Key Takeaways

• Your deductible under a PSHB plan can reset mid-year in ways that are not clearly disclosed, often tied to specific care timelines and plan rule changes.

• Understanding when and why deductibles can reset can help you avoid thousands in unexpected out-of-pocket costs during critical periods of care.

Why You Should Not Assume One Deductible Per Year

When you enroll in a Postal Service Health Benefits (PSHB) plan, it’s easy to assume your deductible resets on January 1 and remains consistent for the full calendar year. That’s the general rule, but some plan details create exceptions—and they aren’t always clearly explained upfront.

In 2025, most PSHB plans still operate on a calendar-year basis. However, the way certain deductibles apply to family coverage, hospital readmissions, and changes in care settings can result in what effectively feels like a reset—without any formal notice.

Family Deductibles Can Create Mid-Year Surprises

In family coverage tiers (Self Plus One or Self and Family), the deductible is typically split into two parts:

• Per-person deductible: Applied individually to each covered member

• Family deductible cap: Once this threshold is reached, the plan covers other expenses regardless of who incurred them

This setup can cause issues when only one family member has used the majority of services early in the year. If another family member requires care mid-year, you may be responsible for their full per-person deductible even if your overall family spending feels substantial.

How Hospitalization Can Trigger a New Deductible Period

Hospital stays under PSHB plans often operate within the deductible framework. What many enrollees overlook is that readmissions and transfers between care facilities (e.g., from hospital to skilled nursing) may trigger new deductible applications, especially if they occur after a break in care.

The 60-Day Rule: A Critical Timeline

Under many PSHB plans in 2025, there is a 60-day benefit period window for hospital coverage. If you are discharged and then readmitted after 60 days, your deductible may start over—tied to a new benefit period.

This is not considered a mid-year plan change, so you won’t get formal notice. But the result is the same: you must pay your deductible again before coverage resumes.

Mid-Year Enrollment Changes Can Reset or Reapply Deductibles

Although PSHB enrollment is generally locked for the year unless you have a Qualifying Life Event (QLE), certain events like marriage, divorce, or birth of a child allow you to make changes. What many do not realize is:

• If you switch from Self Only to Self and Family, a new deductible may apply to the newly added members.

• Switching plans during a QLE (such as from a low-deductible to high-deductible plan) may reset the deductible counter for the remainder of the year.

No Retroactive Credit for Past Spending

If you hit your deductible under Plan A and then change to Plan B during a QLE, your prior spending doesn’t carry over unless both plans explicitly state that they share data. Most don’t. This means:

• You could pay two deductibles in a single calendar year

• You may lose progress toward out-of-pocket maximums

Prescription Drug Deductibles Can Have Their Own Reset Cycle

Even within the same plan, your medical deductible and prescription drug deductible might be separate. In 2025, many PSHB plans include a standalone deductible for medications—particularly brand-name or specialty drugs.

What’s important to understand:

• These deductibles are often tier-specific

• Switching medications mid-year or switching pharmacies may trigger deductible reapplication

• Some drug deductibles reset based on coverage phases, not calendar dates

The Donut Hole Is Gone, But Phase-Based Deductibles Remain

While the Medicare Part D donut hole has been eliminated in 2025, PSHB plans integrated with Medicare Part D Employer Group Waiver Plans (EGWPs) can still include phase-based cost structures:

1. Deductible Phase – Out-of-pocket costs before coverage begins

2. Initial Coverage Phase – Copays and coinsurance apply

3. Catastrophic Phase – Plan covers 100% after $2,000 out-of-pocket cap

If your drug spending reaches the catastrophic phase and you change plans mid-year due to a QLE, the new plan might require you to start back at the deductible phase.

Care Settings Matter More Than You Might Think

Many PSHB plans in 2025 differentiate between inpatient and outpatient services, and apply deductibles separately. That means:

• A procedure at an outpatient surgical center may fall under a different deductible than the same procedure done at a hospital

• Switching from outpatient to inpatient care (e.g., same-day surgery that requires overnight monitoring) may restart deductible calculations

This can catch you off guard, especially if:

• You’re in a high-deductible plan

• You didn’t plan for an extended hospital stay

Medicare Coordination Doesn’t Always Eliminate Deductibles

If you’re Medicare-eligible and enrolled in both Medicare Part B and a PSHB plan, you may assume you’re off the hook for deductibles. That’s only partly true.

Some PSHB plans waive or reduce deductibles for enrollees with Medicare Part B, but not all do. And even if they do, it often applies to medical deductibles only, not:

• Prescription drug deductibles

• Dental or vision deductibles (if offered as optional benefits)

Moreover, deductibles for out-of-network care may still apply, regardless of your Medicare status.

Medicare Enrollment Timing Affects Deductible Relief

Under PSHB rules in 2025, your Medicare Part B coordination benefits begin only after enrollment is active. If you turn 65 mid-year and delay enrollment, you might:

• Miss out on waived deductibles for part of the year

• Pay a prorated share until Medicare benefits start

Watch for Subtle Changes in Plan Documents

The PSHB plan brochures issued during Open Season typically include the full year’s deductible rules. However, mid-year plan updates due to federal regulation changes or administrative clarifications may alter how deductibles apply in practice.

These changes rarely come with formal mailings unless they are drastic. Instead, they may appear as:

• Website updates

• Revised FAQ pages

• Addenda to existing plan documents

You’re responsible for keeping up with these. And missing them can lead to unexpected deductible resets, especially for high-use services.

What You Can Do to Stay Ahead of Mid-Year Deductible Shifts

Staying informed about how and when your PSHB deductible might reset is the best defense against mid-year surprises. Here are some actionable steps:

• Review your plan’s summary of benefits each January

• Save a PDF copy of the full plan brochure at the start of the year

• Track each family member’s deductible progress using your insurer’s online portal

• Ask about coordination rules if you become eligible for Medicare mid-year

• Confirm deductible policies when switching plans or changing enrollment tiers

Also, keep in mind that some plans offer deductible trackers or real-time dashboards. If yours does, use it. If not, you may need to log expenses manually.

Small Details That Can Trigger Big Expenses

It’s not always the major surgeries or hospitalizations that trigger the largest deductible implications. Some seemingly minor scenarios that have caused mid-year resets or duplicate applications include:

• Multiple ER visits coded as separate episodes

• Specialist referrals processed out-of-network

• Reinitiating physical therapy after a care gap

These are technical distinctions that matter in PSHB deductibles. Make sure you ask your provider how your service will be coded and double-check it matches your plan’s deductible logic.

When Deductibles Stack Up Without You Realizing

You could be in a situation where more than one deductible applies simultaneously. For instance:

• You may owe a medical deductible, a separate drug deductible, and a facility fee deductible

• If you switch to family coverage, each new member could trigger their own per-person deductible

• When care spans different calendar years (e.g., late December surgery with rehab in January), deductibles restart automatically

This makes timing care strategically—within a benefit period and after reviewing plan resets—critical for avoiding duplicated costs.

Don’t Assume Your Deductible Is One-and-Done

Understanding how your PSHB deductible works in 2025 is essential for avoiding financial surprises. While the calendar year may serve as the default reset point, the reality is more complex.

If you’re undergoing ongoing treatment, switching plans, or reaching new coverage phases, be aware that your deductible could quietly reset—or be reapplied—without formal notice. Stay proactive by reading plan updates, monitoring spending, and confirming your current deductible status directly with your insurer.

To make sure you’re not paying more than you should, reach out to a licensed agent listed on this website. They can help you understand how your PSHB plan’s deductible works—and when it might reset—based on your specific situation.