More than five years after the No Surprises Act (NSA) became law, the Congressional Budget Office (CBO) is revisiting a key question: whether a law designed to protect patients from surprise medical bills is also producing the broader cost-savings effects originally projected. In a June 15, 2026, CBO report, the office called for new research on how the NSA, and particularly, its independent dispute resolution (IDR) process, has impacted healthcare prices, provider network participation, and broader market trends. For employer plan sponsors, the report is relevant because developments regarding the NSA may affect plan costs, premiums, and fiduciary oversight responsibilities.
Background
The NSA, signed into law on December 27, 2020, protects health plan enrollees from surprise medical bills for out-of-network emergency services, air ambulance services, and certain nonemergency services furnished by out-of-network providers at in-network facilities. For NSA-covered services, participant cost-sharing is generally limited to the in-network rate, and providers cannot “balance bill” a participant for the difference between the plan’s payment and the provider’s billed charge. If a plan and an out-of-network provider cannot agree on the remaining payment amount following a 30-day negotiation period, either party can initiate the NSA IDR process. Under the IDR process, a certified arbitrator selects one party’s final payment offer after considering several factors, including the qualifying payment amount (QPA), which is generally the median contracted rate for similar services in the same geographic area.
CBO Estimates and Later Developments
When the NSA was enacted, CBO estimated that it would reduce both out-of-network and in-network provider payment rates for services that historically generated surprise bills. Although the NSA focuses on out-of-network services, CBO expected about 80% of the projected savings to result from lower in-network prices. CBO reasoned that limiting surprise billing and tying the payment process to the QPA would reduce providers’ leverage in network negotiations, putting downward pressure on prices and lowering private health insurance premiums by roughly 1%.
CBO now reports the law appears to be protecting patients from many surprise bills, and some data suggest that prices for certain affected services have declined after adjusting for inflation. At the same time, IDR activity has far exceeded early projections; providers reportedly win more than 80% of IDR cases, and arbitration awards often exceed the QPA and other payment benchmarks. Notably, CBO observes that if high arbitration awards strengthen providers’ ability to remain out-of-network or to demand higher in-network rates, the law could increase, rather than reduce, plan costs and premiums over time.
Research Request
CBO is seeking newer research to better assess how the NSA is affecting prices, provider networks, and healthcare markets. Existing studies generally rely on claims data ending in 2023, when IDR trends were still developing. CBO also wants research that separates the NSA’s effects from broader price trends, compares outcomes in markets with heavier IDR use, and sheds more light on arbitrators’ decision-making. Additionally, CBO requests analysis of whether the IDR process is contributing to provider consolidation or other market changes that could affect employer plan costs.
Employer Takeaway
For employers, CBO’s research request is a reminder that the NSA’s long-term impact on plan costs remains uncertain. Although employers generally rely on TPAs, insurers, or other service providers to administer NSA requirements and handle IDR activity, plan sponsors should understand the law’s basic requirements and how arbitration outcomes, administrative costs, and provider negotiation dynamics may affect plan spending over time. As part of prudent plan oversight, self-insured plan sponsors should request vendor reporting on NSA-covered claims, arbitration activity, and IDR trends.
Employers should also confirm that their service providers are prepared to comply with the May 28, 2026, IDR process final rule, which includes new federal IDR identification and registration requirements for self-insured plans. Vendor oversight is especially important now that the DOL has identified compliance with the NSA as a 2026 enforcement priority. For more information, see NFP’s June 2, 2026, article, Departments Issue Final Rule to Improve NSA Independent Dispute Resolution Process, and January 27, 2026, article, DOL Sets 2026 Employee Benefit Enforcement Priorities.
NFP will continue to monitor NSA developments, agency guidance, enforcement efforts, and new research on the law’s cost and market effects and provide timely updates in Compliance Corner.