July is UV Safety Awareness Month

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Summer is a great time to enjoy longer days and spend more time outdoors. It is also a good time to think about protecting your skin from ultraviolet (UV) rays.

UV rays cause sunburns, premature aging, and an increased risk of skin cancer. While a sunburn may fade after a few days, repeated exposure to UV rays can have lasting effects on your skin.

The good news is that a few simple habits can make a difference:

  • Choose a broad-spectrum sunscreen with an SPF of 30 or higher and reapply every two hours, or more often if swimming or sweating.
  • Wide-brimmed hats, sunglasses with UV protection, and lightweight long sleeves can help reduce sun exposure.
  • The sun’s rays are typically strongest between 10:00 a.m. and 4:00 p.m., so try to limit sun exposure during these hours.
  • UV rays can pass through clouds, so sun protection is important even when it is overcast outside.
  • Become familiar with your skin and talk with your healthcare provider if you notice a new or changing mole, spot, or lesion.

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Why Prior Authorization Matters

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Your healthcare provider recommends a medical test or procedure, but before you can schedule it, your health plan may require one more step: prior authorization.

Prior authorization is a process some health insurance plans use to determine whether certain medications, imaging tests, procedures, or medical services meet the plan’s coverage requirements before they are provided. While not every service requires prior authorization, many plans use it for higher-cost services or treatments.

The purpose of prior authorization is to help ensure that care is medically appropriate and consistent with a health plan’s guidelines. Requirements vary by insurance carrier and health plan, which means a service that requires prior authorization under one plan may not require it under another.

One common misconception is that if a healthcare provider recommends a service, it is automatically covered by insurance. Provider recommendations and insurance coverage decisions are separate. Even experienced healthcare providers may not know the specific requirements of every health plan.

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Why Healthcare Costs Can Vary So Much for the Same Service

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Many people are surprised to learn that the cost of healthcare services can vary significantly, even when the service itself appears to be exactly the same.

For example, two individuals may receive the same imaging test, lab work, or office visit and receive very different bills depending on where the service was performed, whether the provider was in-network, and how their health plan is structured.

One of the biggest factors affecting cost is provider networks. In-network providers have negotiated contracted rates with insurance carriers, which are generally lower than out-of-network pricing. Out-of-network care may result in higher deductibles, coinsurance percentages, or additional balance billing depending on the plan.

Health plan design also plays a major role in what someone pays out of pocket. Traditional PPO plans often include fixed copays for services such as office visits or prescriptions, which can make costs feel more predictable. HSA-compatible high-deductible health plans typically operate differently. In many cases, individuals enrolled in HSA plans may pay the full contracted cost of services until the deductible is met, after which coinsurance may apply.

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IRS Announces 2027 HSA Contribution Limits

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The IRS released the contribution limits for Health Savings Accounts (HSAs) for 2027. In the upcoming year, we will see an HSA contribution limit increase to $4,500 for individuals and an increase to $9,000 for a family. The IRS implemented inflation-adjusted parameters for health savings accounts in Revenue Procedure 2026-24.

For 2027, individuals with self-only coverage can contribute up to $4,500 to their HSAs, up from $4,400 in 2026. Individuals enrolled in family coverage can contribute up to $9,000, up from $8,750 in 2026. The IRS also noted that the 2027 catch-up contribution for those aged 55 and older will remain $1,000, unchanged from 2026.

Health Savings Accounts remain a valuable tool for individuals and families enrolled in qualified high-deductible health plans (HDHPs). HSAs offer tax advantages, allow unused funds to roll over from year to year, and can serve as a long-term savings vehicle for future healthcare needs.

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Understanding Copays vs. Coinsurance

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Many people have heard the terms copay and coinsurance, but understanding the difference between the two can help make healthcare costs more predictable and easier to understand.

A copay is usually a fixed dollar amount paid for a specific service, such as a primary care visit, specialist appointment, or prescription. For example, you may pay a $30 copay for an office visit regardless of the total cost of the appointment.

Coinsurance works differently. Instead of paying a fixed amount, coinsurance is a percentage of the cost of a service that you are responsible for paying after meeting your deductible. For example, if your plan has a 20 percent coinsurance, you may pay 20 percent of the allowed cost for a covered service while your health plan pays the remaining amount. Out-of-network care may also result in higher out-of-pocket costs, as coinsurance percentages and allowed amounts can differ from those for in-network services.

