[Federal Register Volume 73, Number 38 (Tuesday, February 26, 2008)]
[Notices]
[Pages 10249-10255]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-3562]


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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), Center for 
Medicare & Medicaid Services (CMS).

ACTION: Notice of a Modified or Altered System of Records (SOR).

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter existing system of records 
titled, ``Enrollment Data Base (EDB), System No. 09-70-0502, last 
modified 67 Federal Register 3203 (January 23, 2002). The EDB currently 
maintains enrollment-related data, data elements pertaining to Medicare 
Secondary Payer (MSP), and data regarding Direct billing and Third Part 
premium collection information for Medicare premiums. We are amending 
the purpose of the EDB to include maintaining enrollment and 
entitlement data currently maintained in the following CMS systems of 
records: Medicare Beneficiary Database (MBD), System No. 09-70-0536; 
and the Medicare Prescription Drug System (MARx), System No. 09-70-
4001.
    We are modifying the language in published routine use number 1 to 
permit disclosures to a grantee of a CMS-administered grant program 
that perform a task for the agency. CMS occasionally contracts out 
certain of its functions when doing so would contribute to effective 
and efficient operations. CMS must be able to give a contractor, 
consultant or grantee whatever information is necessary for the 
contractor, consultant, or grantee to fulfill its duties. We will 
modify existing routine use number 5 that permits disclosure to Peer 
Review Organizations (PRO). Organizations previously referred to as 
PROs will be renamed to read: Quality Improvement Organizations (QIO). 
Information will be disclosed to QIOs for health care quality 
improvement projects. The modified routine use will be renumbered as 
routine use number 5. We will delete published routine use number 8 
authorizing disclosure to support constituent requests made to a 
congressional representative. If an authorization for the disclosure 
has been obtained from the data subject, then no routine use is needed. 
The Privacy Act allows for disclosures with the ``prior written 
consent'' of the data subject.

[[Page 10250]]

    We are modifying the language in the remaining disclosure 
provisions to provide a proper explanation as to the need for the 
disclosure and to provide clarity to CMS's intention to disclose 
individual-specific information contained in this system. We will also 
take the opportunity to update any sections of the system that were 
affected by the recent reorganization or because of the impact of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(MMA) (Pub. L. 108-173) provisions and to update language in the 
administrative sections to correspond with language used in other CMS 
system notices.
    The primary purpose of the SOR is to maintain information on 
Medicare enrollment for the administration of the Medicare program, 
including the following functions: Ensuring proper Medicare enrollment, 
claims payment, Direct billing and Third Party premium collection 
information, 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 agency contractors, 
consultants, or to a grantee of a CMS-administered grant; (2) assist 
another Federal or state agency, agency of a state government, an 
agency established by state law, or its fiscal agent; (3) assist third 
parties where the contact is expected to have information relating to 
the individual's capacity to manage his or her own affairs; (4) assist 
providers and suppliers of services for administration of Title XVIII 
of the Act; (5) support Quality Improvement Organizations (QIO); (6) 
assist other insurers for processing individual insurance claims; (7) 
facilitate research on the quality and effectiveness of care provided, 
as well as payment-related and epidemiological projects; (8) support 
litigation involving the Agency; and (9) combat fraud and abuse in 
certain health benefits programs. We have provided background 
information about the new 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 DATE: CMS filed a new SOR report with the Chair of the House 
Committee on Government Reform and Oversight, the Chair of the Senate 
Committee on Homeland Security & Governmental Affairs, and the 
Administrator, Office of Information and Regulatory Affairs, Office of 
Management and Budget (OMB) on February 12, 2008. To ensure that all 
parties have adequate time in which to comment, the new system will 
become effective 30 days from the publication of the notice, or 40 days 
from the date it was submitted to OMB and the Congress, whichever is 
later. We may defer implementation of this system or one or more of the 
routine use statements listed below if we receive comments that 
persuade us to defer implementation.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance, Enterprise Architecture and Strategy 
Group, Office of Information Services, CMS, Room N2-04-27, 7500 
Security Boulevard, Baltimore, Maryland 21244-1850. The telephone 
number is (410) 786-5357. Comments received will be available for 
review at this location, by appointment, during regular business hours, 
Monday through Friday from 9 a.m. to 3 p.m., Eastern Time zone.

