The Zadroga Act established the WTCHP to provide medical monitoring and treatment benefits, and reactivated the VCF to provide financial compensation to eligible individuals. As of March 31, 2014, there were 67,783 WTCHP enrollees, including responders and survivors from the WTC attack site and responders from the Pentagon and Shanksville, Pennsylvania, attack sites. Monitoring, for the purposes of this report, includes initial health and diagnostic evaluations, screening tests, and monitoring exams. Treatment provided by the WTCHP must be deemed medically necessary, and in accordance with the WTCHP’s medical treatment protocols. WTCHP services are provided to enrollees at no cost, through contracts with Clinical Centers of Excellence (CCE) in the New York metropolitan area and the Nationwide Provider Network (NPN) for those who reside outside of the New York metropolitan area. Under the Zadroga Act, the Administrator may publish a rule to add conditions to the list of covered conditions at his discretion. If the Administrator receives a written petition requesting the addition of a condition to the list, the law specifies certain time frames in which he must respond to that petition. Specifically, upon receipt of a petition to add a health condition to the list, the Administrator is required to respond within 60 days in one of four specified ways: (1) request a recommendation of the STAC; (2) publish a proposed rule in the Federal Register to add the condition; (3) publish in the Federal Register a determination not to publish such a rule; or (4) publish in the Federal Register a determination that insufficient evidence exists to take any such action. If the Administrator chooses to request a recommendation of the STAC, the STAC has up to 180 days to provide it, and the Administrator has up to 60 days, following the receipt of the STAC’s recommendation, to publish a decision on whether to add the condition in the Federal Register. Therefore, when a recommendation from the STAC is requested for a review based on a petition, up to 300 days may elapse from the time the Administrator receives the petition to when he publishes a response in the Federal Register. In response to the September 2011 written petition from members of Congress to add coverage for cancer, the Administrator requested a recommendation from the STAC, which, in March 2012, provided its recommendation to add certain types of cancers to the list. The Administrator then conducted his own assessment of available scientific evidence, including an assessment of the STAC’s recommendation. To obtain coverage for treatment for a condition included on the list, a WTCHP enrollee must obtain a determination from a CCE or NPN physician, and a certification from the WTCHP. Specifically, a physician must determine that (1) the condition for which the enrollee seeks coverage is on the list; and (2) exposure to airborne toxins, other hazards, or adverse conditions resulting from the September 11 attacks is “substantially likely to be a significant factor in aggravating, contributing to, or causing the condition.” The WTCHP then reviews the physician’s determination and certifies that the enrollee satisfactorily meets the exposure assessment and symptom requirements. Once an enrollee’s condition has been certified for coverage, a WTCHP provider can be reimbursed for treatment services provided for that specific health condition. The Zadroga Act established the WTCHP Fund and made appropriations to that fund for the federal share of expenditures for the last calendar quarter of fiscal year 2011, as well as for each of fiscal years 2012 through 2016, totaling a maximum of about $1.6 billion. 2014, cumulative WTCHP obligations totaled about $0.8 billion. About one-half of that amount ($450.9 million) was obligated to pay for claims from the CCEs and the NPN. The remaining amount ($326.2 million) was obligated for CCE and NPN infrastructure, education and outreach, the STAC, data centers, and other activities. Claims paid from October 2012 (when cancers were added to the list) through March 2014 totaled about $140.7 million. In addition, the estimated costs of the CCE and NPN contracts for the 5-year period ranged from about $5.9 million to nearly $55.0 million. (See table 1.) The Zadroga Act specified that the federal share of funding for the WTCHP was to be the lesser of either 90 percent of expenditures for a year, or an amount specified for that year. The amount provided for fiscal year 2016 is limited to any unexpended funds remaining available from fiscal years 2011 through 2015. Federal payments are conditioned on New York City agreeing to contribute 10 percent of the program’s costs through fiscal year 2015 and one-ninth of any federal spending in fiscal year 2016. The NPN is operated by Logistics Health, Inc., which subcontracts with health systems, such as UnitedHealthcare, to provide services to enrollees, according to WTCHP officials. Rules reactivating the VCF under the Zadroga Act became effective