Top 25 health insurance companies in the U.S.

Offering or enrolling in health insurance is a significant decision for employers and individuals. It can be overwhelming to know where to start, especially if you’re a small business without an HR team or a benefits specialist to help. But, putting in the time and research to set up a formal health benefit plan is well worth the effort.

There are several advantages to offering an employer-sponsored health insurance plan, including helping to retain and attract employees, making your business stand out, and contributing toward a happy and healthy workforce.

In this article, we’ll list the top 25 health insurance companies in the United States by market share and provide alternative coverage options if you want to offer something more cost-effective and flexible than traditional group health plans.

Takeaways from this blog post:

• Health insurers in the U.S. earned approximately $1 trillion in total net earned premiums in 2022, with UnitedHealth leading in premium writing at $221 billion.
• Multiple Blue Cross Blue Shield-affiliated companies rank on the list of insurers by market share.
• Group health insurance plans are the traditional choice for employers looking to offer coverage to their employees. But, health reimbursement arrangements (HRAs) and health stipends are more flexible options for providing health benefits to employees

What is traditional group health insurance?

Employers comparing health insurers are most likely looking to secure a group health plan. So, let’s review those types of policies before diving into the top health insurance companies in the U.S.

With traditional group health insurance, employers choose a group medical plan for their organization and offer coverage to their employees and eligible dependents at a reduced rate. Most insurers require employers to meet a 70% minimum participation rate to receive coverage.

Insurance carriers offer various plan types, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). A covered person will be responsible for paying their portion of the premium plus meeting their annual deductible before their insurer begins sharing the cost of their medical claims.

Employers can buy a group health policy directly from an insurance carrier, licensed agent, or broker. Small businesses can purchase a policy on the Small Business Health Options (SHOP) marketplace and apply for the Small Business Health Care Tax Credit to save on premiums¹.

The cost of group health insurance varies, but rates generally increase annually. The average annual premium for group health insurance in 2023 was $8,435 for self-only coverage and $23,968 for family coverage. Of those amounts, employers contributed $7,034 to their employees’ self-only plans and $17,393 to their family plans².

While their familiarity makes them a popular choice for employers and employees, their high costs may be too much for smaller businesses to afford.

Group coverage isn’t the only way to purchase health coverage. Individuals can also purchase their own health insurance policies from the Health Insurance Marketplace or state exchanges. Many of the same group carriers available offer individual health insurance plans.

Top 25 U.S. health insurance companies listed by market share

If you’re interested in offering a group health plan or you’re an individual looking to purchase a plan on the exchanges, understanding which health insurance companies are credible and provide a wide range of products and medical providers is an excellent place to start searching for coverage.

Below are the top 25 health insurance companies in the United States listed by market share size in descending order, according to NAIC³.

Market share size doesn’t necessarily correlate with the quality of the product or medical service, nor does it guarantee the company will retain its position throughout the year.

However, market share size indicates competitiveness, financial health, and the structural security of the company, and insurers with higher market shares hold larger direct written premium amounts. They may also have a more extensive network of providers.

How much do health insurance companies receive in premiums?

According to the 2022 NAIC Health Insurance Report, U.S. health insurers earned approximately $1 trillion in total net earned premiums⁴. This was an 11.4% increase in premium spending from U.S. consumers from 2021 at $898 billion.

UnitedHealth, which tops our above list, wrote roughly $221 billion in premiums in 2022. In contrast, Blue Cross Blue Shield of Massachusetts wrote $8.6 billion.

National health professionals in the insurance industry expect increases in medical services needed due to inflation, worsening health conditions, and older and higher-risk patients needing care.

Considering this, employers of all sizes can better attract and retain their employees by offering a range of health insurance options and other extra benefits, such as wellness healthcare programs, to support their employees’ need for medical services going forward.

Why HRAs and health stipends can be a better option for small employers

With premium prices rising, it can be difficult for small and midsize businesses to budget for group medical insurance. But, more health insurance options exist for organizations that can’t afford a traditional benefit. Health reimbursement arrangements (HRAs) are one of those options.

An HRA is a health benefit you can use to reimburse employees, tax-free, for out-of-pocket medical services, health insurance premiums, and other healthcare expenses. With an HRA, you set a monthly allowance that your employees can spend on healthcare costs. Once employees make an approved purchase, you reimburse them up to their allowance amount.

Because HRAs are customizable, you can offer your employees greater flexibility and freedom over their health benefits at a price you can afford.

Below, we’ll go over four alternative health benefits that might be right for your organization.

Qualified small employer HRA

A qualified small employer HRA (QSEHRA) is a health benefit specifically for employers with fewer than 50 full-time equivalent employees (FTEs) who don’t offer a group plan.

With a QSEHRA, you set an allowance up to the annual maximum contribution limit that works for your budget, and your staff picks the insurance policy and out-of-pocket medical expenses that work best for them and their families. QSEHRA reimbursements are income-tax-free for employees as long as their policy provides minimum essential coverage (MEC).

