Margaret Hvatum is 70, a part-time computer science professor in suburban St. Louis, and in January she ran a 5K, a 10K, a half-marathon, and a full marathon over four consecutive days. By the end of that same month she was in a hospital bed.
Hvatum has primary immunodeficiency, a rare condition that leaves her body unable to fight infections effectively. Before her 2005 diagnosis she had four bouts of shingles. For more than a decade she relied on an expensive medicine to manage the condition, and on her insurance to cover it. Then her Humana Medicare Advantage plan denied it, and weeks later she was hospitalized.
The reason this case matters beyond one patient is what it reveals about a reform that was supposed to prevent exactly this.
The pledge, and the carve-out
In the summer of 2025, following intense public scrutiny of prior authorization, the nation's largest insurers, including Humana, signed a pledge outlining commitments to ease the burden on patients. Among them: reducing the number of services requiring prior approval, and honoring existing prior authorizations for a 90-day period when patients switched plans.
That second commitment addresses a real and well-understood problem. Patients with chronic conditions who switch plans at open enrollment can find themselves starting from zero with a new insurer, re-justifying a treatment they have been stably receiving for years. The 90-day continuity promise was designed to bridge that gap.
It did not apply to Hvatum. Humana said the pledge to honor existing approvals comes with limitations, and that the commitments are for medical services only.
Why the drug carve-out inverts the promise
The continuity protection was meant to help patients on ongoing treatment who change plans. Now consider who those patients actually are.
Someone receiving a one-time surgery does not need 90 days of continuity; the procedure happens and is finished. The people who genuinely need continuity across a plan switch are people on maintenance therapy for chronic conditions, and for a large share of them, that maintenance therapy is a drug. Immunoglobulin replacement for immunodeficiency. Biologics for autoimmune disease. Specialty drugs for MS, hemophilia, and rare conditions.
So a carve-out excluding drugs removes the protection from a substantial portion of the population it was designed to protect. There is a coherent industry rationale for treating drugs separately: they run through different benefit structures, pharmacy benefit managers, formularies, and regulatory frameworks than medical services. But an explanation of why the gap exists is not a defense of leaving it there, and a patient does not experience a formulary and a medical benefit as different things. They experience a medicine they have taken for a decade suddenly not being covered.
What the rules already require, and what they don't
There is real regulatory movement here, and it is worth being precise about its limits.
Rules proposed under the first Trump administration and finalized under the Biden administration took effect requiring insurers to respond to prior authorization requests within seven days, or 72 hours for urgent requests, and to process requests electronically rather than by phone or fax. Those rules apply to certain categories of insurance, including Medicare Advantage and Medicaid, and Humana's own provider documentation confirms that effective January 1, 2026, CMS requires prior authorization decisions within 7 days for certain medical services.
Note the recurring qualifier: certain medical services. Speed requirements govern how fast a decision comes, not whether the answer is yes. A rule that guarantees a fast denial is an improvement over a slow denial, and it is not the same as coverage.
The reform that keeps almost passing
The legislative fix has an unusual profile: it is genuinely bipartisan, industry-supported, and stuck anyway.
A bill sponsored by Rep. Mike Kelly targeting Medicare Advantage prior authorization became eligible for House fast-track consideration under rules for bills with broad support. It would require plans to adopt electronic systems using standardized transactions, and to submit data to the federal government including which services are subject to prior authorization and the percentage and number of requests approved and denied.
It is supported by a coalition of Medicare Advantage insurers called the Better Medicare Alliance, by Humana itself, and by patient and provider groups. And yet it has failed repeatedly. The House passed it by voice vote after it reached the consensus calendar in 2022, but it died in the Senate over concerns about a $16 billion cost estimate.
That $16 billion score is worth understanding, because it explains the paradox. The cost estimate reflects the assumption that if prior authorization becomes easier and faster, more care gets approved, and more approved care means more Medicare spending. The reform is expensive precisely because the status quo is effective at what it does.
The scale, and the incentive
More than half of eligible Medicare beneficiaries now choose Medicare Advantage, roughly 35 million people in 2026, and nearly half of all Medicare Advantage enrollees are covered by UnitedHealth Group or Humana.
The payment structure matters too. In 2026, Medicare Advantage plans receive an additional $2,664 per enrollee above their estimated costs of providing Medicare-covered services, according to MedPAC. Plans are paid prospectively, meaning care they do not deliver is money they keep. That does not make any individual denial improper, but it is the structural reason denials get sustained scrutiny.
What patients can actually do
For someone on an ongoing specialty medication, especially heading into a plan change, a few things follow directly from this case.
Ask specifically whether continuity protections cover drugs, not just whether they exist. Check formulary placement before switching plans, not after. Start re-authorization before the old one lapses, since the process takes time and the gap is where the harm occurs. And keep the documentation of prior approvals and treatment history, because re-establishing medical necessity is far easier with a paper trail than from memory.
A 70-year-old who runs marathons and manages a rare immune disorder should not also need to be an expert in the boundary between pharmacy and medical benefits. But until the carve-outs close, that boundary is where people fall through.