How is the QPA calculated?

The plan or insurer calculates it itself, from its own contracts. It is the median of the rates it had contracted as of January 31, 2019, for the same or a similar service, by a provider in the same or a similar specialty, in the same region, across its plans in the same market (for a self-insured employer plan, other self-insured plans), raised for inflation since then (42 U.S.C. § 300gg-111(a)(3)(E)). On August 11, 2026, the full federal appeals court for the Fifth Circuit held the federal rule for that calculation unlawful in two respects: it counted rates for services a provider never plans to provide, and it left out bonus and incentive payments (No. 23-40605, 5th Cir., en banc).