[Federal Register: January 14, 2008 (Volume 73, Number 9)]
[Notices]
[Page 2257-2263]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr14ja08-68]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Privacy Act of 1974; Report of a Modified or Altered System of
Records
AGENCY: Department of Health and Human Services (HHS), Centers for
Medicare & Medicaid Services (CMS).
ACTION: Notice of a Modified or Altered System of Records (SOR).
-----------------------------------------------------------------------
SUMMARY: In accordance with the Privacy Act of 1974, we are proposing
to modify or alter an existing SOR, ``Health Plan Management System
(HPMS) ,'' System No. 09-70-4004, established at 63 Federal Register
43187 (August 12, 1998). We will broaden the scope of this system by
including a new activity related to health plan and Part D plan
management referred to as the Complaint Tracking Module (CTM). CTM will
collect and maintain identifiable information on individuals who are,
but not limited to, complainants, including beneficiaries, relatives
and caregivers, Congresspersons and their staff, State Health Insurance
Program representatives, and providers of service and their staff. The
CTM stores complaint data, including, but not limited to, the
following: Date complaint received; date of incident; issue level;
complainant and/or beneficiary information; complaint summary;
complaint category; complaint resolution summary; and plan resolution
summary. Plans use the CTM to track the beneficiary complaints assigned
to their organization, enter complaint case resolutions, and close out
complaints.
In addition, HPMS will collect information from health plans and
Part D plan organizations pertaining to individuals who market and/or
sell health insurance and prescription drug plan products on behalf of
these plan organizations and who are licensed or authorized by a State
Insurance Commissioner or other certifying agencies. We are sharing
data pertaining to all agents/brokers to assist CMS and State Insurance
Commissioners in improving oversight of the sales marketplace and in
avoiding fraudulent sales practices that mislead and harm Medicare
beneficiaries. We propose to assign a new CMS identification number to
this system to simplify the obsolete and confusing numbering system
originally designed to identify the Bureau, Office, or Center that
maintained information in the Health Care Financing Administration
systems of records. The new assigned identifying number for this system
should read: System No. 09-70-0500.
We will delete routine use number 1 authorizing disclosure to
support constituent requests made to a congressional representative. If
an authorization for the disclosure has been obtained from the data
subject, then no routine use is needed. The Privacy Act allows for
disclosures with the ``prior written consent'' of the data subject. We
propose to delete published routine use number 5 authorizing disclosure
to a contractor for the purpose of collating, analyzing, aggregating or
otherwise refining or processing records in this system or for
developing, modifying and/or manipulating automated information systems
software. We also propose to add a routine use for the release of
information that permits disclosure to agency contractors, consultants,
and CMS grantees that perform a task for the agency. 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, consultant or grantee whatever information is necessary for
the contractor, consultant, or grantee to fulfill its duties.
We propose to delete published routine use number 2 authorizing
disclosure to the Bureau of Census;
[[Page 2258]]
published routine use number 7 authorizing disclosure to state Medicaid
agencies; number 8 authorizing disclosure to an agency of a state
Government, or established by state law, for purposes of determining
the quality of health care services provided in the state; published
routine use number 9 authorizing disclosure to another Federal or state
agency; published routine use number 10 authorizing disclosure to other
Federal agencies or states to support the administration of other
Federal or state health care programs; and published routine use number
11 authorizing disclosure to the Social Security Administration. These
routine uses duplicate the intended releases and as such will be
combined into a single routine use to ``assist 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 (c) evaluate and monitor the quality of health
care in the program and contribute to the accuracy of health plan
operations.''
We will modify existing routine use number 6 that permits
disclosure to Peer Review Organizations (PRO). Organizations previously
referred to as PROs will be renamed to read: Quality Improvement
Organizations (QIO). Information will be disclosed to QIOs for health
care quality improvement projects. The modified routine use will be
renumbered as routine use number 4. We propose to delete published
routine use number 14 authorizing disclosures to any entity that makes
payment for or oversees administration of health care services to
combat fraud and abuse against such entity or the program or services
administered by such entity. This disclosure provision falls outside
the scope of the stated purpose for the collection of data maintained
in this system.
We will broaden the scope of this system by including the section
titled ``Additional Circumstances Affecting Routine Use Disclosures,''
that addresses ``Protected Health Information (PHI)'' and ``small cell
size.'' The requirement for compliance with HHS regulation ``Standards
for Privacy of Individually Identifiable Health Information'' apply
when ever the system collects or maintain PHI. This system may contain
PHI. In addition, our policy to prohibit release if there is a
possibility that an individual can be identified through ``small cell
size'' will apply to the data disclosed from this system.
