Human Resources

The GAP is administered by American Fidelity Assurance (AFA).

The easiest way to file a gap insurance claim is through your online account at Americanfidelity.com or the mobile app, AFmobile. Download American Fideity mobile app from the App Store or Google Play. 

 When filing a gap insurance claim you will need to provide the following documentation:

• Statement of Insured, completed via  online claim filing  or paper claim form
• Itemized Bills with diagnosis from each of your providers with a complete breakdown of charges for each date of service
• Explanation of Benefits (EOB) from your primary medical insurance carrier

We may also need:

• Authorization to Disclose Information Including PHI: This form gives American Fidelity authorization to get records from your medical provider(s) and others who may hold information necessary for us to review your claim. Upload the form via your online account, or mail or fax it.

Forms are available on the Employee Benefit Forms page of the Human Resources website: Employee Benefit Forms.

You can also visit American Fidelity's website to file an online claim or download the AF mobile app.

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 the Surest Plan, 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.

To access a copy of your Explanation of Benefits, go to member login site with Surest  and create an account.

Employees can visit www.americanfidelity.com and to set up an online account or download the AFmobile app.

This supplement benefit works in conjunction with the Surest Plan and is provided only to Surest 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: