ATT015_SurvivorCCE_BEAST.docx

Benefits Eligibility Assessment Screening Tool for Survivors WTC Health Program

Table of Contents

Section 1 Introduction to Benefits Assessment Questionnaire and WTC-Related Health Condition Screening

“In addition to providing medical monitoring and medical and mental health treatment services, the WTC Health Program also offers benefits counseling services to our members. Benefits counseling is a service provided by a benefits counselor, social worker, or other designated staff person, who helps a member to identify the benefits he or she may be eligible for and explains how to apply for those benefits. Benefits counselors also refer members to external benefits experts as needed to help the member access benefits. Benefits counseling services cover several areas of service, including program benefits counseling, September 11th Victim Compensation Fund assistance, disability benefits counseling, cancer and transplant care assistance, social services assistance, care for non-covered conditions assistance, and workers’ compensation counseling, should that apply to you.”

Today, I am going to ask you some questions to determine how the program might best help you in terms of your benefits counseling needs and interests. In order to do so, I’m first going to ask some questions about your health conditions and WTC-related work you might have done so that I better know which specific benefits to ask you about today.”

1.1 Have you been diagnosed with a physical and/or mental health condition related to your 9/11 exposure?

· Yes (Proceed to Section 2 on page 4)

· No (Skip to Section 3 on page 5)

Section 2 WTC Survivors WTC-Related Illness and Related Benefits

2.1 Do you have a WTC Health Program certified physical health condition?

· Yes (“Populate” VCF, including registration assessment, into plan; Proceed to question 2.2)

· No (Rule out VCF; Proceed to question 2.2)

2.2 Did you perform any 9/11 clean-up work or volunteer activities in the NYC disaster area? Or, by chance, any rescue and recovery work?

· Yes (“Populate” Workers’ Compensation, including WTC12 assessment, into plan; Proceed to question 2.3)

· No (Rule out Workers’ Compensation; Proceed to question 2.3)

2.3 Do your WTC-related health conditions disable you from working?

· Yes (“Populate” SSD/SSI into plan; Proceed to question 2.4)

· No (Rule out SSD/SSI; Proceed to Section 4 on page 6)

2.4 Are you a member of a union?

· Yes (“Populate” Union-based Disability Benefits into plan; Proceed to Section 4 on page 6)

· No (Rule out Union-based Disability Benefits; Proceed to Section 4 on page 6)

Section 3 Assessment of WTC12 Registration for Survivors with No Health Conditions

3.1 Did you perform any 9/11 clean-up work or volunteer activities in the NYC disaster area? Or, by chance, any rescue and recovery work?

· Yes (“Populate” WTC12 Registration into Assessment; Proceed to Section 4 on page 6)

· No (Rule out Workers’ Compensation Registration; Proceed to Section 4 on page 6)

Section 4 Cancer/Transplant Care Assistance

4.1 Since 9/11, have you been diagnosed with cancer?

· Yes (“Populate” Cancer Care Assistance into plan; Proceed to question 4.2)

· No (Rule out Cancer Care Assistance; Proceed to question 4.2)

4.2 Are you awaiting or have you had an organ transplant?

· Yes (“Populate” Transplant Care Assistance; Proceed to Section 5 on page 7)

· No (Rule out Transplant Care Assistance; Proceed to Section 5 on page 7)

Section 5 Care for Non-Covered Conditions Assistance [We will start the conversation with a detailed discussion of the WTCHP requirements concerning Survivors and the requirements for health care coverage under the Affordable Care Act.]

Interviewer: “I am now going to ask you some questions about medical insurance coverage and access to medical care for health conditions that are not covered by the WTC Health Program.”

5.1 Do you have health insurance?

· Yes (Rule out Care for Noncovered Conditions Assistance/Health Insurance; Proceed to question 5.2)

· No (“Populate” Care for Noncovered Conditions Assistance/Health Insurance; Proceed to question 5.2)

5.2 Do you currently have a primary care doctor?

· Yes (Rule out Care Noncovered Conditions Assistance/Access to Primary Care Doctor; Proceed to question 5.3)

· No (“Populate” Care for Noncovered Conditions Assistance/Access to Primary Care Doctor; Proceed to question 5.3)

5.3 At this time, are you having any problems accessing the medical care you need for conditions that are not covered by the WTC Health Program?

· Yes (“Populate” Care for Noncovered Conditions Assistance/Access to Care; Proceed to Section 6 on page 8)

· No (Rule out Care for Noncovered Conditions Assistance/Access to Care; Proceed to Section 6 on page 8)

Section 6 Social Services Assistance Interviewer: “Due to disabling 9/11 health conditions, some program members have had trouble paying rent, mortgage, or utility bills; buying food; or securing transportation. I am now going to ask you some questions about basic needs assistance.”

6.1 As of today, are you having trouble paying your basic needs expenses, specifically shelter, utilities, food, or transportation?

· Yes (Populate “Social Services Assistance”; Conclude interview)

· No (Rule out Social Services Assistance; Conclude interview)