[Federal Register Volume 65, Number 117 (Friday, June 16, 2000)]
[Notices]
[Pages 37792-37795]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-15231]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration


Privacy Act of 1974; Report of Altered Systems

AGENCY: Department of Health and Human Services (HHS), Health Care 
Financing Administration (HCFA).

ACTION: Notice of the modification or alteration to 20 systems of 
records.

-----------------------------------------------------------------------

SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are correcting information provided in 20 HCFA systems of 
records specified in Appendix A. These systems are all related to 
research or demonstration projects under the control of the Office of 
Strategic Planning. We are deleting the published routine uses in the 
system of records listed in Appendix A and replacing them with four 
revised routine uses. The routine uses are being prioritized and 
renumbered accordingly. We are taking the opportunity to update those 
sections of the SORs that were affected by the recent reorganization. 
We are also updating the language in the administrative sections to 
correspond with language used in other HCFA system of records.
    The primary purpose of the corrections to these systems is to 
shorten the language, make the routine uses easier to read, and provide 
clarity to HCFA's intention to disclose individual-specific information 
related to the purposes for which the information is being collected.

EFFECTIVE DATES: HCFA filed a correction to a system report with the 
Chair of the House Committee on Government Reform and Oversight, the 
Chair of the Senate Committee on Governmental Affairs, and the 
Administrator, Office of Information and Regulatory Affairs, Office of 
Management and Budget (OMB) on June 12, 2000. To ensure that all 
parties have adequate time in which to comment, the corrected systems 
of records, including routine uses, will become effective 40 days from 
the publication of the notice, or from the date it was submitted to OMB 
and the Congress, whichever is

[[Page 37793]]

later, unless HCFA receives comments that require alterations to this 
notice.

ADDRESSES: The public should address comments to: Director, Division of 
Data Liaison and Distribution (DDLD), HCFA, 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: Sydney P. Galloway, Privacy Act 
Coordinator, Systems, Technical, and Analytic Resources Group, Office 
of Strategic Planning (OSP), HCFA, Mailstop C3-24-07, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. The telephone number is 410-
786-6645.

SUPPLEMENTARY INFORMATION:

I. Collection and Maintenance of Data in the System

Agency Policies, Procedures, and Restrictions on the Routine Use

    We are establishing the following policies, procedures and 
restrictions on routine use disclosures of information that will be 
maintained in these systems. In general, routine uses of these systems 
(or a subset thereof) will be approved for the minimum set of data 
elements in the record needed to accomplish the purpose of the 
disclosure after HCFA:
    (a) Determines that the use or disclosure is consistent with the 
reason that the data is being collected, e.g., conducting research 
related to specific projects and demonstrations, and monitoring the 
quality of care provided to patients.
    (b) Determines:
    (1) That the purpose for which the disclosure is to be made can 
only be accomplished if the record is provided in individually 
identifiable form;
    (2) That the purpose for which the disclosure is to be made is of 
sufficient importance to warrant the potential effect and/or risk on 
the privacy of the individual that additional exposure of the record 
might bring; and
    (3) That there is a strong probability that the proposed use of the 
data would in fact accomplish the stated purpose(s).
    (c) Requires the information recipient to:
    (1) Establish administrative, technical, and physical safeguards to 
prevent unauthorized use of disclosure of the record; and
    (2) Remove or destroy at the earliest time all patient-identifiable 
information.
    (d) Determines that the data are valid and reliable.

