Key Takeaways

• Coinsurance under the Postal Service Health Benefits (PSHB) program can become significantly more expensive when you seek out-of-network care. The percentage may stay the same, but the total billable amount often skyrockets.

• Unlike copayments, coinsurance exposes you to a percentage of the service cost, and for out-of-network providers, that cost is typically not capped by plan-negotiated rates, leading to unpredictable bills.

How Coinsurance Works Under PSHB

Coinsurance is your share of the cost of a covered service, calculated as a percentage rather than a flat fee. Under the PSHB program in 2025, most plans follow a coinsurance model that varies depending on whether you stay in-network or go out-of-network.

For in-network services, your coinsurance might range from 10% to 30%, and because these providers have agreed to the plan’s rate schedule, the base amount you owe is lower. For out-of-network services, you might face coinsurance as high as 40% or 50%, and that percentage applies to the provider’s full charges, not a pre-negotiated amount.

The Big Gap Between In-Network and Out-of-Network Costs

The most important difference comes down to the pricing model:

• In-network providers agree to the insurer’s contracted rate. Even if your coinsurance is 30%, it applies to a much smaller total.

• Out-of-network providers can charge whatever they want. Your 40% coinsurance could apply to a dramatically inflated bill, and your plan might only cover a small portion.

As a result, your actual financial responsibility could exceed your expectations by hundreds or even thousands of dollars.

The Surprise Billing Factor

While some federal protections exist against surprise billing, they don’t eliminate all out-of-network exposure. If you receive care from an out-of-network provider—especially in non-emergency situations—you could be billed for the difference between what the provider charges and what your plan covers. This is known as balance billing, and it is legal in many scenarios.

When Surprise Bills Happen Most Often

• During outpatient procedures at facilities that employ third-party providers.

• When you receive specialty care that isn’t readily available in-network.

• When you travel or move and inadvertently seek care from an out-of-network provider.

The Coinsurance Math: A Closer Look

Let’s break down how coinsurance affects you in real terms:

• In-Network Visit:

  • Provider charges: $1,000

  • Plan negotiated rate: $500

  • Coinsurance (20%): $100

• Out-of-Network Visit:

  • Provider charges: $1,000

  • Plan allowable amount: $500

  • Coinsurance (40% of $1,000): $400

  • Remaining balance ($500 not covered): You may owe this too.

This makes it clear that the same coinsurance percentage results in dramatically different outcomes. The out-of-network scenario can easily leave you paying not only your coinsurance but also a surprise balance.

What You Should Know About Out-of-Pocket Maximums

PSHB plans include annual out-of-pocket maximums to protect you from unlimited financial exposure. However, there’s a catch:

• Only allowed charges apply toward your out-of-pocket maximum.

• Balance-billed amounts typically do not count.

So, if you’re balance billed for an out-of-network visit, that amount may not bring you closer to your annual cap. Even worse, you could pay beyond your limit without realizing it.

Scenarios That Trigger Unexpected Costs

You might think you’re playing it safe by going to a preferred hospital or urgent care center. But the reality is more complex:

• Hospital-based care may involve providers who bill separately. You may choose an in-network hospital, but if the anesthesiologist or radiologist is out-of-network, you’re on the hook.

• Emergency room visits can result in mixed billing. While emergency services are protected under federal rules, follow-up care or transport may not be.

• Telehealth services might also be out-of-network if provided by a third-party vendor that isn’t in your plan’s directory.

These situations all turn what you thought would be predictable expenses into surprises.

What Makes Out-of-Network Coinsurance So Risky

Out-of-network coinsurance doesn’t just hit your wallet—it also introduces:

• Unpredictability: You won’t know your share until after services are billed.

• Higher service charges: No cap on what out-of-network providers can charge.

• Coordination issues: If your provider doesn’t handle billing with your plan, you may be responsible for filing claims yourself.

