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HealthSun MediSun Extra (D-SNP) H5431 019 0 Plan Details

This page provides coverage and cost details for HealthSun Health Plans, Inc.’s H5431-019-0 Medicare SNP plan for 2025. Enrollment is subject to eligibility.

CMS 2025 Rating: ☆☆☆☆☆*

*CMS rated this HealthSun Health Plans, Inc. plan (H5431-019-0) 5 (Excellent) out of 5 stars.

Best Insurance Company Ranking
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The HealthSun Health Plans, Inc. logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.

Individuals must meet all Dual-Eligible SNP qualification requirements to join this D-SNP plan.

HealthSun MediSun Extra Basic Plan Details

Plan ID
H5431-019-0
Plan Type
HMO D-SNP
Plan Year
2025
Premium
$0.00/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
3,450.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Enhanced
$590.00 deductible
Supplemental Benefits
Vision, Hearing
Availability
See List
Insured By
HealthSun Health Plans, Inc.

Health Plan Out-of-Pocket Costs

The following table is a summary of the most common out-of-pocket costs you will incur if you join this HealthSun Health Plans, Inc. plan:

Doctor's Office Visits

Primary
$0 Copay
Specialist
$0 Copay
Prior Authorization Required, Referral Required

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
$0 Copay
Urgent care
$0 Copay
Ground ambulance
$0 Copay
Inpatient hospital care
$0.00 per stay
Skilled Nursing Facility
$0.00 per stay

Foot Care

Foot Exams and Treatments (Medicare-covered)
$0 Copay
Prior Authorization Required
Routine Foot Care
$0 Copay
Prior Authorization Required

Chiropractic Care

Medicare-covered chiropractic
$0 Copay
Prior Authorization Required, Referral Required
Routine chiropractic
$0 Copay
Prior Authorization Required, Referral Required

Mental Health Services

Outpatient individual therapy
$0 Copay
Outpatient group therapy
$0 Copay
Inpatient psychiatric hospital care
$0.00 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
$0 Copay
Prior Authorization Required, Referral Required
Occupational therapy
$0 Copay
Prior Authorization Required, Referral Required

Medical Equipment and Supplies

Diabetes supplies
$0 Copay
Prior Authorization Required
Durable medical equipment
$0 Copay
Prior Authorization Required
Prosthetics
Not Covered

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
$0 Copay
Prior Authorization Required, Referral Required
Lab services
$0 Copay
Prior Authorization Required, Referral Required
Outpatient x-rays
$0 Copay
Prior Authorization Required, Referral Required
Diagnostic tests and procedures
$0 Copay
Prior Authorization Required, Referral Required

Medicare Part B Drugs

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
$0 Copay
Prior Authorization Required
Oral exam
$0 Copay
Dental x-rays
$0 Copay
Cleaning
$0 Copay
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered
Maximum dental benefit
$5,000.00 (Every year)

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Not Covered
Hearing exam
Covered
Limits may apply

Vision Services

Medicare-covered eye exam
$0 Copay
Routine eye exam
$0 Copay
1 Every year
Eyewear benefits
None

Prescription Drug Costs & Benefits

HealthSun MediSun Extra includes enhanced benefit Medicare Part D. Enhanced benefits offer greater coverage than basic, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.

As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.

Prescription Drug Premium with Extra Help

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 premium assistance details with Extra Help.

Low Income Premium Subsidy: ${part_d_lips_amount}
Low Income Premium Subsidy CMS Pays: $0.00
Low Income Subsidy Premium: $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 Deductible

The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before HealthSun Health Plans, Inc. begins paying its share.

Prescription Drug Out-of-Pocket Costs

In addition to the plan's monthly premium and deductible, HealthSun MediSun Extra has out-of-pocket costs you must pay when you pick up your prescriptions.

Drug Tier Retail Mail Order
Preferred Generic$1.00$1.00
Generic$2.00$2.00
Preferred Brand$25.00$25.00
Non-Preferred Drug25.00%25.00%
Specialty Tier25.00%25.00%
Supplemental Drugs*$0.00$0.00
*The Part D deductible does not apply.

How to Qualify to Enroll in
HealthSun MediSun Extra

To qualify for enrollment in HealthSun MediSun Extra in Miami-Dade County, you must be eligible for both Medicare and Medicaid. To be eligible for Medicare, you must be age 65 or older, or have Social Security Disability Insurance for 24 months. To be eligible for Medicaid, your income and assets must be at or below Florida's state thresholds.

Before enrolling in HealthSun MediSun Extra, or any other dual-eligible SNP, be sure to ask the following questions:

  • What costs should I expect to pay out-of-pocket (premiums, deductibles, copayments)?
  • Will I be able to use my doctors? Are they in the plan's network?
  • Are the plan's in-network providers and facilities in convenient locations?
  • Does the plan provide coverage for services I receive from out-of-network providers?
  • Do I need a referral to see a specialist?
  • Are my medications on the Part D plan's formulary? What if I can't afford my medications?
  • What special accommodations does the plan make for persons with disabilities?
  • Does the plan offer free meal delivery after a stay in the hospital?
  • What help is offered for caregivers? Is adult day care covered?
  • Does the plan offer a prepaid card for over the counter medications and covered groceries?