Key Takeaways

• Many PSHB enrollees are surprised to learn that coinsurance can create higher-than-expected bills even after meeting their deductible.

• Understanding how coinsurance applies in different care settings—especially with out-of-network providers—can protect you from costly misunderstandings.

What Coinsurance Means Under PSHB in 2025

Coinsurance is the percentage of medical costs you’re responsible for after you’ve met your annual deductible. In the Postal Service Health Benefits (PSHB) program, coinsurance applies to a variety of services, including hospital stays, surgeries, specialty visits, and even some prescriptions. Unlike copayments—which are fixed amounts—coinsurance is variable and based on the cost of the service.

In 2025, PSHB plans generally follow a structure where you pay between 10% and 30% of the cost for in-network services. For out-of-network care, your share can jump to 40% or more. And that’s after you’ve already paid your deductible.

Understanding these percentages before you use your benefits can make a substantial difference in how prepared you feel—both medically and financially.

Why Coinsurance Often Catches People Off Guard

Coinsurance is deceptively simple in theory, but in practice it behaves differently depending on where and how you get your care. After your first major claim—say, a surgery or hospital stay—you might expect insurance to cover most of the remaining costs. That’s when coinsurance kicks in, and that’s where the surprise happens.

Here’s why coinsurance under PSHB can be unexpectedly costly:

• Cost visibility is low. You rarely know the full cost of a medical service beforehand.

• Out-of-pocket maximums are high. Some PSHB plans have maximums as high as $7,500 for Self Only or $15,000 for family coverage.

• Specialist and hospital services are expensive. A 20% coinsurance on a $10,000 procedure still means you’re paying $2,000.

For those unfamiliar with PSHB plan structures, coinsurance can lead to sticker shock, especially when high-cost services aren’t obvious up front.

How Deductibles and Coinsurance Work Together

Your deductible is the amount you must pay out of pocket each year before your plan starts sharing costs. Once that threshold is met, coinsurance applies until you hit your out-of-pocket maximum.

Here’s how the progression works in a typical year under PSHB in 2025:

1. You pay 100% of eligible costs until you reach your deductible (e.g., $500–$1,500 depending on plan type).

2. After that, you pay a percentage (coinsurance) for each service until you reach your out-of-pocket cap.

3. Once you hit your out-of-pocket maximum, the plan covers 100% of approved services for the remainder of the calendar year.

If your first major claim occurs early in the year, you may find yourself paying the full deductible and coinsurance in quick succession.

In-Network vs Out-of-Network: A Cost Difference That Matters

A key aspect of managing coinsurance costs under PSHB is using in-network providers. While most PSHB plans offer nationwide provider networks, using out-of-network services can double or even triple your cost share.

In-network services typically come with these advantages:

• Lower coinsurance rates (10–30%)

• No balance billing

• Predictable costs under negotiated rates

On the other hand, out-of-network care means:

• Higher coinsurance rates (often 40–50%)

• Potential balance billing from the provider

• Higher risk of reaching your out-of-pocket limit faster

You should confirm a provider’s network status before scheduling services, especially for expensive or elective procedures.

How PSHB Coinsurance Applies to Common Services

To better understand what you could be paying coinsurance for, here’s a breakdown of some common categories where coinsurance applies under PSHB:

• Hospital stays: After the deductible, coinsurance can apply to each day in the hospital.

• Outpatient surgery: Coinsurance often applies even when services are performed in an ambulatory setting.

• Specialist visits: Especially for follow-ups or ongoing care (e.g., cardiology, dermatology).

• Diagnostic tests: MRIs, CT scans, and lab tests often involve a percentage cost share.

• Durable medical equipment (DME): Wheelchairs, oxygen tanks, and prosthetics often fall under coinsurance categories.

These categories can carry high price tags, so your portion—even if it’s only 20%—can add up quickly.

The Surprising Impact of Timing

The time of year your major claim happens matters. If you have a large medical expense in January, you may face both your full deductible and months of coinsurance payments. If it occurs later in the year and you’ve already met your deductible, the coinsurance impact may still push you to your out-of-pocket maximum quickly.

Here’s a timeline-based view:

• January–March: You’re likely paying full deductible + early coinsurance.

• April–August: Midyear costs may overlap with partial deductible coverage.

• September–December: Costs here may trigger the out-of-pocket maximum if you’ve had prior claims.

The first major claim in a calendar year often serves as a wake-up call about how coinsurance and deductibles work together.

Strategies to Avoid Surprise Costs

You can’t avoid coinsurance, but you can prepare for it. Here are steps to help minimize financial strain:

• Verify network status: Always confirm your providers and facilities are in-network.

• Estimate costs ahead of time: Use your plan’s cost estimator tools or contact the provider’s billing office.

• Track your deductible status: Know how close you are to meeting your deductible and out-of-pocket maximum.

• Use preventive care benefits: Many PSHB plans cover annual checkups and screenings with no cost share.

• Choose generic or preferred medications: Coinsurance applies less heavily here in many plans.

Taking proactive steps helps reduce the surprise factor when you finally see your medical bill.

What to Do After Receiving a High Coinsurance Bill

If your first major claim results in an unexpectedly high bill, here’s how to handle it:

• Review the Explanation of Benefits (EOB): Check what your plan covered and what portion is your responsibility.

• Compare provider billing statements: Sometimes discrepancies exist between the insurer’s EOB and the provider’s invoice.

• Check for coding errors: A wrong billing code can dramatically inflate your coinsurance.

• Request an itemized bill: This gives you transparency into every charge.

• Negotiate payment terms: Most providers offer payment plans if you can’t pay the full amount at once.

Understanding the why behind your bill can make a big difference in what you ultimately pay.

Planning Ahead With Coinsurance in Mind

The PSHB program offers several plan types, from high-deductible options to more traditional PPO-style plans. When choosing your coverage during Open Season (November–December), pay close attention to:

• Coinsurance percentages

• Deductible amounts

• Out-of-pocket maximums

Also, consider how often you expect to use your healthcare. If you anticipate needing specialty care or surgery, a plan with a lower coinsurance rate—even if the premium is slightly higher—may save you more in the long run.

Remember, coinsurance costs are not just a footnote in your benefits brochure—they’re a central factor in your total healthcare spending.

Prepare Now to Stay Ahead Later

Many PSHB enrollees don’t fully grasp the financial weight of coinsurance until their first major medical bill arrives. But you don’t have to be caught off guard.

By learning how coinsurance works, staying within your plan’s network, and reviewing cost-sharing features before you need care, you can avoid the most common pitfalls.

If you have questions or want help reviewing plan options, get in touch with a licensed agent listed on this website. A professional can walk you through the specifics and help you compare options tailored to your needs.