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Zywave Health Plan Benchmarks
How does your plan compare?
Table of Contents
Introduction .............................................................................................................................................................................. 4
Plan Type ................................................................................................................................................................................ 7
By Region ................................................................................................................................................................... 8
By Group Size .......................................................................................................................................................... 11
By Industry ............................................................................................................................................................... 14
Coinsurance ......................................................................................................................................................................... 18
By Region ................................................................................................................................................................. 19
By Group Size .......................................................................................................................................................... 22
By Industry ............................................................................................................................................................... 25
By Plan Type ............................................................................................................................................................ 29
ER Copay .............................................................................................................................................................................. 32
By Region ................................................................................................................................................................. 33
By Group Size .......................................................................................................................................................... 36
By Industry ............................................................................................................................................................... 39
By Plan Type ............................................................................................................................................................ 43
Individual Deductible ........................................................................................................................................................... 46
By Region ................................................................................................................................................................. 47
By Group Size .......................................................................................................................................................... 50
By Industry ............................................................................................................................................................... 53
By Plan Type ............................................................................................................................................................ 57
Individual Out-of-Pocket Maximum .................................................................................................................................... 60
By Region ................................................................................................................................................................. 61
By Group Size .......................................................................................................................................................... 64
By Industry ............................................................................................................................................................... 67
By Plan Type ............................................................................................................................................................ 71
Office Visits .......................................................................................................................................................................... 74
By Region ................................................................................................................................................................. 75
By Group Size .......................................................................................................................................................... 78
By Industry ............................................................................................................................................................... 81
Zywave Health Plan Benchmarks
How does your plan compare?
By Plan Type ............................................................................................................................................................ 85
Rx Deductible ....................................................................................................................................................................... 88
By Region ................................................................................................................................................................. 89
By Group Size .......................................................................................................................................................... 92
By Industry ............................................................................................................................................................... 95
By Plan Type ............................................................................................................................................................ 99
About Zywave ...................................................................................................................................................................... 102
4
Zywave Health Plan Benchmarks
How does your plan compare?
Introduction
This report, based on 2011 plan data from close to 50,000 employers nationwide and nearly 70,000
plans*, benchmarks information for seven key plan design measures:
Plan Type
Coinsurance
ER Copay
Individual Deductible
Individual Out-of-Pocket Maximum
Office Visits
Rx Deductible
For each item, we’ve broken down the data by region, group size, industry and plan type, to help you
compare your offerings against like companies and plans.
* Though this is a large sample size, care should be taken in applying and interpreting this data. It has not been validated for statistical significance or margin of error. It is informational in nature and should be used in conjunction with the advice of a licensed insurance broker.
5
Zywave Health Plan Benchmarks
How does your plan compare?
Benchmarks by Region
This map illustrates which states constitute each region, as well as what percentage of employers from
the data set operate in each region.
West – 19%
North Central – 26%
South Central – 23 %
North East – 16 %
South Atlantic – 16%
Benchmarks by Group Size
To help you compare your plan with employers of similar size, we’ve broken down data by number of
employees, based on the following ranges:
< 25 employees
26 – 50 employees
51 – 99 employees
100 – 499 employees
500 – 999 employees
1,000 – 2,499 employees
2,500 – 4,999 employees
5,000+ employees
5
26%
23%
16% 19%
16%
6
Zywave Health Plan Benchmarks
How does your plan compare?
Benchmarks by Industry
We’ve also segmented the benchmark data by industry, including the following:
Agriculture/Forestry/Fishing
Education
Finance/Insurance/Real Estate
Health Care
Manufacturing
Mining/Construction/Wholesale
Retail
Service
State/Local Government
Transportation/Communications /Utilities
Other
Benchmarks by Plan Type
The data is also segmented by plan type, to help plan sponsors benchmark their plans against similar
plan types. Here is the overall breakdown we found:
7
8
Plan Type
By Region
Plan Type by Region
This section displays the prevalence of different plan types in each of the five regions. Here are some
highlights from a regional comparison standpoint:
PPO plans were by far the most popular in most of the country, and were a close second (28%) in
the South Atlantic region.
