Privacy Act of 1974: New System of Records, 65011-65014 [2013-25725]
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Federal Register / Vol. 78, No. 210 / Wednesday, October 30, 2013 / Notices
U.S. Office of Personnel Management.
Elaine Kaplan,
Acting Director.
[FR Doc. 2013–25724 Filed 10–29–13; 8:45 am]
BILLING CODE 6820–B2–P
OFFICE OF PERSONNEL
MANAGEMENT
Privacy Act of 1974: New System of
Records
U.S. Office of Personnel
Management (OPM).
ACTION: Notice of a new system of
records.
AGENCY:
The U.S. Office of Personnel
Management (OPM) proposes to add
OPM/Central–19: External Review
Records for Multi-State Plan (MSP)
Program to its inventory of records
systems subject to the Privacy Act of
1974 (5 U.S.C. 552a), as amended. This
action is necessary to meet the
requirements of the Privacy Act to
publish in the Federal Register notice of
the existence and character of records
maintained by the agency. 5 U.S.C.
552a(e)(4).
DATES: This action will be effective
without further notice on December 9,
2013 unless comments are received that
would result in a contrary
determination.
ADDRESSES: Send written comments to
the Office of Personnel Management,
ATTN: Padma Shah, U.S. Office of
Personnel Management, 1900 E Street
NW., Room 2347, Washington, DC
20415.
FOR FURTHER INFORMATION CONTACT:
Padma Shah by telephone at 202–606–
2128, or by email at mspp@opm.gov.
SUPPLEMENTARY INFORMATION: The
Patient Protection and Affordable Care
Act, Public Law 111–148, was enacted
on March 23, 2010, and the Health Care
and Education Reconciliation Act,
Public Law 111–152, was enacted on
March 30, 2010 (collectively referred to
as ‘‘the Affordable Care Act’’).
Section 1334 of the Affordable Care
Act and its implementing regulations
(codified at 45 CFR part 800) direct
OPM to establish the Multi-State Plan
(MSP) Program to foster competition
among plans offering coverage on the
individual and small group health
insurance markets on the Affordable
Insurance Exchanges (referred to as
‘‘Exchanges’’ or ‘‘Health Insurance
Marketplaces’’). Specifically, OPM must
contract with private health insurance
issuers to offer at least two MSP options
on each of the Exchanges in the 50
States and the District of Columbia, in
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which issuers may phase in coverage
over a period of 4 years.
Under section 1334(a)(4) of the
Affordable Care Act, OPM must
administer the MSP Program ‘‘in a
manner similar to the manner in which’’
it implements the contracting provisions
of the Federal Employees Health
Benefits (FEHB) Program under 5 U.S.C.
8901 et seq. In the MSP Program final
rule (78 FR 15560, March 11, 2013),
OPM interpreted section 1334(a)(4) of
the Affordable Care Act to require
implementation of a uniform, nationally
applicable external review process for
MSP options, consistent with the
requirements of section 2719 of the
Public Health Service Act and similar to
the process administered by OPM under
the FEHB Program. This process will
ensure that MSP Program contracts are
administered consistently throughout
all 51 jurisdictions that would be served
by an MSP option. Specifically, under
45 CFR 800.503, OPM is authorized to
conduct external review of adverse
benefit determinations by MSP issuers
using a process similar to the FEHB
Program disputed claims process. In
addition to requests for external review,
we anticipate that MSP enrollees may
contact OPM about inquiries or
complaints regarding MSP options,
which may have to be referred to other
appropriate entities such as State
insurance departments, State consumer
assistance programs, and the U.S.
Department of Health and Human
Services.
The purpose of this system of records
is to provide a central database through
which OPM may conduct external
review of adverse benefit
determinations under the MSP Program,
refer MSP enrollees to other entities
about their inquiries or complaints, and
correspond with MSP enrollees. OPM
will collect, manage, and analyze health
services data that MSP enrollees, MSP
issuers, health care providers, and
others will furnish through secure data
transfer. The information contained in
the database will help ensure that (1)
MSP enrollees have adequate access to
independent review of adverse benefit
determinations, (2) MSP enrollees are
referred to appropriate entities about
their inquiries or complaints, (3) OPM
corresponds with MSP enrollees, and (4)
OPM collects the information necessary
for the enforcement of MSP Program
contracts and implementation of the
program.
OPM will use identifiable data to
create records that are necessary to
facilitate external review of MSP issuer
adverse benefit determinations by OPM
analysts and independent review
organizations. Likewise, OPM will use
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65011
identifiable data to create records about
MSP enrollee inquiries or complaints,
which may have to be referred to other
State and Federal Government agencies.
However, OPM and external analysts
using the database for analysis purposes
will have access only to de-identified
data.
U.S. Office of Personnel Management.
Elaine Kaplan,
Acting Director.
OPM CENTRAL–19
SYSTEM NAME:
External Review Records for MultiState Plan (MSP) Program
SYSTEM LOCATION:
Office of Personnel Management,
1900 E Street NW., Washington, DC
20415.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:
This system will contain records on
MSP enrollees who request external
review of adverse benefit
determinations, and MSP enrollees who
contact OPM about an inquiry or
complaint.
