[Federal Register Volume 68, Number 91 (Monday, May 12, 2003)]
[Notices]
[Pages 25376-25382]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-11748]


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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)(formerly the Health Care Financing 
Administration).

ACTION: Notice of a 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, ``1-800 Medicare + 
Choices Helpline (HELPLINE), System No. 09-70-0535.'' We are proposing 
to amend the purpose of the HELPLINE to include maintaining utilization 
and bill processing data and change the name to read the ``1-800-
Medicare Helpline'' to reflect this amended purpose. Information 
collected will also be used to update the Enrollment Data Base, System 
No. 09-70-0502, which is now used to maintain enrollment-related data. 
The HELPLINE will retrieve utilization data used for bill payment 
record processing maintained in the ``Common Working File,'' System No. 
09-70-0526.
    CMS proposes 6 new routine uses to permit release of information 
to: (1) Another Federal and/or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent; 
(2) providers and suppliers of services for administration of Title 
XVIII of the Social Security Act (the Act); (3) third parties where the 
contact is expected to have information relating to the individual's 
capacity to manage his or her own affairs; (4) other insurers, third 
party administrators (TPA), employers, self-insurers, managed care 
organizations, other supplemental insurers, non-coordinating insurers, 
multiple employer trusts, group health plans (i.e., health maintenance 
organizations (HMOs) or a competitive medical plan (CMP) with a 
Medicare contract, or a Medicare-approved health care prepayment plan 
(HCPP)), directly or through a contractor, and other groups providing 
protection for their enrollees to assist in the processing of 
individual insurance claims; and (5) combat fraud and abuse in certain 
health benefits programs.
    We are modifying the language in the remaining routine uses to 
provide an easy to read format to CMS's intention to disclose 
individual-specific

[[Page 25377]]

information contained in this system. The routine uses will then be 
prioritized and reordered according to their proposed usage. We will 
also take the opportunity to update any sections of the system that 
were affected by the recent reorganization and to update language in 
the administrative sections to correspond with language used in other 
CMS SORs.
    The primary purpose of the SOR is to provide general information to 
beneficiaries and future beneficiaries so that they can make informed 
Medicare decisions, maintain information on Medicare enrollment for the 
administration of the Medicare program, including the following 
functions: Ensuring proper Medicare enrollment, claims payment, 
Medicare premium billing and collection, coordination of benefits by 
validating and verifying the enrollment status of beneficiaries, and 
validating and studying the characteristics of persons enrolled in the 
Medicare program including their requirements for information. 
Information retrieved from this SOR will also be disclosed to: (1) 
Support regulatory, reimbursement, and policy functions performed 
within the Agency or by a contractor or consultant; (2) another Federal 
or state agency, agency of a state government, an agency established by 
state law, or its fiscal agent; (3) providers and suppliers of services 
for administration of Title XVIII of the Act; (4) third parties where 
the contact is expected to have information relating to the 
individual's capacity to manage his or her own affairs; (5) other 
insurers for processing individual insurance claims; (6) support 
constituent requests made to a congressional representative; (7) 
support litigation involving the Agency; and (8) combat fraud and abuse 
in certain health benefits 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 proposed 
routine uses, CMS invites comments on all portions of this notice. See 
Effective Dates section for comment period.

EFFECTIVE DATES: CMS filed a modified 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 March 13, 2003. To ensure that all parties have 
adequate time in which to comment, the new SOR, including routine uses, 
will become effective 40 days from the publication of the notice, or 
from the date it was submitted to OMB and the Congress, whichever is 
later, unless CMS receives comments that require alterations to this 
notice.

ADDRESSES: The public should address comments to: Director, Division of 
Privacy Compliance Data Development, OIS, 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 Taylor, Health Insurance 
Specialist, Division of Call Center Operations, Customer Teleservice 
Operations Group, Center for Beneficiary Choices, CMS, 7500 Security 
Boulevard, C2-26-20, Baltimore, Maryland 21244-1850. The telephone 
number is 410-786-6736.

