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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5433 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 5433
To prohibit health insurance issuers and certain health care providers
under Medicare from being under common ownership, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 17, 2025
Ms. Hoyle of Oregon (for herself, Mr. Ryan, Ms. Jayapal, and Ms.
Ocasio-Cortez) introduced the following bill; which was referred to the
Committee on the Judiciary, and in addition to the Committees on Energy
and Commerce, and Ways and Means, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To prohibit health insurance issuers and certain health care providers
under Medicare from being under common ownership, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Patients Over Profit Act'' or the
``POP Act''.
SEC. 2. PROHIBITION ON COMMON OWNERSHIP OF HEALTH INSURANCE ISSUERS AND
CERTAIN HEALTH CARE PROVIDERS UNDER MEDICARE.
(a) In General.--It shall be unlawful for any person to both--
(1) directly or indirectly own, operate, or control the
whole or any part of an applicable provider or a management
services organization that has a management services agreement
with an applicable provider; and
(2) directly or indirectly own, operate, or control the
whole or any part of a health insurance issuer.
(b) Divestment.--Any person in violation of subsection (a) shall
divest either the applicable provider (or, if applicable, the
management services organization) or the health insurance issuer of
such person--
(1) in the case of an applicable provider, management
services organization, or health insurance issuer acquired on
or before the date of enactment of this Act, not later than 2
years after such date of enactment; or
(2) in the case of an applicable provider, management
services organization, or health insurance issuer acquired
after the date of enactment of this Act, not later than 1 year
after the date of acquisition.
(c) Civil Actions.--
(1) In general.--When the Inspector General of the
Department of Health and Human Services, the Assistant Attorney
General in charge of the Antitrust Division of the Department
of Justice, the Federal Trade Commission, or an attorney
general of a State has reason to believe that a person is in
violation of subsection (a) or (b), such Inspector General,
Assistant Attorney General, Federal Trade Commission, or
attorney general of a State may bring a civil action in an
applicable district court of the United States for the relief
described in paragraph (2).
(2) Injunctive and equitable relief.--In any action
described in paragraph (1), the applicable court, on a finding
that a person is in violation of subsection (a) or (b), shall
issue an order requiring such person--
(A) to cease and desist from such violation, and
divest either the applicable provider (or, if
applicable, the management services organization) or
the health insurance issuer of such person; and
(B) to disgorge any revenue received from the
provision of health care services during the period of
such violation.
(3) Deposit and distribution.--Any revenue disgorged
pursuant to an action under this subsection for a violation of
subsection (a) or (b) shall be deposited into a fund created by
the Federal Trade Commission and distributed by the Federal
Trade Commission to be put to use in the interest of serving
the health care needs of the harmed community. Receipt of any
funds under this paragraph shall not alter or diminish the
rights of an individual to bring an action or recover any
amount as otherwise authorized by law.
(d) FTC Review.--
(1) Reporting required.--Any divestment of an applicable
provider, management services organization, or health insurance
issuer required under subsection (b) shall be reported to the
Federal Trade Commission and the Assistant Attorney General in
charge of the Antitrust Division of the Department of Justice
under section 7A of the Clayton Act (15 U.S.C. 18a) without
respect to the thresholds under subsection (a)(2) of that
section.
(2) Tolling of divestment period during review.--The
divestment period under subsection (b) shall be tolled during
the pendency of any waiting period required under section 7A of
the Clayton Act (15 U.S.C. 18a).
(3) Review of effect of divestiture.--With respect to each
divestiture undertaken pursuant to subsection (b), in addition
to any applicable review under section 7A of the Clayton Act
(15 U.S.C. 18a), the Federal Trade Commission and the Assistant
Attorney General in charge of the Antitrust Division of the
Department of Justice shall review the effect on competition,
financial viability, and the public interest--
(A) of the divestiture; and
(B) of the subsequent acquisition of the applicable
provider (or, if applicable, the management services
organization) or the health insurance issuer of such
person by the acquiring person.
(e) Rulemaking Authority.--The Federal Trade Commission shall
promulgate rules to carry out this section. Such rules shall not
diminish any obligation under this section.
(f) Rule of Construction.--Nothing in this section shall be
construed to limit the authority of the Federal Trade Commission, the
Inspector General of the Department of Justice, the Department of
Health and Human Services, or the attorney general of a State under any
other provision of law.
