How a fully insured plan works
A fully insured plan is the traditional setup: you pick a carrier plan, pay a monthly premium per enrolled employee, and the carrier pays claims. Small group premiums come from the carrier's rate filings, not your team's actual health spending, so a young, healthy team subsidizes everyone else in the pool.
KFF's 2025 survey put the average employer family premium at $26,993 and single coverage at $9,325, with family premiums up 6% in a year, the third straight year of 6% or more.
Where the premium goes
Under the ACA, small group carriers must spend at least 80% of premiums on care and quality improvement. Up to 20% can go to administration, broker commissions and profit. Because that margin is a percentage of premium, a carrier earns more as premiums rise, not when your team's care costs less.
When we quote young San Francisco tech teams, we often see premiums around $1,200 per employee per month against expected claims that are a small fraction of that. That gap is why fully insured premiums feel so high for young teams.
The same MRI, three prices
Prices inside the system are just as opaque. Using the hospital's own published price data, a brain MRI at UCSF lists a gross charge of $5,730 and a cash price of $1,719, while one large PPO's negotiated rate is about $698. Your team never sees those numbers on a fully insured plan. Our care team does, and routes people to high-quality care at a fair price before the bill arrives.
Fully insured vs. Prescience
| Fully insured | Prescience | |
|---|---|---|
| Who keeps unspent dollars | The carrier | Priced into a cost usually 10–20% below comparable coverage |
| Price | Carrier rate filing, renewed each year | One contribution set in your quote, usually 10–20% below comparable coverage |
| Deductible your team sees | Often thousands of dollars | Effective $0 |
| Care support | Carrier member services | 24/7 physician-led care navigation |
How a Prescience plan works
At Prescience, we design and run your company's health plan, from setup and enrollment to claims, compliance and COBRA. What your team gets:
- An effective $0 deductible, so the plan helps from the first visit.
- Simple copays shown before a visit, capped by a low out-of-pocket maximum.
- A broad national PPO network, plus providers we contract with directly.
- 24/7 physician-led care navigation: a care team that finds the right provider, books appointments and explains costs up front.
What your company gets: one monthly cost set in your quote, usually 10–20% below comparable fully insured coverage and fixed before the plan starts, with no admin fees. You keep your payroll provider, and the plan can start mid-year.
Is this riskier than a fully insured plan?
No. Your team has real group health coverage with a broad national network and a low out-of-pocket maximum, and your quote fixes your company's cost before the plan starts. Your plan documents spell out every benefit.
See what your team would pay with Prescience
Answer a few questions about your team and get a quote in about 60 seconds, or talk it through with one of our benefits experts.