SUPPLEMENTARY INFORMATION:

I. Description of the Modified System

A. Background

    The ``1-800-Medicare + Choices Helpline, System No. 09-70-0535, was 
established as a new system to broadly disseminate information to 
Medicare beneficiaries and prospective Medicare beneficiaries on the 
coverage options provided under the Medicare + Choice program in order 
to promote an active, informed selection among such options. The 
information campaign included, general information, information 
comparing plan options, information on Medi-gap and Medicare Select. 
This information is to be provided through toll-free telephone service, 
Internet site, print, and local education and outreach. Notice of this 
system was published at 66 Federal Register 16679 (Mar 20, 2001).

B. Statutory and Regulatory Basis for System

    Authority for maintenance of the system is given under Title 41 
Code of Federal Regulation (CFR) Chapter 101-20.302, Conduct on Federal 
Property, and OMB Circular A-123, Internal Control Systems, and Title 
42 United States Code (U.S.C.) section 1395w-21 (d) (Pub. L. 105-3, the 
Balanced Budget Act of 1997).

II. Collection and Maintenance of Data in the System

A. Scope of the Data Collected

    The collected information will contain name, address, telephone 
number, health insurance claim (HIC) number, geographic location, race/
ethnicity, sex, date of birth, as well as, background information 
relating to Medicare or Medicaid issues. The HELPLINE will also 
maintain a caller history for purposes of re-contacts by customer 
service representatives or CMS, contain information related to Medicare 
enrollment and entitlement, group health plan enrollment data, as well 
as, background information relating to Medicare or Medicaid issues.
    Information is collected on individuals age 65 or over who have 
been, or currently are, entitled to health insurance (Medicare) 
benefits under Title XVIII of the Act or under provisions of the 
Railroad Retirement Act, individuals under age 65 who have been, or 
currently are, entitled to such benefits on the basis of having been 
entitled for not less than 24 months to disability benefits under Title 
II of the Act or under the Railroad Retirement Act, individuals who 
have been, or currently are, entitled to such benefits because they 
have ESRD, individuals age 64 and 8 months or over who are likely to 
become entitled to health insurance (Medicare) benefits upon attaining 
age 65, and individuals under age 65 who have at least 21 months of 
disability benefits who are likely to become entitled to Medicare upon 
the 25th month of their being disabled.

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 HELPLINE 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 HELPLINE. CMS has the following policies and procedures 
concerning disclosures of information that will be maintained in the 
system. Disclosure of information from the SOR will be approved only to 
the extent necessary to accomplish the purpose of the disclosure and 
only after CMS:

[[Page 25378]]

    1. Determines that the use or disclosure is consistent with the 
reason data is being collected; e.g., maintain a caller history for 
purposes of re-contacts by customer service representatives or CMS, 
contain information related to Medicare enrollment and entitlement, 
group health plan enrollment data, as well as, background information 
relating to Medicare or Medicaid issues, insuring proper reimbursement 
for services provided, claims payment, and coordination of benefits 
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 HELPLINE 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 a CMS function 
relating to purposes for this SOR.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or consultant whatever information is 
necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor or consultant from using or disclosing the information 
for any purpose other than that described in the contract and requires 
the contractor or consultant to return or destroy all information at 
the completion of the contract.
    2. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    Other Federal or state agencies in their administration of a 
Federal health program may require HELPLINE information in order to 
support evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided;
    In addition, other state agencies in their administration of a 
Federal health program may require HELPLINE information for the 
purposes of determining, evaluating and/or assessing cost, 
effectiveness, and /or the quality of health care services provided in 
the state;
    Disclosure under this routine use shall be used by state Medicaid 
agencies pursuant to agreements with the HHS for determining Medicaid 
and Medicare eligibility, for quality control studies, for determining 
eligibility of recipients of assistance under Titles IV, XVIII, and XIX 
of the Act, and for the administration of the Medicaid program. Data 
will be released to the state only on those individuals who are 
patients under the services of a Medicaid program within the state or 
who are residents of that state.
    We also contemplate disclosing information under this routine use 
in situations in which state auditing agencies require HELPLINE 
information for auditing state Medicaid eligibility considerations. CMS 
may enter into an agreement with state auditing agencies to assist in 
accomplishing functions relating to purposes for this SOR.
    3. To providers and suppliers of services directly or through 
fiscal intermediaries (FIs) or carriers for the administration of Title 
XVIII of the Act.
    Providers and suppliers of services require HELPLINE information in 
order to establish the validity of evidence or to verify the accuracy 
of information presented by the individual, as it concerns the 
individual's entitlement to benefits under the Medicare program, 
including proper reimbursement for services provided.
    4. To third party contacts in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: The individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exist, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. The data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program, the amount of reimbursement, and 
in cases in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or

