Key Takeaways

• Coinsurance under PSHB plans in 2025 can add up quickly, especially if you use out-of-network providers or need high-cost specialty care. It’s not a flat fee—it’s a percentage, and that percentage can represent thousands.

• Understanding how coinsurance works within your selected plan can help you manage risk and avoid paying more in out-of-pocket costs than your actual annual premium.

Why Coinsurance Deserves Your Full Attention in 2025

Many Postal Service employees and annuitants entering the PSHB system this year are discovering a crucial truth: coinsurance can drastically affect your annual medical expenses. Unlike copayments—which are fixed fees for services like doctor visits—coinsurance is a percentage of the total cost. And when that cost is high, your share can be shockingly large.

The coinsurance clause doesn’t always sound alarming at first glance. A figure like 20% may not seem threatening until you apply it to an MRI, surgery, or hospital stay that runs into the tens of thousands. This means a $40,000 surgery could cost you $8,000 out of pocket. That’s more than most enrollees pay in annual PSHB premiums.

How PSHB Coinsurance Works in Practice

In 2025, PSHB plans generally include two main types of cost-sharing beyond premiums:

• Deductibles: What you pay before your plan begins covering services.

• Coinsurance: A percentage of covered medical costs that you continue to pay after meeting your deductible.

Depending on your plan and provider network status, coinsurance rates typically range:

• In-network care: 10% to 30% of allowed charges

• Out-of-network care: 40% to 50% of allowed charges

That range alone should get your attention. The jump in cost from in-network to out-of-network services can more than double your coinsurance burden.

Also, some plans distinguish between types of services. For example:

• Primary care: Lower coinsurance or copay

• Specialty care: Higher coinsurance, particularly for advanced imaging, surgery, or durable medical equipment

Coinsurance continues until you hit your annual out-of-pocket maximum. For 2025, in-network caps generally fall around $7,500 for Self Only coverage and $15,000 for Self Plus One or Self and Family. If you hit that cap, your plan pays 100% for the rest of the year.

The Hidden Risk: You May Pay More Than You Think

Many enrollees underestimate how fast coinsurance adds up. Even without major surgery, a combination of outpatient diagnostics, physical therapy, or specialist visits can push your costs higher than expected.

Let’s say you have:

• Three specialist visits billed at $400 each

• A diagnostic procedure costing $2,000

• Monthly medications totaling $1,200 over the year

With a 30% coinsurance, those services alone can push your out-of-pocket payments beyond $1,500—and that’s before counting deductibles or copayments.

Now factor in:

• High-cost prescriptions

• Physical rehabilitation

• Emergency room visits

• An unexpected outpatient procedure

You can easily exceed your total annual premium in cost-sharing alone. And if you used out-of-network services by mistake or necessity, the financial exposure could double.

The In-Network Advantage

The difference between in-network and out-of-network coinsurance rates is not just a minor inconvenience. In 2025, this difference is one of the biggest cost drivers in PSHB plans.

In-network providers have agreements with your plan to accept lower rates. That means:

• You’re billed less overall

• Your coinsurance applies to the discounted rate, not the provider’s standard charge

With out-of-network care:

• Coinsurance is higher

• Providers can balance bill you—charging you the difference between their fee and what the plan covers

• You pay more, and you pay it faster

That’s why plan brochures and summary of benefits always emphasize using in-network providers. It’s not just about access—it’s about preventing you from paying twice as much for the same service.

Medicare and Coinsurance for PSHB Annuitants

If you’re retired and eligible for Medicare, coordinating PSHB with Medicare Part B can significantly reduce your coinsurance costs. In fact, many PSHB plans in 2025 offer enhanced benefits for enrollees who are also enrolled in Medicare Part B:

• Waived or reduced deductibles

• Lower coinsurance or copayments

• Coverage of services Medicare partially pays for

That said, if you opt out of Part B when you’re required to enroll, your PSHB coinsurance costs may rise steeply. Some plans may not cover services fully unless Medicare pays its share first.

Tips to Control Coinsurance Costs

You can’t avoid coinsurance altogether under most PSHB plans, but you can reduce your exposure by being proactive:

1. Choose Your Plan Carefully

Some PSHB plans have lower coinsurance rates or more generous out-of-pocket limits. Review each plan’s Summary of Benefits and compare:

• In-network coinsurance rates

• Out-of-pocket maximums

• Medicare coordination policies

2. Use In-Network Providers

Always verify that a provider or facility is in-network before scheduling care. Call the number on your plan card or check the plan’s online directory.

3. Coordinate With Medicare (If Eligible)

Enroll in Medicare Part B if you’re required and eligible. PSHB plans integrate with Medicare to lower your financial exposure substantially.

4. Consider Preauthorization Requirements

For high-cost services like imaging or inpatient care, check whether your plan requires prior approval. Skipping this step can result in denied claims, leaving you responsible for 100% of the cost.

5. Track Your Spending

Keep receipts and EOBs (Explanation of Benefits) so you know how close you are to your annual deductible and out-of-pocket maximum. This helps you plan upcoming care strategically.

What to Expect if You Need Major Care

Coinsurance matters most when the stakes are highest—after a diagnosis, surgery, or hospital admission. Here’s what to expect:

• After meeting your deductible, you’ll still owe coinsurance until you hit the out-of-pocket maximum.

• Some plans separate in-network and out-of-network maximums, so hitting one doesn’t cap the other.

• If you don’t have Medicare and aren’t enrolled in a plan with good cost-sharing protections, your financial burden could reach five figures.

The PSHB program is designed to offer strong coverage, but it’s your responsibility to understand your financial responsibilities before a major event occurs. Don’t wait until after a hospital stay to discover how your plan works.

Why 2025 Is Different

2025 is the first year of full PSHB implementation. If you were previously in the fehb system, you might assume coinsurance rules are unchanged. But PSHB plans were built specifically for Postal Service members and come with different cost structures, formularies, and provider networks.

Key differences you should pay attention to include:

• Coinsurance percentages for in-network vs. out-of-network

• What counts toward the out-of-pocket limit

• Whether your current providers are still in-network

• Coordination rules with Medicare Part B

Staying Ahead of PSHB Surprises

This year, the most informed enrollees are those who read their plan details, review their provider options, and stay aware of how cost-sharing works.

• Check your PSHB plan’s benefit booklet carefully.

• Use the PSHB Navigator tool online to compare plans if eligible.

• Monitor your claims and track cost-sharing throughout the year.

• Reassess your plan each Open Season to ensure it still meets your needs.

Don’t Let Coinsurance Catch You Off Guard

Coinsurance is one of the most overlooked but expensive elements in the PSHB system. If you don’t understand how it works or which providers to use, you may end up paying more out of pocket than you ever expected—even more than your total premium for the year.

Make sure you understand your PSHB plan’s cost-sharing details and use that knowledge to make informed, confident decisions about your care. And if you’re unsure, speak to a licensed agent listed on this website who can help you analyze your plan.