Key Takeaways

• Coinsurance can significantly increase your out-of-pocket costs under the Postal Service Health Benefits (PSHB) Program—especially during a serious illness or extended hospital stay.

• Understanding how coinsurance differs from copayments and deductibles helps you prepare financially and avoid being blindsided by unexpected bills.

Why Coinsurance Deserves More of Your Attention in 2025

If you’re enrolled in a PSHB plan in 2025, you’re likely familiar with the basics: premiums, deductibles, copayments. But there’s one element that often gets missed until you’re facing a large medical bill—coinsurance. While it may sound like just another health insurance term, coinsurance plays a direct role in determining how much you actually pay when serious medical situations arise.

Coinsurance is the percentage of the cost of a covered service that you’re responsible for after you’ve met your deductible. And depending on the service, that percentage can translate into thousands of dollars—especially for hospital visits, outpatient surgery, or specialist care.

What Coinsurance Really Means for You

In PSHB plans, coinsurance typically applies to certain higher-cost services such as:

• Emergency room visits

• Inpatient hospital stays

• Outpatient procedures

• Durable medical equipment

• Imaging and lab tests

Unlike copayments (which are flat fees), coinsurance is a percentage of the total approved cost. If your coinsurance is 20% and the service costs $10,000, you’re paying $2,000—after your deductible is met. It’s easy to see how quickly these expenses can add up.

How Coinsurance Compares to Copays and Deductibles

Coinsurance is often confused with other out-of-pocket costs. Here’s how they differ:

• Copayments are fixed amounts for specific services like doctor’s visits or prescriptions.

• Deductibles are the amount you must pay in full before your plan starts covering certain costs.

• Coinsurance kicks in after you meet your deductible and remains in effect until you hit your out-of-pocket maximum.

While copays offer predictability, coinsurance adds variability. That makes budgeting more difficult, especially if you require unexpected or ongoing medical treatment.

2025 PSHB Coinsurance Trends to Know

As of 2025, most PSHB plans follow a similar cost-sharing model, with:

• In-network coinsurance ranging between 10% and 30%

• Out-of-network coinsurance running significantly higher, often 40% to 50%

What’s important is that your share grows as your total medical costs rise. This means a $1,000 service might feel manageable, but a $25,000 procedure? Not so much.

What Happens When You Reach the Out-of-Pocket Maximum

Fortunately, PSHB plans include an annual out-of-pocket maximum. Once you reach this threshold, your plan covers 100% of approved costs for the rest of the year. In 2025, typical PSHB out-of-pocket maximums are:

• $7,500 for Self Only

• $15,000 for Self Plus One and Self & Family

Even so, reaching these amounts means you’ve already paid a substantial sum—often in deductibles, copays, and coinsurance combined.

The Hidden Triggers of High Coinsurance Costs

Many people assume coinsurance will only apply in major emergencies. But there are routine situations where it kicks in:

• Diagnostic imaging (MRIs, CT scans)

• Specialist visits after a referral

• Chronic condition management (like diabetes or heart disease)

• Physical therapy or rehab

• Outpatient surgery centers

Each of these can carry coinsurance, and when treatment spans several visits, the costs stack up quickly.

In-Network vs. Out-of-Network: Why It Matters More Than Ever

Sticking with in-network providers is key in 2025. PSHB plans reward this with:

• Lower coinsurance rates

• Pre-negotiated pricing

• Simpler claims processing

Out-of-network care not only triggers higher coinsurance, but also leaves you exposed to balance billing—the difference between what your provider charges and what your plan pays. That amount is entirely your responsibility and does not count toward your out-of-pocket maximum.

You Can’t Skip Coinsurance, But You Can Prepare for It

There’s no way to eliminate coinsurance unless you never use high-cost services—which is neither realistic nor advisable. What you can do is reduce your financial exposure with smart planning:

• Review your plan’s Summary of Benefits every year during Open Season.

• Track your deductible progress and know when coinsurance starts.

• Budget for coinsurance costs based on your expected healthcare usage.

• Use in-network providers whenever possible.

• Check whether your plan offers cost-sharing reductions for medicare enrollees.

Planning Ahead: The Role of Medicare in Managing Coinsurance

If you’re Medicare-eligible in 2025 and enrolled in a PSHB plan, your coinsurance costs may be significantly reduced—but only if you’re also enrolled in Medicare Part B. Many PSHB plans coordinate benefits with Medicare, often waiving or lowering:

• Coinsurance amounts

• Deductibles

• Copayments

This coordination can prevent high out-of-pocket costs, especially during hospitalization or specialist care. But if you don’t enroll in Part B, your PSHB plan becomes your primary payer—and you’ll pay the full coinsurance amount out of pocket.

Watch for Policy Changes Each Year

PSHB plans are still evolving, especially in this early transition phase from FEHB. That means coinsurance structures, deductibles, and provider networks may shift from year to year. Always pay attention to:

• Plan brochures and benefit charts during Open Season

• Updates in cost-sharing and annual maximums

• Provider directory changes that affect your in-network access

A change of just 10% in coinsurance can mean hundreds or even thousands of dollars, depending on your usage.

The Reality of Coinsurance in High-Usage Scenarios

Coinsurance is most financially painful when your health needs increase suddenly or when you rely on frequent services. Examples include:

• A surgery followed by physical therapy

• A chronic condition requiring specialist care and regular lab work

• Emergency care followed by hospital admission

Even a single major event can push you close to your plan’s out-of-pocket maximum. This is why understanding coinsurance—and planning for it—is more than just insurance literacy. It’s a financial strategy.

Use Open Season to Your Advantage

During the November–December Open Season, evaluate your plan with coinsurance in mind:

• Compare in-network vs. out-of-network coinsurance percentages.

• Look at how your plan coordinates with Medicare if you’re eligible.

• Identify services you’re likely to use and how they’re covered.

• Factor coinsurance into your total expected yearly costs, not just premiums.

Remember: the plan with the lowest premium may come with much higher coinsurance—and that’s a tradeoff you need to see clearly.

Coinsurance Awareness Leads to Smarter Choices

Coinsurance may not get as much attention as premiums or deductibles, but its impact is just as real—and often more financially damaging. In 2025, with healthcare costs continuing to rise, being coinsurance-aware helps you:

• Avoid unexpected bills

• Make smarter plan choices

• Use healthcare services more strategically

• Protect your long-term budget

If you don’t actively think about coinsurance now, your first major claim might force you to.

Take Control of What Coinsurance Could Cost You

Understanding coinsurance under your PSHB plan isn’t just about terminology—it’s about being prepared. When you know how much you could owe, and why, you’re in a stronger position to:

• Choose the right plan during Open Season

• Budget for high-cost services before they happen

• Get the care you need without financial regret

If you’re unsure how coinsurance works under your current plan or what changes may apply this year, now is the time to act. Get in touch with a licensed agent listed on this website for clear, tailored advice that fits your specific needs.