Key Takeaways

• Understanding coinsurance rules can help you avoid unexpected medical bills and plan your healthcare expenses more effectively.

• USPS employees covered under the Postal Service Health Benefits (PSHB) program should be aware of how coinsurance applies to their in-network and out-of-network services.

What Exactly is Coinsurance?

When you visit a doctor or hospital, your health plan often requires you to share the cost of care. Coinsurance is the percentage of covered medical expenses that you pay after meeting your deductible. Unlike copayments, which are fixed amounts, coinsurance is a percentage of the total cost of care. If your coinsurance rate is 20%, you pay 20% of the bill, while your plan covers the remaining 80%.

For USPS employees, coinsurance rates vary depending on your health plan, whether you choose an in-network provider, and the type of service received.

1. Coinsurance Only Kicks in After You Meet Your Deductible

Before your health plan covers a percentage of the costs, you typically have to meet your annual deductible. This means that for the first few medical expenses each year, you will be responsible for paying the full amount until the deductible is satisfied.

• In-Network Deductibles: Typically lower than out-of-network deductibles, making it more cost-effective to use providers within your plan’s network.

• Out-of-Network Deductibles: Often higher and require you to pay more out of pocket before coinsurance applies.

• Annual Reset: Deductibles reset every year, so be prepared to start fresh at the beginning of each calendar year.

USPS employees enrolled in PSHB plans should review their deductible requirements carefully to plan for their healthcare costs throughout the year.

2. In-Network Providers Save You Money

One of the biggest factors affecting how much you pay in coinsurance is whether you visit an in-network or out-of-network provider. Most health plans negotiate lower rates with in-network providers, which translates to lower out-of-pocket costs for you.

• Lower Coinsurance Rates: In-network providers typically have lower coinsurance rates, often around 10%-30%.

• Out-of-Network Risks: Out-of-network providers may result in higher coinsurance rates, sometimes as high as 50%, or may not be covered at all.

• Balance Billing: Some out-of-network providers may bill you for the difference between what your plan pays and what they charge.

To avoid unexpected expenses, USPS employees should always check whether a provider is in-network before scheduling an appointment.

3. Some Services Are Exempt from Coinsurance

Certain healthcare services may not require you to pay coinsurance at all. Depending on your PSHB plan, these exemptions could include:

• Preventive Care: Annual check-ups, screenings, and vaccinations are often covered at 100%, meaning no coinsurance applies.

• Some Generic Medications: Certain generic drugs may be fully covered without cost-sharing.

• Emergency Services: Some plans waive higher coinsurance rates for out-of-network emergency room visits.

Reviewing your plan’s details can help you take advantage of fully covered services and minimize out-of-pocket expenses.

4. Out-of-Pocket Maximums Provide Financial Protection

Health plans set an annual limit on how much you have to pay out of pocket. Once you reach this limit, your plan covers 100% of covered expenses for the rest of the year.

• PSHB Limits for 2025: The in-network out-of-pocket maximum is $7,500 for Self Only coverage and $15,000 for Self Plus One and Self & Family plans.

• Out-of-Network Costs: Some plans may have separate, higher limits for out-of-network expenses.

• Coinsurance Stops: Once you hit the maximum, you no longer owe coinsurance for covered services.

USPS employees should track their out-of-pocket spending throughout the year to ensure they are taking advantage of their plan’s financial protections.

5. Specialty Care and Hospital Stays May Have Different Coinsurance Rates

Coinsurance rates are not the same for all types of medical care. While routine doctor visits may have lower coinsurance, specialty care and hospital stays often have higher percentages.

• Primary Care vs. Specialist Visits: A primary care visit may have a 10% coinsurance, while a specialist could require 20%-30%.

• Hospital Stays: Inpatient stays usually involve higher coinsurance or a daily copayment.

• Surgery and Advanced Procedures: These may require pre-authorization and could have coinsurance rates up to 30%-40%.

Checking your plan details before seeking specialized care can help you budget for potential expenses.

6. Coinsurance Applies Differently to Prescription Drugs

Prescription drug coverage often follows a tiered system, where different levels of medications come with varying coinsurance rates.

• Generic Medications: Usually have the lowest coinsurance or may be fully covered.

• Brand-Name Medications: Often come with higher coinsurance, sometimes around 20%-30%.

• Specialty Drugs: High-cost medications may have the highest coinsurance rates or require additional approvals.

USPS employees should use their plan’s formulary to determine the expected cost of prescriptions and consider mail-order options for long-term medications.

How to Minimize Your Coinsurance Costs

Here are a few strategies USPS employees can use to keep coinsurance expenses under control:

• Use In-Network Providers: This ensures you pay the lowest possible coinsurance rates.

• Take Advantage of Preventive Care: Many services are fully covered, saving you from out-of-pocket expenses.

• Track Your Healthcare Spending: Knowing how close you are to your deductible and out-of-pocket maximum can help you plan medical visits more efficiently.

• Ask About Cost Estimates: Before scheduling a procedure or specialist visit, request an estimate to avoid surprises.

• Review Your Plan Annually: During Open Season, compare your options to ensure you have the best plan for your healthcare needs and budget.

Preparing for Your Next Doctor’s Visit

Understanding these coinsurance rules will help you make informed choices about your healthcare. Before scheduling your next doctor’s visit:

• Check your deductible status to know how much you’ll need to pay before coinsurance applies.

• Verify if the provider is in-network to avoid higher out-of-pocket costs.

• Ask your insurance provider about potential costs and available exemptions.

• Keep track of your spending to stay within your out-of-pocket maximum.

By staying informed, USPS employees can take control of their healthcare expenses and avoid unnecessary financial burdens.

Make the Most of Your Healthcare Coverage

Being aware of how coinsurance works ensures that you are prepared for medical expenses and can make the best use of your health benefits. If you need personalized guidance on how coinsurance impacts your specific health plan, get in touch with a licensed agent listed on this website for professional advice.