The COVID-19 pandemic took a brutal toll on Danielle Miele's family, but after two exorbitant ambulance bills she's afraid to call 911.

Her teenage son attempted suicide in 2022, Miele said. His mental health deteriorated during the pandemic, and he needed an ambulance transfer from the Roseville emergency room where Miele took him to a treatment center in San Mateo. The ambulance company hit Miele with a $9,000 out-of-network charge, which was sent to collections "almost immediately," she said.

The virus also left Miele with seizures that mimic the symptoms of a heart attack, she said. Miele called 911 the first time a seizure happened. The 15-minute ride to the hospital cost $4,000 without help from insurance.

"The last time I had one of my seizures I basically said, 'I'm going to die here at home ... I'm not getting another ambulance,'" Miele said. "I'd maybe rather die at home than have more medical debt."

A new California law taking effect Jan. 1 targets the kind of "surprise" ambulance bills that put Miele's family in debt even though they had medical insurance. These bills take the form of out-of-network charges for commercially insured patients who have no control over which ambulance company responds to a call for help.

Under the new law, patients will only have to pay the equivalent of what they would have paid for an in-network service. Health insurance and ambulance companies will have to settle the bill directly even if they don't have an existing contract.

Supporters of the new law argue it will make a big difference for thousands of families like Miele's. The second time that Miele's son needed an emergency psychiatric hold, the ambulance company that arrived was part of the family's insurance network. Their co-pay: $83.

Ambulance companies did not oppose the legislation, which includes assurances that health insurance plans reimburse them for services.

Californians hit with millions in surprise bills

The California Association of Health Plans, which represents insurers, opposed the bill before it became law because of its potential to increase premiums by $67.3 million statewide. In contrast, people with commercial health insurance stand to save approximately $44.5 million in direct charges for ambulance rides, according to a legislative analysis.

Katie Van Dynze, a legislative advocate for Health Access California, said the law closes a longstanding gap in California's consumer protections against surprise medical billing for those with commercial insurance. Health Access California, a consumer advocacy group, sponsored the new legislation.

"It's the last remaining gap, but it's a really big one," Van Dynze said. "You could be insured but it doesn't matter."

Approximately 14 million Californians with state-regulated commercial health plans will benefit from the law's protections. According to an analysis by the Kaiser Family Foundation, 73% of all ground ambulance transports in California resulted in an out-of-network charge in 2018 among people with large employer insurance. California also has the highest median surprise ambulance bill in the nation at $1,209, according to a study published last year by the U.S. Public Interest Research Group.

In a statement at the time of the law's passage, Assemblymember Tasha Boerner, the Democrat from Carlsbad who authored the measure, said people have no control over which ambulance company picks them up in a time of crisis.

"The last thing anyone should be thinking about when they call 911 is whether they can afford the ambulance ride," Boerner said in her statement.

The law also protects uninsured people from receiving an expensive ambulance bill by limiting their out-of-pocket cost to the Medi-Cal or Medicare rate, whichever is greater. Medi-Cal is the state's health insurance program for very low-income residents and already protects its enrollees from these types of bills.

About 6 million Californians enrolled in federally regulated health plans won't be shielded by the law, but a national committee is working on a solution to the U.S. No Surprises Act, which protects Americans from many kinds of surprise bills, including air-ambulance transports, but doesn't cover ground ambulance rides. Generally, those are Californians who work for large multi-state or multinational private companies with self-funded health plans. Californians can ask their employer what kind of health plan they offer.

$4,400 bill for newborn's ambulance trip

Lainey Arebalo and her family are thankful that future emergencies will be covered in California. Her health insurance company doesn't contract with any ambulance companies in San Luis Obispo County where they live, leaving them with no choice but to pay out of pocket.

In September, minutes after Arebalo gave birth to her son Brady, doctors made the decision to transfer him to a larger hospital about 20 miles away. Brady wasn't breathing properly and needed to be admitted to a neonatal intensive care unit. The ambulance came and whisked him away.

Over the next month letters started arriving from the ambulance company: Arebalo owed $4,400 for the transfer, she said.

"Here I am, you know, less than two months after giving birth being told I would be sent to collections," Arebalo said.

Insurance covered nearly all of Brady's five-day hospital stay, which totaled $109,000, Arebalo said, but wouldn't pay for the out-of-network ambulance ride. Eventually, insurance paid about a third of the bill after Arebalo filed a grievance, but the remaining unexpected expense still cut into the family's finances. She ended her maternity leave early to return to work as a special education teacher in order to help pay the bills. She's on a payment plan of $200 per month.

"It was definitely a surprise bill, and one that I'm still paying," Arebalo said.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

This story was originally published by CalMatters and can be viewed here.