II. Proposed Routine Use Disclosures of Data in the System

    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 correcting the language in the 
following routine use disclosures of information maintained in these 
systems:
    1. To 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. HCFA 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. HCFA 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.
    2. To agency contractors, or consultants who have been engaged by 
the agency to assist in the performance of a service related to this 
system of records and who need to have access to the records in order 
to perform the activity.
    We contemplate disclosing information under this routine use only 
in situations in which HCFA may enter into a contractual or similar 
agreement with a third party to assist in accomplishing HCFA function 
relating to purposes for these systems of records.
    HCFA occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. HCFA must be 
able to give a contractor or consultant whatever information is 
necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor or consultant from using or disclosing the information 
for any purpose other than that described in the contract and requires 
the contractor or consultant to return or destroy all information at 
the completion of the contract.
    3. To a member of congress or to a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    Beneficiaries sometimes request the help of a member of congress in 
resolving an issue relating to a matter before HCFA. The member of 
congress then writes HCFA, and HCFA must be able to give sufficient 
information to be responsive to the inquiry.
    4. 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, HCFA 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 HCFA is involved in litigation, or occasionally when 
another party is involved in litigation and HCFA's policies or 
operations could be affected by the outcome of the litigation, HCFA 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved. A determination would be made in each instance that, 
under the circumstances involved, the purposes served by the use of the 
information in the particular litigation is compatible with a purpose 
for which HCFA collects the information.

III. Safeguards

    The systems will conform with applicable law and policy governing 
the privacy and security of federal automated information systems. 
These include but are not limited to: the Privacy Act of 1974, Computer 
Security Act of 1987, the Paperwork Reduction Act (PRA) of 1995, the 
Clinger-Cohen Act of 1996, and OMB Circular A-130, Appendix III, 
``Security of Federal Automated Information Resources.'' HCFA has 
prepared a comprehensive system security plan as required by the Office 
of Management and Budget (OMB) Circular A-130, Appendix III. This plan 
conforms fully to guidance issued by the National Institute for 
Standards and Technology (NIST) in NIST Special Publication 800-18,

[[Page 37794]]

``Guide for Developing Security Plans for Information Technology 
Systems.'' Paragraphs A-C of this section highlight some of the 
specific methods that HCFA is using to ensure the security of this 
system and the information within it.
    A. Authorized users: Personnel having access to the system have 
been trained in Privacy Act and systems security requirements. 
Employees who maintain records in the system are instructed not to 
release any data until the intended recipient agrees to implement 
appropriate administrative, technical, procedural, and physical 
safeguards sufficient to protect the confidentiality of the data and to 
prevent unauthorized access to the data. In addition, HCFA is 
monitoring the authorized users to ensure against excessive or 
unauthorized use. Records are used in a designated work area or work 
station and the system location is attended at all times during working 
hours.
    To assure security of the data, the proper level of class user is 
assigned for each individual user as determined at the agency level. 
This prevents unauthorized users from accessing and modifying critical 
data. The system database configuration includes five classes of 
database users:
     Database Administrator class owns the database objects, 
e.g., tables, triggers, indexes, stored procedures, packages, and has 
database administration privileges to these objects;
     Quality Control Administrator class has read and write 
access to key fields in the database;
     Quality Indicator (QI) Report Generator class has read-
only access to all fields and tables;
     Policy Research class has query access to tables, but are 
not allowed to access confidential patient identification information; 
and
     Submitter class has read and write access to database 
objects, but no database administration privileges.
    B. Physical Safeguards: All server sites have implemented the 
following minimum requirements to assist in reducing the exposure of 
computer equipment and thus achieve an optimum level of protection and 
security for the each system:
    Access to all servers is controlled, with access limited to only 
those support personnel with a demonstrated need for access. Servers 
are to be kept in a locked room accessible only by specified management 
and system support personnel. Each server requires a specific log-on 
process. All entrance doors are identified and marked. A log is kept of 
all personnel who were issued a security card, key and/or combination 
which grants access to the room housing the server, and all visitors 
are escorted while in this room. All servers are housed in an area 
where appropriate environmental security controls are implemented, 
which include measures implemented to mitigate damage to Automated 
Information System (AIS) resources caused by fire, electricity, water 
and inadequate climate controls.
    Protection applied to the workstations, servers and databases 
include:
     User Log-ons--Authentication is performed by the Primary 
Domain Controller/Backup Domain Controller of the log-on domain.
     Workstation Names--Workstation naming conventions may be 
defined and implemented at the agency level.
     Hours of Operation--May be restricted by Windows NT. When 
activated all applicable processes will automatically shut down at a 
specific time and not be permitted to resume until the predetermined 
time. The appropriate hours of operation are determined and implemented 
at the agency level.
     Inactivity Log-out--Access to the NT workstation is 
automatically logged out after a specified period of inactivity.
     Warnings--Legal notices and security warnings display on 
all servers and workstations.
     Remote Access Services (RAS)--Windows NT RAS security 
handles resource access control. Access to NT resources is controlled 
for remote users in the same manner as local users, by utilizing 
Windows NT file and sharing permissions. Dial-in access can be granted 
or restricted on a user-by-user basis through the Windows NT RAS 
administration tool.
    There are several levels of security found in each system. Windows 
NT provides much of the overall system security. The Windows NT 
security model is designed to meet the C2-level criteria as defined by 
the U.S. Department of Defense's Trusted Computer System Evaluation 
Criteria document (DoD 5200.28-STD, December 1985). Netscape Enterprise 
Server is the security mechanism for all transmission connections to 
the system. As a result, Netscape controls all information access 
requests. Anti-virus software is applied at both the workstation and NT 
server levels.
    Access to different areas on the Windows NT server are maintained 
through the use of file, directory and share level permissions. These 
different levels of access control provide security that is managed at 
the user and group level within the NT domain. The file and directory 
level access controls rely on the presence of an NT File System (NTFS) 
hard drive partition. This provides the most robust security and is 
tied directly to the file system. Windows NT security is applied at 
both the workstation and NT server levels.
    C. Procedural Safeguards: All automated systems must comply with 
federal laws, guidance, and policies for information systems security 
as stated previously in this section. Each automated information system 
should ensure a level of security commensurate with the level of 
sensitivity of the data, risk, and magnitude of the harm that may 
result from the loss, misuse, disclosure, or modification of the 
information contained in the system.

