Current through all regulations passed and filed through September 16, 2024
(A)
Definitions.
For the purposes of rules promulgated
by this agency in accordance with section
1347.15 of the Revised Code
effective April 9, 2009, the following definitions apply:
(1)
"Access" as a
noun means an instance of copying, viewing, or otherwise perceiving; whereas,
"access" as a verb means to copy, view, or otherwise perceive.
(2)
"Acquisition of a
new computer system" means the purchase of a "computer system," as defined in
this rule, that is not a computer system currently in place nor one for which
the acquisition process has been initiated as of April 7, 2009.
(3)
"Confidential
personal information" (CPI) has the meaning as defined by division (A)(1) of
section 1347.15 of the Revised Code. The
appendix to this rule identifies, in accordance with division (B)(3) of section
1347.15 of the Revised Code, the
federal statutes and regulations and state statutes and administrative rules
that make personal information maintained by the agency
confidential.
(4)
"Employee of the state agency" means each employee of a
state agency regardless of whether he or she holds an elected or appointed
office or position within the state agency. "Employee of the state agency" is
limited to the specific employing state agency.
(5)
"Incidental
contact" means contact with the information that is secondary or tangential to
the primary purpose of the activity that resulted in the
contact.
(6)
"Individual" means a natural person and in the context
used in division (C)(1)(b) of section
1347.15 of the Revised Code, and
paragraph (E)(4)(b)(iv) of this rule, means the subject of the confidential
personal information or the subject of the confidential personal information's
authorized representative, legal counsel, legal custodian or legal guardian,
and anyone as otherwise permitted under state or federal law acting on behalf
of, or in furtherance of, the interests of the subject of the confidential
personal information. "Individual" does not include an opposing party in
litigation, or the opposing party's legal counsel, or an investigator, auditor
or any other party who is not acting on behalf of, or in furtherance of the
interests of, the subject of the confidential personal information, even if
such individual has obtained a signed release from the subject of the
confidential personal information.
(7)
"Information
owner" means the individual appointed in accordance with division (A) of
section 1347.05 of the Revised Code to
be directly responsible for a system.
(8)
"Interconnection
of Systems" Refers to a linking of systems that belong to more than one agency,
or to an agency, and other organization, which linking of systems results in a
system that permits each agency or organization involved in the linking to have
unrestricted access to the systems of the other agencies and
organizations.
(9)
"Person" means a natural person.
(10)
"Personal
information" has the same meaning as defined in division (E) of section
1347.01 of the Revised
Code.
(11)
"Personal information system" means a "system" that
"maintains" "personal information" as those terms are defined in section
1347.01 of the Revised Code.
"System" includes manual and computer systems.
(12)
"Research" means
a methodical investigation into a subject.
(13)
"Routine" means
commonplace, regular, habitual, or ordinary.
(14)
"Routine
information that is maintained for the purpose of internal office
administration, the use of which would not adversely affect a person" as that
phrase is used in division (F) of section
1347.01 of the Revised Code
means personal information relating to employees and maintained by the agency
for internal administrative and human resource purposes.
(15)
"System or
Information System" As defined in section
1347.01 of the Revised Code,
"system" means any collection or group of related records that are kept in an
organized manner and that are maintained by a state or local agency, and from
which personal information is retrieved using the person's name or by an
identifying number, symbol, or other identifier assigned to the person.
"System" includes both records that are manually stored and records that are
stored using electronic data processing equipment.
(16)
"Upgrade" means
a substantial redesign of an existing computer system for the purpose of
providing a substantial amount of new application functionality, or application
modifications that would involve substantial administrative or fiscal resources
to implement, but would not include maintenance, minor updates and patches, or
modifications that entail a limited addition of functionality due to changes in
business or legal requirements.
(B)
Procedures for
accessing confidential personal information.
(1)
Criteria for
accessing confidential personal information.
Personal information systems of the
Ohio department of medicaid (ODM) are managed on a "need-to-know" basis whereby
the information owner determines the level of access required for an employee
of the agency to fulfill his or her job duties. The determination of access to
confidential personal information shall be approved by the employee's
supervisor, the information's owner, designee operating under guidlines
approved by the information's owner before providing the employee with access
to confidential personal information within a personal information system. The
agency shall establish procedures for determining a revision to an employee's
access to confidential personal information upon a change to that employee's
job duties including, but not limited to, transfer or termination. Whenever an
employee's job duties no longer require access to confidential personal
information in a personal information system, the employee's access to
confidential personal information shall be removed.
(2)
Individual's
request for a list of confidential personal information.
Based upon a request of any individual
for a list of confidential personal information about the individual maintained
by ODM, or its predecessor ODJFS, ODM shall do the following:
(a)
Verify the
identity of the individual by a method that provides safeguards commensurate
with the risk associated with the confidential personal
information.
(b)
Provide to the individual the confidential personal
information that does not relate to an investigation about the individual or is
otherwise not excluded from being released under Chapter 1347. of the Revised
Code, or other federal/state laws or regulations.
(c)
If all
information relates to an investigation about that individual, inform the
individual that the agency has no confidential personal information about the
individual that is responsive to the individual's request.
(d)
Notifications
made under this section shall be made in compliance with all applicable state
and federal regulations.
(3)
Notice of invalid
access.
(a)
Upon discovery or notification that confidential personal
information of a person has been accessed by an employee for an invalid reason,
the agency shall notify the person whose information was invalidly accessed as
soon as practical and to the extent known at the time. However, the agency
shall delay notification for a period of time necessary to ensure that the
notification would not delay or impede an investigation or jeopardize homeland
or national security. Additionally, the agency may delay the notification
consistent with any measures necessary to determine the scope of the invalid
access, including which individuals' confidential personal information was
invalidly accessed, and to restore the reasonable integrity of the system.
