Key Takeaways

• In-network and out-of-network providers under PSHB plans come with vastly different copayment structures. Choosing the wrong one can quickly lead to higher out-of-pocket costs.

• Understanding how networks are defined, verified, and billed can help you make smarter decisions when seeking care—especially for specialists, urgent care, or diagnostic services.

What Makes a Provider “In-Network” Under PSHB?

When you’re enrolled in a Postal Service Health Benefits (PSHB) plan, your copayments and other cost-sharing amounts depend heavily on whether the provider you choose is considered “in-network.”

An in-network provider is a doctor, clinic, hospital, or specialist that has a contract with your PSHB plan to offer services at predetermined rates. These rates are typically lower than what you’d be charged by an out-of-network provider, and your copays are usually more predictable.

PSHB networks are managed by the plan administrators and updated regularly. While some providers participate in national networks, many are region-specific. This means that even if a provider is “covered” under one PSHB plan, they may be out-of-network under another.

What to Check Before Scheduling Care

• Confirm provider participation through your plan’s online directory.

• Call the provider to verify network status.

• Ask about the billing process to ensure it aligns with in-network policies.

Why Out-of-Network Copays Are Often Much Higher

Choosing an out-of-network provider under PSHB doesn’t just result in a different copayment—it often leads to higher overall costs. These can include:

• Higher fixed copayments: Out-of-network visits often come with double or even triple the fixed fee for services.

• Coinsurance charges: Instead of a flat copay, you may be billed a percentage of the total cost.

• Balance billing: Out-of-network providers can bill you for the amount not covered by your plan—something in-network providers are prohibited from doing.

In 2025, most PSHB plans include coinsurance rates as high as 40% to 50% for out-of-network services. For high-cost services like MRIs or surgeries, this could translate into thousands in extra expenses.

PSHB Copay Ranges: What You Can Expect in 2025

While exact figures vary by plan, here’s what many PSHB enrollees face when comparing in-network vs. out-of-network copays:

• Primary Care Visit: In-network $20–$40 | Out-of-network $50–$100

• Specialist Visit: In-network $30–$60 | Out-of-network $100–$200

• Urgent Care: In-network $50–$75 | Out-of-network $150 or more

• Emergency Room: In-network $100–$150 | Out-of-network $250 or more

These figures don’t even account for coinsurance or facility fees that may apply to out-of-network care. The higher copays are only the beginning.

The Hidden Triggers That Can Turn In-Network Care Into Out-of-Network Billing

Even if you visit an in-network hospital or clinic, you could still end up with out-of-network charges. This usually happens in three ways:

1. Ancillary Providers Are Out-of-Network

You may visit an in-network facility, but if the anesthesiologist, radiologist, or pathologist isn’t in-network, you could be billed separately and at a higher rate.

2. Labs and Diagnostics Go Through External Vendors

Lab tests or imaging may be sent to out-of-network labs for analysis, triggering a separate bill.

3. Incorrect Billing Codes or Authorizations

If your provider fails to use the correct network codes or obtain prior authorization (if required), your plan may treat the service as out-of-network—even when the provider is technically in-network.

When You Might Still Use Out-of-Network Providers

There are a few circumstances when out-of-network providers may be the only option or the better option despite higher costs:

• Emergencies: Emergency services are typically covered at in-network rates regardless of provider status, but only until you’re stabilized.

• Specialty care not available in-network: If your plan confirms there is no in-network specialist for your condition, they may approve an exception.

• Geographic limitations: If you are traveling or have moved temporarily to an area with limited network coverage, your plan may allow some flexibility.

Always confirm exceptions before you receive services to avoid surprises later.

Prior Authorizations and Referrals Can Affect Network Status

In some PSHB plans, especially for higher-tier care like surgery or specialty diagnostics, you may need a prior authorization or referral from a primary care provider. Even if the provider is in-network, failing to follow the referral or authorization process could result in your claim being processed at out-of-network levels.

Verify these requirements:

• Do you need a referral from your primary care provider?

• Is a prior authorization required before scheduling a procedure or test?

• What is the turnaround time for approval?

In 2025, many PSHB plans respond to authorization requests within 5 to 10 business days, but emergencies may be expedited.

Telehealth and Virtual Visits—Are They In-Network?

With the growing use of virtual care options, it’s important to know whether telehealth services fall under in-network copays. In most PSHB plans for 2025:

• Telehealth with in-network providers is covered with the same low copays as in-person visits.

• Third-party telehealth vendors may be out-of-network unless explicitly included in your plan.

Check your plan documents to avoid receiving a high bill for what seemed like a convenient telehealth session.

Comparing PSHB Networks: National vs. Regional Options

Not all PSHB plans use the same provider networks. Some offer national networks with wider coverage across the U.S., while others are regional networks focused on specific states or service areas.

National networks may be ideal for retirees or workers who move frequently or have family members in multiple states. However, they often come with slightly higher premiums.

Regional networks typically offer more localized provider relationships and may negotiate lower rates. However, using these plans outside their area of coverage often results in out-of-network billing.

Watch for Changes During Open Season

Open Season, which takes place every year from November to December, is your chance to switch PSHB plans if your current network doesn’t meet your needs. It’s also the time when plan networks can change:

• Providers may leave or join networks.

• Coverage areas may expand or shrink.

• New telehealth platforms may be added.

Make it a habit to check the latest provider directories and benefit brochures each year before renewing your current plan.

Making Smarter Copay Decisions Going Forward

Avoiding unnecessary out-of-network costs under PSHB is possible with some proactive steps:

• Keep an updated list of in-network providers near your home and work.

• Use your plan’s website or mobile app to double-check provider status before each visit.

• Ask providers directly about network participation and billing practices.

• Stay informed during Open Season and consider switching plans if your current one lacks network depth.

If you’re unsure whether a provider is truly in-network or what your copay might be, don’t assume—ask first.

When Copays Are Just the Start of Higher Costs

Remember that copays are just one part of the total cost picture. Even if your copay feels manageable, out-of-network services can open the door to coinsurance, facility fees, and non-covered charges.

Understanding this now can help you avoid financial shocks later, especially for:

• Imaging services like MRIs and CT scans

• Outpatient procedures and minor surgeries

• Lab tests and pathology reports

• Specialty consultations and second opinions

Always get written confirmation or pre-authorization when available, especially for high-cost services.

Your Next Step to Clarify PSHB Copay Details

Understanding the difference between in-network and out-of-network care in PSHB plans is essential for managing your healthcare budget. While it might seem like a small distinction, it has major financial consequences if overlooked.

If you still have questions or are considering a change to your current plan, get in touch with a licensed agent listed on this website for personalized help. A quick conversation today could save you significant money tomorrow.