Key Takeaways
- Small businesses in South Carolina are often stuck choosing between pricey group plans, cash stipends, or offering no benefits at all.
- ICHRA (Individual Coverage HRA) is a pre-tax, fixed benefit gaining buzz for being simpler and more affordable.
- This guide compares each option and offers tips for navigating the health insurance marketplace—including in South Carolina. Note: Not all ICHRA providers are alike! We also provide tips on what questions to ask for the best fit.
Health insurance is a struggle for almost all small businesses - why?
The size of a business plays a significant role when it comes to health insurance costs, and unfortunately, small employers often find themselves at a disadvantage. This is particularly true for startups, non-profits, and any business with fewer than 20 employees.
The challenges faced are numerous:
- To secure a traditional small group plan, the sales process is typically time-consuming. It's not uncommon for the process to span more than six weeks and demand more than 30 hours of meetings, calls and emails.
- Participation criteria often requires that at least 70% or more of their employees enroll in order to qualify for coverage.
- The biggest concern, of course, is the cost itself. Employee health insurance has become an increasingly expensive endeavor for small businesses. Over the past decade alone – average premium costs have risen by a staggering 25%. Individual health coverage currently amounts to nearly $8,000 per person annually while families face expenses nearing $23,000.
These escalating costs coupled with growing complexity have rendered employee health insurance nearly unattainable for countless SMBs . In fact, only 39% of small businesses with less than ten employees offer healthcare benefits - marking an all-time low.
Given these challenges, how can smaller companies retain their existing talent pool while simultaneously attracting new recruits without offering competitive health benefits? The situation seems unfair and far from easy to resolve.
However daunting it may seem, there are three previously mentioned options currently available: traditional health insurance plans, giving financial compensation in lieu of insurance, or pre-taxed benefit programs (ICHRA). Before we dive into the advantages and disadvantages for each, let’s get a quick overview on this new ICHRA option.
Understanding ICHRA in under 30 seconds
The hard-to-say-acronym ICHRA, or “ICK-ruh,” is a newish solution meant to improve access to employee health insurance coverage. It happens to be a whole lot simpler, too. (Gone are the days of confusion and limited options.)
Thanks to a game-changing federal regulation passed in 2019, small business owners can give pre-tax cash to their employees for health insurance premiums that they buy and own. Not to mention these advantages:
- No participation requirements.
- No minimum contribution amounts.
- No long-winded sales process.
Pros/cons of option #1: Traditional group health insurance plans
Traditional "fully-insured" group health plans are what most small businesses are used to. The way it works is the company contacts a broker who will research options based on the type of business, the budget, and basic employee info (like age and location), and all employees pay the same rate. Larger companies may use a "self-funded" group health plan arrangement but this puts all the risk on the employer so is not an option for small businesses.
Most smaller businesses (76%) typically choose one plan for all team members. On the other hand, large companies with more than 200 employees offer 3 or more health plans, typically offer options with varying deductibles, copays, and premiums.
Lower risk for small businesses: Fully insured plans shift the financial risk of high medical claims from small businesses to the insurance company.
Regulations: State regulations ensure carriers provide consistent and predictable benefits.
Employee recruitment and retention: Offering health benefits makes companies more competitive in attracting and keeping talent.
Cost: These plans have the highest premiums.
Participation rates: At least 70% of employees must enroll.
Fewer options: Small businesses often can only choose from limited pre-designed plans and only one for employees.
Less premium predictability: High medical costs can lead to higher premiums the next year, complicating budgeting.
Time drain: Managing this process can take over 60 hrs each year.
Pros/cons of option #2: Just give employees the extra money
Small businesses often give up after learning of the financial and time costs of group plans and just opt to give the extra cash to employees via their paychecks. It is a well-meaning option and there are some helpful upsides, but overall, this option doesn’t often translate into the intended value.
Simplicity: Employers just add extra money to a paycheck.
Budgeting: Employers have control and predictability, giving only what they can afford.
Perception: Employees may not realize they're getting cash instead of health insurance.
Taxes: Taxes take up to 38% of the extra cash, reducing its value.
No guaranteed benefit: Employees might not use the money for insurance, leaving many without coverage.
Pros/cons of option #3: Pre-tax, fixed health benefit (ICHRA)
ICHRA (the pre-tax, fixed health benefit) is the newest health insurance option for small businesses. Instead of offering traditional group health insurance, employers can give money to employees to help cover their individual health premiums BEFORE any taxes are taken out.
