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Small Business

The best health insurance for small business in 2023

Finding the best health insurance for small business is probably on that long to do list of yours as a business owner. This post outlines your small employer health insurance options for 2023 and hopefully saves you a little time and stress in the decision-making department. After all, health benefits for small business is essential to taking care of your team.

Small Business Group Health Insurance for Beginners 

There are a lot of what ifs when it comes to starting your own business. First, do you have a great idea for product or service? How will it be marketed? How big is the market you will compete in? What does the competition look like? Should you hire a team to do a spiffy logo and website or should you go the DIY approach? 

Then there's the financial piece. How are you going to finance your business? Can you afford to launch a company without a loan? Do you qualify for one? Are you planning on fundraising with potential investors?  Do you understand the tax implications of owning a small business (trust us, go ahead and find yourself a good CPA to help guide you through this process). 

Now let's talk about the questions you should ask about your group health insurance, because whether you like it or not, that plays into the financial reality of your company and needs to be a part of your growth plan for 2023. More business equals more employees equals a greater need for group health insurance for small business. 

Do I have a plan for health insurance if I leave my current company's health insurance plan to go out on my own? Does my spouse have a health plan that can cover me? Am I planning on growing?  Do I have to offer my employees health insurance?  How do I even get health insurance for my small business? 

Ready to learn how much you can reduce benefits cost?

Health insurance for small business is important. Here's why.

Small business health insurance can be a major financial deterrent when you're considering going out on your own. But it doesn't have to be.

There are tax-friendly small business health insurance tools on the market called health reimbursement arrangements that help new business owners like you afford benefits, either for you personally or your growing team. These HRA health reimbursement arrangements are proven and affordable alternatives to small business health insurance. We'll touch on the subject later on in this post.

So keep reading!

If you are planning on growing in 2023 or in the future, having a competitive health benefits package for small business is key to recruiting and maintaining the top talent in a tight job market. Your company is only as good as the team you build, and it's just common sense to ensure that those valuable team-members remain loyal.

Compensation is a big driving factor, but other things like employee benefits and culture are also extremely important to today's workforce.

While the Great Resignation is showing signs of slowing down in 2023, it's still as important as ever to offer employee benefits that make you stand out from other employers. Don't take those trusted employees for granted!

And remember, employee benefits aren't just important to ensure that your team is happy and covered, if you fail to offer competitive benefits, it can bring some serious consequences with it. These might include:

  1. Financial consequences of hiring and training new hires.
  2. Risk of losing employees you depend on (and information and ideas) to competitors.
  3. Crushing workloads from being understaffed.
  4. Hours lost in recruitment and training for new hires.

How much does losing an employee actually cost you? 

Wondering how much losing an employee actually costs? It's more than you would think.

The true cost of losing an employee can be detrimental for small businesses.

A study by the Society for Human Resource Management (SHRM) shares that on average, the cost to hire an employee is $4,129, taking around 42 days to fill a position.

And if you're replacing an employee instead of hiring for a new position, the numbers are even worse.

Another study by SHRM shares that it takes up to 50-60% of a worker's annual salary to find a direct replacement.

Turnover can be quite costly, summing up to a total of 90-200% of an employee’s annual salary.


That's reason enough to make sure your most valuable employees are 100% satisfied with their compensation packages.

Am I required to provide small business health insurance for my employees?

This is a great question. Are you required to provide small business health insurance to employees? It depends.

Under the Employer Mandate, the Affordable Care Act requires that all employers with more than 50 employees must offer health insurance that's affordable.

To find out if the rule applies to you, you first have to figure out how many full-time equivalent (FTE) employees you have on your team. Use the formula below to calculate your FTE number.

How to calculate full-time equivalent (FTE) employees?

(Total hours worked by part-time employees each week / 30) + # of full-time employees = Your FTE number).

If you have 49 FTE, you technically aren't required to offer insurance; If you have 50 FTE, 95% of your full-time workforce must be covered. But there are a lot of other reasons to offer health insurance - like keeping your employees healthy and boosting recruitment and employee retention. 

Kaiser Family Foundation reports that 56% percent of small firms and 99% of large firms offer health benefits to at least some of their workers, for an overall offer rate of 57%.

How much does health insurance for small business cost?

Looking for how much it costs to insure employees? This is a great question to ask. It's also often the deciding factor of whether or not a small business can offer a health benefit to their team. 

