Key Takeaways

• Coinsurance under PSHB can seem manageable at first glance, but it quickly becomes a financial burden during extended care, hospitalizations, or when specialists and out-of-network providers are involved.

• Understanding how coinsurance works in 2025 PSHB plans—and how it differs from copayments or deductibles—can help you plan for real out-of-pocket costs that might otherwise catch you off guard.

Why Coinsurance Deserves More Attention Than It Gets

Many Postal Service retirees and employees enrolled in PSHB plans assume their monthly premium is the main cost to watch. It’s predictable, after all. But hidden just beneath the surface of your coverage is another number that deserves equal, if not more, scrutiny: your coinsurance rate.

Coinsurance is your share of the cost for a covered healthcare service, calculated as a percentage. For example, if your PSHB plan specifies 20% coinsurance for outpatient surgery, you pay 20% of the approved cost while the plan covers the remaining 80%. That may not sound bad until you see that 20% of $5,000 is $1,000—per service.

Unlike copayments, which are fixed dollar amounts, coinsurance fluctuates based on the cost of care. That means the more care you need, the more you owe.

The Current PSHB Coinsurance Structure in 2025

As of 2025, PSHB coinsurance varies by plan and service type. Here’s what many retirees are facing:

• In-network coinsurance: Usually between 10% and 30% depending on the type of service

• Out-of-network coinsurance: Often 40% to 50%, or more

• Coinsurance waived or reduced with Medicare Part B enrollment

Coinsurance applies after you’ve met your annual deductible. So if your deductible is $500, you pay 100% until that amount is met. Afterward, coinsurance kicks in for further services.

Coinsurance also continues until you hit your plan’s out-of-pocket maximum, which can be as high as $7,500 for Self Only coverage and $15,000 for Self Plus One or Self and Family coverage.

When Coinsurance Costs Start to Snowball

A major misconception is that coinsurance only becomes an issue during catastrophic events. In reality, many common scenarios push you into high-cost territory faster than expected:

• Multiple specialist visits in a short time frame

• Imaging services like MRIs or CT scans, often priced in the thousands

• Outpatient surgeries or procedures done outside a hospital

• Skilled nursing facility stays, especially if Medicare isn’t your primary payer

• Chronic conditions requiring frequent labs or treatments

If you’re seeing several different providers in one quarter, or having recurring therapy appointments, your 20% share stacks up rapidly. Even one outpatient procedure can cost you hundreds, sometimes thousands.

Medicare Part B Can Reduce Your Coinsurance Risk

For Postal Service retirees who are eligible for Medicare Part B, enrolling can significantly cut down your coinsurance responsibilities. Many PSHB plans coordinate with Medicare to reduce or eliminate coinsurance and deductibles.

If you retired before January 1, 2025, you are not required to enroll in Part B. But if you retired on or after that date and are Medicare-eligible, PSHB rules require you to enroll in Part B to keep your PSHB plan. In return, your PSHB plan generally reduces your out-of-pocket costs when Medicare is your primary coverage.

Not enrolling in Medicare Part B when required can result in:

• Full coinsurance charges with no secondary coverage

• Higher deductibles

• Loss of some PSHB benefits

This is where coinsurance can really explode in cost, especially during hospitalizations or specialist care. Without Part B picking up primary responsibility, you are left covering the full coinsurance share yourself.

High Coinsurance Services to Watch Out For

In 2025, PSHB enrollees should pay close attention to the following services where coinsurance typically applies and is most financially impactful:

• Emergency room visits: Usually carry a higher coinsurance and sometimes an additional facility fee

• Advanced imaging (MRI, CT, PET scans): Often cost thousands before insurance

• Physical therapy or occupational therapy: Frequent visits equal frequent coinsurance

• Home health care or skilled nursing: Especially without Medicare coordination

• Durable medical equipment (DME): Items like CPAP machines or mobility aids

These services may not be weekly occurrences, but when they do happen, the bills are significant. You may not reach your out-of-pocket maximum, but you can still easily end up paying $2,000–$5,000 annually out-of-pocket depending on usage.

Comparing Coinsurance to Copayments and Deductibles

It’s easy to confuse coinsurance with other forms of cost-sharing, so here’s how they differ:

• Deductible: The amount you pay each year before your plan starts to share costs

• Copayment: A fixed amount you pay for a specific service (e.g., $30 for a primary care visit)

• Coinsurance: A percentage of the cost of services you pay after the deductible is met

In general, coinsurance has the highest variability and is the least predictable. That makes it risky, especially if your health changes unexpectedly or if you delay care and suddenly need multiple services.

How the Out-of-Pocket Maximum Protects You (Eventually)

Every PSHB plan includes an annual out-of-pocket maximum. This cap limits how much you have to spend in a calendar year on deductibles, coinsurance, and copayments. Once you hit that number, the plan covers 100% of allowed costs.

But here’s the catch: those caps in 2025 can be high.

• Self Only: Up to $7,500 in-network

• Self Plus One / Self and Family: Up to $15,000 in-network

And if you go out of network? Those limits may not apply or may be even higher. Until you hit those caps, you keep paying your percentage. And even if you hit them, it’s likely because you already spent thousands.

What You Can Do Now to Prepare

Here are steps you can take in 2025 to protect yourself from unexpected coinsurance costs:

• Review your plan brochure in full. Know which services involve coinsurance and what those percentages are.

• Use in-network providers whenever possible. Going out of network can double or triple your coinsurance.

• Enroll in Medicare Part B if you’re required or eligible and want to lower your PSHB costs.

• Track your expenses toward the deductible and out-of-pocket maximum throughout the year.

• Consider preventive care while it’s fully covered. Avoid future conditions that may lead to coinsurance-heavy treatments.

These proactive steps can help reduce the surprise factor of coinsurance and give you more control over your annual healthcare spending.

Why Coinsurance Should Factor Into Your Plan Choices

When choosing a PSHB plan during Open Season from November to December, most enrollees focus on premiums. But coinsurance, deductibles, and out-of-pocket maximums should weigh just as heavily in your decision.

Two plans with the same monthly premium can have dramatically different cost-sharing structures:

• One might offer lower coinsurance but a higher deductible

• Another may waive coinsurance if you have Medicare Part B

• A third could offer higher coinsurance but lower copayments for frequent visits

If you expect to need surgery, therapy, or ongoing treatment in 2025, coinsurance becomes a central part of your cost analysis. Don’t wait until after you’re hit with a bill to realize you chose a plan that makes you pay 30% of a $10,000 procedure.

Addressing the Bigger Picture of Health Costs

Coinsurance is just one part of the financial equation under PSHB. It’s connected to premiums, copayments, deductibles, and out-of-pocket maximums. When you evaluate or change your plan, you should consider all of these parts as one whole system.

Don’t let coinsurance remain invisible. In 2025, it’s a key variable in your financial health and your access to care. Treat it with the attention it deserves.

Make Coinsurance a Central Part of Your Healthcare Planning

Coinsurance may look small on paper, but it adds up fast. It’s one of the biggest blind spots for PSHB enrollees—especially if you don’t have Medicare Part B as a secondary payer. To avoid big surprises, you need to anticipate how coinsurance fits into your total yearly health spending and factor that into your plan choices.

If you’re unsure about how your coinsurance costs could affect you this year, talk with a licensed agent listed on this website. They can help walk you through your plan options and give you a clearer picture of what to expect.