Many small business owners are unaware of ICHRA because it’s relatively new. This pre-tax fixed benefit became possible in 2020 due to IRS legislation. But we’ve been through the distraction of a global pandemic during that time, so it is understandable that it didn’t grab everyone’s attention. Adoption has been gradual, but significant changes are underway.
Dreamy budgeting: The business decides on the amount they can affordably contribute to employees' health insurance.
Participation rates: No minimum participation required.
Adaptability: Employers can give different amounts to different types of workers ex) full-timers vs. part-timers.
Employee choice: Employees choose a plan that meets their personal needs.
Simple setup: ICHRA streamlines enrollment. Setup takes just 10 minutes.
Privacy for employees: Employees choose their coverage, avoiding the awkwardness of getting in the middle of doctor-patient relationships.
Confusion: Employees may be overwhelmed by marketplace options.
Expectation gap: Marketplace plans might not match the high-end plans some employees expect.
Here’s a summary of options
About the insurance marketplace in South Carolina (where employees shop for a health plan)
When employees are offered an ICHRA—a pre-tax, fixed health benefit—they use it to purchase a qualified health insurance plan. That means a plan that meets the standards set by the Affordable Care Act (ACA), the landmark 2010 law that created the national health insurance marketplace and introduced important consumer protections like coverage for preexisting conditions, maternity care, and prescription drugs.
Back in 2015, just over 8 million people enrolled in health coverage through the ACA marketplace. Fast forward to 2024, and that number has tripled to 24 million. With more plans available than ever, what does that mean for employees shopping for coverage in South Carolina? Let’s take a look.
Health insurance carriers in South Carolina
The marketplace offers several health insurance companies that offer coverage in South Carolina, both national carriers and regional brands. These include:
- Ambetter
- BlueCross BlueShield of South Carolina
- First Choice Next
- Molina
- United Healthcare
Note: The type of carriers vary by city.
Average costs of health insurance coverage in South Carolina
When shopping on the health insurance exchange, you’ll see plans categorized by metal tiers: Gold, Silver, and Bronze. Each tier reflects a trade-off between monthly premiums and out-of-pocket costs:
Gold Plans
- Higher monthly premiums. Lower deductibles, copays, and coinsurance
- Best for: People with high expected medical expenses
Silver Plans
- Moderate premiums and out-of-pocket costs
- Best for: Those with average medical needs
Bronze Plans
- Lowest monthly premiums. Higher out-of-pocket costs
- Best for: Healthy individuals with emergency savings
Below, you’ll find sample pricing for the lowest-cost plan in each metal tier, based on a 35-year-old male in South Carolina cities.
Charleston, South Carolina
FAQ
Do South Carolina small businesses have to offer health insurance?
In South Carolina, businesses with fewer than 50 full-time employees don’t currently need to offer group health insurance. However, if your business has 50 or more full-time team members, you’ll need to provide health insurance benefits to avoid potential penalties.
What's an ICHRA? Why haven't I heard of it before?
ICHRA, short for Individual Health Reimbursement Arrangement, is a relatively new type of health benefit created by federal legislation in 2019 and rolled out the following year. Since then, interest in ICHRA has grown quickly, especially among small business owners. Want to know more about how ICHRA came to be? Check out our article, "ICHRA History Lesson: How the Pre-Tax Health Benefit Came to Be".
How much does health insurance cost for my small business?
Most insurers offering traditional group health plans require employers to pay at least half the insurance premium for their employees. The average cost of a small employer group health plan in 2024 is $8,951, although this price changes depending on where your employees live, their age and possibly other considerations. Most carriers also require that at least 70% of employees participate in a group health plan, so if too many employees decline, your business may not be able to offer this type of policy.
An ICHRA group plan, like the one StretchDollar offers, does not have minimum participation or contribution requirements. The employer can contribute what they can afford, and if only one employee participates, that’s okay.
If you’re looking for guidance on ICHRA pre-tax fixed health benefits, reach out to StretchDollar or get started here.
What are some tips for finding an ICHRA provider?
Two great questions to ask when looking for an ICHRA provider:
- What health insurance carriers are available for my employees on your shopping tool?
- How must does it cost? (What are the fees to use the ICHRA platform?
One of the great things about offering ICHRA health benefits is the choice it gives your employees. Some might prefer a Blue Cross plan, while others could go with Ambetter, Molina, or something else entirely. Choosing an ICHRA provider that lets your employees pick from a wide range of options is a win for everyone.
Also, don’t forget to ask about fees—some providers charge admin or per-employee user fees. It’s good to know about those extra costs upfront since they can add up over time.
Looking for health benefits?
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