On July 30, 2025, federal regulators published FAQs Part 71 providing instructions for group health plans to calculate qualifying payment amounts (QPAs) under the No Surprises Act. The FAQ also calls attention to the revised formula published in June 2025 for determining the way the out-of-pocket limit is calculated for non-grandfathered plan years beginning in 2026.
Applies To:
- No Surprises Act: All-sized employers sponsoring a medical plan.
- OOP Limits: All size employers sponsoring a non-grandfathered medical plan.
Go Deeper:
Questions 1 and 2 on the No Surprises Act: The No Surprises Act requires health plans to run a special payment process for three categories of medical services (brief overview here). Both the member’s cost sharing and the initial payment determination must be based on a federally defined qualifying payment amount (QPA), but the carrier and provider have 30 days to negotiate a different amount for the carrier to pay them. This process and the way the QPA is determined have been the subject of multiple lawsuits.
Given the bouncing back and forth about which rules apply and do not apply based on what courts overturn, these FAQs instruct plans to follow the 2023 QPA rules, but grant enforcement relief for following the 2021 rules for services provided before February 1, 2026. They also encourage States to do the same. The second FAQ says if a plan is wanting to use the 2021 QPA rules, they must disclose they are utilizing the 2021 rules if the provider asks how the QPA was determined.
The insurance carrier or third party administrator (TPA) determines the QPA on behalf of group health plans, so they are primarily responsible for following these rules and providing required notices.
Questions 3 and 4 on Revising the 2026 OOP Limit: In June 2025, a final rule revised the methodology to calculate the premium adjustment percentage which is used to index the annual out-of-pocket limit (OOP) for the upcoming calendar year. Non-grandfathered plans must include deductibles, coinsurance and copays toward the OOP.
These FAQs just call attention to the changes published in June which result in the non-grandfathered plan OOP for 2026 being $10,600 for self-only coverage and $21,200 for other-than-self-only coverage (note $10,600 is a per-person limit within family coverage).
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