Medicare, the federal health insurance program that serves the nation’s elderly, certain disabled individuals and individuals with end-stage renal disease, had total program expenditures of $565 billion in 2011, making it one of the largest federal programs. The Medicare program is administered by CMS and consists of four parts: A, B, C, and D. Medicare parts A and B are also referred to as fee-for-service programs. Part A covers hospital and other inpatient stays, hospice, and home health service; and Part B covers hospital outpatient, physician, and other services. The Medicare card is used as proof of eligibility for both of these programs. Part C is Medicare Advantage, under which beneficiaries receive benefits through private health plans. Part D is the Medicare outpatient prescription drug benefit. CMS requires that cards issued by Part C and Part D health plans do not display an SSN. For most individuals, SSA determines eligibility for Medicare and assigns the individual’s HICN. However, for the approximately 550,000 Railroad Retirement beneficiaries and their dependents, the RRB determines Medicare eligibility and assigns this number. CMS or RRB mails paper cards to all beneficiaries, which display the individual’s full name, gender, eligibility status (Part A and/or Part B), their effective date of eligibility, and the SSN-based HICN, referred to on the card as the Medicare Claim Number. (See fig. 1.) The HICN is constructed using the 9-digit SSN of the primary wage earner whose work history qualifies an individual for Medicare, followed by a 1- or 2-character code, referred to as the beneficiary identification code, that specifies the relationship of the card holder to the individual who makes the beneficiary eligible for benefits. In most cases, the SSN on the card is the card holder’s own; however, approximately 14 percent of Medicare beneficiaries have cards that contain the SSN of the family member whose work history makes the beneficiary eligible for Medicare benefits. A unique identifier is an essential component for administering health insurance. Such an identifier is used by providers to identify beneficiaries and submit claims for payment. As Medicare’s primary unique identifier, the HICN is used by beneficiaries, providers, and CMS and its contractors. State Medicaid programs, which are jointly funded federal- state health care programs that cover certain low-income individuals, use the HICN to coordinate payments for dual-eligible beneficiaries— individuals who are enrolled in both Medicare and Medicaid. (See table 1 for examples of various interactions that require the HICN). Beneficiaries must use their HICN when interacting with CMS, such as when they log into the Medicare website or call 1-800-MEDICARE for assistance. Using their issued card, beneficiaries also provide this information to providers at the time of service, and providers use this information to confirm eligibility and submit claims to receive payment for services. CMS and its contractors operate approximately 50 information technology (IT) systems, many of which are interdependent, that use this information in some manner to process beneficiary services and claims and conduct a number of other activities related to payment and program-integrity efforts. These IT systems vary considerably in terms of age and interoperability, making them difficult to change. In its November 2011 report, CMS proposed three options for removing SSNs from Medicare cards. One option would involve altering the display of the SSN through truncation, and the other two options would involve the development of a new identifier. All three options would vary with regard to the type of identifier displayed on the card and the actions providers and beneficiaries would need to take in order to use the identifier for needed services. CMS officials told us that they limited their options to those retaining the basic format of the current paper card, and did not consider other options that they believed were outside the scope of the congressional request. For example, CMS did not consider using machine-readable technologies, such as bar codes or magnetic stripes. Option 1: Truncating the SSN: Under this option, the first five digits of the SSN would be replaced with ‘X’s (e.g., XXX-XX-1234) for display on the card. However, the full SSN would continue to be used for all Medicare business processes. As a result, when interacting with CMS, beneficiaries would need to recall the full SSN or provide additional personally identifiable information in order for CMS to match the beneficiary with his or her records. To interact with CMS, providers would also need to obtain the complete SSN using an existing resource. This would involve querying an existing database, calling a CMS help line, or asking the beneficiary for the complete SSN or other personally identifiable information. Option 2: Developing a New Identifier for Beneficiary Use: Under this option, the SSN would be replaced by a new identifier not based on the SSN that would be displayed on the card, similar to private health insurance cards. CMS refers to this new identifier as the Medicare Beneficiary