICATION AND DETERMINATION PROCESS FOR

SCREENING ELIGIBILITY.— (i) IN GENERAL.—The WTC Program Administrator 

in consultation with the Data Centers shall establish a 

process for individuals, other than individuals described in subparagraph (A)(i), to be determined to be 

screening-eligible WTC survivors. Under such process— 

(I) there shall be no fee charged to the applicant 

for making an application for such determination; 

(II) the Administrator shall make a determination on such an application not later than 60 days 

after the date of filing the application; 

(III) the Administrator shall make such a determination relating to an applicant’s compliance 

with this title and shall not determine that an individual is not so eligible or deny written documentation under clause (ii) to such individual unless the Administrator determines that— 

(aa) based on the application submitted, the 

individual does not meet the eligibility criteria; or 

(bb) the numerical limitation on certifications of certified-eligible WTC survivors set 

forth in paragraph (3) has been met; and 

(IV) an individual who is determined not to be 

a screening-eligible WTC survivor shall have an 

opportunity to appeal such determination in a 

manner established under such process. 

(ii) WRITTEN DOCUMENTATION OF SCREENING-ELIGIBILITY.— 

(I) IN GENERAL.—In the case of an individual 

who is described in subparagraph (A)(i) or who is 

determined under clause (i) (consistent with paragraph (3)) to be a screening-eligible WTC survivor, 

the WTC Program Administrator shall provide an 

appropriate written documentation of such fact. 

(II) TIMING.— 

(aa) CURRENTLY IDENTIFIED SURVIVORS.—In 

the case of an individual who is described in 

subparagraph (A)(i), the WTC Program Administrator shall provide the written documentation under subclause (I) not later than 

July 1, 2011. 

(bb) OTHER MEMBERS.—In the case of another individual who is determined under 

clause (i) and consistent with paragraph (3) to 

be a screening-eligible WTC survivor, the WTC 

Program Administrator shall provide the written documentation under subclause (I) at the 

time of such determination. 

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(2) CERTIFIED-ELIGIBLE WTC SURVIVORS.— (A) DEFINITION.—The term ‘‘certified-eligible WTC survivor’’ means, subject to paragraph (3), a screening-eligible 

WTC survivor who the WTC Program Administrator certifies under subparagraph (B) to be eligible for followup 

monitoring and treatment under this part. 

(B) CERTIFICATION OF ELIGIBILITY FOR MONITORING AND

TREATMENT.— (i) IN GENERAL.—The WTC Program Administrator 

shall establish a certification process under which the 

Administrator shall provide appropriate certification to 

screening-eligible WTC survivors who, pursuant to the 

initial health evaluation under subsection (b), are determined to be eligible for followup monitoring and 

treatment under this part. 

(ii) TIMING.— (I) CURRENTLY IDENTIFIED SURVIVORS.—In the 

case of an individual who is described in paragraph (1)(A)(i), the WTC Program Administrator 

shall provide the certification under clause (i) not 

later than July 1, 2011. 

(II) OTHER MEMBERS.—In the case of another individual who is determined under clause (i) to be 

eligible for followup monitoring and treatment, the 

WTC Program Administrator shall provide the certification under such clause at the time of such determination. 

(3) NUMERICAL LIMITATION ON CERTIFIED-ELIGIBLE WTC SUR- VIVORS.— 

(A) IN GENERAL.—The total number of individuals not 

described in paragraph (1)(A)(i) who may be certified as 

certified-eligible WTC survivors under paragraph (2)(B) 

shall not exceed 25,000 at any time. 

(B) PROCESS.—In implementing subparagraph (A), the 

WTC Program Administrator shall— 

(i) limit the number of certifications provided under 

paragraph (2)(B)— 

(I) in accordance with such subparagraph; and 

(II) to such number, as determined by the Administrator based on the best available information and subject to amounts made available under 

section 3351, that will ensure sufficient funds will 

be available to provide treatment and monitoring 

benefits under this title, with respect to all individuals receiving such certifications through the end 

of fiscal year 2020; and 

(ii) provide priority in such certifications in the order 

in which individuals apply for a determination under 

paragraph (2)(B). 