The cost of health insurance for small business should be measured in both dollars and in time.

If you're going with a group plan, you'll want to consider the percentage of premiums you are willing to cover, whether or not you are covering employees or their families as well, whether you use third-party services to find insurance for you, since they have a fee as well.

But it also takes time to search and compare plans that meet the needs of your business, to educate your team on their plan options, and the administrative burden of setting up and maintaining the plan.

And did we mention paperwork?

So much paperwork.

According to the Kaiser Family Foundation's 2022 Employee Benefits Survey, what most consider the gold standard of data for healthcare, annual premiums for employer-sponsored family health coverage reached $22,463 this year, with workers on average paying $6,106 toward the cost of their coverage. Good grief!

The Wall Street Journal reports that employers shouldered 71% of that cost, while employees paid for the rest. The average deductible among covered workers in a plan with a general annual deductible is $1,655 for single coverage.

Pro tip: The best way to budget for health benefits is either a percentage of your payroll or a monthly per-employee amount. 

Your options for health insurance for small business

Historically, the best small business health insurance option was small-group insurance for many small employers who are looking to offer health benefits for their employees, but that's just not the case in 2023.

While these group health insurance for small business plans are the most widely known and understood, they are not the only health insurance options for small business in 2023. There are affordable and flexible alternatives to group health insurance.

You actually have THREE small business health insurance options!

What works best for you depends on a few things, including: 

  • how your company is set up
  • how individual and group plan costs vary in your geographic area
  • the health of the individual market near you

Here are your options for health care for small business:

  1. Small group insurance (small business group health insurance)
  2. Self funded plans
  3. Health Reimbursement Arrangements (HRAs)

It's that last option we are jazzed up about. But first, let's drill out the details in each option just to cover all of the bases.

Ready to learn how much you can reduce benefits cost?

Group health insurance for small business

What is small business group health insurance?

Historically speaking, small business group health insurance—or fully-funded insurance—has been the primary option for many small employers who are looking to offer health benefits for their employees. It's also referred to as corporate health insurance or group health insurance and sometimes includes vision and dental insurance for small businesses, if it's included in the plan.

It is geared toward businesses with less than 50 full time employees everywhere except four states where it applies to businesses with up to 10 employees.

According to Kaiser Family Foundation, 56% of small businesses with 3 to 199 employees offer health benefits. 81% of those companies offer one type of plan.

Group insurance plans for small businesses provide coverage to a group of members, usually comprised of company employees or members of an organization. Dental and vision insurance for small businesses can be included in the small business group plan or purchased separately. 

Small employer group health insurance members usually receive insurance at a reduced cost because the insurer’s risk is spread across a group of policyholders. 

How small business group health insurance works

Small group health insurance plans are purchased by employers, and then offered to employees.

Small business health insurance plans can only be purchased by groups, not individuals, and they usually require at least 70% participation in the plan to be valid.

In most states, you need at least one employee to qualify, you must contribute to employee premiums, and you can sign up any time of year instead of just during open enrollment. 

How much do employers pay for health insurance?

The cost of a group health plan for small business is technically shared by everyone in the group, and by the employer and employees. These plans can cost less because the risk pool is bigger. But in many markets, the difference in cost is negligible. 

Employers who own small businesses can put most or all of the cost of their group health insurance over onto their employees, but it’s better for attracting and retaining talent if they pay a portion of the premiums.

Once the company chooses a group health insurance plan for small business, group members are given the option to accept or decline the coverage.

In some areas, plans may come in tiers ( like gold, silver, bronze) that offer basic coverage or advanced insurance with add-ons.

The premium costs are then split between the company and its employees based on the specifics of the plan. Another thing to consider is whether or not insurance coverage will be extended to dependents of group members for an extra cost.

There are lots of options out there for small business health plans; you can choose between managed care (HMO, PPO, and POS), indemnity fee-for-service, and high-deductible health plans.

Check out our health insurance 101 post for more information on decoding all of the confusing insurance jargon.

Remember that not all plans are created equal! 

Where to buy group health insurance for small business

As an employer, you can buy small-group plans directly from an insurance company, via a broker or private exchange, or from your state’s SHOP Exchange. You can sign up any time, not just during open enrollment. 

Questions to ask when buying group health insurance in 2023

There are some basic questions you'll want to ask when buying group health insurance, if that's the route you choose to go. 

