Key Takeaways

• Coinsurance under your 2025 PSHB plan can significantly affect how much you pay out of pocket for major services like hospital stays, diagnostic tests, and surgeries.

• Understanding the structure of in-network vs. out-of-network coinsurance rates, and how they interact with deductibles and out-of-pocket maximums, can help you better manage your annual healthcare costs.

Understanding Coinsurance in a PSHB Plan

Coinsurance is the percentage of costs you share with your health plan after you meet your deductible. Unlike a copayment, which is a fixed dollar amount per service, coinsurance represents a split between what you pay and what your PSHB plan covers.

For example, if your PSHB plan outlines a 20% coinsurance for a hospital stay, and the approved charge is $10,000, you are responsible for $2,000—assuming you’ve already met your deductible.

How PSHB Coinsurance Is Structured in 2025

In 2025, coinsurance in Postal Service Health Benefits (PSHB) plans typically falls into structured ranges based on several factors:

• In-Network Services: Most PSHB plans set coinsurance rates for in-network services between 10% and 30%.

• Out-of-Network Services: Coinsurance rates can rise sharply, often between 40% and 50%.

• Plan Type: High-deductible plans may have higher coinsurance rates until you reach your out-of-pocket maximum.

Coinsurance Only Kicks In After the Deductible

You don’t start paying coinsurance until your annual deductible is met. In-network deductibles for PSHB plans in 2025 generally range between $350 and $500 for standard plans, and between $1,500 and $2,000 for high-deductible plans. Once that’s paid, your coinsurance applies until you hit your out-of-pocket maximum.

So, for example, if you’re on a high-deductible PSHB plan and haven’t met your $1,500 deductible yet, you’re still paying full costs for covered services until you do. After that, your coinsurance percentage applies.

The Role of Out-of-Pocket Maximums

Coinsurance can be financially challenging, especially if you need costly treatments. That’s where out-of-pocket maximums protect you. In 2025, PSHB out-of-pocket caps generally range up to $7,500 for Self Only coverage, and $15,000 for Self Plus One or Self and Family, for in-network services.

Once you reach this cap, your plan pays 100% of covered costs for the rest of the calendar year. However, this maximum only applies to in-network expenses unless otherwise stated.

Coinsurance vs. Copayments: Knowing the Difference

It’s common to confuse coinsurance with copayments, but they function differently:

• Coinsurance is a percentage of the cost you pay.

• Copayment is a flat fee for a service (e.g., $30 to see a specialist).

PSHB plans in 2025 often use both. You might pay a $20 copay to see a primary care provider and 20% coinsurance for a diagnostic scan.

How Medicare Part B Affects Coinsurance Under PSHB

If you’re a retiree enrolled in Medicare Part B, your coinsurance under PSHB often decreases—or may even be waived altogether. Many PSHB plans offer enhanced coordination with Medicare, meaning they reduce or eliminate cost-sharing for enrollees who also have Part B.

In 2025, this includes:

• Lower coinsurance for outpatient services.

• Waived deductibles or reduced cost-sharing when Medicare is primary.

• Reduced prescription drug costs through integrated Part D benefits.

To get these benefits, however, you must be enrolled in both PSHB and Medicare Part B. If you opt out of Part B when it’s required, you may lose access to these cost-saving enhancements.

Why Out-of-Network Coinsurance Costs More

The cost difference between in-network and out-of-network services is steep. In-network providers agree to negotiated rates with your PSHB plan, but out-of-network providers don’t. That means:

• You pay more: Out-of-network coinsurance is typically 40% to 50%.

• Balance billing risk: Providers may charge more than what your plan allows, and you may be responsible for the difference.

• Higher out-of-network deductibles: These can range from $1,000 to $3,000.

Whenever possible, stay in-network to avoid these costs and risks.

