Member Frequently Asked Questions

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 Sun Plus Advantage Plan?

SunPlus Advantage is a Benefit Plan offered by HealthSun Health Plan a Medicare Advantage approved HMO that allows you to choose your own primary care physician. Together, you and your primary care physician (PCP) coordinate all of your care. You even have the option to change your Primary Care Physician at any time. Your Primary Care Physician, will refer you to specialists or hospitals when you need specialized care.

What is the Healthy Advantage Plan?

If you enroll in this plan HealthSun Health Plans will pay your Medicare Part B monthly premium of $96.40 per month. This means that while you are enrolled in this plan, the U.S. Social Security Administration will increase the amount of your monthly Social Security check by $96.40. You will not have to complete any paperwork to receive this benefit, only the enrollment application. You might not see the increase in your Social Security check for several months after the effective date of the plan. However, once the Social Security Administration completes the application processing, your next check will include the increases for all of the delayed months. If you disenroll from this plan, some delays may occur. Your monthly Social Security Check might include the additional $96.40 for several months after your disenrollment. Once the processing is completed, the U.S. Social Security Administration will deduct the full amount for the retroactive monthly Part B payments from your next Social Security check.

What is the Medimax Plan?

The MediMax Plan has a $310 yearly deductible but if the beneficiary qualifies he or she would receive assistance towards the payment of the deductible. In addition, the plan provides reductions to the co-pays and provides for more OTC benefits than our other Plans while offering the defined standard Part D benefit.

The MediMax Benefit Plan offered by HealthSun Health Plan allows you to choose your own primary care physician. Together, you and your primary care physician (PCP) coordinate all of your care. You even have the option to change your Primary Care Physician at any time. Your Primary Care Physician will refer you to specialists or hospitals when you need specialized care.

What is the Sun Plus Diabetes Needs Plan?

If you have been diagnosed with Diabetes mellitus you may be eligible to join this plan. The SunPlus Diabetes Special Needs Plan offererd by HealthSun Health Plans allows for you to choose your own primary care physician. You will receive coordination of care for your medical needs. This will occur with the help of your your primary care and all other providers involved in your medical care.

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 an emergency, you should get care immediately. You do not have to contact your PCP or get permission in 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.

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.