MCA-Sedgwick to Replace LHI as Network Administrator
The World Trade Center Health Program (WTC Health Program) has announced that Managed Care Advisors (MCA)-Sedgwick will replace Logistics Health Incorporated (LHI) as the vendor who administers the program’s Nationwide Provider Network (NPN).
WTC Health Program Administrator Dr. John Howard, M.D., states that the NPN transition is not immediate, and that program participants should continue to access their WTC Health Program benefits through LHI until further notice.
This transition could affect the providers, case managers, and care coordinators that participants have been assigned to. However, the WTC Health Program is attempting to create as little disruption as possible to the services participants are receiving. A number of legal teams are monitoring this transition and are ready to assist WTC Health Program participants who have questions or concerns about the matter.
Who Is MCA-Sedgwick?
Based in Bethesda, Maryland, and established in 1997, Managed Care Advisors (MCA) specializes in managed healthcare, employee benefits, worker’s compensation, and disability management. They provide their services to federal, state, and local governmental entities, corporations, and public or private health plans. In September 2021, MCA was acquired by Sedgwick, and will operate as a wholly owned subsidiary of Sedgwick Public Sector, a holding company that will deliver claims services to government entities.
Why Was LHI Replaced?
Wisconsin-based Logistics Health Incorporated (LHI) was founded in 1999 as a subsidiary of OptumServe. After administering medical services for several government programs, the company was awarded an $11 million contract to administer benefits to the 9/11 community in 2008. Unfortunately, in recent years, as the caseload has grown for the NPN, WTC Health Program participants have complained that the service they have received from LHI has left much to be desired.
Some complaints mentioned by participants in reports by national news outlets include:
- WTC Health Program members being billed for services that the program was supposed to cover.
- A member being forced to sign a contract stating that if they were “disruptive or abusive” to staff, their membership to the program would be suspended.
- Difficulty accessing services or obtaining prescriptions in a timely manner.
- Failure of LHI to locate a provider in certain areas for participants to obtain yearly health screenings.
Days after these complaints were publicized in news reports, the U.S. House of Representatives Oversight and Reform and Judiciary committees demanded a briefing from the company and WTC Health Program administrators. With LHI’s contract expiring in 2021, the announcement was made that it would be seeking a new vendor to administer the Nationwide Provider Network.
What Type of Changes Can Participants Expect During the Transition?
According to the letter from Dr. Howard, administrators of the WTC Health Program and MCA-Sedgwick believe that most members who are accessing care through the provider network will be able to continue working with their provider after the transition takes place. However, if this cannot happen, members can expect to be contacted this spring by MCA-Sedgwick to assist them in continuing to obtain their program benefits through another provider.
Additional Changes: New Pharmacy Benefit Manager
In addition to announcing the change in NPN vendor, the program also announced that it would have a new Pharmacy Benefits Manager. Express Scripts is replacing OptumRx. The program notes that this change is not related to the replacement of LHI, but instead is the result of a “normal contract review and renewal process.” Again, the WTC Health Program states that members do not need to do anything, but in the coming months, they can expect to receive more information from Express Scripts in the mail, a new ID card, and additional instructions about their next steps.
The program anticipates that members may continue using the same pharmacy as they currently are, as Express Scripts has a retail pharmacy network of over 62,000 pharmacies. Members made 98 percent of recent retail claims at pharmacies included in the network.
Members can obtain through Express Scripts 90-day supplies of their WTC-related long-term medications at Walgreens/Duane Reade retail pharmacies. They will also have the option of obtaining 30-day supplies of these medications from other in-network pharmacies.
Members will receive more information about pharmacy benefits through Express Scripts by mail to once the transition completes. They will also have the opportunity to register for the Express Scripts Member Portal, which will allow online access to prescription and pharmacy information.
What Does a Pharmacy Benefits Manager Do?
A Pharmacy Benefits Manager (PBM) is a company that contracts with the federal government to administer the drug benefit arm of the WTC Health Program. They provide all pharmacy services for the program and ensure that members get coverage of the prescription drugs used to treat their 9/11-related conditions.
The provision of services requires the use of a call center and customer service to administer these pharmacy benefits and to coordinate services such as home-delivery of prescriptions, processing prescription drug claims, and maintaining a list of prescription medications that are covered by the program.
About the WTC Health Program
The World Trade Center Health Program is a federal program that provides medical monitoring and treatment of 9/11-related medical conditions. These benefits are provided to New York City residents through one of the program’s several Clinical Centers of Excellence. Members of the program who do not live in New York City can access these services through the program’s Nationwide Provider Network.
Yearly health screenings and treatment of 9/11-related medical conditions—including prescription medications —are provided at no cost and without co-pay to members who agree to obtain these services and prescriptions through providers affiliated with the program.
To receive the benefits, individuals must have been either a responder who worked for FDNY; a general responder—including NYPD responders—who assisted with the rescue, recovery, or cleanup operations at Ground Zero; or anyone who was living, attending school or daycare, or working in the Lower Manhattan exposure zone on September 11, 2001, to July 31, 2002; and the responders at the 9/11 terror attack sites at the Pentagon and in Shanksville, PA.
The WTC Health Program also provides certification of 9/11-related medical conditions. The participant can use this certification to partially satisfy the eligibility criteria to obtain compensation through the other federal 9/11 benefit program, the September 11th Victim’s Compensation Fund (VCF). Additionally, it funds research into the physical and mental health conditions that have been incurred as a result of the 9/11 terror attacks.
What Illnesses Will the WTC Health Program Cover?
The WTC Health Program covers more than 60 cancers and nearly two-dozen other illnesses.
The most common illnesses program members suffer include:
- Chronic rhinosinusitis, which impacts more than 27,000 responders and more than 6,600 survivors participating in the program.
- Gastroesophageal reflux disorder (GERD), impacting more than 25,000 responders and more than 5,500 survivors.
- Many types of cancer (over 70 types), which have been diagnosed in more than 15,500 responders and more than 10,600 survivors.
- Asthma, which is suffered by more than 13,600 responders participating in the group, as well as more than 5,000 survivors.
- Sleep apnea that is caused by another 9/11-related condition, which has been diagnosed in more than 15,000 responder members, and more than 1,500 survivor members.
- Post-traumatic stress disorder (PTSD), which is suffered by more than 9,000 responders and more than 3,800 survivors participating in the program.
Are the VCF and the WTC Health Program the Same Thing?
No. However, the James Zadroga 9/11 Health and Compensation Act, which was signed into law in 2011, funds both programs. The VCF had previously operated from 2001-2004 and gained reauthorization through the Zadroga Act.
The WTC Health program replaced previous programs that offered similar services—the Medical Monitoring and Treatment Program and the WTC Environmental Health Center Community Program.
The current WTC Health Program is housed under the U.S. Department of Health, Centers for Disease Control & Prevention (CDC) and administered by the National Institute for Occupational Safety and Health (NIOSH)
The VCF is administered by the Department of Justice, with a Special Master appointed to lead the program by the Attorney General. In 2019, the VCF obtained permanent reauthorization, allowing claimants to file claims until October 2090.
Trust a 9/11 Benefits Attorney to Keep You Updated on WTC Health Program Changes
Experienced 9/11 benefits attorneys are not here solely to help the 9/11 community obtain the federal benefits they deserve after suffering illnesses related to toxic exposure. They are here to provide this community with the information, assistance, and support they need, too.
Hopefully, MCA-Sedgwick will make positive changes in the care provided to program participants. If you have questions about your 9/11 benefits or need assistance applying to the WTCHP, contact a 9/11 benefits attorney today.Posted under: NYPD, Survivors