[[Page 25379]]

evaluation and measurement of activities.
    Third parties contacts require HELPLINE information in order to 
provide support for the individual's entitlement to benefits under the 
Medicare program; to establish the validity of evidence or to verify 
the accuracy of information presented by the individual, and assist in 
the monitoring of Medicare claims information of beneficiaries, 
including proper reimbursement of services provided.
    5. To insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their 
enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. In order to receive the information, they must agree 
to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom they serve as a TPA;
    b. Utilize the information solely for the purpose of processing the 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data and prevent 
unauthorized access.
    Other insurers, TPAs, HMOs, and HCPPs may require HELPLINE 
information in order to support evaluations and monitoring of Medicare 
claims information of beneficiaries, including proper reimbursement for 
services provided.
    6. To a Member of Congress or a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    Beneficiaries often request the help of a Member of Congress in 
resolving some issue relating to a matter before HCFA. The Member of 
Congress then writes HCFA, and HCFA must be able to give sufficient 
information tin response to the inquiry.
    7. 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.
    8. To a CMS contractor (including, but not limited to FIs and 
carriers) that assists in the administration of a CMS-administered 
health benefits program, or to a grantee of a CMS-administered grant 
program, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
    We contemplate disclosing information under this routine use only 
in situations in which CMS may enter into a contract or grant with a 
third party to assist in accomplishing CMS functions relating to the 
purpose of combating fraud and abuse.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor or grantee whatever information is necessary 
for the contractor or grantee to fulfill its duties. In these 
situations, safeguards are provided in the contract prohibiting the 
contractor or grantee from using or disclosing the information for any 
purpose other than that described in the contract and requiring the 
contractor or grantee to return or destroy all information.
    9. To another Federal agency or to an instrumentality of any 
governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
    Other agencies may require HELPLINE information for the purpose of 
combating fraud and abuse in such Federally funded programs.

B. Additional Circumstances Affecting Routine Use Disclosures

    This system contains Protected Health Information as defined by HHS 
regulation ``Standards for Privacy of Individually Identifiable Health 
Information'' (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), 
Subparts A and E. Disclosures of Protected Health Information 
authorized by these routine 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 not 
directly identifiable, except pursuant to one of the routine uses or if 
required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals who are familiar with the enrollees could, because of the 
small size, use this information to deduce the identity of the 
beneficiary).

I. Safeguards

A. Administrative Safeguards

    The HELPLINE 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

[[Page 25380]]

the authorized users to ensure against 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:
    [sbull] Database Administrator class owns the database objects; 
e.g., tables, triggers, indexes, stored procedures, packages, and has 
database administration privileges to these objects;
    [sbull] Quality Controls Administrator classes have read and write 
access to key fields in the database;
    [sbull] Quality Indicator Report Generator class has read-only 
access to all fields and tables;
    [sbull] Policy Research class has query access to tables, but are 
not allowed to access confidential patient identification information; 
and
    [sbull] Submitter classes have 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 
HELPLINE 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 grant 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:
    [sbull] User Log on--Authentication is performed by the Primary 
Domain Controller/Backup Domain Controller of the log-on domain.
    [sbull] Workstation Names--Workstation naming conventions may be 
defined and implemented at the Agency level.
    [sbull] 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.
    [sbull] Inactivity Log-out--Access to the NT workstation is 
automatically logged out after a specified period of inactivity.
    [sbull] Warnings--Legal notices and security warnings display on 
all servers and workstations.
    [sbull] 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

