Texas Medical Association et al. v. Department of Health and Human Services et al. (TMA III)

Why this Matters

The plaintiffs argue that regulations outlining the methodology used to calculate the No Surprises Act’s qualifying payment amount (the basis for determining individual cost sharing for items and services covered by the balance-billing protections) are invalid under the Administrative Procedure Act. The design of the qualifying payment amount is critical to the No Surprises Act’s mission to promote lower health care premiums and costs, both for consumers directly for out-of-network services as well as through the arbitration process. The plaintiffs appeal, and defendants cross-appeal a partially denied cross-motion for summary judgment.

Potential Impact

Setting aside the methodology to calculate the qualifying payment amount for health care services in virtually all settings could expose patients to higher cost sharing and make the arbitration process more likely to raise health care costs and premiums.