At least 15% of plans were HSAs in all regions except the North East, where only 8% were. The
North Central region had the highest rate of HSA plans at 21%.
About one-fourth of plans in the West, South Atlantic and North East region were HMOs.
Meanwhile, HMOs represented only 5% of South Central plans.
Point-of-sale plans also vary widely be region, from 6% in the West to 29% in the South Atlantic
region.
The South Atlantic was the most balanced region, with four different plan types registering at 15%
or more. On the other hand, the South Central and West regions had one dominant plan type
(PPO) at over 50%, with other plans being much less prevalent.
9
Plan Type
By Region
10
Plan Type
By Region
11
Plan Type
By Group Size
Plan Type by Group Size
This section shows which plan types were most popular based on number of employees. Comparing
among company sizes, the following can be seen:
PPO is the dominant plan type among all sizes, representing between 43 and 60% of all plans.
HMOs are the second most popular plan for every group size.
As a general trend, HSAs and point-of-sale plans are more popular among smaller employers,
and decrease in popularity among larger group sizes.
Regarding plan type, there is much less variation among group sizes than among region.
12
Plan Type
By Group Size
13
Plan Type
By Group Size
14
Plan Type
By Industry
Plan Type by Industry
This section segments plan type based on industry. The following are some observations when
comparing between different industries:
Unsurprisingly, PPO is the most popular among all industries, representing between 44 and 56
percent of all plans.
HMOs are second most popular in the following industries: Education, Finance/Insurance/Real
Estate, Manufacturing, Mining/Construction/Wholesale, Retail, Service, State/Local Government
and Transportation/Communications/Utilities.
HSAs are second most popular in Agriculture/Forestry/Fishing, and HSA and POS plans are tied
for that spot in Health Care.
Again, there is not a lot of variation among industries regarding plan type.
15
Plan Type
By Industry
16
Plan Type
By Industry
17
Plan Type
By Industry
18
19
Coinsurance
By Region
Coinsurance by Region
In this section, coinsurance is analyzed by region. Here are some highlights that can be pulled from the
data:
There was reasonable variation by region, but the top two coinsurance amounts in all regions
were 80-89% and 100% (not necessarily in that order).
The North East region was the most decisive region, with 70 percent of plans having a
coinsurance of 100 percent.
Overall, < 60% and 60-69% coinsurance amounts were the least popular.
20
Coinsurance
By Region
21
Coinsurance
By Region
22
Coinsurance
By Group Size
Coinsurance by Group Size
Coinsurance is examined by employer size in this next section, beginning with some high-level
observations.
As with region, 80-89% and 100% are the two most popular coinsurance amounts across the
board.
The group sizes were pretty consistent with no major outliers. However, by far the lowest
prevalence of 100% coinsurance was groups with over 5,000 employees (24%).
90-99% coinsurance amounts were most popular among employer groups of 500-2,499
employees.
23
Coinsurance
By Group Size
24
Coinsurance
By Group Size
25
Coinsurance
By Industry
Coinsurance by Industry
View coinsurance amounts broken down by industry in this section. Following are some highlights of the
data.
Generally, the distribution is pretty even among industries, with none standing out particularly.
80-89% and 100% were the top two coinsurance choices in all industries (not necessarily in that
order) on a reasonably even level—each accounting for between 32 and 45 percent of plans in
the industry.
26
Coinsurance
By Industry
27
Coinsurance
By Industry
28
Coinsurance
By Industry
29
Coinsurance
By Plan Type
Coinsurance by Plan Type
In this section, coinsurance is segmented by plan type, beginning with some general observations.
As you might expect, coinsurance varies considerably by plan type, though 100% and 80-89%
were the two most popular among each.
A majority of these plan types used 100% coinsurance: HMOs, HRAs, HSAs and point-of-sale
plans. The first three all had prevalence over 64%.