FOR FURTHER INFORMATION CONTACT: Kathryn Cox, Health Insurance 
Specialist, Division of Enrollment and Eligibility Policy, Medicare 
Enrollment and Appeals Group, Centers for Beneficiary Choices, Mail 
Stop C2-12-16, Centers for Medicare & Medicaid Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1849. She can be reached by telephone at 
410-786-5954 or e-mail [email protected].

SUPPLEMENTARY INFORMATION: The EDB is the authoritative source of 
information for anyone who has ever been entitled to receive Medicare. 
Both personal and financial information is stored on the system. The 
EDB is CMS's single resource of managing Medicare entitlement data. 
CMS's major operation functions and goals are directly supported by the 
EDB including Medicare entitlement and premium billing (both direct 
beneficiary and third-party billing). The system contains personally 
identifiable information in the form of names, entitlement, health 
insurance number etc. Numerous CMS critical systems are directly 
supported by EDB. The Direct Billing System (DB) was integrated into 
the EDB in 1996. This system deals with all EDB beneficiaries who are 
(or were) billed directly for their Medicare premiums. The EDB 
maintains a history of all direct-billing information and payments. In 
addition, Medicare claim payments and managed-care enrollment are 
supported indirectly by the EDB.
    The EDB includes the following types of information for each 
Medicare enrollee: Beneficiary identification (e.g., name, birth date, 
address, date of death); Part A and Part B enrollment (current and 
historical); Medicare card issuance; Medicare Secondary Payer (MSP); 
Third-party payer; Medicare Advantage enrollment; Common Working File 
(CWF) host site; Hospice information; Cross-reference numbers; Direct 
billing; Disability data; and ESRD data.

I. Description of the Proposed System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for maintenance of the system is given under sections 
226, 226A, 1811, 1818, 1818A, 1831, 1836, 1837, 1838, 1843, 1876, and 
1881 of the Social Security Act (the Act) and Title 42 Code of Federal 
Regulations (CFR), parts 406, 407, 408, 411 and 424. Authority for 
maintenance of the system section 1862 of the Act was a published 
authority in the published SOR. We included section 1862 in the 
modified SOR since we do maintain a limited number of data elements in 
the EDB pertaining to MSP. Authority for maintenance of the system 
section 1870 of the Act was included in the modified system since the 
EDB does maintain data regarding direct billing for Medicare premiums. 
Section 1870(g) describes refunding these premiums.

B. Collection and Maintenance of Data in the System

    The system contains information related to Medicare enrollment and 
entitlement and MSP data containing other party liability insurance 
information necessary for appropriate Medicare claim payment. It 
contains hospice election, Direct billing and Third Party Premium 
collection information, and group health plan enrollment data. The 
system also contains the individual's health insurance numbers, name, 
geographic location, race/ethnicity, sex, and date of birth. 
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

[[Page 10251]]

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.

II. Agency Policies, Procedures, and Restrictions on Routine Uses

    A. 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 EDB 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 EDB.
    CMS has the following policies and procedures concerning 
disclosures of information that will be maintained in the system. 
Disclosure of information from the system will be approved only to the 
extent necessary to accomplish the purpose of the disclosure and only 
after CMS:
    1. Determines that the use or disclosure is consistent with the 
reason that the data is being collected; e.g., to collect and maintain 
a person-level view of identifiable data to establish a data warehouse 
to study chronically ill Medicare beneficiaries.
    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. The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To support agency contractors, or consultants, or to a grantee 
of a CMS-administered grant program who have been engaged by the agency 
to assist in the accomplishment of a CMS function relating to the 
purposes for this system and who need to have access to the records in 
order to assist CMS.
    We contemplate disclosing 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 function 
relating to purposes for this system.
    CMS occasionally contracts out certain of its functions when doing 
so would contribute to effective and efficient operations. CMS must be 
able to give a contractor, consultant or grantee whatever information 
is necessary for the contractor or consultant to fulfill its duties. In 
these situations, safeguards are provided in the contract prohibiting 
the contractor, consultant or grantee from using or disclosing the 
information for any purpose other than that described in the contract 
and requires the contractor, consultant or grantee to return or destroy 
all information at the completion of the contract.
    2. To assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. contribute to the accuracy of CMS's proper payment of Medicare 
benefits;
    b. enable such agency to administer a Federal health benefits 
program, or, as necessary, to enable such agency to fulfill a 
requirement of a Federal statute or regulation that implements a health 
benefits program funded in whole or in part with Federal funds; and/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 EDB information in order to support 
evaluations and monitoring of Medicare claims information of 
beneficiaries, including proper reimbursement for services provided.
    3. To assist third party contacts (without the consent of the 
individuals to whom the information pertains) 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; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of program activities.
    Third parties contacts require EDB 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 or the 
representative of the applicant, and assist in the monitoring of 
Medicare claims information of beneficiaries, including proper 
reimbursement of services provided.
    Senior citizen volunteers working in the carriers and 
intermediaries' offices to assist Medicare beneficiaries' request

