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Small Business

Inform your health care reform strategy.

Under health care reform, businesses with 50 or fewer full-time-equivalent employees aren’t required to offer health insurance and are not subject to potential tax penalties. If you choose to offer coverage, small business exchanges and financial assistance will be available to make this easier. If you choose not to offer coverage, your employees will still be able to buy individual coverage.

What to consider

As a small business, you have several coverage options:

• continue purchasing group health care coverage directly from an insurer
• make coverage available to your employees through the Small Business Health Options Program  external page (SHOP) if available in your state
• offer neither group coverage nor access to the SHOP — sending your employees to the individual marketplace  external page in your state

Decide which coverage option works best for your business and your employees.

Weigh the pros and cons of each health care coverage option described above.

Get familiar with the SHOP.

Get to know the available plan levels and cost sharing.

Learn how your current plan will affect your upcoming renewal.

• If you have a metal plan, decide whether you’ll keep that plan or select a different metal plan.
• If you have a nonmetal plan and have the option to keep that plan, decide whether you’ll keep that plan or choose a metal plan.
• If you have a nonmetal plan and can’t keep that plan, you may be offered a metal plan that most closely resembles your current plan. Decide whether you’ll offer that metal plan or choose a different metal plan.

Find out if you’re eligible for a tax credit.

If you have 24 or fewer full-time-equivalent employees, evaluate whether you’re eligible for a tax credit . You can carry any eligible health care tax credit back one year.

Determine if you’re subject to the employer shared responsibility regulations.

If you’re a larger small business with part-time workers — or a subsidiary of a larger organization — you’ll need to determine whether you’re subject to the ACA’s employer shared responsibility regulations .

Limit FSA contributions.

Starting in 2015, make sure you’re limiting annual employee paycheck contributions to flexible spending accounts (FSAs) to $2,550.

Provide written notice about marketplaces.

Provide written notice about health insurance marketplaces to new employees.

Review your current wellness program.

Review your current wellness program to make sure you’re maximizing employee rewards. Starting in 2014, the maximum reward for health-contingent wellness programs is 30% of the cost of coverage (with an additional 20% for programs that prevent or reduce tobacco use).

• Learn more about Health Care Reform  external page

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Although we have attempted to present accurate information, Kaiser Permanente disclaims any express or implied warranty as to the accuracy of any material contained herein, any liability with respect to it, and any responsibility to update this material for subsequent developments. As required by the IRS, we inform you that any tax advice contained in this document was not intended or written to be used or referred to, and cannot be used or referred to, (i) for the purpose of avoiding penalties under the Internal Revenue Code, or (ii) in promoting, marketing, or recommending to another party any transaction or matter addressed herein. Users should consult with their own attorney or tax professional before making tax-related decisions.

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Book of Business Commission levels, contact information, summary of benefits, etc Small Group Quoting Request quotes, view and edit quotes, purchase plans

Small Group

For businesses with 1 to 50 employees.

Our health plans for small businesses offer fully integrated care and coverage that makes plans easy to use and administer. With smart benefit design, coordinated care, chronic condition management, and preventive care, your employees can better engage with their health and you can better control your health care costs.

Important Plan Documents

• Summaries of Benefits and Coverage
• Evidence of Coverage
• Benefit Summaries

Small Group Contacts

We appreciate the opportunity to partner with you and we look forward to a productive relationship.

Find the right plan in 3 easy steps

Our flexible plan design lets your client customize a health plan that fits their company's size, needs, and budget. (Adult and family dental benefits are optional.)

View our plans

1. Determine whether you’ll offer multiple plans

Groups of 1 to 5 employees can offer up to 3 plans. You can offer any combination of Core, Connect, Access PPO, and Summit PPO plans.

Groups with 6 to 50 employees can offer any number of plans. You can offer any combination of Core, Connect, Access PPO, and Summit PPO plans. Offering up to 4 plans may be ideal for groups of this size.

For a plan to be available to new group members during the contract year, a group must have at least one employee enrolled in the plan at the time of a new group setup or at renewal. Federal regulations require that groups must have at least one common-law employee enrolled to offer coverage. That means there must be at least one employee on the payroll who is not the owner or spouse of the owner.  

2. Decide on your provider network(s)

Washington Permanente Medical Group is one of the largest multispecialty groups in the state, with more than 60 specialties, including 17 surgical specialties.

