[Federal Register: October 18, 2004 (Volume 69, Number 200)]
[Notices]
[Page 61388-61393]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr18oc04-78]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Report of Modified or Altered System
AGENCY: Department of Health and Human Services (HHS) Centers for
Medicare & Medicaid Services (CMS)(formerly the Health Care Financing
Administration).
ACTION: Notice of Modified or Altered System of Records (SOR).
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SUMMARY: In accordance with the requirements of the Privacy Act of
1974, we are proposing to modify or alter an SOR, ``Group Health Plan
System,'' System No. 09-70-4001. We propose to broaden the scope of
this system with the redesign of the electronic processing procedure
used to process data currently from a Common Object Business Oriented
Language (commonly referred to as COBOL) format resident on the CMS
mainframe to Data Base 2 format (commonly known as DB2). To more
accurately reflect the changes proposed for this system, we will modify
the name to read: ``Medicare Managed Care System (MMCS).'' We propose
to delete published routine use number 5 authorizing disclosures to
contractors; published routine use number 6 authorizing disclosures to
contractors; and published routine use number 7 authorizing disclosures
to a Medicaid State Agency.
Proposed routine use number 1 for contractors and consultants makes
material changes to published routine uses numbers 5 and 6. Routine
uses 5 and 6 authorized release to contractors. They are being deleted
because their meaning is unclear as to what data is being disclosed to
what entity. Routine use number 7 is being deleted because disclosure
to a State Medicaid Agency will now be made under proposed routine use
number 2 that reads, ``to another Federal and/or state agency, agency
of a state government, an agency established by state law, or its
fiscal agent.''
CMS proposes to add new routine uses to permit release of
information to: (1) Third parties where the contact has information
relating to the individual's capacity to manage his or her own affairs;
(2) other insurers, third party administrators (TPA), employers, self-
insurers, managed care organizations, other supplemental insurers, non-
coordinating insurers, multiple employer trusts, group health plans
(i.e., health maintenance organizations (HMOs) or a competitive medical
plan (CMP) with a Medicare contract, or a Medicare-approved health care
prepayment plan (HCPP)), directly or through a contractor, and other
groups providing protection for their enrollees to assist in the
processing of individual insurance claims; and (3 & 4) combat fraud and
abuse in certain health benefits programs.
The security classification previously reported as ``None'' will be
modified to reflect that the data in this system are considered to be
``Level Three Privacy Act Sensitive.'' We are modifying the language in
the remaining routine uses to provide clarity and uniformity to CMS's
intention to disclose individual-specific information contained in this
system. The routine uses will then be prioritized and reordered
according to their proposed usage. We will also take the opportunity to
update any sections of the system that were affected by the recent
reorganization and to update language in the administrative sections to
correspond with language used in other CMS SORs.
The primary purpose of the SOR is to maintain a master file of
Medicare Managed Care Organizations (MCO) plan members for accounting
and payment control; expedite the exchange of data with MCOs; and
control the posting of pro-rata amounts to the Part B deductible of
currently enrolled MCO members. MMCS include the following entities:
Health Maintenance Organizations (HMO), Competitive Medical Plans
(CMP), Health Care Prepayment Plan (HCPP), and Medicare Choice
Organizations (MCO). Information in this system will also be disclosed
to: (1) Support regulatory, reimbursement, and policy functions
performed within the Agency or by a contractor or consultant, (2)
support another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent;
(3) provider and suppliers of service directly or dealing through
contractors, fiscal intermediaries (FI) or carriers for administration
of Title XVIII; (4) provide information to third party contacts in
situations where the contact has information relating to the
individual's capacity to manage his or her affairs; (5) other insurers,
third party administrators (TPA), and other groups providing protection
for their enrollees to assist in the processing of individual insurance
claims (6) facilitate research on the quality and effectiveness of care
provided, as well as payment-related projects, (7) support constituent
requests made to a congressional representative, (8) support litigation
involving the Agency, and (9 & 10) combat fraud and abuse in certain
health benefits programs.
