General 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 2008-2009 open enrollment period ends on June 30, 2008. Individuals who join after the enrollment period are eligible to receive benefits for dates of service 30 days after payment is received in full. All 2008-2009 memberships expire on June 30, 2009.

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 with 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 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 should immediately be delivered to EMSA, if there is an outstanding balance on my account.