IV. Effect of the Modified System of Records on Individual Rights

    HCFA proposes to establish each 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 each 
system will be subject to the authorized releases in accordance with 
the routine uses identified in each systems of records.
    HCFA will monitor the collection and reporting of all data. All 
information on beneficiaries is completed by the contractor and 
submitted to HCFA through standard systems located at the contractor 
sites. HCFA will utilize a variety of onsite and offsite edits and 
audits to increase the accuracy of all data.
    HCFA will take precautionary measures (see item III. above) to 
minimize the risks of unauthorized access to the records and the 
potential harm to individual privacy or other personal or property 
rights including not collecting patient identifiable data for non-
Medicare and non-Medicaid patients. HCFA will collect only that 
information necessary to perform the system's functions. In addition, 
HCFA will make disclosure of identifiable data from the modified system 
only with consent of the subject individual, or his/her legal 
representative, or in accordance with an applicable exception provision 
of the Privacy Act.
    HCFA, therefore, does not anticipate an unfavorable effect on 
individual privacy as a result of the disclosure of information 
relating to individuals.

    Dated: June 12, 2000.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
    The corrections to the systems of records listed in Appendix A are 
as follows:
* * * * *

[[Page 37795]]

  

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

SYSTEM LOCATION:
    HCFA Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850.
* * * * *

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OF USERS AND THE PURPOSES OF SUCH USES:
    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.'' Disclosure may be made:
    1. To 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.
    2. To agency contractors, or consultants who have been engaged by 
the agency to assist in the performance of a service related to this 
system of records and who need to have access to the records in order 
to perform the activity.
    3. To a member of Congress or to a Congressional staff member in 
response to an inquiry of the Congressional Office made at the written 
request of the constituent about whom the record is maintained.
    4. 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, HCFA 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.
* * * * *

