HealthSun Health Plans

What HealthSun Health Plans does

HealthSun Health Plans is a private, Florida-based Medicare Advantage HMO organization that operates as a Dual Eligible Special Needs Plan (D-SNP) under both a Medicare contract and a Medicaid contract with the State of Florida Agency for Health Care Administration. The company serves Medicare-eligible individuals — including dual-eligible beneficiaries and chronically ill members qualifying for chronic condition Special Needs Plans (C-SNPs) — across the three South Florida counties of Miami-Dade, Broward, and Palm Beach. HealthSun markets a portfolio that includes standard HMO plans (HealthAdvantage 001, 012, 013; MediMax 006), enhanced HMO Plus plans (017, 018, 020), D-SNP plans (MediSun Extra 019, MediSun Plus 016, Full Dual Plus 025, Full Dual Extra 026), and C-SNP plans (VitalCare 021, 022). Most plans carry a $0 monthly premium and incorporate Part D prescription drug coverage alongside supplemental benefits including Special Supplemental Benefits for the Chronically Ill (SSBCI) such as grocery, utility, chronic meal, and transportation allowances.

The company's technical footprint consists of member- and provider-facing digital platforms rather than a self-developed clinical or AI stack. Members access plan information through the HealthSun Member Portal and the CarelonRx pharmacy benefit portal; the AaNeel Connect portal (built by partner AaNeel Infotech) delivers the CMS-mandated Patient Access API exposing claims, provider directory, medications, and clinical profiles. Network providers use the HealthSun Provider Portal for eligibility verification, claim status, referrals, ICD-10 search, EDI 835 remittance export, pre-certification workflows, and EFT enrollment via the EnrollSafe/PayeeHub. Clinical policy and coverage decisions are sourced from third parties — Elevance/Simply Healthcare medical policies, MCG criteria, and Florida Dental Benefits/Ideal Dental for dental — rather than proprietary HealthSun systems. The company maintains a 4.5 out of 5 Medicare Star Rating sustained across contract years 2018-2026 and is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC).

HealthSun generates revenue primarily through Medicare Advantage capitation premiums paid by CMS on behalf of enrolled beneficiaries, with additional revenue streams from Medicare Part D prescription drug coverage administered through CarelonRx and from supplemental SSBCI benefits. The go-to-market model is sales-led: licensed field sales representatives operate in each of the three South Florida counties with dedicated English and Spanish phone lines, supplemented by the Medicare.gov Plan Finder, provider referrals, and direct website enrollment. The company is privately held (Florida-incorporated), headquartered at 11430 NW 20th Street, Suite 300 in Miami (per the company-issued address), with Coconut Creek listed as the firmographic city, and falls in the 251-500 employee band. There are no disclosed institutional investors beyond a single 2016 funding event with Summit Partners, no parent company, and no M&A activity.

Name

HealthSun Health Plans

Legal name

HealthSun Health Plans, Inc.

Website

https://healthsun.com

Company type

Private

Founded year

2005

Operating status

Operating

Headcount range

251–500 employees

Short description

HealthSun Health Plans is a private Medicare Advantage HMO serving Medicare and dual-eligible beneficiaries across Miami-Dade, Broward, and Palm Beach counties in Florida. It offers HMO, D-SNP, and C-SNP plans with prescription drug coverage, SSBCI supplemental benefits, and a coordinated provider network.

Ownership category

akta.pro rank

Product category

Medicare Advantage Health Insurance

NAICS

Direct Health and Medical Insurance Carriers (524114), Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292)

SIC

Accident & Health Insurance (6321), Hospital & Medical Service Plans (6324), Services-Health Services (8000)

akta.pro primary industry

Medicare Advantage (MA) Plans (FSAIAGAA)

akta.pro secondary industries

D-SNP Supplemental Benefits & Flex Card/OTC Administration (HLAEAFAN), MA Chronic Condition Management & Supplemental Benefits (SSBCI) (HLAEACAI), Chronic Condition Special Needs Plans (C-SNP) (FSAIAGAE), D-SNP Medicare–Medicaid Integration & State Contracting (HLAEAFAH)

