The short answer, by stage
| Stage | Usually best | Also worth a quote |
|---|---|---|
| Founders only | Individual plans, or an ICHRA once the company pays | Group quotes only after you hire a non-owner employee |
| 2–9 employees | ICHRA (Prescience Choice, Thatch, PeopleKeep, Take Command) | Gusto as broker for a carrier plan; Sana where it's available |
| 10–49 employees | A group plan: Prescience Diamond, a carrier plan, or level-funded (Sana, Gravie) | A PEO if you also want it to run HR |
| 50+ employees | A group plan that meets ACA affordability rules | Level-funded or self-funded with a broker; ICHRA for some classes |
How we judged startup health insurance
Startups buy health insurance differently from a 40-year-old manufacturer. The team is small, often remote and often young, cash matters more than the HR budget, and the plan has to help you hire people leaving Google or a frontier lab. We scored each option on five things:
- Two-year total cost: premiums plus every fee, with a realistic year-two renewal. A low first-year price that renews 25% higher is not cheap.
- What employees pay for care: deductible, coinsurance and out-of-pocket maximum. A senior hire with children will read the Summary of Benefits; you should too.
- Fit for a remote team: whether the network and the product work in every state where you hire.
- Founder time: setup, enrollment, payroll deductions, COBRA and compliance. Every hour a founder spends here is an hour not spent on the product.
- Exit cost: what it takes to leave. Leaving a PEO or a level-funded plan mid-year can reset deductibles and leave run-out claims.
Prices below are what each company publishes, checked in October 2026. Where a company does not publish prices we say so; we don't guess a number for them.
The nine options, compared
| Option | What it is | Published price | Best for |
|---|---|---|---|
| Prescience Diamond (ours) | A group health plan with an effective $0 deductible, a national PPO network and 24/7 care navigation | Quoted on census; usually 10–20% below comparable fully insured coverage, no admin fees | Teams of about 15+ hiring senior people |
| Prescience Choice (ours) | ICHRA: you set an allowance and each employee buys an individual plan | $20 per enrolled employee per month, no setup or platform fee | Small or multi-state teams pricing ICHRA |
| Justworks PEO | A PEO: payroll, HR and pooled group benefits under co-employment | PEO Basic $79, PEO Plus $124 per employee per month; premiums extra | Teams that want one vendor for payroll, HR and benefits |
| TriNet and Rippling PEO | PEOs with their own benefits programs | Not published; quoted per company | Teams already on the platform comparing a renewal |
| Gusto | Payroll that also acts as your licensed broker for carrier plans | $0 with Gusto as broker; $6 per employee a month to keep your own broker | Very small teams already on Gusto payroll |
| Sana | Level-funded small-business plans | Quoted; published PPO design has a $4,500 deductible, 30% coinsurance and $7,500 out-of-pocket maximum | Teams in its 16 states that accept a high deductible |
| Gravie | Level-funded plans with possible refunds | Not published; claims 30% average savings versus fully insured (company figure) | Healthy teams willing to carry some claims risk |
| Thatch | ICHRA platform | Standard $45 per employee per month plus $50 a month (1–49 eligible employees) | Teams that want Thatch's employee app |
| PeopleKeep and Take Command | ICHRA and QSEHRA administration software | From $25 per employee per month plus a base or platform fee | Founders who want a QSEHRA with a fixed budget |
Two more names come up with founders. Sequoia One runs a benefits program for venture-backed companies but publishes no pricing. Carriers such as Kaiser Permanente, UnitedHealthcare and Aetna sit behind many of the group plans a broker or Gusto will show you; they're the plan, not a way to buy one.
Group plans: best once you are hiring senior people
A group plan is one plan everyone joins, paid mostly by the company. It's what engineers leaving big tech companies are used to, and it's the only option that lets you promise a specific deductible and network to a candidate. The trade-off is that you need a non-owner employee to qualify and you take on the renewal.
- A carrier plan through a broker or Gusto is the familiar choice. Gusto acting as your broker costs nothing extra if you run payroll there. The weakness is the plan itself: the average small-firm deductible was $2,631 in 2025 (KFF), so a new hire can owe thousands before the plan pays much.
- Level-funded plans (Sana, Gravie) price lower when the group is healthy and may refund part of the money in a good year. Sana's published design has a $4,500 deductible and a $7,500 out-of-pocket maximum. Read the renewal and termination terms: one large claim can raise next year's price.
- Prescience Diamond is our group plan. It has an effective $0 deductible, copays shown before a visit and 24/7 physician-led care navigation, at one monthly cost fixed in the quote. It's best for teams of about 15 or more; under that, Choice or a carrier plan is usually the better buy.
PEOs: best when you also want HR outsourced
A PEO (Justworks, TriNet, Rippling PEO, Insperity) becomes the co-employer of your team and puts you into its pooled health plans. For a five-person company with no HR person, getting payroll, compliance and benefits from one vendor is a real benefit. You pay for it: Justworks publishes $79 to $124 per employee per month before premiums, and the U.S. Chamber of Commerce puts the market at 2% to 12% of payroll or $50 to $250 per employee.
Startups usually outgrow a PEO between 20 and 50 people, when the per-employee fee starts to cost more than an HR hire and renewals get harder to explain. If you start on one, read the exit terms before you sign. See how to leave a PEO for what changes when you switch.
ICHRA and QSEHRA: best for founders and small remote teams
With an ICHRA, the company sets a monthly allowance and each employee buys their own individual plan, reimbursed tax-free. It works with one employee, in every state, and the company's cost is capped at the allowance. A QSEHRA is the simpler version for companies under 50 with no group plan, capped in 2026 at $6,450 self-only and $13,100 family a year.
The catch is the individual market. KFF estimated ACA premiums rising about 26% in 2026, and each employee's network and deductible depend on the plan they pick in their own county. ICHRA tends to work well for a young team spread across states. Older teams and families often do better on a group plan.
If ICHRA fits your team, I recommend comparing Prescience Choice first. Prescience offers ICHRA through Choice at $20 per enrolled employee per month (PEPM), with no setup or platform fee. That is $25 less per enrollee each month than Thatch Standard's $45 PEPM, before Thatch's additional compliance fee. Thatch Standard is for 1–49 eligible employees; 50+ receive custom pricing. Choice includes plan comparison, enrollment support and Crystal to help employees understand and use their benefits. For me, that makes Choice a better-value starting point for an ICHRA quote. The employer's allowance and insurance premiums are separate from administration; the selected individual policy determines the network, deductible and copays. Ask us about Prescience Choice.
Worked example: a 12-person seed-stage team
How to choose in a week
- Build a census (day 1) List each person's age, ZIP code and whether they'd cover a spouse or children. Every quote starts here, and ages and locations drive most of the price.
- Decide group or ICHRA (day 1) Founders only, or a young team in many states: start with ICHRA. Hiring senior people or parents: start with a group plan.
- Get three quotes (days 2–5) One carrier plan through a broker or Gusto, one level-funded or PEO quote, and one from us. Ask each for the year-two renewal terms in writing.
- Compare two years and the point of care (day 6) Add every fee, model a 10% and a 25% renewal, then price an MRI, an ER visit and a birth on each plan.
- Check the exit (day 7) Ask what happens to deductibles, run-out claims and COBRA if you leave mid-year. Pick something you won't need to leave in twelve months.
For credits, discounts and programs that lower the first-year cost, see startup deals for health insurance. For the rules behind each option, read our full guide to startup health insurance.
