164.314(a)(2) Organizational Requirements

Requirements for Group Health Plans

High Risk Moderate Implementation Medium Cost

Except when the only ePHI disclosed to a plan sponsor is disclosed pursuant to 164.504(f)(1)(ii) or (iii), or as permitted under 164.508(a)(3)(i), a group health plan must ensure that its plan documents provide that the plan sponsor will reasonably and appropriately safeguard ePHI.

Implementation Guidance

Develop and implement group health plan security procedures including plan document requirements and sponsor responsibilities.

Required Documentation

Group health plan security procedures, plan document requirements, sponsor responsibility documentation.

Best Practices

Comprehensive plan document requirements, clear sponsor responsibilities, effective security procedures.

Common Violations

Inadequate plan document requirements, insufficient sponsor responsibilities, lack of security procedures.

Testing Procedures

Review plan document requirements, verify sponsor responsibilities, test security procedures.

Audit Considerations

Plan document completeness, sponsor responsibility implementation, security procedure effectiveness.

NIST Cybersecurity Framework Alignment

This HIPAA control aligns with the following NIST Cybersecurity Framework functions and controls:

Identify (ID)

  • ID.AM-1: Physical devices and systems within the organization are inventoried
  • ID.AM-2: Software platforms and applications within the organization are inventoried
  • ID.AM-3: Organizational communication and data flows are mapped

Protect (PR)

  • PR.AC-1: Identities and credentials are issued, managed, verified, revoked, and audited
  • PR.AC-3: Remote access is managed
  • PR.DS-1: Data-at-rest is protected
  • PR.DS-2: Data-in-transit is protected

Detect (DE)

  • DE.AE-1: A baseline of network operations and expected data flows is established
  • DE.CM-1: The network is monitored to detect potential cybersecurity events
  • DE.CM-3: Personnel activity is monitored to detect potential cybersecurity events

Respond (RS)

  • RS.CO-1: Personnel know their roles and order of operations when a response is needed
  • RS.CO-2: Incidents are reported consistent with established criteria
  • RS.AN-1: Notifications from detection systems are investigated

Recover (RC)

  • RC.RP-1: Recovery plan is executed during or after a cybersecurity incident
  • RC.IM-1: Recovery plans incorporate lessons learned
  • RC.CO-1: Public relations are managed

Note: This mapping provides a general alignment between HIPAA controls and NIST Framework functions. Specific implementation may vary based on your organization's risk profile and compliance requirements.

Implementation Templates & Checklists

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Implementation Checklist

Step-by-step checklist to ensure complete implementation of this control

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Policy Template

Ready-to-customize policy template for this specific control

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Risk Assessment Form

Comprehensive risk assessment form for this control

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Training Materials

Staff training materials and awareness resources

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Expert Implementation Recommendations

Based on our experience with 500+ healthcare organizations, here are our expert recommendations for implementing this control:

High Priority

Start with Risk Assessment

Conduct a comprehensive risk assessment to identify specific vulnerabilities and threats related to this control. This will help prioritize implementation efforts and allocate resources effectively.

  • Identify all systems and data covered by this control
  • Assess current security measures and gaps
  • Evaluate potential impact of security incidents
  • Document findings and remediation priorities
Medium Priority

Develop Comprehensive Policies

Create detailed policies and procedures that address all aspects of this control. Ensure policies are specific, actionable, and aligned with your organization's risk profile.

  • Define roles and responsibilities clearly
  • Establish approval workflows and escalation procedures
  • Include specific technical requirements and standards
  • Regular review and update schedules
Low Priority

Implement Monitoring and Testing

Establish ongoing monitoring and testing procedures to ensure the control remains effective over time. Regular testing helps identify new vulnerabilities and compliance gaps.

  • Automated monitoring where possible
  • Regular manual testing and validation
  • Incident response procedures
  • Continuous improvement processes

Recommended Implementation Timeline

1

Week 1-2: Assessment & Planning

Conduct risk assessment and develop implementation plan

2

Week 3-4: Policy Development

Create and review policies and procedures

3

Week 5-8: Implementation

Deploy technical controls and train staff

4

Week 9-10: Testing & Validation

Test controls and validate compliance

Related Controls

164.314(a)(1) - Business Associate Contracts, 164.308(a)(1) - Security Officer

Quick Facts

Control ID: 164.314(a)(2)
Category: Organizational Requirements
Subcategory: Group Health Plans
Risk Level: High
Difficulty: Moderate
Cost: Medium
Timeframe: 2-4 months
Views: 21
Last Updated: Dec 4, 2025

Actions

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Additional Resources

NIST SP 800-66 Rev. 2: Group Health Plan Guidance, HHS Group Health Plan Guidance, Plan Document Templates

Related Controls

164.314(a)(1) High

Business Associate Contracts or Other Arrangements

A covered entity may permit a business associate to create, receive, maintain, or transmit ePHI on the covered entity's ...