How PSHB Plans Try to Encourage In-Network Use

To steer you away from out-of-network providers, PSHB plans in 2025 do the following:

• Set higher coinsurance for out-of-network services (up to 50%).

• Enforce separate and higher deductibles for out-of-network care.

• Apply different out-of-pocket maximums or exclude balance billing amounts from those totals.

• Require preauthorization or deny coverage for non-emergency out-of-network care unless you demonstrate medical necessity.

Avoiding Out-of-Network Pitfalls

Here’s how to stay in control of your coinsurance costs:

1. Confirm Network Participation Ahead of Time

Always verify whether every provider involved in your care is in-network. This includes:

• Surgeons

• Anesthesiologists

• Imaging services

• Labs

• Outpatient facilities

Check your plan’s directory and, when in doubt, call the provider directly.

2. Review Your Plan’s Summary of Benefits

Each PSHB plan publishes a Summary of Benefits and Coverage (SBC). This document outlines your coinsurance responsibilities, deductibles, and out-of-pocket caps for both in-network and out-of-network care.

Get familiar with these:

• Coinsurance percentage

• In-network deductible vs. out-of-network deductible

• Separate out-of-pocket limits

3. Get Preauthorization When Required

Some PSHB plans require prior approval for out-of-network services. Without it, you may face full denial of payment, leaving you to cover the entire cost.

Always check:

• If the service needs approval

• How to request it

• Whether a comparable in-network option exists

4. Use Your Plan’s Support Services

You can contact your plan’s customer service or access digital tools to:

• Locate in-network providers near you

• Estimate costs of common procedures

• Understand coinsurance responsibilities

These tools can help you make better choices before incurring unnecessary costs.

When Out-of-Network Care Might Be Unavoidable

Sometimes, going out-of-network can’t be helped:

• You live in a rural area with limited in-network options.

• You require a specialist who isn’t contracted.

• You experience a medical emergency while traveling.

In such cases, document everything and communicate with your plan as early as possible. If the plan determines the service was medically necessary and unavailable in-network, you may receive partial coverage or an exception.

medicare and Out-of-Network Coinsurance

If you’re enrolled in both PSHB and Medicare Part B, your out-of-pocket costs could be lower. Many PSHB plans coordinate with Medicare to reduce your share of coinsurance. However, this coordination usually applies only for in-network services unless otherwise stated.

Check your plan’s Medicare coordination policy to understand:

• Whether deductibles are waived

• How Medicare covers out-of-network care

• If the plan offers additional cost-sharing support

This integration can cushion the financial impact but does not eliminate the risks associated with going out-of-network.

Your Annual Financial Exposure Can Escalate

In 2025, PSHB plans set separate out-of-pocket maximums for in-network and out-of-network services. For example:

• In-network maximum: $7,500 (Self Only), $15,000 (Self & Family)

• Out-of-network maximum: Could be much higher or even uncapped

Remember, coinsurance continues until you reach the plan’s out-of-pocket cap for that provider type. And again, many out-of-network charges don’t even count toward these limits.

If you’re not monitoring this, you could inadvertently pay more than expected across the calendar year.

Staying Informed Helps You Stay Protected

Coinsurance percentages may appear manageable on paper. But once out-of-network billing enters the equation, you lose cost predictability. As a PSHB enrollee, your best strategy is:

• Staying in-network whenever possible

• Verifying provider participation before appointments

• Understanding coinsurance and deductible structures

• Using your plan’s resources to estimate total exposure

Knowledge is the only real safeguard against these hidden expenses.

Out-of-Network Decisions Can Cost You More Than Just Money

Coinsurance for out-of-network care under PSHB in 2025 can turn routine visits into expensive financial setbacks. What appears to be a small percentage share often masks the larger reality of inflated provider charges, non-covered services, and balance billing. Make it a habit to confirm in-network status, understand your plan rules, and reach out for support before seeking care. For personalized help evaluating your coverage options, contact a licensed agent listed on this website.