CATEGORIES OF RECORDS IN THE SYSTEM:
In order to process a request for
external review, OPM may require an
MSP enrollee or an authorized
representative to submit the following
information about the enrollee, which
OPM may also collect, as necessary, to
process enrollee inquiries and
complaints:
a. The adverse benefit determination
that the individual received from the
MSP issuer.
b. Name.
c. Date of birth.
d. Gender.
e. Social Security Number.
f. Phone number(s), postal address(es)
(current and mailing), and email
address(es).
g. Insurance identification (ID)
number.
h. Group number.
i. Scanned copy of insurance ID card.
j. The State and county of coverage.
k. An indication of whether the
external review request is for an urgent
claim.
l. A brief statement of the reason for
the external review request.
m. The MSP issuer’s name.
n. The name of the MSP option that
covers the MSP enrollee.
o. The claim number.
p. Subscriber’s information: Name,
Social Security Number, date of birth,
gender, phone number(s), postal
address(es) (current and mailing), and
email address(es).
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q. In cases where an authorized
representative requests external review,
evidence of authorization and the
following information about the
authorized representative: name, phone
number(s), postal address(es) (current
and mailing), and email address(es).
r. Name of health care provider.
s. Health care provider address(es).
t. Any additional information
necessary to process the request for
external review.
In addition, MSP enrollees may
choose to submit additional information
that will become part of the system of
records. This information may include,
but is not limited to, the following:
a. A statement about why the MSP
enrollee believes the MSP issuer’s
adverse benefit determination was
wrong, based on specific benefit
provisions in the plan brochure,
contract, or statement of benefits.
b. Copies of documents that support
the request for external review, such as
physicians’ letters, operative reports,
bills, medical records, and explanation
of benefits (EOB) forms.
c. Copies of all letters the MSP
enrollee sent to the MSP issuer about
the claim.
d. Copies of all letters the MSP issuer
sent to the MSP enrollee about the
claim.
MSP issuers will provide additional
information and documentation.
Consequently, the records in the system
may include the following information
about the MSP enrollee:
a. Personal identifying information
(name, Social Security Number, date of
birth, gender, phone number, etc.).
b. Postal address(es) (current and
mailing).
c. Dependent information (spouse,
dependents and their addresses).
d. Employment information.
e. Health care provider information.
f. Health care coverage information.
g. Health care procedure information.
h. Health care diagnoses information.
i. Provider charges and
reimbursement information on coverage,
procedures and diagnoses.
j. Any other letters or other
documents submitted in connection
with the adverse benefit determination
by MSP enrollees, health care providers,
or MSP issuers.
The aforementioned information may
also be collected, as necessary, to
process MSP enrollee inquiries and
complaints.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
OPM has authority to administer the
MSP Program under section 1334 of the
Affordable Care Act (42 U.S.C. 18054).
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PURPOSE:
OPM operates this system of records
to support the administration of the
MSP Program. The primary purpose of
this system of records is to aid in the
administration of external review of
adverse benefit determinations for MSP
enrollees. OPM must have the capacity
to collect, manage, and access health
insurance benefits appeals information
and documents on an ongoing basis in
order for OPM to:
a. Determine eligibility for the MSP
Program external review process.
b. Review adverse benefit
determinations by MSP issuers to
provide effective external review.
c. Track the progress of individual
requests for external review and ensure
that MSP enrollees do not submit
duplicative requests.
d. Make information available for any
subsequent litigation related to a
disputed external review decision.
e. Monitor whether MSP issuers are
providing benefits to which MSP
enrollees are entitled under the terms of
the applicable MSP Program contract.
f. Maintain records for parties to the
dispute so that the MSP enrollee and
MSP issuer can obtain a record of past
external reviews in which they were
involved.
g. Track and report information about
the administration of the MSP Program.
h. Refer MSP enrollees to appropriate
entities about their inquiries or
complaints.
i. Correspond with MSP enrollees.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:
In addition to those disclosures
otherwise permitted under 5 U.S.C.
552a(b), all or a portion of the records
or information contained in this system
may be disclosed outside of OPM, for a
routine use under 5 U.S.C. 552a(b)(3) as
follows:
a. For Claims Adjudication—To
disclose information to agency
contractors conducting claim reviews
for the purpose of adjudicating an
appeal.
b. For Law Enforcement Purposes—To
disclose pertinent information to the
appropriate Federal, State, or local
agency responsible for investigating,
prosecuting, enforcing, or implementing
a statute, rule, regulation, or order,
where OPM becomes aware of an
indication of a violation or potential
violation of civil or criminal law or
regulation.
c. For Congressional Inquiry—To
provide information to a Congressional
office from the record of an individual
in response to an inquiry from that
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Sfmt 4703
Congressional office made at the request
of that individual.
d. For Judicial/Administrative
Proceedings—To disclose information to
another Federal agency, to a court, or a
party in litigation before a court or in an
administrative proceeding being
conducted by a Federal agency, when
the Government is a party to the judicial
or administrative proceeding. In those
cases where the Government is not a
party to the processing, records may be
disclosed if a subpoena has been signed
by a judge.
e. For the National Archives and
Records Administration or the General
Services Administration—To disclose
information to the National Archives
and Records Administration (NARA) or
General Services Administration for use
in records management inspections
conducted pursuant to 44 U.S.C. 2904
and 2906.