Two plan types had 80-89% as the most popular coinsurance amount: PPOs (45%) and
Indemnity (70%).
PPO plans had other coinsurance ranges with some popularity after the top two, with 70-79%
coinsurance at 8% prevalence and 90-99% coinsurance representing 12% of plans. Other plan
types had very low percentages other than the top two coinsurance ranges.
30
Coinsurance
By Plan Type
31
Coinsurance
By Plan Type
32
33
Emergency Room Copay
By Region
ER Copay by Region
This section illustrates which emergency room copay amounts were most common in each region. Here
are some highlights of the regional breakdowns.
There was quite a bit of variation among different regions, but the two most popular ER copays
were $100-$124 and $150+ (not necessarily in that order).
The North Central region was the most decisive, with 60% of plans using an ER copay of $150 or
more.
Conversely, the North East region was the most balanced, with three different copay amounts
garnering at least 18% popularity, and no amount registering at less than 6%.
Despite the wide variation among regions, $0-$24, $25-$49, and $125-$149 were consistently the
least common ER copays.
34
Emergency Room Copay
By Region
35
Emergency Room Copay
By Region
36
Emergency Room Copay
By Group Size
ER Copay by Group Size
In this section, view the most common emergency room copays by group size. Here are some
comparative highlights:
As with the regional breakdown, $100-$124 and $150+ are the two most popular ER copay
amounts among all group sizes.
There is a visible trend that smaller plans with less than 100 employees have a higher prevalence
of ER copays of $150+ (47% or more). Larger groups still have that as their first or second option,
but at a lower prevalence (24-35%).
Another trend can be seen among the lower deductibles ($0-$24, $25-$49 and $50-$74).
Prevalence is lower among smaller groups, but grows somewhat for larger employers.
The least common ER copay was consistent among all plans: $125-$149.
37
Emergency Room Copay
By Group Size
38
Emergency Room Copay
By Group Size
39
Emergency Room Copay
By Industry
ER Copay by Industry
In this section, emergency room copay is segmented by industry to examine any trends, starting with
high-level observations from the data.
There wasn’t much variance by industry regarding emergency room copay. In every industry
except one, $150 was the most popular ER copay amount, followed by $100-$124.
The one unique industry was State and Local Government: 38% of plans had a $150+ ER copay,
followed by $50-$74 (22%) and $100-$124 (21%).
There was some variation among the four lowest copay ranges, but the least common overall
copay was $125-$149.
40
Emergency Room Copay
By Industry
41
Emergency Room Copay
By Industry
42
Emergency Room Copay
By Industry
43
Emergency Room Copay
By Plan Type
ER Copay by Plan Type
This section displays emergency room copay amounts by plan type, and this page includes observations
when comparing at a high level.
There was considerable variation of emergency room copay choices based on plan type.
HRA plans were the most diverse, with $150+, $100-$124, $75-$99 and $25-$49 all registering
with at least 14 percent prevalence among plans.
HMO, PPO, and POS plans were similarly distributed, with $150+ as the most popular ER copay,
followed by $100-$124.
HSAs were unique and also quite diverse, with their highest prevalence being $100-$124 (49%),
followed by $0-$24 (22%) and $150+ (19+).
44
Emergency Room Copay
By Plan Type
45
Emergency Room Copay
By Plan Type
46
47
Individual Deductible
By Region
Individual Deductible by Region
In this section, see how individual deductibles compare by region. Here are some general highlights.
Among all regions, $2,500+ was the most popular individual deductible and $750-$$999 was the
least common.
In all regions besides the West, $1,000-$1,499 was the second most prevalent individual
deductible.
The South Central Region was the most decisive, with 42% of plans having an individual
deductible over $2,500. After that, however, four different amounts registered with at least 10% of
plans.
Results vary in all regions, as all had four or five deductible amounts garnering at least 10%
popularity in the region.
