New 'POP Act' Bans Shared Ownership of Medicare Insurers and Doctors, Forcing Two-Year Sell-Off

The new Patients Over Profit Act (POP Act) is taking a hard line on who can own what in the Medicare space. Simply put, this bill says you can no longer own both a health insurance plan that works with Medicare (like a Medicare Advantage plan) and specific types of healthcare providers who bill Medicare. This is a direct shot at what’s called vertical integration, where the same company controls both the financing (the insurance) and the delivery (the doctor’s office or clinic).

The Check-Out Line: Separating Insurers from Providers

Starting now, if you’re an entity that owns or controls a Medicare Advantage issuer, you cannot also own or control an “applicable provider” or the management company running that provider. The idea here is to eliminate the conflict of interest where an insurance company might steer you to its own doctors, potentially limiting choice or necessary care to boost its own profits. The bill defines “applicable provider” broadly as almost anyone getting paid under Medicare Part B or through a Medicare Advantage plan, but it makes some big exceptions: hospitals, rural hospitals, pharmacies, and durable medical equipment suppliers (think wheelchairs) are specifically excluded. This means vertical integration can still happen in those big areas, which is a key detail.

Divestiture Deadlines: How Long You Have to Sell

If you’re currently one of the entities breaking this new rule, you can’t just shrug it off. The POP Act forces a sell-off, or “divestiture.” If you acquired both sides of the business before this law was enacted, you get two years to sell off either the insurance side or the provider side. If you bought the provider or insurer after the law passed, your deadline is shrunk to just one year. For the busy people relying on Medicare, this means the market for your care could shift quickly as these large corporations restructure.

The Enforcement Hammer and Community Payback

This isn't just a slap on the wrist. The bill gives serious teeth to enforcement agencies—the Inspector General, the DOJ Antitrust Division, the FTC, and State Attorneys General. They can sue violators in federal court. If the court finds a violation, it doesn't just stop the illegal ownership; it forces the violator to return (or “disgorge”) all the money they earned from providing healthcare services while they were breaking the law. That money doesn't go back into the government’s general fund. Instead, it goes into an FTC-managed fund to be distributed to support community healthcare needs in the area that was harmed. This is a significant penalty—not just losing the business structure, but losing the profits earned from it.

The Medicare Advantage Catch

For those enrolled in Medicare Advantage (MA) plans, the bill adds a specific rule starting with the 2026 plan year. The Secretary of Health and Human Services (HHS) is explicitly banned from contracting with or paying any MA organization that violates this ownership rule. Furthermore, if an MA plan breaks this rule and submits a claim for payment, the bill automatically considers that claim a false or fraudulent claim under federal law. This puts MA organizations on notice: comply with the ownership ban or lose your ability to operate in the massive Medicare market.