Benefits - GAP
In the upper right hand corner of the reimbursement form, there is a place to enter an account number, although account numbers are not assigned until after the first claim is received. This field should be left blank on the first claim submission.
The GAP is administered by American Fidelity Assurance (AFA) who also administers our Flexible Spending and Health Savings Accounts.
Claims can be sent to American Fidelity by fax or by mail. If you fax your claim, a follow up phone call is not required but is welcome to ensure your claim has been received. If faxing, please allow 48 hours for the system to process the fax.
American Fidelity Assurance Company
Attn: Benefits Division
P O Box 25160
Oklahoma City, OK 73125-0160
After the first claim submission to American Fidelity, you will be able to create an online account to submit future claims. Visit www.afadvantage.com to create a log on and password.
Dr. Office Visit:
• A copy of the bill, OR
• An EOB (Explanation of Benefits), OR
• Office notes
Note: Routine care is not reimbursable under the GAP Plan.
Out-Patient Hospital: • A copy of the hospital bill
• A copy of the EOB
• A copy of the hospital bill
Note: There is no limit to the number of hospitalization benefits payable. Each hospitalization benefit is payable on its own. There is a limit for the out-patient benefit if the treatment is for the same condition within a 90-day period.
Forms are available on the Employee Benefit Forms page of the Human Resources website: https://www.washoecounty.us/humanresources/files/hrfiles/GAP_Claim_Form.pdf. Forms can also be obtained from your department’s Human Resources representative.
Please note that the Health Insurance Portability and Accountability Act does require that information submitted on this claim form is protected and only disclosed as necessary to process your claim. Employers, plan sponsors and providers are subject to ensuring that your data is private and secure.
To follow up on a fax (after 48 hours to allow processing time): 1-800-662-1113
For any other plan or claim questions, contact the local American Fidelity office at 829-1313.
The following out-of-pocket expenses are covered:
Maximum In-Hospital Benefit:
• Up to $1,000 per hospital confinement
Maximum Out-patient Benefit:
• Treatment in a hospital emergency room
• Out-patient surgery in a hospital out-patient facility or free-standing out-patient surgery center
• Diagnostic testing in a hospital out-patient facility or MRI facility
• Up to $200 for treatment of the same or related conditions unless separated by a period of 90 consecutive days (then a new out-patient benefit will be payable)
Physician Out-patient Treatment Benefit:
• Treatment in a hospital out-patient clinic, free-standing emergency care clinic or physician’s office
• Up to $25 per treatment; $125 maximum per family per calendar year (non-routine care excluded)
If your dependents are covered under your HMO, you may also purchase GAP coverage for them. You may enroll dependents during the annual Open Enrollment period (mid-October through mid-November for a January 1 effective date) by meeting with an American Fidelity representative, or anytime during the year with a qualifying event. Rates can be found on the Human Resources website and premiums are collected pre-tax through payroll deduction. To enroll your dependents outside of the Open Enrollment period (with a qualifying event), contact American Fidelity at 829-1313.
Just as with your health plans, dependents can only be dropped during Open Enrollment or with a qualifying event. To delete a dependent, you must contact American Fidelity directly. Dependent GAP coverage is privately purchased insurance and it is the responsibility of the employee to maintain the integrity of that policy. Calling Health Benefits to delete a dependent from your health insurance plan will not automatically delete them from your GAP Plan.
Sign up for “My Hometown Benefits” at www.hometownhealth.com to view all of your claims and print EOBs.
Employees can visit www.afadvantage.com and request an online account once they have submitted their first claim. This is a very useful tool for reviewing flex plans and any outstanding claims, and we encourage all GAP participants to avail themselves of this convenient resource.
This supplement benefit works in conjunction with the HMO Plan and is provided only to HMO participants. The GAP was added as a result of health insurance negotiations to offset plan design changes that helped the County meet budget needs in FY 2010/2011. The cost of the GAP Plan is covered by the County for all employees and retirees, and is available on a voluntary basis for dependents.
A list of qualifying events can be found under the “Eligibility Quick Reference” link on the Medical-Dental-Vision page of the Human Resources website: