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SORN 09-90-0275

System Name: "Pre-Existing Condition Insurance Plan (PCIP)," OCIIO, OS/HHS.

Security Classification: None.

System Location: Office of Consumer Information and Insurance Oversight, U.S. Department of Health & Human Services, 200 Independence Avenue, SW., Suite 738F, Washington, DC 20201.

Categories of Individuals Covered by the System: Information in this system is maintained on individuals who apply to enroll in the Pre-Existing Condition Insurance Plan.

Categories of Records in the System: Information in this system is maintained on individuals who enroll in the Pre-Existing Condition Insurance Plan. Information maintained in this system includes, but is not limited to, the applicant's first name, last name, middle initial, mailing address or permanent residential address (if different than the mailing address), date of birth, Social Security Number (if the applicant has one), gender, email address, telephone number. The system will also maintain information to make a decision about an applicant's eligibility. We collect and maintain information that the applicant submits pertaining to (1) his or her citizenship or immigration status, since only individuals who are citizens or nationals of the U.S. or lawfully present are eligible to enroll; (2) coverage an individual had during the prior twelve months from the date of application in order to establish that such individual has been without creditable coverage for at least six months are eligible to enroll and to assess whether insurers are discouraging an individual from remaining enrolled in prior coverage due to health status; and (3) an insurance company's denial of coverage, offer of coverage with a medical condition exclusion rider, or, for an applicant is guaranteed an offer of coverage, coverage that is medically underwritten. Information will also be maintained with respect to the applicant's premium amount and payment history.

Authority for Maintenance of the System: Authority for the collection, maintenance, and disclosures from this system is given under provisions of Section 1101 of the Patient Protection and Affordable Care Act (Pub. L. 111-148).

Purpose(s) of the System: The purpose of this system of records is to collect and maintain information on individuals who apply for enrollment in the program. This information will enable HHS acting through NFC, OPM, and any third-party administrator(s) to determine applicants' eligibility, enroll eligible individuals into the program, adjudicate appeals of eligibility and coverage determinations, bill and collect premium payments, and process and pay claims for covered health care items and services furnished to eligible individuals.

Information maintained in this system will also be disclosed to: (1) Support regulatory, reimbursement, and policy functions performed by an HHS 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) support litigation involving the Department; (4) combat fraud and abuse in certain health benefits programs; and (5) assist efforts to respond to a suspected or confirmed breach of the security or confidentiality of information maintained in this system of records.

Routine Uses of Records Maintained in the System, Including Categories or Users and the Purposes of Such Uses: 

B. Entities Who May Receive Disclosures Under Routine Use These routine uses specify circumstances, in addition to those provided by statute in the Privacy Act of 1974, under which HHS may release information from the PCIP without the consent of the individual to whom such information pertains. Each proposed disclosure of information under these routine uses will be evaluated to ensure that the disclosure is legally permissible, including but not limited to ensuring that the purpose of the disclosure is compatible with the purpose for which the information was collected. We propose to establish the following routine use disclosures of information maintained in the system:

1. To support HHS contractors, consultants, or HHS grantees who have been engaged by HHS to assist in accomplishment of an HHS function relating to the purposes for this SOR and who need to have access to the records in order to assist HHS.

2. To assist another Federal or state agency, agency of a state government, an agency established by state law, or its fiscal agent pursuant to agreements with HHS to determine applicants' eligibility for the Pre-existing Condition Insurance Plan, enroll eligible individuals into the plan, adjudicate appeals of eligibility and coverage determinations, bill and collect premium payments, and process and pay claims for covered health care items and services furnished to eligible individuals.

3. To support the Department of Justice (DOJ), court, or adjudicatory body when:

e. The Department or any component thereof, or
f. Any employee of HHS in his or her official capacity, or
g. Any employee of HHS in his or her individual capacity where the DOJ has agreed to represent the employee, or
h. The United States Government, is a party to litigation or has an interest in such litigation, and by careful review, HHS 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.

4. To assist an HHS contractor that assists in the administration of an HHS-administered health benefits program, or to a grantee of an HHS-administered grant program, when disclosure is deemed reasonably necessary by HHS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud, waste or abuse in such program.

5. 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, waste or abuse in a health benefits program funded in whole or in part by Federal funds, when disclosure is deemed reasonably necessary by HHS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud, waste or abuse in such programs.

6. To assist appropriate Federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department'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 unnecessary for the assistance.
C. Additional Circumstances Affecting Routine Use Disclosures 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: We will be storing records in hardcopy files and various electronic storage media (including DB2, Oracle, and other relational data structures).

Retrievability: Information is most frequently retrieved by first name, last name, middle initial, date of birth, or Social Security Number (SSN).

Safeguards: HHS 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 and HHS policies and standards as they relate to information security and data privacy. These laws and regulations include 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 E-Government Act of 2002, and the Clinger-Cohen Act of 1996; OMB Circular A-130, Management of Federal Resources, Appendix III, Security of Federal Automated Information Resources also applies. Federal and HHS policies and standards include but are not limited to: all pertinent National Institute of Standards and Technology publications; and the HHS Information Systems Program Handbook.

Retention and Disposal: Records are maintained with identifiers for all transactions after they are entered into the system for a period of 10 years. Records are housed in both active and archival files in accordance with HHS data and document management policies and standards.

System Manager and Address: Anthony Culotta, High Risk Pool Program Division, Office of Insurance Programs, Office of Consumer Information and Insurance Oversight, U.S. Department of Health & Human Services, 200 Independence Avenue, SW., Suite 738F, Washington, DC 20201.

Notification Procedure: For purpose of notification, the subject individual should write to the system manager who will require the system name, and the retrieval selection criteria (e.g., name, SSN, etc.).

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).

Record Source Categories: Record source categories include applicants who voluntarily submit data and personal information for the PCIP program.

Systems Exempted From Certain Provisions of the Act: None.