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January 15, 2026 – 2025 certainly was a busy year in the regulatory world, with a slew of new regulations, models, and initiatives. Even so, the Trump administration still has a long regulatory (and deregulatory) “to-do” list for 2026 – including continued implementation of the No Surprises Act. The law, enacted in 2020 during President Trump’s first term, attempted to end the practice of surprise medical bills and balance billing by certain out-of-network providers. As stated in a late 2024 Regs & Eggs blog post, there were numerous issues and areas for potential action that the incoming Trump administration could begin to address in 2025. However, with ongoing legal challenges, proposed regulations that haven’t been finalized, and whole provisions of the law that are yet to be implemented, the administration had its hands full – and many items that started on the administration’s No Surprises Act “to-do” list in 2025 are now being carried over into 2026.
Here are some of the major items on the No Surprises Act regulatory “to-do” list for 2026:
The federal IDR process provides an opportunity for a third-party arbitrator (called a certified IDR entity) to select payment amounts for certain out-of-network services. If a provider and health plan cannot come to an agreement on a payment amount for an eligible out-of-network service after exhausting a 30-day open negotiations period, a provider or health plan (usually a provider) can trigger the IDR process. Both parties in a dispute (providers and health plans) present offers to a certified IDR entity, and the entity selects one of the offers using factors prescribed in the No Surprises Act.
Since the IDR process went into effect in 2022, stakeholders have reported multiple issues. In an attempt to address these concerns, the US Departments of Health and Human Services (HHS), Labor, and Treasury under the Biden administration issued the IDR operations proposed rule, which was published in the Federal Register on November 3, 2023 (click here for our summary). As with any proposed rule, the IDR operations rule had a public comment period, and many expected the final rule to be issued in either 2024 or 2025. The first unified agenda put out by the Trump administration targeted November 2025 for release of this final rule. However, work on the rule may have been impeded by the long government shutdown, and November 2025 came and went. The final rule may now be issued early this year. Even if the rule is released within the next few months, some policies may not be effective for 90 or even 180 days after the rule is issued.
The departments, especially the Centers for Medicare & Medicaid Services (CMS) under HHS, have produced many resources on the IDR process and are in regular communication with participating stakeholders, including IDR entities and disputing parties. However, some guidance documents seem to have been in a holding pattern in 2025 in light of ongoing litigation and the IDR operations rule still under development. One notable guidance document CMS did release in 2025 provided technical assistance for reopening closed disputes. This guidance created a formalized process for disputing parties to ask CMS to have a certified IDR entity reopen a dispute if a party believed the certified IDR entity committed a specific type of error during the IDR process. CMS also released revised frequently asked questions (FAQs) on the calculations of qualified payment amounts (QPAs) and a few other updates on No Surprises Act implementation (including a fact sheet that highlights the departments’ efforts to reduce the backlog of unresolved IDR disputes.)
Once the IDR operations final rule is released, we could see the departments issue more subregulatory guidance and FAQs to help effectuate the rule’s policies and address other notable issues that stakeholders have identified in areas such as IDR eligibility, “batching” of similar disputes, the 90-day “cooling off period,” and enforcement of IDR requirements.
CMS released data and reports on the IDR process during 2025 and will probably do so on a similar schedule in 2026. CMS publishes federal IDR public use files (PUFs) and federal IDR supplemental tables every six months, and overarching reports on the IDR process every other month. The latest PUFs include comprehensive data on disputes from the fourth quarter of 2024, and the latest bimonthly data report reflects disputes received from October to November 2025. Historically, CMS has also released enforcement reports and market conduct reviews that detail compliance with No Surprises Act requirements.
Many provisions in the No Surprises Act have not been fully implemented yet. In August 2021, the departments issued a guidance document stating that they did not plan to implement certain requirements by the statutory deadline of January 1, 2022. As stated in the guidance document, these provisions included:
The departments have been making progress on these provisions, and we could see further action in 2026. With respect to the first requirement, the departments included a proposal in their December 2025 transparency in coverage proposed rule that would require health plans to make available to enrollees, at their request, cost-sharing estimates and other price disclosures via a phone number. This phone number would need to be the same one that is required to be found on the health plan’s insurance ID card under the No Surprises Act. The departments could finalize the proposal this year, with a potential effective date of January 1, 2027.
The departments also have provided updates on the implementation of the AEOB requirement, noting some of the difficulties involved in sharing good faith estimate information between providers and between providers and health plans. The departments have been testing industry-wide standards for data sharing. In their latest update, from December 2024, the departments noted that they would use the information gathered from this testing to develop proposed requirements that “maximize the meaningfulness and usability of AEOBs for consumers.” The latest unified agenda states that the departments plan to issue a proposed rule to implement the AEOB requirement in March 2026, but this timing could have been impacted by last year’s prolonged government shutdown.
CMS released FAQs on July 30, 2025, regarding enforcement of QPA calculations. Because of the ongoing Texas Medical Association (TMA) III lawsuit, the departments have been exercising enforcement discretion since October 2023 on how health plans calculate the QPA. The departments have extended the period of enforcement discretion six months at a time, allowing health plans to rely on any QPAs that have already been calculated using a good faith, reasonable interpretation of the current methodology.
In the latest FAQs, the departments responded to the US Court of Appeals for the Fifth Circuit’s grant of en banc rehearing to the TMA III plaintiffs. Based on that legal development, the departments decided to extend the period of enforcement discretion for another six months, until February 1, 2026. The departments stated that “[o]nce the Fifth Circuit’s en banc decision in TMA III is released, the Departments . . . will evaluate whether it is necessary to provide additional enforcement relief. The Departments . . . do not currently expect any such additional enforcement relief would extend beyond August 1, 2026, the first day of the calendar month that is 12 months after the issuance of these FAQs, but will reassess the status of QPA recalculations and provide additional guidance as appropriate.” The departments therefore will likely issue a revised set of FAQs in February 2026 and perhaps revisit the August 1, 2026, enforcement discretion expiration date.
The No Surprises Act requires the departments to conduct audits of QPA calculations. While only one audit has been released thus far (in 2024), we could see more in 2026. The departments are also required to issue annual reports to Congress on the number of health plans that have been audited.
The departments may move forward with other audits, including audits of certified IDR entities to make sure they are using appropriate and consistent approaches to rendering payment decisions.
We will be carefully monitoring the No Surprises Act to-do list to see which items get crossed off in 2026 and which carry over into 2027 and future years. In the meantime, please reach out if you have any questions about No Surprises Act implementation issues, and check out McDermott’s No Surprises Act Resource Center to browse our full library of insights on its implementation.
Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.
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