48
Individual Deductible
By Region
49
Individual Deductible
By Region
50
Individual Deductible
By Group Size
Individual Deductible by Group Size
This section displays the popularity of individual deductibles by employer size. Here are some highlights
from a group size comparison standpoint:
There is a definite trend based on size. The smaller four group sizes (fewer than 500 employees)
all had $2,500+ as the most popular individual deductible. However for larger group sizes (more
than 500 employees), the most popular deductibles were on the lowest end of the spectrum.
Based on our group size segmentation, the mid-sized groups (100-499, 500-999) seemed to be a
bit more indecisive, with deductibles at both ends of the spectrum registering at reasonable
popularity.
51
Individual Deductible
By Group Size
52
Individual Deductible
By Group Size
53
Individual Deductible
By Industry
Individual Deductible by Industry
View the prevalence of different individual deductibles segmented by industry, starting with a general
overview of the data.
Most industries share a similar pattern: $2,500+ was the most popular deductible, followed by
$1,000-$1,499 and $500-749.
The two outliers were Education and State and Local Government. In both of these industries, the
two most popular individual deductibles (with almost identical prevalence) were $2,500+ and $0-
$249.
The least popular deductible among all industries was $750-$999.
54
Individual Deductible
By Industry
55
Individual Deductible
By Industry
56
Individual Deductible
By Industry
57
Individual Deductible
By Plan Type
Individual Deductible by Plan Type
This section shows individual deductible amounts by plan type, beginning with a high level comparison
overview.
As would be expected, there was a good deal of variation by plan type.
HMO and Indemnity plans had similar distributions, with $0-$249 being the most popular and
several other amounts having at least 10% prevalence.
The distribution for HSA plans was interesting. The law mandates that HSA-eligible plans have an
individual deductible of at least $1,200 (for 2011-2012), yet 70% of HSA plans had an individual
deductible over $2,500.
HRA plans also had $2,500+ as the most popular deductible, but at a lower rate (44%).
POS and PPO plans were similar, with $2,500+ as the most popular individual deductible but
several other amounts showing popularity.
58
Individual Deductible
By Plan Type
59
Individual Deductible
By Plan Type
60
61
Individual Out-of-Pocket Maximum
By Region
Individual Out-of-Pocket Maximum by Region
This section displays the most common out-of-pocket maximums in each of the five regions. Here are
some highlights from a regional comparison standpoint.
In all regions except the North East, the most popular out-of-pocket maximum amount was
$2,500-$3,499.
In the North East, the most popular was $5,000-$7,499 with 28%, followed closely by $2,500-
$3,499 (27%).
In all regions, the least popular ranges were < $249, $250-$499, $500-$999 and $7,500+.
62
Individual Out-of-Pocket Maximum
By Region
63
Individual Out-of-Pocket Maximum
By Region
64
Individual Out-of-Pocket Maximum
By Group Size
Individual Out-of-Pocket Maximum by Group Size
In this section, view the popularity of different individual out-of-pocket maximum amounts, segmented by
group size, starting with an overview of the data.
For all group sizes, $2,500-$3,499 was the most popular out-of-pocket maximum amount.
There appears to be a slight trend by size.
o For the four smaller group sizes (under 500 employees), after the most popular amount,
the next most popular are $3,500-$4,999 and $5,000-$7,499.
o For larger group sizes, the next most popular out-of-pocket maximums tended to be
$2,000-$2,499 and $1,500-$1,999.
65
Individual Out-of-Pocket Maximum
By Group Size
66
Individual Out-of-Pocket Maximum
By Group Size
67
Individual Out-of-Pocket Maximum
By Industry
Individual Out-of-Pocket Maximum by Industry
In this section, compare individual out-of-pocket maximum amounts by industry, starting with overall
observations.
In all industries, $2,500-$3,499 was the most popular out-of-pocket maximum, representing 29-
34% of all the plans.
There is some variance in the next most popular amounts, but they tend to be either $3,500-
$4,999 and $5,000-$7,499 or $2,000-$2,499 and $1,500-$1,999.
