Top 25 health insurance companies in the U.S.

Offering or enrolling in health insurance is a significant decision for employers, individuals, and families. 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.

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

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

In this blog post, you’ll learn:

• How the top health insurance companies contributed to nearly $1.08 trillion in total net earned premiums in 2023
• Which health insurers have the greatest market share in the U.S.
• How health reimbursement arrangements (HRAs) are a more flexible option for providing health benefits to employees than traditional group coverage

What is traditional group health insurance?

Employers comparing health insurers are most likely looking into 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. If you don’t have enough employees who enroll in coverage, you won’t be able to offer the plan.

Insurance carriers offer various plan types, such as:

• Health maintenance organizations (HMOs)
• Preferred provider organizations (PPOs)
• Exclusive provider organizations (EPOs)
• Point-of-service plans (POS)

A covered person will be responsible for paying their portion of the premium. They'll also have to meet 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 in many states 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.

According to KFF, the average annual premium for group health insurance in 2024 was:

• $8,951 for self-only coverage
• $25,572 for family coverage

Of those amounts, employers contributed the following on average toward premiums:

• $7,584 to their employees’ self-only plans
• $19,276 to their family plans²

While the familiarity of a group health plan makes it a popular choice for employers and employees, its 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. Employers can offer a stand-alone health reimbursement arrangement (HRA) to reimburse employees for their insurance premiums instead of offering a group plan.

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.

One way to rank health insurance companies is by market share or size. Market share reflects a company’s percentage of the health insurance market.

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 2023 NAIC Health Insurance Report, U.S. health insurers earned approximately $1.08 trillion in total net earned premiums⁴. This was an 8% increase in premium spending from U.S. consumers from 2022 at $1 trillion.

UnitedHealth, which tops our above list as the largest insurer, wrote roughly $248 billion in premiums in 2023. In contrast, Health Net Community Solutions wrote $8.35 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’ future need for medical services.

Why HRAs and health stipends are 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. Small organizations may also have trouble meeting minimum participation requirements. However, more health insurance options exist for organizations that want to break free from traditional benefits. 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, or a combination of the two. 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.

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

Individual coverage HRA (ICHRA)

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. It’s for employers of all sizes and has no maximum contribution limits. Our interactive expense tool has the complete list of eligible HRA expenses.

You can use the ICHRA as a stand-alone benefit instead of group health insurance. 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 using employee classes.

The ICHRA is customizable, so you can make it fit your needs by setting different allowance amounts or eligibility according to 11 employee classes. From there, employees simply choose to opt in or out of the benefit before it begins.

Only those with a qualified individual health plan can participate in the benefit. Employees will attest monthly that they still have individual health insurance coverage to continue receiving reimbursements.

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 have 50 or more full-time equivalent employees (FTEs) and are looking to save money while still following all requirements under the Affordable Care Act (ACA).

Qualified small employer HRA (QSEHRA)

A qualified small employer HRA (QSEHRA) is a health benefit specifically for employers with fewer than 50 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.

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.

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, to comply with federal regulations, you must give them the same allowance amount as your full-time employees. Employees need minimum essential coverage (MEC) to participate in the QSEHRA.

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, like deductibles, coinsurance, and more.

Integrated HRAs come with some unique perks over other HRAs. Employers can set any 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 taxable 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 medical expenses, 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 individualized employee benefits

HRAs and health stipends are excellent ways to provide a comprehensive health benefit as a small business. But you might be wary about administering them on your own. Luckily, PeopleKeep’s health benefit administration software can help you administer your HRA or health stipend quickly and easily.

PeopleKeep’s HRA solutions give 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. That way, 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 to 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 affordable health benefits 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, we would love to help you get started.

This article was originally published on January 13, 2020. It was last updated on January 2, 2025.

1. https://www.healthcare.gov/small-businesses/choose-and-enroll/shop-marketplace-overview/
2. https://www.kff.org/report-section/ehbs-2024-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/topics-industry-snapshot-analysis-reports-2023-annual-report-health.pdf