Agencies Issue New Guidance for No Surprises Act and ACA Compliance

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On July 30, 2025, the Departments of Health and Human Services, Labor, and Treasury alongside the Office of Personnel Management (collectively, the “Agencies”), jointly released a new set of FAQs titled “Part 71” as guidance to the ongoing implementation of the No Surprises Act (the “Act”) and certain provisions of the Affordable Care Act (“ACA”). This set of questions builds upon previous releases (i.e., sets 62, 67, and 69, as further detailed below) and reflects developments following the case of Texas Medical Association, et al. v. United States Department of Health and Human Services et al. (the “TMA” case). Earlier FAQs addressed how plans should treat qualified payment amounts (“QPAs”) during recalculation and expectations around compliance timelines. Part 71 builds upon these standards and reaffirms that plans and issuers should continue good-faith efforts to comply with cost-sharing limitations and dispute resolution timelines.

Background

Part 71 addresses the implementation of the Act under the Consolidated Appropriations Act of 2021 and the limitations on cost-sharing under the ACA. The Agencies issued interim final rules in 2021 and the final rules in August 2022. One of the main goals of these provisions is to protect consumers from unexpected, out-of-network medical bills, particularly for emergency, ambulance, and similar services. The Act also introduced the Federal Independent Dispute Resolution (“IDR”) process, which is to be utilized in certain events (e.g., when plans or issuers do not agree with providers on out-of-network payment rates).

This guidance comes in the wake of judicial developments­—namely, the TMA case, which reshaped key elements of the IDR process. On August 24, 2023, the U.S. District Court for the Eastern District of Texas ruled that key aspects of the IDR process violated the Administrative Procedure Act. Among other things, the district court found that the agencies unlawfully attempted to prioritize the QPA as the default benchmark, even though the Act stated that the QPA should be one of several equally weighted factors the arbitrators must consider. As such, arbitrators cannot treat the QPA as the de facto correct amount.

Subsequently, on October 6, 2023, the Agencies issued FAQs, Part 62 wherein the Agencies acknowledged the impact of the TMA case on QPAs and the challenges associated with recalculating QPAs in accordance with the regulations post-TMA. On May 1, 2024, the Agencies followed up with FAQs Part 67 after consideration of feedback from plans and issuers relating to the recalculation methodologies. On October 30, 2024, the Fifth Circuit issued an opinion and order in the TMA case, which partially reversed the district court’s decision. Thereafter, in January of this year, the Agencies issued FAQs Part 69 and stated that, unless the Fifth Circuit altered its judgment, plans and issuers have to calculate QPAs using a good faith and reasonable interpretation of the regulations that still remain in effect. On May 30, 2025, the Fifth Circuit vacated its prior panel opinion, and the district court’s decisions from August 24, 2023, continue to bind the Agencies.

Part 71

Part 71 reiterates that Sections 102 through 105 of the Act extended statutory protections under multiple federal codes, including, but not limited to, the Internal Revenue Code, ERISA, and the ACA. For example, Part 71 further discusses the ACA’s maximum annual out-of-pocket cost-sharing limits for essential health benefits under Section 1302(c)(1) of the ACA. The FAQs clarify how cost-sharing limits apply when out-of-network services are billed. Furthermore, the QPAs should not push an enrollee’s payments above ACA caps.

As for the calculation of QPAs, Part 71 provides that plans and issuers “must continue to comply with the requirements related to disclosure of information about the QPA,” such as “the requirement to include a statement certifying that the QPA applies for purposes of the recognized amount (or, in the case of air ambulance services, for calculating the participant's, beneficiary's, or enrollee's cost sharing).” The Agencies further assured plans and issuers of their discretion to exercise enforcement for disclosures regarding QPAs, presumably hinting at some leeway. Part 71 also emphasizes existing administrative rules on timely claims and appeals. In particular, plans and issuers must make good-faith efforts to issue coverage decisions within 30 calendar days (per ERISA and ACA claims procedures), even during transition periods caused by litigation and regulatory updates.

Employer Impact

These FAQs are intended to offer clarification and compliance guidance for health plans, issuers, providers, and other stakeholders. In light of the TMA case, fiduciaries and issuers faced legal uncertainty over QPAs and how to implement the standards set forth therein. Plans should continue to implement IDR processes for applicable out-of-network disputes.  With respect to the timelines, plans should notify participants or beneficiaries promptly of denials or requests for more information and make coverage determinations within the 30-day regulatory timeframes. Enrollees can rest easy that the Act is aimed at protecting them from catastrophic out-of-network bills and providing an avenue for disputes through the IDR process.

Conclusion

True to previous guidance, Part 71 frames compliance with the Act as a collaborative effort between plans and providers as well as enrollees themselves. Although Part 71 encourages compliance and attempts to assist stakeholders, the Agencies nevertheless make clear that deadlines and statutory obligations remain enforceable.