Key Takeaways

• Coinsurance under PSHB might seem straightforward, but the actual amounts you pay out of pocket can vary dramatically depending on your service, provider, and Medicare status.

• In 2025, understanding how your coinsurance interacts with deductibles, out-of-pocket maximums, and Medicare Part B enrollment is essential to avoid unexpectedly high costs.

What Coinsurance Means Under PSHB in 2025

Coinsurance is the percentage of medical costs you pay after meeting your deductible. Unlike copayments, which are fixed amounts, coinsurance is a proportion of the total bill. With the Postal Service Health Benefits (PSHB) program now fully in place for 2025, the coinsurance structure is more relevant than ever.

Most PSHB plans have different coinsurance rates for in-network and out-of-network services:

• In-network coinsurance generally ranges between 10% and 30%.

• Out-of-network coinsurance may rise as high as 40% to 50%.

If your medical service costs $5,000 and your plan includes 30% coinsurance, you’re responsible for $1,500 after your deductible. But that’s just the beginning.

How Deductibles Shift the Cost Burden

Before coinsurance kicks in, you need to satisfy your plan’s deductible. In-network deductibles in PSHB plans typically fall between $350 and $500, while out-of-network deductibles often range from $1,000 to $3,000.

Until you hit that threshold, you’re paying 100% of the cost. Only afterward do coinsurance percentages apply. Here’s a general flow:

1. You pay the full amount until your deductible is met.

2. After the deductible, you share costs with the plan using coinsurance.

3. Once you hit your out-of-pocket maximum, the plan pays 100%.

This sequence may sound manageable, but real financial strain comes from high-cost services like hospitalizations, surgeries, or specialist visits where coinsurance can quickly snowball.

When Medicare Matters Most

If you’re 65 or older and enrolled in Medicare Part B, your PSHB coinsurance burden could drop dramatically. Many PSHB plans coordinate with Medicare to offer cost-sharing reductions or even eliminate coinsurance after Medicare pays its share.

Here’s what changes for Medicare-eligible enrollees:

• Deductibles may be waived or reduced.

• Coinsurance may be lower or even eliminated.

• The plan may pay as if Medicare is the primary payer.

However, if you don’t enroll in Medicare Part B when required, your PSHB plan won’t coordinate benefits. That means you could be on the hook for both the deductible and full coinsurance amounts as if you had no secondary coverage at all.

Out-of-Pocket Maximums: Not a Safety Net for Everyone

In 2025, PSHB plans cap your in-network out-of-pocket costs at around $7,500 for Self Only and $15,000 for Self Plus One or Family. While this offers a ceiling to your expenses, the path to reaching that limit can still be financially draining.

Here’s where the math turns complex:

• Only in-network coinsurance and deductibles count toward the out-of-pocket maximum.

• Out-of-network costs often have a separate, higher maximum.

• Prescription drug costs may or may not count, depending on how your plan integrates with Medicare Part D.

So if you receive out-of-network care, your cost-sharing may continue beyond the regular maximum.

Specialty Care and Coinsurance Surprises

Coinsurance doesn’t apply uniformly across all services. Specialist visits, lab tests, physical therapy, and outpatient procedures often have separate coinsurance rules. In-network specialist visits typically involve:

• $30 to $60 copayments, or

• 20% to 30% coinsurance

For outpatient surgery or hospital care, coinsurance can reach 25% to 30% even within the network. If you go out-of-network, that could rise to 50% or more.

The financial exposure increases when multiple services are billed under one encounter. A single hospital visit might involve:

• Room and board charges

• Diagnostic tests

• Surgeon and anesthesiologist fees

Each component can carry its own coinsurance percentage.

Pharmacy Costs: A Separate Equation

Prescription drugs under PSHB are often integrated with Medicare Part D for those who are eligible. In 2025, the Medicare Part D out-of-pocket cap is set at $2,000 annually, which limits your spending on medications.

But here’s the catch:

• If you’re not enrolled in Medicare, your drug costs under PSHB may not have the same cap.

• Tiered coinsurance or copayments for brand-name and specialty drugs can still result in hundreds of dollars monthly.

