A major medical plan must be a group medical plan (whether a fully insured plan or an employer sponsored self-funded plan) that provides benefits for hospital confinements and requires you to pay a deductible and/or portion of coinsurance. A major medical plan does not include Medicare, Medicaid or government sponsored programs not typically considered major medical coverage (such as, but not limited to, veterans’ benefits, etc.)

Employers choose the benefits and plan structure along with the assistance of insurance professionals. The insurance professional should have reviewed and analyzed your major medical plan coverage and its associated costs, to determine the most effective GAP plan(s) available.

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.