Key Takeaways

  • Coinsurance under the Postal Service Health Benefits (PSHB) Program is one of the most misunderstood parts of your coverage. It’s a percentage-based cost-sharing structure that can lead to surprisingly high out-of-pocket bills.

  • Understanding your plan’s coinsurance terms, especially for hospital stays, specialist visits, and out-of-network care, can help you avoid financial strain when unexpected medical situations arise.

Understanding Coinsurance Under PSHB Plans

Coinsurance is not the same as a copay. Instead of a flat fee, coinsurance requires you to pay a percentage of the cost of certain medical services. In 2025, most PSHB plans follow a model where you split costs with the plan once you meet your deductible. For example, if your plan has a 20% coinsurance for specialist visits, you pay 20% of the bill while the plan covers the remaining 80%.

Coinsurance typically applies after you’ve met your annual deductible. But this doesn’t mean the remaining costs are small. If your total medical bill is high, your share can still be substantial—even with good coverage.

The Role of Deductibles and Out-of-Pocket Maximums

Before coinsurance kicks in, you first need to meet your deductible. For PSHB plans in 2025, in-network deductibles range from $350 to $500 for low-deductible plans and up to $2,000 for high-deductible options. Once that amount is paid out-of-pocket, coinsurance begins.

You are protected by out-of-pocket maximums, which cap your total spending for covered services. For 2025, PSHB plans generally cap in-network costs at $7,500 for Self Only coverage and $15,000 for family coverage. However, those numbers do not include premiums and can exclude services from out-of-network providers.

Why Coinsurance Feels Invisible—Until It Doesn’t

Unlike a copayment, which you pay up front, coinsurance is often billed after the service is provided. This makes it easy to underestimate how much you owe. Here’s what typically happens:

  • You visit a hospital or specialist.

  • Your provider bills your insurance.

  • Your plan pays its share based on negotiated rates.

  • You receive a bill weeks later for your portion (coinsurance).

If the total cost of a procedure is $4,000 and your coinsurance is 20%, you could receive a bill for $800—sometimes long after the service.

High-Impact Areas Where Coinsurance Hits Hard

Hospital Stays

Inpatient care costs are among the highest you can incur, and coinsurance for these services can significantly strain your budget. For example:

  • You may face 20% coinsurance after meeting your deductible.

  • Daily hospital costs can quickly exceed $2,000, especially in multi-day stays.

Even with an out-of-pocket cap, you could approach it quickly during a hospital admission.

Outpatient Surgery

Many PSHB plans in 2025 treat outpatient surgery as a coinsurance service, meaning you’ll be billed a percentage after the deductible. Outpatient procedures may cost between $3,000 and $6,000, so your portion can add up fast.

Specialty Care

Seeing specialists—such as dermatologists, cardiologists, or neurologists—can trigger coinsurance costs. If you need frequent follow-ups, your coinsurance payments can accumulate, especially if each visit costs several hundred dollars.

Emergency Services

Emergency room visits often involve facility charges, physician fees, and diagnostics, all of which can be subject to coinsurance. Even if you have a fixed copay for ER visits, additional services may be billed separately with coinsurance applied.

Diagnostic Imaging

High-cost diagnostics like MRIs and CT scans are commonly billed under coinsurance. If your plan covers 80% of the cost, you are responsible for the remaining 20%, which can mean hundreds of dollars per test.

What Changes When You See Out-of-Network Providers

Out-of-network services are typically subject to higher coinsurance rates—sometimes up to 50%—and are often excluded from the out-of-pocket maximum. This means:

  • You might pay much more than you expect.

  • Your total costs may not be capped.

  • You may also be responsible for balance billing—the difference between what your provider charges and what your plan pays.

If you unknowingly go out-of-network, your coinsurance exposure could be much higher than anticipated.

Medicare Part B and Coinsurance Coordination

If you’re a Medicare-eligible annuitant and enrolled in Medicare Part B, many PSHB plans will coordinate benefits to reduce your coinsurance burden.

For example:

  • Your PSHB plan may waive or significantly reduce coinsurance for services covered by both Medicare and your plan.

  • Some PSHB plans in 2025 also offer partial reimbursement for Part B premiums and additional cost-sharing reductions.

But you must be actively enrolled in Medicare Part B to access these benefits. If you’re not, you’ll face full PSHB coinsurance obligations.

Annual Reviews Are Critical

Your coinsurance burden depends on which PSHB plan you choose. Every year during the Open Season (from November to December), you have the opportunity to:

  • Compare coinsurance percentages for common services

  • Evaluate how plans treat Medicare coordination

  • Consider plan differences in deductibles and out-of-pocket caps

Skipping this annual review means you could miss out on switching to a plan that offers better coinsurance protection—especially if your healthcare needs change.

How to Estimate Your Coinsurance Costs Ahead of Time

Being caught off guard by coinsurance is frustrating. To avoid this, make it a habit to:

  • Ask providers for cost estimates before scheduling care

  • Use your plan’s online cost calculator if available

  • Review your plan brochure, focusing on coinsurance rates for hospital, specialist, and outpatient services

  • Keep track of your deductible progress and how close you are to the out-of-pocket maximum

Preparation doesn’t remove the cost, but it prevents surprise billing from upending your budget.

Timing Matters—So Does the Type of Service

In 2025, cost-sharing is often tied to how and when you access services. Same service, different setting—different coinsurance:

  • Urgent care vs. Emergency room: Urgent care typically carries a lower coinsurance burden than the ER.

  • Telehealth vs. In-person visits: Some PSHB plans offer lower cost-sharing for telehealth, making it a more affordable option.

  • In-network vs. Out-of-network: Always confirm a provider’s network status.

Understanding these differences allows you to take control of where and how you seek care.

You’re Still on the Hook, Even With the $2,000 Drug Cap

Although 2025 brings a $2,000 out-of-pocket cap for prescription drugs under Medicare Part D, coinsurance still applies to medical services. That cap only applies to covered drugs—not hospitalizations, specialist visits, or diagnostic tests.

Coinsurance for medical services can continue even after you hit the drug cost limit, so don’t assume you’re done spending for the year.

When to Seek Help

If you’re feeling overwhelmed, you’re not alone. Coinsurance can be difficult to track and manage, especially if you face ongoing care. You can:

  • Speak to a licensed insurance agent listed on this website for plan guidance

  • Contact your plan directly for personalized cost estimates

  • Explore whether switching plans or enrolling in Medicare Part B would reduce your burden

Know What to Expect Before the Bill Arrives

You can’t always avoid coinsurance, but you can prepare for it. Understanding how coinsurance works under PSHB plans in 2025 is the first step. Be proactive:

  • Compare plan details each year

  • Ask questions before care

  • Track your spending during the year

If you’re nearing retirement or already enrolled, don’t assume everything is covered—read the fine print. And when in doubt, speak with a licensed insurance agent listed on this website who can walk you through your options and help you select the right plan.