Identifier (MBI). This number would be used by beneficiaries when interacting with CMS. Providers, however, would be required to continue to use the SSN when interacting with CMS and conducting their business processes. To obtain this information, providers would be expected to electronically request it from CMS using the new identifier. CMS said it would need to create a new database for this purpose. Option 3: Developing a New Identifier for Beneficiary and Provider Use: Under this option, the SSN would be replaced by a new identifier not based on the SSN, which would be displayed on the card. As in option 2, CMS referred to this number as the MBI. In contrast to option 2, however, this new number would be used by both beneficiaries and providers for all interactions with CMS. Under this option, the SSN would no longer be used by beneficiaries or providers when interacting with CMS, which could eliminate the need for providers to collect or keep the SSN on file. CMS and its contractors would continue to use the SSN for internal data purposes, such as claims processing. Table 2 summarizes the characteristics of the CMS options. CMS, SSA, and RRB reported that all three options would generally require similar efforts, including coordinating with stakeholders; converting IT systems; conducting provider and beneficiary outreach and education; conducting training of business partners; and issuing new cards. However, the level and type of modifications required to IT systems vary under each option. These systems are responsible for various business functions that perform claims processing, eligibility verification, health plan enrollment, coordination of benefits, program integrity, and research efforts. According to CMS, between 40 and 48 of its IT systems would require modifications, depending on the option selected. The truncated SSN option would require modifications to 40 systems; the option that uses a new identifier for beneficiary use would require modifications to 44 systems; and the option that uses a new identifier for beneficiary and provider use would require modifications to 48 systems. In its 2011 report, CMS estimated that any of the 3 proposed options would likely take up to 4 years to implement. During the first 3 years, CMS would coordinate with stakeholders; complete necessary IT system conversions; conduct provider and beneficiary outreach and education; and conduct training of business partners. In the fourth year, CMS would issue new Medicare cards to all beneficiaries over a 12-month period. CMS officials stated that the agency could not implement any of the options without additional funding from Congress. In its report, CMS noted that the actual time needed for implementation could vary due to changing resources or program requirements. Similar to its 2006 report, CMS has not taken action needed to implement any of the options for removing the SSN it presented in its report. DOD has taken steps to remove the SSN from display on the approximately 9.6 million military identification cards that are used by active-duty and retired military personnel and their dependents to access health care services. DOD is replacing the SSNs previously displayed on these cards with two different unique identifiers not based on the SSN. In 2008, DOD began its SSN removal effort by removing dependents’ SSNs from display on their military identification cards, but retained the sponsor’s SSN and left SSNs embedded in the cards’ bar codes. The dependents’ cards did not display any unique identifier. On June 1, 2011, DOD discontinued issuing any military identification card that displayed an SSN and began issuing cards that displayed two different unique identifiers; however, SSNs continued to be embedded in the cards’ bar codes. Starting December 1, 2012, DOD will discontinue embedding the SSN in the cards’ bar codes. With the exception of cards issued to retired military personnel, DOD anticipates that the SSNs will be completely removed from all military identification cards by December 2016.contain the SSN as an identifier, and because some contractors providing DOD officials reported that because retirees’ cards may still health care services may continue to use the SSN for eligibility purposes and processing claims, DOD’s IT systems will continue to support multiple identifiers, including the SSN, until such time as all SSNs have been replaced with the two new unique identifiers. DOD cards issued to active- duty military personnel also contain a smart chip, which is used for accessing facilities and IT systems, and may be used to access health care services in some facilities. Cardholders’ SSNs are concealed in the smart chip. VA has also taken steps to remove the SSN from display on its identification and health care cards. The Veterans Identification Card (VIC) is issued by VA to enrollees and can be used by veterans to access health care services from VA facilities and private providers. In 2011, 8.6 million veterans were eligible to receive health care services and, according to VA officials, about 363,000 dependents of veterans were VA eligible to receive care through VA’s dependent-care programs.