An introductory resource guide for implementing the ... - NIST

1 NIST Special Publication 800-66 Revision 1 An introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Matthew Scholl, Kevin Stine, Joan Hash, Pauline Bowen, Arnold Johnson, Carla Dancy Smith, and Daniel I. Steinberg I N F O R M A T I O N S E C U R I T Y Computer Security Division Information Technology Laboratory National Institute of Standards and Technology Gaithersburg, MD 20899-8930 October 2008 Department of Commerce Carlos M. Gutierrez, Secretary National Institute of Standards and Technology Patrick D. Gallagher, Deputy Director An introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Reports on Information Systems Technology The Information Technology Laboratory (ITL) at the National Institute of Standards and Technology (NIST) promotes the economy and public welfare by providing technical leadership for the nation s measurement and standards infrastructure.

2 ITL develops tests, test methods, reference data, proof of concept implementations, and technical analyses to advance the development and productive use of information technology. ITL s responsibilities include the development of management, administrative, technical, and physical standards and guidelines for the cost-effective security and privacy of other than national security-related information in federal information systems. The Special Publication 800-series reports on ITL s research, guidelines, and outreach efforts in information system security, and its collaborative activities with industry, government, and academic organizations. iiAn introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Authority This document has been developed by the National Institute of Standards and Technology (NIST) to further its statutory responsibilities under the Federal Information Security Management Act (FISMA) of 2002, 107-347.

3 NIST is responsible for developing standards and guidelines, including minimum requirements, for providing adequate information security for all agency operations and assets, but such standards and guidelines shall not apply to national security systems. This guideline is consistent with the requirements of the Office of Management and Budget (OMB) Circular A-130, Section 8b(3), Securing Agency Information Systems, as analyzed in A-130, Appendix IV: Analysis of Key Sections. Supplemental information is provided in A-130, Appendix III. This guideline has been prepared for use by federal agencies. It may also be used by nongovernmental organizations on a voluntary basis and is not subject to copyright. (Attribution would be appreciated by NIST.)

4 Nothing in this document should be taken to contradict standards and guidelines made mandatory and binding on federal agencies by the Secretary of Commerce under statutory authority. Nor should these guidelines be interpreted as altering or superseding the existing authorities of the Secretary of Commerce, Director of the OMB, or any other federal official. There are references in this publication to documents currently under development by NIST in accordance with responsibilities assigned to NIST under the Federal Information Security Management Act of 2002. The methodologies in this document may be used even before the completion of such companion documents. Thus, until such time as each document is completed, current requirements, guidelines, and procedures (where they exist) remain operative.

5 For planning and transition purposes, agencies may wish to closely follow the development of these new documents by NIST. Individuals are also encouraged to review the public draft documents and offer their comments to NIST. All NIST documents mentioned in this publication, other than the ones noted above, are available at Certain commercial entities, equipment, or materials may be identified in this document in order to describe an experimental procedure or concept adequately. Such identification is not intended to imply recommendation or endorsement by the National Institute of Standards and Technology, nor is it intended to imply that the entities, materials, or equipment are necessarily the best available for the purpose.

6 IiiAn introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule ivAcknowledgments The authors wish to thank their colleagues who helped update this document, prepared drafts, and reviewed materials. In addition, special thanks are due to Patricia Toth from NIST, and Lorraine Doo and Michael Phillips from the Centers for Medicare and Medicaid Services (CMS), who greatly contributed to the document s development. The authors also gratefully acknowledge and appreciate the many contributions from the public and private sectors whose thoughtful and constructive comments improved the quality and usefulness of this publication. Disclaimer This publication is intended as general guidance only for federal organizations, and is not intended to be, nor should it be construed or relied upon as legal advice or guidance to non federal entities or persons.

7 This document does not modify the Health Insurance Portability and Accountability Act of 1996 ( hipaa ) or any other federal law or regulation. The participation of other federal organizations with the National Institute of Standards and Technology (NIST) and NIST workgroups in the development of this special publication does not, and shall not be deemed to, constitute the endorsement, recommendation, or approval by those organizations of its contents. An introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Table of Contents Executive vii 1. 1 Purpose and 2 3 4 Document 4 How and Why to Use This 5 2. 6 hipaa Security 6 Security Rule Goals and 6 Security Rule 7 NIST and its Role in Information 9 3.

8 A Framework for Managing 10 NIST Risk Management Framework (RMF).. 10 The NIST RMF and Links to the Security Rule .. 11 4. Considerations when Applying the hipaa Security 15 Administrative 17 Security Management Process ( (a)(1)).. 17 Assigned Security Responsibility ( (a)(2)).. 20 Workforce Security ( (a)(3)).. 21 Information Access Management ( (a)(4)).. 23 Security Awareness and Training ( (a)(5)).. 25 Security Incident Procedures ( (a)(6)).. 27 Contingency Plan ( (a)(7)) .. 29 Evaluation ( (a)(8)).. 31 Business Associate Contracts and Other Arrangements ( (b)(1)). 33 Physical 35 Facility Access Controls ( (a)(1)).. 35 Workstation Use ( (b)).. 37 Workstation Security ( (c)).

9 38 Device and Media Controls ( (d)(1)).. 39 Technical 40 Access Control ( (a)(1)).. 40 Audit Controls ( (b)).. 42 Integrity ( (c)(1)).. 44 Person or Entity Authentication ( (d)).. 46 Transmission Security ( (e)(1)).. 47 vAn introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Organizational 48 Business Associate Contracts or Other Arrangements ( (a)(1)).. 48 Requirements for Group Health Plans ( (b)(1)).. 51 Policies and Procedures and Documentation 52 Policies and Procedures ( (a)).. 52 Documentation ( (b)(1)).. 53 Appendix A: A-1 Appendix B: B-1 Appendix C: C-1 Appendix D: Security Rule Standards and Implementation Specifications Appendix E: Risk Assessment Appendix F: Contingency Planning Appendix G: Sample Contingency Plan G-1 Appendix H: Resources for Secure Remote Use and H-1 Appendix I.

10 Telework Security viAn introductory resource guide for implementing the Health Insurance Portability and Accountability Act ( hipaa ) Security Rule Executive Summary Some federal agencies, in addition to being subject to the Federal Information Security Management Act of 2002 (FISMA), are also subject to similar requirements of the Health Insurance Portability and Accountability Act of 1996 ( hipaa ) Security Rule (the Security Rule), if the agency is a covered entity as defined by the rules implementing hipaa . The hipaa Security Rule specifically focuses on the safeguarding of electronic protected health information (EPHI). Although FISMA applies to all federal agencies and all information types, only a subset of agencies are subject to the hipaa Security Rule based on their functions and use of EPHI.