Content informed and developed with input from people living with IBD and an expert steering committee
Understanding insurance and the healthcare system can be challenging, particularly for individuals from diverse racial and ethnic backgrounds who may face language barriers, health literacy challenges, or different health insurance systems in their countries of origin. Addressing insurance knowledge gaps is crucial in managing IBD effectively, as it can significantly impact a patient’s ability to access care and medications. The checklist below outlines some suggested items healthcare team members should consider when handling patients’ insurance.
Checklist:
- Assess Understanding of Insurance
Coveragea:
- Determine the patient’s understanding of their insurance plan, including what is covered, the costs they are responsible for, and how to navigate the approval process for tests and treatments.
- Identify Language Barriers:
- Confirm whether the patient requires translation services for insurance documents and during discussions with insurance representatives.
- Educate on the Basics of Insuranceb:
- Provide clear explanations about premiums, deductibles, co-pays, co-insurance, out-of-network charges, and how these may affect the patient’s care.
- Explain the Role of Insurance in IBD
Care:
- Describe how insurance can affect access to specialists, procedures, medications, and ongoing care.
- Clarify Medication Coveragec:
- Discuss formulary restrictions, generic vs. brand medications, and the process of obtaining approvals for certain IBD medications.
- Highlight the Importance of
Maintaining Coverage:
- Educate on the potential financial and health consequences of lapses in insurance coverage.
- Guide on Insurance Appealsd:
- Provide information on how to navigate denials and appeals.
- Navigate Public Assistance and
Supplemental Programs:
- Assist in understanding public insurance options and supplemental programs for which they may be eligible.
- Address Cultural Views on Insurance and Health Care:
- Recognize and discuss any cultural beliefs that may impact the patient’s approach to insurance and healthcare utilization.
- Connect with Social Workers or
Patient Navigators:
- Refer patients to social workers or patient navigators who specialize in assisting with insurance-related issues.
aNote for HCPs: If unsure about the specifics of the patient’s insurance, guide patients on where to find this information (e.g., insurance customer service, insurance website).
bNote for HCPs: Use educational materials or refer to insurance specialists who can provide detailed explanations.
cNote for HCPs: You may not know the specifics of the patient’s coverage; therefore, encourage patients to contact their insurance provider or pharmacy for detailed information.
dNote for HCPs: Refer patients to insurance advocates or resources that can help with the appeals process.
Glossary of Insurance Terms2:
Co-pay
- Co-pay is a flat fee paid by a patient in order to access healthcare services.
Co-pay accumulator
- Co-pay accumulator is a feature within an insurance plan where a manufacturer’s payments do not count toward the patient’s deductible and out-of-pocket maximum.
- The manufacturer co-pay card funds prescriptions until the maximum value on the card is reached.
- After that, the patient’s out-of-pocket costs begin counting toward their annual deductible and out-of-pocket cost maximum.
Co-pay adjustment program
- This can either be a co-pay accumulator or co-pay maximizer.
Co-pay card
- A co-pay card, sometimes called a co-pay coupon, is financial assistance that helps patients with insurance afford prescription medications by covering part or all of a member’s deductible and co-pay.
Co-pay maximizer program
- A co-pay maximizer program is within an insurance plan where a manufacturer’s payments does not count toward the patient’s deductible and out-of-pocket maximum.
- The maximum value of the manufacturer’s card is applied evenly throughout the benefit year.
Cost sharing
- Cost sharing includes the share of costs covered by insurance that a patient pays out of their own pocket.
- This term generally includes deductibles, coinsurance, and co-payments, or similar charges, but it does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.
Deductible
- A deductible is an amount an insured party pays out-of-pocket before an insurance company pays a claim.
Out-of-pocket costs
- Out-of-pocket costs includes expenses for medical care that are not reimbursed by insurance, including deductibles, coinsurance, and co-pays for covered services plus all costs for services that aren’t covered.
Related Patient Resources
Find a Support Group
The Crohn's and Colitis Foundation provides information on finding a support group for individuals with IBD. This webpage emphasizes the importance of connecting with others who share similar experiences and offers a search tool to locate local support groups.
Visit Site
References
- 1. Spencer EA, Abbasi S, Kayal M. Barriers to optimizing inflammatory bowel disease care in the United States. Therap Adv Gastroenterol. 2023;16:175628482311696. doi:10.1177/17562848231169652.
- 2. Cavalier D, Doherty B, Geonnotti G, et al. Patient perceptions of copay card utilization and policies. J Mark Access Health Policy. 2023;11(1):2254586. doi:10.1080/20016689.2023.2254586.