Medical care coverage

In 2024, a plan network was available to 99 percent of private industry workers participating in medical care plans. Coverage is considered in-network when plan administrators contract specified rates with health care providers, such as specialists, hospitals, and laboratories. Plan participants usually receive a discount for using services in-network. Services provided outside of the network typically carry higher costs to plan participants. Eighteen percent of private industry workers had one plan network and 75 percent had two networks available.

Non-emergency services outside the network were available to 78 percent of private industry workers participating in medical care plans. For the remaining 22 percent of workers, non-emergency services were not available. That is, any non-emergency services received outside the network costs were the sole responsibility of plan participants. Among workers in different establishment sizes, non-emergency services outside the network were available to 78 percent of workers in establishments with less than 50 workers and 80 percent of workers in establishments with 100-499 workers or more. (See chart 1.)

Coinsurance requirement for medical services

A coinsurance is a requirement that plan participants pay a percentage of medical cost. In 2024, coinsurance was required for 78 percent of private industry workers participating in medical care plans. The percentage of workers with coinsurance ranged from 72 percent for natural resources, construction, and maintenance occupations to 85 percent for sales and related occupations. A fixed coinsurance was present for 22 percent of workers participating in medical care plans with coinsurance requirements. The median variable coinsurance amount was 60 percent for out-of-network services and 80 percent for in-network services. For the most generous coverage⁽¹⁾, the median coinsurance percentage was 90 percent. (See chart 1.)

Out-of-pocket maximum for individual coverage

An out-of-pocket maximum is the annual dollar amount limit that plan participants are required to pay out-of-pocket, in addition to the plan deductible. In 2024, 98 percent of workers had an individual out-of-pocket maximum for private industry workers participating in medical care plans. Ninety-seven percent of workers in establishments with less than 100 workers had an individual out-of-pocket maximum and 98 percent of workers in establishments with 500 workers or more. The median amount was $3,000 for workers in establishments with less than 100 workers and $2,500 for workers in establishments with more than 500 workers. The out-of-pocket maximum ranged from $1,500 at the 10^th percentile to $5,750 at the 90^th percentile for workers in establishments with less than 100 workers and from $1,250 at the 10th percentile to $5,000 at the 90^th percentile for workers in establishments with more than 500 workers. (See chart 2.)

Out-of-pocket maximum for family coverage

Among private industry workers in different average hourly wage categories, the out-of-pocket maximum for family coverage was present for 99 percent for workers in the lowest 25 percent category and 99 percent for workers in the highest 25 percent category in 2024. The out-of-pocket maximum median was $6,000 for the lowest 25 percent and $5,000 for the highest 25 percent. (See chart 3.)

End note

⁽¹⁾ In instances where more than two tiers of benefits (networks) exist, which provide participants with options when selecting services, the most generous coverage refers to the network that provides the lowest out of pocket cost for services (deductible, copayment, or coinsurance) rendered.

Annual deductible

Many health care plans have a deductible. A deductible is a dollar amount that plan participants pay during the benefit period, usually a year, before the insurer starts to make payments for covered medical services. Plans may have individual and family deductibles. In 2024, 94 percent of private industry workers participating in medical care plans had an annual deductible.

Some medical care plans have fixed deductibles while others have variable deductibles. In the case of variable deductibles, insurers may offer tiered networks and provide the insured participants with the lowest costs for using preferred providers. The insured participants may also receive services from other in-network providers.

Of workers participating in medical care plans, 63 percent had a variable annual individual deductible. Among private industry groups, 49 percent of workers in the information industry had a variable annual individual deductible. For workers in the financial activities industry, 72 percent had a variable annual individual deductible. (See chart 1.)

Individual deductible

Most workers participating in medical care plans have either individual or family deductibles. In the case of individual deductibles, once plan participants meet the deductible amount, covered medical benefits begin.

The median individual deductible amount in 2024 was $1,750 for private industry workers participating in medical care plans. Among industries, the individual deductible amount was $1,600 for manufacturing and $2,000 for financial activities industry and professional and business services industry. (See chart 2.)

In 2024, the most generous coverage⁽¹⁾ median variable deductible amount for private industry workers in establishments with 50-99 workers was $1,800, the median in-network amount was $2,000, and the median out-of-network amount was $4,000 among workers participating in medical care plans. For workers in establishments with 100-499 workers, the most generous coverage median deductible amount was $1,500, the median in-network deductible was $2,000, and the median out-of-network amount was $4,000. (See chart 3.)

Family deductible

In 2024, 94 percent of private industry workers participated in medical plans with a family deductible. For private industry workers, the median amount for the annual family deductible was $3,750. A variable deductible for family coverage was required for 63 percent of private industry workers and the most generous coverage median amount was $3,000. The most generous coverage median family variable deductible amount for private industry union workers was $2,300, the median in-network amount was $2,300, and the median out-of-network amount was $4,000 among workers participating in medical care plans. For nonunion workers, the most generous coverage median family deductible amount was $3,000, the median in-network deductible was $4,000, and the median out-of-network amount was $8,000. (See chart 4.)