    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 
HELPLINE. 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 proper level of security clearance for the 
information in this system to provide added security and protection of 
data in this system.
    CMS will monitor the collection and reporting of HELPLINE data. 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: March 13, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare and Medicaid Services.
09-70-0535

SYSTEM NAME:
    1-800 Medicare Helpline (HELPLINE), HHS/CMS/CBC.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive.

SYSTEM LOCATION:
    CMS Data Center, 7500 Security Boulevard, North Building, First 
Floor, Baltimore, Maryland 21244-1850 and at various co-locations of 
CMS Call Center contractors.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    Information is collected on individuals age 65 or over who have 
been, or currently are, entitled to health insurance (Medicare) 
benefits under Title XVIII of the Act or under provisions of the 
Railroad Retirement Act, individuals under age 65 who have been, or 
currently are, entitled to such benefits on the basis of having been 
entitled for not less than 24 months to disability benefits under Title 
II of the Act or under the Railroad Retirement Act, individuals who 
have been, or currently are, entitled to such benefits because they 
have ESRD, individuals age 64 and 8 months or over who are likely to 
become entitled to health insurance (Medicare) benefits upon attaining 
age 65, and individuals under age 65 who have at least 21 months of 
disability benefits who are likely to become entitled to Medicare upon 
the 25th month of their being disabled.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The collected information will contain name, address, telephone 
number, health insurance claim (HIC) number, geographic location, race/
ethnicity, sex, and date of birth, as well as, background information 
relating to Medicare or Medicaid issues. The HELPLINE will also 
maintain a caller history for purposes of re-contacts by customer 
service representatives or CMS, contain information related to

[[Page 25381]]

Medicare enrollment and entitlement, and group health plan enrollment 
data, as well as, background information relating to Medicare or 
Medicaid issues.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of this system is given under provisions 
of 41 Code of Federal Regulations (CFR), Chapter 101-20.302, Conduct on 
Federal Property, Office of Management and Budget (OMB) Circular A-123, 
Internal Control, and Title 42 United States Code (U.S.C.) section 
1395W-21 (d) (Public Law 105-33, the Balanced Budget Act of 1997).

