Key Takeaways
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Coinsurance is one of the most overlooked out-of-pocket expenses in PSHB plans and can significantly affect your total cost of care.
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In 2025, understanding how coinsurance applies across in-network vs. out-of-network services is essential for making cost-effective healthcare decisions.
You’re Covered—But Not Completely
If you’re a postal worker or retiree under the Postal Service Health Benefits (PSHB) Program in 2025, it’s easy to assume your health coverage takes care of most costs. And while it does offer strong protection, many are surprised when coinsurance enters the picture—right after a medical procedure or hospitalization. Unlike copayments, which are usually a fixed amount, coinsurance is a percentage of the cost you pay after meeting your deductible.
In many PSHB plans, coinsurance ranges between 10% and 30% for in-network care, and can shoot up to 40% or 50% for out-of-network services. That seemingly small percentage can translate into large dollar amounts—especially if you need specialized or emergency treatment.
What Is Coinsurance?
Coinsurance is your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount for the service. After you’ve met your plan’s deductible, you typically split the cost with your insurance provider.
For example:
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You have a procedure that costs $2,000.
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You’ve already met your deductible.
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Your coinsurance is 20%.
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You pay $400; your plan covers the remaining $1,600.
Now imagine that procedure costing $10,000. Suddenly, your share is $2,000.
In-Network vs. Out-of-Network: The 2025 Reality
In 2025, coinsurance rates vary significantly based on whether your provider is in-network.
In-network services:
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Lower coinsurance rates (typically 10%-30%).
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Maximum annual out-of-pocket costs are capped (often around $7,500 for Self Only and $15,000 for Self Plus One or Self & Family).
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Access to negotiated rates means the total cost is usually lower.
Out-of-network services:
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Higher coinsurance (as much as 50%).
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Balance billing may apply, where the provider bills you for the difference beyond the plan allowance.
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Higher out-of-pocket maximums—if your plan even counts those expenses toward your max at all.
Why Coinsurance Catches People Off Guard
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Deductible is just the beginning: Once you hit your deductible, many assume the plan covers most remaining costs. Coinsurance proves otherwise.
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Services aren’t priced transparently: You usually won’t know the full cost of a procedure until you get the bill. That makes it hard to anticipate your share.
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Emergency situations: In urgent or emergency care scenarios, you may not have a choice to use in-network providers, triggering higher coinsurance.
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Specialist care: Complex treatments—surgeries, imaging, cancer care—can involve multiple providers. Even one out-of-network provider can hike up your bill.
What Changes in 2025 Mean for You
The PSHB program officially launched in 2025, replacing fehb for postal employees and retirees. With this shift come new coinsurance structures and plan designs. While premiums and plan types remain broad and diverse, many enrollees now face:
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Tiered cost-sharing: Plans may offer different coinsurance rates for primary vs. specialty care, urgent care, and hospital visits.
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More aggressive out-of-network penalties: Coinsurance is just one way plans steer you toward in-network providers. Some out-of-network services now come with no cap on what you might owe.
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Pharmacy coinsurance: While some prescription tiers still offer flat copayments, many expensive medications now fall under coinsurance models, especially after reaching the deductible.
Managing Coinsurance: What You Can Do
You don’t have to be caught off guard by coinsurance if you stay proactive. Here are key strategies to protect your budget:
Review Your Plan Brochure Carefully
Each PSHB plan publishes a detailed brochure, available through OPM. Don’t skim—look for sections that outline:
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Deductible thresholds
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Coinsurance percentages
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In-network vs. out-of-network cost differences
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Maximum out-of-pocket limits
Stay In-Network Whenever Possible
The easiest way to minimize coinsurance is by using in-network providers. Most plans have a searchable online directory. Even in 2025, when more services are offered via telehealth, always check the network status.
Plan for High-Cost Services in Advance
If your doctor recommends surgery or specialized treatment:
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Ask for a cost estimate from your provider.
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Confirm that all providers involved are in-network.
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Get preauthorization if required to avoid additional costs.
Use Preventive Services
Most PSHB plans cover preventive care at 100%, meaning no coinsurance. This includes annual checkups, cancer screenings, and vaccinations. Taking advantage of these can help you avoid higher costs down the line.
Consider a Health Savings Account (HSA) or Flexible Spending Account (FSA)
For those enrolled in eligible high-deductible PSHB plans, contributing to an HSA can provide a tax-free way to cover coinsurance expenses. In 2025, the HSA contribution limits are $4,300 for individuals and $8,550 for families. FSAs allow you to set aside up to $3,300 pre-tax for medical expenses if offered.
Track Your Out-of-Pocket Spending
All PSHB plans are required to provide cost and claims summaries. Monitoring your spending throughout the year helps you:
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Know when you’ve met your deductible
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Anticipate upcoming coinsurance obligations
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Avoid exceeding annual limits unnecessarily
The Link Between medicare and PSHB Coinsurance
If you’re 65 or older and enrolled in Medicare Part B along with your PSHB plan, your out-of-pocket exposure for coinsurance can drop significantly—but only if your PSHB plan coordinates well with Medicare.
Some plans in 2025 offer the following benefits when paired with Medicare Part B:
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Waived or reduced deductibles
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Lower coinsurance rates
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Coverage of services Medicare doesn’t fully pay for
If you opted out of Part B, however, your coinsurance burden might be much higher. And if you’re required to have Part B under PSHB rules and don’t enroll, you could lose drug coverage entirely.
Understanding Your Out-of-Pocket Maximum
The out-of-pocket maximum is your safety net. Once you reach it, the plan covers 100% of eligible in-network costs for the rest of the year. For 2025:
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Self Only plans: Around $7,500 for in-network care
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Self Plus One and Self & Family: Around $15,000 in-network
Out-of-network limits can be much higher—or not apply at all. Make sure you understand which expenses count toward this cap. Some services, like non-covered procedures or excess charges from out-of-network providers, may not count.
Pharmacy Coinsurance in 2025
Medications—especially those in specialty tiers—may now carry coinsurance instead of flat copays. In 2025:
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A new $2,000 out-of-pocket cap on prescription drugs under Medicare Part D applies to eligible retirees with integrated drug plans.
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This cap does not mean you stop paying entirely. Some drugs may still require coinsurance until the cap is met.
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After reaching the cap, your PSHB-integrated Part D plan should cover 100% of covered drug costs.
For those not enrolled in Medicare, standard PSHB coinsurance rules apply, and drug costs can vary significantly by tier and formulary.
PSHB Plans Are Strong—but Not Automatic
Even the best PSHB plans require vigilance. Coinsurance isn’t a trap—it’s just a feature that you need to understand fully to avoid unpleasant surprises. With new plan designs, stricter Medicare coordination rules, and costlier specialty services, 2025 requires a more hands-on approach to managing your healthcare.
The more you engage with your plan details today, the better prepared you’ll be when medical needs arise tomorrow.
Make Sure You’re Covered When It Counts
Coinsurance plays a bigger role in your PSHB costs than you might realize—especially now that plan structures are shifting in 2025. Whether you’re still working or enjoying retirement, understanding how coinsurance fits into your total healthcare spending is no longer optional.
If you’re unsure whether your current plan meets your financial and medical needs, don’t wait for a high bill to force a change. Get in touch with a licensed insurance agent listed on this website. They can walk you through your PSHB plan’s coinsurance terms and help you make sure you’re set up to avoid budget surprises later in the year.
