What is the qualifying payment amount (QPA)?

The qualifying payment amount (QPA) is a benchmark the health plan calculates for an out-of-network item or service. It matters twice: patient cost sharing is often based on it, and IDR entities must consider it when choosing between offers.

Definition

In general, the QPA is the plan’s median contracted rate on January 31, 2019 for the same or a similar item or service, provided by a provider in the same or similar specialty in the same geographic region and insurance market, increased each year for inflation (CPI-U) (42 U.S.C. 300gg-111(a)(3)(E)) (45 CFR 149.140).

Who calculates it

The plan or issuer. When it makes an initial payment or sends a denial, it must give the provider the QPA for each item or service and certain information about how it was calculated (45 CFR 149.140). Where a plan lacks enough contracted rates, the rules call for rates from an eligible database instead. CMS publishes QPA guidance on its plans and issuers resource page (CMS).

Its role in Federal IDR

The IDR entity must consider the QPA, along with other permitted information the parties submit, such as the provider’s training and experience, patient acuity and complexity, market share, and prior good-faith negotiation efforts (42 U.S.C. 300gg-111(c)(5)).

How to read “×QPA” on this site

CMS reports, for each determined line item, the prevailing (selected) offer as a percentage of the QPA. We show it as a multiple: 1.00x means the selected offer equalled the QPA, 3.00x means three times the QPA. We report medians because a few very large ratios would distort an average. Nationally, for 2023 Q1–2025 Q4, the median was 3.92x (n = 6,765,060; methodology).

Common questions

Is the QPA the amount the provider is paid?

Not necessarily. It is a benchmark. The out-of-network rate is set by state law, agreement or an IDR decision; patient cost sharing is often based on the QPA.

What does 4.00x QPA mean?

The selected offer was four times the QPA for that line item.

More in Learn: The No Surprises Act, in plain English · How Federal IDR works, step by step · Which services and specialties are covered? · State surprise billing laws and Federal IDR (including Texas) · Federal IDR glossary

General information, not legal advice. Rules change; check the cited sources. Last reviewed 2026-10-19.