Regulatory Compliance (HIPAA, SOX, FISMA, CMMC)

Regulatory Compliance (HIPAA, SOX, FISMA, CMMC) - CompTIA Security+ Guide

Why Regulatory Compliance is Important

Regulatory compliance frameworks are critical safeguards that protect sensitive data, ensure organizational accountability, and maintain public trust. Organizations operating in healthcare, finance, government, and defense sectors must adhere to specific compliance requirements. Non-compliance can result in:

• Hefty financial penalties and fines
• Loss of business licenses and certifications
• Reputational damage and loss of customer trust
• Legal liability and criminal prosecution
• Operational disruptions and loss of contracts

Understanding these frameworks demonstrates your ability to protect critical assets and maintain organizational integrity—essential skills for security professionals.

What is Regulatory Compliance?

Regulatory compliance refers to adherence to laws, regulations, and standards that govern how organizations handle, protect, and process sensitive data. The major frameworks you need to know for CompTIA Security+ are:

HIPAA (Health Insurance Portability and Accountability Act)

Applies to: Healthcare providers, health plans, and healthcare clearinghouses

Purpose: Protects patient health information (PHI) and ensures privacy, security, and breach notification

Key Requirements:

• Privacy Rule: Controls how PHI is used and disclosed
• Security Rule: Establishes administrative, physical, and technical safeguards
• Breach Notification Rule: Requires notification within 60 days of breach discovery
• Minimum Necessary Standard: Only use and disclose the minimum PHI needed

SOX (Sarbanes-Oxley Act)

Applies to: Public companies and their auditors

Purpose: Ensures accuracy of financial reporting and internal controls

Key Requirements:

• Section 302: CEO and CFO certification of financial reports
• Section 404: Management assessment of internal control effectiveness
• Section 906: Criminal penalties for false certifications
• IT General Controls: Ensure data integrity and system availability

FISMA (Federal Information Security Modernization Act)

Applies to: Federal agencies and contractors handling federal data

Purpose: Establishes information security requirements for federal information systems

Key Requirements:

• Risk-based security controls aligned with NIST standards
• System categorization based on impact analysis
• Security control implementation (low, moderate, high impact)
• Continuous monitoring and assessment
• Incident response and reporting procedures

CMMC (Cybersecurity Maturity Model Certification)

Applies to: Defense Industrial Base (DIB) contractors and subcontractors

Purpose: Protects sensitive unclassified information (CUI) and strengthens cybersecurity posture

Key Requirements:

• Five maturity levels (1-5)
• Level 1: Basic cyber hygiene
• Level 3: Advanced/optimized practices aligned with NIST SP 800-171
• Level 5: Continuously improving processes
• Third-party assessment required for levels 3 and above

How These Frameworks Work

The Compliance Cycle:

1. Assessment and Planning
- Identify applicable regulations for your organization
- Evaluate current security posture against requirements
- Develop remediation plans for gaps

2. Implementation
- Deploy required technical controls (encryption, access controls, monitoring)
- Establish administrative procedures (policies, training, incident response)
- Create physical safeguards (facility access, equipment protection)

3. Monitoring and Maintenance
- Conduct regular audits and assessments
- Monitor system logs and security events
- Update controls and processes as needed

4. Documentation and Reporting
- Maintain compliance evidence (audit logs, assessment reports)
- Document all security controls and their effectiveness
- Report compliance status to stakeholders and regulators

5. Incident Response and Remediation
- Respond to security incidents within regulatory timeframes
- Notify affected parties as required
- Implement corrective actions and prevent recurrence

Key Control Categories Across Frameworks

Administrative Controls:
- Policies and procedures
- Security training and awareness
- Incident response plans
- Access control policies

Technical Controls:
- Encryption (data at rest and in transit)
- Authentication and authorization systems
- Firewalls and intrusion detection
- Security logging and monitoring
- Vulnerability management

Physical Controls:
- Facility access controls
- CCTV and surveillance
- Equipment protection and disposal
- Environmental controls

Exam Tips: Answering Questions on Regulatory Compliance

Tip 1: Know the Applicability
Quickly identify which framework applies to a scenario. Look for keywords:
- Healthcare → HIPAA
- Public company financials → SOX
- Federal agency/data → FISMA
- Defense contractor → CMMC
Answer: Choose the framework that matches the organizational context.