Our doctors and other health care providers have been recognized for the quality of care we offer:

• Washington Permanente Medical Group has been one of the top-ranked medical groups in the state for 16 years in a row. 1
• In 2022, more than 90 Kaiser Permanente physicians were named “Top Docs” in area magazines, including Seattle magazine, Seattle Met, and Spokane/Coeur d'Alene Living. And 375 of our doctors have been named “Top Docs” since 2011. 2

CORE | Offered by Kaiser Foundation Health Plan of Washington

In-network coverage with Washington Permanente Medical Group at lower out-of-pocket expenses and monthly premiums:

• Nearly 1,600 Kaiser Permanente providers practicing at over 30 medical facilities in Washington state and in 8 community hospitals
• More than 16,000 additional network providers and facilities

CONNECT | Offered by Kaiser Foundation Health Plan of Washington in King, Kitsap, Pierce, Snohomish, Spokane, and Thurston counties

ACCESS PPO | Offered by Kaiser Foundation Health Plan of Washington Options, Inc.

A wide range of provider choice with one of the state's largest preferred provider networks:

• Kaiser Permanente providers, medical facilities, and pharmacies
• More than 26,000 additional network providers and facilities
• Most providers and designated pharmacies in our service area, including UW Medicine, Swedish Physicians, MultiCare, CHI Franciscan, PeaceHealth, Providence, and more
• First Choice Health network providers for Alaska, Idaho, Montana, Oregon, and Washington
• First Health network providers for all other states in the United States
• OptumRx network pharmacies nationwide
• Access to any other licensed provider at the out-of-network benefit level

SUMMIT PPO | Offered by Kaiser Foundation Health Plan of Washington Options, Inc.

Our Summit PPO plans provide access to high-value providers while maintaining provider choice

3-tier narrow-network PPO design with no referral requirements

Tier 1 offers access to high-quality Kaiser Permanente providers, pharmacies, and preferred hospitals in all states where we have locations, and to preferred contracted providers in the Washington state service area

Tier 1 and Tier 2 share an in-network deductible and out-of-pocket maximum

Care through our Summit PPO network

80% of employees must live or work in the 6-county area of King, Kitsap, Pierce, Snohomish, Spokane, and Thurston

1 Washington Health Alliance 2008–2023 Community Checkup reports, wacommunitycheckup.org . The 2017–2023 year rankings apply to Kaiser Permanente Washington's medical group, Washington Permanente Medical Group, P.C. Ranking for years prior to 2017 apply to the then-named Group Health Cooperative's medical group, formerly named Group Health Permanente, P.C., and now named Washington Permanente Medical Group, P.C. 2 “Top Doctors 2022,” Seattle , June 16, 2022; “Top Doctors 2022,” Seattle Met , September 2022; “Top Doctors 2022,” Spokane/Coeur d'Alene Living , March 2022.

3. Choose your coverage level(s)

All our plans include the same benefits. The main differences are seen in the monthly premiums versus the member’s cost shares.

4. Consider dental coverage

We work with Delta Dental of Washington to offer your employees dental coverage when paired with one of our 2024 medical plans. There are 2 optional plans to select from — Basic and Standard — that include coverage for your employees and their families. Both plans fulfill the federal mandate to provide pediatric coverage for members up to age 19. If your employee does not choose one of them, the employee's medical plan will be automatically paired with a pediatric-only dental plan offered by Delta Dental.

Groups of 1 to 5 employees can offer up to 3 plans. You can offer any combination of Core, Connect, and Access PPO plans. 

Groups with 6 to 50 employees can offer any number of plans. You can offer any combination of Core, Connect, and Access PPO plans. Offering up to 3 plans may be ideal for groups of this size. 

For a plan to be available to new group members during the contract year, a group must have at least 1 employee enrolled in the plan when offered at the time of a new group setup or at renewal. Federal regulations require that groups must have at least one common law employee enrolled to offer coverage. That means there must be at least one employee on the payroll who is not the owner or spouse of the owner.  

• Washington Permanente Medical Group has been one of the top-ranked medical groups in Washington state for more than a decade. 1
• In 2020, 76 of our providers were named Top Docs in area magazines, including Seattle Magazine, Seattle Met, Spokane/Coeur d'Alene Living; more than 300 of our doctors have been named "top docs" since 2011.