f. For Litigation—To disclose to the
Department of Justice or in a proceeding
before a court, adjudicative body, or
other administrative body before which
OPM is authorized to appear, when—
(1) OPM, or any component thereof;
or
(2) Any employee of OPM in his or
her official capacity; or
(3) Any employee of OPM in his or
her individual capacity where the
Department of Justice or OPM has
agreed to represent the employee; or
(4) The United States, when OPM
determines that litigation is likely to
affect OPM or any of its components—
is a party to litigation or has an
interest in such litigation, and the use
of such records by the Department of
Justice or OPM is deemed by OPM to be
relevant and necessary to the litigation,
provided, however, that the disclosure
is compatible with the purpose for
which records were collected.
g. For Non-Federal Personnel—To
disclose information to contractors,
grantees, or volunteers performing or
working on a contract, service, grant,
cooperative agreement, or job for the
Federal Government, where the
disclosure is compatible with the
purpose for which records are collected.
h. In the Event of a Data Breach—In
the event of a data breach, records may
be disclosed to appropriate Federal
agencies and agency contractors that
have a need to know the information for
the purpose of assisting the agency’s
efforts to respond to a suspected or
confirmed breach of the security or
confidentiality of information
maintained in this system of records,
and the information disclosed is
relevant and necessary for that
assistance.
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i. To researchers inside and outside
the Federal Government, approved in
advance by OPM on the basis of
demonstrated aptitude and a written
research plan, for the purpose of
conducting analysis of health care and
health insurance trends and topical
health-related issues compatible with
the purposes for which the records were
collected and formulating health care
program changes and enhancements to
limit cost growth, improve outcomes,
increase accountability, and improve
efficiency in program administration. In
all cases, researchers external to OPM
will access a public use file that will be
maintained for such purposes; will
contain only de-identified data; and will
be structured, where appropriate, to
protect MSP enrollee confidentiality
where identities may be discerned
because there are fewer records under
certain demographic or other variables.
In all disclosures to analysts under this
routine use, only de-identified data will
be disclosed.
j. If OPM determines that jurisdiction
over an MSP enrollee’s inquiry or
complaint lies with another Federal or
State agency, information in this system
of records may be disclosed to other
agencies, such as a State insurance
department, a State Consumer
Assistance Program, or the U.S.
Department of Health and Human
Services.
POLICIES AND PRACTICES OF STORING,
RETRIEVING, SAFEGUARDING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Paper records will be maintained in
locked file cabinets within OPM and/or
any contractors. Any electronic records
will be maintained in electronic
systems.
RETRIEVABILITY:
Records will primarily be
manipulated, managed and summarized
using a unique number assigned to each
external review or case about an inquiry
or complaint. However, information
may also be accessible by other
identifying information, including
name, date of birth, or Social Security
Number.
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SAFEGUARDS:
OPM will maintain records within its
secure headquarters in Washington, DC.
Electronic records will be maintained
on password-protected computers and
systems. Computer firewalls will be
maintained to prevent access by
unauthorized personnel. Any paper
records will be delivered to a locked
P.O. Box and kept in locked file
cabinets.
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Federal employees and employees of
Federal contractors are required to have
been the subject of a favorable
adjudication following an appropriate
background investigation before they are
allowed physical access to OPM and
access to any records. OPM’s
environment is equipped with
electronic badge readers restricting
access to authorized personnel only and
has safeguards in place to alert security
personnel if unauthorized personnel
attempt to gain access to OPM’s
environment. OPM employs armed
physical security guards 365 days a
year, 24 hours a day, who patrol OPM
headquarters, including entry and exit
points. Closed Circuit Video cameras are
strategically located on every floor and
external to the facility.
The system will employ National
Institute of Standards and Technology
(NIST) Security Controls identified in
the most recent version of Special
Publication SP 800–53. NIST 800–53
security controls are the management,
operational, and technical safeguards or
countermeasures employed within an
organizational information system to
protect the confidentiality, integrity,
and availability of the system and its
information. OPM will perform a
Security Assessment and Authorization
(SA&A) following the NIST 800–53
standard in order to obtain an Authority
to Operate (ATO). The system will
employ role-based access controls to
further restrict access to data, based on
the functions that users are authorized
to perform. The system will be fully
compliant with all applicable provisions
of the Privacy Act, Health Insurance
Portability and Accountability Act
(HIPAA), Federal Information Security
Management Act (FISMA), Federal
Records Act, Office of Management and
Budget (OMB) guidance, and NIST
guidance.
RETENTION AND DISPOSAL:
The records in this system will be
retained for at least 6 years. Records
may be retained for a longer period for
the system purposes established in this
system of records notice, or for other
purposes as required under law (e.g., for
purposes of litigation). A records
retention schedule will be established
with NARA, and no records will be
destroyed until that schedule has been
established. Once that schedule is
established, it will set forth methods for
disposing records that would no longer
be eligible for retention.
SYSTEM MANAGERS AND ADDRESSES:
The system manager is Edward M.
DeHarde, U.S. Office of Personnel
Management, Healthcare and Insurance,
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65013
1900 E Street NW., Room 2347,
Washington, DC 20415.