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Why More People Are Using Telehealth

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Telehealth usage continues to grow as more individuals look for convenient and accessible healthcare options. While virtual care existed before COVID-19, the pandemic significantly accelerated its adoption as healthcare providers and patients looked for safe ways to access care remotely.

Telehealth visits have continued to increase in recent years, and many patients value the convenience and flexibility that virtual care provides. Telehealth is commonly used for primary care visits, behavioral health support, prescription refills, follow-up appointments, and other non-emergency concerns.

For many people, virtual visits reduce travel time and make it easier to fit appointments into busy schedules. A good example of when telehealth may be useful is for concerns such as conjunctivitis (pink eye), where an individual may receive care quickly without an in-person visit and have medication prescribed if necessary.

Many health plans now include telehealth services as part of their benefits, and virtual care can often be a lower-cost option than urgent care or emergency room visits for non-emergency conditions. CalCPA Health medical members have access to LiveHealth Online for virtual medical and behavioral health visits.

Individuals should check with their healthcare providers to see if telehealth options are available. It can also be helpful to review plan documents to understand how telehealth services are covered under a specific health plan, including costs and eligible services.

Understanding when telehealth is appropriate can help individuals make more informed decisions about where to receive care and may provide a convenient option for accessing healthcare when in-person visits are not necessary.

While telehealth can be helpful for many non-emergency concerns, individuals experiencing severe symptoms or medical emergencies should seek in-person or emergency care when appropriate.

Coverage and telehealth services may vary by plan and provider. Members should review their plan documents and confirm coverage details before receiving services.

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Understanding Preventive vs. Diagnostic Care

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One of the most common areas of confusion in healthcare is the difference between preventive and diagnostic care. Many people schedule what they believe is a routine preventive visit, only to later receive a bill they were not expecting.

The difference often comes down to why the service was performed and what was discussed during the visit.

Preventive care is designed to help detect or prevent health issues before symptoms appear. These services may include annual wellness visits, routine screenings, vaccinations, and certain lab tests. When completed in-network, many preventive services are covered at little to no cost under most health plans.

Diagnostic care is different. It occurs when a provider is evaluating a specific symptom, concern, condition, or follow-up issue. Once care becomes diagnostic, out-of-pocket costs such as deductibles, copays, or coinsurance may apply.

For example, an annual wellness visit scheduled as preventive care may be covered in full. However, if additional concerns are addressed during the appointment, such as ongoing headaches, stomach pain, or a new symptom, part of the visit may be billed as diagnostic care.

Similarly, a routine screening mammogram is typically considered preventive care. However, if additional imaging is needed because of a lump, pain, or another concern, those services may be considered diagnostic and billed differently. Even though the tests may seem similar, the reason they are being performed can affect how coverage is applied.

The same can apply to screenings and lab work. A routine screening completed as part of preventive care may be covered differently than a test ordered to investigate a specific medical concern.

This does not mean you should avoid asking questions or discussing your health with your provider. It simply highlights the importance of understanding how services are classified and billed.

Before an appointment, it can be helpful to ask:

  • Is this visit considered preventive or diagnostic?
  • Will any additional concerns discussed during the visit affect how it is billed?
  • Are labs or screenings covered as preventive under my plan?
  • Will I have any out-of-pocket costs?

These conversations can help you better understand your coverage and avoid unexpected surprises later.

Understanding how preventive and diagnostic care work is an important part of being an informed healthcare consumer. Health insurance can feel complicated but asking questions and learning how your plan works can help you make more confident decisions about your care.

Preventive care remains one of the best ways to support long-term health and identify potential concerns early. Staying proactive, scheduling routine visits, and understanding your benefits can help you make the most of your health plan throughout the year.

Note: Coverage, billing, and preventive care classifications vary by plan and provider. Members should review their plan documents and confirm coverage details before receiving services.

 

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Health Insurance Premiums Skyrocketing = Blame the Health Insurance Companies

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By Ron Lang, CEO, CalCPA Health (June 2026 issue of CalBroker Magazine)

Over the past 18 months, health insurance premiums have risen at levels not seen since the early days of the Affordable Care Act (ACA). For consumers, the conclusion feels obvious: insurance companies must be driving up premiums.