In-network coverage with high-performing 2 Washington Permanente medical Group at lower out-of-pocket expenses and monthly premiums:

• Nearly 1,600 Kaiser Permanente providers practicing at over 30 medical facilities in Washington state and in 8 community hospitals. 3
• More than 16,000 additional network providers and facilities 3

In-network coverage with high-performing 2 Washington Permanente Medical Group at lower out-of-pocket expenses and monthly premiums:

• More than 26,000 additional network providers and facilities 3
• First Choice Health network providers for Oregon, Alaska, Montana, Idaho, and Washington

1 Washington Health Alliance 2008-2020 Community Checkup reports, www.wacommunitycheckup.org. The 2017-2020 year rankings apply to Kaiser Permanente Washington's medical group, Washington Permanente Medical Group, P.C. Rankings for years prior to 2017 apply to the then-named Group Health Cooperative's medical group, formerly named Group Health Permanente, P.C. and now named Washington Permanente Medical Group, P.C. 2 Criteria established by American Medical Group Association 3 OIC Provider Network Form A

We work with Delta Dental of Washington to offer your employees dental coverage when paired with one of our 2022 or 2023 medical plans. There are two optional plans to select from—Basic and Standard—that include coverage for your employees and their families. Both plans fulfill the federal mandate to provide pediatric coverage for members up to age 19. If your employee does not choose one of them, the employee's medical plan will be automatically paired with a pediatric-only dental plan offered by Delta Dental.

• Nearly 1,300 Kaiser Permanente providers practicing at over 30 medical facilities in Washington state and in 8 community hospitals. 3

We work with Delta Dental of Washington to offer your employees dental coverage when paired with one of our 2022 medical plans. There are two optional plans to select from—Basic and Standard—that include coverage for your employees and their families. Both plans fulfill the federal mandate to provide pediatric coverage for members up to age 19. If your employee does not choose one of them, the employee's medical plan will be automatically paired with a pediatric-only dental plan offered by Delta Dental.

Kaiser Permanente Small Group support

• Enrollment materials/brochures
• Group quotes
• Contract administration
• Open enrollment
• Producer change
• Provider directories
• Quoting portal questions

Small Group support can be reached at 1-800-542-6312 (WWA) / 1-800-497-2210 (EWA) or via email at [email protected] .

2024 Small Group Forms

2024 Virtual Plus Overview for Consumers (PDF)

Access PPO FAQ (PDF)

Access PPO Network Flyer (PDF)

Administrator Guide (PDF)

Compare Your Options Plan Brochure (PDF)

Core HMO Network Flyer (PDF)

Deductible & Out-of-Pocket Crediting Form (PDF)

Disclosure Document (PDF)

Employee Enrollment and Change Form (PDF)

Employer Attestation Decline Coverage Form (PDF)

Enrollment Census Template (XLS)

Group Master Application (PDF)

Quote Request (PDF)

Small Group Rating Areas (PDF)

2024 Underwriting Guidelines (PDF)

Virtual Plus Plan Guide (PDF)

2024 Virtual Plus Service Area Map (PDF)

Plan and Benefit Details

Lab & X-ray (LX) plans These plans include unlimited lab tests and basic X-ray for only a copay and are not subject to the deductible. Virtual Plus plans Most care begins with a virtual visit. A Kaiser Permanente doctor or clinician provides care, prescriptions, and referrals for in-person care when needed. Virtual care, first in-person primary care visit, and annual in-person preventive visits are covered at no charge. Self-referred in-person care is usually a higher out-of-pocket cost. VisitsPlus plans These include unlimited office visits for only a copay and are not subject to the deductible. Plan availability Many of our small business plans are available in these Washington counties: Benton, Columbia, Franklin, Island, King, Kitsap, Lewis, Mason, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, Yakima. Virtual Plus plans and Summit PPO plans are available to small business employees residing or working in the following counties: King, Kitsap, Pierce, Snohomish, Spokane, and Thurston. Virtual care offered when appropriate and available.

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Email us with your request and you should receive packets within 3 to 5 business days.

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Medicare Advantage in 2024: Enrollment Update and Key Trends

Meredith Freed , Jeannie Fuglesten Biniek , Anthony Damico, and Tricia Neuman Published: Aug 08, 2024

Medicare Advantage enrollment has been on a steady climb for the past two decades following changes in policy designed to encourage a robust role for private plan options in Medicare. After a period of some instability in terms of plan participation and enrollment, The Medicare Modernization Act of 2003 created stronger financial incentives for plans to participate in the program throughout the country and renamed private Medicare plans Medicare Advantage. In 2024, 32.8 million people are enrolled in a Medicare Advantage plan, accounting for more than half, or 54 percent, of the eligible Medicare population, and $462 billion (or 54%) of total federal Medicare spending (net of offsetting receipts, such as premiums). Medicare Advantage enrolls a disproportionate share of people of color in Medicare as well as an increasing number of dual eligible beneficiaries. The average Medicare beneficiary in 2024 has access to 43 Medicare Advantage plans , the same as in 2023, but more than double the number of plans offered in 2018.

