Key Takeaways

  • Your coinsurance might look small on paper, but in the middle of a hospital stay, it can balloon into thousands of dollars you didn’t budget for.

  • Understanding your PSHB plan’s coinsurance structure now helps you avoid financial surprises later, especially for inpatient or specialized care.

What Coinsurance Really Means Under PSHB

Coinsurance is the percentage of costs you’re responsible for after meeting your deductible. Unlike a flat copayment, coinsurance varies with the cost of services. If your PSHB plan has a 20% coinsurance rate for inpatient care, you pay 20% of the bill after the deductible is met. That percentage stays the same, but the dollar amount can vary widely depending on what kind of care you need.

For many PSHB plans, coinsurance applies to:

  • Inpatient hospital stays

  • Specialist visits

  • Imaging services (CT, MRI, PET scans)

  • Durable medical equipment

  • Outpatient surgery centers

  • Mental health and substance use care

When your care is routine, coinsurance might feel manageable. But the second a serious health issue lands you in the hospital or you need unexpected tests or surgery, those percentages add up fast.

The First Hospital Bill Can Be a Shock

Even a short hospital stay can cost tens of thousands of dollars. If your coinsurance is 20% and the total bill is $25,000, you’re responsible for $5,000 — and that’s after your deductible.

While your PSHB plan does cap your annual out-of-pocket costs, the limits for 2025 still allow for significant personal responsibility:

  • $7,500 for Self Only in-network care

  • $15,000 for Self Plus One or Self and Family in-network care

Out-of-network services often have even higher limits. And not all services are subject to caps, so understanding the fine print is critical.

Coinsurance vs Copayment: Why It Feels Different

A $30 copay is predictable. A 20% coinsurance is not.

This unpredictability is what catches most people off guard. Copayments typically apply to:

  • Primary care visits

  • Routine specialist visits

  • Prescription drugs (depending on tier)

Coinsurance often applies when services become more complex or costly. Think surgeries, scans, therapy sessions, or hospitalizations. You can’t always estimate these costs ahead of time, especially during emergencies.

How Your Deductible Interacts with Coinsurance

Before coinsurance even kicks in, you first meet your annual deductible. For 2025, deductibles under PSHB plans generally range from:

  • $350 to $500 for low-deductible plans

  • $1,500 to $2,000 for high-deductible plans

Once you’ve paid the deductible, you share the cost of services through coinsurance until you hit your out-of-pocket maximum. That maximum includes:

  • Your deductible

  • Your coinsurance

  • Eligible copayments

It does not include:

  • Premiums

  • Non-covered services

  • Balance billing from out-of-network providers (unless the plan covers it)

Medicare Makes a Difference If You’re Eligible

If you’re a PSHB annuitant enrolled in Medicare Part A and Part B, your out-of-pocket coinsurance under your PSHB plan may decrease. Many PSHB plans coordinate with Medicare to:

  • Waive or reduce deductibles

  • Eliminate coinsurance for certain services

  • Offer reimbursement for some Medicare Part B premiums

These benefits can dramatically reduce your costs during a hospital stay. But this coordination only applies if you’re enrolled in both Medicare and PSHB and meet specific eligibility criteria.

If you delay or opt out of Medicare Part B and don’t qualify for an exception, you may face higher out-of-pocket costs under your PSHB plan.

When the Costs Spike: Common Scenarios That Trigger High Coinsurance

Here are typical scenarios where coinsurance costs balloon:

1. Inpatient Admissions

Hospital stays can include:

  • Room and board charges

  • Lab work

  • Imaging

  • Physician fees

  • Medication

  • Post-acute care planning

Coinsurance applies to nearly all of these, which means even one overnight stay can quickly exhaust a large part of your annual maximum.

2. Outpatient Surgeries

Even though you aren’t admitted, outpatient surgeries can still cost thousands. Procedures like colonoscopies, biopsies, or orthopedic treatments are billed as facility services, which fall under coinsurance.

3. Emergency Room Visits

ER visits often include:

  • Facility fees

  • Physician evaluation

  • Diagnostic tests

  • Medication

These fees can total thousands, especially if you’re transferred or held for observation. Coinsurance may apply depending on how your plan classifies the care.

4. Imaging and Lab Work

Advanced imaging (like MRI or CT) often triggers coinsurance. A single scan can cost over $1,000, of which you might owe 20% or more.

5. Specialist Care for Chronic Conditions

Seeing multiple specialists for ongoing care — cardiology, endocrinology, neurology — can generate frequent coinsurance bills, especially if lab testing or procedures are ordered.

The Danger of Hitting Your Out-of-Pocket Maximum Too Quickly

Once you reach your plan’s annual limit, your plan pays 100% of covered in-network costs for the rest of the year. That sounds like a relief, but getting there can mean:

  • Thousands paid out in a short time

  • Financial disruption during a health crisis

  • Limited options if care requires travel to out-of-network providers

The problem isn’t the cap itself. The problem is how fast it can be reached when coinsurance is based on percentages of high-cost services. If your out-of-pocket maximum is $7,500 and your hospital bill is $45,000, it won’t take long.

What You Can Do Now to Prepare

You can’t predict an emergency, but you can plan for how you’d handle the financial impact.

Review Your Plan’s Cost-Sharing Details

During the PSHB Open Season from November to December, look at:

  • Coinsurance rates for in-network and out-of-network services

  • Deductibles and out-of-pocket maximums

  • Coverage for inpatient hospital, ER, outpatient care, and diagnostics

Consider Medicare Enrollment If You Qualify

If you’re turning 65 or are already eligible, enrolling in Medicare Part B could reduce your coinsurance responsibilities under PSHB.

Be aware that:

  • Medicare Part B is required for most PSHB annuitants to keep their coverage in 2025

  • Some exceptions apply (for example, if you retired on or before January 1, 2025)

  • Coordination between PSHB and Medicare typically results in lower coinsurance and waived deductibles

Build an Emergency Fund for Medical Expenses

Set aside funds specifically for health-related costs. While this won’t replace insurance, it can soften the blow when coinsurance costs suddenly spike.

Know Your Out-of-Network Risks

Most PSHB plans cover more when you stay in-network. Out-of-network coinsurance is often 40% to 50%, and balance billing can increase your financial responsibility.

If you live in a rural area or plan to travel, verify provider networks in advance.

Use Preventive Services to Stay Ahead

Preventive care is usually covered in full and can help avoid costly medical issues. This includes:

  • Annual physicals

  • Screenings (colorectal, mammogram, prostate, etc.)

  • Vaccinations

  • Health counseling

Taking these steps doesn’t eliminate coinsurance, but it may reduce your need for expensive procedures down the line.

Staying Ahead of the Financial Curve with PSHB

Coinsurance might feel like a small percentage when you’re healthy. But if an illness or accident strikes, that percentage translates into real money and fast decisions. Understanding how coinsurance works with your PSHB plan, particularly in 2025, helps you avoid being caught off guard.

Take the time now to review your benefits, compare your current plan against others, and understand how Medicare coordination works. If you’re unsure about any part of the process, reach out to a licensed agent listed on this website who can help explain the fine print and guide you to the best choices for your health and financial security.