NOTIFICATION AND RECORD ACCESS PROCEDURE:
Individuals wishing to determine
whether this system of records contains
information about them may do so by
writing to the U.S. Office of Personnel
Management, FOIA/PA Requester
Service Center, 1900 E Street NW.,
Room 5415, Washington, DC 20415–
7900 or by emailing foia@opm.gov.
Individuals must furnish the
following information for their records
to be located:
1. Full name.
2. Date and place of birth.
3. Social Security Number.
4. Signature.
5. Available information regarding the
type of information requested, including
the name of the MSP issuer involved in
any external review and the
approximate date of the request for
external review.
6. The reason why the individual
believes this system contains
information about him/her.
7. The address to which the
information should be sent.
Individuals requesting access must
also comply with OPM’s Privacy Act
regulations regarding verification of
identity and access to records (5 CFR
part 297). In addition, the requester
must provide a notarized statement or
an unsworn declaration made in
accordance with 28 U.S.C. 1746, in the
following format:
• If executed outside the United
States: ‘‘I declare (or certify, verify, or
state) under penalty of perjury under the
laws of the United States of America
that the foregoing is true and correct.
Executed on [date]. [Signature].’’
• If executed within the United
States, its territories, possessions, or
commonwealths: ‘‘I declare (or certify,
verify, or state) under penalty of perjury
that the foregoing is true and correct.
Executed on [date]. [Signature].’’
CONTESTING RECORD PROCEDURE:
Individuals wishing to request
amendment of records about them
should write to the U.S. Office of
Personnel Management, FOIA/PA
Requester Service Center, 1900 E Street
NW., Room 5415, Washington, DC
20415–7900. ATTN: Healthcare and
Insurance, National Healthcare
Operations.
Individuals must furnish the
following information in writing for
their records to be located:
1. Full name.
2. Date and place of birth.
3. Social Security Number.
4. Signature.
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Federal Register / Vol. 78, No. 210 / Wednesday, October 30, 2013 / Notices
5. Available information regarding the
type of information that the individual
seeks to have amended, including the
name of the MSP issuer involved in any
external review and the approximate
date of the request for external review.
Individuals requesting access must
also comply with OPM’s Privacy Act
regulations regarding verification of
identity and access to records (5 CFR
part 297). In addition, the requester
must provide a notarized statement or
an unsworn declaration made in
accordance with 28 U.S.C. 1746, in the
following format:
• If executed outside the United
States: ‘‘I declare (or certify, verify, or
state) under penalty of perjury under the
laws of the United States of America
that the foregoing is true and correct.
Executed on [date]. [Signature].’’
• If executed within the United
States, its territories, possessions, or
commonwealths: ‘‘I declare (or certify,
verify, or state) under penalty of perjury
that the foregoing is true and correct.
Executed on [date]. [Signature].’’
RECORD SOURCE CATEGORIES:
Information in this system of records
is obtained from:
a. MSP enrollees who request external
review, or who contact OPM about an
inquiry or complaint.
b. Authorized representatives of MSP
enrollees.
c. Health care providers.
d. MSP issuers.
e. Medical professionals providing
expert medical review under contract
with OPM.
SYSTEM EXEMPTIONS:
None.
[FR Doc. 2013–25725 Filed 10–29–13; 8:45 am]
BILLING CODE 6325–38–P
POSTAL REGULATORY COMMISSION
[Docket No. MC2014–3 and CP2014–3;
Order No. 1860]
New Postal Product
Postal Regulatory Commission.
Notice.
AGENCY:
ACTION:
The Commission is noticing a
recent Postal Service filing concerning
the addition of Priority Mail Express &
Priority Mail Contract 15 to the
competitive product list. This notice
informs the public of the filing, invites
public comment, and takes other
administrative steps.
DATES: Comments are due: October 31,
2013.
ADDRESSES: Submit comments
electronically via the Commission’s
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SUMMARY:
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16:58 Oct 29, 2013
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Filing Online system at https://
www.prc.gov. Those who cannot submit
comments electronically should contact
the person identified in the FOR FURTHER
INFORMATION CONTACT section by
telephone for advice on filing
alternatives.
FOR FURTHER INFORMATION CONTACT:
Stephen L. Sharfman, General Counsel,
at 202–789–6820.
SUPPLEMENTARY INFORMATION:
Table of Contents
I. Introduction
II. Notice of Filings
III. Ordering Paragraphs
I. Introduction
In accordance with 39 U.S.C. 3642
and 39 CFR 3020.30 et seq., the Postal
Service filed a formal request and
associated supporting information to
add Priority Mail Express & Priority
Mail Contract 15 to the competitive
product list.1 The Postal Service asserts
that Priority Mail Express & Priority
Mail Contract 15 is a competitive
product ‘‘not of general applicability’’
within the meaning of 39 U.S.C.
3632(b)(3). Request at 1. The Request
has been assigned Docket No. MC2014–
3.
The Postal Service
contemporaneously filed a redacted
contract related to the proposed new
product under 39 U.S.C. 3632(b)(3) and
39 CFR 3015.5. Id. Attachment B. The
instant contract has been assigned
Docket No. CP2014–3.