The growth in Medicare Advantage enrollment is due to a number of factors, including the availability of plans that charge no premium (other than the Part B premium), and extra benefits offered by most Medicare Advantage plans. Nearly all Medicare Advantage plans offer some benefits not included in traditional Medicare, such as coverage of dental, vision, or hearing services, often for no additional premium. Medicare beneficiaries are also drawn to the financial protection that comes with an out-of-pocket limit, which Medicare Advantage plans are required to provide, while traditional Medicare has no out-of-pocket cap on spending. On the other hand, Medicare Advantage plans have limited provider networks and apply cost management tools such as  prior authorization , which traditional Medicare does not.

Generally, research shows that Medicare pays more to private Medicare Advantage plans for enrollees than their costs would be in traditional Medicare. The Medicare Payment Advisory Commission (MedPAC) reports  that plans receive payments from CMS that are  122%  of spending for similar beneficiaries in traditional Medicare, on average, translating to  an estimated $83 billion in higher spending in 2024 . As Medicare Advantage takes on a more dominant presence in the Medicare program, and with current payments to plans higher for Medicare Advantage than for traditional Medicare for similar beneficiaries, policymakers have become increasingly focused on how well Medicare’s current payment methodology for Medicare Advantage is working to enhance efficiency and hold down beneficiary costs and Medicare spending.

To better understand trends in the growth of the program, this brief provides current information about Medicare Advantage enrollment, by plan type and firm, and shows how enrollment varies by state and county. A second, companion analysis describes Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements in 2024. This analysis does not provide detailed information by enrollee characteristics, such as race/ethnicity, income, or dual status, because that information is not available.

Highlights for 2024:

• More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024. The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%. In 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico), 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans, an increase from 3 states in 2023.
• More than one-third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries are enrolled in Medicare Advantage plans. Three counties (excluding those in Puerto Rico) enroll 80% or more of Medicare beneficiaries in Medicare Advantage plans: Monroe County, NY (Rochester; 82%), Starr, Texas (81%), and Miami-Dade County, Florida (80%). At the same time, 8 percent of all Medicare beneficiaries nationwide live in a county with relatively low enrollment, where less than one third of all Medicare beneficiaries are enrolled in Medicare Advantage plans. The wide variation in county enrollment rates reflect several factors, such as differences in firm strategy, urbanicity of the county, Medicare payment rates, number of Medicare beneficiaries, health care use patterns, and historical Medicare Advantage market penetration.
• Medicare Advantage enrollment is highly concentrated among a small number of firms, with UnitedHealthcare and Humana accounting for nearly half (47%) of all Medicare Advantage enrollees nationwide . In more than a quarter of all U.S. counties (29%; or 931 counties), these two firms account for at least 75 percent of Medicare Advantage enrollment. Since 2017, the market share for UnitedHealthcare and CVS Health has increased (25% to 29% and 8% to 12%, respectively), Humana (18%) and Cigna (2%) have held steady, while other firms’ share of total enrollment has slightly decreased (Blue Cross Blue Shield (BCBS) affiliates, Kaiser Permanente, and Centene). Small firms (which each account for less than 2% of enrollment) have a smaller share of the market in 2024 than in 2017 (19% to 16%).

More than half of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024

In 2024, more than half (54%) of eligible Medicare beneficiaries – 32.8 million people out of 61.2 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in 2007 to 54% in 2024 (Figure 1).

Between 2023 and 2024, total Medicare Advantage enrollment grew by about 2.1 million beneficiaries, or 7 percent – a similar growth rate as the prior year (8%). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 64% by 2034 (Figure 2).

In 2024, nearly two-thirds of Medicare Advantage enrollees are in individual plans that are open for general enrollment.

More than 6 in 10 Medicare Advantage enrollees (62%), or 20.5 million people, are in plans generally available to all beneficiaries for individual enrollment (Figure 3). That is an increase of 0.9 million enrollees compared to 2023. Individual plans have declined as a share of total Medicare Advantage enrollment since 2010 (71%).

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans in 2024, more than double the enrollment in 2019.

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. Enrollment in SNPs increased by 16 percent between 2023 and 2024, and accounts for 20 percent of total Medicare Advantage enrollment in 2024, an increase from 12 percent in 2010. Since 2019, SNP enrollment has more than doubled from 2.92 million to 6.64 million (Figure 4). This increase is due in part to the increasing number of SNP plans  available on average and more dual eligible individuals having access to these plans .

Most SNP enrollees (88%) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs). Another 10 percent of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) and 2 percent are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs).