[[Page 10252]]

for assistance may require access to EDB information.
    Occasionally fiscal intermediary/carrier banks, automated clearing 
houses, value added networks (VAN), and provider banks, to the extent 
necessary transfer to provider's electronic remittance advice of 
Medicare payments, and with respect to provider banks, to the extent 
necessary to provide account management services to providers using 
this information.
    4. To assist providers and suppliers of services dealing through 
fiscal intermediaries or carriers for the administration of Title XVIII 
of the Social Security Act.
    Providers and suppliers of services require EDB 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.
    Providers and suppliers of services who are attempting to validate 
items on which the amounts included in the annual Physician/Supplier 
Payment List, or other similar publications are based.
    5. To support Quality Improvement Organizations (QIO) in order to 
assist the QIO to perform Title XI and Title XVIII functions relating 
to assessing and improving HHA quality of care.
    QIOs will work with HHAs to implement quality improvement programs, 
provide consultation to CMS, its contractors, and to state agencies. 
The QIOs will provide a supportive role to HHAs in their endeavors to 
comply with Medicare Conditions of Participation; will assist the state 
agencies in related monitoring and enforcement efforts; assist CMS and 
help regional home health intermediaries in home health program 
integrity assessment; and prepare summary information about the 
nation's home health care for release to beneficiaries.
    6. To assist 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 EDB information 
in order to support evaluations and monitoring of Medicare claims 
information of beneficiaries, including proper reimbursement for 
services provided.
    7. To support an individual or organization for a research, 
evaluation, or epidemiological project related to the prevention of 
disease or disability, the restoration or maintenance of health, or 
payment-related projects.
    EDB data will provide for research, evaluation, and epidemiological 
projects, a broader, longitudinal, national perspective of the status 
of Medicare beneficiaries. CMS anticipates that many researchers will 
have legitimate requests to use these data in projects that could 
ultimately improve the care provided to Medicare beneficiaries and the 
policy that governs the care.
    8. To assist the Department of Justice (DOJ), court or adjudicatory 
body when:
    a. the Agency or any component thereof, or
    b. any employee of the Agency in his or her official capacity, or
    c. any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. the United States Government,

is a party to litigation or has an interest in such litigation, and by 
careful review, CMS determines that the records are both relevant and 
necessary to the litigation and that the use of such records by the 
DOJ, court or adjudicatory body is compatible with the purpose for 
which the agency collected the records.
    Whenever CMS is involved in litigation, 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.
    9. To assist 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.
    10. To assist another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.
    Other agencies may require EDB information for the purpose of 
combating fraud and abuse in such Federally funded programs.

B. Additional Provisions Affecting Routine Use Disclosures

    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR Parts 160 and 
164, Subparts A and E) 65 Fed. Reg. 82462 (12-28-00). Disclosures of 
such PHI that are otherwise authorized by these routine uses may only 
be made if, and as, permitted or required by the ``Standards for 
Privacy of Individually Identifiable Health Information.''
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law,

[[Page 10253]]

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).

