POP Act Could Ban Your Medicare Plan: What’s Next?

Your Medicare Advantage plan might look completely different in 2026.

The Patients Over Profit (POP) Act—introduced September 17, 2025—proposes something unprecedented: banning health insurers from owning or operating outpatient clinics that bill Medicare. If passed, companies must divest these integrated facilities or face exclusion from Medicare entirely.

According to Sheppard Health Law, “Rather than regulating insurer-provider integration, the POP Act proposes to ban it outright.” The bill sits in committee as of early November 2025, with no floor votes scheduled yet. But its potential impact on Medicare beneficiaries and the healthcare delivery system is massive.

Here’s what this means for your coverage, why Congress is taking this step, and what happens if insurers ignore the law.

Why Congress Wants to Ban Insurer-Owned Clinics

The POP Act targets vertical integration—when health insurers own the doctors’ offices and clinics that treat their members. Proponents argue this creates conflicts of interest that hurt patient care and limit competition.

Three concerns drove the legislation:

• Care decisions influenced by profit motives. When your insurer also owns your doctor’s office, treatment recommendations might prioritize cost savings over optimal care. Critics say this creates inherent conflicts between the insurance company’s financial interests and patient needs.
• Reduced provider choice. Integrated systems often steer patients toward in-network, insurer-owned facilities, limiting access to independent providers who might offer different treatment approaches.
• Competition concerns. Large insurers buying up clinics reduces market competition, potentially driving up costs for patients outside these integrated systems while concentrating market power.

The Federal Trade Commission (FTC) and Department of Justice have been scrutinizing these arrangements for years. The POP Act represents Congress deciding regulation isn’t enough—they want a complete ban.

What the POP Act Actually Does (Beyond the Headlines)

Most coverage focuses on the ban itself. But the enforcement mechanisms matter more for Medicare beneficiaries.

The bill creates a multi-agency enforcement system with teeth:

• Four federal enforcement agencies can pursue violators: Department of Justice, Federal Trade Commission, Office of the Inspector General at Health and Human Services, and—here’s the surprise—state Attorneys General.
• State AGs can sue in their own courts. You won’t need to wait for federal action. Your state’s Attorney General can enforce the law directly, recovering penalties for local communities affected by non-compliant integration.
• An FTC fund distributes recovered penalties to affected communities. Proceeds from violations don’t disappear into general revenue—they go back to communities where integrated systems harmed competition or access.
• False Claims Act exposure. Non-compliant insurers billing Medicare could face treble damages under the False Claims Act, multiplying penalties by three.

That last point matters. False Claims Act cases can result in $11,000 to $22,000 per false claim, plus triple the damages amount. For large Medicare Advantage organizations processing millions of claims annually, this creates existential financial risk.

How This Hits Your Medicare Advantage Coverage

If you’re enrolled in Medicare Advantage, the POP Act could reshape your plan in three ways:

Provider network changes: Insurers owning clinics would need to divest those facilities. Your current primary care doctor might move to a different network, or the clinic might become independent. You’d need to either follow that provider outside your network (potentially at higher cost) or find a new in-network doctor.

Plan availability: Non-compliant Medicare Advantage organizations get barred from offering Medicare Advantage or Medicare Advantage-Prescription Drug plans entirely. If your insurer refuses to divest and continues operating integrated clinics, you’d lose your plan mid-year and need emergency coverage through another carrier or Original Medicare.

Premium and benefit adjustments: Integrated systems claim efficiencies that keep premiums lower. Forced divestiture could increase administrative costs, potentially raising your monthly premiums or reducing supplemental benefits like dental, vision, or gym memberships that many MA plans offer.

The transition period—if the bill passes—remains unclear. Will insurers get 90 days to divest? Six months? A year? Congress hasn’t specified implementation timelines, creating uncertainty for Medicare beneficiaries who rely on stable coverage.

The Bill’s Current Status and Legislative Path Forward

Where does the POP Act stand right now? In committee purgatory.

The bill was introduced September 17, 2025, and immediately referred to multiple committees in both chambers:

• House Judiciary Committee
• House Energy & Commerce Committee
• House Ways & Means Committee
• Senate Judiciary Committee

Multiple committee referrals signal controversial legislation touching several policy areas: antitrust law (Judiciary), healthcare policy (Energy & Commerce), and Medicare financing (Ways & Means). Each committee must hold hearings, consider amendments, and vote to advance the bill.