(g) Enforcement Under Medicare Advantage and Medicare Part D.--
(1) Medicare advantage.--Section 1857 of the Social
Security Act (42 U.S.C. 1395w-27) is amended by adding at the
end the following new subsection:
``(j) Prohibition on Common Ownership of MA Organizations and
Applicable Providers.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, the Secretary may not contract with, or
provide payment under this part to, a Medicare Advantage
organization with respect to offering an MA plan or MA-PD plan
under this part if the organization--
``(A) directly or indirectly owns, operates, or
controls the whole or any part of an applicable
provider or a management services organization that has
a management services agreement with an applicable
provider; or
``(B) is directly or indirectly owned, operated, or
controlled in whole or part by a person who also
directly or indirectly owns, operates, or controls the
whole or any part of an applicable provider or a
management services organization that has a management
services agreement with an applicable provider.
``(2) Certification.--Each Medicare Advantage organization
shall furnish to the Secretary (in a form and manner, and at a
time, specified by the Secretary) a certification of compliance
with this subsection, as well as such information as the
Secretary determines necessary to carry out this subsection.
``(3) False claims submitted by entities in violation of
prohibition on common ownership.--Any claim for payment from an
entity in violation of paragraph (1) constitutes a false or
fraudulent claim for purposes of subchapter III of title 31,
United States Code.
``(4) Definitions.--In this subsection:
``(A) Applicable provider.--
``(i) In general.--Subject to clause (ii),
the term `applicable provider' means any entity
that receives payment for furnishing services
covered under part B or under a Medicare
Advantage plan under part C.
``(ii) Exclusions.--Such term does not
include--
``(I) a hospital (as defined in
section 1861(e)), a critical access
hospital (as defined in section
1861(mm)(1)), or a rural emergency
hospital (as defined in section
1861(kkk)(2));
``(II) a supplier of durable
medical equipment, prosthetics,
orthotics, or supplies; or
``(III) a pharmacy.
``(B) Management services agreement.--The term
`management services agreement' means a contract
between a management services organization and an
applicable provider for management or administrative
services relating to, supporting, or facilitating the
provision of health care services.
``(C) Management services organization.--The term
`management services organization' means any
organization or entity that contracts with an
applicable provider to perform management or
administrative services relating to, supporting, or
facilitating the provision of health care services.''.
(2) Medicare part d.--Section 1860D-12(b)(3) of the Social
Security Act (42 U.S.C. 1395w-112(b)(3)) is amended by adding
at the end the following new subparagraph:
``(G) Prohibition on common ownership.--Section
1857(j).''.
(h) Definitions.--In this section:
(1) Applicable provider.--
(A) In general.--Subject to subparagraph (B), the
term ``applicable provider'' means any entity that
receives payment for furnishing services covered under
part B of title XVIII of the Social Security Act (42
U.S.C. 1395j et seq.) or under a Medicare Advantage
plan under part C of such title (42 U.S.C. 1395w-21 et
seq.).
(B) Exclusions.--Such term does not include--
(i) a hospital (as defined in section
1861(e) of the Social Security Act (42 U.S.C.
1395x(e))), a critical access hospital (as
defined in section 1861(mm)(1) of such Act (42
U.S.C. 1395x(mm)(1))), or a rural emergency
hospital (as defined in section 1861(kkk)(2));
(ii) a supplier of durable medical
equipment, prosthetics, orthotics, and
supplies; or
(iii) a pharmacy.
(2) Health insurance issuer.--The term ``health insurance
issuer'' has the meaning given that term in section 2791 of the
Public Health Service Act (42 U.S.C. 300gg-91).
(3) Management services agreement.--The term ``management
services agreement'' means a contract between a management
services organization and an applicable provider for management
or administrative services relating to, supporting, or
facilitating the provision of health care services.
(4) Management services organization.--The term
``management services organization'' means any organization or
entity that contracts with an applicable provider to perform
management or administrative services relating to, supporting,
or facilitating the provision of health care services.
(5) Person.--The term ``person'' has the meaning given the
term in section 8 of the Sherman Act (15 U.S.C. 7).
<all>
Introduced in House
Introduced in House
Referred to the Committee on the Judiciary, and in addition to the Committees on Energy and Commerce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on the Judiciary, and in addition to the Committees on Energy and Commerce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on the Judiciary, and in addition to the Committees on Energy and Commerce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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