(4) DISQUALIFICATION OF INDIVIDUALS ON TERRORIST WATCH

LIST.—No individual who is on the terrorist watch list maintained by the Department of Homeland Security shall qualify as 

a screening-eligible WTC survivor or a certified-eligible WTC 

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dividual as a certified eligible WTC survivor under paragraph 

(2), the Administrator, in consultation with the Secretary of 

Homeland Security, shall determine whether the individual is 

on such list. 

(b) INITIAL HEALTH EVALUATION TO DETERMINE ELIGIBILITY FOR

FOLLOWUP MONITORING OR TREATMENT.— (1) IN GENERAL.—In the case of a screening-eligible WTC survivor, the WTC Program shall provide for an initial health 

evaluation to determine if the survivor has a WTC-related 

health condition and is eligible for followup monitoring and 

treatment benefits under the WTC Program. Initial health evaluation protocols under section 3305(a)(2)(A)(ii) shall be subject 

to approval by the WTC Program Administrator. 

(2) INITIAL HEALTH EVALUATION PROVIDERS.—The initial 

health evaluation described in paragraph (1) shall be provided 

through a Clinical Center of Excellence with respect to the individual involved. 

(3) LIMITATION ON INITIAL HEALTH EVALUATION BENEFITS.— Benefits for an initial health evaluation under this part for a 

screening-eligible WTC survivor shall consist only of a single 

medical initial health evaluation consistent with initial health 

evaluation protocols described in paragraph (1). Nothing in this 

paragraph shall be construed as preventing such an individual 

from seeking additional medical initial health evaluations at 

the expense of the individual. 

SEC. 3322. FOLLOWUP MONITORING AND TREATMENT OF CERTIFIEDELIGIBLE WTC SURVIVORS FOR WTC-RELATED HEALTH 

CONDITIONS. 

(a) IN GENERAL.—Subject to subsection (b), the provisions of sections 3311 and 3312 shall apply to followup monitoring and treatment of WTC-related health conditions for certified-eligible WTC 

survivors in the same manner as such provisions apply to the monitoring and treatment of WTC-related health conditions for enrolled 

WTC responders. 

(b) LIST OF WTC-RELATED HEALTH CONDITIONS FOR SURVIVORS.—The list of health conditions for screening-eligible WTC 

survivors and certified-eligible WTC survivors consists of the following: 

(1) AERODIGESTIVE DISORDERS.— 

(A) Interstitial lung diseases. 

(B) Chronic respiratory disorder—fumes/vapors. 

(C) Asthma. 

(D) Reactive airways dysfunction syndrome (RADS). 

(E) WTC-exacerbated chronic obstructive pulmonary disease (COPD). 

(F) Chronic cough syndrome. 

(G) Upper airway hyperreactivity. 

(H) Chronic rhinosinusitis. 

(I) Chronic nasopharyngitis. 

(J) Chronic laryngitis. 

(K) Gastroesophageal reflux disorder (GERD). 

(L) Sleep apnea exacerbated by or related to a condition 

described in a previous clause. 

(2) MENTAL HEALTH CONDITIONS.— 

(A) Posttraumatic stress disorder (PTSD). 

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(B) Major depressive disorder. 

(C) Panic disorder. 

(D) Generalized anxiety disorder. 

(E) Anxiety disorder (not otherwise specified). 

(F) Depression (not otherwise specified). 

(G) Acute stress disorder. 

(H) Dysthymic disorder. 

(I) Adjustment disorder. 

(J) Substance abuse. 

(3) ADDITIONAL CONDITIONS.—Any cancer (or type of cancer) 

or other condition added to the list in section 3312(a)(3) pursuant to paragraph (5) or (6) of section 3312(a), as such provisions are applied under subsection (a) with respect to certifiedeligible WTC survivors. 

SEC. 3323. FOLLOWUP MONITORING AND TREATMENT OF OTHER INDIVIDUALS WITH WTC-RELATED HEALTH CONDITIONS. 

(a) IN GENERAL.—Subject to subsection (c), the provisions of section 3322 shall apply to the followup monitoring and treatment of 

WTC-related health conditions in the case of individuals described 

in subsection (b) in the same manner as such provisions apply to 

the followup monitoring and treatment of WTC-related health conditions for certified-eligible WTC survivors. 

