[Federal Register Volume 73, Number 43 (Tuesday, March 4, 2008)]
[Notices]
[Pages 11643-11646]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-4070]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services


Privacy Act of 1974; Report of a Modified or Altered System of 
Records

AGENCY: Department of Health and Human Services (HHS), Centers for 
Medicare & Medicaid Services (CMS).

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

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SUMMARY: In accordance with the requirements of the Privacy Act of 
1974, we are proposing to modify or alter an existing system of records 
titled ``Links of Social Security Administration (SSA) and Health Care 
Financing Administration (HCFA) Data (LOD), System No. 09-70-0069, 
established at 65 Federal Register 50544 (August 18, 2000). The system 
name reflects the former name of the Agency--the Health Care Financing 
Administration. For this reason, we propose to change the name of the 
system to read: the ``Links of Social Security Administration (SSA) and 
the Centers for Medicare & Medicaid Services Data (LOD).'' We propose 
to assign a new CMS identification number to this system to simplify 
the obsolete and confusing numbering system originally designed to 
identify the Bureau, Office, or Center that maintained information in 
the Health Care Financing Administration systems of records. The new 
assigned identifying number for this system should read: System No. 09-
70-0512.
    We propose to modify existing routine use number 2 that permits 
disclosure to agency contractors and consultants to include disclosure 
to CMS grantees who perform a task for the agency. CMS grantees, 
charged with completing projects or activities that require CMS data to 
carry out that activity, are classified separate from CMS contractors 
and/or consultants. The modified routine use will be renumbered as 
routine use number 1. We will delete routine use number 3 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. We 
propose to broaden the scope of the disclosure provisions of this 
system by adding a routine use to permit the release of information to 
another Federal and state agencies to: (1) Allow such agency to comply 
with Title XI, Part C of the Act; (2) enable such agency to administer 
a Federal health benefits program, and/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 (3) support data exchanges between the cooperating 
agencies. The new routine use will be numbered as routine use number 2.
    We will broaden the scope of this system by including the section 
titled ``Additional Circumstances Affecting Routine Use Disclosures,'' 
that addresses ``Protected Health Information (PHI)'' and ``small cell 
size.'' The requirement for compliance with HHS regulation ``Standards 
for Privacy of Individually Identifiable Health Information'' apply 
whenever the system collects or maintains PHI. This system may contain 
PHI. In addition, our policy to prohibit release if there is a 
possibility that an individual can be identified through ``small cell 
size'' will apply to the data disclosed from this system.
    We are modifying the language in the remaining routine uses to 
provide a proper explanation as to the need for the routine use and to 
provide clarity to CMS's intention to disclose individual-specific 
information contained in this system. The routine uses will then be 
prioritized and reordered according to their usage. We will also take 
the opportunity to update any sections of the system that were affected 
by the 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 
SORs.
    The primary purpose of the LOD is to collect and maintain 
information that will be used to conduct research, perform policy 
analysis, and improve program management for populations served by both 
SSA and CMS. Information maintained in this system will also be 
disclosed to: (1) Support regulatory, reimbursement, and policy 
functions performed within the Agency or by a contractor, consultant or 
grantee; (2) assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent; 
(3) facilitate research on the quality and effectiveness of care 
provided, as well as epidemiological projects; and (4) support 
litigation involving the Agency. 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 Dates: CMS filed a modified or altered system report with 
the Chair of the House Committee on Government Reform and Oversight, 
the Chair of the Senate Committee on Homeland Security & Governmental 
Affairs, and the Administrator, Office of Information and Regulatory 
Affairs, Office of Management and Budget (OMB) on February 26, 2008. To 
ensure that all parties have adequate time in which to comment, the 
modified system, including routine uses, will become effective 30 days 
from the publication of the notice, or 40 days from the date it was 
submitted to OMB and Congress, whichever is later, unless CMS receives 
comments that require alterations to this notice.

ADDRESSES: The public should address comments to: CMS Privacy Officer, 
Division of Privacy Compliance, Enterprise Architecture and Strategy 
Group, Office of Information Services, CMS, Room N2-04-27, 7500 
Security Boulevard, Baltimore, Maryland 21244-

[[Page 11644]]

1850. Comments received will be available for review at this location, 
by appointment, during regular business hours, Monday through Friday 
from 9 a.m.-3 p.m., Eastern Time zone.

