Key Takeaways

• Coinsurance under the PSHB program can appear modest at first but quickly compound into significant out-of-pocket expenses if you need extensive care.

• Understanding your plan’s coinsurance percentage, deductibles, and out-of-pocket limits is crucial to avoiding financial surprises during major medical events.

What Coinsurance Really Means for You in 2025

As a Postal Service Health Benefits (PSHB) enrollee in 2025, coinsurance plays a major role in how much you actually pay for medical services. While premiums and deductibles often get the spotlight, coinsurance quietly affects your costs behind the scenes—especially when unexpected or high-cost care enters the picture.

Coinsurance is the percentage of medical costs you’re responsible for after you’ve met your plan’s deductible. For instance, if your plan specifies 20% coinsurance, you pay 20% of the allowed cost of a service, and the plan pays the remaining 80%.

This setup might seem manageable during routine visits, but the reality shifts dramatically once major health events occur.

The Tipping Point: Why It Starts Small

Coinsurance costs usually begin small—especially if you’re healthy and only occasionally visit the doctor. For many PSHB participants, annual preventive care and routine checkups are either fully covered or subject to minimal copayments.

However, once you require:

• Imaging services (like MRIs or CT scans)

• Specialist consultations

• Hospital stays or outpatient surgery

• Long-term therapies such as physical or occupational therapy

—you quickly find that coinsurance stacks up. Unlike copayments, which are fixed fees, coinsurance is a percentage of the total cost, which varies depending on the service.

Where It Gets Expensive: Cost Layers to Watch

Coinsurance doesn’t operate in a vacuum. To understand why it can explode under PSHB, consider how it interacts with other cost components:

Deductible Requirements

You must first meet your plan’s annual deductible, which can range from several hundred to a few thousand dollars depending on the type of PSHB plan you’ve chosen (low-deductible vs. high-deductible).

Only after reaching this threshold does coinsurance apply. This means that during the early part of the year—or after a major procedure—you may find yourself paying full negotiated costs until your deductible resets.

In-Network vs. Out-of-Network Rates

PSHB plans encourage you to use in-network providers by offering lower coinsurance percentages. Out-of-network care often involves higher percentages and balance billing—where you’re billed for the difference between what your plan pays and what the provider charges.

This makes it critical to:

• Confirm network status before care

• Ask your provider to confirm billing practices

No Cap on Individual Services

Coinsurance is not a fixed dollar amount per visit. If your doctor orders a $2,000 imaging scan and your coinsurance is 30%, you’re on the hook for $600. Multiple such services within a short period can lead to thousands in out-of-pocket costs—even if you’re within your plan’s network.

The Role of the Out-of-Pocket Maximum

Here’s where your financial protection kicks in: Every PSHB plan comes with an annual out-of-pocket maximum for covered in-network services. In 2025, this amount typically ranges from $5,000 to $7,500 for Self Only plans, and up to $15,000 for Self Plus One or Self and Family coverage.

Once you reach that limit, the plan pays 100% of allowable charges for the rest of the year. But until you hit that threshold, you’re financially responsible for:

• Deductibles

• Coinsurance

• Copayments

In a serious health event—like surgery or prolonged treatment—you could reach that maximum quickly. But until you do, coinsurance continues applying to each bill.

You Might Not Notice Until It’s Too Late

Many enrollees don’t pay close attention to coinsurance until a high-cost claim arrives. That’s often because:

• Statements from providers and insurers can be delayed.

• Multiple bills come from different providers for the same event.

• The full coinsurance percentage isn’t always apparent on service estimates.

By the time you realize what you owe, it may be several weeks or months after the care was delivered.

What You Can Do to Stay Ahead of Coinsurance Costs

Staying ahead of coinsurance means being proactive—not just at the time of treatment, but throughout the year. Here’s how you can stay in control:

1. Review Your Summary of Benefits

Every PSHB plan provides a Summary of Benefits and Coverage (SBC). This document outlines:

• Coinsurance percentages for various services

• Annual deductible and out-of-pocket maximums

• Differences between in-network and out-of-network costs

Make sure you understand your plan’s layout early in the year so there are no surprises later.