IV. Safeguards

    CMS has safeguards in place for authorized users and monitors of 
such users to ensure against excessive or unauthorized use. Personnel 
having access to the system have been trained in the Privacy Act and 
information security requirements. Employees who maintain records in 
this system are instructed not to release data until the intended 
recipient agrees to implement appropriate management, operational and 
technical safeguards sufficient to protect the confidentiality, 
integrity and availability of the information and information systems 
and to prevent unauthorized access.
    This system will conform to all applicable Federal laws and 
regulations and Federal, HHS, and CMS policies and standards as they 
relate to information security and data privacy. These laws and 
regulations may apply but are not limited to: the Privacy Act of 1974; 
the Federal Information Security Management Act of 2002; the Computer 
Fraud and Abuse Act of 1986; the Health Insurance Portability and 
Accountability Act of 1996; the E-Government Act of 2002, the Clinger-
Cohen Act of 1996; the Medicare Modernization Act of 2003, and the 
corresponding implementing regulations. OMB Circular A-130, Management 
of Federal Resources, Appendix III, Security of Federal Automated 
Information Resources also applies. Federal, HHS, and CMS policies and 
standards include but are not limited to: all pertinent National 
Institute of Standards and Technology publications; the HHS Information 
Systems Program Handbook and the CMS Information Security Handbook.

V. Effects of the Modified System of Records 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. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will take precautionary measures to minimize the risks of 
unauthorized access to the records and the potential harm to individual 
privacy or other personal or property rights of patients whose data are 
maintained in this system. CMS will collect only that information 
necessary to perform the system's functions. In addition, CMS will make 
disclosure from the proposed system only with consent of the subject 
individual, or his/her legal representative, or in accordance with an 
applicable exception provision of the Privacy Act. CMS, therefore, does 
not anticipate an unfavorable effect on individual privacy as a result 
of information relating to individuals.

    Dated: February 13, 2008.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NUMBER: 09-70-0502

SYSTEM NAME:
    Enrollment Database (EDB), HHS/CMS/CBC.

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data.

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

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 system contains information related to Medicare enrollment and 
entitlement and Medicare Secondary Payer (MSP) data containing other 
party liability insurance information necessary for appropriate 
Medicare claim payment. It contains hospice election, Direct billing 
and Third Party Premium collection information, and group health plan 
enrollment data. The system also contains the individual's health 
insurance numbers, name, geographic location, race/ethnicity, sex, and 
date of birth.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of the system is given under sections 
226, 226A, 1811, 1818, 1818A, 1831, 1836, 1837, 1838, 1843, 1876, and 
1881 of the Social Security Act (the Act) and Title 42 Code of Federal 
Regulations (CFR), parts 406, 407, 408, 411 and 424. Authority for 
maintenance of the system section 1862 of the Act was a published 
authority in the published SOR. We included section 1862 in the 
modified SOR since we do maintain a limited number of data elements in 
the EDB pertaining to MSP. Authority for maintenance of the system 
section 1870 of the Act was included in the modified system since the 
EDB does maintain data regarding direct billing for Medicare premiums. 
Section 1870 (g) describes refunding these premiums.

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the SOR is to maintain information on 
Medicare enrollment for the administration of the Medicare program, 
including the following functions: ensuring proper Medicare enrollment, 
claims payment, Direct billing and Third Party premium collection 
information, 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 agency contractors, 
consultants, or to a grantee of a CMS-administered grant; (2) assist 
another Federal or state agency, agency of a state government, an 
agency established by state law, or its fiscal agent; (3) assist third 
parties where the contact is expected to have information relating to 
the individual's capacity to manage his or her own affairs; (4) assist 
providers and suppliers of services for administration of Title XVIII 
of the Act; (5) support Quality Improvement Organizations (QIO); (6) 
assist other insurers for processing individual insurance claims; (7) 
facilitate research on the quality and effectiveness of care provided, 
as well as payment-related and epidemiological projects; (8) support 
litigation involving the Agency; and (9) combat fraud and

