©2024 Seyfarth Shaw LLP www.seyfarth.com 2024 Cal-Peculiarities | 323 inpatient hospital maternity care (including labor and delivery and postpartum care).24 This definition is subject to change when the federal Patient Protection and Affordable Care Act defines the scope of benefits to be provided under its own maternity benefit requirement.25 There are exceptions for specialized health insurance, Medicare supplement insurance, CHAMPUS-supplement insurance, or TRI-CARE supplement insurance, or to hospital indemnity, accident-only, or specified disease insurance.26 8.2.3 Group Coverage Maintained During Pregnancy Leave. As discussed above (§ 2.1), California employers must maintain and pay for coverage for eligible employees who take pregnancy disability leave under a group health plan, throughout the leave (up to four months over a 12month period), at the level and under the conditions coverage would have existed had the employee continued in continuous employment during the leave.27 8.2.4 Consumer Balance Billing Protections. The federal No Surprises Act (NSA) went into effect on January 1, 2022. The NSA was enacted to prohibit health plans, providers, and facilities from issuing surprise medical billing for out-of-network emergency services, out-ofnetwork non-emergency services provided at an in-network facility, and out-of-network air ambulance services.28 However, pre-NSA, California had existing balance billing protections under the Knox-Keene Health Care Service Plan Act of 1975 and AB 72 (collectively, “California Balance Billing Laws”) that protect consumers from surprise medical billing for out-of-network emergency services and non-emergency services provided by out-of-network providers at an in-network facility.29 Although the NSA and California Balance Billing Laws overlap, the NSA does not generally supplant California Balance Billing Laws. Instead, the NSA generally applies to self-insured health care service plans whereas California Balance Billing Laws apply to insured health care service plans, such as Health Maintenance Organizations (HMOs). Note, however, with respect to air ambulance services provided by out-of-network providers, the federal Airline Deregulation Act preempts California Balance Billing Laws; thus, NSA protections apply to insured medical plans when determining cost-sharing for out-of-network air ambulance services.30 On October 8, 2023, Governor Newsom approved Assembly Bill (AB) No. 716, which limits the amount consumers may be billed for out-of-network ground ambulance service.31 Specifically, under the new law, the outof-pocket cost for out-of-network ground ambulance transportation for consumers will be limited to the in-network cost-sharing rates of their health plans, or in the case of uninsured individuals, the maximum out-of-pocket to the applicable Medicare or Medi-Cal rate, whichever is greater.32 Further, under the new law, non-network ambulance providers are prohibited from balance billing patients for amounts in excess of the in-network cost-sharing or Medicare/Medi-Cal rates, as applicable, or sending patients to collections for amounts in excess of these new cost-sharing amounts.33 Ultimately, the new law aims to increase transparency in ambulance costs by requiring certain insurance plans to pay locally-set rates for out-of-network ambulance providers, which will be reported annually by the California Emergency Medical Services Authority.34 Note however, the new law only applies to state-regulated health insurance or health plans that are subject to the California Knox-Keene Act, California Insurance Code, and regulation by the California Department of Managed Healthcare. This means health plans that are fully or partially self-funded are not subject to (all or some of) the provisions in the new law. 8.3 Cal-COBRA The federal Consolidated Omnibus Budget Reconciliation Act (COBRA)35 generally requires employers of 20 or more employees who offer a group health care plan to offer the option of continuing health care coverage for up to 18 months if coverage is lost or reduced.36 Members of the employee’s family must also be given the opportunity to continue their coverage.37
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