By: HUB’s EB Compliance Team

On July 31, the Departments that issue guidance under the Affordable Care Act and the Consolidated Appropriations Act, 2021 issued Part 71 in the continuing parade of FAQs. These new FAQs continue the enforcement relief under the No Surprises Act, but of more immediate importance, update the 2025 out-of-pocket maximums.

No Surprises Act

Previously published articles provided insight into the drama surrounding the Qualifying Payment Amount (“QPA”), meaning the plan’s median contracted rate with participating providers for a particular service (or item) inside a defined geographic region.

The legal battle over how to calculate the QPA under the No Surprises Act is moving to a higher level of review. The Fifth Circuit Court of Appeals will now conduct an en banc review, meaning all 17 judges on the court will hear the case – not just the usual three-judge panel.

While the court review is pending, the federal agencies have issued guidance to help plans stay compliant:

  • Continue using a good faith, reasonable interpretation of the 2023 QPA rules when calculating QPAs.
  • The agencies are extending enforcement discretion for plans and parties in payment disputes that use the 2021 QPA methodology, but only for services provided before February 1, 2026.

This enforcement discretion applies to QPA calculations for purposes of:

  1. Patient cost sharing,
  2. Providing required disclosures with an initial payment or notice of denial of payment, and
  3. Providing required disclosures and submissions under the Federal arbitration process.

This extension builds on previous guidance from FAQs Part 62.

What’s next? Depending on how the Fifth Circuit Court of Appeals rules, the Departments may release additional guidance as appropriate.

OOPM Adjustment

As a result of changes to the premium adjustment methodology, the agencies have now increased the out-of-pocket maximums for 2026 over those previously announced. Now, the self-only out-of-pocket maximum is $10,600 and the family OOPM is $21,200. This is a significant increase over the $10,150 and $20,300 amounts previously announced.

Takeaways

Employers should continue to monitor the QPA litigation as the ultimate outcome could impact plan costs. More immediately, however, plan sponsors that had planned on the old 2026 OOPMs will now need to update any pricing or plan projections for 2026 and make sure any plan communication materials they prepare include the updated amounts.

If you have any questions, please contact your HUB Advisor. View more compliance articles in our Compliance Directory.

NOTICE OF DISCLAIMER

Neither Hub International Limited nor any of its affiliated companies is a law or accounting firm, and therefore they cannot provide legal or tax advice. The information herein is provided for general information only and is not intended to constitute legal or tax advice as to an organization’s or individual's specific circumstances. It is based on Hub International's understanding of the law as it exists on the date of this publication. Subsequent developments may result in this information becoming outdated or incorrect and Hub International does not have an obligation to update this information. You should consult an attorney, accountant, or other legal or tax professional regarding the application of the general information provided here to your organization’s specific situation in light of your or your organization’s particular needs.