But that conclusion overlooks how the system actually works.

Consumers, and often the media, see only the end result: higher premiums. Meanwhile, hospitals, physicians, and pharmaceutical manufacturers largely escape the same level of scrutiny. Health insurers, for their part, have not always been effective at communicating their role in managing these costs.

The reality is that today’s premium increases are the result of multiple factors converging at once, each pushing the total cost of care higher.

 

Why Premiums Are Rising Faster Now

High-Cost (“Nuclear”) Claims

Extremely expensive cases are reshaping the total cost curve. Gene therapies can exceed $2 million for a single treatment, and other breakthrough treatments come with million-dollar price tags. These innovations miraculously improve patients’ lives, but their costs ultimately flow through to premiums.

Prescription Drug Spending

Drug costs continue to outpace overall medical inflation. More individuals are taking medications for more conditions, and specialty drugs, particularly in oncology and rare diseases, carry annual costs in the hundreds of thousands of dollars.

GLP-1 medications, used for diabetes and weight management, are a prime example: high utilization combined with high cost is materially impacting trend.

A decade ago, prescription drugs accounted for less than 10% of total healthcare spending. Today, that figure has doubled to around 20%, a shift driven not by traditional inflation, but by the rise of specialty therapies and high-cost chronic treatments. Prescription drugs, while still a minority of total spend, are now one of the fastest-growing components of overall healthcare costs.

While generics and biosimilars continue to provide savings in some categories, those gains are frequently offset by the introduction of newer, higher-cost therapies. GLP-1 utilization is further accelerating this trend.

Increased Utilization Across the Board

People are simply using more healthcare. Rising rates of obesity, diabetes, cardiovascular disease, and autoimmune conditions are driving more physician visits, diagnostic testing, hospitalizations, and prescriptions. When utilization increases, total costs, and therefore premiums, follow.

Wage and Price Pressures in Healthcare

Healthcare is labor-intensive. Hospitals and physician groups are facing sustained wage pressure for nurses, physicians, and skilled technicians. Many provider contracts renew on multi-year cycles, meaning recent inflation is only now being reflected in negotiated reimbursement rates.

The “Regulatory Stack”

New state and federal mandates, while often well-intentioned, add incremental cost. Recent examples in California include expanded IVF coverage requirements and caps on insulin cost-sharing. Each mandate adds to what some refer to as the “regulatory stack,” while each mandate may be a small percentage increase to premiums, together and over time, they add a material amount.  Meanwhile, legislation that would actually reduce costs, rarely seems to be enacted.

Why Health Insurance Companies Look the Way They Do

Consumers and employers wanting the lowest possible premiums have shaped what health insurers look like. Many of the features consumers associate with “insurance friction” were originally designed by health insurance companies to control doctor/hospital behavior and costs; and protect patients from unnecessary or overpriced care.

These include:

  • Prior authorization and utilization review
  • Second surgical opinions
  • Provider networks that negotiate discounted rates
  • Case management and billing oversight
  • Preferred Provider Networks (and HMO’s)

Care delivered outside of PPO/HMO networks typically lacks these cost and safety controls, which is why out-of-network services are often significantly more expensive.

On the pharmacy side, Pharmacy Benefit Managers (PBMs) deploy tools such as formularies, generic substitution, step therapy, and manufacturer rebates to slow the growth of drug spending. These mechanisms are often criticized, but without them, costs would be significantly higher.

Built-In Limits on Insurance Company Profits

It is also important to understand that health insurers operate under explicit profit constraints. Under federal law (ACA), medical loss ratio (MLR) requirements leave a set percentage (15 or 20%) for insurance carrier expenses, including profit.  Failure to meet MLR thresholds results in premium rebates, thereby limiting carrier profits.  This structure effectively caps margins and ties insurer profitability to overall healthcare spending. When costs rise, premiums must follow, not to increase profits, but to cover claims.

Bottom Line

Health insurers are often the most visible part of the system, but they are not the primary drivers of cost increases. In many ways, they function as financial intermediaries, aggregating and managing the underlying costs generated elsewhere in the healthcare system.

