Member Frequently Ask Questions

Member FAQ

What is an HMO?

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.

What is HealthSun Health Plans?

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).

What is the geographic service area for HealthSun Health Plans?

The HealthSun Health Plans are made available to Medicare beneficiaries in Miami-Dade and Broward County.

What if I have a medical emergency while traveling outside the Miami- Dade County and Broward County areas?

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.

What to do if you have a medical emergency or urgent need for care?

In case of an emergency, you should get care immediately. You do not have to contact your PCP or receive prior authorization in case of an emergency. You can dial 911 for immediate help by phone or go directly to the nearest emergency room, hospital, or urgent care center.

What to do if it is not a medical emergency?

If you need to talk with your PCP or get medical care when the PCP's office is closed, and it is not a medical emergency, call the primary care physician's office number located on your HealthSun Health Plans membership card. There will always be a physician on call to help you. This physician will call you back and tell you what to do.

What are "plan providers"?

"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.

What is a Primary Care Physician (PCP)?

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).

How do you choose a Primary Care Physician (PCP)?

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.

Is there prescription coverage?

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.

Where can I find a list of HealthSun Health Plans providers?

To find a list of providers, please call our Member Services Department at 305-447-4458, or toll free 1-877-336-2069 or
TTY users should call 1- 877-206-0500.

Whom do I call when I have a billing question?

Contact the Member Services Department at 305-447-4458 or toll free
1-877-336-2069, TTY users should call 1-877-206-0500 for assistance with billing issues.