While D-SNPs are designed specifically for dually-eligible individuals , 1.2 million Medicare beneficiaries with full Medicaid benefits were enrolled in Medicare Advantage plans generally available to all beneficiaries (not designed specifically for this population) in 2021, while 2.3 million full dual eligible individuals were in D-SNPs. D-SNPs have increasingly become the main source of Medicare Advantage coverage for dual eligible individuals.

SNP enrollment varies across states. In the District of Columbia and Puerto Rico, SNP enrollees comprise about half of all Medicare Advantage enrollees (49% in DC and 51% in PR). In nine states, SNP enrollment accounts for at least a quarter of Medicare Advantage enrollment: 46% in MS, 34% in AR, 33% in LA and NY, 28% in FL and GA, and 25% in CT, SC and AL.

C-SNP enrollment in 2024 (about 675,000 people) is 45% higher than it was in 2023 – an increase of about 210,000 enrollees. Nearly all (97%) C-SNP enrollees are in plans for people with diabetes or cardiovascular conditions in 2024. Enrollment in I-SNPs has been increasing slightly, with approximately 115,000 enrollees in 2024, up from about 103,000 in 2023.

Slightly less than one in five (17% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.

Group enrollment as a share of total Medicare Advantage enrollment has fluctuated between 17% to 20% since 2010, but the actual number has increased from 1.8 million in 2010 to 5.7 million in 2024 (Figure 5). With a group plan, an employer or union contracts with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. For example, 13 states provide health insurance benefits to their Medicare-eligible retirees exclusively through Medicare Advantage plans.

As with other Medicare Advantage plans, employer and union group plans may provide additional benefits and/or lower cost sharing than traditional Medicare and are eligible for bonus payments if they obtain required quality scores. The employer or union (and sometimes the retiree) may also pay an additional premium for these supplemental benefits. Group enrollees comprise a quarter or more of Medicare Advantage enrollees in nine states: Alaska (100%), Michigan (38%), New Jersey (33%), West Virginia (31%), Maryland (30%), Illinois (29%), Vermont (27%), Kentucky (26%), and Connecticut (25%).

The share of Medicare beneficiaries in Medicare Advantage plans varies by state and county

The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%.

In 30 states, Medicare Advantage enrollees account for more than half of all Medicare beneficiaries, including in 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico) where 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans (Figure 6). In contrast, Medicare Advantage enrollment is relatively low (less than 40%) in 13 states, including five states with less than 30% of beneficiaries enrolled in a Medicare Advantage plan – AK, MD, ND, SD, and WY – all of which (beside MD) are mostly rural. Overall, Puerto Rico has the highest Medicare Advantage penetration, with 95 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan. A decade ago, the share of Medicare beneficiaries in Medicare Advantage plans did not exceed 50 percent in any state (other than Puerto Rico).

The share of Medicare beneficiaries enrolled in Medicare Advantage varies widely across counties.

For example, in Florida, 60% of all Medicare beneficiaries in the state are enrolled in Medicare Advantage, ranging from 21% in Monroe County (Key West) to 80% in Miami-Dade County (Figure 7). In Ohio, 57% of all Medicare beneficiaries are enrolled in Medicare Advantage, with the share ranging from 32% in Mercer County (Celina) to 69% in Stark County (Canton).

In 2024, more than a third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (618 counties). That is substantially more than in 2010 when just 3 percent of the Medicare population lived in a county where 60 percent or more of Medicare beneficiaries were enrolled in a Medicare Advantage plan (83 counties). Many counties with high Medicare Advantage penetration are centered around relatively large, urban areas, such as Monroe County, NY (82%), which includes Rochester, and Allegheny County, PA (74%), which includes Pittsburgh. In contrast, 8 percent of Medicare beneficiaries live in a county where less than one third of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (849 counties). Counties with relatively low enrollment tend to be less populated rural areas. However, others, such Montgomery County, MD (27%) and Suffolk, NY (31%), which includes much of Long Island, are in more populous areas. (This county-level analysis excludes Medicare Advantage enrollment in Connecticut. See methods for more details.)

Variation in the share of eligible Medicare beneficiaries who are enrolled in a Medicare Advantage plan is explained by a combination of factors, including firm-level strategies to target particular geographic areas, the urbanicity of the county and state, variation in Medicare payment rates, the number and characteristics of people eligible for Medicare, health care use patterns, and the historical Medicare Advantage market penetration.

Medicare Advantage enrollment is highly concentrated among a small number of firms

The average Medicare beneficiary is able to choose from Medicare Advantage plans offered by 8 firms in 2024 , one fewer than in 2023 and 2022, and one-third of beneficiaries (33%) can choose among Medicare Advantage plans offered by 10 or more firms.

