Key Takeaways

• Coinsurance under the Postal Service Health Benefits (PSHB) Program can lead to unexpectedly high out-of-pocket costs, especially when combined with deductibles and non-covered services.

• Understanding how coinsurance percentages apply to different services and when they begin is essential to accurately estimating your actual medical expenses.

Understanding the Basics of Coinsurance

Coinsurance is the percentage of the cost of a covered health service that you pay after you meet your deductible. Under PSHB plans in 2025, coinsurance typically ranges from 10% to 30% for in-network services and 40% to 50% for out-of-network services. While this might seem manageable, these percentages can become financially significant depending on the total cost of services.

Unlike copayments, which are fixed amounts, coinsurance is variable. For example, if your plan charges 30% coinsurance for outpatient surgery and the total bill is $3,000, you would be responsible for $900—provided your deductible is already met.

When Coinsurance Starts

Coinsurance doesn’t apply immediately. It only kicks in after you meet your annual deductible, which in 2025 varies widely depending on your plan type:

• Low-deductible plans: $350 to $600 for Self Only, $700 to $1,200 for Self Plus One or Self and Family.

• High-deductible plans: $1,500 to $2,000 for Self Only, $3,000 to $4,000 for Self Plus One or Self and Family.

Once your deductible is met, you enter the coinsurance phase until you reach your out-of-pocket maximum, which caps your total spending for covered services during the calendar year.

How Coinsurance Affects Different Services

Coinsurance under PSHB isn’t uniform across all services. Here’s how it may look in 2025:

• Primary Care Visits: 10% to 20% in-network; up to 50% out-of-network.

• Specialist Visits: 20% to 30% in-network.

• Emergency Room Care: Often 30% plus a fixed copayment.

• Surgical Procedures: 30% is common, especially for outpatient procedures.

• Imaging (MRI, CT scans): 20% to 30%, depending on facility.

• Mental Health Services: 20% to 30% coinsurance after copayment, if any.

These percentages apply after your deductible is met and can differ by service category and provider type.

In-Network vs. Out-of-Network: A Cost Multiplier

One of the most overlooked aspects of coinsurance is how dramatically it increases for out-of-network services. In 2025, in-network coinsurance may be as low as 10%, but out-of-network services can cost you 50% or more of the total bill.

Also, keep in mind:

• Out-of-network expenses may not count toward your in-network deductible or out-of-pocket maximum.

• You may be balance billed for the difference between what your plan pays and what the provider charges.

This means an out-of-network surgery that costs $4,000 could leave you with a $2,000 bill—plus whatever the provider adds as balance billing.

Annual Out-of-Pocket Maximums: Your Safety Net

Every PSHB plan includes an annual out-of-pocket maximum—a cap on the total amount you’ll spend on covered services in a year. For 2025, these are typical figures:

• Self Only: $5,000 to $7,500

• Self Plus One or Self and Family: $10,000 to $15,000

Once you reach this limit, your plan covers 100% of covered services for the rest of the year. But reaching that limit often means you’ve already spent thousands out-of-pocket.

The Hidden Impact of Combined Costs

Coinsurance doesn’t exist in a vacuum. It’s one part of a larger cost-sharing structure that includes:

• Premiums: Monthly payments just to stay covered.

• Deductibles: What you pay before coinsurance begins.

• Copayments: Fixed fees for services like office visits and prescriptions.

• Coinsurance: A percentage of costs after the deductible.

These costs can compound quickly. For example, you might:

• Pay $600 in premiums for a few months.

• Hit a $1,000 deductible due to a surgery.

• Pay 30% coinsurance on a $5,000 procedure = $1,500.

You’re now $3,100 out-of-pocket in just a short time—and that’s before considering other health needs for the year.

Services Most Affected by High Coinsurance

Some services routinely result in high coinsurance costs. In 2025, the most financially significant include:

• Outpatient surgeries

• Specialist procedures

• Advanced imaging (MRI, PET, CT)

• Infusions and specialty drugs administered in clinical settings

• Inpatient hospital stays, especially out-of-network

These are often high-ticket services, meaning your 20%-30% share could equal thousands of dollars.

Why Coinsurance Often Catches People Off Guard

Even if you understand your coinsurance percentage, the final bill often comes as a shock. That’s because:

• The total cost of services is not always disclosed in advance.

• Bills often come weeks after treatment, with little breakdown.

• Providers may charge facility fees in addition to service costs.

• Coinsurance applies only after you’ve met the deductible, creating a layered cost effect.

Strategies to Manage Coinsurance in 2025

You can take control of your coinsurance exposure with a few smart strategies:

• Stay In-Network: Always confirm provider status before scheduling care.

• Request Pre-Treatment Estimates: Ask for cost estimates for planned services.

• Schedule Major Services Early: Reach your deductible sooner to reduce costs later in the year.

• Use Preventive Services: Many are fully covered without coinsurance.

• Track Your Spending: Monitor how close you are to your deductible and out-of-pocket maximum.

These steps help you budget better and avoid costly surprises.

The Importance of Plan Comparison

During the Open Season from November to December, review your PSHB options carefully. Differences in coinsurance, deductibles, and out-of-pocket caps can dramatically impact your annual healthcare expenses.

Ask yourself:

• Are the higher premiums of a low-deductible plan worth the lower coinsurance?

• Will I need specialized care that’s often subject to higher cost-sharing?

• How frequently do I expect to use services that come with high coinsurance?

Balancing your expected healthcare needs with your financial comfort level is key to choosing the right PSHB plan.

What This Means for Your Health Budget

If you’re planning retirement, or already retired and budgeting closely, coinsurance is not just a footnote—it’s a major line item. The timing of procedures, the network status of providers, and your plan’s design all influence what you actually pay.

Understanding the ripple effect of coinsurance on your total healthcare costs can help you avoid financial strain and make more informed decisions year-round.

Protect Yourself From the Unseen Costs

Coinsurance under PSHB in 2025 might look simple on paper—but its real-world impact can be anything but. From deductibles to out-of-pocket maximums, the costs can add up quickly if you’re not prepared.

To get clear, personalized advice on your options and how different plans treat coinsurance, speak with a licensed insurance agent listed on this website. They can help you compare plans, understand cost-sharing nuances, and find coverage that fits your health and financial needs.