Health Plan Management System
Date signed: 4/27/2022
OPDIV: | CMS |
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PIA Unique Identifier: | P-9317971-241429 |
Name: | Health Plan Management System |
The subject of this PIA is which of the following? | Major Application |
Identify the Enterprise Performance Lifecycle Phase of the system. | Operate |
Is this a FISMA-Reportable system? | Yes |
Does the system include a Website or online application available to and for the use of the general public? | No |
Identify the operator: | Contractor |
Is this a new or existing system? | Existing |
Does the system have Security Authorization (SA)? | Yes |
Date of Security Authorization | 8/1/2022 |
Indicate the following reason(s) for updating this PIA. Choose from the following options. | PIA Validation (PIA Refresh/Annual Review) |
Describe in further detail any changes to the system that have occurred since the last PIA. | December, 2021: HPMS will be collecting PII in the Fraud, Waste and Abuse (FWR) Reporting Module: HPMS displays personally identifiable information for Medicare beneficiaries and providers in the FWA Reporting module. Specifically, HPMS collects the beneficiary’s name, MBI, phone number, address, and email address as well as the provider’s NPI, tax ID, and medical license number. CMS uses these data to investigate suspected FWA activity in the Medicare Advantage (MA) and Prescription Drug programs. June 2023 - Drug Price Negotiation: HPMS collects the email address and name of participants submitting data for the voluntary Drug Price Negotiation survey. The email address is used to limit the number of survey submissions to one per email. It is not used in the data analysis. |
Describe the purpose of the system | The Health Plan Management System (HPMS) is an internet accessible web application that serves as the primary plan-based information system supporting the Medicare Advantage (MA) and Prescription Drug Plan (PDP) programs. HPMS is defined as a major application and is maintained for CMS by three contractor groups: Softrams, CGI Federal, and the OIT Cloud Navigator. HPMS is comprised of two web sites: the primary HPMS data collection/display site and a dashboard site that provides management level summation of the data contained with HPMS. HPMS is a day-to-day operational system that addresses the input, data processing, and output needs of the CMS and external user communities. HPMS provides CMS with the means to collect, manage, and disseminate critical MA and PDP data. The primary data sources for benefits, co-payment, and beneficiary education information are the:
Other key data sources include:
These source data provide the basic information upon which a majority of the HPMS modules act and operate. HPMS also provides data extracts for a variety of CMS and other Federal government systems. |
Describe the type of information the system will collect, maintain (store), or share. (Subsequent questions will identify if this information is PII and ask about the specific data elements) | HPMS is a day-to-day operational system that addresses the input, data processing, and output needs of the CMS and external user communities. HPMS provides CMS with the means to collect, manage, and disseminate critical MA and PDP data. The primary data sources for benefits, co-payment, and beneficiary education information are the: Plan Benefit Package (PBP); Summary of Benefits (SB) sentences; and, Bid Pricing Tool (BPT). Other key data sources include: Contract and service area data; Formulary Data; Marketing Data; MA and PDP complaint data; MA county demographics data; and, Financial Data. Additionally, HPMS collects data that may contain PII and/or PHI for:
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Provide an overview of the system and describe the information it will collect, maintain (store), or share, either permanently or temporarily. | HPMS is a web-enabled information system that supports the ongoing business operations of the Medicare Advantage (MA) and Prescription Drug (Part D) programs. All of the data collected in the HPMS application is used to manage the following MA and Part D plan enrollment and compliance processes: application submission, formulary submission, bid and benefit package submissions, marketing material reviews, plan monitoring and oversight, complaints tracking, plan connectivity, financial reporting, financial and plan bid audits, plan surveys, operational data feeds for enrollment, payment, and premium withhold, and data support for the Medicare & You handbook and the www.medicare.gov website. User Account Maintenance: HPMS collects personally identifiable information from its registered users in the User Account Maintenance module. Specifically, HPMS collects the first name, middle initial (optional), last name, e-mail address, organization name, address, city, state, zip code, phone number, and fax number (optional) from each registered user of the system. CMS uses these data to communicate with the users. HPMS collects personally identifiable information on Medicare beneficiaries in the: Part C Improper Payment Measure module. Specifically, HPMS collects the beneficiary’s first name, last name, MBI, date of birth, and medical record information. CMS uses these data to estimate the error rate for Part C payment. Medication Therapy Management Program (MTMP): HPMS collects beneficiary-level MTMP data annually via CMS Enterprise File Transfer (EFT). Specifically, HPMS collects the beneficiary’s first name, last name, Medicare Beneficiary Identifier (MBI), and date of birth. CMS uses these data to evaluate and monitor MTMPs administered by Part D organizations. Performance Metrics Module: HPMS displays the beneficiary-level MTMP data submitted by Part D plans via CMS EFT, as described above, in the MTMP Gentran Submissions section of the Performance Metrics module. Audit Module: HPMS collects universe files in the Audit module, which may contain beneficiary-level data. These data are used by CMS to administer program audits.
