General Information

Windsor Medicare Extra (WME) plans are products of Windsor Health Plan, Inc. Windsor Health Plan, Inc. has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare, to provide Medicare coverage plus additional benefits to Medicare beneficiaries within our approved service areas.

The Medicare program pays us to manage health services for people with Medicare who are members of the Windsor Medicare Extra plans. Windsor Medicare Extra plans provide medical and prescription drug benefits and services through Medicare-certified health care facilities and pharmacies. In addition, our health care professionals are in compliance with Medicare credentialing standards.

The Windsor Medicare Extra plans give you all of the usual Medicare services that are covered for everyone with Medicare however we also have plans that offer additional services such as enhanced vision and hearing benefits, as well as transportation and monthly over the counter drug allotments.

Choices for Getting Your Medicare Coverage

No matter what kind of plan you enroll in you can always get your Original Medicare back but in most cases you will pay less if you enroll in a Medicare Advantage and Prescription Drug (MA-PD) plan from a company like Windsor Medicare Extra. If you choose to keep Original Medicare you can also join a stand alone prescription drug plan (PDP) like Windsor Rx and Windsor Rx Plus. Another choice is to join a Private Fee for Service plan (PFFS) like Windsor Medicare Extra Tennessee Choice or Windsor Medicare Extra Tennessee Choice + RX, if these plans are available in your area and are accepting new members.

Medicare coverage consists of four different “parts,” A, B, C and D. A brief description of each follows:

Part A includes hospital services, critical access hospitals, home health, hospice and skilled nursing facilities. There is usually no premium for enrolling in Part A and enrollment is automatic.
Part B covers services that doctors perform, outpatient care, and other medical services that Part A doesn’t cover. You have your choice of doctors. Part B is optional. Your costs may be higher than in Medicare Advantage Plans. Part B also covers some preventive services. You pay the Part B premium each month which is determined by your level of income. In some cases, this amount may be higher if you didn’t sign up for Part B when you first became eligible. You also pay a Part B deductible each year before Medicare starts to pay its share. You may be able to get help from your state to pay this premium and deductible.
Part C includes a combination of Part A (Hospital) and Part B (Medical) coverage. Private insurance companies like Windsor Medicare Extra are approved by Medicare to provide this coverage. Generally, you must see doctors in the plan’s network. Your costs may be lower than in the Original Medicare Plan, and you may get extra benefits.
Part D is Prescription Drug Coverage Most Part C plans cover prescription drugs. If they don’t, you may be able to choose this coverage. Plans cover different drugs. Medically necessary drugs must be covered.

For more information on Medicare Parts A & B coverage refer to your Medicare and You 2007 booklet that you received in the mail or visit www.medicare.gov and select “Search Tools” at the top of the page. Then select “Find Out What Medicare Covers.” Or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 1-800-MEDICARE, (1-800-633-4227), TTY users should call 1-877-486-2048.

What Kind of Plans Can I Join?

Medicare Advantage Plans (MA). MA plans must cover all Medicare Part A and Part B health care. Some plans like Windsor Medicare Extra cover extras like additional preventive services and transportation. Also called Part C, Medicare Advantage Plans are HMOs, PPOs, Private Fee-for-Service Plans, or Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage Plan like Windsor Medicare Extra, Medicare services are covered through the plan, and are not paid for under the Original Medicare Plan.

Medicare Advantage -Prescription Drug Plans (MA-PD): Some MA plans like Windsor Medicare Extra also offer prescription drug coverage as part of the Medicare Part D (Prescription Drug) benefit. This coverage should lower your prescription drug costs. It can give you greater access to preventive drugs that you need to stay well. If you join a Medicare drug plan, you usually pay a monthly premium. Part D is optional. If you decide not to enroll in a Medicare drug plan when you are first eligible, you may pay a penalty if you choose to join later.

Original Medicare: Original Medicare is always available throughout the country. It is a “fee-for-service” health plan that lets you go to any doctor, hospital, or other health care provider who accepts Medicare. You must pay a deductible. Then Medicare pays its share of the Medicare-approved amount, and you pay your share. If you choose Original Medicare, you must choose a Prescription Drug Plan if you wish to continue to have Medicare prescription drug coverage.