FOR FURTHER INFORMATION CONTACT: Dave Baugh, Senior Technical Advisor, 
Research and Evaluation Group, Office of Research, Development and 
Information, CMS, Mail Stop Room C3-20-17, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850. He can be reached by telephone at 410-
786-7716, or via e-mail at [email protected].

SUPPLEMENTARY INFORMATION: 

I. Description of the Modified or Altered System of Records

A. Statutory and Regulatory Basis for SOR

    Authority for maintenance of this system is given under Section 
1875(a) [42 U.S.C. 1395II(a)] and 1110 of the Social Security Act [42 
U.S.C. 1310].

B. Collection and Maintenance of Data in the System

    Information maintained in this system contains samples of the 
United States population served by programs administered by CMS and 
SSA. The system includes the following information for each: Name, 
social security number, Medicaid identification number, health 
insurance claim number, eligibility for SSA and CMS programs, and 
benefit record information.

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

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

    The Privacy Act permits us to disclose information without an 
individual's consent if the information is to be used for a purpose 
that is compatible with the purpose(s) for which the information was 
collected. Any such disclosure of data is known as a ``routine use.'' 
The government will only release LOD information that can be associated 
with an individual as provided for under ``Section III. Proposed 
Routine Use Disclosures of Data in the System.'' Both individually 
identifiable and non-individually-identifiable data may be disclosed 
under a routine use.
    We will only disclose the minimum personal data necessary to 
achieve the purpose of LOD. 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 
information that will be used to conduct research, perform policy 
analysis, and improve program management for populations served by both 
SSA and CMS.
    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 or disclosure of the record;
    b. Remove or destroy at the earliest time all individually-
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, consultants, or grantees that 
have been contracted by the Agency to assist in accomplishment of a CMS 
function relating to the purposes for this system and who need 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 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, consultant, or grantee 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. Allow such agency to comply with Title XI, Part C of the Act,
    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. Support data exchanges between the cooperating agencies.
    In addition, other state agencies in their administration of a 
Federal health program may require LOD 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 administration of 
Titles IV, XVIII, and XIX of the Act, and for the administration of the 
Medicaid program.
    3. To support an individual or organization for a research, 
evaluation, or epidemiological project related to the prevention of 
disease or disability or the restoration or maintenance of health.
    LOD data may be able to provide for research, evaluation, and 
epidemiological projects a broader longitudinal national perspective of 
the status of health care patients. CMS anticipates that many 
researchers will have legitimate requests to use these data in projects 
that could ultimately improve the care provided to patients and the 
policy that governs the care.
    4. 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

[[Page 11645]]

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.

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 FR 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.'' (See 45 CFR 164-512 
(a)(1)).
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals could, because of the small size, use this information to 
deduce the identity of the beneficiary).

IV. Safeguards

    CMS has safeguards in place for authorized users and monitors such 
users to ensure against 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 modify this system in accordance with the 
principles and requirements of the Privacy Act and will collect, use, 
and disseminate information only as prescribed therein. Data in this 
system will be subject to the authorized releases in accordance with 
the routine uses identified in this system of records.
    CMS will take precautionary measures to minimize the risks of 
unauthorized access to the records and the potential harm to individual 
privacy or other personal or property rights of patients whose data are 
maintained in the system. CMS will collect only that information 
necessary to perform the system's functions. In addition, CMS will make 
disclosure from the proposed system only with consent of the subject 
individual, or his/her legal representative, or in accordance with an 
applicable exception provision of the Privacy Act. CMS, therefore, does 
not anticipate an unfavorable effect on individual privacy as a result 
of information relating to individuals.

