CMMC Compliance for Healthcare Organizations

CMMC Compliance for Healthcare Organizations: Your Step-by-Step Guide to Certification

For healthcare organizations that work with the Department of Defense (DoD) or handle sensitive government contracts, Cybersecurity Maturity Model Certification (CMMC) is no longer optional—it’s a requirement. Any healthcare entity that manages Federal Contract Information (FCI) or Controlled Unclassified Information (CUI) must meet CMMC security standards or risk losing valuable government contracts.

Unlike commercial healthcare compliance frameworks like HIPAA, CMMC focuses on protecting DoD-related data from cyber threats. As cyberattacks on healthcare organizations continue to rise, meeting CMMC standards not only ensures compliance but also strengthens your overall security posture.

This guide breaks down the key considerations, costs, timelines, and risks involved in CMMC compliance for healthcare organizations. Whether you’re preparing for self-assessment or a third-party audit, this information will help you make informed decisions.

Understanding CMMC Levels and Their Impact on Healthcare

CMMC 2.0 is designed to protect sensitive government data across the entire Defense Industrial Base (DIB). It consists of three levels, each with increasing security requirements:

Key Requirements of Level 1

Implements 15 basic security practices derived from FAR 52.204-21.

Focuses on basic cyber hygiene. While Level 1 does not require advanced cybersecurity measures, the DoD expects contractors to implement basic security best practices, including password security, access controls, and network security.
Requires an annual self-assessment (no third-party certification required). Unlike CMMC Level 2, which mandates third-party assessments, Level 1 companies can self-assess their compliance. However, this does not mean the process should be taken lightly.

Key Requirements of Level 2

Implements 110 security controls based on NIST SP 800-171 rev2.
Requires stronger cybersecurity protections, including:
- Multi-factor authentication (MFA) for all privileged accounts.
- End-to-end encryption of CUI.
- Strict access control measures (least privilege).
- Continuous system monitoring and incident response plans.
Some contractors may self-assess, while others must obtain third-party certification from a C3PAO (Cyber-AB Certified Third-Party Assessment Organization). To qualify for self-assessment, the organization must not work with CUI critical to national security.

Key Requirements of Level 3

Implements additional controls from NIST SP 800-172.
Requires enhanced security measures, such as:
- Zero-trust architecture.
- Real-time threat detection.
- Advanced penetration testing.
Third-party assessments conducted by the DoD’s Defense Industrial Base Cybersecurity Assessment Center (DIBCAC).

Important Note: The DoD is still refining Level 3 requirements, but companies should focus on achieving full Level 2 compliance first.

Why CMMC Matters for Healthcare Organizations

Protecting Patient & Government Data

Healthcare organizations handle highly sensitive information, including:

Electronic Health Records (EHRs)
Personally Identifiable Information (PII)
Protected Health Information (PHI)
Controlled Unclassified Information (CUI) from government contracts

CMMC adds a layer of protection beyond HIPAA compliance, ensuring healthcare contractors meet DoD security expectations.

Preventing Cybersecurity Breaches

Ransomware attacks on hospitals and healthcare providers have surged by more than 94% since 2021 (Sophos State of Ransomware in Healthcare Report 2022).
The average cost of a healthcare data breach is $10.93 million per incident (IBM Security Report 2023).
Implementing CMMC security controls helps mitigate these risks by securing network infrastructure, endpoints, and sensitive data.

Maintaining DoD Contract Eligibility

The DoD is increasing enforcement of cybersecurity requirements.
Non-compliance could result in contract loss, fines, and reputational damage.
CMMC compliance ensures continued eligibility for government-funded healthcare programs.

The CMMC 2.0 Timeline

2024: Final rule published indicating that SMBs should begin compliance efforts immediately.
2025: DoD starts including CMMC requirements in contracts.
2026-2028: Full rollout— A three-year phased rollout means more contracts will include CMMC requirements as time goes on.

Waiting until the last moment to get certified really isn’t an option as the entire process typically takes 9-12 months. In fact, according to a DIB Contractor Survey, 73% have spent more than 1 year preparing for CMMC and still aren’t done. Being proactive puts you ahead of the curve.