The security classification previously reported as ``None'' will be
modified to reflect that the data in this system is considered to be
``Level Three Privacy Act Sensitive.'' We are modifying the language in
the remaining routine uses to provide a proper explanation as to the
need for the routine use and to provide clarity 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
usage. We will also take the opportunity to update any sections of the
system that were affected by the impact of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-
173) provisions and to update language in the administrative sections
to correspond with language used in other CMS SORs.
The primary purpose of this modified system is to collect and
maintain information on Medicare beneficiaries enrolled in Medicare
Health Plans in order to develop and disseminate information required
by the Balanced Budget Act of 1997 that will inform beneficiaries and
the public of indicators of health plan performance to help
beneficiaries choose among health plans, support quality improvement
activities within the plans, monitor and evaluate quality improvement
activities within the plans, monitor and evaluate care provided by
health plans; provide guidance to program management and policies, and
provide a research data base for CMS and other researchers. The
information retrieved from this system of records will also be
disclosed to: (1) Support regulatory, reimbursement, and policy
functions performed within the Agency or by a contractor or consultant;
(2) assist another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent,
for evaluating and monitoring the quality of home health care and
contribute to the accuracy of health insurance operations; (3) support
research, evaluation, or epidemiological projects related to the
prevention of disease or disability, or the restoration or maintenance
of health, and for payment related projects; (4) support the functions
of Quality Improvement Organizations (QIO); (5) support litigation
involving the Agency; (6) combat fraud and abuse in certain health care
programs. We have provided background information about the modified
system in the SUPPLEMENTARY INFORMATION section below. Although the
Privacy Act requires only that CMS provide an opportunity for
interested persons to comment on the modified or altered routine uses,
CMS invites comments on all portions of this notice. See EFFECTIVE
DATES section for comment period.
EFFECTIVE 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 Homeland Security & Governmental
Affairs, and the Administrator, Office of Information and Regulatory
Affairs, Office of Management and Budget (OMB) on January 4, 2008. To
ensure that all parties have adequate time in which to comment, the
modified system, including routine uses, will become effective 30 days
from the publication of the notice, or 40 days from the date it was
submitted to OMB and Congress, whichever is later, unless CMS receives
comments that require alterations to this notice.
ADDRESSES: The public should address comments to: CMS Privacy Officer,
Division of Privacy Compliance, Enterprise Architecture and Strategy
Group, Office of Information Services, 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 time zone.
FOR FURTHER INFORMATION CONTACT: Ms. Lori Robinson, Director, Division
of Plan Data, Plan Oversight and Accountability Group, Center for
Beneficiary Choices, Center for Medicare & Medicaid Services, 7500
Security Boulevard, C4-14-21, Baltimore, Maryland 21244-1850. Her
telephone number is (410) 786-1826 or via e-mail at
lori.robinson@cms.hhs.gov.
SUPPLEMENTARY INFORMATION: The Health Plan Management System is a
database containing rates for selected performance measures for each
Medicare health plan. The data are compiled by HIC number, member month
contribution, and a flag to indicate if the member was counted in the
rate's numerator. The system will collect rate information on
categories such as the following:
``Use of Services'' measures such as the frequency of
selected procedures (e.g., percutaneous transluminal coronary artery
angioplasty, prostatectomy, coronary artery bypass with graft,
hysterectomy, cholecystectomy, cardiac catheterization, reduction of
fracture of
[[Page 2259]]
the femur, total hip and knee replacement, partial excision of the
large intestine, carotid endarterectomy); percentage of members
receiving inpatient, day/night and ambulatory mental health and
chemical dependency services; readmission for chemical dependency, and
specified mental health disorders.
``Effectiveness of Care'' measures such as breast cancer
screening, beta blocker treatment after a heart attack, eye exams for
people with diabetes, and follow-up after hospitalization for mental
illness.
``Member Satisfaction'' measures related to quality,
access, and general satisfaction.
``Functional Status'' measures which are patient centered
and track actual outcomes or results of care, addressing both physical
and mental well-being over time.