Part D Improper Payment Measure Module: HPMS collects personally identifiable information on Medicare beneficiaries in the Part D IPM module. Specifically, HPMS collects the beneficiary’s first name, last name, MBI, and prescription drug information. CMS uses these data to estimate the error rate for Part D payment.
Fraud, Waste and Abuse Tracking Module (FWA): HPMS displays personally identifiable information for Medicare providers in the FWA Tracking module. Specifically, HPMS displays the provider’s National Provider Identifier (NPI) number, first name, last name, practice address, city, state, and zip code, tax ID, and medical license number. CMS uses these data to investigate suspected FWA activity in the Medicare Advantage (MA) and Prescription Drug programs.
Compliance Activity Module (CAM): HPMS collects information from plans in response to CMS inquiries related to compliance review activities. These submissions may contain beneficiary-level data. CMS uses this data to perform oversight activities.
Online Enrollment Center (OEC): HPMS contains personally identifiable information for Medicare beneficiaries in the Online Enrollment Center (OEC) Management module. Specifically, HPMS allows designated plan users to download OEC enrollment requests, including, but not limited to, the beneficiary’s first and last name, birth date, address, phone number, email address, MBI, Medicare Part A and B statuses, and primary care physician. MA and Part D organizations use these data to process beneficiary requests to enroll in the selected plan.
Drug Price Negotiation - HPMS collects email address, name and organization from voluntary survey participants. The survey is used to collect information from the public about the drugs selected for the new Part D drug price negotiation program. We collect the email in order to limit the number of survey submissions to one per email. The email and corresponding name are not relevant to the analysis of the information.
Fraud, Waste, and Abuse Reporting - HPMS displays personally identifiable information for Medicare beneficiaries and providers in the FWA Reporting module. Specifically, HPMS collects the beneficiary’s name, MBI, phone number, address, and email address as well as the provider’s NPI, tax ID, and medical license number. CMS uses these data to investigate suspected FWA activity in the Medicare Advantage (MA) and Prescription Drug programs.
HPMS also contains the HICN in legacy data in these modules: CTM, Part C IPM, Part D IPM, MTMP and OEC. The MBI may be used to access records - via a search capability - in the CTM module. HPMS data is stored permanently or for a minimum of ten years as required by the HPMS SORN. |
Does the system collect, maintain, use or share PII? | Yes |
Indicate the type of PII that the system will collect or maintain. |
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Indicate the categories of individuals about whom PII is collected, maintained or shared. |
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How many individuals' PII in the system? | 1,000,000 or more |
For what primary purpose is the PII used? | The majority of PII collected in HPMS is used to support Medicare Advantage (MA) and Part D complaints and perform casework activities. HPMS collects personally identifiable information on Medicare beneficiaries enrolled in Medication Therapy Management Programs (MTMP) offered by Part D plans. This data is submitted to HPMS via CMS’ Electronic File Transfer (EFT) system, and the resulting data is shared with Part D plans and other approved users via the MTMP Gentran Submissions Module in HPMS. These data are collected under the Part D Reporting Requirements Paperwork Reduction Act (PRA) for program evaluation. HPMS collects personally identifiable information on Medicare beneficiaries in our Audit module. This data is included in sample records provided by the MA or Part D organization undergoing the routine audit. CMS uses these data to run analyses to determine whether the organization is meeting program requirements. HPMS collects personally identifiable information on Medicare beneficiaries in our Risk Adjustment Validation module including beneficiary name, beneficiary DOB, beneficiary identifier and beneficiary medical records. The data is used to calculate the national payment error rate. HPMS collects personally identifiable information on Medicare beneficiaries in our Prescription Drug Event Validation module including beneficiary name, beneficiary identifier and prescription drug records. The data is used to calculate the part D payment error rate. HPMS displays personally identifiable information for Medicare providers in the FWA Tracking module. Specifically, HPMS displays the provider’s NPI number, first name, last name, practice address, city, state, and zip code, tax ID, and medical license number. CMS uses these data to investigate suspected FWA activity in the Medicare Advantage (MA) and Prescription Drug programs. HPMS collects the email address and name of participants submitting data for the voluntary Drug Price Negotiation survey. The email address is used to limit the number of survey submissions to one per email. It is not used in the data analysis. HPMS displays personally identifiable information for Medicare beneficiaries and providers in the FWA Reporting module. Specifically, HPMS collects the beneficiary’s name, MBI, phone number, address, and email address as well as the provider’s NPI, tax ID, and medical license number. CMS uses these data to investigate suspected FWA activity in the Medicare Advantage (MA) and Prescription Drug programs. HPMS maintains information on the all the HPMS users, both internal and external in order to provide the appropriate access for every user within the application. The password is NOT stored in the HPMS application. The CMS Enterprise User Administration (EUA) application is the system of record for issuing, maintaining and authenticating the user credentials. (EUA is covered under a separate PIA for CMS) |