Private Fee for Service Plans (PFFS): Medicare Private Fee-for-Service Plans are available in some parts of the country. Windsor Medicare Extra offers PFFS plans in the entire state of Tennessee. These plans are called “Windsor Medicare Extra TN Choice” and “Windsor Medicare Extra TN Choice + Rx.” In Private Fee-for-Service plans, you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The Private Fee-for-Service plan, rather than the Medicare program, decides how much it pays and what you pay for the services you will get. You may get extra benefits that Original Medicare does not cover, like prescriptions drugs as part of the Medicare Part D (Prescription Drug) benefit. Private Fee-for-Service plans are not the same as Medigap (Medicare supplement insurance) policies.

Be sure to look over your current health insurance coverage and ask yourself the following questions:

Are prescription drugs covered?

Are my prescription drugs covered?

What are the out-of-pocket costs?

Are my doctors and hospitals in the plan’s network?

Does the plan offer enhanced benefits above what Original Medicare or other plan’s offer?

Windsor Medicare Extra Eligibility and Enrollment: In general, an individual is eligible to elect and enroll into MA plan when each of the following requirements is met:

You are entitled to Medicare Part A and enrolled in Part B and are entitled to receive services under Medicare Part A and Part B as of the effective date of coverage under the plan.
You have not been medically determined to have End Stage Renal Disease (ESRD) prior to completing the enrollment election.
You permanently reside in our service area.
An individual or his/her legal representative completes an enrollment election and includes all the information required to process the enrollment or meets alternative conditions for enrollment specified by CMS.
You are fully informed of and agree to abide by the rules of the plan that were provided during the election process.
You make a valid election during a valid election period.

Windsor Medicare extra will not deny enrollment to otherwise eligible individuals covered under an employee benefit plan. If the individual enrolls in an MA plan and continues to be enrolled in his/her employer’s or spouse’s health benefits plan, then your benefits will be coordinated and Medicare benefits rules apply.

An MA eligible individual may not be enrolled in more than one MA plan at any given time.

Enrollment/Election Periods

In order for WME to accept an election, the individual must make the election during an election period. There are four types of election periods during which individuals may enroll. They are:

The Annual Election Period (AEP);
The Initial Coverage Election Period (ICEP);
All Special Election Periods (SEP); and
The Open Enrollment Period (OEP).

Unless a CMS-approved capacity limit applies, all MA organizations must accept elections into their MA plans (with the exception of Medicare MSA plans) during the AEP, ICEP, and any SEP that allows enrollment into the specific plan.

The AEP: During the AEP, MA eligible individuals may enroll in or disenroll from an MA plan. The last election made, determined by the application date, will be the election that takes effect. The AEP occurs November 15 through December 31 of every year.

The ICEP: The ICEP is the period during which an individual newly eligible for MA may make an initial election to enroll in an MA plan. This period begins three months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of:

The last day of the month preceding entitlement to both Part A and Part B, or;
The last day of the individual’s Part B initial enrollment period. The initial enrollment period for Part B is the seven (7) month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility, or;
Once an ICEP election is made and enrollment takes effect, the ICEP election has been used. Please note that the ICEP for an MA enrollment election will frequently relate to either the individual’s 65th birthday or the 25th month of disability, but it must always relate to the individual’s entitlement to both Medicare Part A and Part B. When an individual enrolls in an MA-PD plan, s/he has used both the ICEP and the IEP for Part D.

IEP for Part D: The Initial Enrollment Period for Part D (IEP for Part D) is the period during which you are first eligible to enroll in a Part D plan. In general, an individual is eligible to enroll in a Part D plan when he or she is entitled to Part A or enrolled in Part B, and permanently resides in the service area of a Part D plan. Individuals eligible for Medicare prior to age 65 (such as for disability) will have another Initial Enrollment Period for Part D based upon attaining age 65.

Open Enrollment Period:

In 2007 and each year thereafter, an MA eligible individual may make one MA OEP election from January through March 31st.

An individual who is enrolled in an MA-PD plan may elect another MA-PD plan or disenroll from the MA-PD by enrolling in a PDP (there is a corresponding SEP to permit this Part D enrollment). To effectuate this election, the individual must elect an MA-PD plan or enroll in a PDP. Either action will generate an automatic disenrollment from the current MA-PD plan.
An individual enrolled in a PDP may elect an MA-PD. Such individual may not elect an MA plan that does not include Part D coverage.
An individual who is enrolled in an MA plan and who does not have Part D coverage may elect another MA plan that does not include Part D coverage or may elect to disenroll from the MA plan.
An individual enrolled in Original Medicare (or a non-MA Medicare health plan, such as a cost plan) but not in a PDP may elect an MA plan that does not include Part D coverage. Such individual may not elect an MA-PD plan during this period.