Request. To support its Request, the
Postal Service filed six attachments as
follows:
• Attachment A—a redacted copy of
Governors’ Decision No. 11–6,
authorizing the new product;
• Attachment B—a redacted copy of
the contract;
• Attachment C—proposed changes
to the Mail Classification Schedule
competitive product list with the
addition underlined;
• Attachment D—a Statement of
Supporting Justification as required by
39 CFR 3020.32;
• Attachment E—a certification of
compliance with 39 U.S.C. 3633(a); and
• Attachment F—an application for
non-public treatment of materials to
maintain redacted portions of the
contract and related financial
information under seal.
In the Statement of Supporting
Justification, Brian Code, Manager,
1 Request
of the United States Postal Service to
Add Priority Mail Express & Priority Mail Contract
15 to Competitive Product List and Notice of Filing
(Under Seal) of Unredacted Governors’ Decision,
Contract, and Supporting Data, October 23, 2013
(Request).
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Fmt 4703
Sfmt 4703
Retail Alliances, asserts that the contract
will cover its attributable costs, make a
positive contribution to coverage of
institutional costs, and increase
contribution toward the requisite 5.5
percent of the Postal Service’s total
institutional costs. Id. Attachment D at
1. Mr. Code contends that there will be
no issue of market dominant products
subsidizing competitive products as a
result of this contract. Id.
Related contract. The Postal Service
included a redacted version of the
related contract with the Request. Id.
Attachment B. The contract is
scheduled to become effective within 90
days after the Postal Service receives
final regulatory approval from the
Commission. Id. at 3. The contract will
expire one year from the effective date.
Id. The Postal Service represents that
the contract is consistent with 39 U.S.C.
3633(a). Id. Attachment E.
The Postal Service filed much of the
supporting materials, including the
related contract, under seal. Id.
Attachment F. It maintains that the
redacted portions of the Governors’
Decision, contract, customer-identifying
information, and related financial
information should remain confidential.
Id. at 3. This information includes the
price structure, underlying costs and
assumptions, pricing formulas,
information relevant to the customer’s
mailing profile, and cost coverage
projections. Id. The Postal Service asks
the Commission to protect customeridentifying information from public
disclosure indefinitely. Id. at 7.
II. Notice of Filings
The Commission establishes Docket
Nos. MC2014–3 and CP2014–3 to
consider the Request pertaining to the
proposed Priority Mail Express &
Priority Mail Contract 15 product and
the related contract, respectively.
Interested persons may submit
comments on whether the Postal
Service’s filings in the captioned
dockets are consistent with the policies
of 39 U.S.C. 3632, 3633, or 3642, 39 CFR
3015.5, and 39 CFR part 3020, subpart
B. Comments are due no later than
October 31, 2013. The public portions of
these filings can be accessed via the
Commission’s Web site (https://
www.prc.gov).
The Commission appoints Curtis E.
Kidd to serve as Public Representative
in these dockets.
III. Ordering Paragraphs
It is ordered:
1. The Commission establishes Docket
Nos. MC2014–3 and CP2014–3 to
consider the matters raised in each
docket.
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Agencies
[Federal Register Volume 78, Number 210 (Wednesday, October 30, 2013)]
[Notices]
[Pages 65011-65014]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-25725]
-----------------------------------------------------------------------
OFFICE OF PERSONNEL MANAGEMENT
Privacy Act of 1974: New System of Records
AGENCY: U.S. Office of Personnel Management (OPM).
ACTION: Notice of a new system of records.
-----------------------------------------------------------------------
SUMMARY: The U.S. Office of Personnel Management (OPM) proposes to add
OPM/Central-19: External Review Records for Multi-State Plan (MSP)
Program to its inventory of records systems subject to the Privacy Act
of 1974 (5 U.S.C. 552a), as amended. This action is necessary to meet
the requirements of the Privacy Act to publish in the Federal Register
notice of the existence and character of records maintained by the
agency. 5 U.S.C. 552a(e)(4).
DATES: This action will be effective without further notice on December
9, 2013 unless comments are received that would result in a contrary
determination.
ADDRESSES: Send written comments to the Office of Personnel Management,
ATTN: Padma Shah, U.S. Office of Personnel Management, 1900 E Street
NW., Room 2347, Washington, DC 20415.
FOR FURTHER INFORMATION CONTACT: Padma Shah by telephone at 202-606-
2128, or by email at mspp@opm.gov.
SUPPLEMENTARY INFORMATION: The Patient Protection and Affordable Care
Act, Public Law 111-148, was enacted on March 23, 2010, and the Health
Care and Education Reconciliation Act, Public Law 111-152, was enacted
on March 30, 2010 (collectively referred to as ``the Affordable Care
Act'').
Section 1334 of the Affordable Care Act and its implementing
regulations (codified at 45 CFR part 800) direct OPM to establish the
Multi-State Plan (MSP) Program to foster competition among plans
offering coverage on the individual and small group health insurance
markets on the Affordable Insurance Exchanges (referred to as
``Exchanges'' or ``Health Insurance Marketplaces''). Specifically, OPM
must contract with private health insurance issuers to offer at least
two MSP options on each of the Exchanges in the 50 States and the
District of Columbia, in which issuers may phase in coverage over a
period of 4 years.