DATES: CMS filed a modified or altered system report with the Chair of
the House Committee on Government Reform and Oversight, the Chair of
the Senate Committee on Governmental Affairs, and the Administrator,
Office of Information and Regulatory Affairs, Office of Management and
Budget (OMB) on August 19, 2004. To ensure that all parties have
adequate time in which to comment, the modified or altered SOR,
including routine uses, will become effective 40 days from the
publication of the notice, or from the date it was submitted to OMB and
the Congress, whichever is later, unless CMS receives comments that
require alterations to this notice.
ADDRESSES: The public should address comments to: Director, Division of
Privacy Compliance Data Development (DPCDD), CMS, Room N2-04-27, 7500
Security Boulevard, Baltimore, Maryland 21244-1850. Comments received
will be available for review at this location, by appointment, during
regular business hours, Monday through Friday from 9 a.m.-3 p.m.,
Eastern daylight time.
FOR FURTHER INFORMATION CONTACT: Laquia Marks, Information Technology
Specialist, Division of Managed Care Systems, Informational Services
Modernization Group, OIS, CMS, Room N3-16-24, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850. The telephone number is 410-786-3312.
SUPPLEMENTARY INFORMATION:
I. Description of the Modified System
A. Statutory and Regulatory Basis for the SOR
In 1987, CMS established an SOR, Group Health Plan System,'' System
No. 09-70-4001, under the authority of Sec. Sec. 1833(a)(1)(A), 1866,
and 1876 of Title XVIII of the Social Security Act (the Act) (42 U.S.C.
1395 (a)(1)(A), 1395cc, and 1395mm). Notice of this system,
[[Page 61389]]
was published at 52 FR 13525 (Apr. 23, 1987) and a routine use for
Medicaid state agencies added at 57 FR 60819 (Dec. 22, 1992). This
information includes names and health insurance claims numbers of
recipients of Medicare Hospital Insurance (Part A) and Medicare Medical
Insurance (Part B) who are enrolled in a MMCS.
II. Collection and Maintenance of Data in the System
A. Scope of the Data Collected
The system includes the following information about a beneficiary's
health insurance entitlement and supplementary medical benefits usage,
including name, health insurance claims number (HICN), and social
security number.
B. Agency Policies, Procedures, and Restrictions on the Routine Use
The Privacy Act permits us to disclose information without an
individual's consent if the information is to be used for a purpose
that is compatible with the purpose(s) for which the information was
collected. Any such disclosure of data is known as a ``routine use.''
The government will only release MMCS information that can be
associated with an individual as provided for under ``Section III.
Proposed Routine Use Disclosures of Data in the System.'' Both
identifiable and non-identifiable data may be disclosed under a routine
use.
We will only collect the minimum personal data necessary to achieve
the purpose of MMCS. CMS has the following policies and procedures
concerning disclosures of information that will be maintained in the
system. Disclosure of information from the SOR will be approved only to
the extent necessary to accomplish the purpose of the disclosure and
only after CMS:
1. Determines that the use or disclosure is consistent with the
reason data is being collected; e.g., maintain a master file of MCO
plan members for accounting and payment control; expedite the exchange
of data with MCOs; and control the posting of pro-rata amounts to the
Part B deductible of currently enrolled MCO members.
2. Determines that the purpose for which the disclosure is to be
made can only be accomplished if the record is provided in individually
identifiable form;
a. The purpose for which the disclosure is to be made is of
sufficient importance to warrant the effect and/or risk on the privacy
of the individual that additional exposure of the record might bring;
and
b. There is a strong probability that the proposed use of the data
would in fact accomplish the stated purpose(s).
3. Requires the information recipient to:
a. Establish administrative, technical, and physical safeguards to
prevent unauthorized use of disclosure of the record;
b. Remove or destroy at the earliest time all patient-identifiable
information; and
c. Agree to not use or disclose the information for any purpose
other than the stated purpose under which the information was
disclosed.
