Key Takeaways

  • Coinsurance in PSHB plans often appears small on paper, but the actual amounts you may pay can be significantly higher depending on service costs and whether Medicare is involved.

  • Knowing when coinsurance kicks in, and how it differs from copayments or deductibles, helps you avoid surprises—especially if you’re managing chronic conditions or anticipating major procedures.

What Coinsurance Means in Your PSHB Plan

If you’re covered under a Postal Service Health Benefits (PSHB) plan in 2025, understanding coinsurance is crucial. Unlike a flat dollar amount, coinsurance is a percentage of the cost of a service that you’re responsible for after meeting your deductible. And that percentage can make a noticeable dent in your budget depending on the type and cost of care you receive.

In-network PSHB coinsurance typically ranges from 10% to 30%, while out-of-network charges can reach 40% to 50%. Even a routine outpatient surgery or diagnostic scan can come with a hefty bill if coinsurance applies.

Why Coinsurance Isn’t a Minor Detail

You might expect your PSHB plan to cover most costs once you’ve paid your premium. But the truth is, coinsurance can become your primary cost-sharing responsibility once the deductible is met.

Here’s where it gets tricky:

  • Coinsurance doesn’t cap out until you reach your plan’s annual out-of-pocket maximum.

  • It applies after your deductible, not instead of it.

  • It’s calculated on the plan’s allowed amount—not necessarily what the provider charges.

If you’re not tracking your yearly healthcare spending, coinsurance costs can sneak up and pile on.

Comparing Coinsurance to Copayments and Deductibles

Many confuse coinsurance with copayments or deductibles. Here’s a quick breakdown:

  • Copayment: A flat fee (e.g., $30 for a specialist visit).

  • Deductible: The total amount you must pay before the plan begins sharing costs.

  • Coinsurance: A percentage of the cost you pay after meeting the deductible.

In your PSHB plan, all three might apply to a single service. You could pay a deductible, then coinsurance, and potentially even a copay depending on the type of service and provider.

What Triggers Coinsurance Costs

Coinsurance typically applies to the following types of care:

  • Hospital stays and outpatient surgeries

  • Specialist visits beyond the first few visits

  • Advanced imaging (like MRIs and CT scans)

  • Durable medical equipment

  • Home health services

For these, your plan might cover 70% to 90% in-network—but you’re responsible for the remainder.

The Role Medicare Plays for Retirees

If you’re a Medicare-eligible PSHB enrollee, having both Medicare Part B and a PSHB plan can limit your coinsurance exposure significantly. That’s because many PSHB plans coordinate benefits with Medicare, often covering the remaining costs after Medicare pays its share.

However, that coordination depends on your specific enrollment:

  • If you opted into Medicare Part B, PSHB coinsurance often drops or vanishes for covered services.

  • If you declined Part B, you could be left covering the PSHB coinsurance percentage on your own.

In 2025, coordination between PSHB and Medicare has become increasingly important as coinsurance rates haven’t gone down—but costs of care continue to rise.

How Out-of-Network Services Complicate Things

Out-of-network care under PSHB brings higher coinsurance, a separate deductible, and often a separate out-of-pocket maximum. That means:

  • You could pay 40% to 50% of service costs.

  • The plan might only reimburse based on what it deems a reasonable charge.

  • You’re responsible for the balance beyond what the plan allows.

This makes out-of-network care one of the costliest decisions in your coverage path, especially when you’re hit with both coinsurance and balance billing.

Annual Out-of-Pocket Limits Still Matter

In 2025, PSHB plans set annual out-of-pocket maximums for in-network services at about $7,500 for Self Only coverage and $15,000 for Self Plus One or Self & Family. Once you hit these thresholds, the plan covers 100% of covered services.

However, these limits only apply to in-network expenses. Out-of-network coinsurance might not count toward this cap unless explicitly stated in the plan brochure.

Understanding this can make the difference between thousands in unexpected bills and staying within your planned healthcare budget.

Coinsurance on Prescription Drugs

PSHB prescription benefits also involve coinsurance—especially for specialty medications. Instead of a flat copay, you might pay a percentage of the medication’s price until you hit your plan’s pharmacy out-of-pocket maximum.

In 2025, Medicare-eligible enrollees under PSHB plans with Part D coverage benefit from the new $2,000 cap on out-of-pocket prescription drug costs. This helps prevent runaway spending, but only if your PSHB drug coverage is coordinated with Medicare.

Coinsurance and Preventive Services

The good news: preventive care is usually not subject to coinsurance. This includes screenings, immunizations, and wellness visits, which are generally covered at 100% when done in-network.

But if you’re getting diagnostic tests after a screening or need follow-up care, coinsurance can quickly come into play. Always confirm whether a service is preventive or diagnostic before your visit.

Understanding Plan Brochures and Cost Sharing Details

Every PSHB plan publishes a brochure, often over 100 pages long, detailing:

  • Coinsurance percentages by service type

  • In-network vs. out-of-network cost differences

  • When a deductible must be met

  • What counts toward your annual out-of-pocket max

Take time during the November–December Open Season to review these details. Your future self (and your wallet) will thank you.

Questions to Ask Before Receiving Care

To stay in control of your costs, ask your provider or plan the following:

  • Is this service subject to coinsurance?

  • What percentage will I pay if I’ve already met my deductible?

  • Is this provider in-network under my PSHB plan?

  • Will this service count toward my out-of-pocket maximum?

  • Is there a less expensive in-network facility available?

Getting these answers ahead of time helps you avoid unwelcome billing surprises.

Where This Leaves You in 2025

Coinsurance is no longer a footnote in your coverage—it’s a central cost consideration under PSHB. Whether you’re actively employed or retired, it plays a major role in what you pay out-of-pocket in 2025. And if you’re not careful, it can derail even the most thoughtful healthcare budget.

The best way to prepare? Familiarize yourself with how coinsurance works in your plan, coordinate with Medicare if you’re eligible, and avoid out-of-network care unless absolutely necessary.

Make Informed Choices, Not Costly Ones

Coinsurance isn’t hidden—but it’s easy to underestimate. As a postal worker or retiree under PSHB in 2025, you owe it to yourself to check the fine print, plan for your healthcare needs, and understand how much responsibility lands on your side of the equation.

If you still feel unsure about how coinsurance works in your specific plan—or how Medicare fits into your cost-sharing picture—get in touch with a licensed insurance agent listed on this website. They can walk you through your plan’s structure and help you make confident coverage decisions.