The information from HPMS will be augmented by being linked to
other CMS data and other administrative data to provide validation and
greater analytic capacity. The HPMS will be used to:
Develop and disseminate summary information required by
the Balanced Budget Act of 1997 that will inform beneficiaries and the
public of indicators of health plan performance to help beneficiaries
choose among health plans. The information will include plan-to-plan
comparisons of benefits and co-payments supplemented with consumer
satisfaction information and plan performance data.
Support quality improvement activities. Summary data will
be useful for health plans' internal quality improvement, as well as to
CMS and Quality Improvement Organizations in monitoring and evaluating
the care provided by health plans.
Conduct research and demonstrations addressing managed
care quality, access, and satisfaction issues.
Provide guidance for program management and policy
development.
HPMS houses the results of the Health Plan Employer Data and
Information Set (HEDIS) and the Consumer Assessment of Health Plans
Survey (CAHPS). The system will contain information on recipients of
Medicare Part A and Part B services who are enrolled in health plans
and Part D plans. The total number of current enrollees in Medicare
Part C health plans is approximately 9 million.
HEDIS reflects a joint effort of public and private purchasers,
consumers, labor unions, health plans, and measurement experts to
develop a comprehensive set of performance measures for Medicare,
Medicaid, and commercial populations enrolled in managed care plans.
HEDIS measures eight aspects of health care: Effectiveness of care;
access/availability of care, satisfaction with the experience of care,
health plan stability, use of services, cost of care, informed health
care choices, and health plan descriptive information. In 1997, CMS is
requiring reporting of a number of performance measures from HEDIS
relevant to the Medicare managed care population. The HEDIS data is
subject to audit, to ensure that plans submit accurate and complete
data. Another aspect of the audit is to assess the reasonableness of
the HEDIS measures. For example, if all or most health plans have
problems with a particular measure, the problem could be with the
measure, not the plans.
Included in HEDIS is a functional status measure which tracks both
physical health and mental health status over a 2-year period through a
self-administered instrument in which the beneficiary indicates whether
his/her health status has improved, stayed the same, or deteriorated.
The measure is risk adjusted for co-morbid conditions, income, race,
education, social support, age, and gender. It will be used to compare
how well plans care for seniors. It reflects the belief that high
quality health care can either improve or at least slow the rate of
decline in senior members' ability to lead active and independent
lives.
In concert with the Agency for Health Care Policy and Research, CMS
sponsored the development of a Medicare specific version of the CAHPS
consumer satisfaction survey. The survey will collect information about
Medicare enrollees' satisfaction, access, and quality of care within
managed care plans. Beginning in 1997, CMS is requiring all Medicare
contracting plans to participate in an independent third party
administration of an annual member satisfaction survey.
All performance measures are subject to modification as new
performance measurement sets are developed with a stronger focus on
outcomes and chronic disease issues, including patient satisfaction and
quality of life measures relevant to specific diseases.
The Privacy Act permits us to disclose information without the
consent of individuals for ``routine uses''--that is, disclosures that
are compatible with the purpose for which we collected the information.
The proposed routine uses in the new system meet the compatibility
criteria since the information is collected to produce estimates of
health care use and quality, and determinants thereof, by the aged and
disabled enrolled in group health plans. We anticipate the disclosures
under the routine uses will not result in any unwarranted adverse
effects on personal privacy.
The HPMS Complaints Tracking Module (CTM) stores beneficiary
complaints related to the Medicare Advantage (MA) and Part D programs.
This module contains beneficiary complaints that have been collected by
1-800-Medicare as well as beneficiary complaints entered directly into
the CTM by CMS staff. The CTM stores complaint data, including, but not
limited to, the following: Date complaint received; date of incident;
issue level; complainant and/or beneficiary information; complaint
summary; complaint category; complaint resolution summary; and plan
resolution summary. Plans use the CTM to track the beneficiary
complaints assigned to their organization, enter complaint case
resolutions, and close out complaints. CMS uses the CTM to enter
beneficiary complaints received directly by the regional office,
perform casework for those complaints not assigned to an organization,
and to monitor plan progress on resolving complaints timely.
We are sharing data pertaining to all marketing agents/brokers to
assist CMS and State Department of Insurance (DOI) in improving
oversight of the sales marketplace and in avoiding fraudulent sales
practices that mislead and harm Medicare beneficiaries. Beneficiaries
that are enrolled in a health plan or prescription drug plan under
false, fraudulent pretense result in plan organizations receiving
payments to which they are not entitled. As a result, there is a
payment policy component involved. We will require contracted health
plans and prescription drug plans, though contract or program
memorandum (or both) to notify all agents/brokers that sell their
Medicare products that their information is being shared with CMS, its
contractors, and State DOIs.