(b) INDIVIDUALS DESCRIBED.—An individual described in this 

subsection is an individual who, regardless of location of residence— 

(1) is not an enrolled WTC responder or a certified-eligible 

WTC survivor; and 

(2) is diagnosed at a Clinical Center of Excellence with a 

WTC-related health condition for certified-eligible WTC survivors. 

(c) LIMITATION.— (1) IN GENERAL.—The WTC Program Administrator shall 

limit benefits for any fiscal year under subsection (a) in a manner so that payments under this section for such fiscal year do 

not exceed the amount specified in paragraph (2) for such fiscal 

year. 

(2) LIMITATION.—The amount specified in this paragraph 

for— 

(A) the last calendar quarter of fiscal year 2011 is $5,000,000; 

(B) fiscal year 2012 is $20,000,000; or 

(C) a succeeding fiscal year is the amount specified in 

this paragraph for the previous fiscal year increased by the 

annual percentage increase in the medical care component 

of the consumer price index for all urban consumers. 

PART 3—PAYOR PROVISIONS 

SEC. 3331. PAYMENT OF CLAIMS. 

(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 parts 1 and 2 of this subtitle 

shall be paid for by the WTC Program from the World Trade Center 

Health Program Fund. 

(b) WORKERS’ COMPENSATION PAYMENT.— 

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96 

(1) IN GENERAL.—Subject to paragraph (2), payment for treatment under parts 1 and 2 of this subtitle 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 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 to the Secretary 

(with respect to such a law or plan and an individual entitled 

to benefits under title XVIII of such Act) 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 title. 

(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 title 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) the provisions of section 

1862(b) of the Social Security Act 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. 

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 title to the extent that 

they are covered under the WTC Program. The program under 

this title shall not be treated as a legally liable party for purposes of applying section 1902(a)(25) of the Social Security Act. 

(2) RECOVERY BY INDIVIDUAL PROVIDERS.—Nothing in paragraph (1) shall be construed as requiring an entity providing 

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97 

ment 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 title 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 Internal Revenue Code of 1986) 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 

3351 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 the last calendar quarter of fiscal year 2011 

and each calendar quarter in fiscal years 2012 through 

2020 the full contribution amount under this subparagraph 

shall be equal to 10 percent of the expenditures in carrying 

out this title for the respective quarter. 

(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 the date of the enactment 

of this title. 

(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, 

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98 

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 may be recoverable in an action brought under section 

1862(b)(2)(B)(iii) of such Act. 

(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 

3351. 

(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 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 3311(a)(4) or 3321(a)(3) 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. 

SEC. 3332. ADMINISTRATIVE ARRANGEMENT AUTHORITY. 

The WTC Program Administrator may enter into arrangements 

with other government agencies, insurance companies, or other 

third-party administrators to provide for timely and accurate processing of claims under sections 3312, 3313, 3322, and 3323. 

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Subtitle C—Research Into Conditions 

SEC. 3341. RESEARCH REGARDING CERTAIN HEALTH CONDITIONS RELATED TO SEPTEMBER 11 TERRORIST ATTACKS. 

(a) IN GENERAL.—With respect to individuals, including enrolled 

WTC responders and certified-eligible WTC survivors, receiving 

monitoring or treatment under subtitle B, the WTC Program Administrator shall conduct or support— 

(1) research on physical and mental health conditions that 

may be related to the September 11, 2001, terrorist attacks; 

(2) research on diagnosing WTC-related health conditions of 

such individuals, in the case of conditions for which there has 

been diagnostic uncertainty; and 

(3) research on treating WTC-related health conditions of 

such individuals, in the case of conditions for which there has 

been treatment uncertainty. 

The Administrator may provide such support through continuation 

and expansion of research that was initiated before the date of the 

enactment of this title and through the World Trade Center Health 

Registry (referred to in section 3342), through a Clinical Center of 

Excellence, or through a Data Center. 

