POP Act
The POP Act (Patients Over Profit Act) would bar a person from simultaneously owning or controlling both a health insurance issuer (including Medicare Advantage plans) and certain health care providers or management services organizations that have a management services agreement with an applicable provider. The goal is to prevent common ownership that could influence prices or care decisions across Medicare, Medicare Advantage, and related health insurance markets. If a violation occurs, the act requires divestment within specified timeframes and allows federal or state authorities to seek civil remedies, including injunctive relief and disgorgement of profits, with proceeds directed to community health needs. The bill also adds a Medicare-related enforcement provision targeting common ownership in Medicare Advantage, including certifications and potential false-claims penalties for entities in violation. The scope hinges on defined terms like “applicable provider,” “management services organization,” and “management services agreement,” and it creates FTC rulemaking and oversight alongside traditional antitrust enforcement.
Key Points
- 1Prohibition on common ownership: It is unlawful for a person to directly or indirectly own or control both an applicable provider (or an MSO with a management services agreement with an applicable provider) and a health insurance issuer.
- 2Divestment timeline and remedies: If acquired before enactment, divestment must occur within 2 years; if acquired after enactment, within 1 year. Violations can lead to civil actions by the relevant federal or state authorities, with courts ordering divestment and disgorgement of revenue, and directing those funds to a health-care-focused community fund.
- 3Medicare Advantage and Part D enforcement: Starting for plan years beginning in 2026, MA organizations may not contract with or be paid for plans if they have common ownership with an applicable provider or MSO tied to an applicable provider. Requires certification of compliance and imposes false-claims penalties for violations.
- 4Definitions and scope: The act defines applicable provider (generally those paid for Part B services or MA Part C services, with specific exclusions), health insurance issuer, management services agreement, and management services organization. It excludes hospitals, critical access hospitals, rural emergency hospitals, DME suppliers, and pharmacies from the “applicable provider” category.
- 5Enforcement and rulemaking: The Federal Trade Commission would issue rules to carry out the act. Divestiture timing can be tolled during waiting periods (Clayton Act §7A), and post-divestiture reviews would assess competition, financial viability, and public interest.