Under section 1334(a)(4) of the Affordable Care Act, OPM must
administer the MSP Program ``in a manner similar to the manner in
which'' it implements the contracting provisions of the Federal
Employees Health Benefits (FEHB) Program under 5 U.S.C. 8901 et seq. In
the MSP Program final rule (78 FR 15560, March 11, 2013), OPM
interpreted section 1334(a)(4) of the Affordable Care Act to require
implementation of a uniform, nationally applicable external review
process for MSP options, consistent with the requirements of section
2719 of the Public Health Service Act and similar to the process
administered by OPM under the FEHB Program. This process will ensure
that MSP Program contracts are administered consistently throughout all
51 jurisdictions that would be served by an MSP option. Specifically,
under 45 CFR 800.503, OPM is authorized to conduct external review of
adverse benefit determinations by MSP issuers using a process similar
to the FEHB Program disputed claims process. In addition to requests
for external review, we anticipate that MSP enrollees may contact OPM
about inquiries or complaints regarding MSP options, which may have to
be referred to other appropriate entities such as State insurance
departments, State consumer assistance programs, and the U.S.
Department of Health and Human Services.
The purpose of this system of records is to provide a central
database through which OPM may conduct external review of adverse
benefit determinations under the MSP Program, refer MSP enrollees to
other entities about their inquiries or complaints, and correspond with
MSP enrollees. OPM will collect, manage, and analyze health services
data that MSP enrollees, MSP issuers, health care providers, and others
will furnish through secure data transfer. The information contained in
the database will help ensure that (1) MSP enrollees have adequate
access to independent review of adverse benefit determinations, (2) MSP
enrollees are referred to appropriate entities about their inquiries or
complaints, (3) OPM corresponds with MSP enrollees, and (4) OPM
collects the information necessary for the enforcement of MSP Program
contracts and implementation of the program.
OPM will use identifiable data to create records that are necessary
to facilitate external review of MSP issuer adverse benefit
determinations by OPM analysts and independent review organizations.
Likewise, OPM will use identifiable data to create records about MSP
enrollee inquiries or complaints, which may have to be referred to
other State and Federal Government agencies. However, OPM and external
analysts using the database for analysis purposes will have access only
to de-identified data.
U.S. Office of Personnel Management.
Elaine Kaplan,
Acting Director.
OPM CENTRAL-19
SYSTEM NAME:
External Review Records for Multi-State Plan (MSP) Program
SYSTEM LOCATION:
Office of Personnel Management, 1900 E Street NW., Washington, DC
20415.
CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:
This system will contain records on MSP enrollees who request
external review of adverse benefit determinations, and MSP enrollees
who contact OPM about an inquiry or complaint.
CATEGORIES OF RECORDS IN THE SYSTEM:
In order to process a request for external review, OPM may require
an MSP enrollee or an authorized representative to submit the following
information about the enrollee, which OPM may also collect, as
necessary, to process enrollee inquiries and complaints:
a. The adverse benefit determination that the individual received
from the MSP issuer.
b. Name.
c. Date of birth.
d. Gender.
e. Social Security Number.
f. Phone number(s), postal address(es) (current and mailing), and
email address(es).
g. Insurance identification (ID) number.
h. Group number.
i. Scanned copy of insurance ID card.
j. The State and county of coverage.
k. An indication of whether the external review request is for an
urgent claim.
l. A brief statement of the reason for the external review request.
m. The MSP issuer's name.
n. The name of the MSP option that covers the MSP enrollee.
o. The claim number.
p. Subscriber's information: Name, Social Security Number, date of
birth, gender, phone number(s), postal address(es) (current and
mailing), and email address(es).
[[Page 65012]]
q. In cases where an authorized representative requests external
review, evidence of authorization and the following information about
the authorized representative: name, phone number(s), postal
address(es) (current and mailing), and email address(es).
r. Name of health care provider.
s. Health care provider address(es).
t. Any additional information necessary to process the request for
external review.
In addition, MSP enrollees may choose to submit additional
information that will become part of the system of records. This
information may include, but is not limited to, the following:
a. A statement about why the MSP enrollee believes the MSP issuer's
adverse benefit determination was wrong, based on specific benefit
provisions in the plan brochure, contract, or statement of benefits.
b. Copies of documents that support the request for external
review, such as physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms.
c. Copies of all letters the MSP enrollee sent to the MSP issuer
about the claim.
d. Copies of all letters the MSP issuer sent to the MSP enrollee
about the claim.
MSP issuers will provide additional information and documentation.
Consequently, the records in the system may include the following
information about the MSP enrollee:
a. Personal identifying information (name, Social Security Number,
date of birth, gender, phone number, etc.).
b. Postal address(es) (current and mailing).
c. Dependent information (spouse, dependents and their addresses).
d. Employment information.
e. Health care provider information.
f. Health care coverage information.
g. Health care procedure information.
h. Health care diagnoses information.
i. Provider charges and reimbursement information on coverage,
procedures and diagnoses.
j. Any other letters or other documents submitted in connection
with the adverse benefit determination by MSP enrollees, health care
providers, or MSP issuers.
The aforementioned information may also be collected, as necessary,
to process MSP enrollee inquiries and complaints.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:
OPM has authority to administer the MSP Program under section 1334
of the Affordable Care Act (42 U.S.C. 18054).