PURPOSE (S):
    The primary purpose of the SOR is to provide general information to 
beneficiaries and future beneficiaries so that they can make informed 
Medicare decisions, maintain information on Medicare enrollment for the 
administration of the Medicare program, including the following 
functions: ensuring proper Medicare enrollment, claims payment, 
Medicare premium billing and collection, coordination of benefits by 
validating and verifying the enrollment status of beneficiaries, and 
validating and studying the characteristics of persons enrolled in the 
Medicare program including their requirements for information. 
Information retrieved from this SOR will also be disclosed to: (1) 
Support regulatory, reimbursement, and policy functions performed 
within the Agency or by a contractor or consultant; (2) another Federal 
or state agency, agency of a state government, an agency established by 
state law, or its fiscal agent; (3) providers and suppliers of services 
for administration of Title XVIII of the Social Security Act; (4) third 
parties where the contact is expected to have information relating to 
the individual's capacity to manage his or her own affairs; (5) other 
insurers for processing individual insurance claims; (6) support 
constituent requests made to a congressional representative; (7) 
support litigation involving the Agency; and (8) combat fraud and abuse 
in certain health benefits programs.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    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 HELPLINE 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. 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).
    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 Federal Register (FR) 82462 
(12-28-00), subparts A and E. Disclosures of Protected Health 
Information authorized by these routine uses may only be made if, and 
as, permitted or required by the ``Standards for Privacy of 
Individually Identifiable Health Information.'' 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.
    2. To another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. Contribute to the accuracy of CMS's proper payment of Medicare 
benefits,
    b. Enable such agency to administer a Federal health benefits 
program, or as necessary to enable such agency to fulfill a requirement 
of a Federal statute or regulation that implements a health benefits 
program funded in whole or in part with Federal funds, and/or
    c. Assist Federal/state Medicaid programs within the state.
    3. To providers and suppliers of services directly or through 
fiscal intermediaries or carriers for the administration of Title XVIII 
of the Social Security Act.
    4. To third party contacts in situations where the party to be 
contacted has, or is expected to have information relating to the 
individual's capacity to manage his or her affairs or to his or her 
eligibility for, or an entitlement to, benefits under the Medicare 
program and,
    a. The individual is unable to provide the information being sought 
(an individual is considered to be unable to provide certain types of 
information when any of the following conditions exists: The individual 
is confined to a mental institution, a court of competent jurisdiction 
has appointed a guardian to manage the affairs of that individual, a 
court of competent jurisdiction has declared the individual to be 
mentally incompetent, or the individual's attending physician has 
certified that the individual is not sufficiently mentally competent to 
manage his or her own affairs or to provide the information being 
sought, the individual cannot read or write, cannot afford the cost of 
obtaining the information, a language barrier exist, or the custodian 
of the information will not, as a matter of policy, provide it to the 
individual), or
    b. The data are needed to establish the validity of evidence or to 
verify the accuracy of information presented by the individual, and it 
concerns one or more of the following: The individual's entitlement to 
benefits under the Medicare program, the amount of reimbursement, and 
in cases in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of activities.
    5. To insurance companies, third party administrators (TPA), 
employers, self-insurers, managed care organizations, other 
supplemental insurers, non-coordinating insurers, multiple employer 
trusts, group health plans (i.e., health maintenance organizations 
(HMOs) or a competitive medical plan (CMP) with a Medicare contract, or 
a Medicare-approved health care prepayment plan (HCPP)), directly or 
through a contractor, and other groups providing protection for their 
enrollees. Information to be disclosed shall be limited to Medicare 
entitlement data. In order to receive the information, they must agree 
to:
    a. Certify that the individual about whom the information is being 
provided is one of its insured or employees, or is insured and/or 
employed by another entity for whom they serve as a TPA;
    b. Utilize the information solely for the purpose of processing the 
identified individual's insurance claims; and
    c. Safeguard the confidentiality of the data and prevent 
unauthorized access.
    6. To a Member of Congress or a congressional staff member in 
response to an inquiry of the congressional office made at the written 
request of the constituent about whom the record is maintained.
    7. To the Department of Justice (DOJ), court or adjudicatory body 
when:

[[Page 25382]]

    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.
    8. To a CMS contractor (including, but not limited to FIs and 
carriers) that assists in the administration of a CMS-administered 
health benefits program, or to a grantee of a CMS-administered grant 
program, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
    9. To another Federal agency or to an instrumentality of any 
governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    Information is maintained on paper, computer diskette and on 
magnetic storage media.

RETRIEVABILITY:
    The records are retrieved by name and identification 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 HELPLINE system. For computerized 
records, safeguards have been established in accordance with the 
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; CMS Automated Information Systems (AIS) Guide, 
Systems Securities Policies, and OMB Circular No. A-130 (revised), 
Appendix III.

RETENTION AND DISPOSAL:
    Records are maintained for a period of 10 years.

SYSTEM MANAGER(S) AND ADDRESS:
    Director, Division of Call Center Operations, Customer Teleservice 
Operations Group, Center for Beneficiary Choices, CMS, 7500 Security 
Boulevard, C2-26-20, 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, health insurance claim 
number, address, date of birth, 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 systems 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:
    The data contained in these records are furnished by the 
individual, or in the case of some situations, through third party 
contacts that make calls to the 1-800 Medicare Helpline. Updating 
information is also obtained from the Enrollment Data Base, Common 
Working File, and the Master Beneficiary Record maintained by the 
Social Security Administration.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.
[FR Doc. 03-11748 Filed 5-9-03; 8:45 am]
BILLING CODE 4120-03-U