[Federal Register Volume 67, Number 144 (Friday, July 26, 2002)]
[Notices]
[Pages 48911-48914]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-19022]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of Modified or Altered System

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS) (formerly the Health Care Financing 
Administration).

ACTION: Notice of modified or altered System of Records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an SOR, ``Individuals 
Authorized Access to the CMS Data Center, System No. 09-70-0064.'' We 
propose to amend the name of this system to more accurately reflect the 
purpose of this system to read ``Individuals Authorized Access to the 
CMS Computer Services (IACS).'' We propose to delete an unnumbered 
routine use authorizing disclosure to the Social Security 
Administration (SSA). Disclosure of data from this system to the SSA is 
no longer necessary since SSA has been established as a separate agency 
outside of the HHS and a routine use for the purpose stated is no 
longer necessary.
    The security classification previously reported as ``None'' will be 
modified to reflect that data in this system are considered to be 
``Level Three Privacy Act Sensitive.'' We are modifying the language in 
the remaining routine uses to provide clarity to CMS 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 this opportunity to update any sections of 
this SOR that were affected by the recent reorganization and to modify 
language in the administrative sections to correspond with language 
used in other CMS SORs.
    The primary purpose of the SOR is for assigning, controlling, 
tracking, and reporting authorized access to and use of CMS's 
computerized information and resources. Information in this system will 
be used will be used to support regulatory and policy functions 
performed within the Agency or by a contractor or consultant; support 
constituent requests made to a Congressional representative; and to 
support litigation involving the Agency related to this SOR. We have 
provided background information about the proposed system in the 
Supplementary Information section below. Although the Privacy Act 
requires only that the Aroutine use'' portion of the system be 
published for comment, 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 Governmental Affairs, and the 
Administrator, Office of Information and Regulatory Affairs, Office of 
Management and Budget (OMB) on July 19, 2002. To ensure that all 
parties have adequate time in which to comment, the modified or altered 
SOR, including routine uses, will become effective 40 days from the 
publication of the notice, or from the date it was submitted to OMB and 
the Congress, whichever is later, unless CMS receives comments that 
require alterations to this notice.

ADDRESSES: The public should address comments to: Director, Division of 
Data Liaison and Distribution (DDLD), CMS, Room N2-04-27, 7500 Security 
Boulevard, Baltimore, Maryland 21244-1850. Comments received will be 
available for review at this location, by appointment, during regular 
business hours, Monday through Friday from 9 a.m.-3 p.m., eastern 
daylight time.

FOR FURTHER INFORMATION CONTACT: Kenneth Olga, Technology Services 
Group, Office of Information Services, CMS, Room N1-19-18, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850. The telephone 
number is 410-786-4067.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System

A. Statutory and Regulatory Basis For SOR

    In 1994, CMS established an SOR under the authority of 5 U.S.C. 
5552(e)(10). Notice of this system, ``Individuals Authorized Access to 
the CMS Data Center, System No. 09-70-0064,'' was published at 59 
Federal Register (FR) 41330 (Aug. 11, 1994).

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The system contains the name, work address, work phone number, an 
assigned user identification (UserID) number, an associated password, 
and the software system(s) that the individual is authorized to use.

B. Agency Policies, Procedures, and Restrictions on the Routine Use

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release IACS information that can be 
associated with an individual as provided for under ``Section III.A. 
Entities Who May Receive Disclosures Under Routine Use.'' Both 
identifiable and non-identifiable data may be disclosed under a routine 
use. Identifiable data includes individual records with IACS 
information and identifiers. Non-identifiable data includes individual 
records with IACS information and masked identifiers or IACS 
information with identifiers stripped out of the file.
    We will only disclose the minimum personal data necessary to 
achieve the

[[Page 48912]]

purpose of IACS. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. In general, disclosure of information from the SOR will be 
approved only for the minimum information necessary to accomplish the 
purpose of the disclosure after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected; e.g., developing and refining 
payment systems and monitoring the quality of care provided to 
patients.
    2. Determines that:
    a. The purpose for which the disclosure is to be made can only be 
accomplished if the record is provided in individually identifiable 
form;
    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. Entities Who May Receive Disclosures Under Routine Use