Among all industries, < $249 and $250-$499 are the least popular out-of-pocket maximum
amounts.
68
Individual Out-of-Pocket Maximum
By Industry
69
Individual Out-of-Pocket Maximum
By Industry
70
Individual Out-of-Pocket Maximum
By Industry
71
Individual Out-of-Pocket Maximum
By Plan Type
Individual Out-of-Pocket Maximum by Plan Type
This section compares individual out-of-pocket maximum amount by plan type, starting with highlights of
the data.
As with other plan type comparisons, there was a bit more variance here than with other out-of-
pocket maximum segmentations.
The distribution for HSA and HRA plans was almost identical, with $2,500-$3,499, $5,000-$7,499
and $3,500-$4,999 being the three most common ranges, in that order.
PPO and POS plans were somewhat similar, with $2,500-$3,499 being the most popular.
HMO was the only plan type with a different leading out-of-pocket maximum, with $1,500-$1,999
garnering the most popularity.
Indemnity plans were quite divided, with multiple ranges showing at considerable percentages.
72
Individual Out-of-Pocket Maximum
By Plan Type
73
Individual Out-of-Pocket Maximum
By Plan Type
74
75
Office Visit Copay
By Region
Office Visit Copay by Region
In this section, compare office visit copay amounts by region, starting with an overview of regional
highlights.
There was quite a bit of variation by region regarding office visit copay amount.
In both the West and South Central regions, $30-$34 was the most common office visit copay,
with $20-$24 and $25-$29 being the next most popular.
In both northern regions, the most popular office visit copay was $20-$24. In the North Central
region, this was followed closely by $30-$34. In the North East, four other copay amounts
registered considerable popularity.
The South Atlantic region was the most unique, with $25-$29 being the most popular office visit
copay there.
76
Office Visit Copay
By Region
77
Office Visit Copay
By Region
78
Office Visit Copay
By Group Size
Office Visit Copay by Group Size
This section displays which office visit copay amounts are most popular, segmented by employer size.
Here are some highlights of the data.
For the two smallest group sizes (less than 50 employees), the most common office visit copay
amount was $30-$34, followed closely by $25-$29 and $20-$24.
For the rest of the group sizes, the most popular office visit copay amount was $20-$24.
2,500-4,999 employees was an interesting group size. $20-$24 led with 26%, but $15-$19 was a
close second at 24%.
79
Office Visit Copay
By Group Size
80
Office Visit Copay
By Group Size
81
Office Visit Copay
By Industry
Office Visit Copay by Industry
In this section, view office visit copay amounts segmented by industry, starting with a high-level
comparison of the data.
Most industries follow a similar pattern, with three office copay amounts registering high: $20-$24,
$25-29 and $30-$34.
Two industries that deviated from that trend were Education and State/Local Government.
o In the Education industry, $20-$24 was the most common office visit copay, but four
other amounts also registered at significant amounts and there were no particularly low
percentage areas.
o State and Local Government was similar, with $20-$24 being the most popular, but
prevalence spread across the board after that.
82
Office Visit Copay
By Industry
83
Office Visit Copay
By Industry
84
Office Visit Copay
By Industry
85
Office Visit Copay
By Plan Type
Office Visit Copay by Plan Type
View office visit copay amounts segmented by plan type in this section. Following is a high-level
comparison of the data.
Each plan type was pretty unique in its most common office visit copays.
HMO plans favored $20-$24 and $30-$34 as the most popular office visit copays.
The most popular range for HRAs was $25-$29, with several other amounts showing some
prevalence as well.
HSA plans strongly preferred $0-9 office visit copays at a prevalence of 57%.
Meanwhile, Indemnity plans were rather indecisive, with multiple amounts registering high
popularity.
PPO and POS plans were the only two with similarities. Though these two plan types didn’t even
share the same leader, the top three for both were $20-$24, $25-$29 and $30-$34 (not
necessarily in that order).
