NIST SP 800-66

1 NIST Special Publication 800-66 DRAFT Computer Security Division Information Technology Laboratory National Institute of Standards and Technology Gaithersburg, MD 20899-8930 May 2004 Department of Commerce Donald L. Evans, Secretary Technology Administration Phillip J. Bond, Under Secretary of Commerce for Technology National Institute of Standards and Technology Arden L. Bement, Jr., Director I N F O R M A T I O N S E C U R I T Y An Introductory Resource Guide for Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule Pauline Bowen, Arnold Johnson, Joan Hash Carla Dancy Smith, Daniel I.

2 Steinberg DRAFT An Introductory Resource Guide for Implementing the HIPAA Security Rule Reports on Information Systems Technology The Information Technology Laboratory (ITL) at the National Institute of Standards and Technology promotes the United States economy and public welfare by providing technical leadership for the Nation s measurement and standards infrastructure. 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 non-national- security-related information in federal information systems.

3 This 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. i DRAFT An Introductory Resource Guide for Implementing the HIPAA Security Rule Authority This document has been developed by the National Institute of Standards and Technology (NIST) in furtherance of its statutory responsibilities under the Federal Information Security Management Act (FISMA) of 2002, Public Law 107-347. NIST is responsible for developing standards and guidelines, including minimum requirements, that provide adequate information security for all agency operations and assets, but such standards and guidelines shall not apply to national security systems.

4 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 be used by nongovernmental organizations on a voluntary basis and is not subject to copyright. (Attribution would be appreciated by NIST.) 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.

5 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. 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. ii DRAFT An Introductory Resource Guide for Implementing the HIPAA Security Rule Acknowledgments The authors wish to thank their colleagues who reviewed working drafts of this document and contributed to its development.

6 The Centers for Medicare and Medicaid Services involvement with the National Institute of Standards and Technology (NIST) and NIST workgroups does not, and shall not be deemed to, constitute the endorsement, recommendation, or approval of any NIST product or publication, by the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, or the Office of HIPAA Standards. iii DRAFT An Introductory Resource Guide for Implementing the HIPAA Security Rule TABLE OF CONTENTS TABLE OF Executive 1. Purpose and Organization of This Special 2. NIST IT Security Security Program Development Life Publications Directly Supporting Federal Requirements for System Certification and Accreditation (C&A).

7 7 3. HIPAA Security HIPAA Goals and Security Rule Safeguards Included in the HIPAA Security 4. Associating NIST Publications with HIPAA Security Requirements Administrative Security Management Process ( (a)(1))..16 Assigned Security Responsibility ( (a)(2))..19 Workforce Security ( (a)(3)).. 21 Information Access Management ( (a)(4))..23 Security Awareness and Training ( (a)(5))..25 Security Incident Procedures ( (a)(6))..28 Contingency Plan ( (a)(7))..30 Evaluation ( (a)(8))..33 Business Associate Contracts and Other Arrangements ( (b)(1))..36 Physical Facility Access Controls ( (A)(1)).

8 38 Workstation Use ( (b))..41 Workstation Security ( (c)).. 43 Device and Media Controls ( (d)(1))..44 Technical Access Controls ( (a)(1))..46 Audit Controls ( (b))..48 Integrity ( (c)(1))..50 Person or Entity Authentication ( (d))..52 Transmission Security ( (e)(1)).. 54 Appendix A Appendix B Appendix C Appendix D HIPAA Security Rule/NIST Publications iv DRAFT An Introductory Resource Guide for Implementing the HIPAA Security Rule Appendix E HIPAA Security Rule/FISMA Requirements v DRAFT An Introductory Resource Guide for Implementing the 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 (in many areas) similar requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

9 Security Rule (the Security Rule). This Special Publication (SP) summarizes the HIPAA security standards and explains some of the structure and organization of the Security Rule. This SP helps educate readers about security terms used in the HIPAA Security Rule and to improve understanding of the meaning of the security safeguards set out in the Rule. This publication is also designed to direct readers to helpful information in other National Institute of Standards and Technology (NIST) publications on individual topics the HIPAA Security Rule addresses. Readers can draw upon these publications for consideration in implementing the Security Rule.

10 This publication is intended as an aid to understanding security concepts discussed in the HIPAA Security Rule, does not supplement, replace, or supersede the HIPAA Security Rule itself. 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 is subject to the HIPAA Security Rule based on its use of EPHI. All covered entities under HIPAA must comply with the HIPAA Security Rule, which establishes a set of security standards for protecting certain health care information.