I. Description of the Modified or Altered System of Records
A. Statutory and Regulatory Basis for SOR
Authority for maintenance of the system is given under section 1875
of the Social Security Act (the Act) (42 U.S.C. 1395ll), entitled
Studies and Recommendations; section 1121 of the Act (42 U.S.C. 1121),
entitled Uniform Reporting System for Health Services Facilities and
Organizations; and Sec. 1876 of the Act (42 U.S.C. 1395mm), entitled
[[Page 2260]]
Payments to Health Maintenance Organizations and Competitive Medical
Plans. Authority for maintenance and dissemination of Health Plan
information is also given under the Balanced Budget Act of 1997 (Pub.
L. 105-33).
B. Collection and Maintenance of Data in the System.
Information is collected and maintained on recipients of Medicare
Part A (Hospital Insurance) and Part B (supplementary medical
insurance) services who are enrolled in Medicare health plans and
prescription drug plans. CTM will collect and maintain identifiable
information on individuals who are, but not limited to, complainants,
including beneficiaries, relatives and caregivers, Congresspersons and
their staff, State Health Insurance Program representatives, and
providers of service and their staff. The system contains demographic
and identifying data, as well as survey and deficiency data.
Identifying data includes, but is not limited to: Name, title, address,
city, state, ZIP code, e-mail address, telephone numbers, fax number,
licensure number, SSN, Federal tax identification number, alias names,
date of birth, gender, date admitted and/or date discharged. In
addition, the CTM stores complaint data, including, but not limited to,
the following: Date complaint received; date of incident; issue level;
complainant and/or beneficiary information; complaint summary;
complaint category; complaint resolution summary; and plan resolution
summary.
II. Agency Policies, Procedures, and Restrictions on the Routine Use
A. 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 HPMS 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 HPMS. CMS has the following policies and procedures
concerning disclosures of information that will be maintained in the
system. Disclosure of information from this system 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 that the data is being collected, e.g., to collect and maintain
information on Medicare beneficiaries enrolled in Medicare Health
Plans.
2. Determines that:
a. The purpose for which the disclosure is to collect and maintain
information on Medicare beneficiaries enrolled in Medicare Health Plans
in order to develop and disseminate information required by the
Balanced Budget Act of 1997 that will inform beneficiaries and the
public of indicators of health plan performance to help beneficiaries
choose among health plans, support quality improvement activities
within the plans, monitor and evaluate quality improvement activities
within the plans, monitor and evaluate care provided by health plans;
provide guidance to program management and policies, and provide a
research data base for CMS and other researchers;
b. 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
c. 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. The Privacy Act allows 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 compatible use of data is known as a ``routine
use.'' The proposed routine uses in this system meet the compatibility
requirement of the Privacy Act. We are proposing to establish the
following routine use disclosures of information maintained in the
system:
1. To agency contractors, or consultants, or to a grantee of a CMS-
administered grant program who have been engaged by the agency to
assist in the 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 this 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,
consultant or grantee 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,
consultant or grantee from using or disclosing the information for any
purpose other than that described in the contract and requires the
contractor, consultant or grantee to return or destroy all information
at the completion of the contract.
2. To another Federal and/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 HPMS information in order to support
evaluations and monitoring of Medicare claims information of
beneficiaries, including proper reimbursement for services provided;
To another agency or to an instrumentality of any governmental
jurisdiction within or under the control of the United States
(including any State or local law enforcement agencies) for a civil or
criminal law enforcement activity (e.g. police, FBI, State Attorney
General's office);
In addition, other state agencies in their administration of a
Federal health program may require HPMS information for the purpose of
developing and operating Medicaid reimbursement
[[Page 2261]]
systems; or for the purpose of administration of Federal/State program
within the State. Data will be released to the State only on those
individuals who are either patients within the State, of are legal
residents of the State, regardless of the location of the facility in
which the patient is receiving services;
To the agency of a State government, or established by State law,
for purposes of determining, evaluating and/or assessing overall or
aggregate cost, effectiveness, and/or the quality of services provided
in the State; and
State agencies may use HPMS data to perform Federal certification
and State licensure functions, including the investigation of
complaints and entity-reported incidents.