NOTE: An OEP enrollment election into another MA plan that results in an automatic disenrollment from a current plan will count as 1 OEP election.

Open Enrollment Period for Institutionalized Individuals (OEPI)

Beginning January 2006, the OEPI is continuous for institutionalized individuals. For purposes of enrollment under the OEPI election period, an institutionalized individual is defined as an individual who moves into, resides in, or moves out of an institution. The SEP ends two months after the month the individual moves out of the institution.

If You Have Employer or Union Prescription Coverage:

If you have prescription drug coverage from a former or current employer or union, contact your benefits administrator before you make any changes to your drug coverage. If you join a Medicare Prescription Drug Plan or Medicare Advantage Plan, you and your family may lose your employer or union coverage.

What Are Special Election Periods?

You may have a Special Election Period if one of the following things is true:

You have had a change in residence
You recently lost an Employer Group Health Plan
You are a full Benefit Dual Eligible that has Medicaid coverage or other Low Income Subsidy such as SSI cash benefits without Medicaid.
You a current resident of an institution, such as a nursing facility or long-term care hospital.
You recently received a notice telling you that you have been approved for Medicare for a “retroactive” date.
You currently enrolled in a special plan called “PACE.”

Methods for enrolling into a Windsor Medicare Extra plan:

You must complete an enrollment form, or;
Enroll by phone with a WME Enrollment Counselor, or;
Enroll online on the Windsor Medicare Extra website or Medicare’s website, or;
Have a legal authorized representative enroll you through one of the above methods.

Even if you are a Windsor Medicare Extra member and you are electing another one of Windsor Medicare Extra’s plans you must complete a new enrollment election. Call us @ 1-800-316-2273 (or TTY for the hearing impaired 1-800-848-0298) from 7:00 a.m. to 8:00 p.m. Central Standard Time, 7 days a week and we can send you the appropriate plan to plan enrollment form.

Once WME receives notice from Medicare we will send you a notice of confirmation of enrollment, rejection of enrollment, or a denial of enrollment and the reason.

Auto Enrollment

People with Medicare and full Medicaid coverage who haven’t joined a plan on their own will be enrolled by Medicare in a Medicare prescription drug plan with the lowest premium in your area. You will receive a letter from Medicare telling you which plan you were auto enrolled into. Please call the plan you are enrolled in for more information about your new Medicare prescription drug coverage. When you call the plan, they may ask for your address. You may also visit plan website for more information.

Opting Out: You may opt-out, or affirmatively decline, the Part D plan that Medicare auto enrolls you into. For an MA-only plan enrollee, this means declining auto-enrollment into an MA-PD plan in the same organization and maintaining enrollment in the MA only plan. Remember, if you opt out of a Part D plan and stay with an MA plan or Original Medicare only and do not choose another prescription drug plan you will not have any prescription drug coverage. If you would like to switch from the plan that Medicare assigned you to a Windsor Rx or Windsor Rx Plus plan, call 1-800-MEDICARE @ (1-800-633-4227) or toll free @ 1-800-633-4227 (for TTY/TDD users call 1-877-486-2048), 24 hours a day/7days a week; or go to the Medicare website @ www.medicare.gov.

Getting Help Paying for the Costs of Prescription Drug Coverage:

If you have Medicare and have limited income and resources, you may qualify for extra help paying for prescription drugs. The low income subsidy is extra help with prescription drug costs for Medicare-eligible individuals whose income and resources are limited. This help is in the form of payments to the Part D Plan that you join. Persons eligible for Medicaid, Supplemental Security Income (SSI), or a Medicare Saving Program qualify for the extra help automatically and do not need to apply. All others may apply with the Social Security Administration (SSA) by mail, by telephone, on the Internet at http://www.socialsecurity.gov or in person at a community event or an SSA office. Applications may also be filed at a local Medicaid office.

Beneficiaries can also access the Medicare web site for requirements for the low income subsidy: http://www.cms.hhs.gov/medicarereform/lir.asp, or call the Medicare Service Center @ 1-800-MEDICARE (1-800-633-4227) TTY Toll-Free: 866-226-1819.

What Drugs Does Windsor Medicare Extra Plans Cover?

A formulary is a list of drugs selected by Windsor Medicare Extra plans for coverage by our plans. This formulary is reviewed and approved by Medicare. Windsor Medicare Extra plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Windsor Medicare Extra plan network pharmacy, and other plan rules are followed.

Windsor Medicare Extra may add or remove drugs from the formulary during the year.

