Question 1

What are typical health plan deductible benchmarks for employer-sponsored plans?

Accepted Answer

For 2025, median single coverage deductibles are: $1,500–$2,000 for PPO plans, $1,800–$2,500 for HDHP/HSA plans, and $500–$1,000 for HMO plans. Family deductibles are typically 2–3x the single deductible. High-deductible health plans (HDHPs) have grown from 20% of employer plan enrollment in 2015 to 55%+ in 2025. The IRS minimum HDHP deductible for 2026 is $1,650 for single coverage and $3,300 for family coverage.

Question 2

What are typical out-of-pocket maximum benchmarks for employer health plans?

Accepted Answer

For 2025, median out-of-pocket maximums (OOPMs) are: $4,000–$6,000 for single coverage and $8,000–$12,000 for family coverage. The ACA limits OOPMs to $9,200 for single coverage and $18,400 for family coverage in 2026. Most employers set OOPMs well below the ACA maximum to protect employees from catastrophic out-of-pocket costs. HDHPs must have OOPMs at or below the IRS limits ($8,300 single / $16,600 family for 2026) to maintain HSA eligibility.

Question 3

What plan types are most common in employer-sponsored health plans?

Accepted Answer

For 2025, plan type prevalence among employer-sponsored plans: PPO (preferred provider organization) — 47% of covered workers; HDHP/HSA (high-deductible health plan with savings option) — 29%; HMO (health maintenance organization) — 13%; POS (point of service) — 9%; other — 2% (KFF 2025). PPO remains the most common plan type, but HDHP/HSA enrollment has grown significantly as employers shift cost to employees and encourage HSA savings.

Question 4

What are typical copay benchmarks for primary care and specialist visits?

Accepted Answer

For 2025, median copays for employer-sponsored PPO plans: primary care visit — $25–$35; specialist visit — $50–$75; urgent care — $50–$75; emergency room — $250–$350 (waived if admitted); generic prescription — $10–$15; preferred brand — $35–$50; non-preferred brand — $70–$100. HDHP plans typically have no copays before the deductible is met (all services subject to deductible), then coinsurance (typically 10–20%) until the OOPM is reached.

Question 5

How do I benchmark my plan design against market standards?

Accepted Answer

Compare your plan design against benchmarks for your employer size and industry using the data on this page. Key benchmarking dimensions: deductible level (single and family), OOPM (single and family), copay levels (PCP, specialist, ER, Rx tiers), coinsurance rates, and plan type mix. Plans with deductibles significantly above benchmark may face employee satisfaction and recruitment challenges. Plans with deductibles significantly below benchmark may be leaving cost-containment opportunities on the table.

Plan Design Benchmarks

Key benchmark figures

Data sources

Employer Health Benefits Survey

National Survey of Employer-Sponsored Health Plans

Employee Benefits Survey

Health Benefits Survey

Large Employers Health Care Strategy Survey

Health Plan Cost Trend Survey

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