Key Takeaways

• Coinsurance in your PSHB plan may seem manageable on paper, but depending on how your year unfolds, it can quietly stack up to be one of your most expensive healthcare burdens.

• Understanding how coinsurance works with deductibles, copayments, and out-of-pocket limits in 2025 is essential to avoid financial surprises—especially when Medicare is involved.

What Coinsurance Really Means in PSHB Plans

Coinsurance is a cost-sharing structure where you pay a percentage of the allowed charge for covered services after you’ve met your deductible. Unlike a fixed copayment, coinsurance is variable. The more care you need, the more you could owe.

In 2025, most PSHB plans offer in-network coinsurance ranging from 10% to 30% for common services like outpatient surgery, diagnostic tests, and specialist visits. If you go out-of-network, this percentage can rise to 40% or even 50%.

While this seems straightforward, coinsurance exposes you to a wide range of costs depending on the type and frequency of services used. It becomes especially relevant when you receive:

• Imaging or lab work (CT scans, MRIs, blood panels)

• Physical therapy or rehabilitation services

• Outpatient hospital procedures

• Specialty care from high-cost providers

• Durable medical equipment or home healthcare

How Deductibles and Coinsurance Work Together

Coinsurance does not apply until you meet your annual deductible. For 2025, PSHB in-network deductibles typically range between $350 and $500 for lower-deductible plans. High-deductible plans start around $1,500 to $2,000. Once your deductible is met, coinsurance begins.

Here’s where many enrollees are caught off guard:

• You pay 100% of eligible costs up to your deductible

• Then you pay a percentage (coinsurance) of each bill until you hit your plan’s out-of-pocket maximum

Out-of-pocket maximums for 2025 PSHB plans range from $5,000 to $7,500 for Self Only and $10,000 to $15,000 for family coverage. If you’re managing multiple or ongoing conditions, these numbers can become very real.

Medicare Part B and Coinsurance in PSHB

If you’re a Medicare-eligible Postal retiree enrolled in Medicare Part B, your coinsurance structure may look quite different. In 2025, many PSHB plans coordinate benefits with Medicare in ways that reduce or even eliminate coinsurance.

However, this is not automatic. You must:

• Be enrolled in Medicare Part B

• Be in a PSHB plan that coordinates with Medicare

When properly coordinated, Medicare Part B typically pays 80% of covered services, and your PSHB plan may cover the remaining 20%. Some PSHB plans in 2025 even waive deductibles or offer cost-sharing reductions when Medicare is primary.

Still, if you’re not enrolled in Part B—or if you’re ineligible—your PSHB coinsurance remains fully active. That means:

• You’re responsible for all costs until your deductible is met

• Then your coinsurance applies to every covered service until the maximum out-of-pocket amount is reached

Situations Where Coinsurance Becomes a Major Cost

While a 20% or 30% share might seem minor, the costs add up quickly when:

• You have an unexpected hospitalization: Even a short stay can trigger tens of thousands in billed charges.

• You need multiple diagnostic tests: Advanced imaging is expensive and often requires coinsurance.

• You require outpatient surgery: Coinsurance applies to both the surgeon and the facility.

• You use non-preferred providers or facilities: Even within a network, some services are tiered.

• You need durable medical equipment: You could owe a substantial percentage of the cost.

In all these cases, coinsurance is not capped per service—it continues to apply until your out-of-pocket maximum is met.

Out-of-Network and Emergency Care Considerations

PSHB plans generally offer lower cost-sharing for in-network providers. However, emergencies don’t always occur near approved facilities. If you end up at an out-of-network hospital, your coinsurance could double.

Out-of-network deductibles and out-of-pocket maximums are significantly higher. For 2025, these can reach:

• $1,000 to $3,000 for out-of-network deductibles

• $10,000 to $20,000 for out-of-pocket maximums

Even for emergency services, you may face balance billing—charges above what your plan allows—unless protections are in place under federal rules.

