THE FULL COMPARISON
Which of the 12 plan designs fits your company?
Same doctors, 12 different ways to pay for them. Sorted by what's actually available at your size, what each one lets you change, and which one usually fits your industry. The short version lives on the funding options hub.
The 12 designs
What are my options, and what does each one ask of me in return?
Short answer: most employers are shown 2 of the 12. The other 10 sit outside the channels their broker is commissioned in. That's structural, and it isn't anyone's fault.
Same 3 columns for every design. The middle one is where the money is. The last one is what renewal packets leave out.
| Design | What it is | Where the savings come from | The trap |
|---|---|---|---|
| Fully insured Any size, from 2 enrolled | You pay a premium, the carrier pays claims and keeps the leftover money. | Under 50, only plan design and the add-on layers. Over 50, a lower claims line shows up at renewal. | You're managing a spend you're not allowed to read. State premium taxes, commonly 1 to 3%, and every state mandate apply in full. |
| Level-funded Roughly 25 to 500 | A fixed monthly payment bundling expected claims, stop-loss and admin. Under budget, part of the leftover comes back. | The contract: how much leftover returns, a no-new-lasers provision, a rate cap, plus pharmacy sourcing and virtual care that lower claims. | Same plan moved into a level-funded wrapper saves nothing. Renewal is priced on your own claims, so a bad year brings a large increase or a non-renewal. |
| Self-funded Usually 100 and up | You pay claims, buy stop-loss for the large ones, hire an administrator. You own the plan document and the claims file. | The claims file. Every rebate back to you, paying hospitals off a public price list, auditing what hospitals billed, $0-copay sourcing. | Fixed-cost creep. A self-funded plan nobody manages is a fully insured plan with more paperwork. |
| Self-funded captive Usually 50 to 500 per member employer | Self-funded with a shared middle layer. Member employers pool a band of risk and share the leftover money. | Stop-loss spread and money back in a good year. You're pricing your own risk instead of buying someone's estimate of it. | Multi-year commitment and collateral. Leaving early is expensive. Read the exit terms before the rate. |
| CHOICE Arrangement (ICHRA) Any size, including 1 employee | A tax-free monthly allowance by employee class. Each person buys their own marketplace plan. No group contract, no participation minimums, no cap on the allowance. | You set the budget instead of receiving one. Set the allowance by class and county against the 2027 affordability test, and pair a bronze plan with an HSA where that works. | An allowance set on 2025 prices is underwater after 2 years of double-digit increases. Check availability first: 145 counties have 1 insurer, and 18 states have no PPO anywhere. |
| QSEHRA Under 50 full-time equivalents, no group plan | Same idea as a CHOICE Arrangement with simpler rules and one hard cap: $6,450 self-only and $13,100 family for 2026. | Employees keep premium tax credits and still take the QSEHRA, reduced dollar for dollar. For a low-wage workforce that beats a group plan most were declining anyway. | No group plan of any kind, including an HRA or health FSA. Where family silver runs past $1,300 per month, the cap covers most of it, not all. |
| EBHRA Runs alongside a group plan | Up to $2,200 per year in 2026, $2,250 in 2027, for dental, vision, COBRA premiums, short-term coverage and out-of-pocket costs. | The cleanest way to raise a deductible and hand the difference back tax-free without touching the medical plan. | It can't reimburse marketplace medical premiums or the group plan's own premium. People confuse it with a CHOICE Arrangement and end up with the wrong document. |
| GCHRA (integrated HRA) Keeping a group plan | Raise the group deductible, the premium drops, and you fund an HRA that pays the first dollars of the higher deductible. No dollar cap. | The premium saving on a $5,000 deductible versus $1,500 is usually larger than what employees actually spend in that band, because most never reach it. | If your claims show a lot of people hitting the deductible, the arithmetic flips. Run it on your own employees, not an industry average. |
| PEO master plan Too small for large-group rates alone | You join the PEO's master plan. Pooled rates, and the PEO owns most administration and compliance. | A lower premium and the lowest administrative lift on the menu. Compare the all-in fee, not just the medical line. | Control. You pick from their menu, you rarely see claims data, and leaving means fresh underwriting. Some operate under a collective bargaining agreement with wage terms attached. |