As of early November 2025, zero floor votes or amendments have been reported. The bill could move in the current session or the second session of the 119th Congress. If it dies in committee before the second session ends, sponsors must reintroduce it in the 120th Congress, restarting the entire legislative process.

What are the odds of passage? Healthcare legislation affecting major insurers typically faces intense lobbying. The industry will argue divestiture increases costs and reduces care coordination. Consumer advocates will counter that integration harms competition. Expect extended committee debate before any floor votes.

What Happens If Insurers Don’t Comply

The POP Act doesn’t just suggest divestiture—it mandates it with escalating consequences.

First-tier penalties include financial fines calculated per violation. The bill doesn’t specify exact amounts, but similar healthcare enforcement actions typically range from $50,000 to $100,000 per violation. For insurers with hundreds of integrated clinics, this adds up fast.

Second-tier consequences involve program exclusion. Non-compliant Medicare Advantage organizations lose the right to offer MA or MA-PD plans. Since Medicare Advantage enrollment exceeded 30 million beneficiaries nationally in recent years, exclusion from this market represents catastrophic business loss for major insurers.

Third-tier exposure comes through the False Claims Act. Every Medicare claim submitted by a non-compliant integrated entity could be deemed a false claim. Given Medicare Advantage plans process millions of claims monthly, False Claims Act liability could reach billions of dollars in theoretical exposure.

State Attorneys General add another enforcement layer. They can sue in state courts without waiting for federal agencies, creating multiple legal fronts for non-compliant insurers. This distributed enforcement model makes it nearly impossible for companies to hide or delay compliance.

The FTC Fund: Where Penalty Money Actually Goes

Here’s something most coverage misses: the POP Act creates an FTC-administered fund that distributes recovered penalties to affected communities.

How does this work? When enforcement agencies recover fines from non-compliant insurers, those proceeds don’t disappear into general federal revenue. Instead, they go into a dedicated fund managed by the Federal Trade Commission.

The FTC then distributes money to communities where integrated insurer-provider systems harmed competition or reduced access to care. This could mean:

• Grants to independent healthcare providers entering markets dominated by integrated systems
• Funding for community health centers serving areas where clinic consolidation reduced access
• Support for healthcare market studies in regions with high integration levels

This provision transforms the POP Act from pure punishment into a mechanism for rebuilding competitive healthcare markets. Instead of just stopping harmful integration, the law actively funds alternatives.

The community distribution approach also incentivizes state Attorneys General to pursue enforcement aggressively. When recovered penalties benefit their constituents directly, state AGs have political motivation to investigate and prosecute non-compliant insurers.

What Medicare Beneficiaries Should Do Right Now

The bill remains in committee, but you can prepare for potential changes:

Check your plan’s integration status. Does your Medicare Advantage insurer own the clinics or medical groups where you receive care? Look for terms like “integrated care,” “staff model,” or references to insurer-owned facilities in your plan materials. If you’re unsure, call your plan’s member services and ask directly whether your primary care provider works for a clinic owned by the insurance company.

Identify backup providers. Research independent primary care doctors and specialists in your area who accept Medicare. Create a list of alternatives in case your current providers change network status. Check Medicare.gov’s provider directory and read recent patient reviews.

Understand your Medicare options beyond Advantage. Original Medicare with a Medigap supplement offers different structure than Medicare Advantage. If your MA plan disappears, knowing how to transition to Original Medicare or a different MA plan prevents coverage gaps. Review the differences during your plan’s next enrollment period.

Track the bill’s progress. Congress.gov provides free bill tracking. Search “Patients Over Profit Act” and sign up for email alerts when committee action or floor votes occur. State Attorney General websites may also post updates if your state plans enforcement actions.

Don’t make drastic changes yet—the bill hasn’t passed. But informed preparation prevents last-minute scrambling if the POP Act becomes law.

The Bottom Line

The Patients Over Profit Act represents Congress betting that insurer-provider integration hurts Medicare beneficiaries more than it helps. Whether you agree depends on your experience with integrated systems—some patients love coordinated care, others feel trapped in limited networks.

But the enforcement mechanisms matter regardless of ideology. State Attorneys General with direct enforcement power, an FTC fund distributing penalties to affected communities, and False Claims Act exposure create genuine financial risk for non-compliant insurers. This isn’t symbolic legislation.

Track the bill’s committee progress through Congress.gov. If you’re in Medicare Advantage with an integrated plan, start identifying backup providers now. If the POP Act passes, the transition could be abrupt.

For more details on the legislation’s structure and legal implications, read the full analysis from Sheppard Health Law. Your Medicare coverage might depend on what happens next in committee.