UnitedHealthcare and Humana account for nearly half of all Medicare Advantage enrollees nationwide in 2024.

Despite most beneficiaries having access to plans operated by several different firms, Medicare Advantage enrollment is highly concentrated among a small number of firms. UnitedHealthcare, alone, accounts for 29% of all Medicare Advantage enrollment in 2024, or 9.4 million enrollees. Together, UnitedHealthcare and Humana (18%) account for nearly half (47%) of all Medicare Advantage enrollees nationwide, the same as in 2023. In more than a quarter of counties (29%; or 931 counties), these two firms account for at least 75% of Medicare Advantage enrollment. These counties include East Baton Rouge (Baton Rouge), LA (81%), Clark County (Las Vegas), NV (79%), Travis County (Austin), FL (78%), and El Paso County (Colorado Springs), CO (76%). (Again, this county-level analysis does not include Connecticut.)

BCBS affiliates (including Anthem BCBS plans) account for 14% of enrollment, and four firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for another 23% of enrollment in 2024.

UnitedHealthcare and Humana have consistently accounted for a relatively large share of Medicare Advantage enrollment.

UnitedHealthcare has had the largest share of Medicare Advantage enrollment and largest growth in enrollment since 2010, increasing from 20 percent of all Medicare Advantage enrollment in 2010 to 29 percent in 2024. Humana has also had a high share of Medicare Advantage enrollment, though its share of enrollment has grown more slowly, from 16 percent in 2010 to 18 percent in 2024. BCBS plans share of enrollment has been more constant over time but has declined moderately since 2014.

CVS Health, which purchased Aetna in 2018, has seen its share of enrollment double from 6 percent in 2010 to 12 percent in 2024. Kaiser Permanente now accounts for 6 percent of total enrollment, a moderate decline as a share of total Medicare Advantage enrollment since 2010 (9%), mainly due to the growth of enrollment in plans offered by other insurers and only a modest increase in enrollment growth for Kaiser Permanente over that time. However, for those insurers that have seen declines in their overall share of enrollment, the actual number of enrollees for each insurer is larger than it was in 2010.

By absolute numbers, CVS Health had the largest growth in plan year enrollment, increasing by 758,000 beneficiaries between March 2023 and March 2024. Humana had the second largest growth in plan year enrollment, with an increase of about 472,000 beneficiaries between March 2023 and March 2024. UnitedHealthcare plans had the third highest growth in plan year enrollment, increasing by 456,000 beneficiaries – the first time in 8 years it did not have the largest plan growth among all firms. BCBS plans had the fourth largest growth in plan enrollment with an increase of about 283,000, followed by Kaiser Permanente, increasing by about 45,000 beneficiaries between March 2023 and March 2024. However, Centene had fewer enrollees, with enrollment declining by about 202,000 between March 2023 and March 2024.

Meredith Freed, Jeannie Fuglesten Biniek, and Tricia Neuman are with KFF. Anthony Damico is an independent consultant.

• Medicare Advantage

Also of Interest

• Medicare Advantage in 2024: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization
• Medicare Advantage 2024 Spotlight: First Look
• Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022

The small business guide to 401(k) retirement plans

Offering a 401(k) sends a great message to your employees. It says that you’re truly invested in their future with your company—and beyond. They can help employees save for retirement, while potentially providing your business with tax savings and a valuable recruiting and retention tool.

Studies show that half of American families have no retirement savings, and that less than half of small businesses offer a retirement plan . Given this unfortunate reality, it’s not surprising that offering a small business 401(k) can have a big impact on the way your employees think about your company.

How many employees do you need to have a 401(k) plan? Can small businesses even offer a 401(k)?

Let’s get this out of the way. Yes, any size business can offer a 401(k) plan . Traditionally, 401(k) providers charged small and mid-sized businesses exorbitant fees or ignored them altogether—leading millions of smaller businesses out in the cold without an easy way to offer meaningful retirement benefits. Guideline is changing that by offering small businesses an easy, affordable 401(k).

How do I set up a small business 401(k)?

If you’re ready to set up your small business 401(k), these are the four steps you’ll need to take.

For small businesses that are ready to help their employees save for retirement, the IRS website covers the actions you need to set up a 401(k) plan. In case you don’t speak in tax code, here’s a more approachable step-by-step guide.

