HIPAA · 45 CFR Part 160, 162, 164

HIPAA, run as a program. Not as a checklist.

Risk analysis, technical and administrative safeguards, business associate agreements, and breach notification readiness. The OCR audits when something goes wrong; we make sure the program holds up.

What it is·United States Department of Health and Human Services (HHS), Office for Civil Rights (OCR)

United States federal law governing the protection of protected health information (PHI) by covered entities and business associates.

HIPAA is United States federal law, not a certification. Compliance is a continuous obligation rather than a point-in-time pass. The Security Rule (45 CFR §164.302 to 318) requires administrative, physical, and technical safeguards over electronic protected health information (ePHI). The Privacy Rule (45 CFR §164.500 to 534) governs use and disclosure of PHI in any form. The HHS Office for Civil Rights enforces, with civil penalties tiered by culpability and breach impact.

§01

Who needs it

Covered entities (health plans, healthcare providers, healthcare clearinghouses) and business associates (any vendor that creates, receives, maintains, or transmits PHI on behalf of a covered entity). SaaS companies that handle health data for hospital systems, insurance companies, or digital health platforms are typically business associates and need a Business Associate Agreement with each covered entity customer.

§02

The HSD playbook for HIPAA

HSD's engineers begin with the §164.308(a)(1)(ii)(A) risk analysis and risk management plan, then implement administrative safeguards (workforce training, access management, audit controls), physical safeguards (workstation and device security), and technical safeguards (access control, audit logs, encryption, transmission security). We write the BAA template you sign with covered entities, the BAA you sign with downstream subcontractors, the breach notification runbook, and the HIPAA-required policies. There is no formal certification, but customers may request an independent third-party assessment; we coordinate that.

§03

Timeline

Weeks 1 to 2

Risk analysis

Documented risk analysis per §164.308(a)(1)(ii)(A): assets, threats, vulnerabilities, likelihood, impact, controls, residual risk

Weeks 2 to 5

Administrative safeguards

Workforce training program, access management, sanction policy, contingency plan, evaluation procedures

Weeks 3 to 6

Technical safeguards

Unique user identification, automatic logoff, encryption at rest and in transit, audit controls, integrity controls

Weeks 4 to 6

BAA program

Downstream subcontractor inventory, BAA execution; covered entity BAA template ready

Week 6

Breach notification readiness

Runbook, contact list, decision criteria; tabletop exercise documented

Weeks 7 to 10

Optional third-party assessment

Independent assessment if a customer requires one; commonly HITRUST CSF or similar

§04

Cost reality

Line itemRangeNote
Software platforms with HIPAA supportUSD 8,000 to 22,000 per yearMost compliance platforms support HIPAA but it is rarely a primary use case
Remediation consultingUSD 25,000 to 70,000Lower than SOC 2 + ISO 27001 because of narrower scope, higher when PHI flows are complex
Optional third-party assessmentUSD 15,000 to 40,000HITRUST CSF certification adds significantly; lighter independent attestations cost less
HSD bundled programScoped per programRisk analysis, safeguards, BAA, breach readiness in one engagement
§05

What auditors check

Documented risk analysis

Most-cited gap in OCR enforcement actions. Required to be conducted, documented, and updated; cannot be a one-page form.

Workforce training program with records

All workforce members trained on policies and procedures; training tracked; refresher cadence documented.

Audit logs on systems with PHI access

Recording, reviewing, and retaining records of activity in systems that contain ePHI.

Encryption of ePHI at rest and in transit

Encryption is addressable rather than required, but the safeguard documentation must justify the choice if encryption is not implemented.

Business Associate Agreements with all subcontractors

Every downstream vendor handling PHI on the company's behalf has a current, signed BAA with §164.504(e) required terms.

Breach notification timeline and capability

Written runbook, contact lists, decision criteria, evidence the process has been exercised.

§06

Common pitfalls

Treating risk analysis as a checklist

OCR settlements consistently cite inadequate or missing risk analysis. The §164.308(a)(1)(ii)(A) analysis must address the specific environment, not be a template.

Missing BAAs with subcontractors

BAAs flow downstream. If a vendor handling PHI on your behalf does not have a current BAA with you, you are exposed regardless of your other controls.

Confusing addressable with optional

Addressable safeguards must be implemented or the decision to use an alternative documented. Treating addressable as optional is a frequent finding.

No breach notification rehearsal

Sixty days from discovery to notify; reality forces faster. Without a tested runbook, the timeline slips and the violation compounds.

Stale workforce training

Annual training without records of completion is a documentation gap. Train, track, retain.

§07

FAQ

Is HIPAA a certification?+
No. HIPAA is United States federal law. There is no government certification; compliance is demonstrated through a continuous program. Independent assessments such as HITRUST CSF are commercial alternatives some customers request.
What is a Business Associate Agreement?+
A contract between a covered entity and a business associate, or between a business associate and a downstream subcontractor, with terms required by 45 CFR §164.504(e). Required before PHI is disclosed.
What is the difference between PHI and ePHI?+
PHI is protected health information in any form. ePHI is electronic PHI, which the Security Rule specifically governs. The Privacy Rule covers PHI in all forms.
Do all SaaS companies that handle health data need to comply with HIPAA?+
Only those that create, receive, maintain, or transmit PHI on behalf of a covered entity, which makes them business associates. SaaS for health-adjacent use cases that does not touch PHI is not in scope.
What are HIPAA penalties?+
Civil penalties tier by culpability: 100 USD to 50,000 USD per violation for unknowing violations, escalating to 1.5 million USD per identical violation per year for willful neglect uncorrected.
Does HSD do HIPAA without SOC 2?+
Yes. Many digital health customers start with HIPAA, then add SOC 2 once enterprise customers ask. We sequence the program either way.

Want HIPAA scoped for your stack?

Thirty-minute call. Fixed-scope quote inside a week. We tell you honestly when HIPAA should wait or when it should lead.