Key Takeaways

• Coinsurance in PSHB plans can create financial unpredictability, especially when you least expect it. Understanding your plan’s cost-sharing terms is essential to avoiding surprises.

• The impact of coinsurance can vary drastically depending on the type of care, provider network status, and Medicare integration for retirees.

Why Coinsurance Catches People Off Guard

You may be familiar with premiums, deductibles, and even copayments—but coinsurance works differently. With coinsurance, you’re paying a percentage of the cost of services rather than a fixed amount. In 2025, this cost-sharing element in Postal Service Health Benefits (PSHB) plans is often where people experience the most unpredictability.

Coinsurance usually kicks in after you meet your deductible, and because it’s a percentage rather than a flat fee, the final cost to you can vary wildly depending on how expensive the service is. This means one specialist visit could cost significantly more than another, even if they both fall under the same category of care.

The Range of Coinsurance in 2025 PSHB Plans

PSHB coinsurance rates in 2025 typically range from:

• 10% to 30% for in-network services

• 40% to 50% for out-of-network services

The variation means two people with the same plan could have vastly different out-of-pocket costs based on their provider choices. If you unknowingly visit an out-of-network provider, your share of the bill could double or even triple.

Cost Surprises from High-Value Services

Certain services—like outpatient surgery, advanced imaging (e.g., MRIs, CT scans), and specialist care—can run into thousands of dollars. When you apply even a modest coinsurance rate to these types of charges, you’re suddenly dealing with three-digit or four-digit bills.

And because coinsurance applies after your deductible is met, it often comes at a point in the year when you’re already financially strained by prior expenses.

Medicare’s Role for PSHB Annuitants

If you’re retired and enrolled in Medicare, coinsurance still matters. While some PSHB plans coordinate with Medicare and reduce or waive coinsurance for services covered by Medicare Part B, this is not universal.

• With Medicare Part B: Your PSHB plan might pay most or all of the remaining balance after Medicare pays its share.

• Without Medicare Part B: You’re responsible for a higher portion of the bill, even under the same PSHB plan.

This makes it especially important for retirees to review how their PSHB plan interacts with Medicare. In 2025, failure to enroll in Medicare Part B—unless exempt—can significantly increase your coinsurance obligations.

When the Coinsurance Clock Resets

Another thing that makes coinsurance unpredictable is the annual reset of deductibles and out-of-pocket maximums. On January 1st each year, your deductible starts over, which means coinsurance calculations begin from scratch once you meet it again.

So even if you reached your out-of-pocket limit late in the previous year, you could find yourself hit with full coinsurance rates again early in the next one.

Coinsurance and Out-of-Pocket Maximums: A Tense Relationship

Most PSHB plans cap your total in-network out-of-pocket costs at around $7,500 for Self Only and $15,000 for Self Plus One or Self and Family. While this ceiling does provide a safety net, you’d need to hit that limit before your coinsurance obligations go away.

This means you could still be responsible for thousands in coinsurance before that cap kicks in—especially if your care is spread across multiple types of services, each with their own coinsurance structure.

Preventive vs. Curative: Not All Visits Are Equal

Preventive care—like wellness checkups and immunizations—is usually covered at no cost to you under PSHB plans. But once a visit shifts from preventive to diagnostic or curative, coinsurance might kick in.

For example, if your wellness check leads to further testing or specialist referrals, the follow-up visits are often subject to coinsurance. Many plan participants are caught off guard by this transition.

Network Status Can Flip the Script

Even within PSHB plans, provider networks play a huge role in determining what you pay. In-network providers have negotiated rates with your plan, while out-of-network providers do not—leading to higher costs and steeper coinsurance.

• In-network coinsurance: Typically lower and more predictable

• Out-of-network coinsurance: Higher and can result in balance billing

A provider might also leave the network during the year, which can affect what you owe without any change on your part. This unpredictability reinforces the importance of confirming network status regularly.

Emergency Services: A Special Case

Emergency care is one of the few situations where out-of-network care might still be covered at in-network rates. However, this protection only goes so far. Once you’re stabilized, follow-up care at the same out-of-network facility might not receive the same cost-sharing benefits.

In 2025, it’s still common for emergency services to result in substantial coinsurance charges, especially if you require hospitalization or surgery.

Understanding Plan Summaries Isn’t Optional Anymore

Coinsurance may not jump out at you when you skim your plan summary, but it should. In fact, coinsurance rates are often buried in the Summary of Benefits and Coverage (SBC) and vary by type of service.

To get a clear picture of what you might pay, you need to:

• Review your plan’s SBC for coinsurance breakdowns

• Compare services like lab work, imaging, physical therapy, and surgery

• Check how your plan handles Medicare coordination if you’re retired

PSHB plan brochures on OPM’s website usually provide these details, but it’s up to you to review them.

Don’t Assume Coinsurance Is Always the Same

One common misunderstanding is thinking coinsurance applies uniformly across all services. In reality, coinsurance can differ between:

• Primary vs. specialist care

• Outpatient vs. inpatient procedures

• Durable medical equipment vs. prescription drugs

This fragmented structure adds another layer of unpredictability to your healthcare budget.

Why Coinsurance Planning Matters More in 2025

Healthcare inflation and shifting plan structures mean you’re likely to see changes in coinsurance rates or cost thresholds compared to 2024. Many PSHB enrollees saw plan adjustments during the Open Season from November to December 2024, including:

• Higher coinsurance rates for out-of-network services

• Revised out-of-pocket maximums

• Stricter network requirements

If you didn’t actively review your plan at that time, you may now be enrolled in a plan with different cost-sharing terms than last year.

You’re Not Powerless—What You Can Do Next

Coinsurance can be confusing, but not unmanageable. Here’s how to get a better handle on it:

• Verify network status before scheduling non-emergency services

• Use plan tools to estimate your costs in advance

• Ask about Medicare coordination if you’re a retiree

• Keep records of deductible and coinsurance payments to monitor progress toward your out-of-pocket maximum

Each step helps reduce the shock factor that comes when the bill arrives.

Take Control Before Coinsurance Takes You by Surprise

Coinsurance under PSHB plans in 2025 isn’t just a technicality—it’s a core piece of your healthcare costs. Whether you’re still working or enjoying retirement, understanding how it works can make a significant difference in your financial planning.

Don’t wait until the bills start piling up. If you’re unsure how coinsurance will affect you, it’s time to speak with a licensed insurance agent listed on this website who can help you compare plan summaries, explore Medicare coordination options, and clarify what you’re likely to pay out of pocket.