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What are the 3 rules of HIPAA?

Together, these rules create a comprehensive framework for safeguarding protected health information and ensuring compliance.

what are the 3 rules of hipaa

At a Glance

  • The HIPAA Privacy Rule establishes national standards for protecting patient health information and gives patients specific rights to access and control their own medical records.
  • The HIPAA Security Rule requires healthcare organizations to implement specific administrative, physical, and technical safeguards to protect electronic health information from unauthorized access and cyber threats.
  • The HIPAA Breach Notification Rule mandates that healthcare providers must notify affected patients within 60 days if their protected health information is compromised, with additional requirements for larger breaches.

The Health Insurance Portability and Accountability Act (HIPAA) aims to protect patient health information while ensuring the seamless flow of healthcare data.

At its core are 3 main rules: the privacy rule, the security rule, and the breach notification rule. Together, these rules create a comprehensive framework for safeguarding protected health information (PHI) and ensuring compliance for healthcare providers, health plans, and their business associates.

Let’s examine each of these rules in brief to understand their specific requirements and how they work together to protect patient information in today’s healthcare environment.

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Overview of the 3 rules of HIPAA

The 3 rules of HIPAA serve distinct yet interconnected purposes:

  • Privacy rule: Protects all forms of PHI, emphasizing patient rights and limiting the use and disclosure of their information.
  • Security rule: Focuses on the protection of electronic PHI (ePHI) through administrative, physical, and technical safeguards.
  • Breach notification rule: Requires covered entities to notify affected individuals, the Department of Health and Human Services (HHS), and, in some cases, the media when a breach of PHI occurs.

Together, these rules establish clear guidelines for handling patient information securely and address both preventive and responsive measures.

What is the HIPAA Privacy Rule?

The HIPAA Privacy Rule establishes national standards for the protection of individually identifiable health information. It applies to all forms of PHI, including written, electronic, and oral.

Key components:

Patient rights. Patients have the right to:

  • Access and obtain a copy of their health records
  • Request corrections to their information
  • Receive an accounting of who has accessed their PHI

Use and disclosure. PHI can only be used or disclosed for treatment, payment, and healthcare operations unless the patient explicitly authorizes other uses.

Privacy practices. Covered entities must provide patients with a notice of privacy practices detailing how their information will be used and their rights under HIPAA.

Practical examples:

  • Ensuring private conversations between healthcare providers
  • Limiting access to PHI only to authorized personnel
  • Releasing medical records to patients or their representatives in a timely manner

The privacy rule is foundational to HIPAA compliance rules and sets the stage for how patient information is handled and shared.

What is the HIPAA Security Rule?

The HIPAA Security Rule complements the privacy rule by focusing specifically on safeguarding ePHI. It requires covered entities and business associates to implement measures that ensure the confidentiality, integrity, and availability of ePHI.

Key safeguards:

  1. Administrative safeguards: Policies and procedures to manage ePHI security, such as workforce training and risk assessments.
  2. Physical safeguards: Protecting physical access to systems that store ePHI, including secure facility access and device control.
  3. Technical safeguards: Using tools like encryption, access controls, and audit logs to secure electronic data.

Common practices:

  • Training employees on secure password management
  • Encrypting sensitive data during transmission and storage
  • Conducting regular risk assessments to identify and address vulnerabilities

The security rule ensures that ePHI remains protected in an increasingly digital healthcare environment.

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What is the HIPAA Breach Notification Rule?

The HIPAA Breach Notification Rule ensures transparency and accountability when PHI is compromised. It outlines the steps covered entities must take following a breach to notify affected parties and regulatory authorities.

Key requirements

  1. Definition of a breach: A breach is the unauthorized access, use, or disclosure of PHI that compromises its security or privacy.
  2. Notification obligations:
    • Individuals: Must be notified within 60 days of discovering the breach.
    • HHS: Breaches involving fewer than 500 individuals are reported annually, while larger breaches must be reported within 60 days.
    • Media: For breaches affecting 500 or more individuals in a single jurisdiction, notifications must be sent to prominent media outlets.

Exceptions

Some incidents, such as unintentional access by an authorized employee or securely encrypted data breaches, may not qualify as reportable breaches. The breach notification rule ensures that affected parties are informed and can take steps to protect themselves from potential harm.

Why compliance with all 3 rules matters

Compliance with all 3 HIPAA rules is not just about avoiding penalties — it’s about fostering trust and ensuring patient safety. 

Compliance [...] is not just about avoiding penalties — it’s about fostering trust and ensuring patient safety. 

Key reasons include:

  • Avoiding fines and penalties: Non-compliance can result in significant financial penalties and reputational harm. For example, in November 2024, the HHS' Office for Civil Rights (OCR) imposed a $100,000 penalty on a Californian mental health center for failing to provide a patient with timely access to their medical records.
  • Maintaining patient trust: Transparent and secure handling of PHI builds trust with patients and strengthens the healthcare relationship.
  • Strengthening operations: Implementing HIPAA standards promotes operational efficiency and reduces the risk of data breaches.

Protecting patient data confidently and responsibly

By understanding and adhering to the 3 rules of HIPAA, your healthcare organization can navigate the complexities of patient data management confidently and responsibly. These rules work together to create a robust framework for protecting patient information. Each rule addresses a specific aspect of data protection and ensures that healthcare providers and their partners can operate securely and transparently.

For more detailed guidance on each, explore our in-depth articles covering the privacy rule, the security rule, and the breach notification rule. By staying informed and proactive, your healthcare organization can achieve HIPAA compliance and continue delivering high-quality care with confidence.

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Becky Whittaker, specialist SEO copywriter

Becky Whittaker is a specialist SEO copywriter with over a decade of experience and an interest in healthcare and legal marketing. Becky believes that independent practices are critical because they have more opportunities to deliver better patient care and personalize patients’ experiences. She also has a personal connection to the healthcare industry, as her sister-in-law is a pediatrician.

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