(b) TYPES OF RESEARCH.—The research under subsection (a)(1) 

shall include epidemiologic and other research studies on WTC-related health conditions or emerging conditions— 

(1) among enrolled WTC responders and certified-eligible 

WTC survivors under treatment; and 

(2) in sampled populations outside the New York City disaster area in Manhattan as far north as 14th Street and in 

Brooklyn, along with control populations, to identify potential 

for long-term adverse health effects in less exposed populations. 

(c) CONSULTATION.—The WTC Program Administrator shall carry 

out this section in consultation with the WTC Scientific/Technical 

Advisory Committee. 

(d) APPLICATION OF PRIVACY AND HUMAN SUBJECT PROTECTIONS.—The privacy and human subject protections applicable to research conducted under this section shall not be less than such protections applicable to research conducted or funded by the Department of Health and Human Services. 

SEC. 3342. WORLD TRADE CENTER HEALTH REGISTRY. 

For the purpose of ensuring ongoing data collection relating to 

victims of the September 11, 2001, terrorist attacks, the WTC Program Administrator shall ensure that a registry of such victims is 

maintained that is at least as comprehensive as the World Trade 

Center Health Registry maintained under the arrangements in effect 

as of April 20, 2009, with the New York City Department of Health 

and Mental Hygiene. 

Subtitle D—Funding 

SEC. 3351. WORLD TRADE CENTER HEALTH PROGRAM FUND. 

(a) ESTABLISHMENT OF FUND.— 

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100 

(1) IN GENERAL.—There is established a fund to be known as 

the World Trade Center Health Program Fund (referred to in 

this section as the ‘‘Fund’’). 

(2) FUNDING.—Out of any money in the Treasury not otherwise appropriated, there shall be deposited into the Fund for 

each of fiscal years 2012 through 2020 (and the last calendar 

quarter of fiscal year 2011)— 

(A) the Federal share, consisting of an amount equal to 

the lesser of— 

(i) 90 percent of the expenditures in carrying out this 

title for the respective fiscal year (initially based on estimates, subject to subsequent reconciliation based on 

actual expenditures); or 

(ii) $71,000,000 for the last calendar quarter of fiscal 

year 2011, $318,000,000 for fiscal year 2012, 

$354,000,000 for fiscal year 2013, $382,000,000 for fiscal year 2014, $431,000,000 for fiscal year 2015, 

$481,000,000 for fiscal year 2016, $537,000,000 for fiscal year 2017, $601,000,000 for fiscal year 2018, 

$672,000,000 for fiscal year 2019, and $743,000,000 

for fiscal year 2020; plus 

(B) the New York City share, consisting of the amount 

contributed under the contract under section 3331(d). 

(3) CONTRACT REQUIREMENT.— 

(A) IN GENERAL.—No funds may be disbursed from the 

Fund unless New York City has entered into a contract 

with the WTC Program Administrator under section 

3331(d)(1). 

(B) BREACH OF CONTRACT.— In the case of a failure to 

pay the amount so required under the contract— 

(i) the amount is recoverable under subparagraph 

(E)(ii) of such section; 

(ii) such failure shall not affect the disbursement of 

amounts from the Fund; and 

(iii) the Federal share described in paragraph (2)(A) 

shall not be increased by the amount so unpaid. 

(b) MANDATORY FUNDS FOR MONITORING, INITIAL HEALTH EVALUATIONS, TREATMENT, AND CLAIMS PROCESSING.— 

(1) IN GENERAL.—The amounts deposited into the Fund under 

subsection (a)(2) shall be available, without further appropriation, consistent with paragraph (2) and subsection (c), to carry 

out subtitle B and sections 3302(a), 3303, 3304, 3305(a)(2), 

3305(c), 3341, and 3342. 

(2) LIMITATION ON MANDATORY FUNDING.—This title does not 

establish any Federal obligation for payment of amounts in excess of the amounts available from the Fund for such purpose. 

(3) LIMITATION ON AUTHORIZATION FOR FURTHER APPROPRIATIONS.—This title does not establish any authorization for appropriation of amounts in excess of the amounts available from 

the Fund under paragraph (1). 