Individuals can leverage their QSEHRA to receive tax-free reimbursements for health insurance premiums and other out-of-pocket costs, like mental health services, virtual care, and prescription drugs. Our interactive expense tool has the complete list of eligible HRA expenses. But, you can choose to reimburse your employees for only health insurance premiums or their premiums plus qualified out-of-pocket costs when designing your benefit.

If you choose to offer a QSEHRA, you must offer it to at least all your W-2 full-time employees. You have the option to provide it to your part-time employees as well. But you must give them the same allowance amount as your full-time employees to comply with federal regulations.

Individual coverage HRA

Like the QSEHRA, the individual coverage HRA (ICHRA) is a health benefit that can reimburse employees tax-free for individual health insurance premiums and other medical services and expenses. However, it’s for employers of all sizes and has no maximum contribution limits.

You can use the ICHRA as a stand-alone benefit, or you can offer it alongside a group health insurance policy. But, you can’t give your employees a choice between your group health plan or the ICHRA. You have to offer them one or the other.

The ICHRA is customizable, so you can make it fit your needs by setting different allowance amounts according to 11 employee classes. From there, employees simply choose to opt in or out of the benefit before it begins and attest monthly that they still have individual health insurance coverage to continue receiving reimbursements. Only those with a qualified individual health plan can participate in the benefit.

Lastly, as long as you design your benefit with an affordable allowance for your employees, you can leverage an ICHRA to satisfy the employer mandate. This makes an ICHRA a great alternative to traditional group plans if you’re an applicable large employer (ALE) looking to save money while still following all requirements under the Affordable Care Act (ACA).

Integrated HRA

If you want to keep your group health insurance or switch to a high deductible health plan (HDHP) to save on premiums, the integrated HRA is for you.

The integrated HRA, also known as a group coverage HRA (GCHRA), is for employers of all sizes offering a group health insurance plan who want to supplement their benefits. Like the QSEHRA and ICHRA, a GCHRA is a tax-free reimbursement method for employers wanting greater control over their health benefit plan costs.

Only employees who enroll in your group health plan can participate. Additionally, a GCHRA can’t reimburse premiums. But they can reimburse employees for their eligible out-of-pocket costs that aren’t fully paid for by their group health insurance plan, like deductibles, coinsurance, and more.

Integrated HRAs come with some unique perks over other HRAs. Employers can set an unlimited allowance amount, a pre-determined deductible, and a cost-sharing amount for employees. Like ICHRAs, there are seven employee classes that you can use to customize your integrated HRA.

By offering an integrated HRA, you can better support your employees’ individual healthcare needs while still offering the group health plan of your choice.

Health stipend

Your last option for an alternative benefit plan is a health stipend. The federal government doesn’t regulate stipends as much as other traditional health benefits. They also have no contribution limits and can work for companies of all sizes. So, stipends may be more affordable and easier to administer for some employers, especially small business owners.

Stipends are a flat amount of money given to employees to spend on whatever the employer wants to allow, such as a health insurance policy (including supplemental plans, like dental insurance and vision coverage) and other out-of-pocket medical expenses. You can offer them alongside any type of health benefit, whether that’s a traditional group health plan or an HRA.

The IRS considers stipends as extra wages added to your employees’ paychecks. This makes the amount taxable at the end of the year, but your employees will have more choice in how they can spend their stipend money.

It’s important to remember that health stipends don’t satisfy the employer mandate for ALEs. If you’re an ALE, you must offer a group plan or an ICHRA in addition to your health stipend to meet the employer mandate requirements or be subject to costly penalties.

How PeopleKeep can help you provide employee benefits

HRAs and stipends are an excellent way to provide a comprehensive health benefit, but you might be wary about administering them. Luckily, PeopleKeep’s employee benefit administration software can help you administer your HRA and stipends quickly and easily.

PeopleKeep gives employers a simple and effective platform to manage their benefits. Our team of experts helps you manage your plan details and automates time-consuming tasks, like reviewing reimbursement requests and updating benefit plan documents, so you don’t have to worry about self-administration or making compliance errors.

From helping you design your benefit plan to award-winning customer support for your employees, PeopleKeep has what you need to add affordable and customizable benefits to your compensation package.

Conclusion

While the number of health insurance companies offers employers many ways offer a traditional group health benefit, it’s essential to consider other, more flexible options.

HRAs and health stipends are an easy way to offer an affordable health benefit without diving head-first into the waters of group plan administration. They also give your employees the autonomy to choose the right health policy for them. If you’re an employer considering an HRA or stipend, we would love to help you get started.

This article was originally published on January 13, 2020. It was last updated on April 19, 2024.

1. https://www.healthcare.gov/small-businesses/choose-and-enroll/shop-marketplace-overview/
2. https://www.kff.org/report-section/ehbs-2023-summary-of-findings/
3. https://content.naic.org/sites/default/files/publication-msr-hb-accident-health.pdf
4. https://content.naic.org/sites/default/files/inline-files/Health%202022%20Annual%20Industry%20Report.pdf