October 3, 2011.death resulting from traumatic physical injuries, physical health conditions, or diseases considered to have occurred as a result of the September 11 attacks or debris removal. The VCF provides compensation for personal injury or An individual must register with the VCF within 2 years of diagnosis with a covered condition, but not later than October 3, 2016. Individuals with an existing condition have 2 years from the date the condition is added to the WTCHP list to register with the VCF; all registrations must be submitted by October 3, 2016. As such, individuals who were diagnosed with a cancer added to the list on October 12, 2012, are required to register by October 12, 2014. To file a VCF claim, an individual must submit completed eligibility and compensation claim forms, including information that demonstrates a physical health condition included in the WTCHP list resulted from the September 11 attacks, by October 3, 2016. Although there had been over 60,000 individual registrations with the VCF as of March 31, 2014, most claimants had not submitted eligibility or compensation forms as of that date. The Zadroga Act capped funding for VCF compensation at nearly $2.8 billion, which covers both claims and administrative costs. Of that amount, $875 million (31 percent) is available for payments during the VCF’s first 5 years after its reactivation (from Oct. 3, 2011, through Oct. 3, 2016). The act required the VCF to set a rate for prorating payments during the first 5 years to ensure that every eligible claimant received a payment during that period. In January 2013, the VCF set a proration amount of 10 percent of total compensation calculations for those first 5 years. In the VCF’s sixth year (from Oct. 3, 2016, through Oct. 3, 2017), the program will make payments based on the remaining funds. After all payments are made, the VCF shall be permanently closed. In determining whether to add cancers to the list of covered conditions, the Administrator used a hazard-based, multiple method approach. Experts who participated in our meeting indicated that this approach was reasonable. However, the approach could be improved, as it was not clearly communicated and did not include an independent peer review. The WTCHP Administrator used a hazard-based, multiple-method approach—rather than a risk-based approach—to determine whether to add certain types of cancer to the list. The Zadroga Act does not prescribe a specific methodology for assessing evidence to determine whether to add new conditions to the list. According to experts who a hazard-based approach focuses on participated in our meeting,identifying whether particular “hazards”—sources of potential harm—are associated with certain health conditions, and does not attempt to quantify the risks or likelihood of developing those health conditions as would a risk-based approach. Under the Administrator’s hazard-based approach, types of cancer found to be associated with exposures to the September 11 attack sites were added to the list. In contrast, a risk-based approach would have involved determining whether the risk of a specific type of cancer from the September 11 exposures was high or low as a result of quantified levels and durations of exposure, and would have added only those cancers where risk was determined to be high. The Administrator’s hazard-based approach used four methods to determine whether there was an association between a September 11 exposure and a particular cancer that warranted adding that cancer to the list. According to the approach described in rulemaking,Administrator may have added a cancer to the list in the following circumstances: Method 1: Data from published, peer-reviewed epidemiologic studies in the September 11 exposed population supported a causal association between September 11 exposures and the cancer type. Method 2: Multiple published epidemiologic studies supported a causal association between the cancer and a condition already on the list (such as esophageal cancer and gastroesophageal reflux disease). Method 3: A hazard identified at the September 11 attack sites in peer-reviewed studies was identified by the National Toxicology Program to be (or reasonably anticipated to be) a human carcinogen, and the International Agency for Research on Cancer determined that there was at least limited evidence that the hazard causes the cancer. Method 4: The STAC provided a reasonable basis to add a cancer to the list based on its review of scientific and medical evidence. The Administrator characterized his hazard-based, multiple-method approach as a hierarchy in 2012 rulemaking. To determine whether to add a particular type of cancer, the Administrator said he began his review by assessing evidence under Method 1, which he considered to be the strongest type of evidence. If a cancer did not meet the criteria to be added to the list under Method 1, the Administrator considered evidence under Methods 2, 3, or 4, which he considered to be less rigorous forms of evidence.