4. Determines that the data are valid and reliable.
III. Proposed Routine Use Disclosures of Data in the System
A. These routine uses specify circumstances, in addition to those
provided by statute in the Privacy Act of 1974, under which CMS may
release information from the MMCS without the consent of the individual
to whom such information pertains. Each proposed disclosure of
information under these routine uses will be evaluated to ensure that
the disclosure is legally permissible, including but not limited to
ensuring that the purpose of the disclosure is compatible with the
purpose for which the information was collected. We are proposing to
establish or modify the following routine use disclosures of
information maintained in the system:
1. To Agency contractors, or consultants who have been contracted
by the Agency to assist in accomplishment of a CMS function relating to
the purposes for this system and who need to have access to the records
in order to assist CMS.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual or similar
agreement with a third party to assist in accomplishing a CMS function
relating to purposes for this system.
CMS occasionally contracts out certain of its functions when doing
so would contribute to effective and efficient operations. CMS must be
able to give a contractor or consultant whatever information is
necessary for the contractor or consultant to fulfill its duties. In
these situations, safeguards are provided in the contract prohibiting
the contractor or consultant from using or disclosing the information
for any purpose other than that described in the contract and requires
the contractor or consultant to return or destroy all information at
the completion of the contract.
2. To support another Federal or state agency, agency of a state
government, an agency established by state law, or its fiscal agent to:
a. Contribute to the accuracy of CMS's proper payment of Medicare
benefits,
b. Enable such agency to administer a Federal health benefits
program, or as necessary to enable such agency to fulfill a requirement
of a Federal statute or regulation that implements a health benefits
program funded in whole or in part with Federal funds, and/or
c. Assist Federal/state Medicaid programs within the state.
Other Federal or state agencies in their administration of a
Federal health program may require MMCS information in order to support
evaluations and monitoring of Medicare claims information of
beneficiaries, including proper reimbursement for services provided.
In addition, other state agencies in their administration of a
Federal health program may require MMCS information for the purposes of
determining, evaluating and/or assessing cost, effectiveness, and /or
the quality of health care services provided in the state.
Disclosure under this routine use shall be used by state Medicaid
agencies pursuant to agreements with the HHS for determining Medicaid
and Medicare eligibility, for quality control studies, for determining
eligibility of recipients of assistance under Titles IV, XVIII, and XIX
of the Social Security Act (the Act), and for the administration of the
Medicaid program. Data will be released to the state only on those
individuals who are patients under the services of a Medicaid program
within the state or who are residents of that state.
We also contemplate disclosing information under this routine use
in situations in which state auditing agencies require MMCS information
for auditing state Medicaid eligibility considerations. CMS may enter
into an agreement with state auditing agencies to assist in
accomplishing functions relating to purposes for this system to
providers and suppliers of services directly or through fiscal
intermediaries (FIs) or carriers for the administration of Title XVIII
of the Act.
3. To providers and suppliers of services directly or through
fiscal intermediaries (FIs) or carriers for the administration of Title
XVIII of the Act.
Providers and suppliers of services require MMCS information in
order to establish the validity of evidence or to verify the accuracy
of information presented by the individual, as it concerns the
individual's entitlement to benefits under the Medicare program,
[[Page 61390]]
including proper reimbursement for services provided.
4. To provide information to third party contacts in situations
where the party to be contacted has information relating to the
individual's capacity to manage his or her affairs or to his or her
eligibility for, or an entitlement to, benefits under the Medicare
program and,
a. The individual is unable to provide the information being sought
(an individual is considered to be unable to provide certain types of
information when any of the following conditions exists: The individual
is confined to a mental institution, a court of competent jurisdiction
has appointed a guardian to manage the affairs of that individual, a
court of competent jurisdiction has declared the individual to be
mentally incompetent, or the individual's attending physician has
certified that the individual is not sufficiently mentally competent to
manage his or her own affairs or to provide the information being
sought, the individual cannot read or write, a language barrier exist,
or the custodian of the information will not, as a matter of policy,
provide it to the individual), or
b. The data are needed to establish the validity of evidence or to
verify the accuracy of information presented by the individual, and it
concerns one or more of the following: the individual's entitlement to
benefits under the Medicare program, the amount of reimbursement, and
in cases in which the evidence is being reviewed as a result of
suspected fraud and abuse, program integrity, quality appraisal, or
evaluation and measurement of activities.