We will provide 60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug. Original Medicare does not cover very many prescription drugs outside of a hospital. So, if you want to change from your Windsor Medicare Extra plan to Original Medicare, you should think about whether you want to also join a Medicare Prescription Drug Plan. It is important to know that if you are eligible to join a prescription drug plan and you do not, you may have to pay a higher premium when you do join.

Appeals and Grievances: Members of Windsor Medicare Extra plans have the right to appeal any decisions we make related to your medical or prescription drug benefits, including but not limited to a denial, termination, payment, or reduction of services. For more information on the Windsor Medicare Extra plans’ grievance and appeal process, contact Windsor Medicare Extra Member Services at 1-800-316-2273 (or TTY for the hearing impaired 1-800-848-0298) from 7:00 a.m. to 8:00 p.m. Central Standard Time, 7 days a week. You can also access the grievance and appeal process on this website. Simply click on the icon for “Appeals & Grievances.”

Quality Management Program: Windsor Health Plan, Inc. is dedicated to administering benefits to our Windsor Extra plans members effectively and efficiently and we are committed to providing our members access to high quality comprehensive and cost effective medical care. We exercise a stewardship role overseeing the quality of care provided to our members. The intent of Windsor Health Plan’s Quality Management Program is to support contracted providers in order to continually improve the quality and cost effectiveness of services provided to Windsor Extra plans members, and to support the effective and efficient administration of covered benefits. The scope of the Quality Management Program encompasses the populations covered by the Windsor Extra plans and is comprehensive, spanning the full range of clinical and health administrative services provided to all members.

Medication Therapy Management Program: Windsor Health Plan, Inc. recognizes the importance for monitoring medications to prevent potential adverse events and establishing best practices outcomes. Our Windsor Extra plans have a Medication Therapy Management Program that is designed to be patient focused, aimed at improving therapeutic outcomes and identifying best practices. This process will involve a Medication Therapy Management Team consisting of pharmacy, case management, disease management, member service, provider services and utilization management staff with oversight provided by the Chief Medical Officer. The program consists of identifying beneficiaries who are eligible for the program and communicating with the member and providers, developing interventions, promoting educational opportunities and working directly with the member to help them improve their health related outcomes.

Utilization Management Program: Windsor’s Utilization Management Program is designed to oversee the role of the health plan in administering covered benefits performed by Windsor Medicare Extra plans network providers in accordance with medical necessity and appropriateness. Our goal is to offer high quality, medically appropriate care efficiently and to evaluate, monitor and coordinate services for members of Windsor Medicare Extra health plans. An integral part of the Utilization Management Program involves communication. The member and provider receive written and /or verbal notification of the health plan’s decision with regard to a request for services. This information is recorded on-line in the utilization management system. The physicians and member are informed of their rights to appeal any non-coverage decision per the formal appeal and grievance process.

What is “Disenrollment”?

“Disenrollment” from your Windsor Medicare Extra plan means ending your membership in your Windsor Medicare Extra plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice.) The first step is to be sure that the type of change you want to make and when you want to make it fit with the rules about election periods. If the change does not fit with these rules, you won’t be allowed to make the change. Remember, there are limits to when you may leave, how often you can make changes, and what type of plan you can join after you leave.

There are also a few situations where you would be required to leave. Some of those situations are listed below:

If you do not stay continuously enrolled in both Medicare Part A and Medicare Part B.
If you give us information on your enrollment form that you know is false or deliberately misleading, and it affects whether or not you can enroll in your Windsor Medicare Extra plan.
If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you. We cannot make you leave your Windsor Medicare Extra plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare.
If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
If you do not pay your applicable plan premiums, we will tell you in writing that you have a 30 day grace period during which you can pay the plan premiums before you are required to leave your Windsor Medicare Extra plan.

No member of any Medicare health plan can be asked to leave the plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave your plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

You have the right to make a complaint if we ask you to leave your Windsor Medicare Extra plan.

Whether leaving the plan is your choice or not, until your membership ends, you must keep getting your Medicare services through your Windsor Medicare Extra plan or you will have to pay for them yourself. The exceptions are urgently needed care, care for a medical emergency, out-of-area renal (kidney) dialysis services, and care that has been approved by us. There is another possible exception, if you happen to be hospitalized on the day your membership ends. If this happens to you, call our Member Services department at 615-782-7878 or toll free at 1-800-316-2273 to find out if your hospital care will be covered by your Windsor Medicare Extra plan.

