FAQs

Before you select a plan, carefully consider the following questions:

• Do you already have a doctor?
• Are you choosing a new doctor?
• Is freedom to choose doctors and hospitals necessary to you?
• Do you need a prescription drug plan?
• What drugs are covered by the plan’s formulary?
• Does your doctor feel comfortable with the plan’s guidelines
  for your treatment?

HMO stands for Health Maintenance Organization, a health care system that assumes or shares risks and the delivery risks associated with providing comprehensive medical services to a voluntary population in a particular geographic area, usually in return for a fixed, prepaid fee.

"Providers" is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the state to provide health care services. We call them "plan providers" when they participate in HealthSun Health Plans network.

When you become a member of HealthSun Health Plans, you must choose a plan provider to be your PCP. Your PCP is a physician who meets state requirements and is trained to give you basic medical care. Your PCP will also coordinate the rest of the covered services you get as a plan member. For example, in order to see a specialist, you usually need to get your PCP's approval first (this is called getting a "referral" to a specialist).

As of January 1, 2006, anyone entitled to Medicare Part A or enrolled in Medicare Part B, regardless of income, was able to take advantage of the prescription drug benefit. This benefit is designed to help Medicare beneficiaries handle the rising cost of drugs and give them easier access to prescription medications.

Cost-sharing occurs when patients pay for a portion of health care costs not covered by health insurance. Examples include copays (any fixed “copayment” amount that a plan requires when a specific service or drug is received), deductibles (any deductible amount a plan may impose before services or drugs are covered) and coinsurance (any “coinsurance” amount, a percentage of the total amount paid for a service or drug, that a plan requires when a specific service or drug is received.

Learn more about HealthSun Health Plans Medicare Advantage plans by calling 305-447-4458 or 1-877-336-2069 seven days a week from 8:00am to 8:00pm. TTY users should call: 1-877-206-0500.

HealthSun Health Plan is an HMO Plan with a Medicare Contract. Enrollment in HealthSun Health Plans depends on contract renewal.

As a HealthSun Health Plans member you will need to choose a PCP. You can do this by selecting one from the Provider Directory you received from HealthSun Health Plans or you may call Member Services Department at 305-447-4458 or toll free 1-877-336-2069, TTY users should call 1-877-206-0500.

Extra Help is also known as the Low Income Subsidy (LIS). The LIS program is for Medicare beneficiaries with limited income and resources to help them pay for their prescription drug costs including monthly premiums, annual deductibles, and copayments. Many Medicare beneficiaries are eligible for these savings and don’t know it. Those who qualify will enjoy free drug coverage or reduced costs on their Part D benefits.

Get more information on how to receive Extra Help.

HealthSun Health Plans is an HMO for people with Medicare. The Medicare program pays us to manage health services for people with Medicare who are members of HealthSun Health Plans. HealthSun Health Plans is not a Medicare supplement policy.

Since HealthSun Health Plans is a Medicare HMO, this means that you will be getting most or all of your health services from the doctors, hospitals, and other health providers that are part of HealthSun Health Plans ("network providers"). Since these doctors, hospitals, and other providers are the ones we are paying to provide your care, they are the ones you must use (except in special situations such as emergencies).

HealthSun Health Plans are made available to Medicare beneficiaries who reside in Miami-Dade, Broward, and Palm Beach counties.

If you need care when you are outside the service area, your coverage is limited. The only services we cover when you are outside our service area are care for a medical emergency, urgently needed care, renal dialysis and care that HealthSun Health Plans or a plan provider has approved in advance.

Yes. HealthSun Health Plans covers prescriptions that are prescribed by your physician and filled at a contracted pharmacy. The HealthSun Health Plans Formulary is a list of prescription drugs (including insulin) that plan doctors refer to when they need to prescribe drugs.

Here’s a quick review of the key dates and deadlines for the upcoming enrollment dates:

• October 1 Benefit and premium information is available from all plans, so you can shop and compare and be ready to enroll by October 15.
• October 15 – December 7 of each year (Annual Election Period, AEP): Medicare beneficiaries can enroll in a Medicare health benefits plan, such as a Medicare Advantage HMO plan, Original Medicare, or a stand-alone prescription drug plan (PDP).

Yes, you can find more information about our Multi-language Interpreter Services here.