Texas Medical Association v. U.S. Department of Health and Human Services (TMA III)
E.D. Tex. → 5th Cir. (en banc) · Updated
Summary
Providers challenged the rules for calculating the qualifying payment amount (QPA). The district court vacated them in August 2023; a Fifth Circuit panel reversed in 2024, and the full court reheard the case. On August 11, 2026, the en banc court affirmed vacatur of the ghost-rate and incentive-payment rules, reversed on the single-case-agreement exclusion, and remanded. The mandate issued October 2, 2026.
Timeline of rulings
- 5th Cir. (en banc)
Mandate issued.
Read the ruling - 5th Cir. (en banc)
Affirmed in part, reversed in part, remanded: QPA rules allowing unused contracted ('ghost') rates and excluding bonus and incentive payments are contrary to the Act; exclusion of single case agreements upheld; vacatur is the proper remedy.
Read the ruling - 5th Cir.
Rehearing en banc granted and panel opinion vacated (138 F.4th 961).
- 5th Cir.
Panel reversed the district court in large part (120 F.4th 494).
- E.D. Tex.
Summary judgment largely for plaintiffs; QPA-calculation provisions of the July 2021 interim final rule and August 2022 FAQs vacated.
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Why it matters
The en banc ruling requires changes to how plans calculate the QPA, the benchmark used in IDR and in patient cost-sharing, while letting agencies use enforcement discretion during recalculation.
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Sources
General information only, not legal advice. Verdict Consulting Group is not a law firm.