Each covered person has a maximum out-patient benefit per calendar year subject to a maximum benefit for all covered persons within a family unit that is equal to two (2) or three (3) times the individual out-patient benefit maximum. This feature is determined by the plan design the employer and the insurance professional choose. This family maximum applies to the entire family unit, regardless of the number of covered persons within the family unit, however, in no event will the maximum calendar year out-patient benefit for any one person exceed the individual maximum.

Most major medical plans offer reasonably low co-pays for physician office visits, as well as some type of benefit for wellness/preventive care. In determining the most cost-effective GAP plan to offer to employees, from both a benefit and cost perspective, your employer would have taken this into consideration. There is an optional benefit that would allow limited coverage for Physician Office visit charges, but there is an additional premium associated with this benefit. If your employer purchased this benefit, office visits would be considered by your GAP insurance.

Upon acceptance of your employer group, the third-party administrator will issue you a certificate of insurance, outlining the plan benefits, terms, conditions and limitations. An ID card that you can present to providers at the time of service is also issued. Both the ID card and certificate of insurance are sent to your employer, usually to a designated HR staff member, for distribution to you. For a new group, this process can take 10-15 business days. For new enrollees within an existing group, certificates and ID cards are usually handled within 5-10 business days.

Yes, you will need to carry your primary major medical card and your GAP insurance card. When you check in with the receptionist, or a kiosk, at the Doctor’s office, it is the employee’s responsibility to let them know that you have new GAP, or Secondary Insurance.

The overwhelming majority of claims are now paid by the GAP insurance provider directly to the medical care provider. In most instances the employee does not need to pay the bill and apply for reimbursement. There are still some medical care providers that do not accept GAP insurance, but they are rare now. Most providers, if they will file for insurance benefits from more than one carrier, should accept your GAP card reducing, if not eliminating, their requirement that you pay for services up front.

Enrollment in the GAP plan follows those guidelines established for enrollment in your group major medical plan. If you do not elect to enroll in the GAP plan when it is first made available to you, you will not be able to enroll in it until the next allowable period of open enrollment, unless you qualify by law as a “special enrollee” due to certain qualifying events.

No, if an employee is not covered under the group major medical plan, they are generally not eligible to participate in the GAP plan

For an expense to be eligible under GAP, it must be covered by your major medical plan. If an expense is denied by your major medical plan but would otherwise have been an eligible expense under GAP, it will not be covered by GAP. A couple of simple examples to illustrate this are:

1. Expenses that are not medically necessary and do not result from the treatment of an illness or an injury; 2. Physician office visit charges, unless the Physician Office Visit benefit has been purchased; 3. Expenses related to wellness or preventive medicine; 4. Confinement or other covered treatment for Dental or Vision care that is not related to an accidental injury.

Generally, expenses related to the treatment of mental or nervous disorders and the expenses related to treatment of alcoholism, drug addiction, or complications thereof are not covered by most GAP plans. It can be covered by carriers or can be covered by optional rider by some carriers. This is not a complete list of exclusions under the GAP plan. For a full list of exclusions, terms and conditions, you should refer to your certificate of insurance.