Your company is a security service contractor that consults with businesses in the U.S. that require assistance in complying with HIPAA. You advertise a proven track record in providing information program security management, information security governance programs, risk management programs, and regulatory and compliance recommendations. You identify vulnerabilities, threats, and risks for clients with the end goal of securing and protecting applications and systems within their organization.
Your client is Health Coverage Associates, a health insurance exchange in California and a healthcare-covered entity. The Patient Protection and Affordable Care Act (ACA) enables individuals and small businesses to purchase health insurance at federally subsidized rates. In the past 6 months, they have experienced:
• A malware attack (i.e., SQL Injection) on a critical software application that processed and stored client-protected health information (PHI) that allowed access to PHI stored within the database
• An internal mistake by an employee allowed PHI to be emailed to the wrong recipient who was not authorized to have access to the PHI
• Unauthorized access to client accounts through cracking of weak passwords via the company’s website login
Health Coverage Associates would like you to develop a security management plan that would address the required safeguards to protect the confidentiality, integrity, and availability of sensitive data from the attacks listed above and protect their assets from the vulnerabilities that allowed the attacks to occur.
Write a 1- to 2-page high-level executive summary of the legal and regulatory compliance requirements for Health Coverage Associates executives. The summary should provide:
• Accurate information on the HIPAA requirements for securing PHI
• FISMA and HIPAA requirements for a security plan
• Scope of the work you will perform to meet the Health Coverage Associates’ requests
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Executive Summary: Legal and Regulatory Compliance Requirements for Health Coverage Associates
Health Coverage Associates, as a healthcare-covered entity operating in California, is required to comply with several legal and regulatory standards to ensure the protection and security of sensitive data, specifically Protected Health Information (PHI) as mandated by the Health Insurance Portability and Accountability Act (HIPAA). This executive summary outlines the HIPAA requirements for securing PHI, as well as the Federal Information Security Modernization Act (FISMA) and additional HIPAA requirements for a comprehensive security plan. Furthermore, it details the scope of work that our company will undertake to meet Health Coverage Associates' security needs and safeguard their assets from future vulnerabilities and attacks.
HIPAA Requirements for Securing PHI:
Under HIPAA, Health Coverage Associates is mandated to establish and implement appropriate safeguards to protect the confidentiality, integrity, and availability of PHI. These safeguards include administrative, physical, and technical measures:
1. Administrative Safeguards: Health Coverage Associates must develop and implement policies, procedures, and guidelines to manage the selection, development, implementation, and maintenance of security measures. This includes workforce training and awareness programs, risk assessments, and contingency planning to mitigate potential security incidents.
2. Physical Safeguards: Health Coverage Associates must implement physical measures to protect their facilities and equipment that contain PHI. These measures include security access controls, video surveillance, and the need for authorized personnel to accompany visitors in restricted areas.
3. Technical Safeguards: It is essential for Health Coverage Associates to have technical safeguards in place to control access to PHI electronically. This includes utilizing unique user identifications, secure access controls, encryption of PHI, and regularly monitoring and auditing information systems to ensure compliance.
FISMA and HIPAA Requirements for a Security Plan:
In addition to HIPAA requirements, Health Coverage Associates must also adhere to regulations outlined by FISMA. FISMA requires federal agencies and entities that handle federal information, including PHI, to develop and maintain an information security program. The security plan must include the following elements:
1. Risk Assessment: Health Coverage Associates will conduct a comprehensive assessment to identify vulnerabilities, threats, and risks associated with their systems and the protection of PHI. This will help develop a risk management strategy to mitigate identified risks effectively.
2. Security Controls: Based on the risk assessment, Health Coverage Associates will implement necessary security controls to safeguard PHI. These controls include intrusion detection systems, firewalls, data encryption, and disaster recovery plans among others.
Scope of Work:
To meet the requested security needs of Health Coverage Associates, our company will undertake the following scope of work:
1. Conduct comprehensive risk assessments to identify vulnerabilities, threats, and risks associated with systems containing PHI.
2. Develop and implement a tailored security management plan that aligns with HIPAA, FISMA, and other relevant regulations.
3. Provide information program security management, information security governance programs, and risk management programs to effectively protect and secure applications and systems within Health Coverage Associates' organization.
4. Assess and address vulnerabilities that allowed the recent attacks, including the malware attack, internal employee error, and unauthorized access via weak passwords.
5. Design and implement necessary security controls and measures to ensure the confidentiality, integrity, and availability of sensitive data, specifically PHI.
6. Conduct workforce training and awareness programs to ensure proper understanding and compliance with security policies and procedures.
7. Regularly monitor and audit information systems to identify and address any security gaps or incidents promptly.
8. Provide ongoing regulatory and compliance recommendations to ensure Health Coverage Associates' continued adherence to HIPAA and other applicable standards.
In conclusion, Health Coverage Associates must prioritize the implementation of appropriate safeguards to protect the confidentiality, integrity, and availability of PHI as mandated by HIPAA. Our company will work closely with Health Coverage Associates to develop and implement a robust security management plan, addressing the vulnerabilities that led to recent attacks and ensuring the protection of sensitive data within their organization. Through our proven track record, we aim to secure and protect applications and systems, minimizing the risks and potential damages associated with security breaches.
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