Tag Archive for: CalCPA Health

July is UV Safety Awareness Month

, , , , , , ,

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.

Read more

/0 Comments

Why Prior Authorization Matters

, , , , , , , , , , , , , ,

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.

Read more

/0 Comments

Why Healthcare Costs Can Vary So Much for the Same Service

, , , , , , , , , , , , , ,

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.

Read more

/0 Comments

Understanding Copays vs. Coinsurance

, , , , , , , , , , , , , , ,

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.

Read more

/0 Comments

Why More People Are Using Telehealth

, , , , , , , , , , , , ,

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.

/0 Comments

Understanding Preventive vs. Diagnostic Care

, , , , , , , , , , , , , ,

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.

 

/0 Comments

Health Insurance Premiums Skyrocketing = Blame the Health Insurance Companies

, , , , , , , , , , , ,

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.

/0 Comments

Episode 3: Just Surviving Is Not the Goal – Raising the Bar After Triggers and Trauma with Mark Ziegenbein (LIMHP, LMNP, LMFT)

, ,

Getting through the day isn’t the goal — learning how to respond to life in a way that supports your wellbeing is. In this episode, we shift from survival mode to building awareness, perspective, and capacity when stress and triggers show up. You’ll hear how to match your response to what’s actually happening, instead of reacting automatically, and why preparation and support matter more than perfection. It’s about becoming more skillful, not doing it alone, and raising the bar for how we care for ourselves.

/0 Comments

Episode 2: Overhelmed but Functional with John Ebron (Master Mindset Coach, Behavioral Health Consultant)

, ,

Many people continue to meet responsibilities at work and home while quietly carrying an overwhelming mental load. This episode explores the difference between trauma and system overload, helping listeners understand why feeling “overwhelmed but functional” is so common today. We discuss how stress often shows up physically before emotionally and why pushing through can sometimes make things worse. The episode also introduces practical strategies to help regulate the nervous system and restore balance during periods of overload.

/0 Comments

Episode 1: What Do We Mean When We Say Mental Health with Michelle Niehues (MS, LCMFT)

, ,

Mental health doesn’t only appear in moments of crisis—it shows up in everyday experiences, interactions, and challenges. In this episode, we explore what mental health really means and why it’s a normal part of being human. The conversation focuses on how thoughts, emotions, and behaviors influence our daily functioning and relationships. By reframing mental health as something we all experience, this episode encourages more open and supportive conversations in the workplace and beyond.

/0 Comments