3. To assist an individual or organization for research, evaluation
or epidemiological projects related to the prevention of disease or
disability, or the restoration or maintenance of health, and for
payment related projects.
The collected data will provide the research, evaluation and
epidemiological projects a broader, longitudinal, national perspective
of the data. CMS anticipates that many researchers will have legitimate
requests to use these data in projects that could ultimately improve
the care provided to Medicare patients and the policy that governs the
care. CMS understands the concerns about the privacy and
confidentiality of the release of data for a research use. Disclosure
of data for research and evaluation purposes may involve aggregate data
rather than individual-specific data.
4. To Quality Improvement Organizations (QIO) in order to assist
the QIO to perform Title XI and Title XVIII functions relating to
assessing and improving quality of care.
The QIO will work to implement quality improvement programs,
provide consultation to CMS, its contractors, and to state agencies.
The QIO will assist state agencies in related monitoring and
enforcement efforts, assist CMS and intermediaries in program integrity
assessment, and prepare summary information for release to CMS.
5. 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 and that
the use of such records by the DOJ, court or adjudicatory body is
compatible with the purpose for which the agency collected the records.
Whenever CMS is involved in litigation, and occasionally when
another party is involved in litigation and CMS' 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.
6. To assist a CMS contractor (including, but not necessarily
limited to fiscal intermediaries 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 program.
We contemplate disclosing information under this routine use only
in situations in which CMS may enter into a contractual relationship 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 and makes
grants 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.
7. To assist 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 HPMS information for the purpose of
combating fraud and abuse in such Federally-funded programs.
B. Additional Provisions Affecting Routine Use Disclosures
To the extent this system contains Protected Health Information
(PHI) 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 such PHI
that are otherwise 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 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 may apply 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
[[Page 2262]]
applies. Federal, HHS, and CMS policies and standards include but are
not limited to: all pertinent National Institute of Standards and
Technology publications, the HHS Information Systems Program Handbook,
and the CMS Information Security Handbook.
V. Effects of the Modified or Altered System of Records on Individual
Rights
CMS proposes to modify 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 take precautionary measures to minimize the risks of
unauthorized access to the records and the potential harm to individual
privacy or other personal or property rights of patients whose data are
maintained in the system. CMS will collect only that information
necessary to perform the system's functions. In addition, CMS will make
disclosure from the proposed 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 information relating to individuals.
Dated: January 3, 2008.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NO. 09-70-0500
SYSTEM NAME:
``Health Plan Management System (HPMS),'' HHS/CMS/CBC.
SECURITY CLASSIFICATION:
Level Three Privacy Act Sensitive Data.
SYSTEM LOCATION:
The Centers for Medicare & Medicaid Services (CMS) Data Center,
7500 Security Boulevard, North Building, First Floor, Baltimore,
Maryland 21244-1850 and at various co-locations of CMS agents.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
Information is collected and maintained on recipients of Medicare
Part A (Hospital Insurance) and Part B (supplementary medical
insurance) services who are enrolled in Medicare health plans and
prescription drug plans. Identifiable information will also be
collected on individuals who are, but not limited to, complainants,
including beneficiaries, relatives and caregivers, Congresspersons and
their staff, State Health Insurance Program representatives, and
providers of service and their staff.
CATEGORIES OF RECORDS IN THE SYSTEM:
The system contains demographic and identifying data, as well as
survey and deficiency data. Identifying data includes, but is not
limited to: name, title, address, city, state, ZIP code, e-mail
address, telephone numbers, fax number, licensure number, SSN, Federal
tax identification number, alias names, date of birth, gender, date
admitted and/or date discharged. In addition, the CTM stores complaint
data, including, but not limited to, the following: date complaint
received; date of incident; issue level; complainant and/or beneficiary
information; complaint summary; complaint category; complaint
resolution summary; and plan resolution summary.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
Authority for maintenance of the system is given under section 1875
of the Social Security Act (the Act) (42 U.S.C. 1395ll), entitled
Studies and Recommendations; section 1121 of the Act (42 U.S.C. 1121),
entitled Uniform Reporting System for Health Services Facilities and
Organizations; and Sec. 1876 of the Act (42 U.S.C. 1395mm), entitled
Payments to Health Maintenance Organizations and Competitive Medical
Plans. Authority for maintenance and dissemination of Health Plan
information is also given under the Balanced Budget Act of 1997 (Pub.
