I. Purpose: A subscription program is designed to provide residents of St. Marys with financial assistance for services provided that are covered under the subscription program. In thanks for your subscription payment and any donations provided, St. Marys Area Ambulance Service, (hereinafter SMAAS) will provide financial support to any persons covered under your subscription for amounts that are otherwise billable on a per-transport basis for insured services. If insurance does not provide full payment for an ambulance service, less your copayment and deductibles, or denies coverage for an ambulance service, you could be responsible for outstanding balances that insurance does not cover. This subscription is not designated to be an insurance contract of any type.
II. Subscription: Subscribers are entitled to unlimited use of SMAAS emergency ambulance transport, when necessary, and based upon availability of resources, without being responsible for charges to cover insured allowed amount for services that are not paid by insurance for up to one (1) emergency transport. This waiver will be reduced to 50% of the charges on the second (2nd) emergency transport and any thereafter.
Charges not paid by insurance will be waived at 50% for the first three (3) medically necessary non-emergency transports. This waiver of 50% of charges not paid by insurance will be eliminated and billing in full will commence on the fourth (4th) medically necessary non-emergency transport and any thereafter within the subscription period.
Refusal of transports are services typically not covered by insurance, subscribers will be waived of the charge for refusal of transport calls on the first two (2) calls, but charges will apply on the third call and any thereafter within the subscription period.
These benefits for subscribers only apply to persons listed on this subscription application that satisfy the Paragraph 3 criteria. This subscription is non-refundable and non-transferable. This subscription program is not available to persons without insurance coverage or to persons receiving Medicaid (Medical Assistance) benefits. Dual Eligible individuals residing in a Skilled Nursing Facility receiving Medicaid Benefits either as a primary or secondary insurer are not eligible for subscription under the Medicaid Guidelines.
III. Available Subscription Plans: Subscription is effective upon receipt by SMAAS of the subscription application and fee and expires April 30th of the following year.
A. Family Plan ($50): Covers husband, wife, and unmarried children living at home under 18 years of age, as well as full time college students up to 24 years of age. All persons must be listed on the subscription application.
B. Individual Plan ($40): Covers the person listed in the subscription application only.
IV. Payment: Subscribers are responsible for payment of the subscription fee as outlined in these subscription application Terms and Conditions. SMAAS will submit bills directly to your insurance for payment of ambulance services that are provided. If a subscriber receives payment for ambulance services provided by SMAAS directly from an insurance company, such payment must be turned over to SMAAS. It is improper and illegal to keep reimbursement received for ambulance services provided by SMAAS. Subscribers are expected to cooperate with SMAAS in all collection efforts and recognize that SMAAS may initiate legal action for failure to pay for amounts they may be responsible to pay. Any individuals who have failed to remit insurance payments to SMAAS in the past and have had legal action taken against them to obtain restitution will not be eligible for future subscriptions. SMAAS reserves the right to determine eligibility on a case-by-case basis. If you receive a bill from SMAAS in error for an ambulance service for which you believe you are insured, please forward your insurance information to SMAAS so that your insurance can be billed directly. If you ever feel that you are billed inappropriately, please contact SMAAS so that it can resolve the problem.
V. Transportation that is covered as part of this Subscription:
A. Emergency Ambulance Transportation: I understand that my subscription will include waiver of all charges not paid by insurance for the first emergency transport within the subscription period, and 50% waiver of all charges not paid by insurance starting on the second emergency transport and any thereafter within the subscription period. I understand that insurance coverage for ambulance transportation by SMAAS covered by this subscription may be limited to transport to the closest appropriate medical facility.
B. Non-Emergency Ambulance Transportation: I understand that in addition to emergency transportation provided by SMAAS, my subscription includes 50% waiver of all charges not paid by insurance for up to three (3) insured medically necessary non-emergency ambulance transports. SMAAS’ provision of non-emergency ambulance service is subject to availability of staff and equipment. Emergency transports always have priority. I understand that the provision of nonemergency ambulance service is a service that may be available, but not guaranteed. Subscribers will not be responsible for 50% of charges not paid by insurance for up to three (3) non-emergency ambulance transports, but may be responsible for additional milage cost, or other services that are not covered under insurance. A Physicians Medical Necessity Certification may be required to demonstrate that ambulance transport is warranted. In the event that nonemergency ambulance transport is not medically necessary, warranted, or properly authorized, I understand that I may be responsible for the entire cost of the transport.
VI. Additional Payment liabilities not covered by the subscription:
A. I understand that insurance may pay for transport only to the closest appropriate facility. Any transportation beyond the closest appropriate facility at the request of me, my family, or my doctor, may make me responsible for additional payments that are not covered under my insurance. I understand that in these situations, I am responsible for such additional charges, and may or may not be advised of additional charges at the time of the transport.
B. If ambulance transport is not medically necessary or reasonable, I understand that I may be responsible for the entire charge of the transport.
C. I understand that this subscription only applies to insured ambulance transports provided by SMAAS. SMAAS will honor subscriptions from Fox Twp. Ambulance, Ridgway Ambulance, and Bennetts Valley Ambulance at the specific Ambulance Service terms and conditions, intern if you are transported by any of these ambulance services listed, your subscription to SMAAS will be honored by the transporting service at our Terms and Conditions. In the event that another ambulance service provider with which I do not have a subscription conducts the transport, I will be responsible for all amounts not covered by insurance and I will be subject to the billing terms and conditions of the transporting ambulance service provider.
D. Since insurance cannot be billed for refusal of transport, SMAAS reserves the right to charge $200 for these calls. This charge will be waived for the first two (2) calls for refusal of transport for active subscribers, but will apply on the third call and each thereafter within the subscription period.
Disclaimers: This subscription program is not a contract for the provision of ambulance services. Another ambulance service provider may respond when we are unable to respond with an ambulance. This is not a solicitation for the offer or sale of an insurance product. The terms and provisions of the subscription program are subject to change without prior notice. Medicare beneficiaries may be billed for copayments or deductibles if required by law. All subscription applications are subject to acceptance by SMAAS and may be cancelled or revoked in the sole discretion of SMAAS. The subscribe acknowledges that SMAAS will bill available thirdparty insurance for services rendered and agrees to remit any third party insurance payments received directly by the subscriber to SMAAS.
By signing the application, I hereby apply for a subscription with SMAAS for the persons listed and I agree to the terms and conditions of the subscription program described above. I verify that none of the listed persons of authorized Medicare or any other insurance benefits be made on by behalf to SMAAS for any ambulance services provided to me by SMAAS now, in the past, or in the future. I understand that I am financially responsible for the services and supplies provided to me by SMAAS regardless of my insurance coverage, and in some cases, I may be responsible for an amount in addition to that which was paid by my insurance and the amount of my copayment and deductible covered by my subscription. I agree to immediately remit to SMAAS any payment that I receive directly from my insurance or any source whatsoever for the services provided to me by SMAAS and I assign all rights to such payment to SMAAS. I authorize SMAAS to appeal payment denials or other adverse actions on my behalf without further authorization and direct any holder of medical information or other relevant documentation about me to release such information to SMAAS, its billing agents, the Centers for Medicare and Medicaid Services, and /or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by SMAAS, now, in the past, or in the future. A copy of this form is valid as an original.