164.314(b)(1) Requirements for Group Health Plans (Standard)
Except when the only ePHI disclosed to a plan sponsor is disclosed pursuant to 164.504(f)(1)(ii) or (iii), or as authorized under 164.508, a group health plan must ensure that its plan documents provide that the plan spo
8
artefacts
0
held by a system
0
at each review
hard
to go live
Policy repository / GRC workspace
where the evidence lives
teal = a system already holds it · olive = produced at each review
system holds itEvidence a system already holds
none for this control
periodic reviewEvidence produced at each review
none for this control
governing documentDocuments that govern the control
- Plan document amendments addressing ePHI safeguards · Policy repository / GRC workspace
- Plan sponsor security obligations documentation · Policy repository / GRC workspace
- Records of disclosures to plan sponsor · Policy repository / GRC workspace
- Determination of group health plan applicability · Policy repository / GRC workspace
- Procedures for limited disclosures under 164.504(f) · Policy repository / GRC workspace
- Annual review of plan sponsor compliance · Policy repository / GRC workspace
- Plan sponsor workforce training records · HR system / LMS
- Coordination procedures between plan and sponsor · Policy repository / GRC workspace
First move
This control is evidenced by people and documents, not systems. Put the document under version control with an owner and review date, and log each review as a record with reviewer and date. Do not try to automate it.
Common gaps auditors find
- Plan documents not updated to reflect ePHI safeguards
- Plan sponsor practices not aligned to plan obligations
- Disclosures exceed allowed scope
- No applicability determination
- Plan sponsor training absent
- No annual compliance review
Do this for your whole sheet
Paste the rows you run your controls from and get this mapping for every control at once, with the periodic-review ones flagged and a first move per row. No account for the first run.
Build my evidence sheet164.314(a)(2)(iii) Business Associate Contracts with Subcontractors · 164.314(b)(2) Implementation Specifications for Group Health Plans