Here are the must-ask questions: 

  1. What does my plan cover? Ask your broker or provider for a detailed breakdown of what the plan offers. Dig in to the fine print. You'll need a solid understanding of this to help your employees understand their coverage.
  2. How much will group health insurance cost me? You'll want to have this nailed down before you sign on the dotted line. The cost to insure employees or the cost of small business health insurance can greatly vary based on size and health of your group, the average age of your employees, claim history for your company, the type of occupation, and the type of coverage and add-on benefits. 
  3. Who exactly should my plan cover? To manage expectations and avoid surprises, you'll want to understand who is eligible for group health insurance among your employees. You must offer it to all full time equivalent employees, but there's some wiggle room with part-time employees and even family members of your employees. You'll want to offer the same benefit equally and fairly to all.
  4. Who do I go to if I have questions about my insurance? This is a big one. There's nothing worse than dealing with confusing health insurance and not knowing where to turn. Make sure you have someone dedicated to help you. 

Benefits of small business group health insurance

These ACA-compliant plans are well known, tax-free, have solid product options, and are proven to be an effective retention strategy. Coverage is generally guaranteed, meaning that anyone who applies and meets the criteria will be accepted to the program.

Purchase of a SHOP plan may qualify the buyer for the Small Business Health Care Tax Credit.

For your employees, they might have access to a wider network of doctors than if they were on an individual plan. 

Why small business health insurance isn't the best insurance for small business 

The shortcomings can be detrimental to small business owners' budgets; small group plans are expensive, one-size-fits-all, with unpredictable premium increases year over year and participation rate requirements.

The traditional small business insurance plans also separates patients from the process; they simply swipe their card and aren't empowered to make financially savvy decisions.

We'll go out on a limb and say that this attitude doesn't help an already expensive healthcare system.

And remember, since your employees will all be in the same risk pool, one sick employee means higher prices.

Self-funded plans

What is a self-funded plan? 

With the cost of healthcare continuing to rise, some employers are looking to self-funding as a means to save on costs.

Technically speaking, self-insured employers pay for claims out of pocket when they arise as opposed to paying a predetermined premium to a carrier for a small group plan.

This type of plan, also known as a self-insured plan, is usually seen with a large enterprise as a means to control their healthcare spend and manage their own risk pool.

How a self-funded plan works

When an employer opts for self-funding for health benefits for their employees, they usually set up a special trust fund that earmark money to later pay incurred claims.

If the employee chooses not to keep claim processing in house, a third-party administrator (TPA) is engaged to process claims and may also offer additional services like premium collection, generating claim utilization reviews, contracting for PPO services, and offering overall service for the chosen employee benefit plan. In this model, the employer assumes the risk. 

Where to buy a self-funded plan

To set up a self-funded plan, you’ll want to allow yourself some time to make the transition, especially if you’re switching from a traditional group plan. There are several steps you’ll need to plan for. Many carriers offer administrative service contract options directly, or you can coordinate and engage a third-party administrator to draft plan documents.

Also consider bringing on board partner fiduciaries, CPAs, and brokers to help manage the set up process. Make sure that ERISA, HIPAA, and other regulatory mandates are met. Acquire a stop-loss policy and consider ERISA Bonds or Fiduciary Liability Insurance for risk mitigation purposes.

Create an administrative service agreement for your TPA or in-house plan administrator if you choose not to outsource. Publish and distribute a summary plan description (SPD) and Summary of Benefits and Coverage (SBC) to all covered employees.

Benefits of a self-funded plan

The benefits of this type of plan are that it's more customizable to your workforce, you have control over the health plan reserves so you can maximize your interest income, it’s more affordable per enrolled employee than a traditional plan, there's no pre-funding of health coverage, and you aren't subject to state health insurance premium taxes (usually around 2 to 3%).

They’re also subject to fewer regulations and allow employers to customize their healthcare plan to meet their unique business needs.

And because companies are paying only for the healthcare costs of their own employees, there may be money left over at the end of the year that can go toward other business needs.

Where self-funded plans fall short

While self-funded plans allow the company to potentially save the profit margin that an insurance carrier adds to its premium, the potential risk is much higher since the company is responsible for paying out the actual claims—especially in the event of catastrophic claims which could potential bankrupt a company.

What is stop loss insurance? 