| Shelf-rated (flat-rate) trust plan A Guaranteed acceptance, any size | Major medical PPO through a trust plan shared by many employers. One published rate per tier. No employee list, no medical questions. | The rate ignores your employees' ages and locations. A 57-year-old crew pays what a 24-year-old pays. That's the whole design change, and it's a big one over 45. | Fixed designs, no claims data, specialty drugs only through the trust's own program, and it's a member benefit rather than a conventional employer plan. Counsel first at 50+ employees. |
| Shelf-rated (flat-rate) trust plan B 5+ enrolled, full-time W-2 | Major medical PPO through a trust plan reached via a PEO operating under a collective bargaining agreement. One all-in flat rate covering medical, dental, vision, life, accident and admin. | One invoice, one flat rate, and workforce terms that cost nothing if you already meet them. | If you don't already meet them, a wage floor and a mandatory annual raise for every employee is the real price. 1-year minimum. Domestic partners not covered. Seniority-based layoffs. |
| Shelf-rated (flat-rate) limited medical plan C Hourly, high turnover, most decline today | A limited medical plan at a flat rate, no age rating. Copays per visit with annual caps on visits, tests and hospital days. Unlimited $0 telemedicine. | At roughly a third of major medical, more people say yes. Paired with $0-copay pharmacy and virtual care it's a real floor for people who have had nothing. | Caps on office visits, inpatient days and ER visits per year. No chemotherapy, dialysis, transplants, NICU, hospital imaging or specialty drugs. Confirm with counsel before it's your mandate offer. |
Rates and terms for the 3 shelf-rated plans come from the plans' own 2026 documents, names withheld. Ask for the current rate sheet before quoting anything.
By company size
What's actually available at my size, and what's just theory?
Short answer: under 25 enrolled, a standard insured plan, a CHOICE Arrangement or a shelf-rated plan. 25 to 100, level funding usually wins. Over 100, self-funding opens design changes that aren't available below it.
Size doesn't tell you what's best. It tells you what's on the menu. Stop-loss carriers set minimum enrollment thresholds, and those thresholds are the real gate.
| Enrolled | Realistically available | Usually comes out ahead | Why |
|---|---|---|---|
| 1 to 9 | Marketplace plans, CHOICE Arrangement, QSEHRA, guaranteed issue shelf-rated plan, standard insured in some states | CHOICE Arrangement or shelf-rated | Small-group participation minimums are hard to clear. Shelf rates ignore a small, older workforce entirely |
| 10 to 25 | Standard insured, CHOICE Arrangement, shelf-rated, level funded in some states | Depends almost entirely on average age | This is the crossover band. A younger workforce favors age-rated. An older one favors shelf-rated |
| 26 to 50 | Standard insured, level funded, CHOICE Arrangement, PEO master plan, shelf-rated | Level funded with an HRA overlay | First size where you can own claims data and still cap the downside contractually |
| 51 to 100 | Level funded, self-funded, captive entry in some programs | Level funded, moving to self-funded | Enough claim volume for your own experience to start meaning something |
| 101 to 250 | Self-funded, captive, full carve-outs | Self-funded with the full set of design changes | Pharmacy and payment-integrity carve-outs become worth the administrative load |
| 251 to 500 | Self-funded, captive, direct contracting | Captive | Stop-loss spread and money back in a good year start to outweigh the capital commitment |
| 500+ | Everything | Captive with the full set of design changes | Claims are credible. You're pricing your own risk, not buying someone's estimate of it |
What each design lets you change
Which savings are you allowed to go after?
Several of the biggest ones aren't options you turned down. Your plan type doesn't allow them.
On a standard insured plan you don't own the contract and don't see the claims, so the pharmacy contract, the audit of what hospitals billed, and paying hospitals off a public price list are all out of reach. Shelf-rated plans trade those away for a price that ignores your employees' ages.
| Savings source | Standard insured | Shelf-rated trust | CHOICE Arrangement | Level funded | Self-funded or captive |
|---|---|---|---|---|---|
| Your own claims data | No | No | No | Yes | Yes |
| Pharmacy contract where every rebate comes back to you | No | No | No | Yes | Yes |
| Audit of what hospitals billed your plan | No | No | No | Limited | Yes |
| Paying hospitals a set multiple of the Medicare price | No | No | No | No | Yes |
| $0 out-of-pocket for employees who use better-rated doctors | Partial | Partial | No | Yes | Yes |
| Specialty drug management | No | No | No | Yes | Yes |
| Money back in a good claims year | No | No | Underspend is yours | Yes | Yes |
| Price unaffected by an older or sicker workforce | No | Yes | Employees rated individually | No | No |
| Predictable fixed cost | Yes | Yes | Yes, you set it | Within the cap | No |
The crossover
Am I better off age-rated or shelf-rated?