How to Disenroll

First, use any of the following ways to tell us that you want to leave your Windsor Medicare Extra plan:

You can write or fax a letter to or fill out a disenrollment form and send it to Windsor Medicare Extra, Attention: Member Services at 7100 Commerce Way Suite 285 Brentwood, TN 37027 or to our fax number at 615-782-7986. Be sure to sign and date your letter or form. To get a disenrollment form, call us at our Member Services department at 615-782-7878 or toll free at 1-800-316-2273. TTY users should call 1-800-848-0298.
You can call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY Users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

We will then send you a letter that tells you when your membership will end. In most cases, your disenrollment date will be the first day of the month that comes after the month we receive your request to leave.

On your disenrollment date, your membership in your Windsor Medicare Extra plan ends and you can start using your red, white, and blue Medicare card to get services under Original Medicare. You will not get anything in writing that tells you that you have Original Medicare, because you will automatically be in Original Medicare when you leave your Windsor Medicare Extra plan.

If You Disenroll from your Medicare Advantage Plan -do you need to buy a Medigap (Medicare supplement insurance) policy?

If you want to change from your MA plan to Original Medicare, you should think about whether you need to buy a Medigap policy to supplement your Original Medicare coverage. For Medigap advice, you should contact TN Commission on Aging and Disability at 1-877-801-0044. If you are at least 65 and have been eligible for Part B for less than six months, you may still be in your Medigap open enrollment period. If you leave our plan while you are still in your open enrollment period, and you do not have a guaranteed issue right, the Medigap insurer can refuse to sell you a policy, or impose limits based on your health. If you have a “guaranteed issue right,” this means that for a limited period the Medigap insurer must sell you a Medigap policy, even if you have health problems. This is a special, temporary right, which means that if you decide to change to Original Medicare, in certain situations you have a limited time to buy a Medigap policy on a guaranteed issue basis. For example, you have a guaranteed issue right to buy a Medigap policy if you are in a trial period. You may be in a trail period if, in the past 12 months you:

dropped a Medigap policy to join your Windsor Medicare Extra plan or Medicare health plan for the first time; or
joined your Windsor Medicare Extra plan another Medicare health plan when you first became entitled to Medicare at age 65.

Under certain circumstances, if you lose your health plan coverage while you are still in a trial period, the trial period can last for an extra 12 months. TN Commission on Aging and Disability can tell you about other situations where you may have guaranteed issue rights. You may also have a guaranteed issue right if you move out of our service area, or if we stop providing Medicare benefits.

If you do want to buy a Medigap policy, you should refer to your Medicare and You 2007 booklet that Medicare sent you and be sure to follow the instructions for buying a Medigap policy.

Contract Termination or Service Area Reduction:

Windsor Health Plan, Inc. has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed, and either Windsor Health Plan, Inc. or CMS can decide to end it.

If we leave the Medicare program or change our service area so that it no longer includes the area where you live, we will tell you in writing. If this happens, your membership in your Windsor Medicare Extra plan will end, and you will have to change to another way of getting your Medicare benefits. All of the plan benefits and rules will continue until your membership ends. This means that you must continue to get your medical care in the usual way through your Windsor Medicare Extra plan until your membership ends.

Whenever a Medicare health plan leaves the Medicare program or stops serving your area, you will be provided a special enrollment period to make choices about how you get Medicare, including choosing a Medicare Prescrition Drug Plan and guaranteed issue rights to a Medigap policy.

Important Contacts

Below are telephone numbers for organizations that provide nationwide services. These numbers were correct at the time of printing. Sometimes these numbers change.

Social Security

Call for address or name changes, death notification, enrolling in Medicare, to replace your Medicare card, for information about signing up for extra help with prescription drug costs, and about Social Security benefits. www.socialsecurity.gov 1-800-772-1213 TTY 1-800-325-0778

1-800-MEDICARE Helpline

Medicare Service Center @ 1-800-MEDICARE (1-800-633-4227) TTY Toll-Free: 866-226-1819. TTY 1-877-486-2048 or go to www.medicare.gov
Coordination of Benefits Contractor 1-800-999-1118 TTY 1-800-318-8782

Department of Health and Human Services

Office of the Inspector General 1-800-447-8477 TTY 1-800-377-4950 To report fraud or other concerns.

Office for Civil Rights 1-800-368-1019 TTY 1-800-537-7697

Department of Veterans Affairs 1-800-827-1000 TTY 1-800-829-4833

TRICARE

TRICARE for Life 1-888-363-5433 1-866-773-0404

Railroad Retirement Board (RRB)

(RRB beneficiaries only) Local RRB office or 1-800-808-0772