86
Office Visit Copay
By Plan Type
87
Office Visit Copay
By Plan Type
88
89
Rx Deductible
By Region
Rx Deductible by Region
This section shows Rx deductibles segmented by each of the five regions. Here are some highlights of
the data.
The most popular Rx deductible among all regions is $0-$49, but there is some variation by
region beyond that.
The $50-$99 deductible amount registers at less than 3% in all industries but the North East,
where it has 14% popularity.
$100-$149 is the second most popular Rx deductible in the two northern regions, but is much less
popular in the rest of the country.
In the southern and west regions, the second most common Rx deductible amount is interestingly
$250+.
90
Rx Deductible
By Region
91
Rx Deductible
By Region
92
Rx Deductible
By Group Size
Rx Deductible by Group Size
This section displays which Rx deductible amounts are most popular depending on group size. Here are
some highlights of the data.
The four smaller group sizes (less than 500 employees) share a similar distribution: $0-$49 is the
most common Rx deductible in all four, followed by $100-$149 and $250+ (not necessarily in that
order).
There is more variation among the larger groups.
o For groups with 500-999 employees, 44% of plans used $0-$49 for Rx deductible
amount, but several other amounts also had popularity.
o For the 1,000-2,499 group size, almost half of plans had a $0-$49 deductible and 27%
had a $100-$149 Rx deductible.
o Groups with 2,500-4,999 employees also preferred a $0-$49 deductible range (55%), but
also had two other amounts with 18%.
o The 5,000+ employee group size was most split, with $0-$49 representing 46% of plans
and $100-$149 representing 42% of plans.
93
Rx Deductible
By Group Size
94
Rx Deductible
By Group Size
95
Rx Deductible
By Industry
Rx Deductible by Industry
Discover which Rx deductible amounts were most popular in each industry. Here is an overview of the
data.
The most popular Rx deductible across all industries was $0-$49, but some variation among
industries can be seen after that.
The Finance/Insurance/Real Estate industry was the most decisive, with 68% of plans going with
an Rx deductible in the $0-$49 range.
On the other end of the spectrum, the Agriculture/Forestry/Fishing industry had several popular
Rx deductible amounts: $0-$49 had 38%, $100-$149 had 30% and $250+ had 18%.
96
Rx Deductible
By Industry
97
Rx Deductible
By Industry
98
Rx Deductible
By Industry
99
Rx Deductible
By Plan Type
Rx Deductible by Plan Type
In this section, view Rx deductible comparisons by plan type, beginning with an overview of the data.
HMOs and HRAs were similar, with $0-$49 representing about half of those plans, and $100-
$149 and $250+ being the next most popular (not necessarily in that order).
Also similar were HSA and Indemnity plans. Leading the way for both was $240+, with $0-$49
being the second most common Rx deductible.
PPO and POS plans were nearly identical in their distribution. A vast majority of those plans had
a $0-$49 Rx deductible, and the next most common were $250+ and $100-$149.
100
Rx Deductible
By Plan Type
101
Rx Deductible
By Plan Type
102
About Zywave
About Zywave
Zywave is the leading provider of software-as-a-service (SaaS) technology solutions for the insurance
and financial services industries. The company’s products include Web-enabled marketing
communications, business intelligence and analytics, agency automation, and needs-assessment and
financial planning tools. More than 350,000 financial and insurance professionals, including 90 of the Top
100 U.S. insurance firms and dozens of the world’s largest financial institutions, use Zywave’s proven
solutions to help them differentiate from the competition, enhance client services, improve efficiencies
and achieve organic growth. To learn more, visit www.zywave.com.
For a comprehensive benchmark report of your organization please contact:
Bob McCollins
Associated Benefits Consultants
Phone: 614-264-9694
Email: [email protected]
This data has not been validated for statistical significance or margin of error. It is informational in nature and should be used in
conjunction with the advice of a licensed insurance broker.
© 2012 Zywave, Inc. All rights reserved.
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