    These routine uses specify circumstances, in addition to those 
provided by statute in the Privacy Act of 1974, under which CMS may 
release information from the IACS without the consent of the individual 
to whom such information pertains. Each proposed disclosure of 
information under these routine uses will be evaluated to ensure that 
the disclosure is legally permissible, including but not limited to 
ensuring that the purpose of the disclosure is compatible with the 
purpose for which the information was collected. We are proposing to 
establish or modify the following routine use disclosures of 
information maintained in the system:
    1. To Agency contractors, or consultants who have been contracted 
by the Agency to assist in accomplishment of a CMS function relating to 
the purposes for this SOR and who need to have access to the records in 
order to assist CMS.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contractual or similar 
agreement with a third party to assist in accomplishing CMS functions 
relating to purposes for this SOR.
    CMS occasionally contracts out certain of its functions when this 
would contribute to effective and efficient operations. CMS must be 
able to give a contractor whatever information is necessary for the 
contractor to fulfill its duties. In these situations, safeguards are 
provided in the contract prohibiting the contractor from using or 
disclosing the information for any purpose other than that described in 
the contract and to return or destroy all information at the completion 
of the contract.
    2. 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.
    Individuals sometimes request the help of a Member of Congress in 
resolving some issue relating to a matter before CMS. The Member of 
Congress then writes CMS, and CMS must be able to give sufficient 
information to be responsive to the inquiry.
    3. To the Department of Justice (DOJ), court or adjudicatory body 
when
    a. The Agency or any component thereof; or
    b. Any employee of the Agency in his or her official capacity; or
    c. Any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee; or
    d. The United States Government; is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation.
    Whenever CMS is involved in litigation, or occasionally when 
another party is involved in litigation and CMS's policies or 
operations could be affected by the outcome of the litigation, CMS 
would be able to disclose information to the DOJ, court or adjudicatory 
body involved. 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 CMS collects the information.

B. Additional Circumstances Affecting Routine Use Disclosures

    This SOR contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), as 
amended by 66 FR 12434 (2-26-01)). Disclosures of Protected Health 
Information authorized by these routine uses may only be made if, and 
as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information''.
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

A. Administrative Safeguards

    The IACS system will conform to 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 1984, Computer 
Security Act of 1987, the Paperwork Reduction Act of 1995, the Clinger-
Cohen Act of 1996, and the Office and Management and Budget (OMB) 
Circular A-130, Appendix III, ``Security of Federal Automated 
Information Resources.'' CMS has prepared a comprehensive system 
security plan as required by 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, 
``Guide for Developing Security Plans for Information Technology 
Systems. Paragraphs A-C of this section highlight some of the specific 
methods that CMS is using to ensure the security of this system and the 
information within it.
    Authorized users: Personnel having access to the system have been 
trained in Privacy Act and systems security requirements. Employees and 
contractors 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, CMS is monitoring 
the authorized users to ensure against

[[Page 48913]]

excessive or unauthorized use. Records are used in a designated work 
area or workstation and the system location is attended at all times 
during working hours.
    To insure 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 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 
IACS 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 
that 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 resources caused by fire, electricity, water and 
inadequate climate controls.
    Protection applied to the workstations, servers and databases 
include:
     User Log on--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.

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.

V. Effect of the Modified System on Individual Rights

    A. CMS proposes to establish this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. We will only 
disclose the minimum personal data necessary to achieve the purpose of 
IACS. Disclosure of information from the SOR will be approved only to 
the extent necessary to accomplish the purpose of the disclosure. CMS 
has assigned a higher level of security clearance for the information 
in this system to provide added security and protection of data in this 
system.
    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. 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 the disclosure of information 
relating to individuals.

