Key Takeaways

• Paying “20% after deductible” under a PSHB plan may seem manageable, but it can lead to thousands in out-of-pocket costs depending on the frequency and type of care you receive.

• Understanding how deductibles, coinsurance, and out-of-pocket maximums work together in 2025 can help you make smarter choices before you schedule care.

What 20% Really Means in 2025

When you see “20% after deductible” in your PSHB plan brochure, it’s easy to overlook the potential impact. That percentage might seem small at first glance. But if your deductible is already hundreds—or even thousands—of dollars, then your real out-of-pocket cost is not just the 20%. It’s the total cost until you hit that deductible plus the 20% coinsurance that follows.

And remember: this applies per calendar year. Every January, your deductible and cost-sharing reset.

The Deductible: Where Costs Start

In 2025, most PSHB plans have in-network deductibles ranging from $350 to $2,000, depending on whether you’re in a low- or high-deductible option. If you’re on a Self Plus One or Family plan, that deductible is even higher—often double.

Here’s how it works:

• Until you meet your deductible, you typically pay 100% of the allowed cost for non-preventive services like MRIs, surgeries, or hospital stays.

• Once the deductible is met, you switch to paying 20% of the cost through coinsurance.

This 20% applies every time you receive a covered service—until you hit the plan’s out-of-pocket maximum.

The Myth of “Just One Visit”

You might think: “I’m healthy. One checkup and I’m good.” But here’s what actually counts toward that 20%:

• Imaging services (like CT scans, MRIs)

• Outpatient surgery

• Hospital admission

• Physical therapy

• Specialty treatments (infusions, dialysis, chemotherapy)

A single outpatient surgery could easily cost $6,000 or more. Once you’ve met your deductible, your 20% coinsurance means you’ll owe at least $1,200—on top of the deductible you already paid.

And if you need follow-up care, physical therapy, or another round of scans? The costs stack up fast.

Understanding the Out-of-Pocket Maximum

The only thing standing between you and limitless coinsurance is your annual out-of-pocket maximum. In 2025, many PSHB plans set this around:

• $7,500 for Self Only (in-network)

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

This includes:

• Deductibles

• Coinsurance

• Copayments

Once you reach this limit, your plan covers 100% of additional in-network care for the rest of the year.

But until you get there, every covered service—especially high-cost ones—pulls money out of your pocket.

Medicare-Eligible? Here’s How That 20% Can Change

If you’re a Medicare-eligible Postal Service annuitant and enrolled in both PSHB and Medicare Part B in 2025, your coinsurance may look very different.

Why? Because many PSHB plans coordinate benefits with Medicare to:

• Waive or reduce deductibles

• Lower or eliminate coinsurance

• Offer enhanced prescription drug benefits via integrated Part D coverage

However, not all plans offer the same coordination. It’s critical to check how your PSHB plan works with Medicare Part B. If you’re not enrolled in Part B, you may face full coinsurance costs—no reductions.

Watch Out for Out-of-Network Services

That 20% coinsurance usually applies only to in-network providers. If you receive care out-of-network, your cost-sharing jumps dramatically:

• Coinsurance rates can rise to 40%-50%

• Deductibles and out-of-pocket maximums are higher

• Some plans don’t even count these toward your in-network limits

Make sure every provider you see in 2025 is in-network under your specific PSHB plan. You can usually confirm through your plan’s online provider directory or by calling them directly.

When Multiple Visits Multiply Your Costs

Even when your services are medically necessary and covered, your 20% share can accumulate quickly:

• Five physical therapy sessions at $150 each = $750 total

  • You pay 20% = $150

• Two specialist visits at $300 each = $600

  • You pay 20% = $120

• MRI scan at $2,000

  • You pay 20% = $400

That’s $670 in coinsurance alone, and this is after you’ve already met your deductible.

Add on another procedure or two, and you’re suddenly approaching your out-of-pocket max.