Keywords

• Medicare Advantage plans
• Dual Eligible Special Needs
• Chronic Condition SNP
• Medicare Part D coverage
• HMO health insurance

Headquarters

HQ city

Coconut Creek

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2C

Offering type

Services

Cost components

Operations, Personnel, Technology or R&D, Marketing or Sales, Supply Chain

Revenue model

1. Medicare Advantage Plan Premiums: HealthSun generates revenue through Medicare Advantage plan premiums paid by CMS on behalf of enrolled Medicare beneficiaries. As an HMO D-SNP plan, the company receives capitation payments for managing member healthcare across medical, pharmacy, and supplemental benefits.
2. Medicare Part D Prescription Drug Coverage: Revenue from administering Medicare Part D prescription drug benefits, including formulary management, pharmacy network contracting, and drug pricing. The company works with CarelonRx as the pharmacy benefit manager.
3. Special Supplemental Benefits for the Chronically Ill (SSBCI): Additional benefits provided to qualifying chronically ill members including grocery allowances, utility assistance, transportation, and chronic meals. These SSBCI benefits are funded through Medicare Advantage supplemental benefit payments.

Pricing tiers

Go-to-market motion1 record

Distribution channels1 record

Marketing channels4 records

Core offering

HealthSun Health Plans is a private Medicare Advantage HMO organization offering individual Medicare Advantage, Dual Eligible Special Needs (D-SNP), and Chronic Condition Special Needs (C-SNP) plans to beneficiaries in Miami-Dade, Broward, and Palm Beach counties. The company administers integrated medical, prescription drug, dental, and supplemental benefits—including Special Supplemental Benefits for the Chronically Ill (SSBCI)—through contracts with Medicare and the State of Florida Agency for Health Care Administration.

Product overview

HealthSun Health Plans is an HMO D-SNP organization with a Medicare contract and a Medicaid contract with the State of Florida Agency for Health Care Administration, serving Medicare beneficiaries primarily in Miami-Dade, Broward, and Palm Beach counties. The company offers a portfolio of Medicare Advantage plans including standard HealthAdvantage HMO plans (plans 001, 012, 013), HealthAdvantage Plus enhanced HMO plans (plans 017, 018, 020), MediMax HMO (plan 006), MediSun Extra and MediSun Plus D-SNP plans (plans 019, 016), HealthSun MediSun Full Dual Plus and Full Dual Extra D-SNP plans (plans 025, 026), and VitalCare C-SNP plans for chronic conditions (plans 021, 022). The product portfolio is complemented by provider-facing and member-facing digital platforms including the HealthSun Provider Portal for claims, eligibility, and referral management; the HealthSun Member Portal for plan information and claims; AaNeel Connect for CMS interoperability access to claims and clinical data; the CarelonRx pharmacy benefit portal; and an online formulary search tool. Supplemental offerings include Special Supplemental Benefits for the Chronically Ill (SSBCI) providing OTC allowances, grocery, utility, and transportation benefits; telemedicine services; and dental benefits managed through Florida Dental Benefits and Ideal Dental. The company maintains a 4.5-star Medicare quality rating.

Differentiator

Problem solved

Functional benefit

Products and services

• HealthAdvantage Plan (HMO) Standard Medicare Advantage HMO plan family (plans 001, 012, 013) offering comprehensive medical coverage, prescription drug benefits, and supplemental benefits for Medicare-eligible individuals in South Florida.
• HealthAdvantage Plus (HMO) Enhanced Medicare Advantage HMO plan family (plans 017, 018, 020) offering richer supplemental benefits compared to standard HealthAdvantage plans for Medicare-eligible members.
• MediMax (HMO) Medicare Advantage HMO plan (006) with formulary and coverage tailored to members who also have Medicaid eligibility in South Florida.
• MediSun Extra and MediSun Plus (HMO D-SNP) HMO D-SNP plans (MediSun Extra plan 019, MediSun Plus plan 016) designed for individuals eligible for both Medicare and Medicaid, offering dual-eligible coordination of benefits and specialized supplemental benefits.
• HealthSun MediSun Full Dual (HMO D-SNP) HMO D-SNP plans (Full Dual Plus plan 025, Full Dual Extra plan 026) offering full dual eligibility coordination with rich supplemental benefits including grocery, utility, and transportation allowances for qualifying chronically ill members.
• VitalCare (HMO C-SNP) Chronic Condition Special Needs Plans (plans 021, 022) designed for Medicare beneficiaries with specific chronic conditions, providing targeted care management and condition-specific benefits.
• HealthSun Provider Portal Web-based digital portal for network providers to access member eligibility verification, claim status, explanation of payments, referral submission and search, ICD-10 search, EDI 835 remittance export, admission notifications, EFT enrollment, and pre-certification workflows.
• HealthSun Member Portal Secure online portal where HealthSun members can log in to access their plan information, claims, benefits, and health tools.

