Key Takeaways

  • PSHB coinsurance may appear familiar if you’ve had health coverage before, but its structure and cost-sharing can be very different from what you’re used to.

  • Understanding when coinsurance kicks in, how it interacts with deductibles and out-of-pocket limits, and where you’re likely to pay more can help you avoid unexpected medical bills.

What Coinsurance Really Means in PSHB

Coinsurance under the Postal Service Health Benefits (PSHB) program represents a shared cost between you and your plan for certain healthcare services. Unlike a flat copayment, coinsurance is a percentage of the allowed cost of a service, and it becomes your responsibility after your deductible has been met.

For 2025, coinsurance ranges typically between:

  • 10% to 30% for in-network services

  • 40% to 50% for out-of-network services

This percentage-based system means the more expensive the care, the more you may owe—even if you’ve already paid your premiums.

Coinsurance vs. Copayments

Many people confuse coinsurance with copayments, but they work very differently:

  • Copayment is a fixed dollar amount (like $30) you pay at the time of service.

  • Coinsurance is a percentage (e.g., 20%) of the allowed cost that you owe after meeting the deductible.

Both may apply in the same plan, but coinsurance can lead to higher costs if you require ongoing or expensive care.

When Coinsurance Applies

Coinsurance doesn’t apply immediately. You first need to meet your annual deductible. Once that’s satisfied, your plan begins sharing costs, with you paying your coinsurance share until you hit your out-of-pocket maximum.

This sequence matters:

  1. Pay full cost until deductible is met

  2. Coinsurance starts after the deductible

  3. Plan pays full cost once the out-of-pocket maximum is reached

For 2025, in-network deductibles range from $350 to $2,000 depending on the plan, and out-of-pocket maximums can go as high as $15,000 for families.

Services Most Affected by Coinsurance

You’re more likely to face coinsurance charges for:

  • Hospital stays

  • Outpatient surgery

  • Advanced imaging (MRI, CT scans)

  • Specialist visits not covered by a copay

  • Emergency care (especially out-of-network)

  • Durable medical equipment

  • Physical therapy

Even if your doctor is in-network, the facility or a specialist involved might not be, increasing your coinsurance burden.

Why Coinsurance Costs Add Up Quickly

With coinsurance, there’s no predictable payment structure. For example, a single procedure costing $3,000 might result in a $600 coinsurance bill if your plan requires 20% coinsurance—and that’s just one procedure. If multiple services are rendered, or you require follow-up care, these charges compound quickly.

Also, keep in mind:

  • Some services have separate cost-sharing rules

  • Out-of-network coinsurance often doesn’t count toward in-network out-of-pocket maximums

  • You could be billed for balance billing if the provider charges more than the plan’s allowed amount (especially out-of-network)

Medicare’s Role in Reducing Coinsurance

If you’re Medicare-eligible and enrolled in Medicare Part B, some PSHB plans in 2025 offer substantial relief from coinsurance costs:

  • Waived or reduced deductibles

  • Lower coinsurance percentages

  • No balance billing in many cases

  • Integrated prescription drug benefits

But these benefits only apply if you’re enrolled in both Medicare Part B and the right PSHB plan that coordinates with it. If you opt out of Part B, your coinsurance burden remains similar to non-retirees.

In-Network vs. Out-of-Network Coinsurance

The coinsurance structure in PSHB dramatically shifts depending on your provider’s network status.

  • In-network: You pay a smaller share, and your costs count toward your in-network out-of-pocket maximum.

  • Out-of-network: You pay a higher percentage, and these costs may not count toward your in-network cap.

Also, plans often include a separate out-of-network deductible—often $1,000 or more—before coinsurance even begins.

Why You Can’t Assume It’ll Work Like FEHB

If you were previously enrolled in the Federal Employees Health Benefits (FEHB) program, PSHB may look familiar. But coinsurance can work differently:

  • Different network agreements

  • New Medicare Part B coordination rules

  • New deductibles and cost-sharing levels

  • Integrated Medicare Part D coverage with distinct rules

If you assume that your out-of-pocket experience under FEHB will carry over to PSHB without changes, you could be in for unexpected charges—especially for services like imaging, surgery, or post-discharge therapy.

Annual Reset and Why It Matters

Every January, your coinsurance and deductible totals reset. This means:

  • You’ll start paying out-of-pocket again

  • Previous year’s expenses don’t carry over

  • You may face large bills early in the year if you need care before reaching your deductible

This reset can create significant cost spikes, especially if you schedule elective procedures or experience a health event early in the calendar year.

Reviewing Your PSHB Plan Documents Carefully

Every PSHB plan has a Summary of Benefits and a full brochure. Don’t just rely on premiums to compare plans—dig into:

  • Deductibles

  • Coinsurance rates (in and out of network)

  • Out-of-pocket maximums

  • Specialty services like home health or rehab

Some plans label coinsurance details under “cost sharing” or “member responsibility.”

Common Traps to Watch For

There are several areas where people get tripped up by coinsurance:

  • Out-of-network anesthesiologists or radiologists during in-network hospital stays

  • Facility fees that apply coinsurance in addition to physician charges

  • Medical equipment rental with ongoing coinsurance each month

  • Separate billing from specialists and labs not in your plan’s network

Without reviewing your plan’s provider directory or checking in advance, these can add thousands to your bill.

Coinsurance for Families

Coinsurance calculations can be even more complex with Self Plus One or Self and Family plans:

  • Deductibles and out-of-pocket limits are often aggregate, meaning one family member could trigger the limit for all

  • Still, individual limits may apply in some plans for high-cost services

  • Pediatric and maternity care often involve multiple providers, each with their own billing

If you’re the primary enrollee, ensure your spouse and dependents understand what’s covered, who’s in-network, and how cost-sharing applies.

Being Proactive Can Prevent Surprises

To keep coinsurance manageable, try these steps:

  • Confirm provider network status before appointments

  • Compare coinsurance percentages between plans during Open Season (November to December)

  • Use preauthorization channels when required

  • Contact your plan before major procedures for a cost estimate

  • If Medicare-eligible, coordinate properly with Part B

Advance planning makes a major difference when dealing with coinsurance—especially if you face surgery, extended care, or a new diagnosis.

How to Reduce Coinsurance Shock in 2025

In 2025, many plans offer tools you can use:

  • Out-of-pocket calculators on plan websites

  • Pre-service cost estimators

  • Help lines for benefit clarifications

  • Medicare coordination specialists in select plans

During Open Season, it’s worth contacting the plan directly or speaking with a licensed agent listed on this website who understands PSHB and can walk you through cost scenarios based on your healthcare needs.

Coinsurance Isn’t a Hidden Fee—But It’s Often Misunderstood

Coinsurance under PSHB isn’t an extra charge—it’s a standard part of cost sharing. But it’s easy to underestimate the financial impact it can have if you don’t fully understand how it works. From deductibles and networks to Medicare and cost-sharing resets, each factor contributes to how much you actually pay.

To get ahead of coinsurance surprises, take time to:

  • Review your plan’s benefits and costs

  • Ask questions before scheduling procedures

  • Stay in-network whenever possible

  • Coordinate your PSHB plan with Medicare Part B if you’re eligible

You don’t have to navigate this alone—connect with a licensed agent listed on this website who can help you evaluate your PSHB plan, understand cost-sharing, and prepare for healthcare expenses throughout 2025.