End note

⁽¹⁾ In instances where more than two tiers of benefits (networks) exist, which provide participants with options when selecting services, the most generous coverage refers to the network that provides the lowest out of pocket cost for services (deductible, copayment, or coinsurance) rendered.

High deductible health plans

High deductible health plans (HDHP) typically feature higher deductibles and lower insurance premiums than those of traditional health plans. These plans include catastrophic coverage to protect against large medical expenses but hold the insured responsible for routine out-of-pocket expenses until the plan deductible is met.⁽¹⁾

In 2024, among private industry workers participating in medical care plans, 50 percent of all workers, 44 percent of West census area workers, 56 percent of Midwest census area workers, and 48 percent of Northeast census area workers participated in HDHPs. For nonhigh deductible health plans, the participation rate was 49 percent for all workers, 56 percent for West census area workers, 44 percent for Midwest census area workers, and 51 percent for Northeast census area workers. (See chart 1.)

Among private industry workers that participated in HDHPs during 2024, the median annual individual deductible for all private industry workers was $2,750. The median amount for workers in establishments with less than 50 workers was $3,000, in establishments with 500 workers or more the median amount was $2,500. (See chart 2.)

Tax-favored accounts

Health savings accounts (HSAs) are employee-owned portable accounts that use tax-exempt contributions to pay for medical expenses. HSAs are used in combination with employer-provided HDHPs with annual maximum limits on out-of-pocket and deductible expenses. Other features include the rollover of unused contributions from year to year and tax-free interest.

Similar to HSAs, Health Reimbursement Arrangements (HRAs) are tax-favored accounts that reimburse employees for qualified medical expenses. However, HRAs consist of funds set aside by employers only with no employee contributions. Employees receive tax-free reimbursements for qualified medical expenses up to a maximum dollar amount for a coverage period. An HRA may be offered with any qualified medical plan.

Among private industry workers participating in HDHPs, 51 percent of workers participated in plans with HSAs and 9 percent participated in plans with HRAs in 2024. For workers in goods-producing industries, 51 percent of workers participated in HSAs and 6 percent participated in HRAs. Fifty-one percent of workers participated in HSAs and 10 percent participated in HRAs among workers in service-providing industries. (See chart 3.)

Nonhigh deductible health plans

Among private industry workers that participated in non-high deductible health plans in 2024, 86 percent of management, business and financial workers, 88 percent of sales and related workers, 82 percent of installation, maintenance, and repair workers, and 80 percent of production workers had an annual individual deductible. Fourteen percent of management, business and financial workers, 12 percent of sales and related workers and 18 percent of installation, maintenance, and repair workers, and 20 percent of production workers participated in plans without an annual individual deductible. (See chart 4.)

End notes

⁽¹⁾ For more information on high deductible health plans, see the High deductible health plans factsheet.

Services provided

Estimates are available for types of coverage, including coinsurance and copayment for hospital room and board benefits, physician office visits, and specialist office visits. Among private industry workers who participated in medical care plans, 94 percent had coverage of hospital room and board, 100 percent had coverage of physician office visits, and 97 percent had coverage of specialist office visits in 2024.

The two types of limits on coverage are copayments and coinsurance. Copayments are predetermined dollar amounts that plan participants must pay when services are received before any remaining charges are paid by insurers when the deductible has been met. For hospital room and board benefits, the copayment may vary based on salary or length of stay.

Coinsurance is a form of medical cost sharing that requires a participant to pay a stated percentage of medical expenses after the deductible amount, if any, has been paid. After the deductible and coinsurance are paid, insurers are responsible for costs up to the allowable charges. Participants may be responsible for any charges in excess of what insurers determine to be "usual, customary, and reasonable." Coinsurance rates may differ between services received from an approved provider and those received from providers not on the approved list. In addition to overall coinsurance rates, rates may also differ for different types of services.

Hospital room and board

Among private industry workers participating in medical care plans, 4 percent of all workers had full coverage for hospital room and board benefits. Five percent of management, professional, and related workers, 3 percent of sales and office workers, and 2 percent of natural resources, construction, and maintenance workers had full coverage for hospital room and board benefits. Ninety percent of all private industry workers, 90 percent of management, professional, and related workers, 91 percent of sales and office workers, and 94 percent of natural resources, construction, and maintenance workers had coverage with limits for hospital room and board benefits. (See chart 1.)