How Your Plan’s Design Affects Coinsurance Exposure

Not all PSHB plans handle coinsurance the same way. In 2025, your exposure depends on:

• Whether your plan has a deductible and at what level

• How coinsurance is structured (flat percentage vs. tiered)

• Which services are subject to coinsurance

• Whether you have Medicare Part B

• What your plan’s out-of-pocket maximum is and how quickly you reach it

Some plans offer tiered coinsurance for specialist care or brand-name prescriptions. Others apply coinsurance only after copayment limits are exceeded.

Review your plan’s Summary of Benefits closely. Look for sections titled:

• “Cost-Sharing”

• “Out-of-Pocket Limits”

• “Coordination with Medicare”

These sections outline how your specific plan will manage coinsurance.

The Difference Between Copayments and Coinsurance

Many PSHB enrollees assume they’re paying fixed amounts for services. But coinsurance and copayments work very differently:

• Copayments are flat fees (e.g., $30 for a specialist visit)

• Coinsurance is a percentage (e.g., 20% of $800 is $160)

While copayments are easier to predict, coinsurance is tied to the actual cost of the service. The higher the cost, the more you pay.

This distinction becomes more important if your healthcare needs increase during the year. A few hospital visits or procedures could shift your financial burden dramatically.

How to Reduce Coinsurance Burden in 2025

While you can’t eliminate coinsurance entirely, you can make choices that reduce your exposure:

• Enroll in Medicare Part B if eligible and your plan offers cost coordination

• Choose in-network providers to access lower coinsurance rates

• Review your plan’s deductible and maximum out-of-pocket limits

• Consider a lower-deductible plan if you anticipate higher usage

• Track your spending toward your deductible and out-of-pocket maximum throughout the year

• Use preventive care (often exempt from coinsurance)

Understanding your plan’s cost-sharing rules can help you avoid unwanted surprises. Coinsurance is manageable—but only if you plan for it.

When PSHB Coinsurance Isn’t Worth Ignoring

By midyear, many enrollees begin noticing that coinsurance has eaten up more of their budget than expected. This usually comes down to one issue: underestimated care needs.

If you’re only visiting a primary care provider once or twice a year, coinsurance might seem harmless. But if:

• You receive a serious diagnosis

• You start needing frequent labs or imaging

• You require rehab, home health, or surgery

…then coinsurance takes center stage in your total annual spending. And it doesn’t take long to find yourself within reach of your out-of-pocket maximum.

Understanding Your True Financial Exposure

When comparing PSHB plans, don’t stop at premiums and copays. Look deeper into:

• Deductibles (in-network and out-of-network)

• Coinsurance percentages across service categories

• Out-of-pocket maximums

• Medicare Part B coordination

Then ask yourself:

• If you had an unexpected illness, could you afford your maximum exposure?

• If your provider is out-of-network, what changes?

• If you decline Medicare Part B, what extra costs will you face?

Answering these questions now can spare you financial stress later in the year.

How to Rethink Your Plan Choice With Coinsurance in Mind

For 2025, take coinsurance as seriously as your monthly premium. It’s not just an add-on—it’s a built-in cost structure that can quietly balloon if not monitored.

Here’s how to rethink your PSHB options:

• Balance premium costs against potential coinsurance exposure

• Prioritize plans with clear Medicare coordination if eligible

• Understand your family’s likely healthcare usage for the year ahead

• Factor in any planned surgeries, therapy, or chronic care needs

• Consider switching to a plan with a lower out-of-pocket maximum

Coinsurance is often overlooked—but in 2025, with rising healthcare service costs, it’s a detail that demands more attention than ever.

Make Informed Decisions Before It Becomes a Costly Surprise

Your PSHB plan’s coinsurance clause might not seem urgent when you’re healthy. But one unexpected diagnosis or procedure could make it the most expensive feature in your coverage.

If you have Medicare Part B, take full advantage of coordination opportunities. If you don’t, take a hard look at how much you could owe under your current plan.

To avoid a surprise bill later, it pays to prepare now.

Speak with a licensed agent listed on this website to walk through your plan’s coinsurance rules and understand how they may impact your budget in 2025.