HealthSun HealthAdvantage Plan (HMO) 2024 Benefit Details for Plan H5431-001-0 in Miami-Dade County, FL
HealthSun HealthAdvantage Plan is a HMO Medicare Advantage plan, {with_without_pdp} Part D prescription drug benefits, available in 2024.
This health plan, from HealthSun Health Plans, Inc., includes all Original Medicare benefits, and may offer extra services, but out-of-pocket costs are different.
See more Miami-Dade County, Florida Medicare Advantage Plans.
This plan is rated 4.5 (Good+) stars by CMS making it a top-rated plan.
Plan Basics | |
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Plan ID: | H5431 001 0 |
Plan Type: | Local HMO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $1,500/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $0.00 deductible |
Rx Gap Coverage: | Yes |
Supplemental Benefits: | Vision, Hearing |
Availability: | Miami-Dade County, FL |
Insured By: | HealthSun Health Plans, Inc. |
Summary of Benefits |
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Health Plan Cost Sharing
This HealthSun Health Plans, Inc. Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $0 Copay Authorization Required, Referral Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $0 Copay Authorization Required |
Routine foot care: | $0 Copay Authorization Required |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $0 Copay Authorization Required, Referral Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $50 Copay |
Urgent care: | $0 Copay |
Ground ambulance: | $75 Copay |
Inpatient hospital coverage: | $0.00 per stay |
Outpatient hospital coverage: | $0 Copay Authorization Required, Referral Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $20.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 Copay |
Outpatient group therapy visit with a psychiatrist: | $0 Copay |
Inpatient hospital - psychiatric: | $0.00 per stay |
Outpatient group therapy visit: | $0 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $0 Copay Authorization Required, Referral Required |
Occupational therapy visit: | $0 Copay Authorization Required, Referral Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | $0 Copay Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | $0 |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $0 Copay Authorization Required, Referral Required |
Lab services: | $0 Copay Authorization Required, Referral Required |
Outpatient x-rays: | $0 Copay Authorization Required, Referral Required |
Diagnostic tests and procedures: | $0 Copay Authorization Required, Referral Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our HealthSun HealthAdvantage Plan Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits HealthSun Health Plans, Inc. includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Authorization Required, Referral Required |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay Authorization Required, Referral Required |
Vision | Maximum vision benefit: | $400.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
HealthSun HealthAdvantage Plan includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $0.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $0.00 |
Part D Premium with Full LIS Assistance: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before HealthSun Health Plans, Inc. begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, HealthSun HealthAdvantage Plan has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $0.00 copay | $0.00 copay |
2 (Generic) | $0.00 copay | $0.00 copay |
3 (Preferred Brand) | $0.00 copay | $20.00 copay |
4 (Non-Preferred Brand) | $25.00 copay | $35.00 copay |
5 (Specialty Tier) | 33% | 33% |
6 (Supplemental Drugs) | $0.00 copay | $0.00 copay |
CMS 5-Star Rating Marks
The following table shows the quality ratings for this HealthSun Health Plans, Inc. plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent ratings for HealthSun HealthAdvantage Plan.
CMS Measure | Star Rating |
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2024 Overall 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 |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- HealthSun HealthAdvantage Plan
- HealthSun HealthAdvantage Plus
- HealthSun HealthAdvantage Plan
- HealthSun HealthAdvantage Plan
- HealthSun HealthAdvantage Plus
Contact HealthSun Health Plans, Inc.
Plan Website: | http://www.HealthSun.com |
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Formulary Information: | http://www.HealthSun.com |
Pharmacy Information: | HealthSun Health Plans, Inc. Pharmacy Page |
Prospective Members: | (855)573-0370 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- HealthSun Health Plans, Inc., http://www.HealthSun.com, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H5431-001-0 Plan Detail Page
The data on this HealthSun HealthAdvantage Plan plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by HealthSun Health Plans, Inc. to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from HealthSun Health Plans, Inc., at (855)573-0370, prior to enrollment.