At Lupus Colorado, we know that navigating insurance hurdles can be one of the most frustrating—and harmful—barriers to managing chronic illness. That’s why we’re celebrating recent wins for patients and spotlighting new consumer protections that can make your healthcare more dependable and affordable.
Thanks to all who shared your stories to help pass these life-changing reforms!
Are You Covered by a Colorado-Regulated Insurance Plan or Colorado Medicaid?
If your health insurance card says “CO-DOI,” your plan is regulated by the Colorado Division of Insurance. If you’re covered by Health First Colorado (Medicaid), you’re under a different set of rules. Either way, important new protections are now in effect—but only if insurers comply.
Let’s break down what you need to know.
Co-Pay Accumulators: Know the Law, Protect Your Wallet
What is a Co-Pay Accumulator Adjustment Program (CAAP)?
These programs block third-party assistance (like manufacturer co-pay cards) from counting toward your deductible or out-of-pocket maximums. That means even if you receive help paying for your medication, your insurer may pretend you didn’t—leaving you to pay again.
What Changed?
As of January 1, 2025, CAAPs are illegal for state-regulated insurance plans in Colorado, thanks to Senate Bill 195. But some carriers haven’t gotten the memo. A recent report from the AIDS Institute flagged several plans, including Anthem, Rocky Mountain, and Cigna, as being out of compliance.
What You Can Do:
If you suspect your insurer is using a co-pay accumulator, file a complaint with the Colorado Division of Insurance (DOI). Even if you’re not sure, your experience matters and should be investigated.
Step Therapy Delays: You Deserve Timely Treatment
What is Step Therapy?
Also called “fail first,” step therapy forces patients to try insurer-preferred medications before covering the drug your doctor actually prescribed. This can delay the most effective treatment by weeks—or even months.
What Changed?
New laws (HB22-1370 and HB23-1183) put guardrails around step therapy for both state-regulated plans and Colorado Medicaid. You cannot be forced to try or fail another medication if:
- The insurer-required drug is contraindicated
- It lacks clinical effectiveness for your condition
- You’ve already tried and failed it
- You’re currently stable on your prescribed medication
What You Can Do:
If you believe your insurer is improperly applying step therapy rules, file a complaint (if you have a state-regulated plan) or grievance (if you have Medicaid). These filings trigger direct investigations and regulatory action from the state.
Take Action: Your Voice Matters
Even if you’re unsure whether your situation qualifies, don’t wait. Filing a complaint or grievance can make a real difference—not only for you but for others with lupus or chronic conditions facing the same obstacles.
File a Complaint or Grievance Here:
- State-Regulated Insurance → File with the Division of Insurance (DOI)
- Colorado Medicaid (Health First Colorado) → File with HCPF
Still Have Questions?
Lupus Colorado is here for you. If you need help understanding your insurance rights or submitting a complaint, reach out to:
Kristy Kibler at kristy@lupuscolorado.org