Ensuring the privacy and security of data is paramount, particularly for organizations that handle sensitive and personally identifiable information. This responsibility becomes even more acute when it pertains to government-related services and operations. MARS-E — Minimum Acceptable Risk Standards for Exchanges — is a stringent set of security controls established to protect healthcare data within insurance exchanges. But how does MARS-E compliance affect your organization, and what are the implications of its non-compliance? This Peak Post aims to provide an in-depth analysis of MARS-E, shedding light on its significance, the requirements for adherence, and the overall impact on your organization’s data governance, security infrastructure, and operational procedures.
MARS-E: An Overview
MARS-E is a set of controls derived from the National Institute of Standards and Technology (NIST) Special Publication 800-53, designed specifically to ensure the secure handling of PII by health insurance exchanges. With the advent of online healthcare exchanges, protecting the personal health information of individuals has become paramount. MARS-E standards, currently in their 2.0 version, address this need by providing comprehensive guidelines for security and privacy controls.
MARS-E Classes
The MARS-E standards group controls into three (3) classes based on their nature:
1. Technical Controls: These controls are executed by information systems and include the hardware, software, and related technology used to protect and process data. Technical controls include access controls, identification and authentication measures, and encryption methods.
For instance, access controls limit who can access specific resources and under what circumstances. This could involve implementing multi-factor authentication (MFA), which requires users to verify their identity using multiple evidence types before gaining access.
Encryption methods, another technical control, protect sensitive data by transforming it into an unreadable format, which can only be reverted to a readable format with the correct decryption key.
Technical controls also include network security measures such as firewalls and intrusion detection systems that monitor and control incoming and outgoing network traffic based on predetermined security rules.
2. Operational Controls: These controls are the processes and methods that a system’s human users follow to secure data. Operational controls include personnel security, contingency planning, hardware and software maintenance, system and information integrity, and protection from malicious software. These controls mainly involve day-to-day operations that contribute to the ongoing security of an organization.
Personnel security, a key operational control, involves processes to ensure that staff members are trustworthy, adequately trained, and aware of their roles in maintaining data security.
Contingency planning prepares an organization for potential security incidents or system failures, ensuring business continuity and minimizing disruptions. This could involve having data backups or disaster recovery plans in place.
System and information integrity measures, like regular audits and monitoring procedures, help detect and prevent unauthorized system changes or errors. Protection from malicious software involves implementing antivirus solutions and other tools to prevent, detect, and remove malware.
3. Management Controls: These are the overarching strategies, policies, and procedures that guide how an organization manages its risk and security efforts. Management controls include risk assessment, planning, system and services acquisition, certification, accreditation, and security assessment processes. They provide the structure and framework for the IT environment and guide the implementation of both technical and operational controls.
Risk assessment involves identifying potential threats, assessing the potential impact of those threats, and determining appropriate measures to mitigate the risks.
System and services acquisition policies guide the process of purchasing and implementing new technologies, ensuring that they meet the organization’s security requirements.
Certification, accreditation, and security assessment processes ensure that systems and processes meet specified security standards before they are approved for use.
These control classes form the backbone of MARS-E and allow organizations to develop a comprehensive security plan to protect sensitive health information.
Does MARS-E Impact Your Organization
Determining whether MARS-E will impact your organization largely depends on your organization’s engagement with health information exchanges and the type of data you handle. Here are some key considerations:
1. Type of Organization
MARS-E applies specifically to health insurance exchanges, Medicaid agencies, Children’s Health Insurance Programs (CHIP), and any health plans, entities, or individuals that interact with these groups or handle related data. If your organization falls into one of these categories, MARS-E is likely to impact you.
2. Data Handled
The type of data your organization handles is a key factor. MARS-E standards focus on securing personally identifiable information (PII) and protected health information (PHI). If your organization processes, stores, or transmits such data, you will likely need to comply with MARS-E.
3. Interaction with Health Information Exchanges
If your organization uses health information exchanges for sharing clinical and administrative data among healthcare providers, payers, and patients, it’s likely that you’ll need to comply with MARS-E standards.
4. Federal and State Requirements
Certain federal and state programs may require MARS-E compliance. If your organization is part of a federal or state program related to health insurance or healthcare services, it would be prudent to check whether MARS-E applies.