    Dated: February 25, 2008.
Charlene Frizzera,
Chief Operating Officer, Centers for Medicare & Medicaid Services.
SYSTEM NO. 09-70-0512

SYSTEM NAME:
    ``Links To Social Security Administration and Centers For Medicare 
& Medicaid Services Data (LOD),'' HHS/CMS/ORDI

SECURITY CLASSIFICATION:
    Level Three Privacy Act Sensitive Data

SYSTEM LOCATION:
    Centers for Medicare & Medicaid Services (CMS) Data Center, 7500 
Security Boulevard, North Building, First Floor, Baltimore, Maryland 
21244-1850 and at various other locations.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
    The system includes samples of the United States population served 
by Social Security Administration (SSA) and CMS programs.

CATEGORIES OF RECORDS IN THE SYSTEM:
    The collected information will include, but is not limited to name, 
social security number (SSN), Medicaid identification number, health 
insurance claim number (HICN), eligibility for SSA and CMS programs, 
and benefit record information.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
    Authority for maintenance of this system is given under Section 
1875(a) [42 U.S.C. 1395II(a)] and 1110 of the Social Security Act [42 
U.S.C. 1310].

PURPOSE(S) OF THE SYSTEM:
    The primary purpose of the LOD is to collect and maintain 
information that will be used to conduct research, perform policy 
analysis, and improve program management for populations served by both 
SSA and CMS. Information maintained in this system will also be 
disclosed to: (1) Support regulatory, reimbursement, and policy 
functions performed within the Agency or by a contractor, consultant or 
grantee; (2) assist another Federal or state agency, agency of a state 
government, an agency established by state law, or its fiscal agent; 
(3) facilitate research on the quality and effectiveness of care 
provided, as well as epidemiological projects; and (4) support 
litigation involving the Agency.

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:

[[Page 11646]]

    1. To agency contractors, consultants or grantees, who have been 
engaged by the agency to assist in the performance of a service related 
to this collection and who need to have access to the records in order 
to perform the activity.
    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. Allow such agency to comply with Title XI, Part C of the Act,
    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. Support data exchanges between the cooperating agencies.
    3. To an individual or organization for a research project or in 
support of an evaluation project related to the prevention of disease, 
disability, or quality care projects, the restoration or maintenance of 
health, and payment related projects.
    4. To the Department of Justice (DOJ), court or adjudicatory body 
when:
    a. The agency or any component thereof, or
    b. Any employee of the agency in his or her official capacity, or
    c. Any employee of the agency in his or her individual capacity 
where the DOJ has agreed to represent the employee, or
     d. The United States Government, is a party to litigation or has 
an interest in such litigation, and, by careful review, 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.
    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 FR 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.'' (See 45 CFR 164-512 (a) 
(1).)
    In addition, our policy will be to prohibit release even of data 
not directly identifiable, except pursuant to one of the routine uses 
or if required by law, if we determine there is a possibility that an 
individual can be identified through implicit deduction based on small 
cell sizes (instances where the patient population is so small that 
individuals could, because of the small size, use this information to 
deduce the identity of the beneficiary).

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

RETRIEVABILITY:
    The collected data are retrieved by an individual identifier; e.g., 
beneficiary name, health insurance claim number, State assigned 
personal identifier, or social security number.

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

RETENTION AND DISPOSAL:
    CMS will retain information for a total period not to exceed 25 
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, Information and Methods Group, Office of Research, 
Development & Information, Mail Stop C3-16-07, 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, employee 
identification number, tax identification number, national provider 
number, and for verification purposes, the subject individual's name 
(woman's maiden name, if applicable), HICN, and/or SSN (furnishing the 
SSN is voluntary, but it may make searching for a record easier and 
prevent delay).

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

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

RECORDS SOURCE CATEGORIES:
    Sources of information contained in this records system include 
data collected from SSA systems of records, e.g., Supplemental Security 
Record (09-60-0103), Master Beneficiary Record (09-60-0090), Disability 
Determination Files (09-60-0044), and Social Security Account Number 
Identification File (09-60-0058) and LOD systems of records, e.g., 
Medicaid Statistical Information System (09-70-0541), Current 
Beneficiary Survey (09-70-0519), Common Working Files (09-70-0526), 
National Claims History Files (09-70-0558) and Enrollment Data Base 
(09-70-0502).

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:
    None.
[FR Doc. E8-4070 Filed 3-3-08; 8:45 am]
BILLING CODE 4120-03-P