HIPAA Security Standards

The Final HIPAA Security Rule was published on February 20, 2003. Most covered entities, including CareFirst, were required to comply with the Security Rule by April 21, 2005.

The Security regulation established specific standards to protect electronic health information systems from improper access or alteration. In addition, the rule adopts implementation specifications that provide instructions for implementing the security standards. Under the rule, covered entities must develop procedures to protect the confidentiality, integrity, and availability of electronic protected health information.

Implementation Specifications

Within the final rule, Implementation Specifications are marked as either Required or Addressable. If the Implementation Specification is Required, the covered entity must implement the standard as stated.

However, if the Implementation Specification is Addressable, the covered entity must do one of the following:

  1. implement one or more of the addressable implementation specifications;
  2. implement one or more alternative security measures;
  3. implement a combination of both; or
  4. not implement either an addressable implementation specification or an alternative security measure, after documenting that the cost of the proposed security measures exceeds the value of the content being secured.

An Implementation Specification marked as Addressable does NOT mean it is optional.

CareFirst is compliant with the Security rules. Shown below are tables summarizing the Security rule sections with the required and addressable implementation specifications.

Administrative Safeguards

Administrative Safeguards
StandardsSectionsImplementation Specifications
(R)= Required,
Security Management Process 164.308(a)(1) Risk Analysis (R)

Risk Management (R)

Sanction Policy (R)

Information System Activity Review (R)
Assigned Security Responsibility 164.308(a)(2) (R)
Workforce Security 164.308(a)(3) Authorization and/or Supervision (A)

Workforce Clearance Procedure (A)

Termination Procedures (A)

Information Access Management 164.308(a)(4) Isolating Health care Clearinghouse Function (R)

Access Authorization (A)

Access Establishment and Modification (A)

Security Awareness and Training 164.308(a)(5) Security Reminders (A)

Protection from Malicious Software (A)

Log-in Monitoring (A)

Password Management (A)
Security Incident Procedures 164.308(a)(6) Response and Reporting (R)
Contingency Plan 164.308(a)(7) Data Backup Plan (R)

Disaster Recovery Plan (R)

Emergency Mode Operation Plan (R)

Testing and Revision Procedure (A)

Applications and Data Criticality Analysis (A)

Evaluation 164.308(a)(8) (R)
Business Associate Contracts and Other Arrangement 164.308(b)(1) Written Contract or Other Arrangement (R)

Physical Safeguards

Physical Safeguards
StandardsSectionsImplementation Specifications
(R)= Required,
Facility Access Controls 164.310(a)(1) Contingency Operations (A)

Facility Security Plan (A)

Access Control and Validation Procedures (A)

Maintenance Records (R)
Workstation Use 164.310(b) (R)
Workstation Security 164.310(c) (R)
Device and Media Controls 164.310(c) Disposal (R)

Media Re-use (R)

Accountability (A)

Data Backup and Storage (A)

Technical Safeguards

Technical Safeguards
StandardsSectionsImplementation Specifications
(R)= Required,
Access Control 164.312(a)(1) Unique User Identification (R)

Emergency Access Procedure (R)

Automatic Logoff (A)

Encryption and Decryption (A)
Audit Controls 164.312(b) (R)
Integrity 164.312(c)(1) (A)
Mechanism to Authenticate Electronic Protected Health Information 164.310(c) (A)
Person or Entity Authentication 164.312(d) (R)
Transmission Security 164.312(e)(1) Integrity Controls (A)

Encryption (A)