Key Takeaways

• Out-of-network deductibles under PSHB can be more than double the in-network amounts, but this detail is often buried deep in plan brochures.

• Failing to understand the difference between in-network and out-of-network deductible structures can lead to substantial, unexpected costs—especially for services outside your primary area.

Why Out-of-Network Deductibles Matter More Than You Think

If you’re enrolled in the Postal Service Health Benefits (PSHB) Program, you’ve probably seen your deductible amount listed in the summary section of your plan brochure. It likely looks manageable—especially if you’ve selected a low or standard deductible option.

But what many PSHB enrollees miss is this: that figure only applies to in-network services. If you use an out-of-network provider, your deductible can double—or even triple—depending on the plan. And this shift isn’t usually displayed prominently in marketing materials or even in summary tables. It often requires a detailed look at the full benefits brochure, especially the footnotes and exclusions section.

What Is an Out-of-Network Deductible?

A deductible is the amount you must pay for health services out of your own pocket before your plan begins covering costs. Most PSHB plans offer different deductibles based on whether you see an in-network or out-of-network provider.

• In-network providers have negotiated lower rates with the insurance plan.

• Out-of-network providers have no agreement with the insurer, meaning higher billed charges—and higher deductibles.

For instance, while your in-network deductible might be $500, your out-of-network deductible could be $1,000 or more.

In 2025, many PSHB plans list in-network deductibles between $350 and $600 for Self Only coverage, but out-of-network deductibles can reach as high as $1,500 or more for the same tier. And that’s just the deductible—coinsurance and maximum out-of-pocket costs are also substantially higher out of network.

Why This Isn’t Stated Clearly in Most Places

One of the challenges in understanding PSHB deductibles is the way information is presented. Here’s what often happens:

• Summary pages list only the in-network deductible. The out-of-network amount may appear later in a chart or in a different section.

• Marketing materials simplify language to focus on selling points like low premiums or coverage features, often skipping complex deductible structures.

• Out-of-network costs are included as footnotes or in side-by-side comparison tables that aren’t prominently displayed.

This format assumes the reader is already familiar with how deductibles work—which, in practice, leads many to assume the deductible is a flat rate no matter where care is received.

How Network Status Impacts What You Pay

To understand how deductibles vary, it helps to break down the layers of cost exposure:

1. Deductibles

• In-network deductibles are the lower amount you pay before the plan starts cost-sharing.

• Out-of-network deductibles are often 2x–3x the in-network amount.

• Deductibles typically reset every calendar year.

2. Coinsurance After Deductible

• Once you meet your deductible, you usually pay a percentage of the service cost.

• Coinsurance might be 20% in-network but 40%–50% out-of-network.

• This can result in a single visit costing hundreds more.

3. Out-of-Pocket Maximums

• Out-of-network out-of-pocket maximums are usually much higher.

• Some plans cap in-network costs at $7,500 for Self Only but allow up to $15,000 or more for out-of-network.

These differences make it crucial to stay in-network whenever possible.

Hidden Scenarios That Trigger Out-of-Network Costs

The idea of going out-of-network might sound like a choice, but there are situations where you may not even realize it’s happening. Some common cases include:

• Emergency services outside your home area: If you visit an ER in another state, the hospital or physicians might not be in your plan’s network.

• Specialist referrals: Your primary doctor may refer you to a specialist who is out of network without explicitly stating so.

• Lab work or imaging: Tests ordered by your doctor may be processed by an out-of-network facility, even if your visit itself was in-network.

Unless you’re carefully checking each service provider, you may inadvertently trigger an out-of-network deductible.

The Impact on Families and Self Plus One Plans

For those enrolled in Self Plus One or Self and Family coverage, the cost risk is amplified. Out-of-network deductibles are often listed per person and per family, meaning that if more than one family member receives out-of-network care, you may have to meet the higher deductible multiple times.

• A Self Plus One plan might list an in-network deductible of $700 total, but $3,000 for out-of-network combined.

• In a Self and Family plan, the out-of-network deductible can exceed $4,000.

The key takeaway: unless all household members strictly stay in-network, total exposure climbs fast.

Why Timing Matters: When Deductibles Reset

All PSHB deductibles reset on a calendar-year basis. That means if you receive care in December and again in January, you may have to pay your full deductible twice in a short period.

And if either of those services is out-of-network:

• The out-of-network deductible may apply on top of the in-network deductible.

• Some plans have separate tracking for in-network and out-of-network amounts. That means paying toward one doesn’t count toward the other.

In these situations, one hospital stay or procedure could trigger a full out-of-network deductible at the start of a new year—regardless of how much you paid last year.

Strategies to Avoid the Higher Deductible Surprise

The best way to avoid the elevated out-of-network deductible under PSHB is to proactively confirm the network status of all providers and services. Here are some strategies:

• Use the official plan directory: Always start by verifying doctors, hospitals, labs, and imaging centers directly from your plan’s current network list.

• Double-check referrals: If a doctor refers you, confirm that every provider and facility involved is in-network—even if they’re in the same building.

• Ask in advance: Before scheduling procedures, ask your doctor whether any part of the service may be billed out-of-network.

• Know your plan’s structure: Some PSHB plans offer partial out-of-network coverage, while others may not cover certain services at all unless pre-authorized.

By staying informed and asking the right questions, you can often avoid triggering higher deductibles altogether.

medicare Integration and Out-of-Network Considerations

If you’re a Medicare-eligible annuitant enrolled in a PSHB plan with Medicare Part B, your deductible structure might differ. Some PSHB plans coordinate with Medicare in a way that:

• Waives or reduces in-network deductibles.

• Limits exposure to out-of-network charges if Medicare pays first.

However, even in these cases, not all services are protected from out-of-network pricing. Especially if you opt out of Part B or use services Medicare doesn’t cover, the higher PSHB deductible may still apply.

Always review your specific plan’s Medicare coordination section to understand these rules.

What You Need to Check in Your PSHB Plan Brochure

Finding the out-of-network deductible amount in your PSHB brochure may take some digging. Look for:

• The Benefits Summary Table: Often appears early, but may only show in-network costs.

• Detailed Cost-Sharing Chart: Usually mid-way through the brochure. This chart may list both in-network and out-of-network deductibles and maximums.

• Footnotes or Asterisks: Some plans hide deductible details in notes or refer you to additional sections.

• Glossary or Definitions: These can help clarify whether a deductible applies per person, per family, or per coverage tier.

If you still have questions after reading, that’s a sign to seek clarification from a licensed agent listed on this website.

What This Means for Your 2025 Budget

In 2025, healthcare expenses under PSHB remain manageable—if you stay within your network. But if you venture outside it, your financial exposure climbs fast. You should budget not just for routine services but for unexpected scenarios where out-of-network deductibles might kick in:

• Emergency room visits out of town

• Specialist care not listed in your plan

• Imaging or labs sent to third parties

And remember: those deductibles reset every January.

If your plan uses a dual-deductible model—one for in-network and one for out-of-network—these amounts do not cross-accumulate. Paying down one will not count toward the other, so always track both if there’s a chance you’ll receive mixed care.

Make Informed Choices to Avoid Costly Surprises

The PSHB deductible system isn’t always as transparent as it should be. Out-of-network costs can easily double or triple what you expected, and you may not see it coming unless you read the fine print. Understanding where, when, and why higher deductibles apply can protect you from financial strain later.

Get ahead of the surprises by reviewing your plan’s network details and deductible structure each year—and make sure your providers are still in network.

If you’re uncertain, don’t wait. Get in touch with a licensed agent listed on this website to get clarity on how your plan handles in- and out-of-network deductibles before your next appointment.