Most small business owners set their benefits package once and never look at the numbers again. Here’s the benchmark data that changes that.
If you’re a small business owner offering health insurance, you’ve probably asked yourself some version of this question at renewal time:
Are we paying too much? Too little? Are our employees getting a good deal or are we hemorrhaging money on a plan that still isn’t competitive?
The problem is, most business owners are making these decisions in the dark. They know what they’re paying. They just don’t know how that compares to anyone else.
That’s exactly what this video is going to fix.
Matt Vaadi sat down with Matt Wilson from Scott Insurance to walk through benchmarking data from Milliman, one of the most respected actuarial firms in the country, covering more than 20,000 companies nationally. The data includes small group benchmarks (under 50 employees) and Southeast regional data, so if you’re operating in North Carolina, South Carolina, or Georgia, this is your peer group.
Here’s what the numbers actually show.
The 5 Plan Design Benchmarks That Matter Most
When you’re evaluating a health plan, whether you’re choosing one for the first time or reviewing your renewal, these are the five numbers that tell you whether your plan is competitive, average, or below the market.
1. The Deductible
The deductible is what your employee pays out of pocket before insurance kicks in. It’s also the number employees ask about most when enrolling.
National and small group median (PPO): $1,500 Southeast regional median (PPO): $2,000
For high-deductible health plans (HDHPs): National and small group median: ~$3,300 Southeast regional median: ~$3,500
If your plan has a deductible above these numbers, your plan is less rich than the median. That doesn’t always mean it’s wrong, but it means your employees are absorbing more risk than most of their peers at other companies.
2. Out-of-Pocket Maximum
Most employees overlook the out-of-pocket maximum, but they probably should pay attention to it. It’s the worst-case scenario. The most any covered member will pay in a 12-month period before insurance covers 100%.
PPO median: $5,000 (consistent across national, regional, and small groups) HDHP median: $6,000 to $6,500
When you see claims data, and we’ll get to that in a minute, this number becomes a lot more meaningful. A half-million-dollar NICU stay hitting a $5,000 out-of-pocket cap is insurance doing exactly what it’s supposed to do.
3. Primary Care Copay
For PPO plans, the primary care copay is what employees pay when they visit their family doctor. It’s one of the most visible parts of a plan, employees feel it every time they go to the doctor.
Benchmark: $25 across national, regional, and small group
Plans with a $20 copay are beating the benchmark. Plans at $40+ are starting to affect employee satisfaction.
4. Specialty Drug Copay
This is where the numbers get uncomfortable. Specialty drugs, the ones with the TV commercials and the catchy jingles, are the single biggest driver of high healthcare costs in most employer groups.
National and small group benchmark: $150 Southeast regional benchmark: $250
Here’s something worth knowing about those TV drug ads: newer does not mean more effective. The clinical data doesn’t support the marketing budget. A strategy called step therapy, starting with generic, proven drugs before moving to newer branded options, can meaningfully reduce both employee and employer costs without compromising care quality.
5. Employer Contribution Percentage
This is the one number most employees actually notice in their paychecks and the one most employers have the most control over.
PPO, employee-only: ~78% national median; HDHP, employee-only: ~80 to 81% national median
That means that on a $761/month PPO premium, the average employer is covering about $594 of that. The employee pays roughly $167. Want to estimate your specific employer costs? Use this 2026 SC Employer Cost Calculator by Bound to run the numbers for your team.
On family coverage, the picture shifts:
PPO, family: ~60 to 63% of the national median. HDHP, family: ~58 to 66% national median
That’s a significant drop, and it’s intentional for many employers. More on that below.
The Family Coverage Gap (And Why It’s Not an Accident)
One of the more surprising pieces of this data is the gap between how much employers contribute for employee-only coverage versus family coverage.
Employers kick in 78 to 81% for employee-only plans. Drop to family coverage, and that number falls to the low-to-mid 60s, leaving employees covering closer to 40% of a $2,300+ monthly premium.
For most employees, the situation feels like they’re getting penalized for having a family. But there’s a strategy behind it.
Many employers intentionally contribute less to family coverage because they’d rather the working spouse stay on their own employer’s plan. It keeps your group smaller and healthier, reduces claims risk, and controls costs over time. When you understand that logic, it changes how you might communicate this decision to employees, and how you might structure your contribution strategy deliberately rather than by default.
The Case for High-Deductible Plans (And Why HSAs Beat 401(k)s)
High-deductible health plans get a negative reputation because of the deductible. But paired with a Health Savings Account (HSA), they’re one of the most powerful financial tools available to employees.