Describe the secondary uses for which the PII will be used (e.g. testing, training or research) | This data is also shared with other federal agencies (e.g., Office of the Inspector General (OIG) for research purposes. |
Describe the function of the SSN. | Not applicable |
Cite the legal authority to use the SSN. | Not applicable
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Identify legal authorities governing information use and disclosure specific to the system and program. | Authority for maintenance of the system is given under section 1875 of the Social Security Act (the Act) (42 U.S.C. 1395ll), entitled Studies and Recommendations; section 1121 of the Act (42 U.S.C. 1121), entitled Uniform Reporting System for Health Services Facilities and Organizations; and § 1876 of the Act (42 U.S.C. 1395mm), entitled Payments to Health Maintenance Organizations and Competitive Medical Plans. Authority for maintenance and dissemination of Health Plan information is also given under the Balanced Budget Act of 1997 (Pub. L. 105–33). 42 CFR 422.503 42 CFR 422.504 42 CFR 423.504 42 CFR 423.505 42 CFR 423.153 42 CFR 425.118 42 CFR 425.204 The Improper Payments Elimination and Recovery Act of 2012; Public Law 112-248 and 42 CFR § 422.310
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Are records on the system retrieved by one or more PII data elements? | Yes |
Identify the number and title of the Privacy Act System of Records (SORN) that is being used to cover the system or identify if a SORN is being developed. | 09-70-0500 - Health Plan Management System |
Identify the sources of PII in the system: Directly from an individual about whom the information pertains |
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Identify the sources of PII in the system: Government Sources |
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Identify the sources of PII in the system: Non-Government Sources |
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Identify the OMB information collection approval number and expiration date | 0938-0763 (PBP/Formulary/MTMP) – 3/31/2026 0938-1000 (Audit) - 5/31/2024 0938-1327 (PACE Audit) - 11/30/2025 OMB 0938-1449 (Drug Price Negotiation) - 8/31/2024 OMB 0938-1262 (Fraud, Waste, and Abuse Reporting) -
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Is the PII shared with other organizations? | Yes |
Identify with whom the PII is shared or disclosed and for what purpose. |
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Describe any agreements in place that authorizes the information sharing or disclosure (e.g. Computer Matching Agreement, Memorandum of Understanding (MOU), or Information Sharing Agreement (ISA)). | The Complaint Tracking Module business owner has a Memorandums of Understanding (MOU) in place with States (SHIPs) to support information sharing on complaint data. HPMS has a DUA agreement for each HPMS Development Contractor.
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Describe the procedures for accounting for disclosures | HPMS is a web based application and all access to HPMS data is obtained via the user interface. HPMS does not mail/distribute information outside of CMS by any other means. All HPMS users must request access to the system using the standard CMS user ID request form. Moreover, due to the sensitive nature of the complaint, audit, performance metrics, and beneficiary-level MTMP data, each user must separately request access to those functions in the system. End user utilization is tracked in the system and samples are reviewed quarterly. Additionally, there are Data Use Agreements in place with our development contractors which track what data is being disclosed, with whom, when and for what purpose. HPMS contains PII policy information in the Website Policy section of the application - accessible to all users. |
Describe the process in place to notify individuals that their personal information will be collected. If no prior notice is given, explain the reason. | HPMS provides its users with a privacy policy page that explains how we will use their account information. In regard to the MTMP, CTM, National RADV, Prescription Drug Event Validation, CAM, OEC, Performance Metrics and Audit modules these are records obtained through routine program administration activities in support of the Medicare Parts C and D and Medicare Shared Savings programs. Beneficiaries are asked to provide their PII information as part of the complaint submission process controlled by 1-800-Medicare. EUA is the system of record for issuing the CMS User ID. HPMS is a consumer of that information. |
Is the submission of the PII by individuals voluntary or mandatory? | Voluntary |
Describe the method for individuals to opt-out of the collection or use of their PII. If there is no option to object to the information collection, provide a reason. | There is no formal 'opt out' policy. Submission of a complaint is a voluntary action on the part of an individual as is requesting access to HPMS. The user's credentials are issued via the EUA system and not under the purview of HPMS. |
Describe the process to notify and obtain consent from the individuals whose PII is in the system when major changes occur to the system (e.g., disclosure and/or data uses have changes since the notice at the time of original collection). Alternatively, describe why they cannot be notified or have their consent obtained. | All major system changes concerning PII are published for comment in the Federal Register as part of a modification of the HPMS System of Record (SOR). The user's credentials are issued via the EUA system and not under the purview of HPMS. |
