A founder's guide to health benefits in the US and abroad
Most small US companies don't start out global. Then you hire a contractor in Brazil, an engineer in Germany, a designer who prefers 1099 work, and suddenly "what health benefits do we offer?" has several answers instead of one. Getting it right matters because benefits are one of the main ways a small team competes with bigger employers for talent.
SafetyWing for Startups (formerly Remote Health) is one option built for this situation: a group health plan for US employees and a global plan for team members outside the US and Canada, managed from the same place. But the decisions below apply whichever provider you choose. This guide walks through how to sort your team, person by person.
Once you have about five full-time W-2 employees in the US, you can offer a real group health plan instead of a stipend. Your contractors and staff outside the US and Canada can't join that plan, but they can sit on a separate global plan, managed from the same place. The work is deciding who goes where.
Decide these three things first
1. Who is a W-2 employee and who is a contractor. In the US, only employees can join a group plan.
2. Where each person lives. Everyone outside the US needs a global plan.
3. How many W-2 employees you have. Group plans need a minimum number of enrolled employees.
Get these right and the rest is matching people to the plan they're eligible for.
What to decide before you look at a single plan
Sort your team before you shop. Every plan has rules about who can be on it, so a person's employment status, the country they live in, and the size of the group they belong to settle what you can offer them before budget or stage comes into it. Most founders start by comparing plans and work backwards. It goes faster the other way.
Employee or contractor?
In the US, employer health plans are for common-law employees, which in practice means your W-2 staff. A 1099 contractor is self-employed in the eyes of the IRS and can't be enrolled in your group plan or in a tax-free reimbursement arrangement, however many hours they work for you. Putting a US contractor on employee benefits would be a flag to regulators that they were an employee all along.
Outside the US the rules are looser and vary by country, which is why the global half of this guide looks so different from the US half. If you're unsure which side of the line someone sits on, settle it with your accountant first.
Where does each person live?
US health plans are built around a US provider network and US law. A global health plan is built the other way round: any clinic, any country, the same benefits wherever the member lives outside the US.
How many W-2 employees?
Group plans need a minimum number of enrolled employees to open, and for SafetyWing for Startups US that's about five W-2 employees. With two or three, you're generally looking at a stipend or reimbursement arrangement until you grow.
Your US team: the three routes for a small company
A small US company has three ways to give employees health coverage: give them money toward a plan they buy themselves, buy a fully insured small-group plan from a carrier, or set up a self-funded group plan.
Route 1: a stipend or a reimbursement arrangement
The simplest version is a taxable stipend: you add money to payroll and the employee buys their own plan, or doesn't. The tax-advantaged versions are reimbursement arrangements. A QSEHRA (qualified small employer health reimbursement arrangement) is for companies under 50 full-time equivalents that don't offer a group plan; for 2026 the IRS caps it at US$6,450 for an individual and US$13,100 for a family (IRS Revenue Procedure 2025-32). An ICHRA (individual coverage HRA) is available at any size and lets you vary the allowance by class of employee, but employees must buy an individual-market plan to use it.
What it means for the employee: they shop the individual market alone, with the individual market's deductibles. In many states, there's a thin set of plans with high deductibles. With under five people, it's far better than nothing. But it also isn't what a candidate expects when you say "we offer health insurance."
Route 2: a fully insured small-group plan
This is the classic route for small US companies. You pay a fixed premium to a carrier, the carrier takes the risk, and the carrier keeps whatever your team doesn't use. "Small group" usually means up to 50 employees, though a few states draw the line at 100. Employees get a plan that looks familiar: a deductible, coinsurance, copays, a card.
The part nobody warns first-time buyers about is renewal. In 52 product-feedback calls with US buyers between June and September 2026, around 45 raised renewal cost or timing without being asked, and especially: "they wait until the last minute so you can't shop." Next year's rates might only arrive two to four weeks before the deadline, and because you never see your own claims data, you never learn why it went up.
Route 3: a self-funded group plan
Self-funding is how most large companies run their health plans, and for good reason: you pay for the care your team actually uses rather than an insurer's estimate of it. For a long time it was out of reach for small teams. That's starting to change.
It works like this. You pay a fixed amount every month, the same way you would with regular insurance. If your team's claims come in under what was budgeted, part of the unused money can come back to you at the end of the year. A separate stop-loss policy (insurance for the plan itself) caps what the plan can owe, so the monthly amount is the most you'll pay that year.
SafetyWing for Startups US is a self-funded group health plan for US W-2 employees on the Cigna PPO network (a PPO is a provider network you can use without referrals). On the most comprehensive plan, staying in-network means no deductible, no coinsurance and nothing to pay at the doctor. The only thing an employee pays is US$10 to US$50 for a prescription. Other plan options add deductibles and copays in exchange for a lower monthly cost, so you can match coverage to your budget. Out-of-network care exists but costs more: a US$1,000 deductible, up to 30% coinsurance, capped at US$2,000 out of pocket for an individual. Family members can be added without limit, and you pay for at most three people per employee, the employee included.
