Healthcare Basics for Employers and Employees
Plain-language explanations you can hand straight to your crew or your team — no insurance jargon.
PCP vs. Urgent Care vs. ER
Your primary care provider (PCP) is for ongoing and preventive care. Urgent care is for things that need same-day attention but aren’t life-threatening. The ER is for emergencies — and it’s almost always the most expensive option.
Emergency Room Cost Impact
An ER visit typically costs far more than an urgent care visit for the same non-emergency issue — for both the plan and the employee’s share.
Telehealth
A phone or video visit with a provider, often available same-day, without travel or time off work.
Specialist Referrals
Some plans require a referral from your PCP before seeing a specialist; others allow you to self-refer.
Pharmacy Tiers
Drug plans group medications into tiers (generic, preferred brand, non-preferred brand, specialty) — lower tiers usually cost less out of pocket.
Deductibles
The amount you pay out of pocket before your plan starts sharing costs for most services.
Copays & Coinsurance
A copay is a flat fee per visit. Coinsurance is a percentage of the cost you pay after the deductible is met.
Out-of-Pocket Maximum
The most you’ll pay in a plan year before your plan covers 100% of covered costs.
HSA / FSA / HRA
Tax-advantaged accounts that help pay for medical costs — HSAs are employee-owned and portable; FSAs are use-it-or-lose-it; HRAs are employer-funded and employer-owned.
PPO vs. HMO
PPOs generally allow you to see any provider, often at a higher cost for out-of-network care. HMOs generally require a PCP and referrals, usually at a lower cost.
Network Basics
In-network providers have agreed to negotiated rates with your plan; out-of-network care usually costs more.
Prior Authorization
Some services or medications require your plan’s approval before they’re covered.
Employee vs. Employer Contribution
The employer pays part of the premium; the employee pays the rest through payroll deduction. The split varies by plan and by employer.
Why Family Coverage Costs More
Covering a spouse and/or children adds more people — and more expected claims — to the plan, which raises the premium.
How to Read an SBC
The Summary of Benefits and Coverage (SBC) is a standardized document every plan provides, showing deductibles, copays, and example costs for common scenarios — a fast way to compare plans apples-to-apples.
Want this as a printable playbook for your crew?
We can help you build a simple, field-friendly version of this page.