Describe the process in place to resolve an individual's concerns when they believe their PII has been inappropriately obtained, used, or disclosed, or that the PII is inaccurate. If no process exists, explain why not. | Medicare beneficiaries would need to report these concerns to 1-800-Medicare. HPMS users would report any PII concerns to the HPMS Help Desk. The individual should be able to identify the information/record in question and identify the desired remediation action. The user's credentials are issued via the EUA system and not under the purview of HPMS. |
Describe the process in place for periodic reviews of PII contained in the system to ensure the data's integrity, availability, accuracy and relevancy. If no processes are in place, explain why not. | HPMS maintains data integrity by designing the application per Federal security standards and by ensuring adherence to those standards via an annual independent security audit. All PII is encrypted at rest in the database or on the file servers, e.g. pdf uploads. Application data is backed up per approved agency schedules to guarantee recoverability in the event of a data loss/corruption. Application availability is maintained via a combination of built in redundancies, for example, server clustering and disaster recovery site, and relies on approved agency web hosting contractor sites/staff. PII data is reviewed for accuracy via a variety of module specific activities including: Complaint records are reviewed and analyzed individually by trained caseworkers as part of the complaint casework and resolution process. MTMP records are audited by trained plan data validation review consultants as part of the plan reporting business process. Audit submissions are reviewed by designated audit staff as part of the routine audit business process. HPMS users can access and update their account information at any time. HPMS collects only relevant PII necessary to implement application functionality. The job codes assigned via EUA to the user's credentials are periodically reviewed to ensure the user has the HPMS-Production job code. User are required to accept the HPMS Rules of Behavior annually to maintain their access and must recertify their user credentials per EUA controls. |
Identify who will have access to the PII in the system and the reason why they require access. |
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Describe the procedures in place to determine which system users (administrators, developers, contractors, etc.) may access PII. | Access for the modules that contain PHI/PII are classified using sensitive access types in HPMS. Designated CMS user access administrators only grant access to those developers and contractors whose work requires such data. System and database administrators are restricted to the encrypted data only. Uploaded files that contain PHI/PII are encrypted at rest and can only be viewed via the website. |
Describe the methods in place to allow those with access to PII to only access the minimum amount of information necessary to perform their job. | Access for the modules that contain PHI/PII are classified using sensitive access types in HPMS. Additionally, restrictions are in place so that a given user, e.g. a plan, can only see records/data applicable to their beneficiaries in the CTM module. |
Identifying training and awareness provided to personnel (system owners, managers, operators, contractors and/or program managers) using the system to make them aware of their responsibilities for protecting the information being collected and maintained. | We have defined security roles as well as a security awareness training plan, as mandated by FISMA. Additionally, all HPMS users are required to recertify their access annually and take a computer based security course. Users annually review and accept the HPMS rules of behavior, which outline a user's responsibilities for accessing PII including adherence to the Privacy Act of 1974. |
Describe training system users receive (above and beyond general security and privacy awareness training) | End users working with HPMS complaint data must attend routine caseworker trainings and meetings as well as abide by standard operating procedures. Plan data validation reviewers must also take required training prior to accessing HPMS and the related plan reporting data. Audit reviewers are provided training and must adhere to standard operating procedures. |
Do contracts include Federal Acquisition Regulation and other appropriate clauses ensuring adherence to privacy provisions and practices? | Yes |
Describe the process and guidelines in place with regard to the retention and destruction of PII. Cite specific records retention schedules. | CMS will retain HPMS data for a minimum of 10 years. The following disposition schedules apply:
The destruction of PII will conducted in accordance with all CMS policies in place at the time of the data removal. |
Describe, briefly but with specificity, how the PII will be secured in the system using administrative, technical, and physical controls. | The system encrypts all PII/PHI at rest in the database or on the file server, e.g. PDF upload using Advanced Encryption Standard (AES) encryption (symmetric encryption - one single key for both encrypting/decrypting files on the server.) Other methods for securing these data include, but are not limited to: All traffic is encrypted using Transport Layer Security (TLS); Users must obtain CMS user IDs and passwords and are granted access to only those HPMS modules and contract numbers required by their job functions; Contractor staff undergo background investigations and security checks; Contractor staff undergo security awareness training; and Use of a multi-zone security architecture, operating system integrity and hardening, monitoring and maintenance of all hardware components, administration of firewalls, host and network based intrusion detection services. Additionally, HPMS is hosted at a CMS approved data center that adheres to all CMS required physical security controls, using security guards and locked cages. The web hosting contractor is required to undergo an annual independent security audit to ensure adherence to those controls. |