    Dated: July 22, 2002.
Thomas A. Scully,
Administrator, , Centers for Medicare & Medicaid Services.
09-70-0064

System Name:
    ``Individuals Authorized Access to the Centers for Medicare & 
Medicaid Services (CMS) Computer Services (IACS), HHS/CMS/OIS, System 
No. 09-70-0064.''

Security Classification:
    Level 3 Privacy Act Sensitive.

System Location:
    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850.

Categories of Individuals Covered by the System:
    Individuals with an approved need for access to the computer 
resources and information maintained by CMS.

Categories of Records in the System:
    The system contains the name, work address, work phone number, an 
assigned user identification (UserID) number, an associated password, 
and the software system(s) that the individual is authorized to use.

Authority for Maintenance of the System:
    Authority for maintenance of the system is given under 5 U.S.C. 
552(e)(10).

Purpose(s):
    The primary purpose of the SOR is for assigning, controlling, 
tracking, and reporting authorized access to and use of CMS's 
computerized information and resources. Information in this system will 
be used to support regulatory and policy functions performed within the 
agency or by a contractor or consultant; support constituent requests 
made to a Congressional representative; and to support litigation 
involving the Agency related to this SOR.

Routine Uses of Records Maintained in the System, Including Categories 
or 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

[[Page 48914]]

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 use in this system meets the 
compatibility requirement of the Privacy Act. This SOR contains 
Protected Health Information as defined by HHS regulation ``Standards 
for Privacy of Individually Identifiable Health Information'' (45 CFR 
parts 160 and 164, 65 FR 82462 (12-28-00), as amended by 66 FR 12434 
(2-26-01)). Disclosures of Protected Health Information authorized by 
these routine uses may only be made if, and as, permitted or required 
by the ``Standards for Privacy of Individually Identifiable Health 
Information''.
    In addition, our policy will be to prohibit release even of non-
identifiable data, except pursuant to one of the routine uses, if there 
is a possibility that an individual can be identified through implicit 
deduction based on small cell sizes (instances where the patient 
population is so small that individuals who are familiar with the 
enrollees could, because of the small size, use this information to 
deduce the identity of the beneficiary). We are proposing to establish 
the following routine use disclosures of information that will be 
maintained in the system:
    1. To Agency contractors, or consultants who have been contracted 
by the Agency to assist in accomplishment of a CMS function relating to 
the purposes for this SOR and who need to have access to the records in 
order to assist CMS.
    2. 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.
    3. 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.

Policies and Practices for Storing, Retrieving, Accessing, Retaining, 
and Disposing of Records in the System:
Storage:
    Computer diskette and on magnetic storage media.

Retrievability:
    Information can be retrieved by the name and assigned UserID 
number.

Safeguards:
    CMS 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, CMS has physical safeguards in place to reduce the 
exposure of computer equipment and thus achieve an optimum level of 
protection and security for the IACS system. For computerized records, 
safeguards have been established in accordance with 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; CMS Automated Information Systems (AIS) Guide, 
Systems Securities Policies; and OMB Circular No. A-130 (revised), 
Appendix III.

Retention and Disposal:
    Records are maintained in a secure storage area with identifiers. 
Disposal occurs three years from the time the individual no longer 
requires access to the HDC.

System Manager(s) and Address:
    Director, Technology Services Group, Office of Information 
Services, CMS, Room N1-19-18, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850. The telephone number is 410-786-4067.

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, and for verification purposes, the subject individual's name 
(woman's maiden name, if applicable), social security number (SSN) 
(furnishing the SSN is voluntary, but it may make searching for a 
record easier and prevent delay), address, date of birth, and sex.

Record Access Procedure:
    For purpose of access, use the same procedures outlined in 
Notification Procedures above. Requestors should also reasonably 
specify the record contents being sought. (These procedures are in 
accordance with Department regulation 45 CFR 5b.5(a)(2).)

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

Record Source Categories:
    Sources of information contained in this records system include 
data collected from applications submitted by the individuals requiring 
access to computer services.

Systems Exempted From Certain Provisions of the Act:
    None.
[FR Doc. 02-19022 Filed 7-25-02; 8:45 am]
BILLING CODE 4120-03-P