• Out-of-network pharmacy claims may not be covered at all.

Even if you hit your deductible and coinsurance limits for medical services, your pharmacy costs could keep accumulating if they’re managed separately.

Emergency Room and Urgent Care Coinsurance

Emergency services typically have a fixed copayment or coinsurance percentage. Here’s how it generally looks under PSHB:

• Emergency Room Visits: $100 to $150 copay or 20% coinsurance

• Urgent Care: $50 to $75 copay or similar coinsurance

If you’re admitted to the hospital from the ER, some plans apply inpatient coinsurance instead. And if the emergency happens out of network, you may still face higher cost-sharing despite the nature of the situation.

Family Coverage Brings Multiple Layers

If you’re enrolled in a Self Plus One or Self and Family plan, coinsurance applies separately to each covered individual. Each family member may need to:

• Meet their own deductible

• Reach their individual out-of-pocket maximum, or

• Contribute to a family-wide out-of-pocket max

This layered approach means coinsurance costs can multiply quickly if more than one person in your household needs frequent or complex care.

Why Plan Design Choices Matter

During the PSHB Open Season (November through December), the plan you choose can significantly influence how much coinsurance you pay in the following year. Factors to compare:

• Deductible amounts

• Coinsurance percentages

• Network size and access to preferred providers

• Coordination with Medicare

• Prescription coverage integration

Small differences in plan design can result in thousands of dollars in extra coinsurance costs over the year, especially if you anticipate high healthcare utilization.

Timing of Services Affects Cost Exposure

Coinsurance resets each calendar year. If you schedule procedures early in the year before hitting your deductible, your coinsurance costs will be much higher. But if you’ve already met your deductible and are nearing your out-of-pocket maximum, the same procedure later in the year could cost far less.

Strategically:

• Consider bundling elective services after you’ve met your deductible.

• Track your spending to know when you’re approaching caps.

• Time specialist visits and tests in a sequence that reduces duplicated cost exposure.

The Role of Preventive Services

Not everything triggers coinsurance. Most PSHB plans, aligned with federal standards, cover preventive services at no cost to you when delivered by in-network providers. These typically include:

• Screenings (cancer, blood pressure, diabetes)

• Immunizations

• Annual wellness exams

However, if a preventive visit leads to additional diagnostic services, coinsurance might apply to the resulting tests or procedures.

Thinking Beyond Just Coinsurance

While coinsurance is a major cost factor, it’s one part of a broader out-of-pocket puzzle. To manage your overall costs effectively:

• Understand how coinsurance works with deductibles and copays.

• Verify if your provider is in-network.

• Know whether you’re required to enroll in Medicare Part B.

• Track your progress toward your out-of-pocket maximum.

• Review the PSHB plan brochure in detail during Open Season.

Coinsurance might be a percentage, but the financial impact can feel like a whole lot more without proper planning.

Why It’s Worth Doing the Math Ahead of Time

The biggest mistake people make under PSHB in 2025 is underestimating how coinsurance adds up. It’s tempting to focus on premiums alone, but what you actually spend during the year can be dominated by coinsurance, especially in high-use scenarios.

Take the time to calculate:

• Your total risk exposure (deductible + coinsurance up to the out-of-pocket max)

• How your plan coordinates with Medicare if you’re eligible

• What services are most likely to incur high coinsurance

Even seemingly small percentages like 20% or 30% can turn into thousands of dollars, depending on your healthcare needs.

Understand the Real Cost Behind That Percentage

Coinsurance is one of the most misunderstood elements of PSHB plans, but also one of the most financially significant. What looks like a simple percentage often becomes a substantial out-of-pocket expense, especially when combined with high deductibles, separate drug costs, and provider network limitations.

Choosing the right PSHB plan during Open Season—and knowing how Medicare Part B fits in—is your best defense against coinsurance surprises. Don’t rely on assumptions. Look at the math, evaluate the risks, and prepare to protect your financial health just as much as your physical health.

For personalized guidance on selecting the right plan or understanding your cost-sharing obligations, get in touch with a licensed agent listed on this website.