Key Considerations for Small Businesses

Business Size and Internal Capabilities
- Do you have in-house IT/security staff with compliance experience?
- Can your team handle ongoing cybersecurity management and audits?
- How much time can your staff dedicate to compliance efforts?

Type of Data You Handle
- Only FCI? A Level 1 self-assessment may be enough.
- Handling CUI? You’ll need a Level 2 third-party assessment.

Contract Eligibility and Competitive Advantage
- DoD is increasing enforcement of cybersecurity requirements.
- Non-compliance means losing current and future contracts.
- Early compliance can be a competitive advantage in securing DoD contracts.

Cost and Budget Considerations
- DIY approaches may save upfront costs but can lead to costly mistakes.
- Hiring a consultant requires a greater investment but reduces risk and speeds up certification.
- Implementing security controls may require new tools, software, or system upgrades.

Key Considerations for Healthcare Organizations

Business Size and Internal Capabilities

Do you have in-house IT/security staff with compliance experience?

Can your team handle ongoing cybersecurity management and audits?

How much time can your staff dedicate to compliance efforts?

Type of Data You Handle

Only FCI? A Level 1 self-assessment may be enough.

Handling CUI? You’ll need a Level 2 third-party assessment.

Contract Eligibility and Competitive Advantage

DoD is increasing enforcement of cybersecurity requirements.

Non-compliance means losing current and future contracts.

Early compliance can be a competitive advantage in securing DoD contracts.

Cost and Budget Considerations

DIY approaches may save upfront costs but can lead to costly mistakes.

Hiring a consultant requires a greater investment but reduces risk and speeds up certification.

Implementing security controls may require new tools, software, or system upgrades.

DIY vs. Hiring a Consultant: Which is Right for You?

Factor	DIY (Self-Assessment)	Consultant-Assisted
Cost	Lower upfront cost	Higher initial investment, but cost-effective long term
Time	Takes longer	Faster due to expert guidance
Compliance Risk	Higher (risk of errors)	Lower (expert ensures compliance)
Best for	Level 1 businesses with strong IT teams	Level 2 businesses or those needing guidance

DIY vs. Hiring a Consultant: Which is Right for You?

How Healthcare Organizations Can Prepare for CMMC

Step 1: Determine Your CMMC Level

- Do you only support FCI systems? → Level 1 (Self-assessment)
- Do you process, store, or transmit CUI? → Level 2 required
- Not sure? → Review client contracts or ask Contracting Officer (CO).

Step 2: Conduct a CMMC Gap Analysis

Identify missing security controls and create a remediation plan to fix weaknesses before an assessment.

A gap analysis identifies where your current cybersecurity posture falls short of CMMC requirements. This helps you proactively address deficiencies before an official assessment.

How to Perform a Gap Analysis:

Compare Your Existing Security Practices to CMMC Requirements
- Level 1: Do you meet the 15 basic security practices outlined in FAR 52.204-21?
- Level 2: Have you fully implemented all 110 NIST SP 800-171 controls?
- Level 3: Are you prepared for additional NIST SP 800-172 controls and a government-led assessment?
Evaluate Key Areas of Compliance:
- Access Controls – Are users and devices properly authenticated?
- Data Encryption – Is CUI encrypted at rest and in transit?
- Incident Response – Do you have a documented incident response plan?
- Logging & Monitoring – Are you tracking and reviewing logs for suspicious activity?
- Personnel Training – Are all employees trained in cyber hygiene and phishing awareness?
Test Your Existing Security Measures
- Conduct internal security audits and vulnerability scans.
- Review policies, procedures, and system configurations for compliance.
- Identify weak points that need remediation.
Document the Findings and Create an Action Plan
- Categorize gaps as high, medium, or low risk.
- Assign responsibilities and set deadlines for remediation.

As a Cyber-AB Registered Practitioner Organization (RPO), Alluvionic’s CMMC gap analysis services provide defense contractors with a clear, actionable roadmap to CMMC Level 1 or Level 2 certification, ensuring you meet Department of Defense (DoD) cybersecurity requirements without unnecessary costs or delays.

