Securing reliable health coverage remains a pivotal concern for employers, individuals, and families alike. Navigating the landscape of health insurance options can be daunting, especially for small businesses without dedicated HR or benefits teams. Nonetheless, dedicating time to research and choose the right coverage options can significantly enhance employee satisfaction and overall well-being. Offering employer-sponsored health plans not only helps attract and retain talent but also fosters a healthier, more productive workforce.
In this comprehensive guide, we highlight the top 25 health insurance companies in the U.S. based on market share, providing insights into their prominence within the industry. Additionally, we explore alternative coverage solutions such as health reimbursement arrangements (HRAs) and stipends, which present flexible and cost-effective options for organizations seeking to diversify their benefits offerings.
> What you’ll discover in this article:
- How the largest health insurers contributed nearly $1.08 trillion in premiums during 2023.
- Which companies dominate the U.S. market in terms of share and influence.
- How innovative benefit models, like HRAs, can serve as practical alternatives to traditional group health plans.
What Is Traditional Group Health Insurance?
When employers evaluate health insurance options, they are often considering group health plans. These plans involve a primary insurer providing coverage to a company’s employees and their dependents at negotiated rates. Typically, insurers require a minimum participation rate—often around 70%—to ensure enough enrollees for the plan to be viable. If participation falls short, the employer may need to explore other options.
Various plan types are available under traditional group coverage, including:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Exclusive Provider Organizations (EPOs)
- Point-of-Service (POS) Plans
Participants usually pay a share of the premium, along with meeting annual deductibles before the insurer covers medical expenses. Employers can purchase these plans directly from insurance carriers, through licensed brokers, or via the Small Business Health Options Program (SHOP) marketplace, which also offers access to the Small Business Health Care Tax Credit to reduce costs.
The cost of group health insurance continues to rise, with the average annual premiums in 2024 reaching approximately $8,951 for individual coverage and $25,572 for family plans, according to KFF. Employers typically contribute a significant portion—around $7,584 for individual plans and $19,276 for family coverage—toward these premiums. While group insurance remains popular due to familiarity and comprehensive coverage, its high costs can be prohibitive for smaller businesses.
Individuals can also purchase health insurance independently through the federal or state exchanges, often using plans offered by the same insurers that provide group coverage. Additionally, employers have the option to utilize stand-alone HRAs to reimburse employees for health expenses, offering more flexibility than traditional plans.
Top 25 U.S. Health Insurance Companies by Market Share
Understanding which insurers hold the largest slices of the market can guide both employers and consumers in making informed choices. Market share reflects a company’s dominance in the industry and often correlates with financial stability and provider networks.
According to data from the National Association of Insurance Commissioners (NAIC), the following companies lead the U.S. health insurance market in 2023:
| Rank | Company | Market Share 2022 | Market Share 2023 |
| — | — | — | — |
| 1 | UnitedHealth Group (including UnitedHealthcare) | 15.34% | 16.37% |
| 2 | Elevance Health Inc. (formerly Anthem) | 7.16% | 7.08% |
| 3 | Centene Corporation | 6.68% | 6.76% |
| 4 | Humana | 6.03% | 6.61% |
| 5 | CVS Health (including Aetna) | 5.82% | 6.43% |
| 6 | Kaiser Foundation (Kaiser Permanente) | 6.18% | 6.19% |
| 7 | Health Care Services Corporation (HCSC) | 3.53% | 3.65% |
| 8 | Cigna | 2.39% | 2.64% |
| 9 | Molina Healthcare | 1.99% | 2.04% |
| 10 | GuideWell (including Florida Blue) | 1.84% | 1.91% |
Market share figures are indicative of a company’s competitiveness and financial resilience but do not necessarily reflect the quality of care or customer satisfaction. Larger market shares often mean a broader provider network and greater resources to support policyholders. For a detailed analysis of industry size and trends, consult NAIC reports.
How Much Revenue Do These Insurers Generate?
The industry’s total premium income reached approximately $1.08 trillion in 2023, marking an 8% increase over the previous year, as reported by the NAIC. This growth reflects rising healthcare costs, inflation, and an aging population requiring more extensive medical services.
UnitedHealth remains the dominant player, with premiums totaling nearly $249 billion in 2023. Meanwhile, smaller companies like Health Net Community Solutions reported premiums around $8.35 billion. Industry experts anticipate continued increases in healthcare utilization, emphasizing the importance for organizations to offer diverse and adaptable benefits—such as virtual reality applications in medical training and patient care—to meet evolving needs.
| Rank | Insurer | 2023 Premiums (USD) |
| — | — | — |
| 1 | UnitedHealth Group | $248,763,012,672 |
| 2 | Elevance Health Inc. | $107,650,449,800 |
| 3 | Centene | $102,711,951,802 |
| 4 | Humana | $100,521,046,979 |
Offering a variety of insurance options remains essential for attracting and retaining employees, especially as healthcare demands grow.
Alternatives for Small Employers: HRAs and Health Stipends
Rising premium costs and participation requirements can make traditional group plans challenging for smaller businesses. Fortunately, innovative benefit models like Health Reimbursement Arrangements (HRAs) and stipends offer flexible, cost-effective alternatives.
An HRA allows employers to reimburse employees tax-free for out-of-pocket medical expenses and insurance premiums. These plans can be tailored to fit organizational needs, providing more control over benefit costs. For example, the individual coverage HRA enables employees to buy their own insurance and receive tax-free reimbursements, offering flexibility compared to traditional group plans.
Similarly, the qualified small employer HRA is designed for companies with fewer than 50 full-time employees, allowing them to set allowances for employees to purchase coverage suitable for their needs. These options help small firms meet legal requirements while controlling costs.
Another approach involves integrated HRAs, which supplement existing group insurance plans by reimbursing out-of-pocket expenses like deductibles and coinsurance. These plans can be customized with variable allowance amounts and employee classifications, providing tailored support.
Alternatively, health stipends are taxable payments that employees can use for health-related expenses, including supplemental insurance plans like dental or vision coverage. While stipends are simpler to administer and free from some regulatory constraints, they do not satisfy employer mandate requirements for large employers.
How PeopleKeep Simplifies Benefit Administration
Managing HRAs and stipends can be complex, but specialized software solutions streamline the process. Platforms like PeopleKeep offer intuitive tools for administering these benefits, automating tasks such as reimbursement approval and compliance tracking. This ensures employers can provide personalized benefits without administrative burdens or risking errors.
By leveraging such services, small businesses can confidently offer flexible benefits that meet employee needs while maintaining regulatory compliance and controlling costs.
Final Thoughts
Although established insurance giants provide extensive options for traditional group health coverage, exploring alternative benefits like HRAs or stipends can yield significant advantages—especially for smaller organizations. These models empower employees by giving them the autonomy to choose suitable coverage and help employers manage expenses more effectively.
Considering such flexible options can be a strategic move toward building a comprehensive, adaptable benefits package that supports your workforce’s health and financial well-being. If you’re interested in implementing HRAs, learn more about virtual reality’s role in modern medicine and how technological innovations are shaping healthcare.
This article was initially published on January 13, 2020, and has been thoroughly updated as of January 2, 2025.