(c) LIMITS ON SPENDING FOR CERTAIN PURPOSES.—Of the 

amounts made available under subsection (b)(1), not more than 

each of the following amounts may be available for each of the following purposes: 

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(1) SURVIVING IMMEDIATE FAMILY MEMBERS OF FIRE- FIGHTERS.—For the purposes of carrying out subtitle B with respect to WTC responders described in section 3311(a)(2)(A)(ii)— 

(A) for the last calendar quarter of fiscal year 2011, $100,000; 

(B) for fiscal year 2012, $400,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

(2) WTC HEALTH PROGRAM SCIENTIFIC/TECHNICAL ADVISORY

COMMITTEE.—For the purpose of carrying out section 3302(a)— 

(A) for the last calendar quarter of fiscal year 2011, $25,000; 

(B) for fiscal year 2012, $100,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

(3) EDUCATION AND OUTREACH.—For the purpose of carrying 

out section 3303— 

(A) for the last calendar quarter of fiscal year 2011, $500,000; 

(B) for fiscal year 2012, $2,000,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

(4) UNIFORM DATA COLLECTION.—For the purpose of carrying 

out section 3304 and for reimbursing Data Centers (as defined 

in section 3305(b)(2)) for the costs incurred by such Centers in 

carrying out activities under contracts entered into under section 3305(a)(2)— 

(A) for the last calendar quarter of fiscal year 2011, $2,500,000; 

(B) for fiscal year 2012, $10,000,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

(5) RESEARCH REGARDING CERTAIN HEALTH CONDITIONS.—For 

the purpose of carrying out section 3341— 

(A) for the last calendar quarter of fiscal year 2011, 

$3,750,000; 

(B) for fiscal year 2012, $15,000,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

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by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

(6) WORLD TRADE CENTER HEALTH REGISTRY.—For the purpose of carrying out section 3342— 

(A) for the last calendar quarter of fiscal year 2011, $1,750,000; 

(B) for fiscal year 2012, $7,000,000; and 

(C) for each subsequent fiscal year, the amount specified 

under this paragraph for the previous fiscal year increased 

by the percentage increase in the consumer price index for 

all urban consumers (all items; United States city average) 

as estimated by the Secretary for the 12-month period ending with March of the previous year. 

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DISSENTING VIEWS 

We, the undersigned Members of the Committee on Energy and 

Commerce, offer the following comments on H.R. 847, the ‘‘James 

Zadroga 9/11 Health and Compensation Act of 2009.’’ Republicans 

have supported and continue to support providing monitoring and 

treatment of benefits for first responders to the 2001 World Trade 

Center (WTC) tragedy. Although this bill has been represented as 

merely authorizing in statute the existing WTC-related program, 

H.R. 847 in fact changes the program significantly without providing needed protections to ensure taxpayer funds are spent properly and effectively. H.R. 847 increases federal spending by creating a new entitlement program without requiring Congress to 

find wasteful spending programs that could be cut or eliminated. 

The bill provides incentives to providers to over-utilize services 

while at the same time providing inflated reimbursement rates. 

The legislation also does not protect taxpayer funds for paying for 

benefits for illegal aliens. Republicans offered amendments to authorize and improve the existing program, but they were defeated. 

The debate over H.R. 847 has been intentionally 

mischaracterized by some proponents of the legislation. During the 

markup of H.R. 847, some implied that supporters of the legislation 

were the only ones who support providing health care benefits to 

those who responded to the attack and charged that those that 

questioned the structure of the bill opposed providing help to these 

heroes. This mischaracterization does a disservice to the legislative 

process. 

The Majority Committee Report rightfully noted that ‘‘The WTC 

Health Programs currently funded by the federal government are 

not authorized in statute. That is, there is no legislation authorizing the appropriation of funds to the National Institute for Occupational Health and Safety (NIOSH) to support these programs. 

The absence of such legislation has not precluded—and should not 

preclude—the funding of these programs. It is far preferable, however, for the Congress to set forth in an authorizing statute the 

purpose and scope of the programs needed, the individuals intended to be assisted, and the resources necessary to such programs. An authorizing statute can improve accountability of the 

agency responsible for administering the programs, transparency, 

and stability of funding over time.’’ 