California’s Health Care Affordability Council was chartered to cap premiums and healthcare spending, but to date, has had little measurable effect on overall costs. If the goal is to meaningfully address rising premiums, the focus must be on the drivers of healthcare cost: provider/hospital costs, pharmaceutical pricing, and regulatory design.

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A Few Months In: Are You Using Your Health Plan?

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We are a few months into the year, which makes this a good time to pause and take a closer look at how you are using your health plan.

Whether you selected new coverage this year or have been on the same plan for a while, this is often when expectations meet reality. You may have filled a prescription, visited a provider, received a bill, or you may not have used your plan at all.

Wherever you are, now is a good time to check in.

Are you actively using your benefits, or are you only thinking about your plan when something comes up? Health insurance is often treated as something you deal with when you need care, but it is meant to be used throughout the year.

Some questions to ask yourself:

  • Have you scheduled your annual wellness visit?
  • Are you using in-network providers?
  • Do you know what your copay is and whether you have coinsurance? Do you understand the difference between the two?
  • Do you know how much of your deductible you have met?
  • Do you understand what services are considered preventive care?
  • Do you know where to go depending on the situation, such as telehealth, urgent care, or the emergency room?

If any of these are unclear, you are not alone. Many people do not fully understand their coverage until they need to use it.

One area that is often overlooked is preventive care. Routine exams, screenings, and labs are often covered at little to no cost when done in-network. Taking care of these early can help you stay ahead of potential health issues.

If you have already used your plan this year, your claims can give you a clearer picture of how your costs work. This includes how your deductible applies and what your copays look like.

Small decisions can affect your costs. Where you go for care, whether a provider is in-network, and whether you ask questions ahead of time can all impact what you pay. Before your visit, consider asking about expected costs, whether prior authorization is required, and whether the service will be considered preventive or diagnostic. Writing your questions down in advance can help you feel more prepared and confident in your decisions.

If you have not spent much time thinking about your health plan yet, that is okay. There is still plenty of time to make the most of it.

Start by taking a look at your plan details, such as your Summary of Benefits or plan documents, so you understand what is covered and how your costs are structured. It can also be helpful to check your progress by seeing how much of your deductible you have met and where you stand in relation to your out-of-pocket maximum.

Scheduling preventive care is one of the easiest ways to use your benefits and stay on top of your health. If you expect to need services later this year, take time to plan ahead by confirming providers and facilities in advance, making sure they are in-network, and understanding what your costs may be.

Your health plan is something you can use to support your health and make more informed decisions about care. Taking a few minutes now to understand how your plan is working can help you avoid surprises and feel more confident in your choices throughout the year.

 

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CalCPA Health + GoodRx

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Helping Lower Your Pharmacy Costs — Automatically

CalCPA Health PPO and HSA medical plan enrollees now benefit from built-in GoodRx prescription pricing (when available) as part of their pharmacy coverage through Express Scripts Rx.

There’s nothing you need to do. No coupons. No discount cards. No separate enrollment.

When you present your CalCPA Health plan ID at the pharmacy, your prescription is automatically processed through your benefit. If the GoodRx price is lower than your plan’s already negotiated cost, you will automatically receive the lower GoodRx price.

What This Means for You

Lowest Available Price on Eligible Generic Medications

Eligible generic medications (excluding specialty generics) are automatically compared to GoodRx pricing to ensure you receive the lowest available price.

Effortless Member Experience

No need to search for GoodRx coupons or present a discount card. The comparison happens automatically through your CalCPA Health benefit.

Supports Medication Adherence

You receive discounted medications without delay, helping you stay on track with your prescribed treatments.

Claims Count Toward Your Plan

Unlike stand-alone discount programs, prescriptions processed through this partnership apply toward your deductible and out-of-pocket maximum.

This program ensures you receive competitive pricing while maintaining the protections and accumulators of your CalCPA Health pharmacy benefit.

Reminder: Mail Order Savings

For many maintenance medications, the Express Scripts mail-order pharmacy offers lower copays and overall drug costs. Be sure to compare your options for additional savings.

Questions? If you have questions about your pharmacy coverage:

CalCPA Health remains committed to helping members access care affordably and confidently.

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