"Investigation" as used in this paragraph means the investigation of the
circumstances and involvement of an employee surrounding the invalid access of
the confidential personal information. Once the agency determines that
notification would not delay or impede an investigation, the agency shall
disclose the access to confidential personal information made for an invalid
reason to the person.
(b)
Notification provided by the agency shall inform the
person of the type of confidential personal information accessed and the date
or dates of the invalid access, if known.
(c)
Notification may
be made by any method reasonably designed to accurately inform the person of
the invalid access, including written, electronic, or telephone
notice.
(d)
Notifications made under this section shall be made in
compliance with all applicable state and federal regulations.
(4)
Appointment of a data privacy point of contact and completion of a risk of harm
assessment.
(a)
The ODM director shall designate an employee of ODM to
serve as the data privacy point of contact under the working title of "ODM
HIPAA privacy official."
(b)
The ODM HIPAA privacy official shall work with the
state of Ohio chief privacy officer and the state of Ohio chief information
security officer within the state of Ohio office of information technology to
assist ODM with both the implementation of privacy protections for the
confidential personal information that ODM maintains and compliance with
section 1347.15 of the Revised Code and
the rules adopted thereunder.
(c)
The ODM HIPAA
privacy official shall ensure the timely completion of the "privacy impact
assessment" developed by the state of Ohio office of information
technology.
(C)
Valid reasons for
accessing confidential personal information.
Pursuant to the requirements of
division (B)(2) of section
1347.15 of the Revised Code,
this rule contains a list of valid reasons, directly related to the ODM
exercise of its powers or duties, for which only employees of the agency may
access confidential personal information regardless of whether the personal
information system is a manual system or computer system.
Except as prohibited by federal and
state law, performing the following functions constitute valid reasons for
authorized employees of the agency to access confidential personal
information:
(1)
Responding to a public records request, which would
require all appropriate redaction of any responsive records as required by
law;
(2)
Responding to a request from an individual for the list
of the confidential personal information the agency maintains on that
individual;
(3)
Administering a constitutional provision or
duty;
(4)
Administering a statutory provision or
duty;
(5)
Administering an administrative rule provision or
duty;
(6)
Complying with any state or federal program
requirements;
(7)
Processing or payment of claims or otherwise
administering a program with individual participants or
beneficiaries;
(8)
Auditing purposes;
(9)
Licensure (or
permit, eligibility, filing, etc.) processes;
(10)
Investigation or
law enforcement purposes;
(11)
Administrative
hearings;
(12)
Litigation, complying with an order of the court, or
subpoena;
(13)
Human resource matters (for example, hiring, promotion,
demotion, discharge, salary/compensation issues, leave requests/issues, time
card approvals/issues);
(14)
Complying with an executive order or
policy;
(15)
Complying with an agency policy or a state
administrative policy issued by the department of administrative services, the
office of budget and management, or other similar state agency;
(16)
Complying with a
collective bargaining agreement provision; or
(17)
Research in the
furtherance of agency specific programs in so far as allowed by
statute.
(D)
Confidentiality statutes and administrative
rules.
The federal statutes and regulations
and state statutes and administrative rules listed in the appendix to this rule
make personal information maintained by the agency confidential and identify
the confidential personal information that are subject to rules promulgated by
this agency in accordance with section
1347.15 of the Revised
Code.
(E)
Restricting and logging access to confidential personal
information systems.
For personal information systems that
are computer systems and contain confidential personal information, ODM shall
do the following:
(1)
Access restrictions.
Access to confidential personal
information that is kept electronically shall require a password or other
sufficient authentication measure as determined by the ODM HIPAA privacy
official in conjunction with the chief information security official will
determine what constitutes sufficient authentitication measures.
(2)
Acquisition of a new computer system.
When the agency acquires a new computer
system that stores, manages, or contains confidential personal information, ODM
shall include a mechanism for recording specific access by employees of ODM to
confidential personal information in the system.
(3)
Upgrading
existing computer systems.
When ODM modifies an existing computer
system that stores, manages, or contains confidential personal information,
that results in over half of the lines of code associated with that system
being modified, then that system must have an automated mechanism for recording
specific access by employees of ODM to any confidential personal information
that is accessed via that system.
(4)
Logging
requirements regarding confidential personal information in existing ODM
computer systems.
(a)
ODM shall require employees who access confidential
personal information within ODM computer systems to maintain a log that records
that access.
(b)
Access to confidential information is not required to
be entered into the log under the following circumstances:
(i)
The ODM employee
is accessing confidential personal information for official agency purposes
including research, and the access is not specifically directed toward a
specifically named individual or a group of specifically named
individuals.
(ii)
The ODM employee is accessing confidential personal
information for routine office procedures and the access is not specifically
directed toward a specifically named individual or a group of specifically
named individuals.
(iii)
The ODM employee comes into incidental contact with
confidential personal information and the access of the information is not
specifically directed toward a specifically named individual or a group of
specifically named individuals.
(iv)
The employee of
the agency accesses confidential personal information about an individual based
upon a request made under either of the following circumstances:
(a)
The individual
requests confidential personal information about himself or herself; or
(b)The
individual makes a request that ODM take some action on that individual's
behalf and accessing the confidential personal information is required in order
to consider or process that request.
(v)
ODM shall use a
consistent electronic means for logging where reasonably possible. If the
logging requirements are already being met through existing means, then no
additional logging is required in those instances.
(5)
Log
management.
Each office within ODM shall use the
log provided by the agency, currently identified as "CPI Log", or its successor
system. Nothing in this rule limits the agency from requiring logging in any
circumstance that it deems necessary.
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