Named customers1 record

Segments3 records

Ideal customer profiles3 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration1 record

Feature4 records

Partnerships

Three partnerships are on record, tiered core.

• AaNeel InfotechcoreTechnology or IntegrationHealthSun partnered with AaNeel Infotech, a healthcare software solutions company, to offer AaNeel Connect - a CMS interoperability tool providing members secure access to their health information including claims, provider directories, medication lists, and clinical health profiles through a patient access API.
• CarelonRxcoreTechnology or IntegrationCarelonRx serves as the pharmacy benefit manager for HealthSun, providing the member portal for prescription drug management, formulary access, and pharmacy services.
• State of Florida Agency for Health Care AdministrationcoreStrategic or Co-development PartnerHealthSun holds a Medicaid contract with the State of Florida Agency for Health Care Administration, enabling the company to serve dual-eligible Medicare/Medicaid beneficiaries through D-SNP plans.

Scale indicators3 records

Recent moves6 records

Expansion highlights5 records

Broad incumbents

• UnitedHealthcare: Largest U.S. health insurer and leading MA carrier with AARP-branded plans and aggressive D-SNP growth. Operates a substantial South Florida MA footprint directly competing with HealthSun for dual-eligibles.
• Centene Corporation: Leading Medicaid managed-care operator with significant Medicare exposure through WellCare (also a Florida plan). Competes for dual-eligible members via similar Medicaid-MA integration strategy as HealthSun.
• Humana: Largest Medicare Advantage carrier in the U.S. with a deep D-SNP portfolio and a major Florida presence. Humana competes with HealthSun for the same dual-eligible and chronic-condition members in Miami-Dade, Broward, and Palm Beach counties.
• Elevance Health: National Blues-affiliated insurer with MA, Medicaid, and D-SNP capabilities. Provides medical policies that HealthSun itself uses, while also competing for similar membership in Florida.
• CVS Health / Aetna: National MA carrier with growing D-SNP presence and integrated pharmacy/retail strategy via CVS. Competes with HealthSun on MA membership and pharmacy benefit design in South Florida.

Direct peers

• Molina Healthcare: Government-program-focused managed care company with a strong dual-eligible and Medicaid franchise in Florida. Closely comparable business model to HealthSun's Medicaid-contracted D-SNP operation.
• Florida Blue (GuideWell): Dominant Florida-headquartered Blue Cross Blue Shield plan offering Medicare Advantage HMO and SNP products across the same three counties HealthSun serves. Closest direct regional competitor on plan type, geography, and member demographic.
• Simply Healthcare Plans (Elevance Health): Florida-focused Medicaid and Medicare plan owned by Elevance/Anthem. Directly competes with HealthSun in South Florida and is already a partner (provides Elevance medical policies), making it both a peer and a strategic counterparty.

Emerging players

• Alignment Healthcare: Tech-enabled MA carrier focused on senior care and dual-eligibles in select markets. Comparable specialty focus on chronically ill and dual-eligible members, though currently concentrated in California and select Western states.
• Devoted Health: Mission-driven MA insurer targeting dual-eligibles and seniors with value-based care and technology-enabled care management. Highly comparable D-SNP/C-SNP strategic orientation, though with broader geographic ambition than HealthSun.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat4 records

Key risks6 records

Key highlights7 records

Customer concentration

• LinkedInlinkedin.com/company/healthsun-health-plans-inc

Compliance7 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles1 record

Funding overview

Funding rounds1 record

Investors1 record

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about HealthSun Health Plans