Membership Agreement and Description

TotalCare is an ambulance service subscription program sponsored by the Emergency Medical Services Authority (EMSA). TotalCare provides for the prepayment of co-payments and deductibles for all medically necessary ambulance services for which the patient (or his or her insurance provider) has financial responsibility. In addition, TotalCare members pay a reduced rate of 40% off the regular cost of non-emergency transports.

The TotalCare 2010-2011 eastern division open enrollment period ends on June 30, 2010. All 2010-2011 eastern division memberships expire on June 30, 2011. The TotalCare 2010-2011 western division open enrollment period ends on September 30, 2010. All 2010-2011 western division memberships expire on September 30, 2011. Individuals who join after the enrollment period are eligible to receive benefits for dates of service 30 days after payment is received in full.

Who Is Covered?

One membership covers the applicant and all permanent members of the applicant’s household. A spouse being cared for in a nursing home may be covered under the applicant’s membership. In many communities, a small monthly fee is added to most residential water/utility bills to support ambulance operations and provide benefits. TotalCare is designed for those individuals living in nursing homes and apartment complexes not participating in a city utility bill program.

If you have questions about an individual’s eligibility, please call 396-2888 before submitting your application.

TotalCare annual membership fee: $45

Member Benefits

TotalCare membership benefits are applied to emergency and non-emergency ambulance transports provided by EMSA within the EMSA service area. Patient preference usually determines to which hospital the patient is transported; however, in cases of life endangerment, the closest appropriate hospital will be used.

Emergency transports are fully covered. An emergency is defined as an unforeseen condition that requires urgent and unscheduled medical attention. Emergency transports always result in the ambulance taking the patient to a hospital emergency room.

Non-emergency transports are fully covered if insurance or other third-party coverage provided benefits for the service (even if subject to deductible, co-payment or co-insurance). If no insurance or other third-party coverage is available or if the claim is denied, the TotalCare member is charged a reduced fee (40% off EMSA’s standard non-emergency rate). A non-emergency transport is a medical transfer that does not have a hospital emergency room as the final destination.

Excluded Services

TotalCare members must present a completed physician certification statement (PCS) to receive benefits for non-emergency transports. TotalCare provides no coverage for non-emergency transports without a PCS. The patient’s physician usually completes certificates.

Repetitive transports for services such as dialysis, radiation therapy and chemotherapy are not eligible for TotalCare benefits without additional screening and insurance approvals.

TotalCare does not cover non-emergency transports to and from doctors’ offices, dentists’ offices, physical therapy centers, pharmacies, freestanding clinics and other facilities. Transports outside of EMSA’s service area are also not included in the program. Members will receive a full bill for excluded services. Before requesting non-emergency service, please call 396-2888 to determine the transport’s eligibility.

Agreement

I acknowledge that my insurance provider and/or I am responsible for payment of ambulance services provided to me by EMSA. I acknowledge that it is my responsibility to provide EMSA, within 60 days of the date of service, with any valid insurance and third-party payer information pertaining to me or anyone living in my household who receives EMSA services and that failure to do so nullifies this agreement. In addition, I agree to furnish any information requested by my insurance company in order to facilitate payment of ambulance claims for me or anyone living in my household. In consideration for payment of the membership fee, I hereby assign to EMSA all ambulance benefits that any covered family member or I may otherwise be entitled to receive from any insurance or other third-party payer for services provided under my TotalCare membership. EMSA will accept this assignment as payment in full for emergency transports, and for non-emergency transports if insurance or other third-party payer coverage provides benefits for the transport. I understand that EMSA will file my ambulance insurance claims for each covered person and is entitled to receive payment from all insurance or other third-party payers up to the amount of EMSA’s usual charges. If no insurance or other third-party payer benefits are available or if the insurance company or other third-party payer denies payment for non-emergency service, I understand that I will remain responsible for payment of EMSA’s reduced fee for TotalCare members (40% off EMSA’s standard non-emergency rate). Any insurance or other third-party payment I receive related to EMSA’s services provided under my TotalCare membership must immediately be delivered to EMSA, if there is an outstanding balance on my account. Violation of the terms of this agreement will result in termination of this agreement, and the patient (or responsible party) will be billed for all charges related to services provided.