5. Legal and Contractual Obligations
Sometimes, compliance with standards like MARS-E is a legal or contractual requirement. For instance, contracts with healthcare partners or providers may require MARS-E compliance.
If you’re uncertain whether MARS-E applies to your organization, consider consulting with a legal expert or a cybersecurity consultant knowledgeable in healthcare regulations. Also, remember that even if MARS-E doesn’t strictly apply to your organization, following its guidelines can still strengthen your data security and privacy practices.
Impact of MARS-E on Your Organization
Compliance with MARS-E directly influences your organization in several ways:
1. Enhanced Data Security
The primary impact of MARS-E compliance is the enhancement of your organization’s data security posture. MARS-E provides a set of rigorous security controls that, when implemented effectively, can considerably reduce the risk of data breaches and unauthorized access to sensitive health information.
2. Trust and Reputation
Adherence to MARS-E guidelines helps to build trust among users and partners. Consumers, in particular, are increasingly aware of their data rights, and they often prefer to interact with organizations that take data privacy and security seriously. MARS-E compliance can be a distinguishing factor, enhancing your organization’s reputation in the healthcare industry.
3. Regulatory Compliance
MARS-E compliance ensures your organization abides by federal regulations related to health information security and privacy. Compliance prevents potential legal implications, fines, or sanctions that could arise from non-compliance.
4. Operational Efficiency
While implementing MARS-E standards requires a robust initial effort, over the long term, having established security protocols can lead to greater operational efficiency. These guidelines offer a structured approach to handle and protect sensitive data, making everyday operations smoother and reducing the likelihood of incidents that require remediation.
5. Improved Risk Management
MARS-E provides a framework for identifying and managing risks associated with the handling of PII. This results in an improved overall risk management strategy, which is beneficial not just for data security, but for the operational and financial health of the organization as well.
Impact of Non-Compliance With MARS-E
Non-compliance with MARS-E can have significant implications for an organization, particularly those dealing with healthcare data. These consequences span legal, financial, operational, and reputational domains.
1. Legal Implications: MARS-E is a set of compliance standards put in place by the Centers for Medicare & Medicaid Services (CMS). Non-compliance can lead to serious legal penalties, including fines and sanctions. This could range from cease and desist orders to legal action by affected parties for breach of personal data.
2. Financial Implications: Penalties for non-compliance can be extremely high, potentially reaching millions of dollars depending on the nature and severity of the violation. This financial burden can be debilitating, especially for smaller organizations. Further, non-compliant organizations may also face additional costs related to legal fees, potential settlements, and the required system and process changes to achieve compliance.
3. Operational Implications: Non-compliant organizations could face interruptions to their operations. If a breach occurs due to non-compliance, the organization may be required to halt certain operations until security vulnerabilities are addressed. This could lead to delays, loss of business, and a significant impact on service delivery.
4. Reputational Damage: Perhaps one of the most detrimental effects of non-compliance is the potential harm to an organization’s reputation. Public knowledge of a data breach or non-compliance can cause a loss of trust among customers and partners, and rebuilding this trust can be a long and challenging process.
5. Loss of Business Opportunities: Non-compliance can also lead to loss of business opportunities. For instance, government agencies or businesses that prioritize data security may avoid partnerships with non-compliant organizations.
Ensuring MARS-E compliance should therefore be a top priority for organizations dealing with sensitive healthcare data. Beyond the legal requirement, it demonstrates a commitment to data security, strengthening customer trust and operational integrity. By investing in compliance, organizations can avoid the damaging consequences of non-compliance, secure their operations, and promote a culture of data safety and security.
______
Adopting MARS-E guidelines is not merely about compliance—it is about a commitment to robust data security, trust building, operational efficiency, and effective risk management. It is an investment that yields significant dividends in the form of a secure and trusted environment for consumers and partners alike, and a testament to your organization’s dedication to privacy and security.
Note: The specific impacts of MARS-E compliance can vary based on an organization’s size, complexity, and the nature of the data it handles. Therefore, it’s crucial to consult with a cybersecurity expert or a knowledgeable consultant when planning for MARS-E compliance.