Although some claim this bill simply authorizes the existing program at NIOSH, H.R. 847 operates in a significantly different manner than the current program. The NIOSH does not have expertise 

in administering a health care payment program. The current program functions as a block grant program and individual grantees 

must conduct research, monitor conditions, and provide treatment 

for those afflicted with World Trade Center-related conditions. 

Under the bill, NIOSH could have vastly expanded functions, many 

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of which it has no expertise in doing, such as negotiating provider 

payment rates, approving treatment protocols, establishing a competitive bidding program for prescription drugs, and evaluating the 

health of potential enrollees in the program. Since the Administration was not invited to testify on the legislation, we were unable 

to hear its position on the proper agency to perform the activities 

set forth in the legislation. Republicans advocated that the Secretary of Health and Human Services have the discretion to determine which agency had the necessary expertise to administer the 

WTC health care program. 

Mr. Rogers offered an amendment that would authorize in statute the current WTC health program at NIOSH while also providing needed accountability improvements to ensure the funds 

were being spent appropriately. In addition to codifying the existing monitoring and treatment program for first responders, the Republican amendment would provide for outreach to educate eligible 

individuals about the benefits of the program and allow for continued data collection about 9–11 conditions. The amendment also 

contained needed accountability reforms like requiring the Secretary to verify citizenship/legal residency so that only those lawfully present in the United States receive services and mandating 

an annual accounting of the use of funds by the program. The 

amendment set funding for the program in Fiscal Year 2011 at 

President Obama’s requested level of $150 million. The amendment 

was not agreed to by a roll call vote of 19 Yeas to 30 Nays. 

Some proponents of the legislation also mischaracterized the debate over whether the program should be funded on an annual 

basis or if the government should set mandatory obligations for the 

program for the next ten years. The Committee on Energy and 

Commerce is an authorizing committee with a mission to set policy 

and specify spending priorities. It is the function of the Committee 

on Appropriations to allocate funds to the program this Committee 

authorizes. Republicans find suspect the suggestion that if a program is funded through the normal appropriations process then the 

recipients of those funds must hold out a tin cup each year to beg 

for money. Many federal health care programs, including those that 

provide health care services to our current military and veterans, 

and those that conduct research, are funded through the regular, 

yearly appropriations process. This does not mean these programs 

are at risk of being eliminated. When there is agreement that a 

program is a priority, it gets funded. Republicans believe that in 

a time of a $13 trillion national debt and the expectation that the 

current budget will add an additional $10 trillion of debt by the 

end of the decade, a new multi-billion program can and should be 

accompanied by a reduction in wasteful or unneeded programs. 

The only reason to pass a mandatory spending program is to 

grow the size of government and excuse Congress of its obligation 

to cut or eliminate wasteful spending. The Taxpayers for Common 

Sense have calculated that last year almost $16 billion was spent 

on Congressional earmarks. $772 million was spent on earmarks in 

the Labor-Health and Human Services appropriations bill alone. 

This demonstrates there are funds in the annual appropriations 

bill that can be used to offset the spending of the new program this 

bill would create. Proponents of the legislation have argued that 

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the Committee on Appropriations will not fund the World Trade 

Center health care program even though there would be more than 

sufficient funds to cover the expense of the program just by simply 

eliminating earmarks. Instead of prioritizing our federal spending, 

like eliminating earmarks, the proponents of the legislation offered 

a promise to pay for the bill in the future with tax increases. 

With scarce federal resources, we must ensure that we spend the 

people’s money efficiently. Therefore, those funds should not be 

used on those who are in the country illegally. The underlying bill 

does not require the Secretary to verify applicants’ citizenship. H.R. 

847 establishes a cap for the number of people who may enroll in 

the program. Due to the lack of a citizenship verification requirement, American citizens may be blocked from accessing the program. Such a scenario is unacceptable. Mr. Buyer offered an 

amendment that would ensure only Americans and those in the 

country legally would be provided benefits under this program. 

That amendment was defeated by a vote of 16 Yeas to 27 Nays. 