When Coinsurance Surprises You

Some services that feel routine may come with coinsurance, especially if you’re in a high-deductible PSHB plan. Common triggers include:

• Advanced imaging (CT, MRI, PET scans)

• Outpatient surgery

• Specialist procedures not covered by flat copay

• Emergency room visits, especially out-of-network

Even if a service seems straightforward, you should check ahead to understand whether it falls under coinsurance.

Coinsurance in PSHB High-Deductible Health Plans (HDHPs)

If you’re enrolled in a high-deductible PSHB plan, your coinsurance costs can feel more visible because you’re paying more upfront until you meet the deductible. But there’s a tradeoff:

• Lower premiums compared to standard plans

• Eligibility to contribute to a Health Savings Account (HSA)

• Higher cost-sharing until you reach your maximum

In 2025, HSA-eligible HDHPs under PSHB often carry deductibles of $1,500 (Self Only) or $3,000 (Family), with coinsurance up to 30% until the annual limit is met.

Coordinating Coinsurance With a Flexible Spending Account (FSA)

If you’re still working and not enrolled in Medicare, a Flexible Spending Account (FSA) can help soften the blow of coinsurance. You can use FSA funds to pay coinsurance for eligible medical expenses.

For 2025, the FSA contribution limit is $3,300, with a carryover of up to $660 if your plan allows. This is especially useful if you expect to incur coinsurance due to planned procedures or ongoing care.

Reviewing Your Plan Documents: A Must

Coinsurance terms are clearly outlined in your PSHB plan brochure. Don’t guess—verify:

• The percentage owed for specific services

• What services fall under coinsurance vs. copayment

• How Medicare affects your coinsurance if you’re eligible

Your plan brochure lists these details in the Summary of Benefits or Cost-Sharing sections. Review them every year during Open Season (November to December), or when you experience a qualifying life event.

If You’re Retired, Your Coinsurance Could Look Different

Coinsurance may shift depending on whether you’re an active postal worker or retired. For annuitants, coordination with Medicare plays a major role:

• If you’re retired and enrolled in Medicare Part B, your coinsurance may be reduced to 0% for many services.

• If you declined Part B (and weren’t exempt), your coinsurance will follow the plan’s standard structure—often resulting in higher costs.

Knowing your enrollment status matters more in 2025 because PSHB plans now fully integrate with Medicare for eligible enrollees.

Annual Planning Helps You Budget for Coinsurance

It’s wise to anticipate healthcare needs for the year and estimate potential coinsurance costs:

• Think about planned surgeries or therapies.

• Consider expected specialist visits.

• Estimate prescription costs if you hit the Part D cap.

Use this projection to decide whether a standard PSHB plan or a high-deductible plan with an HSA is more cost-effective for your situation.

Don’t Ignore Preventive Care—It’s Often Exempt From Coinsurance

Most PSHB plans cover routine preventive services without coinsurance, even before you meet your deductible. This includes:

• Annual wellness visits

• Cancer screenings

• Vaccinations

Taking advantage of these services keeps your overall costs lower and may help you avoid expensive procedures later.

Your PSHB Plan’s Coinsurance Isn’t Set in Stone

While PSHB plans have consistent patterns, they’re not identical. Each plan sets its own cost-sharing rules. That’s why:

• You must compare plan brochures side by side.

• Don’t assume your current plan still has the same coinsurance terms as last year.

• If you’re Medicare-eligible, review how each PSHB plan coordinates benefits.

What worked for you in 2024 may not serve you best in 2025.

Understanding Your Coinsurance Gives You Power

Coinsurance isn’t always intuitive, but it’s one of the most important cost-sharing elements in your PSHB plan. Understanding it puts you in control of your financial planning, especially if you expect moderate to high medical use.

Whether you’re still working or retired, knowing your coinsurance structure, how it interacts with Medicare, and how it applies to in-network vs. out-of-network care can help you avoid financial stress.

Talk with a licensed agent listed on this website to walk through your PSHB plan’s specific coinsurance terms—and see if there’s a better option for your needs this year.