Third parties contacts require MMCS information in order to provide
support for the individual's entitlement to benefits under the Medicare
program; to establish the validity of evidence or to verify the
accuracy of information presented by the individual, and assist in the
monitoring of Medicare claims information of beneficiaries, including
proper reimbursement of services provided.
5. To insurance companies, third party administrators (TPA),
employers, self-insurers, managed care organizations, other
supplemental insurers, non-coordinating insurers, multiple employer
trusts, group health plans (i.e., health maintenance organizations
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or
a Medicare-approved health care prepayment plan (HCPP)), directly or
through a contractor, and other groups providing protection for their
enrollees. Information to be disclosed shall be limited to Medicare
entitlement data. In order to receive the information, they must agree
to:
a. Certify that the individual about whom the information is being
provided is one of its insured or employees, or is insured and/or
employed by another entity for whom they serve as a TPA;
b. Utilize the information solely for the purpose of processing the
identified individual's insurance claims; and
c. Safeguard the confidentiality of the data and prevent
unauthorized access.
Other insurers, TPAs, HMOs, and HCPPs may require MMCS information
in order to support evaluations and monitoring of Medicare claims
information of beneficiaries, including proper reimbursement for
services provided.
6. To an individual or organization for a research, evaluation, or
epidemiological project related to the prevention of disease or
disability, the restoration or maintenance of health, or payment-
related projects.
MMCS data will provide for research, evaluation, and
epidemiological projects, a broader, longitudinal, national perspective
of the status of Medicare beneficiaries. CMS anticipates that many
researchers will have legitimate requests to use these data in projects
that could ultimately improve the care provided to Medicare
beneficiaries and the policy that governs the care.
7. To a Member of Congress or a congressional staff member in
response to an inquiry of the congressional office made at the written
request of the constituent about whom the record is maintained.
Beneficiaries often request the help of a Member of Congress in
resolving some issues relating to a matter before CMS. The Member of
Congress then writes CMS, and CMS must be able to give sufficient
information tin response to the inquiry.
8. To the Department of Justice (DOJ), court or adjudicatory body
when:
a. The Agency or any component thereof, or
b. Any employee of the Agency in his or her official capacity, or
c. Any employee of the Agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
d. The United States Government, is a party to litigation or has an
interest in such litigation, and by careful review, CMS determines that
the records are both relevant and necessary to the litigation.
Whenever CMS is involved in litigation, or occasionally when
another party is involved in litigation and CMS's policies or
operations could be affected by the outcome of the litigation, CMS
would be able to disclose information to the DOJ, court, or
adjudicatory body involved.
9. To a CMS contractor (including, but not limited to FIs and
carriers) that assists in the administration of a CMS-administered
health benefits program, or to a grantee of a CMS-administered grant
program, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud or abuse in such programs.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contract or grant with a
third party to assist in accomplishing CMS functions relating to the
purpose of combating fraud and abuse.
CMS occasionally contracts out certain of its functions when doing
so would contribute to effective and efficient operations. CMS must be
able to give a contractor or grantee whatever information is necessary
for the contractor or grantee to fulfill its duties. In these
situations, safeguards are provided in the contract prohibiting the
contractor or grantee from using or disclosing the information for any
purpose other than that described in the contract and requiring the
contractor or grantee to return or destroy all information.
10. To another Federal agency or to an instrumentality of any
governmental jurisdiction within or under the control of the United
States (including any state or local governmental agency), that
administers, or that has the authority to investigate potential fraud
or abuse in, a health benefits program funded in whole or in part by
Federal funds, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud or abuse in such programs.
Other agencies may require MMCS information for the purpose of
combating fraud and abuse in such Federally funded programs.
B. Additional Circumstances Affecting Routine Use Disclosures
This system contains Protected Health Information as defined by HHS
regulation ``Standards for Privacy of Individually Identifiable Health
Information'' (45 CFR Parts 160 and 164, 65 FR 82462 (12-28-00),
Subparts A and E. Disclosures of Protected Health Information
authorized by these routine
[[Page 61391]]
uses may only be made if, and as, permitted or required by the
``Standards for Privacy of Individually Identifiable Health
Information.''