PURPOSE:
OPM operates this system of records to support the administration
of the MSP Program. The primary purpose of this system of records is to
aid in the administration of external review of adverse benefit
determinations for MSP enrollees. OPM must have the capacity to
collect, manage, and access health insurance benefits appeals
information and documents on an ongoing basis in order for OPM to:
a. Determine eligibility for the MSP Program external review
process.
b. Review adverse benefit determinations by MSP issuers to provide
effective external review.
c. Track the progress of individual requests for external review
and ensure that MSP enrollees do not submit duplicative requests.
d. Make information available for any subsequent litigation related
to a disputed external review decision.
e. Monitor whether MSP issuers are providing benefits to which MSP
enrollees are entitled under the terms of the applicable MSP Program
contract.
f. Maintain records for parties to the dispute so that the MSP
enrollee and MSP issuer can obtain a record of past external reviews in
which they were involved.
g. Track and report information about the administration of the MSP
Program.
h. Refer MSP enrollees to appropriate entities about their
inquiries or complaints.
i. Correspond with MSP enrollees.
ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES
OF USERS AND THE PURPOSES OF SUCH USES:
In addition to those disclosures otherwise permitted under 5 U.S.C.
552a(b), all or a portion of the records or information contained in
this system may be disclosed outside of OPM, for a routine use under 5
U.S.C. 552a(b)(3) as follows:
a. For Claims Adjudication--To disclose information to agency
contractors conducting claim reviews for the purpose of adjudicating an
appeal.
b. For Law Enforcement Purposes--To disclose pertinent information
to the appropriate Federal, State, or local agency responsible for
investigating, prosecuting, enforcing, or implementing a statute, rule,
regulation, or order, where OPM becomes aware of an indication of a
violation or potential violation of civil or criminal law or
regulation.
c. For Congressional Inquiry--To provide information to a
Congressional office from the record of an individual in response to an
inquiry from that Congressional office made at the request of that
individual.
d. For Judicial/Administrative Proceedings--To disclose information
to another Federal agency, to a court, or a party in litigation before
a court or in an administrative proceeding being conducted by a Federal
agency, when the Government is a party to the judicial or
administrative proceeding. In those cases where the Government is not a
party to the processing, records may be disclosed if a subpoena has
been signed by a judge.
e. For the National Archives and Records Administration or the
General Services Administration--To disclose information to the
National Archives and Records Administration (NARA) or General Services
Administration for use in records management inspections conducted
pursuant to 44 U.S.C. 2904 and 2906.
f. For Litigation--To disclose to the Department of Justice or in a
proceeding before a court, adjudicative body, or other administrative
body before which OPM is authorized to appear, when--
(1) OPM, or any component thereof; or
(2) Any employee of OPM in his or her official capacity; or
(3) Any employee of OPM in his or her individual capacity where the
Department of Justice or OPM has agreed to represent the employee; or
(4) The United States, when OPM determines that litigation is
likely to affect OPM or any of its components--
is a party to litigation or has an interest in such litigation, and
the use of such records by the Department of Justice or OPM is deemed
by OPM to be relevant and necessary to the litigation, provided,
however, that the disclosure is compatible with the purpose for which
records were collected.
g. For Non-Federal Personnel--To disclose information to
contractors, grantees, or volunteers performing or working on a
contract, service, grant, cooperative agreement, or job for the Federal
Government, where the disclosure is compatible with the purpose for
which records are collected.
h. In the Event of a Data Breach--In the event of a data breach,
records may be disclosed to appropriate Federal agencies and agency
contractors that have a need to know the information for the purpose of
assisting the agency's efforts to respond to a suspected or confirmed
breach of the security or confidentiality of information maintained in
this system of records, and the information disclosed is relevant and
necessary for that assistance.
[[Page 65013]]
i. To researchers inside and outside the Federal Government,
approved in advance by OPM on the basis of demonstrated aptitude and a
written research plan, for the purpose of conducting analysis of health
care and health insurance trends and topical health-related issues
compatible with the purposes for which the records were collected and
formulating health care program changes and enhancements to limit cost
growth, improve outcomes, increase accountability, and improve
efficiency in program administration. In all cases, researchers
external to OPM will access a public use file that will be maintained
for such purposes; will contain only de-identified data; and will be
structured, where appropriate, to protect MSP enrollee confidentiality
where identities may be discerned because there are fewer records under
certain demographic or other variables. In all disclosures to analysts
under this routine use, only de-identified data will be disclosed.
j. If OPM determines that jurisdiction over an MSP enrollee's
inquiry or complaint lies with another Federal or State agency,
information in this system of records may be disclosed to other
agencies, such as a State insurance department, a State Consumer
Assistance Program, or the U.S. Department of Health and Human
Services.
POLICIES AND PRACTICES OF STORING, RETRIEVING, SAFEGUARDING, RETAINING,
AND DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:
Paper records will be maintained in locked file cabinets within OPM
and/or any contractors. Any electronic records will be maintained in
electronic systems.
RETRIEVABILITY:
Records will primarily be manipulated, managed and summarized using
a unique number assigned to each external review or case about an
inquiry or complaint. However, information may also be accessible by
other identifying information, including name, date of birth, or Social
Security Number.
