Overview of the No Surprises Act QPA Changes
The IRS has issued Notice 2025-65, which sets forth the percentage increase for calculating Qualifying Payment Amounts (QPAs) for items and services furnished in 2026, pursuant to the rules under IRC sections 9816-9817, ERISA, and the Public Health Service Act.(irs.gov)
Key points:
- The percentage increase for 2025-2026 is 1.0265311701, meaning QPAs increase by ~2.65%.(irs.gov)
- Plans and issuers may round resulting QPAs to the nearest dollar.
- The notice also provides cumulative percentage increases if the base year of QPA origination is earlier (e.g., 2019, 2021, etc.).(irs.gov)
- Effective January 1, 2026.(irs.gov)
Who is Impacted and How
Patients / Covered Individuals
- Higher cost-sharing ceilings: When insured patients receive surprise bills that fall under QPA rules, the provider/in-network amount they’re compared against will be higher—this could lead to higher out-of-pocket liability in some scenarios.
- Greater transparency importance: Patients should understand how estimates are calculated, especially in emergencies or with out-of-network providers.
Insurance Plans & Issuers
- Must use updated QPA values in crafting contracts, notices, and in dispute resolution for surprise-billing claims. A 2.65% increase may seem small, but in high cost states or for specialty services, this can shift payment responsibility significantly.
- Critical for budgeting: health plan finance teams should update model assumptions to reflect these new baseline increases to avoid underfunding.
Example: How the Increase Works
Imagine a medical service that in 2025 has a QPA of $1,000. In 2026, it increases by 2.6531% to $1,026.53. Depending on rounding rules, the plan/issuer may treat this as $1,027. If the provider bills $1,500 and the patient’s cost sharing is based on the QPA, the 2026 obligation might increase moderately, especially for high-deductible plans or coinsurance calculations.
Compliance Tips for Employers & Insurers
- Audit your billing contracts: Ensure agreements with providers and third parties reflect the new QPA rules and incorporate new increase factors.
- Provider network negotiation: With a new baseline, negotiate out-of-network reimbursement based on updated QPAs to preserve provider-network stability.
- Train internal operations & billing teams on the change to avoid miscalculations or miss-submission of claims.
Actionable Steps for Individuals & Employers Now
- Review your plan’s surprise billing policy to understand how your cost share is affected if you receive a surprise bill.
- Insurers: Update provider fee schedules, paperwork, and disclosure documents to reflect January 1, 2026 changes.
- Employers offering coverage: Communicate to employees that surprise billing protections remain, but cost-sharing may shift slightly due to increased baseline QPAs.
Conclusion
The No Surprises Act continues to evolve in application—with the 2026 QPA increases being a straightforward but meaningful change. Whether you’re an insurer, employer, or patient, knowing how the change fits into your financial planning or health care decisions will help avoid unwelcome surprises.