In addition, our policy will be to prohibit release even of data
not directly identifiable, except pursuant to one of the routine uses
or if required by law, if we determine there is a possibility that an
individual can be identified through implicit deduction based on small
cell sizes (instances where the patient population is so small that
individuals who are familiar with the enrollees could, because of the
small size, use this information to deduce the identity of the
beneficiary).
IV. Safeguards
CMS has safeguards in place for authorized users and monitors such
users to ensure against excessive or unauthorized use. Personnel having
access to the system have been trained in the Privacy Act and
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and information systems
and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS, and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations include but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: All pertinent NIST
publications; the HHS Automated Information Systems Security Handbook
and the CMS Information Security Handbook.
V. Effect of the Modified SOR on Individual Rights
CMS proposes to establish this system in accordance with the
principles and requirements of the Privacy Act and will collect, use,
and disseminate information only as prescribed therein. Data in this
system will be subject to the authorized releases in accordance with
the routine uses identified in this system of records.
CMS will monitor the collection and reporting of MMCS data. MMCS
information on individuals is completed by contractor personnel and
submitted to CMS through standard systems located at different
locations. CMS will utilize a variety of onsite and offsite edits and
audits to increase the accuracy of MMCS data.
CMS will take precautionary measures (see item IV. above) to
minimize the risks of unauthorized access to the records and the
potential harm to individual privacy or other personal or property
rights. CMS will collect only that information necessary to perform the
system's functions. In addition, CMS will make disclosure of
identifiable data from the modified system only with consent of the
subject individual, or his/her legal representative, or in accordance
with an applicable exception provision of the Privacy Act.
CMS, therefore, does not anticipate an unfavorable effect on
individual privacy as a result of the disclosure of information
relating to individuals.
Dated: August 19, 2004.
Mark B. McClellan,
Administrator.
SYSTEM No. 09-70-4001
SYSTEM NAME:
``Medicare Managed Care System (MMCS)'' HHS/CMS/CBC
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive
SYSTEM LOCATION:
CMS Data Center, 7500 Security Boulevard, North Building, First
Floor, Baltimore, Maryland 21244-1850.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Recipients of Medicare hospital insurance (Part A) and Medicare
medical insurance (Part B) who are enrolled in a Medicare Managed Care
Plan.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system contains information about a beneficiary's health
insurance entitlement and medical insurance benefits usage.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Authority for maintenance of the system is given under the
provisions of Sec. Sec. 1833(a)(1)(A), 1866, and 1876 of Title XVIII
of the Social Security Act (the Act) (42 U.S.C. 1395(A)(1)(a), 1395cc,
and 1395mm).
PURPOSE(S) OF THE SYSTEM:
The primary purpose of the SOR is to maintain a master file of
Medicare Managed Care Organizations (MCO) plan members for accounting
and payment control; expedite the exchange of data with MCOs; and
control the posting of pro-rata amounts to the Part B deductible of
currently enrolled MCO members. MMCS include the following entities:
Health Maintenance Organizations (HMO), Competitive Medical Plans
(CMP), Health Care Prepayment Plan (HCPP), and Medicare Choice
Organizations (MCO). Information in this system will also be disclosed
to: (1) Support regulatory, reimbursement, and policy functions
performed within the Agency or by a contractor or consultant, (2)
support another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent;
(3) provider and suppliers of service directly or dealing through
contractors, fiscal intermediaries (FI) or carriers for administration
of Title XVIII; (4) provide information to third party contacts in
situations where the contact has information relating to the
individual's capacity to manage his or her affairs; (5) other insurers,
third party administrators (TPA), and other groups providing protection
for their enrollees to assist in the processing of individual insurance
claims (6) facilitate research on the quality and effectiveness of care
provided, as well as payment-related projects, (7) support constituent
requests made to a congressional representative, (8) support litigation
involving the Agency, and (9 & 10) combat fraud and abuse in certain
health benefits programs.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OR USERS AND THE PURPOSES OF SUCH USES:
A. These routine uses specify circumstances, in addition to those
provided by statute in the Privacy Act of 1974, under which CMS may
release information from the MMCS without the consent of the individual
to whom such information pertains. Each proposed disclosure of
information under these routine uses will be evaluated to ensure that
the disclosure is legally permissible, including but not limited to
ensuring that the purpose of the disclosure is compatible with the
purpose for which the information was collected. We are proposing to
establish or modify the following routine use disclosures of
information maintained in the system:
[[Page 61392]]
1. To Agency contractors, or consultants who have been contracted
by the Agency to assist in accomplishment of a CMS function relating to
the purposes for this system and who need to have access to the records
in order to assist CMS.
