What’s New Under the No Surprises Act for 2026
Effective January 1, 2026, payers (group health plans and issuers) must use updated indexing factors to calculate the Qualifying Payment Amount (QPA) for items or services provided under certain surprise billing clauses. (irs.gov)
The percentage increase—the factor by which QPA increases over the prior year—is derived from the change in CPI-U (Consumer Price Index for All Urban Consumers) over the previous year. For 2025–2026, that factor is approximately 1.0265311701. (irs.gov)
Plans may calculate QPAs either by using cumulative factors from the base year (which could be 2019 or later) or by compounding the prior year’s QPA by the annual CPI-U increase. Either approach is acceptable so long as it’s applied consistently. (irs.gov)
Why This Matters: Compliance & Consumer Protection
- The QPA often sets the baseline cost for balancing billing disputes and determines what patients must pay when they receive services from out-of-network providers under surprise billing rules.
- Lower plans’ negotiated rates can affect cost sharing and dispute outcomes. Updated indexing helps preserve fairness in cost burden as healthcare costs rise.
- If your insurer or issuer miscalculates QPA or uses inconsistent methods, you may have a grievance under federal regulation.
Practical Steps for Individuals and Employers
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Review your health plan’s notices and contracts. Ask whether the QPA for 2026 will be calculated using cumulative or year-over-year indexing—and whether calculations are transparent.
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Understand how your enrollee documents define “out-of-network.” QPA matters mainly when cost sharing, surprise billing, or Independent Dispute Resolution (IDR) come into play.
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Track billed charges vs. allowed QPA amounts. If a provider wishes to balance bill beyond the QPA, documentation may assist in disputes.
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Employer sponsors should coordinate with insurers. Ensure that summary plan documents, plan notices, and provider directories reflect correct indexing and QPA methodology in compliance with Notice 2025-65. (irs.gov)
Example Scenarios
- Scenario 1: Jane, who lives in a rural area, gets emergency surgery from an out-of-network specialist. The balance bill should reference the QPA as the baseline instead of negotiated rate inflation, and her cost share reflects that.
- Scenario 2: A policyholder reviewing renewal paperwork for their health plan notices an insurer listing two methods for calculating QPA. They ensure consistency and that the CPI-U increase is properly applied.
Bottom Line
Patients are protected from unexpected medical bills in many situations. With Notice 2025-65, the IRS clarifies how inflation adjustments impact what you may pay. Always know your plan’s methodology, monitor for errors, and assert your rights under the No Surprises Act.