Many companies choose to purchase stop-loss insurance to mitigate this risk. Since self-funded plans are not managed by an insurance carrier, the responsibility of ensuring Minimum Value Coverage falls in the hands of the employer. 

Reimburse for health insurance with an HRA 

What is an HRA? 

A health reimbursement arrangement is an affordable, tax-advantaged alternative to traditional small employer health insurance where employers are reimbursing employees for health insurance and medical expenses (if applicable) on a pre-tax basis.

Unlike Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) that are accounts, HRA stands for Health Reimbursement Arrangement, meaning that the model operates on reimbursements.

Employees will pay the insurance company or doctor’s office directly and then submit a claim to get reimbursed for their expenses tax-free. Dental and vision insurance for small businesses can be reimbursed with an HRA, as well! 

The use of new reimbursement models of HRAs put the employer's reimbursements on nearly the same tax playing field as traditional small group plans, but without all the hassles and requirements.

Before, a big advantage for group plans was that they were deductible expenses for employers and were taken out of employee paychecks on a pre-tax basis.

With an HRA, employers can make reimbursements without having to pay payroll taxes and employees don’t have to recognize income tax. In addition, reimbursements made by the company count as a tax deduction. 

ICHRAs have grown 3.5x in the past year and QSEHRAs have doubled in size on the market during that same time period, according to the HRA Council. 

How an HRA works

The reimbursement model is simple: An employer decides how much money to contribute each month, provides their employees with standard information about how the HRA works, and outsources some administrative functions like verifying coverage with an HRA administrator.

The employee chooses a plan that works for them, submits receipts for premium payments and medical expenses (if applicable), and gets reimbursed. 

HRAs that work best for health insurance for small business

There are a few different kinds of HRAs that are worth noting.

QSEHRA: To cut quickly through the insurance jargon (it stands for “Qualified Small Employer Health Reimbursement Arrangement” by the way), a QSEHRA allows small employers (businesses with less than 50 FTEs) to set aside a fixed amount of money each month - 2023 QSEHRA limits are $5,850 for self-only coverage and $11,800 for family coverage (up from $5,450 and $11,050, respectively over last year) that employees can use to purchase individual health insurance or use on medical expenses, tax-free. 

This means employers get to offer benefits in a tax-efficient manner without the hassle or headache of administering a traditional group plan and employees can choose the plan they want.

Reimbursement amounts can vary based on age and family size.

ICHRAThe individual coverage HRA has all the same benefits as QSEHRA, but with no maximum contribution limits and no company size limit. In addition to the flexibility of varying rates based on age and family size like QSEHRA, the hallmark feature of ICHRA is that benefits can be scaled across different classes of employees.

That means an employer can offer one reimbursement amount to seasonal workers, another amount to part-time, and varying amounts based on geographic area, allowing further streamlining of total benefit spend.

An ICHRA, sometimes referred to as an ICHRA plan, can also be integrated with a group plan, which is another distinction and one of the pros when you look at ICHRA pros and cons.

Ask our experts which HRA is best for your business

How to set up an HRA

It’s not advisable to administer your own HRA because of HIPAA, so you’ll want to go through a third-party administrator (like Take Command, the HRA administrators). You can sign up any time, and a new HRA offering qualifies employees for a special enrollment period so they can sign up for their individual plan without waiting for open enrollment.

Benefits of reimbursing for health insurance 

  • Optimized Benefits
  • Tax Efficiency
  • Flexible Design
  • Budget Control
  • Allows employers to get out of the health insurance risk management game. 

What's the best insurance for small business?

Wondering what the best small business health insurance option is for your company in 2023? Are you looking into how to get health insurance for a small business? 

We're here for you!

While we always advise our clients to speak with their CPA before jumping in, we are ready to chat on our website if you have any specific questions about your business and how HRAs stack up against group plans in your area.

Setting up a small business HRA or setting up an ICHRA is simple and quick, and our team is here to help if you need it. 

And remember, what's best for one company isn't necessarily best for another.

It is important to consider your company's unique makeup, your company size, whether or not you want to participate in the health plan as an owner, and your location market conditions to determine what the best plan will be for your company benefits. 

Looking for more employee benefit ideas? Check out our Employee Benefits Guide. 

Ask our experts how to get started today (it's easy!)

This post was originally published March 2020 and has been updated by our team on February 20, 2023. 

Small Business