2. To support another Federal or state agency, agency of a state
government, an agency established by state law, or its fiscal agent to:
a. Contribute to the accuracy of CMS's proper payment of Medicare
benefits,
b. Enable such agency to administer a Federal health benefits
program, or as necessary to enable such agency to fulfill a requirement
of a Federal statute or regulation that implements a health benefits
program funded in whole or in part with Federal funds, and/or
c. Assist Federal/state Medicaid programs within the state.
3. To providers and suppliers of services directly or through
fiscal intermediaries (FIs) or carriers for the administration of Title
XVIII of the Act.
4. To provide information to third party contacts in situations
where the party to be contacted has information relating to the
individual's capacity to manage his or her affairs or to his or her
eligibility for, or an entitlement to, benefits under the Medicare
program and,
a. The individual is unable to provide the information being sought
(an individual is considered to be unable to provide certain types of
information when any of the following conditions exists: the individual
is confined to a mental institution, a court of competent jurisdiction
has appointed a guardian to manage the affairs of that individual, a
court of competent jurisdiction has declared the individual to be
mentally incompetent, or the individual's attending physician has
certified that the individual is not sufficiently mentally competent to
manage his or her own affairs or to provide the information being
sought, the individual cannot read or write, a language barrier exists,
or the custodian of the information will not, as a matter of policy,
provide it to the individual), or
b. The data are needed to establish the validity of evidence or to
verify the accuracy of information presented by the individual, and it
concerns one or more of the following: the individual's entitlement to
benefits under the Medicare program, the amount of reimbursement, and
in cases in which the evidence is being reviewed as a result of
suspected fraud and abuse, program integrity, quality appraisal, or
evaluation and measurement of activities.
5. To insurance companies, third party administrators (TPA),
employers, self-insurers, managed care organizations, other
supplemental insurers, non-coordinating insurers, multiple employer
trusts, group health plans (i.e., health maintenance organizations
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or
a Medicare-approved health care prepayment plan (HCPP)), directly or
through a contractor, and other groups providing protection for their
enrollees. Information to be disclosed shall be limited to Medicare
entitlement data. In order to receive the information, they must agree
to:
a. Certify that the individual about whom the information is being
provided is one of its insured or employees, or is insured and/or
employed by another entity for whom they serve as a TPA;
b. Utilize the information solely for the purpose of processing the
identified individual's insurance claims; and
c. Safeguard the confidentiality of the data and prevent
unauthorized access.
6. To an individual or organization for a research, evaluation, or
epidemiological project related to the prevention of disease or
disability, the restoration or maintenance of health, or payment-
related projects.
7. To a Member of Congress or a congressional staff member in
response to an inquiry of the congressional office made at the written
request of the constituent about whom the record is maintained.
8. To the Department of Justice (DOJ), court or adjudicatory body
when:
a. The Agency or any component thereof, or
b. Any employee of the Agency in his or her official capacity, or
c. Any employee of the Agency in his or her individual capacity
where the DOJ has agreed to represent the employee, or
d. The United States Government, is a party to litigation or has an
interest in such litigation, and by careful review, CMS determines that
the records are both relevant and necessary to the litigation.
9. To a CMS contractor (including, but not limited to FIs and
carriers) that assists in the administration of a CMS-administered
health benefits program, or to a grantee of a CMS-administered grant
program, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud or abuse in such programs.