Tip 2: Understand the Scope of Protected Data
Different frameworks protect different data types:
- HIPAA: Patient health information (PHI)
- SOX: Financial records and company information
- FISMA: Federal information systems and data
- CMMC: Controlled unclassified information (CUI)
Answer: Select controls specifically designed to protect the identified data type.

Tip 3: Match Controls to Requirements
Questions often ask which control meets a specific requirement. Remember:
- All frameworks require encryption for sensitive data
- All require access controls and authentication
- All require audit logging and monitoring
- All require incident response procedures
Answer: Choose the control that directly addresses the stated requirement.

Tip 4: Focus on Timeframes and Notifications
Regulatory questions often test your knowledge of specific deadlines:
- HIPAA: 60-day breach notification requirement
- SOX: Annual compliance certifications
- FISMA: Continuous monitoring requirements
- CMMC: Recurring assessment requirements
Answer: Identify the correct timeframe when breach notification or reporting is involved.

Tip 5: Distinguish Between Roles and Responsibilities
Different roles have different compliance duties:
- HIPAA: Covered entities and business associates
- SOX: CEO/CFO certifications, internal auditors
- FISMA: Agency CISOs and system owners
- CMMC: C3PAO assessors and contractors
Answer: Choose the answer reflecting the correct party responsible for the action.

Tip 6: Recognize Control Implementation Levels
CMMC uses maturity levels; FISMA uses impact levels. Questions may ask about appropriate control strength:
- Basic controls for low-impact systems
- Advanced controls for high-impact systems
- Risk-based approach to control selection
Answer: Select controls proportionate to the system's risk level.

Tip 7: Know Documentation Requirements
All frameworks require extensive documentation:
- Risk assessments and analysis
- Security plans and procedures
- Audit logs and evidence
- Training records
Answer: Choose documentation-related answers when asked about proof of compliance.

Tip 8: Understand Continuous Improvement
Modern frameworks emphasize ongoing processes:
- Regular assessments and audits
- Vulnerability scanning and penetration testing
- Incident response exercises
- Policy updates based on lessons learned
Answer: Select answers reflecting continuous monitoring and improvement, not one-time compliance.

Tip 9: Recognize Third-Party Involvement
Some frameworks require independent assessment:
- HIPAA: Requires internal compliance officers
- SOX: Requires external auditors
- FISMA: May use accredited assessors
- CMMC: Requires C3PAO (Certified Third-Party Assessors)
Answer: Know when external validation is mandatory.

Tip 10: Look for Trick Answer Elements
Exam answers may include:
- Correct controls but from wrong framework
- Right concept but wrong timeframe
- Correct requirement but wrong implementation
Answer: Ensure the entire answer (not just part of it) correctly addresses the question.

Common Question Patterns

Pattern 1: Scenario-Based Compliance
Question: "A healthcare provider discovers a breach of patient records. What must they do?"
Strategy: Identify the framework (HIPAA), recall the requirement (60-day notification), select the action (notify affected individuals).

Pattern 2: Control Selection
Question: "Which control best addresses the requirement to protect sensitive financial data?"
Strategy: Think about applicable framework (SOX), required control type (encryption), select the specific technology or procedure.

Pattern 3: Regulatory Requirement Matching
Question: "Which requirement is specific to federal contractors?"
Strategy: Identify CMMC or FISMA applies, recall the specific requirement, eliminate non-applicable options.

Pattern 4: Timeline and Notification
Question: "Within what timeframe must a healthcare breach be reported?"
Strategy: Know HIPAA's 60-day requirement, select the answer matching this deadline.

Pattern 5: Responsibility and Role Assignment
Question: "Who is responsible for certifying compliance with SOX requirements?"
Strategy: Recall Section 302 requires CEO and CFO certifications, select that answer.

Final Study Recommendations

• Create comparison charts: Compare frameworks side-by-side by purpose, scope, and key requirements
• Memorize key terms: PHI (HIPAA), CUI (CMMC), Federal information (FISMA), financial records (SOX)
• Practice scenario questions: Test your ability to identify correct framework and appropriate controls
• Review actual framework documents: NIST SP 800-53 (FISMA), NIST SP 800-171 (CMMC baseline)
• Understand the why: Know the business reason behind each control and requirement
• Stay current: Regulatory requirements evolve; understand the core concepts, not just memorized facts

Mastering regulatory compliance frameworks demonstrates you understand how security protects organizations, manages risk, and maintains public trust—core competencies for any security professional.