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
* * * * *

SAFEGUARDS:
    HCFA has safeguards 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 systems security 
requirements. Employees who maintain records in the system are 
instructed not to release any data until the intended recipient agrees 
to implement appropriate administrative, technical, procedural, and 
physical safeguards sufficient to protect the confidentiality of the 
data and to prevent unauthorized access to the data.
    In addition, HCFA has physical safeguards in place to reduce the 
exposure of computer equipment and thus achieve an optimum level of 
protection and security for the HCFA system. For computerized records, 
safeguards have been established in accordance with Department of 
Health and Human Services (HHS) standards and National Institute of 
Standards and Technology guidelines, e.g., security codes will be used, 
limiting access to authorized personnel. System securities are 
established in accordance with HHS, Information Resource Management 
(IRM) Circular #10, Automated Information Systems Security Program, 
HCFA Automated Information Systems (AIS) Guide, Systems Securities 
Policies, and OMB Circular No. A-130 (revised), Appendix III.
* * * * *

SYSTEM MANAGER(S) AND ADDRESS:
    Director, Office of Strategic Planning, HCFA, Room C3-20-11, 7500 
Security Boulevard, Baltimore, Maryland, 21244-1850. The telephone 
number is 410-786-6501.

NOTIFICATION PROCEDURE:
    For purpose of access, the subject individual should write to the 
system manager who will require the system name, health insurance claim 
number, address, age, and sex, and for verification purposes, the 
subject individual's name (woman's maiden name, if applicable) and 
social security number (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 reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2)).

CONTESTING RECORD PROCEDURES:
    The subject individual should contact the system manager named 
above, and reasonably identify the record and specify the information 
to be contested. State the corrective action sought and the reasons for 
the correction with supporting justification. (These procedures are in 
accordance with Department regulation 45 CFR 5b.7).
* * * * *

Appendix A

09-70-0022  Municipal Health Services Program, HHS/HCFA/OSP
09-70-0030  National Long-Term Care Study Follow up, HHS/HCFA/OSP
09-70-0033  Person-Level Medicaid Data System, HHS/HCFA/OSP
09-70-0036  Evaluation of Competitive Bidding for Durable Medical 
Equipment Demonstrations, HHS/HCFA/OSP
09-70-0039  Evaluation of the Medicare Alzheimer's Disease 
Demonstration, HHS/HCFA/OSP
09-70-0040  Health Care Financing Administration Medicare Heart 
Transplant Data File, HHS/HCFA/OSP
09-70-0042  Medicare Cancer Registry Record System, HHS/HCFA/OSP
09-70-0045  Evaluation of the Arizona Health Care Cost Containment 
and Long Term Care Systems Demonstration, HHS/HCFA/OSP
09-70-0046  Home Health Quality Indicator System (HHQUIS), HHS/HCFA/
OSP
09-70-0048  Monitoring of the Home Health Agency Prospective Payment 
Demonstration, HHS/HCFA/OSP
09-70-0049  Evaluation of the Home Health Agency (HHA) Prospective 
Payment Demonstration, HHS/HCFA/OSP
09-70-0050  The Medicare/Medicaid Multi-State Case Mix and Quality 
Data Base for Nursing Home Residents, HHS/HCFA/OSP
09-70-0051  Quality Assurance for the Home Health Agency (HHA) 
Prospective Payment Demonstration, HHS/HCFA/OSP
09-70-0052  Post-Hospitalization Outcomes Studies, HHS/HCFA/OSP
09-70-0053  The Medicare Beneficiary Health Status Registry Pilot, 
HHS/HCFA/OSP
09-70-0057  Evaluation of the Medicaid Extension of Eligibility to 
Certain Low Income Families Not Otherwise qualified to receive 
Medicaid Benefits Demonstration, HHS/HCFA/OSP
09-70-0058  Evaluation of the Medicare SELECT Program, HHS/HCFA/OSP
09-70-0059  The Medicaid Necessity, Appropriateness, and Outcomes of 
Care Study, HHS/HCFA/OSP
09-70-0063  Evaluation of the Medicaid Demonstration for Improving 
Access to Care for Substance Abusing Pregnant Women, HHS/HCFA/OSP
09-70-0066  Evaluation of, and External Quality Assurance for, the 
Community Nursing Organization (CNO) Demonstration, HHS/HCFA/OSP
[FR Doc. 00-15231 Filed 6-15-00; 8:45 am]
BILLING CODE 4120-03-P