Rule of thumb
- Average age under 35: age-rated usually wins.
- Average age over 45: shelf-rated usually wins.
- In between: model both. It's close enough that the answer turns on your dependents and your claims history.
What the two words actually mean
- Age-rated: your premium changes with each employee's age. ACA small group works this way.
- Shelf-rated: one published rate per coverage tier, identical for a 24-year-old and a 64-year-old, anywhere in the country.
- The federal band is 3:1. A 64-year-old can be priced at 3 times a 21-year-old for the identical plan. A handful of states compress it further, and two use pure community rating.
- Shelf-rated asks you nothing. No age rating, no census, no medical questions. That's what produces a predictable crossover.
| Your census | Age-rated small group | Shelf-rated plan | What usually happens |
|---|---|---|---|
| Average age under 35, few dependents | Priced near the bottom of the 3:1 band | Pays the same flat rate as everyone | Age-rated wins, often by a wide margin |
| Average age 35 to 45 | Mid-band | Flat | Close. Model both |
| Average age 45 to 55 | Upper-band, climbing fast | Flat | Shelf-rated often wins |
| Average age 55+ | Near the top of the band | Flat | Shelf-rated usually wins, sometimes substantially |
| Known high-cost claimant | The pool absorbs it, but renewals reflect the block | Guaranteed issue, no medical underwriting | Shelf-rated removes underwriting risk entirely |
What if my team is older, or someone is sick?
- A 12-person landscaping company, average age 57, two diabetics. Expensive in the age-rated market and hard to underwrite for level funding.
- A shelf-rated plan doesn't ask. It charges the same rate it charges a 24-year-old.
- That isn't a loophole. It's what happens when a plan prices a national pool instead of your 12 people. Eligibility rules apply and not every employer qualifies.
- The reverse is just as true. A 12-person design studio, average age 29, is subsidizing that same national pool and will almost always do better age-rated.
By industry
Which design usually fits my industry?
Industry is a rough guide. Your employees' ages and how many enroll family predict it better. 2 restaurants with 40-year and 26-year average ages land in different places. Use this as the starting guess, then check your own employee list.
| Industry | What drives the decision | Design to run first | Highest-value add-on |
|---|---|---|---|
| Restaurant and quick service | Turnover above 75%, variable hours, low take-up | CHOICE Arrangement, or the limited medical plan as a floor | $0-copay pharmacy, virtual primary care |
| Construction and trades | Older workforce, injury exposure, mixed W-2 and 1099 | Shelf-rated trust plan, or level funded if insurers will approve the group | Musculoskeletal program, steering to better-rated doctors |
| Home health and senior care | Low wage, high turnover, heavy behavioral health need | CHOICE Arrangement | $0-copay pharmacy, behavioral health access |
| Staffing | Extreme turnover, complicated ACA measurement periods | CHOICE Arrangement with a minimum value plan. Limited medical only after counsel confirms minimum value | Front-door navigation, eligibility automation |
| Trucking and logistics | Older, dispersed, high chronic condition burden | Shelf-rated with a national network | $0-copay pharmacy, virtual care, chronic condition management |
| Professional services and tech | Younger, healthier, high expectations on benefits | Level funded, moving to self-funded past 100 | Pharmacy contract where every rebate comes back, virtual care |
| Manufacturing | Stable workforce, older skew, high family enrollment | Self-funded past 100, captive past 250 | Paying hospitals off a public price list, audit of what hospitals billed |
| Nonprofit and mission-driven | Tight budget, grant-funded, low tolerance for variance | CHOICE Arrangement for a fixed budget, or level funded with a rate cap | $0-copay pharmacy, the supplemental wrap |
