[Federal Register Volume 73, Number 9 (Monday, January 14, 2008)]
[Notices]
[Pages 2257-2263]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 08-72]


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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).

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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 
<a href="/cdn-cgi/l/email-protection#2f43405d46015d404d46415c40416f4c425c0147475c01484059"><span class="__cf_email__" data-cfemail="ec80839e85c29e838e85829f8382ac8f819fc284849fc28b839a">[email protected]</span></a>.

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:
    <bullet> ``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.
    <bullet> ``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.
    <bullet> ``Member Satisfaction'' measures related to quality, 
access, and general satisfaction.
    <bullet> ``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:
    <bullet> 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.
    <bullet> 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.
    <bullet> Conduct research and demonstrations addressing managed 
care quality, access, and satisfaction issues.
    <bullet> 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


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