HealthSun HealthAdvantage Plan (HMO) H5431-013 is a 2023 Medicare Advantage Plan or Part-C by HealthSun Health Plans, Inc. available to residents in Florida. This plan includes extra prescription drug (Part-D) coverage. HealthSun Health Plans, Inc. HealthSun HealthAdvantage Plan (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,450 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay
$3,450 out-of-pocket. This can be an extremely nice safety net.
HealthSun Health Plans, Inc. works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for HealthSun HealthAdvantage Plan (HMO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance)
and Part B (Medical Insurance) coverage from HealthSun Health Plans, Inc. and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all
the benefits of Original Medicare from HealthSun Health Plans, Inc. except hospice care. Original Medicare still provides you with hospice care if you sign up for
Medicare Advantage in Florida.
What type of plan is HealthSun HealthAdvantage Plan (HMO)
HealthSun HealthAdvantage Plan (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.
How much does HealthSun HealthAdvantage Plan (HMO) cost?
Monthly Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. HealthSun Health Plans, Inc. charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. HealthSun HealthAdvantage Plan (HMO) has a monthly drug premium of $0 and a $0 drug deductible. This HealthSun Health Plans, Inc. plan offers a $0 Part-D Basic Premium that is Not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by HealthSun Health Plans, Inc. above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
HealthSun Health Plans, Inc. Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers extra coverage. This HealthSun Health Plans, Inc. plan does offer extra coverage through the gap.
MOOP
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. HealthSun HealthAdvantage Plan (HMO) by HealthSun Health Plans, Inc. MOOP is $3,450. Once you spend $3,450 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.
Formulary and Drug Coverage
HealthSun HealthAdvantage Plan (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.
By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what HealthSun HealthAdvantage Plan (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from HealthSun Health Plans, Inc. helps
get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
$0 per day for days 1 through 20 $55 per day for days 21 through 100
Occupational therapy visit
Rehabilitation services
$5 copay
Physical therapy and speech and language therapy visit
Rehabilitation services
$0-5 copay
Cleaning
Preventive dental
$0 copay
Dental x-ray(s)
Preventive dental
$0 copay
Fluoride treatment
Preventive dental
$0 copay
Oral exam
Preventive dental
$0 copay
Preventive care
$0 copay
Outpatient hospital coverage
$15 copay per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$0 copay per stay
Outpatient group therapy visit
Mental health services
$0 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$0 copay
Outpatient individual therapy visit
Mental health services
$0 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$0 copay
Chemotherapy
Medicare Part B drugs
0-20% coinsurance
Other Part B drugs
Medicare Part B drugs
0-20% coinsurance
Diabetes supplies
Medical equipment/supplies
$0 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
$0 copay or 10% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
10% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$3,450 In-network
Inpatient hospital coverage
$20 per day for days 1 through 6 $0 per day for days 7 through 90
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$0 copay
Hearing exam
Hearing
$0 copay
Health plan deductible
$0
Ground ambulance
$250 copay
Foot exams and treatment
Foot care (podiatry services)
$0 copay
Routine foot care
Foot care (podiatry services)
$0 copay
Emergency
Emergency care/Urgent care
$75 copay per visit (always covered)
Urgent care
Emergency care/Urgent care
$0 copay
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0 copay
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$0-15 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$0-15 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0-15 copay
Diagnostic services
Comprehensive dental
Not covered
Endodontics
Comprehensive dental
$0 copay
Extractions
Comprehensive dental
$0 copay
Non-routine services
Comprehensive dental
Not covered
Periodontics
Comprehensive dental
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0 copay
Restorative services
Comprehensive dental
$0 copay
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
HealthSun HealthAdvantage Plan (HMO) Reviews
Is HealthSun HealthAdvantage Plan (HMO) a good plan? HealthSun HealthAdvantage Plan (HMO) received a 5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.
Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare HealthSun HealthAdvantage Plan Reviews among several different plans.
2022 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing
Staying Healthy, Screening, Testing, & Vaccines
Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity
Managing Chronic And Long Term Care for Older Adults
Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy
Member Experience with H5431-013 Health Plan
Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination
Member Complaints and Changes in Plans Performance
Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement
Health Plan Customer Service Rating for HealthSun Health Plans, Inc.
Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language
Drug Plan Customer Service Ratings
Total Rating
Call Center, TTY, Foreign Language
Ratings For Member Complaints and Changes in the Drug Plans Performance
Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement
Member Experience with the Drug Plan
Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs
Drug Safety and Accuracy of Drug Pricing
Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for HealthSun HealthAdvantage Plan (HMO) requires you to live in that plan’s service area. The service area is listed below:
How much does HealthSun HealthAdvantage Plan (HMO) cost?
HealthSun Health Plans, Inc. charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
How much is HealthSun HealthAdvantage Plan (HMO) MOOP?
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. HealthSun HealthAdvantage Plan (HMO) by HealthSun Health Plans, Inc. MOOP is $3,450. Once you spend $3,450 you will pay nothing for Part A or Part B covered services.
What type of plan is HealthSun HealthAdvantage Plan (HMO)?
HealthSun HealthAdvantage Plan (HMO) is a Local HMO. With a health maintenance organization you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).
Is HealthSun HealthAdvantage Plan (HMO) a good plan?
HealthSun HealthAdvantage Plan (HMO) received a 5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.
Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit.
Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.
Site Search:
MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.
Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
