119-hr5433

[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).
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