Small Group Health Plans | Out-of-Pocket Costs

Small Business Health Insurance – Small Group Health Plans

Under the Patient Protection and Affordable Care Act, businesses having up to 100 employees can shop for insurance at a state health insurance exchange or a federal exchange in states that have not established their own exchange. Through exchanges, it is hoped that small business will have more insurance choices in a competitive environment that will lead to lower premiums.

Small Business Health Options Program

Exchanges will serve businesses through a Small Business Health Options Program (SHOP). A business will register at a SHOP and define the employer contribution towards the cost of health insurance. An employee can then use the SHOP to compare plans and see what costs would be after the employer contribution is made. The SHOP will send the employer a monthly bill for employer and employees. The employees will pay through payroll deduction. The employer will pay the SHOP who will pass the payment to the insurer.

Small Business Tax Credit

Companies with up to 25 employees with average wages below $50,000 may be eligible for a small business tax credit worth up to 35% of health insurance costs.

Penalties for Non-Compliance

Many businesses will have a strong incentive to use these exchanges starting in 2015 because companies with 50 or more full-time employees must provide health insurance for all workers or face stiff penalties. This penalty begins at $40,000 and increases by $2,000 for every worker above 50. Businesses obtaining coverage for employees must have benefits that cover at least 60% of medical costs. Additionally, the employee premium must be less than 9.5% of the employee’s family income. If a company provides health insurance coverage below the minimum requirement of the Affordable Care Act, they can receive a fine of $3,000 for each employee receiving a premium tax credit from the insurance exchange.

Exceptions to Insurance Exchanges

If a company has less than 50 workers then the obligation to enroll in health insurance falls on the employee not the employer. Additionally, companies with more than 100 employees will need to shop outside of health insurance exchanges for employee health insurance coverage.

Out-of-Pocket Costs in Small Group Plans

Based on 2014 data for 32 states, HealthPocket found the below averages for out-of-pocket costs within small group health insurance plans.

Metal TierBronzeSilverGoldPlatinum
Medical Deductible for an individual enrollee$4,216$2,384$1,278$323
Medical Deductible for a family$8,667$4,946$2,872$647
Primary care visit33% Co-Insurance Fee$34$23$16
Specialist visit33% Co-Insurance Fee$54$43$29
Annual cap on out-of-pocket costs for an individual$6,224$5,690$3,758$1,620
Annual cap on out-of-pocket costs for a family$12,518$11,445$7,926$3,240

While the Affordable Care Act does have caps on deductibles for small group plans ($2,000 individual / $4,000 family), those caps are waived if it would interfere with the plan meeting its proper ratio of insurance payments to enrollee out-of-pocket costs.

To review the full findings of HealthPocket’s research on small business health plans, see “1-in-3 Obamacare Small Business Health Plans Exceed Deductible Cap.” provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.