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Health First SunSaver H1099-016 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Health First SunSaver H1099-016 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Health First SunSaver H1099-016 (HMO) in 2025, please refer to our full plan details page.
Health First SunSaver H1099-016 (HMO) is a HMO plan offered by Health First Shared Services, Inc. available for enrollment in 2025 to people living in Counties: VO, FL, HA, HI. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Health First SunSaver H1099-016 (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Health First SunSaver H1099-016 (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Health First SunSaver H1099-016 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Health First SunSaver H1099-016 (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for Tier 1 and 2 drugs, and coinsurance for Tier 3 and 4 drugs. After your total drug costs reach $2000, you enter the next coverage phase. If you qualify for the low-income subsidy (LIS), your Part D costs are $0. Once your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs in the catastrophic coverage phase.
Additional Benefits
The Health First SunSaver H1099-016 (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes no copay for primary care, preventive services, and vision services, and covers outpatient services with copays ranging from $0-$150. The plan also covers emergency services, ambulance services, and transportation services. Additional benefits include hearing, dental, and home health services, with varying copays and coinsurance depending on the specific service.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $160 copay for days 1-8 and no copay for days 9-90. For Inpatient Hospital Psychiatric, you pay a $191 copay for days 1-8 and no copay for days 9-90. Additional days, non-Medicare-covered stays, and upgrades are not covered for either service.
Outpatient Services See details
Outpatient Services includes coverage for Outpatient Hospital Services with a copay between $0 and $150, and Observation Services with a $175 copay. Ambulatory Surgical Center (ASC) Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay of $20. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan with a $15 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and air ambulance services each have a $260 copay, and there is no coinsurance. Transportation Services to any health-related location are covered, with up to 32 one-way trips per year via bus or subway.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Health First SunSaver H1099-016 (HMO) plan. Emergency Services has a $140 copay, Urgently Needed Services has a $25 copay, and Worldwide Emergency Coverage has a $140 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Health First SunSaver H1099-016 (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $10 copay, and physician specialist services with a $20 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a $20 copay for individual and group sessions, and physical therapy and speech-language pathology services have a $10 copay. Additional telehealth benefits are covered with a copay between $0 and $25. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Health First SunSaver H1099-016 (HMO) plan covers preventive services, including an annual physical exam with no copay. Other preventive services like EKG following Welcome Visit have a $35 copay.
Hearing Services See details
Hearing services include hearing exams with a $35 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered up to a maximum of $1000 every two years, but hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a copay of $0-$15, eyewear with no copay, and contact lenses with no copay. Eyeglass upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, other dental services with a $1,000 annual maximum, and services like oral exams (limited to 2 per year), dental x-rays (limited to 1 every 12-36 months), and cleaning (limited to 2 per year). Additional services such as fluoride treatment (limited to 1 per year), other preventive services, and orthodontics are also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Health First SunSaver H1099-016 (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by the Health First SunSaver H1099-016 (HMO) plan. DME has a 20% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a 10-20% coinsurance and Diabetic Therapeutic Shoes/Inserts have a 10% coinsurance.
Diagnostic and Radiological Services See details
The Health First SunSaver H1099-016 (HMO) plan covers diagnostic and radiological services. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $35, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at least $100, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have a copay of $35.
Home Health Services See details
Home Health Services are covered by the Health First SunSaver H1099-016 (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Health First SunSaver H1099-016 (HMO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Health First SunSaver H1099-016 (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $150 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $130.00 every three months, and a Meal Benefit for a chronic illness. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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