Pricing is quoted based on a short census, because it depends on your team's ages and locations. When something goes wrong, a real person answers the chat in under 60 seconds, around the clock, and you get an account manager. SafetyWing for Startups has been used by 2,000+ companies since 2019. Details are on the SafetyWing for Startups US page.
Who the US plan is not for
1099 contractors and part-time staff. Not eligible.
Anyone living outside the US. They go on the global plan.
Teams below five W-2 employees. Use a stipend or reimbursement arrangement until you reach five.
People attached to out-of-network care. Search the Cigna provider directory for the two or three doctors your people care most about before you move anyone. Asking a team to change their healthcare and then finding out their therapist isn't in network is the worst version of this process.
Everyone abroad: one plan across 175+ countries
Employees and contractors living outside the US and Canada can go on SafetyWing for Startups Global, a single health plan that covers employees, contractors and freelancers in 175+ countries with the same benefits wherever they live.
The plan has three tiers: the Standard plan at US$116/month per employee covers comprehensive, routine, and emergency medical care. Premium covers everything in the Standard plan, plus dental, vision, and expanded wellness coverage at US$175/month per employee. At US$224/month per employee, everything across the Standard and Premium plans is covered, plus higher limits for wellness and maternity (SafetyWing for Startups Global).
Teams of five or more get the group rate, with medical history disregarded. Teams of one to four pay the individual rate and get a medical history review.
Because there's no network, members visit any public or private provider in their country or while traveling, with no deductible and no coinsurance. Claims satisfaction runs at seven times the global average, and the same 24/7 human support covers both plans. As a real life example, a design company called Superside covers 112 members in 22 countries on one plan.
Contractors are where the global plan earns its keep. In most countries outside the US, giving a contractor health cover doesn't create the same classification problem, and it's one of the most effective ways to keep a good contractor in Brazil from leaving for a client who offers it.
Who the global plan is not for
Anyone living in the US or Canada. US staff go on the US plan.
An employee in a country with mandatory local health insurance, as their primary cover. In places like Germany, Switzerland, the Netherlands and Australia, local law requires residents to hold national coverage first. The global plan can't replace it, but it can add extra coverage on top. The section on employers of record explains how this works.
Anyone who needs the plan to satisfy a specific country's tax or visa rule. Some visas and tax arrangements require a particular type of health insurance. The global plan may or may not qualify, and SafetyWing can't advise on country-by-country rules, so check with a local adviser before relying on it for that purpose.
Where an employer of record fits
An employer of record (EOR) is a company that legally employs someone in a country where you have no entity. It runs their payroll and local taxes and bills you for it. When it comes to health coverage, an EOR does one of two things, depending on the country.
In some countries, health insurance is mandatory and handled through payroll. Germany, Switzerland, the Netherlands and Australia all have rules that can prevent a global plan from serving as someone's primary health insurance. There, the EOR enrolls the employee in the required national coverage, and that comes first. A global plan can then sit on top as extra coverage for things like dental, vision and maternity (SafetyWing for Startups Global FAQ). That's the situation for an employee in Germany hired through an EOR: they're covered by German statutory insurance automatically, through the EOR's payroll.
In many other countries, there's no such requirement, and the EOR's health plan is an optional add-on priced country by country.
If you buy health coverage through an EOR in each country, you'll end up with a separate plan for every location. Your employee in Portugal has one plan, your employee in Mexico has another, and each comes with its own coverage, deductible and renewal date. That means more plans to manage, and teammates doing the same job end up with different benefits depending on where they live. A global plan gives everyone the same coverage under one policy. It can also cover your contractors, which EOR plans can't, since the EOR doesn't employ them.
The rule of thumb: where the law requires national coverage, that comes first. For everyone else, including contractors, the global plan can be the main coverage.
Questions to ask any provider before you sign
Take these into every conversation, including ours.
Who exactly is eligible? W-2 only? Part-time? Contractors? Dependents? Get it in writing.
What's the minimum number of enrolled employees, and what happens if we dip below it after a departure?
What comes out of my employees' paychecks, and what do they pay at the doctor? Deductible, coinsurance and copays, in dollars.
Can my people keep their doctors? Search the directory for named providers before you commit.
When will I see next year's number, and how much notice do I get? Two weeks leaves no time to shop.
If our claims come in lower than expected, where does the money go?
Does it plug into my payroll or HRIS, or is it another login?
When something goes wrong at 11pm, who answers, and how fast?
For the global plan: which countries are covered, and which require local statutory insurance alongside it?
Can I add and remove people month to month as the team changes?
Where to start
Both plans sit in one dashboard, so adding the next contractor in Colombia is a form, not a project. Start with the plan page for the people you have most of: SafetyWing for Startups US for your US employees, and SafetyWing for Startups Global for everyone else.
SafetyWing for Startups US (formerly Remote Health USA) page and FAQ: https://safetywing.com/remote-health-us
SafetyWing for Startups Global (formerly Remote Health Global) page, pricing and FAQ: https://safetywing.com/remote-health and https://safetywing.com/remote-health/compare-our-plans