In 2024, among private industry workers participating in medical care plans with hospital room and board coverage limits, 90 percent of workers had coverage with limits. Eleven percent of all private industry workers were subject to copayment only and 72 percent were subject to coinsurance only. For union workers, 78 percent were subject to coinsurance only and 14 percent were subject to copayment only. For nonunion workers, 71 percent were subject to coinsurance only and 11 percent were subject to copayment only. (See chart 2.)

Physician office visits

Among private industry workers participating in medical care plans in 2024, 100 percent had physician office visit coverage limits. Sixty percent were subject to copayment only and 30 percent were subject to coinsurance only. Among full-time workers, 60 percent were subject to copayment only and 30 percent were subject to coinsurance only. Fifty-eight percent of part-time workers were subject to copayment only and 39 percent were subject to coinsurance only. (See chart 3.)

Specialist office visits

Among private industry workers participating in medical care plans in 2024, 97 percent of workers had coverage limits for specialist office visits. Fifty-nine percent were subject to copayment only and 32 percent were subject to coinsurance only. Among occupational groups, 58 percent of management, professional, and related workers had copayment only and 31 percent had coinsurance only. For sales and office occupations, 58 percent had copayment only and 35 percent had coinsurance only for specialist office visits. For production, transportation, and material moving occupations, 56 percent had copayment only and 34 percent had coinsurance only for specialist office visits. (See chart 4.)

Outpatient prescription drugs

Prescription drug plans provide coverage for outpatient prescription drugs, which include the following:⁽¹⁾

• Generic drugs: These are drugs not under any patents.
• Formulary drugs: These are both generic and brand-name drugs approved by the healthcare provider. Drugs not approved by the healthcare provider are nonformulary drugs, for which enrollees receive less generous benefits, such as a higher copayment per prescription.
• Mail-order drugs: These are drugs that can be ordered through the mail.
• Brand-name drugs: These are drugs that once were, or still are, under patents.

Among private industry workers participating in outpatient prescription drug plans in 2024, 100 percent had coverage of generic drugs and brand-name formulary drugs, 92 percent had coverage of brand-name nonformulary drugs, 83 percent had coverage of mail order drugs, and 46 percent were subject to an annual deductible.

For workers in establishments with less than 50 workers, 100 percent had coverage of generic drugs and brand-name formulary drugs, 96 percent had coverage of brand-name nonformulary drugs, 79 percent had coverage of mail order drugs, and 50 percent were subject to an annual deductible.

For workers in establishments with 50-99 workers, 100 percent had coverage of generic drugs and brand-name formulary drugs, 97 percent had coverage of brand-name nonformulary drugs, 81 percent had coverage of mail order drugs, and 45 percent were subject to an annual deductible.

For workers in establishments with 100-499 workers, 100 percent had coverage of generic drugs and 99 percent had access to brand-name formulary drugs, 88 percent had coverage of brand-name nonformulary drugs, 88 percent had coverage of mail order drugs, and 43 percent were subject to an annual deductible. (See chart 1.)

In 2024, the median generic drug limits coverage for all private industry workers was $10 for those participating in outpatient prescription drug plans. Among private industry workers participating in outpatient prescription drug plans with brand-name drug on formulary limits coverage, the median copayment was $30 for union workers and $35 for nonunion workers. The median copayment for brand-name drugs not on formulary limits was $60 for all private industry workers participating in outpatient prescription drug plans with brand-name drug not on formulary coverage. The median copayment for union workers was $50 and $60 for nonunion workers. (See chart 2.)

Generic drug limits

Among workers that participated in outpatient prescription drug plans in 2024, 70 percent of private industry workers, 66 percent of workers in the goods-producing industry, and 71 percent of workers in the service-providing industry were subject to a copayment. For private industry workers, 21 percent of all private industry workers, 23 percent of workers in the goods-producing industry, and 21 percent of workers in the service-providing industry were subject to a coinsurance. Eight percent of all private industry workers, 7 percent of workers in the goods-producing industry, and 8 percent in the service-providing industry were subject to a coinsurance had a minimum or maximum dollar amount apply. (See table 1.)

Brand-name drugs on formulary

Among private industry workers that participated in outpatient prescription drug plans with brand-name formulary coverage, 60 percent of workers, 62 percent of workers in the goods-producing industry, and 59 percent of workers in the service-providing industry were subject to copayments in 2024. Thirty-three percent of private industry workers, 29 percent of workers in the goods-producing industry, and 35 percent of workers in the service-providing industry were subject to coinsurance. (See table 1.)

Brand name drugs not on formulary

Among private industry workers participating in outpatient prescription drug plans with brand-name drugs not on formulary coverage, 59 percent of workers were subject to copayment and 33 percent were subject to coinsurance. For workers in the goods-producing industry, 57 percent were subject to copayment and 32 percent were subject to coinsurance. For workers in the service-providing industry, 60 percent were subject to copayment and 34 percent were subject to coinsurance. (See table 1.)