How Coinsurance Differs from Copayments

Coinsurance is not the same as a copayment. Many confuse the two:

• Copayments are flat fees (like $30 for a primary care visit)

• Coinsurance is a percentage of the service cost (like 20% of a $2,000 bill)

PSHB plans typically use copayments for low-cost, routine care such as:

• Primary care and specialist visits

• Urgent care

• Generic prescriptions

But coinsurance kicks in for high-cost or advanced services, which is where your out-of-pocket risk increases substantially.

You Don’t Always Know the Full Cost Upfront

Another challenge with coinsurance is unpredictability. You rarely know the full price of a service until it’s billed. So when you hear “20% coinsurance,” that percentage is only meaningful after the provider’s allowed amount is determined.

Factors that influence your cost include:

• Where the procedure is performed (hospital vs. clinic)

• Whether pre-authorization was required

• Whether the billing code is bundled with other services

This can lead to surprise bills and higher-than-expected balances, especially if you didn’t verify the cost beforehand.

High-Deductible Plans Can Increase Risk

Some PSHB plans in 2025 are high-deductible health plans (HDHPs) that qualify for a Health Savings Account (HSA). These plans often:

• Have lower premiums

• Require higher deductibles ($1,500 or more)

• Include coinsurance after the deductible

If you’re enrolled in an HDHP, you’re likely to pay 100% of all non-preventive costs until the deductible is met. Only then do you begin sharing costs with the plan via coinsurance.

While HSAs offer tax advantages and can help offset these costs, not everyone has enough saved in their HSA to absorb a year of frequent medical care.

Planning Ahead: Tips to Reduce Surprises

Here’s how to be proactive with coinsurance and cost-sharing under PSHB:

• Review your plan brochure thoroughly: Focus on the Summary of Benefits section

• Know your deductible and out-of-pocket maximum: These are key to understanding your financial exposure

• Confirm your provider is in-network: Avoid out-of-network coinsurance rates

• Ask for cost estimates: Most providers can give you a ballpark amount for common services

• Use preventive care: Many services are covered in full before the deductible

• Coordinate with Medicare if eligible: This can reduce or eliminate coinsurance in many cases

Why 2025 Planning Matters More Than Ever

With coinsurance amounts tied directly to service costs, healthcare inflation means 20% in 2025 is more expensive than it was a few years ago. A procedure that cost $5,000 in 2020 might now cost $6,500 or more.

And because PSHB plans reset their deductible and out-of-pocket limits every calendar year, your planning must happen now—not midyear after the bills arrive.

If you’re considering surgery, chronic care, or have ongoing treatment needs, reviewing your plan’s cost-sharing structure should be a priority.

Managing Coinsurance in the Bigger Picture

Coinsurance is just one part of the overall cost structure of a PSHB plan, but it’s the part that often catches you off guard. Unlike premiums—which are predictable and fixed—coinsurance is dynamic, based on how much healthcare you actually use.

It’s important to think in terms of total cost of care:

• Premiums

• Deductibles

• Copayments

• Coinsurance

• Out-of-pocket maximums

Balancing these elements with your expected health needs is the best way to avoid financial stress from unexpected bills.

Understand Before You’re Billed

Coinsurance under PSHB can either be a manageable detail or a costly surprise. In 2025, it pays—literally and figuratively—to understand what “20% after deductible” actually means before you’re billed for services.

Take the time to:

• Review your plan documents

• Confirm costs ahead of care

• Consider Medicare coordination if you’re eligible

And most importantly, speak with someone who understands the PSHB landscape.

Get Clarity Before the Costs Arrive

You don’t need to wait for a big bill to learn how your PSHB coinsurance works. Understanding your responsibilities upfront helps you take control of your budget, your benefits, and your peace of mind.

If you’re unsure about your plan’s coinsurance rules or want help comparing options, get in touch with a licensed agent listed on this website. They can walk you through your plan, help you estimate costs, and guide you toward better financial outcomes.