Dr. Burgess also offered a common sense amendment to ensure 

benefits go to those that truly need them. The amendment would 

have precluded millionaires from accessing this new health entitlement program. That amendment was first defeated by a vote of 16 

Yeas to 29 Nays. After a motion to reconsider the vote, the amendment was defeated again by a vote of 21 Yeas to 22 Nays. 

Additionally, the World Trade Center health program should be 

about providing benefits to first responders, not about providing 

additional revenue for New York area hospitals. But H.R. 847 increases reimbursement rates only for New York hospitals and provides incentives for those hospitals to engage in wasteful behavior. 

With respect to reimbursement, the bill actually reimburses New 

York area hospitals at a rate that is 140% of the Medicare reimbursement rate and provides a perverse incentive for hospitals to 

use unnecessary services because it will result in higher payments 

from the federal government. 

The Patient Protection and Affordable Care Act will slash over 

$150 billion in payments to hospitals for care provided to seniors. 

The Chief Actuary for the Centers for Medicare and Medicaid Services concluded in an April 22, 2010, letter that these Medicare cuts 

to hospitals and other Part A providers could lead to 15% of those 

providers going out of business. The Actuary stated these cuts 

could ‘‘possibly jeopardize access to care for beneficiaries.’’ It is difficult to reconcile the justification to cut hospital payments to every 

hospital in the country while at the same time creating a new program that provides reimbursement rates so far above the Medicare 

payment level in the New York City area. Mr. Shimkus offered an 

amendment that would have reimbursed these New York area hospitals at the Medicare reimbursement rate, but that amendment 

was defeated by a vote of 17 Yeas to 26 Nays. 

H.R. 847 also fails to encourage quality care by those New York 

hospitals. During the health care reform debate, there was universal recognition that our federal health care programs must start 

reimbursing providers based on the quality of services they provide 

rather than the volume of services they provide. The health care 

reform bill failed to make this transition because existing government programs are slow to adapt and change. In the creation of the 

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106 

new program under H.R. 847, there were no existing policies to 

prevent Congress from demanding this program pay for quality 

rather than volume. 

However, under H.R. 847, hospitals participating in the program 

would receive financial windfalls for ordering more tests regardless 

of the quality of care. Participants in the program would have no 

incentive to question the cost of their care because imposing any 

form of cost sharing is prohibited. We are disappointed the Majority created only a superficial fix for this issue by giving the Secretary discretion to modify reimbursement methods after the program is already up and running. The benefits of the bill are delayed until July 2011, which is ample time for the Secretary to develop a reimbursement method that is fair to all taxpayers, does 

not reward over-utilization of services, and promotes quality of 

care. 

Republicans and Democrats share a common goal, which is to ensure that first responders of the World Trade Center attack have 

their conditions monitored and receive treatment for conditions associated with the attacks. Republicans offered an amendment to 

authorize the program and fund it at the President’s requested 

level. We offered amendments to increase the accountability of how 

taxpayer dollars are spent and offered an amendment that would 

ensure that Americans and those in this country legally get care 

rather than those in the country illegally. Unfortunately, these 

amendments were defeated. 

We continue to believe those who responded to the World Trade 

Center attack should get the treatment they need because they dutifully answered a call for help. The opposition to H.R. 847 is not 

opposition to providing health benefits. Rather, it is an opposition 

to the structure and administration of the program. We believe it 

is important to pay for our priorities and eliminate unnecessary 

spending in other areas. We believe that federal benefits should not 

go to those in the country illegally. We also believe that programs 

should not provide incentives to hospitals in the New York City 

area to order unnecessary tests while paying those providers rates 

far beyond what other federal programs reimburse, particularly 

when hospitals in other parts of the country may be forced to close 

due to the recently enacted Medicare cuts called for in the health 

care reform law. Unfortunately, H.R. 847 fails to meet these principles shared by most Americans. For these reasons we encourage 

a ‘‘no’’ vote on H.R. 847. 

JOE BARTON. 

JOHN SHIMKUS. 

JOSEPH R. PITTS. 

PHIL GINGREY. 

ROBERT E. LATTA. 

CLIFF STEARNS. 

ROY BLUNT. 

JOHN B. SHADEGG. 

MIKE ROGERS (MI). 

STEVE BUYER. 

Æ 

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