Step 1: Choose a plan that meets your business goals

The big difference between 401(k) plan designs is how and when an employer makes contributions on behalf of its employees. Here are three types of plan designs, their requirements, and some other implications:

• Standard profit sharing 401(k) plan: This plan gives employers the flexibility to make outright contributions to employee accounts, make contributions contingent on what employees’ defer (i.e., matching), or not contribute at all. An employer can also set up these contributions with a vesting schedule. These plans are subject to annual IRS nondiscrimination tests.
• Safe Harbor profit sharing 401(k) plan: This plan type is similar to a standard profit sharing plan design, but it requires employers to contribute to their employees’ accounts. There are very specific rules about how contributions are structured in these plans, and contributions usually have to vest immediately. But in exchange, these plans get “safe harbor status” and are exempt from some annual IRS nondiscrimination tests and the consequences of failure. Standard plans must pass these tests every year. Check out our Safe Harbor 401(k) guide for more details.
• SIMPLE 401(k): Businesses with fewer than 100 employees can open a SIMPLE 401(k). Similar to the Safe Harbor plan, SIMPLE plans require employers to make contributions to their participants’ 401(k) accounts that vest immediately. SIMPLE plans are also exempt from nondiscrimination testing. However, they are very prescriptive about start and closure dates, and once you commit to contributions for the year you cannot change your mind.

What other 401(k) plan features should I consider?

Offering retirement benefits is a great way to attract and retain talent. But specific plan features can really boost participation and make your small business 401(k) plan even more enticing.

Traditional vs. Roth 401(k). What’s the difference?

Generally speaking, the key difference between the two is when employee contributions are taxed. With traditional accounts, contributions are made before taxes are taken out of pay. Under Roth accounts, contributions are taxed first and then deposited. When an employee retires, withdrawals from traditional accounts are taxed at ordinary income rates, whereas Roth withdrawals can generally be made on a tax-free basis.¹ Read more about traditional vs Roth accounts .

Should I match employee contributions?

Matching contributions can be hugely beneficial for both employees and employers. For employees, they’re an additional form of compensation that can help maximize their retirement savings.

For employers, matching contributions may be tax deductible as an ordinary business expense, up to the annual corporate tax deduction limit on all employer contributions (25% of covered payroll).* Vesting schedules can help small business owners further customize their plan design to meet their business goals. Read more in our guide to 401(k) matching .

What is 401(k) profit sharing?

Profit sharing works like a bonus to an employee’s retirement account—with one big difference. Rather than be taxed immediately on that bonus, profit sharing contributions go straight into eligible employees’ retirement accounts without any tax taken at contribution. Employees won’t have to pay taxes on that money until they retire.* For employers, these deposits are income tax-deductible and also aren’t subject to Social Security or Medicare taxes—making profit sharing a win-win for both parties.

Step 2: Pick your dream team

Small business 401(k) plans can involve a lot of different service providers and advisors. When setting up your plan, you can choose to take an a la carte approach with several different providers. Or find one provider who can handle most, if not all, of the services required to set up and administer your plan.

When you offer a retirement plan through Guideline , we handle your recordkeeping, compliance testing, day-to-day plan administration, and more. That means your small business doesn’t have to sweat keeping track of disparate systems or vendors just to manage your 401(k) plan.

401(k) recordkeepers

No surprise: small business 401(k) plans require a lot of recordkeeping. Between all of the contributions, earnings, losses, plan investments, expenses, and benefit distributions, it’s a lot to keep track of. 401(k) recordkeepers are responsible for the following, to name a few:

• Logging employer and employee contributions
• Tracking investments
• Processing 401(k) loans and withdrawals
• Basic customer support

Financial advisors and fiduciary responsibilities

In the context of retirement, there are generally two kinds of financial advisors that take on fiduciary responsibility: 3(21) and 3(38). These numbers refer to sections of the Employee Retirement Income Security Act (ERISA), the law dictating many of the rules surrounding retirement plans. Here’s how these “fiduciaries” differ:

A Section 3(21) advisor will do the heavy lifting in selecting and maintaining investments for your plan and hopefully provide you with advice to make better decisions on your own. That said, you’re still responsible for calling the shots. If you don’t consider yourself a retirement pro, this approach leaves you and your company on the hook for bad or risky decisions. A Section 3(38) investment manager has full control over money management for your plan. That means they also take on liability for investment selection and sometimes asset management. Your duties are limited as a plan sponsor to prudently select and monitor a fiduciary. Therefore, opting for a 3(38) investment manager might be the best decision if you aren't well versed in how retirement plans work.