2. Ask for Cost Estimates

Before undergoing a test, procedure, or specialist visit, ask for a cost estimate. Most provider offices can give you an approximate cost based on your insurance plan.

Request the estimate in writing when possible, and verify whether the provider is in-network.

3. Track Your Spending Through the Year

Many health plans, including PSHB options, offer online portals or mobile apps where you can:

• View claims

• Track deductible status

• See where you are in relation to your out-of-pocket maximum

Logging in regularly can help you understand when coinsurance will kick in—and when it might end.

4. Don’t Skip Preventive Care

Most preventive services are covered at 100% when performed by in-network providers. Take advantage of these services to catch health issues early—before they require expensive intervention subject to coinsurance.

5. Know Your Appeal Rights

Sometimes billing errors or out-of-network denials cause inflated coinsurance charges. You have the right to:

• Request itemized bills

• Challenge denied claims

• File an appeal with your PSHB plan

If something seems off, don’t hesitate to investigate.

High-Deductible Plans Make Coinsurance More Noticeable

In 2025, more PSHB enrollees are choosing high-deductible health plans (HDHPs), often paired with Health Savings Accounts (HSAs). These plans tend to:

• Offer lower monthly premiums

• Require you to meet a high deductible before coverage begins

• Involve coinsurance after the deductible until the out-of-pocket maximum is reached

If you’re enrolled in an HDHP, you’ll likely feel the impact of coinsurance more acutely—especially in the early part of the year before hitting your deductible.

Using an HSA to pay coinsurance costs can help, but you must budget and contribute regularly to avoid gaps in available funds when expenses arise.

Comparing Coinsurance to Copayments: Why It Matters

It’s easy to confuse coinsurance with copayments, but they operate differently:

• Copayments are flat fees (e.g., $25 for a specialist visit)

• Coinsurance is a percentage (e.g., 20% of the allowed cost)

While copayments give you predictable costs, coinsurance fluctuates with the price of care. A specialist visit may cost you far more under a coinsurance structure if the provider charges high rates—even if they’re in-network.

Understanding which services use which payment type is critical to budgeting accurately.

Timing Matters: Your Coinsurance Resets Each Year

Like your deductible and out-of-pocket maximum, coinsurance resets annually—on January 1 for most PSHB plans. This means:

• All costs start fresh at the beginning of the year

• Medical services early in the year may cost more out of pocket

• Late-year procedures could be fully covered if you’ve met your maximum

Planning non-urgent treatments later in the year (after you’ve met the deductible) can reduce what you owe in coinsurance.

When to Re-Evaluate Your Plan

Open Season, typically held from November to December each year, is your chance to:

• Review how much you paid in coinsurance this year

• Compare plan options for the next year

• Choose a plan that better fits your health needs and financial situation

If you faced high coinsurance costs this year, look for plans with:

• Lower coinsurance percentages

• Lower deductibles

• A more robust in-network provider list

You can also consult with a licensed agent listed on this website during Open Season to ensure you’re making an informed decision.

Coinsurance Can Be Managed—If You Stay Informed

Coinsurance is one of those healthcare terms that seems minor until it isn’t. While it may feel invisible when your health needs are simple, it becomes a central financial factor when something major happens. And because it works as a percentage rather than a fixed amount, the risk of surprise expenses is always there.

Take the time to understand how your PSHB plan calculates coinsurance and how it fits into the broader picture of your deductible and out-of-pocket maximum. Don’t assume coinsurance will stay small—because once the bills start arriving, it usually doesn’t.

Need personalized help evaluating your options? Reach out to a licensed agent listed on this website for guidance that aligns with your specific needs and circumstances.