Here’s the comparison:
401(k)
- Pre-tax contributions ✓
- Tax-free investment growth ✓
- Taxed on withdrawal ✗
HSA
- Pre-tax contributions ✓
- Tax-free investment growth ✓
- Tax-free withdrawal for qualified medical expenses ✓
The HSA wins on that third leg. Every dollar your employee withdraws from a 401(k) in retirement gets taxed as ordinary income. HSA withdrawals for medical expenses? Zero tax.
Healthcare is projected to be one of the largest retirement expenses most Americans will face. Having a tax-free bucket specifically for that purpose, one that compounds over decades if you don’t use it, is a significant financial advantage.
Employer HSA funding benchmarks:
- Employee-only: ~$750/year (regional benchmark)
- Family: ~$1,000/year
If you’re offering an HDHP, contributing to employees’ HSAs isn’t just a nice-to-have. It’s what separates a competitive HDHP offering from one that just looks cheap.
The Claims Data That Puts All of This in Context
Sometimes the best way to understand why health insurance works the way it does is to look at what it’s actually paying for.
According to Sun Life’s 2024 high-cost claim data, the top conditions driving the most expensive claims are:
- Cancer (malignant neoplasm): Nearly $500 million in total claims; average individual claim well into six figures
- Cardiovascular disease: $173 million in total claims
- Premature/NICU newborns: Average claim ~$500,000; highest recorded claim $7.2 million
- Hemophilia and blood disorders: Average ~$400,000 per claim
- Leukemia: Average ~$300,000 per claim
These aren’t fringe cases. They happen in groups of 10, 20, 50 employees.
When a member with a $5,000 out-of-pocket maximum runs up $500,000 in NICU costs, that cap is doing exactly what you paid for. Understanding these numbers also helps you have more informed conversations with your broker about stop-loss coverage, plan design tradeoffs, and risk tolerance.
Dental and Vision: What’s Standard, What’s Not
Dental Benchmarks
- Deductible: $50 (benchmark, hasn’t moved much in a decade)
- Annual benefit maximum: $1,500 national benchmark (was $1,000 not long ago, it’s creeping up)
- Preventive services: 100% covered on most benchmark plans, use it
- Basic services (cavities, etc.): 80% benchmark
- Major services (root canals, crowns): 50% benchmark, employees pay the other half
- Orthodontic maximum: ~$1,500 national; ~$1,200 Southeast; typically child-only
Employer contribution for dental:
- Employee-only: 56% nationally, 35% regionally
- Family: 34% nationally, 20% regionally
Most employers do contribute something toward dental. Unlike vision, a fully voluntary dental plan is the exception rather than the rule.
Vision Benchmarks
- Exam copay: $10 (standard, unchanged for years)
- Materials copay: $25
- Contact allowance: ~$130 to $150
- Frames allowance: ~$130
Vision is the reverse of dental; the majority of employers offer it as a voluntary benefit with no employer contribution. If you’re kicking in money toward vision, you’re ahead of most.
Using This Data to Make Better Decisions
Here’s the practical takeaway from all of this:
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Validate Your Current Strategy
Are you trying to offer average benefits or beat the benchmark? Now you know what the benchmark actually is. Run your current plan against these numbers. Where are you winning? Where are you falling short?
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Know Your Contribution Story
Your employees don’t know that you’re covering 78% of their premium. They don’t know how that compares to the market. Part of your job during open enrollment is to tell them. That data belongs in your enrollment communications.
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Make Your Family Coverage Decision Intentional
Whether you contribute equally to family coverage or pull back from the benchmark, that should be a deliberate strategy, not something that happened because you never revisited it.
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Look at the HDHP + HSA Combination Seriously
If you haven’t modeled what a high-deductible plan with employer HSA funding would cost versus your current PPO, it’s worth doing before your next renewal.
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Revisit Annually
These benchmarks move. The dental annual maximum benchmark used to be $1,000. Now it’s $1,500. Plan costs post-COVID haven’t slowed down. Your strategy from three years ago may not be competitive today.
How to Move Forward With Confidence
Employee benefits are more than just a line item in the budget. They are a reflection of how a company values its people and positions itself in the market. Without benchmarking, it is easy to assume that everything is working as intended. With the right data, it becomes possible to evaluate your strategy with clarity and confidence.
If you are preparing for your next renewal, now is the time to review how your benefits compare. A data driven approach can help you make smarter decisions, control costs, and create a more competitive offering for your team.
