Choosing the right health insurance plan is a major decision for employers, individuals, and families. For small businesses without an HR team or benefits specialist, it can be overwhelming. However, investing the time to establish a formal health benefits plan pays off—helping attract and retain employees while promoting a healthy workforce.
This guide will cover the top 25 health insurance companies in the U.S., alternative coverage options, and why HRAs (Health Reimbursement Arrangements) may be a more flexible solution for small businesses.
Understanding Traditional Group Health Insurance
Most employers looking at health insurance start with a group health plan. These plans cover employees and eligible dependents at reduced rates. Typically, insurers require at least 70% employee participation to activate coverage.
Types of group health plans include:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Exclusive Provider Organizations (EPOs)
- Point-of-Service Plans (POS)
Employees usually pay a portion of the premium and meet an annual deductible before the insurer shares costs.
Group plans can be purchased directly from an insurance carrier, a licensed agent, or through marketplaces like SHOP, which may offer tax credits to small businesses.
Average 2024 premiums:
- Self-only coverage: $8,951 annually ($7,584 employer contribution)
- Family coverage: $25,572 annually ($19,276 employer contribution)
While group plans are familiar and widely used, smaller businesses may find the costs prohibitive.
Top 25 Health Insurance Companies by Market Share (2023)
Here are the largest U.S. health insurers, ranked by market share according to NAIC:
| Rank | Company | Market Share (2023) | Direct Premiums (2023) |
|---|---|---|---|
| 1 | UnitedHealth Group (UnitedHealthcare) | 16.37% | $248.76B |
| 2 | Elevance Health Inc. (Anthem) | 7.08% | $107.65B |
| 3 | Centene Corp. | 6.76% | $102.71B |
| 4 | Humana | 6.61% | $100.52B |
| 5 | CVS Health (Aetna Health) | 6.43% | $97.61B |
| 6 | Kaiser Foundation (Kaiser Permanente) | 6.19% | $94.12B |
| 7 | Health Care Services Corp (HCSC) | 3.65% | $55.50B |
| 8 | Cigna Health | 2.64% | $39.58B |
| 9 | Molina Healthcare | 2.04% | $30.94B |
| 10 | GuideWell (Florida Blue) | 1.91% | $28.98B |
| 11 | Independence Health Group | 1.85% | $28.17B |
| 12 | Highmark Group | 1.32% | $20.07B |
| 13 | Blue Cross Blue Shield of Michigan | 1.20% | $18.24B |
| 14 | Blue Cross Blue Shield of New Jersey | 1.11% | $16.95B |
| 15 | UPMC Health System | 0.95% | $14.40B |
| 16 | Blue Cross Blue Shield of North Carolina | 0.82% | $12.44B |
| 17 | Caresource | 0.77% | $11.77B |
| 18 | Health Net of California | 0.75% | $11.33B |
| 19 | Local Initiative Health Authority | 0.73% | $11.10B |
| 20 | Carefirst Inc. | 0.72% | $10.97B |
| 21 | Metropolitan | 0.65% | $9.85B |
| 22 | Blue Cross Blue Shield of Massachusetts | 0.61% | $9.31B |
| 23 | Blue Cross Blue Shield of Tennessee | 0.61% | $9.29B |
| 24 | Point32Health Inc. | 0.57% | $8.69B |
| 25 | Health Net Community Solutions | 0.55% | $8.36B |
Market share reflects competitiveness, financial strength, and network size but doesn’t guarantee product quality.
Alternative Health Benefits for Small Employers
Rising premiums make traditional group insurance challenging for small businesses. HRAs and health stipends offer flexibility and cost control:
1. Individual Coverage HRA (ICHRA)
- Reimburses employees tax-free for individual health insurance premiums and medical expenses.
- Suitable for any employer size.
- Employees must have individual health insurance coverage.
- Can satisfy ACA employer mandates if designed properly.
2. Qualified Small Employer HRA (QSEHRA)
- Designed for businesses with fewer than 50 employees.
- Provides tax-free reimbursement for premiums and out-of-pocket medical costs.
- Must be offered equally to all full-time employees.
3. Integrated HRA (GCHRA)
- Supplements a group health plan or high-deductible plan.
- Reimburses eligible out-of-pocket costs, not premiums.
- Offers customizable allowances, deductibles, and employee classes.
4. Health Stipend
- Flat, taxable cash allowance for employees to spend on health expenses.
- Flexible, easy to administer, and suitable for businesses of any size.
- Does not satisfy ACA employer mandate for ALEs.
How PeopleKeep Can Help
PeopleKeep’s software simplifies administration of HRAs and health stipends:
- Automates reimbursement requests and document updates.
- Ensures compliance and reduces administrative burden.
- Provides customizable plans and excellent customer support.
Conclusion
While traditional group health plans dominate, HRAs and health stipends offer small businesses flexible, affordable alternatives. They empower employees to select coverage that suits their needs while keeping costs manageable for the employer.
