Key Takeaways

• Coinsurance under the Postal Service Health Benefits (pshb) program is not always a simple, fixed percentage. It varies based on multiple factors, and misunderstanding this can lead to unexpected out-of-pocket expenses.

• Understanding how coinsurance interacts with deductibles, out-of-pocket limits, Medicare, and provider networks in 2025 can help you make smarter decisions during Open Season and throughout the year.

What Coinsurance Really Means in the PSHB Program

Coinsurance is often misunderstood as a static percentage of medical costs that you are responsible for after meeting your deductible. But under the PSHB program in 2025, that assumption could leave you vulnerable to major financial surprises.

You might think your plan offers 20% coinsurance for most services—but that percentage isn’t always consistent. Instead, your actual cost-sharing may fluctuate based on the service type, provider network status, and even whether Medicare is involved.

To avoid unexpected bills and make informed decisions about care, you need to dig deeper into how coinsurance works in real-world situations under PSHB.

1. The Coinsurance Percentage Is Just the Start

While PSHB plans might advertise coinsurance rates like 10%, 20%, or 30% for in-network care, these numbers don’t exist in a vacuum.

Several variables change the actual cost you pay:

• Whether your deductible has been met

• The network status of your provider (in-network vs. out-of-network)

• Whether the service is preventive or diagnostic

• If Medicare is your primary or secondary payer

For example, a plan might advertise 20% coinsurance for outpatient procedures, but:

• That 20% kicks in only after you meet a $500 deductible

• If you see an out-of-network provider, the coinsurance might jump to 40%

• If Medicare Part B pays first, your coinsurance might be reduced or even waived

2. Out-of-Network Care Comes with Higher Coinsurance and Exposure

In 2025, PSHB plans consistently penalize out-of-network care with higher coinsurance percentages. Many plans list 40%-50% coinsurance rates for these services.

But it’s not just about a higher percentage. Out-of-network charges can also:

• Exceed the plan’s allowable limits, meaning you pay the difference (balance billing)

• Not count toward your in-network out-of-pocket maximum, prolonging your exposure

If you’re not careful, that 40% coinsurance rate could mean hundreds or thousands more in unexpected charges, especially for high-cost services.

3. Coinsurance Works Differently Before and After You Meet Your Deductible

Your annual deductible in a PSHB plan resets every January. Until you meet it, you typically pay 100% of the cost for covered services (except preventive care, which may be covered in full).

Once your deductible is met, coinsurance kicks in. But that doesn’t mean you’re done paying. Here’s how the math often works:

• Let’s say your deductible is $600

• Your outpatient surgery costs $3,000

• You pay the first $600 in full (deductible)

• You then pay 20% of the remaining $2,400 = $480 in coinsurance

Your total out-of-pocket cost is $1,080 for a single procedure, even though the plan lists 20% coinsurance.

4. Medicare Integration Can Change Your Coinsurance

If you’re a Medicare-eligible Postal Service retiree enrolled in a PSHB plan, your coinsurance responsibility could be significantly reduced—but only if you’re enrolled in Medicare Part B.

In 2025, many PSHB plans coordinate benefits with Medicare. Here’s how that affects coinsurance:

• Medicare Part B pays first for outpatient services

• PSHB plans often waive or reduce coinsurance for services Medicare covers

• Prescription drug coverage is handled through a Medicare Part D EGWP, which caps out-of-pocket spending at $2,000 annually

However, if you didn’t enroll in Medicare Part B when eligible, your coinsurance could remain at standard PSHB levels—meaning higher costs.

5. Out-of-Pocket Maximums Still Leave You Exposed

You may assume your out-of-pocket maximum protects you from runaway costs. While it does cap your annual spending for in-network covered services, this protection has limits:

• Out-of-network services may not count toward the same limit

• Non-covered services and balance billing aren’t included

• Separate limits may exist for prescription drugs vs. medical care

For example, in 2025:

• The in-network out-of-pocket max might be $7,500 for Self Only

• But for out-of-network, it could rise to $10,000 or more

• And for drug costs, there may be a separate $2,000 limit

If you experience a major illness, coinsurance percentages apply until each of these thresholds is met—which may involve thousands of dollars across different care categories.

6. High-Cost Services Can Skew Coinsurance Impacts

The real risk of coinsurance lies in high-dollar services. Even with a seemingly low coinsurance rate, costs add up fast:

• Specialist procedures often run several thousand dollars

• Hospital admissions may cost tens of thousands

• Rehabilitation or outpatient therapies can be recurring

Coinsurance percentages might seem harmless until you apply them to actual billed charges. A 20% coinsurance on a $15,000 hospital bill still means you owe $3,000—and that’s assuming the service was in-network.

This is why you should always:

• Review your plan’s Summary of Benefits and Coverage (SBC)

• Verify network status before scheduling major services

• Understand how preauthorization or referrals affect cost-sharing

7. Coinsurance Differs Based on Service Type

Coinsurance isn’t uniform across all services in your PSHB plan. Instead, it may vary by category:

• Primary care visits may have lower coinsurance or flat copayments

• Specialist visits often come with higher cost-sharing

• Emergency services might use coinsurance and a fixed ER fee

• Mental health services may have different coinsurance rules

Each of these services may have a different combination of:

• Deductible requirements

• Coinsurance percentages

• Copayment options

Misunderstanding these differences can lead you to incorrectly estimate your potential financial responsibility.

8. Coinsurance and Preventive Care Are Not the Same

Don’t confuse coinsurance with what you pay for preventive care. Under the PSHB program, most preventive services are fully covered with no cost-sharing—provided they are received from in-network providers.

Examples include:

• Annual check-ups

• Routine vaccinations

• Cancer screenings (e.g., mammograms, colonoscopies)

But once a screening leads to a diagnosis or treatment plan, the services may shift from preventive to diagnostic—triggering coinsurance.

Understanding where that line is drawn matters. A diagnostic colonoscopy may incur full cost-sharing under your plan, while a routine screening colonoscopy does not.

9. Understanding Your Plan Materials Is Crucial

Your plan brochure or Summary of Benefits and Coverage (SBC) outlines coinsurance terms, but it requires careful reading. Look specifically for:

• A breakdown of coinsurance by service category

• Differences in in-network vs. out-of-network rates

• Whether coinsurance applies before or after the deductible

• Maximum out-of-pocket amounts and what counts toward them

Don’t rely solely on the overview pages. Drill into the fine print, especially for services you expect to use often.

Don’t Let Coinsurance Surprise You in 2025

Coinsurance under the PSHB program can appear straightforward at first glance, but the actual application is far more complex. It changes based on network status, deductibles, Medicare integration, service type, and more.

To protect your finances and plan your care wisely:

• Review your plan’s detailed documents during Open Season

• Ask your provider whether they are in-network before receiving care

• Enroll in Medicare Part B if you’re eligible and your plan reduces coinsurance

If you’re unsure how your PSHB coinsurance works or want help comparing options, get in touch with a licensed agent listed on this website. You deserve clarity before you commit.