SAFEGUARDS:
OPM will maintain records within its secure headquarters in
Washington, DC. Electronic records will be maintained on password-
protected computers and systems. Computer firewalls will be maintained
to prevent access by unauthorized personnel. Any paper records will be
delivered to a locked P.O. Box and kept in locked file cabinets.
Federal employees and employees of Federal contractors are required
to have been the subject of a favorable adjudication following an
appropriate background investigation before they are allowed physical
access to OPM and access to any records. OPM's environment is equipped
with electronic badge readers restricting access to authorized
personnel only and has safeguards in place to alert security personnel
if unauthorized personnel attempt to gain access to OPM's environment.
OPM employs armed physical security guards 365 days a year, 24 hours a
day, who patrol OPM headquarters, including entry and exit points.
Closed Circuit Video cameras are strategically located on every floor
and external to the facility.
The system will employ National Institute of Standards and
Technology (NIST) Security Controls identified in the most recent
version of Special Publication SP 800-53. NIST 800-53 security controls
are the management, operational, and technical safeguards or
countermeasures employed within an organizational information system to
protect the confidentiality, integrity, and availability of the system
and its information. OPM will perform a Security Assessment and
Authorization (SA&A) following the NIST 800-53 standard in order to
obtain an Authority to Operate (ATO). The system will employ role-based
access controls to further restrict access to data, based on the
functions that users are authorized to perform. The system will be
fully compliant with all applicable provisions of the Privacy Act,
Health Insurance Portability and Accountability Act (HIPAA), Federal
Information Security Management Act (FISMA), Federal Records Act,
Office of Management and Budget (OMB) guidance, and NIST guidance.
RETENTION AND DISPOSAL:
The records in this system will be retained for at least 6 years.
Records may be retained for a longer period for the system purposes
established in this system of records notice, or for other purposes as
required under law (e.g., for purposes of litigation). A records
retention schedule will be established with NARA, and no records will
be destroyed until that schedule has been established. Once that
schedule is established, it will set forth methods for disposing
records that would no longer be eligible for retention.
SYSTEM MANAGERS AND ADDRESSES:
The system manager is Edward M. DeHarde, U.S. Office of Personnel
Management, Healthcare and Insurance, 1900 E Street NW., Room 2347,
Washington, DC 20415.
NOTIFICATION AND RECORD ACCESS PROCEDURE:
Individuals wishing to determine whether this system of records
contains information about them may do so by writing to the U.S. Office
of Personnel Management, FOIA/PA Requester Service Center, 1900 E
Street NW., Room 5415, Washington, DC 20415-7900 or by emailing
foia@opm.gov.
Individuals must furnish the following information for their
records to be located:
1. Full name.
2. Date and place of birth.
3. Social Security Number.
4. Signature.
5. Available information regarding the type of information
requested, including the name of the MSP issuer involved in any
external review and the approximate date of the request for external
review.
6. The reason why the individual believes this system contains
information about him/her.
7. The address to which the information should be sent.
Individuals requesting access must also comply with OPM's Privacy
Act regulations regarding verification of identity and access to
records (5 CFR part 297). In addition, the requester must provide a
notarized statement or an unsworn declaration made in accordance with
28 U.S.C. 1746, in the following format:
If executed outside the United States: ``I declare (or
certify, verify, or state) under penalty of perjury under the laws of
the United States of America that the foregoing is true and correct.
Executed on [date]. [Signature].''
If executed within the United States, its territories,
possessions, or commonwealths: ``I declare (or certify, verify, or
state) under penalty of perjury that the foregoing is true and correct.
Executed on [date]. [Signature].''
CONTESTING RECORD PROCEDURE:
Individuals wishing to request amendment of records about them
should write to the U.S. Office of Personnel Management, FOIA/PA
Requester Service Center, 1900 E Street NW., Room 5415, Washington, DC
20415-7900. ATTN: Healthcare and Insurance, National Healthcare
Operations.
Individuals must furnish the following information in writing for
their records to be located:
1. Full name.
2. Date and place of birth.
3. Social Security Number.
4. Signature.
[[Page 65014]]
5. Available information regarding the type of information that the
individual seeks to have amended, including the name of the MSP issuer
involved in any external review and the approximate date of the request
for external review.
Individuals requesting access must also comply with OPM's Privacy
Act regulations regarding verification of identity and access to
records (5 CFR part 297). In addition, the requester must provide a
notarized statement or an unsworn declaration made in accordance with
28 U.S.C. 1746, in the following format:
If executed outside the United States: ``I declare (or
certify, verify, or state) under penalty of perjury under the laws of
the United States of America that the foregoing is true and correct.
Executed on [date]. [Signature].''
If executed within the United States, its territories,
possessions, or commonwealths: ``I declare (or certify, verify, or
state) under penalty of perjury that the foregoing is true and correct.
Executed on [date]. [Signature].''
RECORD SOURCE CATEGORIES:
Information in this system of records is obtained from:
a. MSP enrollees who request external review, or who contact OPM
about an inquiry or complaint.
b. Authorized representatives of MSP enrollees.
c. Health care providers.
d. MSP issuers.
e. Medical professionals providing expert medical review under
contract with OPM.
SYSTEM EXEMPTIONS:
None.
[FR Doc. 2013-25725 Filed 10-29-13; 8:45 am]
BILLING CODE 6325-38-P