Step 3: Remediate CMMC Gaps

A CMMC gap analysis is like a cybersecurity health check—it identifies the vulnerabilities in your systems, policies, and processes. But just knowing the problems isn’t enough. Remediation is where the real work happens.

CMMC remediation is the process of:

Implementing missing cybersecurity controls (e.g., multi-factor authentication, secure backups, network monitoring).
Enhancing policies and procedures to align with NIST SP 800-171.
Deploying the right security tools to protect your systems from cyber threats.
Training your staff on cybersecurity best practices.
Documenting all security measures so you’re fully prepared for a CMMC assessment.

For companies with limited internal cybersecurity resources, remediation can feel like an insurmountable challenge. You have contracts to fulfill, projects to complete, and employees to manage—you can’t afford a security project that drags on for months and drains your budget. RPOs, like Alluvionic, can lead the remediation effort, ensuring compliance while minimizing disruption to your business.

Step 4: Prepare for CMMC Assessments

Depending on your CMMC level, you’ll need to undergo self-assessments or third-party assessments to maintain compliance.

Assessment Types by Level:

Level 1:
- Annual self-assessment with results submitted to SPRS.
Level 2:
- Some contractors may self-assess, while others must obtain third-party certification from a C3PAO (Cyber-AB Certified Third-Party Assessment Organization). To qualify for self-assessment, the organization must not work with CUI critical to national security.
Level 3:
- Assessments are conducted by the Defense Industrial Base Cybersecurity Assessment Center (DIBCAC).
- It is estimated that only roughly 1% of contractors would require CMMC level 3.

How to Prepare:

Gather all required documentation (policies, procedures, system security plans).
Ensure security controls are properly implemented and tested.
Conduct mock assessments to identify any remaining gaps.

Working with a Cyber-AB Registered Practitioner Organization (RPO) like Alluvionic will help ensure readiness.

Why Choose Alluvionic?

We Make CMMC Crystal Clear
No jargon. No confusion. Just a simple step-by-step process to help IT companies get compliant without the headache.

Trusted by 125+ Government Contractors
We’ve helped IT firms, MSPs, and cybersecurity companies navigate DFARS, NIST, and CMMC, eliminating wasted time and stress.

An Established CMMC Partner
As a Cyber-AB RPO since 2021, we’ve been doing CMMC right since day one.

Women-Owned. Small Business Focused.
We understand the challenges small & mid-sized MSPs face, and we tailor solutions to fit your budget and timeline.

Take the Next Step Toward Compliance

Don’t wait until CMMC requirements delay your contract eligibility. Take proactive steps to secure your business and remain competitive.

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Step 2: Conduct a CMMC Gap Analysis

Identify missing security controls and create a remediation plan to fix weaknesses before an assessment.

A gap analysis identifies where your current cybersecurity posture falls short of CMMC requirements. This helps you proactively address deficiencies before an official assessment.

How to Perform a Gap Analysis:

Compare Your Existing Security Practices to CMMC Requirements
- Level 1: Do you meet the 15 basic security practices outlined in FAR 52.204-21?
- Level 2: Have you fully implemented all 110 NIST SP 800-171 controls?
- Level 3: Are you prepared for additional NIST SP 800-172 controls and a government-led assessment?
Evaluate Key Areas of Compliance:
- Access Controls – Are users and devices properly authenticated?
- Data Encryption – Is CUI encrypted at rest and in transit?
- Incident Response – Do you have a documented incident response plan?
- Logging & Monitoring – Are you tracking and reviewing logs for suspicious activity?
- Personnel Training – Are all employees trained in cyber hygiene and phishing awareness?
Test Your Existing Security Measures
- Conduct internal security audits and vulnerability scans.
- Review policies, procedures, and system configurations for compliance.
- Identify weak points that need remediation.
Document the Findings and Create an Action Plan
- Categorize gaps as high, medium, or low risk.
- Assign responsibilities and set deadlines for remediation.

Download Our Project Assurance^® Checklist

It’s simple. A project that gets off on the right foot is likely to take a successful journey. So why do so many projects fail? Use this checklist to assure your project succeeds from the beginning.

Whether you need project management, process improvement, cybersecurity, product development, training, or government services, Alluvionic has the expertise to provide Peace of Mind and Project Assurance^®.