Key Takeaways

• A 20% coinsurance under PSHB can lead to significant out-of-pocket costs, especially for high-cost services like surgeries, hospital stays, or specialist care.

• You can reduce your financial burden by choosing the right plan type, understanding cost-sharing tiers, and coordinating effectively with Medicare if eligible.

Understanding Coinsurance in the PSHB Landscape

Coinsurance refers to the percentage of a medical service cost you must pay after meeting your deductible. Under many Postal Service Health Benefits (PSHB) plans, coinsurance typically ranges between 10% and 30% for in-network services. A common figure seen in 2025 is 20% coinsurance—meaning you cover one-fifth of the bill after any deductibles are paid.

For example, if you receive a covered medical service costing $5,000, and you’ve already met your deductible, you could be responsible for $1,000 out-of-pocket. And if this type of expense occurs multiple times a year, it can quietly add up to thousands.

Why a 20% Coinsurance Feels More Expensive Now

Rising Healthcare Costs

Health service costs in the U.S. have continued to rise into 2025, with increases in surgical fees, diagnostic testing, and hospital services. A 20% share of today’s prices is simply a larger amount than it was a few years ago.

Frequency of Use

If you’re retired or managing a chronic condition, the need for specialist visits, lab work, imaging, or therapy may be frequent. Coinsurance applies every time—unlike copayments, which are fixed. This makes your share unpredictable and potentially much larger.

Deductibles and Maximums

PSHB plans typically come with annual deductibles and out-of-pocket maximums. In 2025, deductibles can range from $350 to $1,500 for Self Only plans. While the out-of-pocket maximum does offer some protection (e.g., $7,500 for Self Only in-network), you may still need to pay thousands before you reach it.

1. Break Down What Services Are Affected

Coinsurance doesn’t apply to everything. It often kicks in for:

• Hospital stays and surgeries

• Specialist visits without a copay

• Diagnostic services like MRIs or CT scans

• Outpatient procedures

• Certain types of therapy (e.g., physical or occupational therapy)

Knowing where coinsurance applies helps you estimate and prepare for future bills.

2. Review the Full Cost-Sharing Layout

PSHB plans follow a cost-sharing structure that combines:

• Monthly premiums

• Deductibles

• Copayments

• Coinsurance

• Out-of-pocket maximums

In 2025, even with generous government contributions covering roughly 70% of premiums, coinsurance is where many retirees and workers feel financial pressure. Review your plan brochure annually to see:

• If copayments are available instead of coinsurance for certain services

• If in-network and out-of-network coinsurance rates differ dramatically

• Whether your plan includes a separate out-of-pocket max for prescription drugs

3. Explore Medicare Coordination If You’re Eligible

If you’re age 65 or older or otherwise Medicare-eligible, Medicare Part B can greatly reduce your out-of-pocket burden under PSHB. Here’s how:

• Medicare pays first. PSHB plans become secondary, which may result in little or no coinsurance.

• Some PSHB plans waive deductibles or coinsurance when Medicare is primary.

• Part D prescription drug benefits are included automatically via an EGWP (Employer Group Waiver Plan), with a $2,000 annual cap in 2025.

To benefit from these savings, you must be enrolled in both Medicare Parts A and B. If you delay Part B without an exemption, you may face a coverage gap and late penalties.

4. Take a Closer Look at Your Out-of-Pocket Maximums

Every PSHB plan includes an annual limit on what you’ll pay for covered services. For 2025:

• Self Only plans typically have an in-network max around $7,500.

• Self Plus One and Self & Family plans cap in-network costs at about $15,000.

However, not all services may count toward this cap. Pay attention to exclusions in your plan details:

• Out-of-network services often have a separate, higher limit.

• Some coinsurance may not count if the provider is outside the plan’s network.

• Prescription drug costs may or may not be included in the main out-of-pocket limit, depending on the plan.

5. Compare Plan Options During Open Season

You’re not locked into your current plan forever. Every November to December, you can evaluate other PSHB options. If coinsurance has become too burdensome:

• Consider switching to a plan with more fixed copays and less reliance on percentage-based coinsurance.

• Look for plans that integrate better with Medicare if you’re eligible.

• Review the total package: some plans with higher premiums offer much lower cost-sharing in return.

It’s often worth doing the math: a higher premium can still result in lower total yearly costs if coinsurance and deductibles are reduced.

6. Avoid Out-of-Network Surprise Bills

Staying in-network is crucial under PSHB. Out-of-network services can come with:

• Coinsurance rates as high as 50%

• Higher deductibles

• No cap on balance billing from providers

Always confirm a provider is in-network before scheduling high-cost procedures. Use your plan’s online directory or call the customer service line directly.

7. Use Preauthorization to Prevent Denials

Many services that involve coinsurance also require prior authorization. Without it, your plan may deny coverage entirely, leaving you responsible for 100% of the bill.

Services commonly requiring preapproval include:

• MRI/CT scans

• Surgeries

• Inpatient admissions

• Durable medical equipment

Request preauthorization early and confirm it has been approved in writing. Keep records in case disputes arise.

8. Monitor Your Year-to-Date Spending

Your coinsurance costs aren’t always easy to track without effort. Consider:

• Logging into your health plan’s portal to view year-to-date spending

• Using any available tools or mobile apps that track out-of-pocket accumulation

• Keeping your Explanation of Benefits (EOB) documents

Tracking helps you plan future care, recognize errors, and estimate when you’ll hit your out-of-pocket maximum.

9. Budget for Medical Expenses Using FSA or HSA (If Applicable)

While annuitants typically can’t contribute to an HSA, active USPS workers in a high-deductible PSHB plan can. These accounts let you:

• Use pre-tax dollars to pay coinsurance

• Cover other qualified medical costs like prescriptions or dental care

Flexible Spending Accounts (FSAs) are available to eligible employees. For 2025, the annual contribution limit is $3,300, with a $660 carryover if your plan allows.

10. Ask Questions—And Don’t Settle for Confusion

The PSHB system is new as of 2025, and coinsurance policies vary across plans. Don’t assume last year’s coverage details are still valid.

You have every right to:

• Call your health plan and request plain-language clarification

• Speak to a licensed agent listed on this website for advice during Open Season or after major health events

• Reassess your plan after significant life changes like retirement, turning 65, or a new diagnosis

Planning for Financial Protection

A 20% coinsurance doesn’t sound alarming at first—but once you experience it with a high-cost service, the numbers can overwhelm you. Fortunately, PSHB enrollees in 2025 have options. From switching plans during Open Season to coordinating with Medicare and budgeting with an FSA, you can take control of your cost-sharing burden.

To get personalized advice or explore your options before next Open Season, get in touch with a licensed agent listed on this website. A quick conversation could help you make smarter, more affordable choices for the year ahead.