I. Purpose: A subscription program is designed to provide St. Marys Area Ambulance Service, Inc. (hereinafter “SMAAS”) with financial support from subscription revenues in exchange for reliable and available ambulance services. In thanks for your subscription payment and any donations provided, SMAAS will provide certain benefits to any persons covered under your subscription that can save you money for amounts that are otherwise billable to the patient on a per-transport basis for insured services, as further described in these terms and conditions. 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: During the subscription period, Subscribers are entitled to unlimited use of SMAAS emergency ambulance transport to the closest appropriate facility, when necessary and reasonable, 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 to the closest appropriate facility during the subscription period.
Charges not paid by insurance will be waived at 50% for the first three (3) medically necessary non-emergency ambulance transports to the closest appropriate facility. 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 ambulance transport and any thereafter within the subscription period.
Refusal of transports are services typically not covered by insurance. For Subscribers, SMAAS will waive 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 to participate in SMAAS’s subscription program.
III. Available Subscription Plans: Subscription is effective upon receipt and acceptance by SMAAS of the subscription application and fee and expires April 30th of the following year. Annual fees are subject to change on an annual basis without prior notice. Failure to submit the subscription fee in a one time payment will result in non-coverage by the subscription for the annual term, and any and all applications submitted without proper payment will be discarded without processing.
A. Family Plan ($75): Covers husband, wife, and unmarried children living at home under 18 years of age (or over the age of 18 and who are still enrolled in and attending high school), as well as full-time college students up to 24 years of age. All persons must be listed on the subscription application. Parents of the husband and wife, in-laws, non-family, and any other persons living in the household are not covered under the family membership.
B. Individual Plan ($50): 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 from your insurance company 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 SMAAS (or another ambulance service with which it has a subscription reciprocity arrangement) charges not paid by insurance for the first medically necessary and reasonable emergency ground ambulance transport to the closest appropriate facility within the subscription period, and 50% waiver of all medically necessary and reasonable emergency ground ambulance charges to the closest appropriate facility not paid by insurance starting on the second emergency transport and any thereafter within the subscription period provided by SMAAS or another ambulance service with which it has a subscription reciprocity arrangement. 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 the emergency ambulance transportation provided by SMAAS described above, my subscription includes 50% waiver of all charges not paid by insurance for up to three (3) insured medically necessary non-emergency ambulance transports provided by SMAAS. 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 non-emergency 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) medically necessary and reasonable non-emergency ambulance transports provided by SMAAS, but may be responsible for additional milage costs, or other services that are not covered under insurance. A Physician’s Medical Necessity Certification may be required to demonstrate that ambulance transport is warranted and medically necessary. In the event that non-emergency 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. At this time, SMAAS has subscription reciprocity arrangements in place with and will honor subscriptions from Fox Twp. Ambulance, Ridgway Ambulance, and Bennetts Valley Ambulance, according to these ambulance services’ specific terms and conditions. In return, this also means that if you are transported by any of these ambulance services listed, your subscription to SMAAS will be honored by the transporting service, according to SMAAS’s subscription Terms and Conditions. These subscription reciprocity arrangements are subject to change by each organization participating and cannot be guaranteed to continue for the duration of the subscription term. In the event that another ambulance service provider with which I do not have a subscription conducts the transport or who does not have a subscription reciprocity arrangement in place at the time of my ambulance services, 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 subscriber acknowledges that SMAAS will bill available third party 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 is a Medicaid beneficiary and that those persons are covered by health insurance. I request that payment 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.
The official registration and financial information of St. Marys Area Ambulance Service, Inc. may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.