THE EMERGENCY PROTECTION PLAN YOU CAN'T AFFORD TO BE WITHOUT

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Get protection from the unexpected ambulance costs for a full year and feel secure knowing your ambulance care will be provided by the most highly skilled, compassionate paramedics anywhere.

The ESP Membership Program is a family protection plan offered by Southwestern Michigan Community Ambulance Service (SMCAS). For just $45.00 a year, ESP members pay no additional out-of-pocket costs for *(medically necessary) ambulance service they may require during the year.

ESP Memberships are available to residents of Niles City, Buchanan City, Niles Township, Buchanan Township, Bertrand Township, Milton Township, Howard Township, and Pokagon Township (Sections 25-36).

Effective Dates:

Memberships will be accepted throughout the calendar year & will be effective upon receipt of payment to SMCAS and will expire 1 year from date of enrollment.

If I have insurance, who receives claim payments:

SMCAS-ESP Program is not insurance and SMCAS will pursue claim payments from your insurer or third party agency (e.g. Medicare, Medicaid, Blue Cross/ Blue Shield, etc.). To help process claims, I authorize release of any medical information necessary to process a claim, and further authorize such payment to be made directly to Southwestern Michigan Community Ambulance Service (SMCAS). If your insurance carrier makes payments directly to you, you are responsible for making payment to SMCAS.

If I have no insurance:

SMCAS-ESP Program is not insurance and SMCAS will bill you a minimal $200 co-payment for services rendered. You are responsible for payment of these co-payment amounts to SMCAS.

*What is medically necessary:

SMCAS-ESP Membership Services are restricted to “medically necessary” defined as “the specific need for ground ambulance service transportation to or from a health care facility (hospital or nursing home), where use of alternate forms of transportation (wheelchair transports, private car, Dial-a-Ride, taxi) would be medically inappropriate given the patient’s condition”. All calls must originate within the service area or servicing hospitals. SMCAS will utilize the guidelines set by insurance carriers to establish medical necessity and reserves the right to require physician certification of the medical necessity. If you abuse your membership, your membership will be revoked. Non-emergency ambulance and wheelchair transfers are not covered under the SMCAS-ESP Program.

If services are needed outside the SMCAS Service Area:

Out-of-area ambulance services are not covered by the ESP Program. If you move out of the service area (as detailed above) your membership will be void.

Who in my home is covered by this program:

The SMCAS-ESP Program covers those individuals residing in your household that you can claim as a dependent on your Federal Income Tax Form. YOU MUST USE THE SERVICES OF SMCAS IN ORDER TO QUALIFY FOR MEMBERSHIP BENEFITS. This membership is non-refundable and non-transferable.

FOR ADDITIONAL INFORMATION

CALL SMCAS AT (269) 684-2170

MONDAY – FRIDAY 8:00 AM – 5:00 PM

SMCAS-ESP MEMBERSHIP PROGRAM AGREEMENT AND APPLICATION