Medicare Plans Overview


Overview of Benefits and Eligibility

HealthSun Health Plans is a Medicare Advantage Health Maintenance Organization (HMO). This website details some features of our plan. It does not list every service that we cover, every limitation, or every exclusion. To get a complete list of our benefits, please click here for the Summary of Benefits or call HealthSun Health Plans Member Service Department and ask for the "Summary of Benefits".

When can I enroll in a Medicare Health Plan?

October 15th through December 7 of every year (Annual Election Period, AEP):
Medicare beneficiaries can choose to enroll in a Medicare Advantage HMO plan, Original Medicare, or a stand-alone prescription drug plan (PDP).

You have choices in your health care

As a Medicare beneficiary, you can choose from different Medicare options. One option is Original Medicare (fee-for-service). Another option is a Medicare Advantage Health Plan, like HealthSun Health Plans, a Medicare Advantage approved HMO. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.

Our members receive all of the benefits that Original Medicare offers. We also offer additional benefits, which may change from year to year.

You may join or leave a plan only at certain times. Please call HealthSun Health Plans at the telephone number listed at the end of this introduction or 1-800-Medicare (1-800-633-4227) for more information. TTY users should call 1-877-486-2048.

Where is coverage available?  What plans are offered?

We offer the following Plans for 2014:

Plan Name Plan Number Service Area
SunPlus Advantage Plan 001 Miami Dade County
SunPlus Advantage Plan 002 Broward County
Healthy Advantage Plan 005 Miami Dade County
Healthy Advantage Plan 009 Broward County
MediMax Plan 006 Miami Dade & Broward Counties
SunPlus Diabetes Special Needs Plan 007 Miami Dade County
SunPlus Diabetes Special Needs Plan 008 Broward County

Our service area includes Miami-Dade and Broward Counties in Florida. You must live in one of these counties to join. If you are in prison, you may not join.

What is included with coverage?

Our Medicare Advantage approved HMO benefit plans cover all the benefits of Original Medicare and much more, including:

  • Medically necessary doctor visits
  • Hospitalization coverage
  • Worldwide coverage for Emergency

Please remember that you must use HealthSun Health Plans' network providers.

View more information about Miami-Dade and Broward Plans or How to Enroll.

Can I choose my doctors?

HealthSun Health Plans has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. Contact our Member Services Department and ask for a current Provider Directory for an up-to-date list. Our number is listed at the end of this introduction.

What happens if I go to a doctor who's not in your network?

If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither HealthSun Health Plans, Inc. nor Original Medicare Plan will pay for these services.

Where can I get my prescriptions if I join this plan?

HealthSun Health Plans has formed a network of pharmacies. You can use any pharmacy in our network. The pharmacies in our network can change at any time. Call us for a current Pharmacy Network List — our hours of operation and numbers are listed at the end of this page.

What happens if I go to a pharmacy that is not in your network?

If you go to a pharmacy that's not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan. For more information, call the telephone number at the end of this page.

Does my plan cover Medicare Part B or Part D drugs?

HealthSun Health Plans does cover both Medicare Part B prescription drugs and Part D prescription drugs.

Does my plan have a prescription drug formulary?

HealthSun Health Plans uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified in writing before the change is made. Contact HealthSun Health Plans for details.

What is a Medication Therapy Management (MTM) program?

A Medication Therapy Management (MTM) Program is a benefit that your plan may offer. You may be identified to participate in a program designed for your specific health and pharmacy needs. It is recommended that you take full advantage of this if you are selected. Contact HealthSun Health Plans for more details.

About Medicare

Medicare is a federal health insurance program for people 65 years old or over and for certain disabled people under 65 years of age. You are automatically enrolled in Medicare hospital insurance (Part A) when you apply for Social Security benefits — usually upon reaching 65 years of age. Part A covers inpatient care in a hospital or a limited stay in a skilled nursing facility. Part B covers physician and outpatient hospital services.

The premium you pay for Part B is deducted from your Social Security benefits. Medicare pays for many health care services and supplies, but it doesn't cover all of your health care costs. For example, you pay a deductible for each hospital stay and coinsurance anytime you use the services of a physician or surgeon. Also, drug coverage is limited.

A Medicare Advantage Plan is a type of Medicare Health Plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. This type of health plan is an alternative to Original Medicare and was created by the Balanced Budget Act of 1997 and the Medicare Modernization Act of 2003. Some examples of Medicare Advantage plans are:

  • Medicare Health Maintenance Organization plans (HMO)
  • Medicare Preferred Provider Organization plans (PPO)
  • Medicare Private Fee-for-Service plans (PFFS)
  • Specials Needs Plans (SNP)
  • Medicare Medical Savings Account Plans (MSA)

Medicare Advantage plans can feature prescription drug benefits, have fixed costs, limits on out-of-pocket expenses, and worldwide coverage for emergency and urgent care.

An HMO is an alternative to Original Medicare and features specific lists of doctors, hospitals, and other providers that you must use to receive benefits. HMOs often provide additional benefits not found in Original Medicare, including coverage for deductibles, steep reductions in coinsurance when you use doctors, a drug benefit plan and wellness or fitness programs. If you select a Medicare Advantage HMO, it replaces your Original Medicare coverage. However, you can return to Original Medicare down the road if you wish.

For additional information on Medicare click on their link: www.Medicare.gov


Additional Questions?

For more information about the plan please call HealthSun Health Plans, Inc. Members Services Department 8:30am to 5:30pm Eastern Standard Time.

Current and Prospective members should call 305-447-4458 or toll free 1-877-336-2069. TTY users should call 1-877-206-0500.

For more information about Medicare, call 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.Medicare.gov on the web.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.

Limitations, co-payments, and restrictions may apply.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of every year.