The average employer spends about $20,000 a year to add a spouse to a group health plan. Structure it as a spousal HRA instead, and that number drops to around $4,000. We call our version the Total Care Option (TCO): the employer reimburses the family's out-of-pocket medical costs, and the spouse and dependents move onto the spouse's employer plan. That's the case for offering the benefit.
Getting people to elect to use the Spousal HRA and effectively make a decision about their healthcare is a separate challenge. It's also what ultimately drives savings for employers. We've helped design hundreds of these programs, enabling employers to provide $33 million in additional coverage to their employees. Total enrollment rarely comes down to open enrollment itself. It comes down to the choices made before open enrollment even opens: the HRA amount, what the plan covers, and how employers educate employees. Underfund it, skip premium coverage, or bury the education in one email, and the benefit sits on the intranet unused: a spouse stays on a plan with a $6,000 deductible they'll never hit, functionally uninsured, while the household budget feels it either way. Land all 3, and enrollment climbs every year after.
Here's what the data says actually moves enrollment.
Fund the Spousal HRA to the ACA maximum
The single biggest lever is the HRA amount, and most employers set it too low.
The 2026 federal out-of-pocket maximum is $21,200. Fund the HRA to that number instead of a conservative figure, like $8,000, and enrollment increases 2.5x, for about $166 more per household a year (which is an immaterial cost compared to $20,000 per year for an employer-sponsored plan). We found at $8,000, average enrollment is 7.4% and average utilization is $2,218. At the ACA maximum, enrollment rises to 17.1% and utilization rises to $2,384.
The reason is simple. The households with real healthcare costs, the ones this benefit exists for, are the ones running the math before they enroll. Fund it too low, and they run that math and conclude it's not worth the paperwork or headache. Fund it to the actual maximum, and the math makes the TCO a compelling choice. Employers see that same math from their own side: Healia customers save 76% per household that enrolls, compared to keeping that spouse on their group health plan. Underfunding the HRA to save costs employers both the savings and the enrollment.
Cover premiums as well as out-of-pocket costs
The second lever is what the HRA reimburses. Plans that reimburse premiums in addition to out-of-pocket costs enroll at 2 to 4x the rate of plans that stop at the deductible. We've found enrollment is 12% in year 1 with premium coverage versus 8% without, and climbs to 32% by year 2.
The mechanism: cover only the deductible, and a family still has to separately justify paying a premium on top of it. Cover the premium too, and staying on two separate plans stops making sense on its own terms.
Put the education in front of people on more than one channel
Neither lever above matters if nobody understands the choice before open enrollment closes.
Our decision-support tool prices every plan combination for a household and surfaces the cheapest one, the way a fare-comparison site prices flights, in under 2 minutes. It's a good tool. It still isn't enough by itself.
Some employees read the postcard. Some show up to the webinar. Some don't hear about it until a coworker explains it at lunch. Betting on one channel is how enrollment stalls. The programs that work run all of it at once:
- the decision-support tool
- webinars
- direct mail and flyers
- on-demand video
- 1:1 sessions
- HR readiness sessions, so the benefits team can answer questions with confidence
- a claims tutorial, so the first reimbursement request isn't the first time anyone sees the process
- dedicated outreach for new hires and life events
A few tactics matter more than the rest. Deliver the message through a voice employees already trust, not an outside vendor's email address alone. Get the internal benefits team on the same page before open enrollment opens, so the message doesn't change mid-stream. Put the tool where employees already look: the intranet, the BenAdmin platform. And start early. Employees absorb an unfamiliar benefit gradually, not in one webinar 3 days before the deadline.
At Healia, we handle these messages end to end so HR teams see the impact, without carrying the burden.
Get the Spousal HRA implementation sequence right
None of the above works if it's decided out of order.
Here's the sequence: a kickoff call where there is agreement on education, BenAdmin, banking, and the launch plan; BenAdmin setup, so the benefit is selectable inside the system employees already use; the education rollout itself; banking and contract, finalized with finance; then go-live during open enrollment. After that, we keep bi-weekly touchpoints to review savings and program feedback, because the work doesn't stop at go-live.
Lock the HRA amount and plan coverage before that first kickoff call. Everything that follows depends on these two choices.
What happens after open enrollment closes decides the next year's renewal
Open enrollment is one event. The claims experience over the next 12 months decides whether next year's number is bigger.
More than 95% of the claims we process are reviewed within 2 business days. Reimbursement lands by ACH 1 to 2 business days after that. Employees notice the difference. Someone who gets paid back in 2 days tells a coworker to enroll next year. One who's still waiting 3 weeks later tells them not to bother. That conversation, not another email from HR, decides next year's enrollment more than anything on this list.
Two more windows matter beyond open enrollment itself.
- New hires make their benefits choices in their first few weeks on the job, often before they've had time to compare their spouse's plan against the group plan, so building the Spousal HRA into onboarding catches people who never sat through an open enrollment at all.
- Qualifying life events like a marriage, a new child, or a spouse's job change makes the benefit newly relevant to someone who ignored it in November. Programs that build outreach around both capture enrollment all year, not just in one 6-week window.
Why this is worth getting right
A woman enrolled in a spousal HRA through her husband's employer, giving their family the financial confidence to start having children. When she was later diagnosed with cancer, that same employer-funded benefit was there when they needed it most, helping cover the cost of her treatment.
Nobody designs a plan for that specific outcome. A well-funded, well-explained benefit means the coverage is there when something like this happens.
Fund it to the real maximum. Cover premiums as well as out-of-pocket costs. Put the education in front of people more than once, on more than one channel. Keep the claims experience fast enough that people talk about it.
Those choices, made before open enrollment opens, decide the number.
Review the numbers
Schedule a call with our team at info@healiahealth.com. We'll analyze what a spousal HRA could look like. No census required, nothing to commit upfront. Bring the numbers. We'll bring the math and show the enrollment impact.