Open Enrollment and IBD: How to Choose a Health Insurance Plan That Works for You

For information about Medicare and Medicaid plans, click here. 

Open Enrollment Is an Opportunity to Protect Your Inflammatory Bowel Disease Care 

Choosing health insurance can feel overwhelming, especially when you live with a chronic disease that requires ongoing care. For people with Crohn’s disease or ulcerative colitis, the right plan can help make medications, specialist visits, testing, and procedures more accessible and affordable. 

Open enrollment is the period when you can enroll in or change your health insurance plan. Employer-sponsored plans often hold enrollment in the fall. Federal ACA Health Insurance Marketplace enrollment generally runs from November 1 through January 15, though you must enroll by December 15 if you want your coverage to start on January 1, 2027. Some state deadlines may differ. Medicare has a separate enrollment period that runs from October 15 to December 7. 

Open enrollment is an opportunity to make sure your coverage still meets your needs. The plan with the lowest monthly premium isn't necessarily the least expensive over the course of the year. Consider access to care, coverage, and what you could realistically pay out of pocket. 

 What Insurance Terms Should You Know? 

Understanding these common terms can help you compare plans: 

• Premium: What you pay each month for insurance. 

• Deductible: What you pay for covered care before your plan begins paying its share, according to plan rules. 

• Copay: A fixed amount you pay for a covered service or medication. 

• Coinsurance: The percentage of a covered cost that you pay. 

• Out-of-pocket maximum: The limit on what you pay for covered, in-network care during the plan year. 

• In network: Providers who have an agreement with your insurer. 

• Prior authorization: Approval required before certain care is covered. 

• Step therapy: A requirement to try certain treatments before receiving coverage for the medication prescribed by your doctor. 

• Copay accumulator: A program that may prevent manufacturer assistance from counting toward your deductible or out-of-pocket maximum. 

• Copay maximizer: A program that changes how manufacturer assistance is applied to medication costs. 

Explore the Foundation's healthcare glossary for more definitions and guidance. 

What Should People Living With IBD Consider During Open Enrollment? 

Is Your Gastroenterologist in Network? 

Confirm that your gastroenterologist (GI) and other specialists are in network. Depending on your needs, this may include a colorectal surgeon, dietitian, or GI psychologist. In-network care generally costs less, while out-of-network care may cost more or not be covered.  

Don't assume every provider at an in-network hospital is also in your insurance network. Check with your insurer and provider's office to confirm coverage and whether you can continue seeing your current care team. 

Are Your Medications Covered? 

Check your plan's formulary, the list of covered prescription drugs, for every medication you take. Find out how much you'll pay. Insurance plans group medications into cost tiers, and lower-tier medications generally cost less than those on higher tiers. Some IBD medications, including biologics, may be on higher-cost specialty tiers. 

Check whether your plan requires prior authorization, step therapy, or the use of a specialty pharmacy. These requirements can affect which medications are covered and how you access them. Learn more about navigating prior authorization. 

You might also check to see whether a biosimilar is available for your medication. Biosimilars are designed to be near identical copies of approved biologic therapies, with no clinically meaningful differences in safety or effectiveness. Some plans prefer certain biosimilars or place them on lower-cost tiers, but coverage varies. 

Don't assume your coverage will stay the same from year to year. Formularies, costs, and insurance requirements can all change. 

What Will Your Care Actually Cost? 

Look beyond your monthly premium. Compare your expected costs for provider visits, bloodwork, imaging, colonoscopies, infusions, procedures, medications and surgery. Check your deductible, copays, coinsurance, and out-of-pocket maximum, including whether separate deductibles apply to medical care and prescriptions.  

Find out whether your plan uses a copay accumulator or copay maximizer. These programs affect how manufacturer copay assistance is applied and may increase how much you pay toward your deductible or out-of-pocket maximum. 

Don't just ask, "What's the premium?" Ask, "What could I realistically spend on my IBD care over the course of the year?" 

What Should You Do Before You Choose a New Plan? 

Use the Foundation's IBD Insurance Checklist to compare plans and prepare for enrollment. 

Before choosing a plan, make sure you: 

• List your current medications and check their coverage and costs. 

• Confirm your GI and other specialists are in network. 

• Review coverage for procedures, imaging, lab work, and infusions. 

• Compare premiums, deductibles, and out-of-pocket maximums. 

• Check prior authorization, step therapy, and specialty pharmacy requirements. 

• Ask about copay accumulators and maximizers. 

• Save your current plan documents for comparison. 

   

What If Your Insurance Changes or Denies Your Care? 

Changing plans may mean starting a new prior authorization process or repeating step therapy requirements, even if you continue the same treatment. Contact your insurer and healthcare team early to understand requirements and help avoid interruptions in care. 

If coverage is denied, you may have the right to appeal. Your healthcare team may be able to provide records or a letter explaining why treatment is medically necessary. Keep copies of denial notices and appeal letters, and document conversations with your insurer. 

The Foundation offers insurance guidance and resources to help patients navigate coverage, denials, and appeals. The IBD Help Center can also connect you with additional support. 

What If You Can't Afford Your IBD Care? 

Financial assistance may help with premiums, medications, and other healthcare expenses. Depending on your circumstances, options may include: 

• Copay assistance: Manufacturer or nonprofit programs that help eligible patients with out-of-pocket medication costs. Manufacturer copay cards often cannot be used with federal health insurance. 

• Patient assistance programs: Programs that help eligible patients access medications or afford treatment-related expenses. 

• Medicaid and CHIP: Public insurance programs offering free or low-cost coverage to eligible adults, children, and families. 

• Medicare: Coverage options for eligible older adults and people with certain disabilities, including prescription drug coverage. 

• Marketplace financial assistance: Financial help with insurance premiums and other costs for eligible enrollees.  

Explore the Foundation's patient financial assistance programs and insurance support resources, or contact the IBD Help Center for guidance. 

Making Health Insurance Choices That Work for You 

Insurance shouldn't stand between people living with IBD and medically appropriate care. The Foundation advocates for affordable, accessible healthcare and works to address unnecessary insurance barriers. 

Take time during open enrollment to compare your options and find coverage that meets your healthcare needs and budget. Explore the Foundation's IBD insurance resources or contact the IBD Help Center for additional support.