Key Takeaways

• Coinsurance under the Postal Service Health Benefits (PSHB) Program varies based on several factors, including provider network status, service type, and Medicare enrollment.

• Assuming a fixed 20% coinsurance rate could lead to unexpected costs, especially for retirees who haven’t coordinated their coverage with Medicare.

Understanding Coinsurance in the PSHB Landscape

Coinsurance in 2025 under the Postal Service Health Benefits (PSHB) Program is not a one-size-fits-all percentage. While many assume a standard 20% coinsurance applies to most services, the reality is more nuanced. Coinsurance can range anywhere from 10% to 50% depending on the plan you select, the provider you visit, the services you receive, and whether you are enrolled in Medicare.

Understanding how coinsurance works is crucial because it affects your out-of-pocket spending throughout the year. You share the cost of services with your health plan after you’ve met your deductible, but the exact amount can fluctuate significantly.

The Network Status of Your Provider Matters

One of the most important factors that influence coinsurance is whether you use in-network or out-of-network providers.

In-Network Services

• Typically carry lower coinsurance rates, often in the range of 10% to 30%.

• Preferred by most PSHB plans due to negotiated rates.

• Subject to in-network deductibles and out-of-pocket maximums.

Out-of-Network Services

• Coinsurance rates can rise to 40% or even 50%.

• Often have higher deductibles.

• May not count toward your in-network out-of-pocket limit.

When you stay within your plan’s network, you are better protected from unexpected charges. Venturing out of network significantly increases your financial liability.

Type of Service Received

Coinsurance isn’t uniform across all categories of care. Different services come with different cost-sharing rules. Here’s how it typically breaks down in 2025:

• Primary care visits: Generally lower coinsurance, around 20% in-network.

• Specialist visits: May carry higher rates, sometimes 30%.

• Urgent care: Often higher than primary care but lower than emergency room visits.

• Emergency room: Typically involves both high copays and high coinsurance, especially if out-of-network.

• Hospitalization and surgery: Usually the highest-cost services, with coinsurance ranging up to 30% in-network, or higher if out-of-network.

This variability underscores the importance of understanding how your plan treats different services.

Medicare Enrollment Significantly Alters Coinsurance

If you’re Medicare-eligible, your decision to enroll—or not—has a direct impact on your coinsurance responsibility under PSHB.

Enrolled in Medicare Part B

• Most PSHB plans in 2025 waive or significantly reduce coinsurance for many services if Medicare is your primary payer.

• You’re typically only responsible for what Medicare doesn’t cover.

• Some plans even reimburse part of your Medicare Part B premium.

Not Enrolled in Medicare Part B

• You could face the full PSHB coinsurance rate.

• Your plan becomes your primary insurer, which increases your share of costs.

• In some cases, plans may not coordinate benefits at all, especially for retirees who were required to enroll.

Failing to enroll in Medicare Part B when required may expose you to avoidable high coinsurance rates and limit your cost-sharing protections.

Deductibles and Coinsurance Work Together

Another overlooked factor is how deductibles interact with coinsurance. In 2025, PSHB plans generally have the following structure:

• Low-deductible plans: $350 to $500 for Self Only.

• High-deductible plans: $1,500 to $2,000 for Self Only.

Coinsurance applies only after you meet your deductible. If you haven’t paid your deductible yet, you may owe the full cost of the service, not just the coinsurance portion. This is especially important early in the plan year.

Your Plan’s Out-of-Pocket Maximum Caps the Risk

PSHB plans in 2025 include an annual out-of-pocket maximum, which provides a ceiling on your financial liability. Once you hit this limit, the plan pays 100% of covered services for the rest of the year.

• In-network maximums: $7,500 Self Only; $15,000 for family.

• Out-of-network maximums: Often higher and may not be capped at all, depending on the plan.

Understanding how your coinsurance contributes to this limit is key. Only in-network coinsurance and cost-sharing typically apply toward your in-network out-of-pocket maximum.

Prescription Drugs Follow a Separate Coinsurance Structure

If you’re enrolled in Medicare and PSHB, your prescription drugs are usually covered through a Part D Employer Group Waiver Plan (EGWP). This coverage includes its own cost structure:

• Annual deductible phase (up to $590 in 2025).

• Initial coverage phase with fixed coinsurance or copay.

• Catastrophic phase kicks in after you reach $2,000 in out-of-pocket spending, covering 100% of costs for the remainder of the year.

This separate framework for prescriptions means coinsurance rules vary from those for medical services. It’s essential to factor both into your total cost outlook.

Supplemental Benefits Can Also Involve Coinsurance

Certain supplemental benefits—like dental, vision, and hearing—may also come with coinsurance responsibilities. These benefits are typically offered through separate plans under FEDVIP or similar add-ons and are not always subject to the same cost protections as core medical services.

For example:

• Dental: May charge 20%–40% coinsurance for major procedures.

• Vision: Often includes coinsurance for lenses, frames, or special exams.

• Hearing: May involve coinsurance for testing and hearing aids.

These benefits don’t count toward your PSHB medical out-of-pocket maximum and should be reviewed independently.

Plan Type and Enrollment Tier Affect Coinsurance Exposure

Different PSHB plans—such as Standard Option vs. High Deductible Health Plans (HDHPs)—come with varying coinsurance rates. In addition, the enrollment tier you choose (Self Only, Self Plus One, Self and Family) affects your overall liability.

• Standard plans: Tend to have predictable coinsurance but higher premiums.

• HDHPs: Lower premiums but higher coinsurance until a high deductible is met.

• Enrollment tiers: Higher tiers can magnify coinsurance costs if multiple family members need care.

Selecting the right balance between premiums, deductibles, and coinsurance is a key part of managing your total healthcare expenses.

Watch for Plan Changes Each Year

Coinsurance rules are not set in stone. Each year during the November–December Open Season, PSHB plans may:

• Adjust coinsurance percentages.

• Redefine in-network vs. out-of-network coverage.

• Introduce or remove cost-sharing benefits for Medicare enrollees.

Always review your plan brochure annually to confirm how your coinsurance is changing for the upcoming year.

Why a Fixed Percentage Can Be Misleading

Assuming that coinsurance is always 20% can lead to underestimating your true exposure. That percentage can shift based on:

• Service type

• Provider network status

• Medicare enrollment

• Plan design and cost-sharing rules

Understanding all of these elements helps you avoid unpleasant surprises and better estimate your actual healthcare costs.

Make Coinsurance Work for You With a Proactive Strategy

Coinsurance can feel complicated, but being proactive with your plan selection, Medicare enrollment, and provider choices helps you control your costs. Pay close attention during the November–December Open Season to select a plan that aligns with your health needs and financial situation.

If you’re uncertain how your coinsurance will function under a specific PSHB plan—or how Medicare impacts your costs—get in touch with a licensed agent listed on this website for personalized guidance. Their expertise can help you make a more informed and cost-effective decision.