The U.S. Department of Labor (DOL), U.S. Department of Health and Human Services (HHS), and the Internal Revenue Service (IRS) have issued FAQs About Consolidated Appropriations Act, 2021 Implementation Part 69. The FAQs provide guidance on the calculation of the qualifying payment amount (QPA) used in the independent dispute resolution (IDR) process under the No Surprises Act. The FAQs also extended enforcement relief a second time for plans, insurers, and parties to IDR disputes. Separately, the IRS issued a notice containing the indexing factor for QPA calculations for the 2025 calendar year.
Plans and insurers should take note of this guidance as they calculate QPAs under the complex patchwork of regulations, guidance, and court decisions.
Guidance on QPA Calculations
The FAQs often guidance in the wake of the Fifth Circuit’s 2024 decision in Texas Medical Association v. HHS (TMA III). In that case, the Fifth Circuit reversed the trial court’s decision vacating QPA calculation provisions in the federal agencies’ interim final regulations and guidance. Before Fifth Circuit’s decision, the agencies had advised plans and insurers to calculate QPAs using a good faith, reasonable interpretation of the No Surprises Act and all regulations remaining in effect after the trial court’s ruling.
Extension of Enforcement Relief for Surprise Billing QPA Calculations
Originally, the agencies had announced that plans and insurers would not be subject to enforcement under the No Surprises Act if they calculated QPAs according to interim final regulations and guidance for items and services furnished before May 1, 2024. FAQ (Part 67) previously extended that enforcement relief to items and services furnished before November 1, 2024.
FAQ (Part 69) further extends enforcement relief to items and services furnished before August 1, 2025, unless the Fifth Circuit grants rehearing in TMA III and changes its ruling. Therefore, plans and insurers must continue to follow requirements concerning the disclosure of information about the QPA according to the guidance not affected by the Fifth Circuit decision.
The FAQs also address the timing of disclosures and open negotiations when a plan or insurer sends initial payment or notice of denial electronically and required disclosures separately. Additionally, the FAQs contain guidance about whether a plan or insurer can recalculate cost-sharing after a certified IDR entity has made a payment determination.
Notice 2025-12
The IRS also released Notice 2025-12, which provides the indexing factor for group health plans and insurers to calculate the QPA for items or services furnished after January 1, 2025, and before January 1, 2026.
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