401(k) third party administrators

There’s a lot of behind-the-scenes work that needs to happen to keep your small business 401(k) plan in good standing. Though their responsibilities vary, 401(k) plan administrators generally handle:

• Preparation of documents and notices for participants and beneficiaries
• Approval of transactions (loans, distributions, etc.)
• Monitoring compliance with plan rules and federal regulations
• Discrimination testing and audit support
• Compliance filing ( Form 5500 , etc.)
• Generation of annual participant census

While 401(k) plan administration can be handled in-house, many choose to outsource the function to a third party administrator (TPA). But not all TPAs are created equal. If yours is an ERISA 3(16) fiduciary, they won’t just handle administration but they will also take on liability for doing these things in accordance with ERISA regulations. Read more about 401(k) administrators .

What’s the difference between a trustee and a custodian?

By law, your 401(k) plan’s assets must be held in a trust account to ensure that they’re used solely to benefit plan participants and their beneficiaries. In other words, your employees' money needs to be kept in a safe place by a custodian and monitored by a trustee.

Keep in mind that custodians are the parties that actually hold your plan’s assets, while trustees are responsible for collecting contributions, investing them, and issuing distributions. These tasks can be delegated to a plan administrator, but the trustee will have ultimate responsibility to ensure the administrator is doing its job.

Payroll providers

Employees will contribute to their retirement accounts come payday. That means you’ll need to partner closely with your payroll provider to ensure employees’ personal information and retirement contributions are accurately reflected in all systems.

When employees update their contribution rates in your retirement vendor’s platform, for example, this should feed into the tool you use to run payroll. Choosing a 401(k) provider that fully integrates with your HR and payroll providers can save time and reduce errors.

Step 3: Make it official

Adopt a written plan.

Once you’ve settled on your plan types and features, you need to create a written plan document that, according to the IRS , “serves as the foundation for day-to-day plan operations.” While that language sounds intimidating, it’s just referring to a description of the benefits, rights, and features under your plan. Your 401(k) plan administrator will usually handle this for you.

Your plan documents should include the following features, for example:

• When employees are eligible to participate
• Vesting schedule information
• Employer matching and/or profit sharing details
• How distributions are handled
• Contact information for the employer and applicable third parties

Getting this information right and making sure that it’s readily available is critical when you need to demonstrate compliance during an audit.

Onboard employees

For many plan designs, you’ll need to notify eligible employees about the 401(k) plan before it goes into effect—usually 30 days in advance. Moving forward, you’ll also need to give notice of any changes. A summary plan description serves as the primary way to share information about your plan and its benefits. If you include plan features like automatic enrollment, Safe Harbor, or a qualified default investment alternative, you may be required to furnish additional notices.

You may also want to give employees a more thorough rundown of your retirement plan. Consider including a “Retirement 101” section in your next open enrollment presentation or all-hands meeting. Doing so could boost 401(k) plan utilization, promote financial literacy, and help dispel misconceptions employees might have about your overall benefits package.

Step 4: Keep it running smoothly

Ongoing nondiscrimination testing.

Offering a retirement plan takes regular upkeep and a close eye on 401(k) plan compliance deadlines to ensure you don’t run afoul of ERISA and IRS rules. Most 401(k) plans are required to pass nondiscrimination testing each year. These look at the value of each employee's account, employee contribution rates, and other details. Employer matching and profit sharing also come under scrutiny. Your company may also want to regularly review or revise your plan features as the company's situation changes.

Government filings

In addition to keeping up with compliance testing, you’ll need to file an IRS Form 5500 each year. This federally-mandated form includes information about your business, your retirement plans, number of participants, and more.

How much will a small business 401(k) cost?

Guideline 401(k) starts at a $39 base fee plus $4 per employee per month. Learn more about our fees and services here .

When evaluating a small business 401(k), consider if there are hidden fees for key functions such as compliance, recordkeeping, and investment management. Also ask about setup fees, monthly fees, annual fees, Form 5500 fees, and whether a provider expects you to pay fees to anyone else. All these standard services are included in Guideline's pricing.

Are there any fees for employees?

Many providers put a lot of the burden for their services on employees, or force employees into investments with high management fees. Ask what fees employees pay. Are there monthly fees or management fees? And what kind of fees are charged by the funds in their portfolios?

For small business plans, the average employee fees are around 1%, but some providers have fees as low as 0.07%. Getting a good answer to this question could mean hundreds of thousands of additional dollars in each employee’s retirement account over the course of several decades.

There’s a lot to consider when setting up a small business 401(k). If you’re currently researching providers, our checklist is below

Give your employees a roadmap to retirement

With Guideline, you can provide an impactful work benefit while minimizing paper work and fees

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