L. 105-33).
PURPOSE(S) OF THE SYSTEM:
The primary purpose of this modified system is to collect and
maintain information on Medicare beneficiaries enrolled in Medicare
Health Plans in order to develop and disseminate information required
by the Balanced Budget Act of 1997 that will inform beneficiaries and
the public of indicators of health plan performance to help
beneficiaries choose among health plans, support quality improvement
activities within the plans, monitor and evaluate quality improvement
activities within the plans, monitor and evaluate care provided by
health plans; provide guidance to program management and policies, and
provide a research data base for CMS and other researchers. The
information retrieved from this system of records will also be
disclosed to: (1) Support regulatory, reimbursement, and policy
functions performed within the Agency or by a contractor or consultant;
(2) assist another Federal and/or state agency, agency of a state
government, an agency established by state law, or its fiscal agent,
for evaluating and monitoring the quality of home health care and
contribute to the accuracy of health insurance operations; (3) support
research, evaluation, or epidemiological projects related to the
prevention of disease or disability, or the restoration or maintenance
of health, and for payment related projects; (4) support the functions
of Quality Improvement Organizations (QIO); (5) support litigation
involving the Agency; (6) combat fraud and abuse in certain health care
programs.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OR USERS AND THE PURPOSES OF SUCH USES:
A. The Privacy Act allows 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 compatible use of data is known as a ``routine
use.'' The proposed routine uses in this system meet the compatibility
requirement of the Privacy Act. We are proposing to establish the
following routine use disclosures of information maintained in the
system:
1. To agency contractors, or consultants, or to a grantee of a CMS-
administered grant program who have been engaged by the agency to
assist in the 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 another Federal and/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' 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 assist an individual or organization for research, evaluation
or epidemiological projects related to the prevention of disease or
disability, or the restoration or maintenance of health, and for
payment related projects.
4. To Quality Improvement Organizations (QIO) in order to assist
the QIO to perform Title XI and Title XVIII functions relating to
assessing and improving quality of care.
5. To the Department of Justice (DOJ), court or adjudicatory body
when:
[[Page 2263]]
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 and that
the use of such records by the DOJ, court or adjudicatory body is
compatible with the purpose for which the agency collected the records.
6. To assist a CMS contractor (including, but not necessarily
limited to fiscal intermediaries 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 program.
7. To assist 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 Provisions Affecting Routine Use Disclosures
To the extent this system contains Protected Health Information
(PHI) as defined by HHS regulation ``Standards for Privacy of
Individually Identifiable Health Information'' (45 CFR Parts 160 and
164, 65 Fed. Reg. 82462 (12-28-00), Subparts A and E. Disclosures of
such PHI that are otherwise 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 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:
All records are stored on the magnetic disk sub-system of the Sun
Solaris 10 Server. Furthermore, these records are saved to magnetic
tape backup on a nightly basis.
RETRIEVABILITY:
The records are retrieved by health insurance claims number or
other individually identifying numbers.
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 may apply 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 National
Institute of Standards and Technology publications; the HHS Information
Systems Program Handbook and the CMS Information Security Handbook.
RETENTION AND DISPOSAL:
CMS will retain identifiable HPMS data for at least 10 years or as
long as needed for program research.
SYSTEM MANAGER(S) AND ADDRESS:
Director, Division of Plan Data, Plan Oversight and Accountability
Group, Center for Beneficiary Choices, Center for Medicare & Medicaid
Services, 7500 Security Boulevard, C4-14-21, Baltimore, Maryland 21244-
1850.
NOTIFICATION PROCEDURE:
For purpose of access, the subject individual should write to the
system manager who will require the system name, HICN, address, date of
birth, and gender, and for verification purposes, the subject
individual's name (woman's maiden name, if applicable), and SSN.
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 specify the
record contents being sought. (These procedures are in accordance with
department regulation 45 CFR 5b.5(a)(2)).
CONTESTING RECORDS PROCEDURES:
The subject individual should contact the system manager named
above, and reasonably identify the records 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).
RECORDS SOURCE CATEGORIES:
The identifying information contained in these records is obtained
from the health plan and Part D organizations (which obtained the data
from the individual concerned) or the individuals themselves. Also,
these data will be linked with CMS administrative data, such as claims
and enrollment.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
None.
[FR Doc. 08-72 Filed 1-11-08; 8:45 am]
BILLING CODE 4120-03-M