[[Page 10254]]

abuse in certain health benefits programs.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES 
OR USERS AND THE PURPOSES OF SUCH USES:
    A. The Privacy Act allows us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such compatible use of data is known as a ``routine 
use.'' The proposed routine uses in this system meet the compatibility 
requirement of the Privacy Act. We are proposing to establish the 
following routine use disclosures of information maintained in the 
system:
    1. To support agency contractors, or consultants, or to a grantee 
of a CMS-administered grant program who have been engaged by the agency 
to assist in the accomplishment of a CMS function relating to the 
purposes for this system and who need to have access to the records in 
order to assist CMS.
    2. To assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent to:
    a. contribute to the accuracy of CMS's proper payment of Medicare 
benefits;
    b. enable such agency to administer a Federal health benefits 
program, or, as necessary, to enable such agency to fulfill a 
requirement of a Federal statute or regulation that implements a health 
benefits program funded in whole or in part with Federal funds; and/or
    c. assist Federal/state Medicaid programs within the state.
    3. To assist third party contacts (without the consent of the 
individuals to whom the information pertains) 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; and the amount of reimbursement; 
any case in which the evidence is being reviewed as a result of 
suspected fraud and abuse, program integrity, quality appraisal, or 
evaluation and measurement of program activities.
    4. To assist providers and suppliers of services dealing through 
fiscal intermediaries or carriers for the administration of Title XVIII 
of the Social Security Act.
    5. To support Quality Improvement Organizations (QIO) in order to 
assist the QIO to perform Title XI and Title XVIII functions relating 
to assessing and improving HHA quality of care.
    6. To assist 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.
    7. To support an individual or organization for a research, 
evaluation, or epidemiological project related to the prevention of 
disease or disability, the restoration or maintenance of health, or 
payment-related projects.
    8. To assist the Department of Justice (DOJ), court or adjudicatory 
body when:
    a. the Agency or any component thereof, or
    b. any employee of the Agency in his or her official capacity, or
    c. any employee of the Agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
    d. the United States Government, is a party to litigation or has an 
interest in such litigation, and by careful review, CMS determines that 
the records are both relevant and necessary to the litigation and that 
the use of such records by the DOJ, court or adjudicatory body is 
compatible with the purpose for which the agency collected the records.
    9. To assist 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.
    10. To assist another Federal agency or to an instrumentality of 
any governmental jurisdiction within or under the control of the United 
States (including any state or local governmental agency), that 
administers, or that has the authority to investigate potential fraud 
or abuse in, a health benefits program funded in whole or in part by 
Federal funds, when disclosure is deemed reasonably necessary by CMS to 
prevent, deter, discover, detect, investigate, examine, prosecute, sue 
with respect to, defend against, correct, remedy, or otherwise combat 
fraud or abuse in such programs.

B. Additional Provisions Affecting Routine Use Disclosures
    To the extent this system contains Protected Health Information 
(PHI) as defined by HHS regulation ``Standards for Privacy of 
Individually Identifiable Health Information'' (45 CFR parts 160 and 
164, subparts A and E) 65 Fed. Reg. 82462 (12-28-00). Disclosures of 
such PHI that are otherwise authorized by these routine uses may only 
be made if, and as, permitted or required by the ``Standards for 
Privacy of Individually Identifiable Health Information.''
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals who are familiar with the enrollees could, because of the 
small

[[Page 10255]]

size, use this information to deduce the identity of the beneficiary).

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, 
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
    All records are stored on magnetic media.

RETRIEVABILITY:
    All Medicare records are accessible by HIC number or alpha (name) 
search. This system supports both on-line and batch access.

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 EDB 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 15 years. All claims-related 
records are encompassed by the document preservation order and will be 
retained until notification is received from DOJ.

SYSTEM MANAGER AND ADDRESS:
    Director, Division of Enrollment & Eligibility Policy, Medicare 
Enrollment and Appeals Group, Centers for Beneficiary Choices, Mail 
Stop C2-09-17, Centers for Medicare & Medicaid Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1849.

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 MSP situations, through third party 
contacts. There are cases, however, in which the identifying 
information is provided to the physician by the individual; the 
physician then adds the medical information and submits the bill to the 
carrier for payment. Updating information is also obtained from the 
Railroad Retirement Board, and the Master Beneficiary Record maintained 
by the SSA.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.

 [FR Doc. E8-3562 Filed 2-25-08; 8:45 am]
BILLING CODE 4120-03-P