Key Takeaways

• Coinsurance is not just a minor detail of your PSHB plan; it can significantly impact your out-of-pocket costs—especially after large medical services.

• Knowing your coinsurance rates and how they interact with deductibles, out-of-pocket maximums, and Medicare can help you avoid financial surprises in 2025.

Understanding Coinsurance Inside PSHB Plans

If you’re enrolled in the Postal Service Health Benefits (PSHB) Program in 2025, understanding coinsurance is crucial to managing your healthcare costs. Unlike a flat copayment, coinsurance is a percentage of the cost of services that you pay after meeting your deductible.

How Coinsurance Works

Coinsurance comes into play after you’ve met your annual deductible. For example:

• If your plan has 20% coinsurance for specialist care, you pay 20% of the bill while your PSHB plan covers the remaining 80%.

• These percentages vary depending on whether the service is in-network or out-of-network.

While coinsurance may seem manageable, the actual costs can add up quickly—especially for high-cost services like hospital stays, surgeries, MRIs, and outpatient procedures.

2025 Coinsurance Landscape: In-Network vs. Out-of-Network

PSHB plans continue to offer tiered coinsurance rates in 2025:

• In-network services typically come with lower coinsurance, ranging from 10% to 30%.

• Out-of-network services are far more costly, often requiring 40% to 50% coinsurance.

This tiered system emphasizes the importance of staying within your plan’s preferred provider network whenever possible.

Know Before You Go

Before you schedule care, it’s critical to verify whether your provider is in-network. Even a single out-of-network service can lead to significantly higher out-of-pocket expenses—expenses that could otherwise be avoided.

The Relationship Between Deductibles and Coinsurance

Your coinsurance responsibility begins after you meet your annual deductible. Deductibles in 2025 vary across PSHB plans, typically falling into these ranges:

• Low-deductible plans: $350 to $600 for Self Only

• High-deductible plans: $1,500 to $2,000 or more

Once your deductible is satisfied, coinsurance applies to eligible services until you reach your out-of-pocket maximum.

What Counts Toward the Deductible?

• Payments for services subject to coinsurance

• Some copayments, depending on the plan

• Out-of-network services usually apply to a separate, higher deductible

Being aware of these mechanics can help you plan for the year, especially if you have known medical expenses.

Out-of-Pocket Maximums: Your Safety Net

Each PSHB plan sets an annual limit on your out-of-pocket spending, known as the out-of-pocket maximum. This cap includes:

• Deductibles

• Coinsurance

• Copayments (in most cases)

For 2025, typical in-network out-of-pocket maximums are:

• Self Only: Around $7,500

• Self Plus One and Family: Around $15,000

Once you hit this limit, your plan covers 100% of eligible in-network expenses for the rest of the calendar year. This is one of the most critical protections built into your PSHB plan.

Why Coinsurance Can Be Financially Surprising

It’s easy to underestimate how much 20% or 30% of a major service can cost. For instance:

• A single outpatient procedure costing $4,000 with 20% coinsurance equals an $800 bill.

• A hospital stay costing $20,000 at 30% coinsurance means you owe $6,000.

These figures can hit unexpectedly—especially if you thought your premiums had you fully covered.

The Medicare Factor for Annuitants

If you’re an annuitant enrolled in Medicare Part B in 2025, your PSHB plan may coordinate benefits to reduce or eliminate coinsurance altogether.

How Coordination Works

• Medicare typically pays first, covering 80% of eligible services.

• Your PSHB plan often pays second, picking up the remaining 20%, depending on your specific plan.

Some PSHB plans even waive deductibles or copayments for Medicare-enrolled retirees. This integration can drastically reduce your financial exposure to coinsurance, making Medicare Part B enrollment more appealing.

When You’ll Likely Encounter Coinsurance

Coinsurance is most often applied to services that are costly or complex, such as:

• Hospital admissions

• Emergency room visits

• Durable medical equipment (like CPAP machines)

• Outpatient surgeries

• Advanced imaging (MRI, CT, PET scans)

• Physical or occupational therapy sessions

Understanding where coinsurance applies can help you better anticipate your costs and avoid sticker shock.

Coinsurance and Preventive Care: What’s Covered at No Cost

The good news? Most PSHB plans fully cover preventive services without applying coinsurance when you use in-network providers. These include:

• Annual physical exams

• Vaccinations (like flu shots and COVID-19 boosters)

• Screenings for cancer, blood pressure, cholesterol, and diabetes

So while coinsurance can be expensive in other areas, preventive care is a bright spot where your PSHB plan works in your favor.

Coordinating With a Health Savings Account (HSA)

If you’re in a high-deductible PSHB plan and have an HSA, you can use your HSA funds to pay for coinsurance. This helps reduce the financial burden and offers tax advantages. For 2025, HSA contribution limits are:

• $4,300 for individuals

• $8,550 for families

• Additional $1,000 catch-up contribution if you’re 55 or older

Using your HSA to cover coinsurance can stretch your healthcare dollars significantly.

Yearly Strategy: How to Plan for Coinsurance Costs

Coinsurance shouldn’t catch you off guard. Here’s how to plan for it proactively:

• Estimate your expected care needs each year

• Add up your premium, deductible, and estimated coinsurance costs

• Use your HSA or FSA to save pre-tax money for out-of-pocket expenses

• Schedule preventive care to minimize exposure to coinsurance

How to Read Your Explanation of Benefits (EOB)

Your EOB isn’t a bill—but it’s your best tool for understanding how coinsurance has been applied. Look for these line items:

• Total cost of service

• Amount covered by the PSHB plan

• Amount you owe (coinsurance)

Review your EOB carefully to ensure the coinsurance amount is correct and reflects in-network rates.

Don’t Confuse Coinsurance With Copayments

Although both represent out-of-pocket costs, they work differently:

• Copayments are flat fees (e.g., $30 for a specialist)

• Coinsurance is a percentage of the cost

Some services may have either one or the other, depending on your plan. High-cost services typically fall under coinsurance.

Retirees: Should You Still Worry About Coinsurance?

Yes—especially if you’re not enrolled in Medicare Part B. Without Medicare coverage, you may be solely responsible for coinsurance costs after your deductible. PSHB plans may help, but the burden can still be substantial.

Retirees should also be cautious about:

• Out-of-network care

• Expensive imaging or surgery

• Not reaching the out-of-pocket maximum early enough in the year to gain full coverage benefits

Make Coinsurance Work for You

To protect your budget, don’t treat coinsurance as an afterthought. Make it a part of your decision-making when choosing your PSHB plan during the November–December Open Season. Consider:

• Whether you’ll hit your deductible quickly

• If Medicare enrollment will reduce coinsurance

• How often you expect to need high-cost services

Understanding how these components fit together can keep your healthcare costs more predictable in 2025.

Protecting Yourself From Surprise Charges

Always:

• Check provider networks

• Request pre-authorization if your plan requires it

• Review billing codes and dispute inaccuracies

Coinsurance is predictable—but only if the billing is done accurately. Stay engaged with your healthcare paperwork to avoid costly missteps.

What You Should Do Next

Coinsurance isn’t just a side cost—it can be one of the most significant expenses you face if you’re not prepared. Take a close look at your PSHB plan’s Summary of Benefits. Speak with a licensed agent listed on this website to explore how your coinsurance responsibilities fit into your overall health coverage in 2025. It’s one conversation that could save you thousands.