10. To another Federal agency or to an instrumentality of any
governmental jurisdiction within or under the control of the United
States (including any state or local governmental agency), that
administers, or that has the authority to investigate potential fraud
or abuse in, a health benefits program funded in whole or in part by
Federal funds, when disclosure is deemed reasonably necessary by CMS to
prevent, deter, discover, detect, investigate, examine, prosecute, sue
with respect to, defend against, correct, remedy, or otherwise combat
fraud or abuse in such programs.
B. Additional Circumstances Affecting Routine Use Disclosures
This system contains Protected Health Information as defined by HHS
regulation ``Standards for Privacy of Individually Identifiable Health
Information'' (45 CFR Parts 160 and 164, 65 FR 82462 (12-28-00),
Subparts A and E. Disclosures of Protected Health Information
authorized by these routine uses may only be made if, and as, permitted
or required by the ``Standards for Privacy of Individually Identifiable
Health Information.''
In addition, our policy will be to prohibit release even of data
not directly identifiable, except pursuant to one of the routine uses
or if required by law, if we determine there is a possibility that an
individual can be identified through implicit deduction based on small
cell sizes (instances where the patient population is so small that
individuals who are familiar with the enrollees could, because of the
small size, use this information to deduce the identity of the
beneficiary).
POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Computer diskette and on magnetic storage media.
RETRIEVABILITY:
Information can be retrieved by name and health insurance claim
number of the beneficiary.
SAFEGUARDS:
CMS has safeguards in place for authorized users and monitors such
users to ensure against excessive or unauthorized use. Personnel having
access to the system have been trained in the Privacy Act and
information security requirements. Employees who maintain records in
this system are instructed not to release data until the intended
recipient agrees to implement appropriate management, operational and
technical safeguards sufficient to protect the confidentiality,
integrity and availability of the information and
[[Page 61393]]
information systems and to prevent unauthorized access.
This system will conform to all applicable Federal laws and
regulations and Federal, HHS, and CMS policies and standards as they
relate to information security and data privacy. These laws and
regulations include but are not limited to: the Privacy Act of 1974;
the Federal Information Security Management Act of 2002; the Computer
Fraud and Abuse Act of 1986; the Health Insurance Portability and
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the
corresponding implementing regulations. OMB Circular A-130, Management
Of Federal Resources, Appendix III, Security of Federal Automated
Information Resources also applies. Federal, HHS, and CMS policies and
standards include but are not limited to: all pertinent NIST
publications; the HHS Automated Information Systems Security Handbook
and the CMS Information Security Handbook.
RETENTION AND DISPOSAL:
Records are maintained in a secure storage area with identifiers.
Disposal occurs three years from the last action on the hospital's cost
report, and should be coordinated with disposal of the reports.
SYSTEM MANAGER AND ADDRESS:
Director, Division of Managed Care Operations, Information Services
Modernization Group, Office of Information Services, CMS, 7500 Security
Boulevard, N3-16-24, Baltimore, Maryland 21244-1850.
NOTIFICATION PROCEDURE:
For purpose of access, the subject individual should write to the
systems manager who will require the system name, SSN, address, date of
birth, sex, and for verification purposes, the subject individual's
name (woman's maiden name, if applicable). Furnishing the SSN is
voluntary, but it may make searching for a record easier and prevent
delay.
RECORD ACCESS PROCEDURE:
For purpose of access, use the same procedures outlined in
Notification Procedures above. Requestors should also reasonably
specify the record contents being sought. (These procedures are in
accordance with Department regulation 45 CFR 5b.5(a)(2)).
CONTESTING RECORD PROCEDURES:
The subject individual should contact the system manager named
above, and reasonably identify the record and specify the information
to be contested. State the corrective action sought and the reasons for
the correction with supporting justification. (These procedures are in
accordance with Department regulation 45 CFR 5b.7).
RECORD SOURCE CATEGORIES:
Data for this system is collected from MCO (which obtained the data
from the individuals concerned), Social Security Administration, and
the Enrollment Database system of records.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
None.
[FR Doc. 04-23251 Filed 10-15-04; 8:45 am]
BILLING CODE 4120-03-P