Key Takeaways

• Medicare Part C (Medicare Advantage) may offer convenience, but it comes with trade-offs in provider access, referrals, and out-of-network restrictions.

• For PSHB enrollees, relying solely on Medicare Advantage can create serious complications with coordination of benefits, billing, and coverage for care.

What Medicare Part C Offers—and Why It Appeals to Many

Medicare Part C, also called Medicare Advantage, combines coverage from Part A and Part B and often includes Part D prescription drug coverage. It’s administered by private insurers and must offer at least the same benefits as Original Medicare.

For some, this packaging feels efficient:

• One card, one plan.

• Potential coverage for vision, dental, or hearing.

• A network-based approach that feels familiar to those used to managed care.

But for Postal Service Health Benefits (PSHB) members, especially retirees with Medicare, Medicare Advantage is not always a perfect fit. What you gain in packaging and simplicity, you often give up in flexibility and federal coordination.

1. You Leave Original Medicare Behind

When you enroll in a Medicare Advantage plan, you are no longer using Original Medicare for your primary coverage. Instead, you receive your benefits through a private insurer that manages the plan. This means:

• Medicare no longer pays your providers directly.

• You follow your Medicare Advantage plan’s rules for coverage, networks, and authorizations.

This matters significantly when you’re trying to coordinate your benefits with your PSHB plan.

2. You May Be Required to Stay In-Network

Most Medicare Advantage plans use provider networks. These can include:

• Health Maintenance Organizations (HMOs), which typically require you to stay within a defined network and get referrals.

• Preferred Provider Organizations (PPOs), which allow some flexibility but often charge more for out-of-network care.

In 2025, network restrictions remain a key concern. Out-of-network providers may not be covered at all, or only at a much higher cost. If you travel frequently or spend time in multiple states, this can create gaps in access.

3. Prior Authorizations Can Delay or Deny Care

Medicare Advantage plans often require prior authorizations for many types of services, including:

• Diagnostic imaging

• Inpatient hospital stays

• Certain outpatient procedures

Unlike Original Medicare, which allows you and your doctor to make decisions about medically necessary care, Medicare Advantage plans introduce a layer of insurer review. In 2025, these authorizations can still lead to delays, denials, or frustration.

For PSHB members, this interferes with the coordination between your plan and Medicare. A procedure might be covered under your PSHB plan, but if your Medicare Advantage plan doesn’t authorize it, you could end up paying out of pocket.

4. PSHB Coordination May Not Work the Way You Expect

If you enroll in Medicare Advantage, your PSHB plan no longer acts as your secondary payer to Original Medicare—because Original Medicare is no longer your primary payer.

This can cause several issues:

• You may not be reimbursed for costs that would have been covered if you had Original Medicare and your PSHB plan working together.

• Your providers may struggle to coordinate billing with a private Medicare Advantage plan and a federal health plan.

• You could face overlapping deductibles or coverage gaps.

The coordination between PSHB and Original Medicare is streamlined and well-established. When you remove Original Medicare from the equation, you may disrupt this integration.

5. Cost Caps Vary—And So Do the Rules

One major selling point of Medicare Advantage is the annual maximum out-of-pocket (MOOP) limit. In 2025, the in-network MOOP for Medicare Advantage plans is capped at $9,350. However, this limit:

• May not include drug costs

• May only apply to in-network services

• Can rise significantly if you receive care out of network

By contrast, your PSHB plan has its own out-of-pocket limits, and many plans integrate with Original Medicare to reduce your costs overall—especially when both are working together. But when Medicare Advantage replaces your Original Medicare, you must rely solely on the MOOP protections provided by that private plan.

6. Provider Choice Is No Longer Nationwide

Original Medicare offers access to any provider in the U.S. who accepts Medicare. This is a key strength for Postal Service retirees who may live in one region part of the year and travel or reside elsewhere at other times.

Medicare Advantage plans, however, are often regionally based. This means:

• You may need to find new providers if you move.

• Emergencies might be covered out of area, but routine care may not.

• You could be forced into narrow networks where provider choice is limited.

In 2025, provider network complaints remain a top concern among Medicare Advantage enrollees.

7. Drug Coverage Isn’t Automatically Better

Most Medicare Advantage plans include Part D drug coverage. But this isn’t always an advantage for PSHB members. Your PSHB plan already provides robust prescription coverage, often through a Medicare Part D Employer Group Waiver Plan (EGWP).

If you enroll in a separate Medicare Advantage plan with Part D, you may:

• Lose access to your PSHB-integrated drug plan

• Be subject to different drug formularies and tier structures

• Encounter unexpected copays or coverage denials for medications previously covered

This trade-off in prescription drug coverage can be significant—especially when you’re used to seamless coverage through your federal retiree health benefits.

8. Extra Benefits Often Come With Trade-Offs

Medicare Advantage plans often promote additional benefits that go beyond Original Medicare—such as dental, vision, hearing, or gym memberships. However, these extras often come with:

• Usage restrictions

• Annual caps

• Limited provider networks for supplemental services

While these benefits may seem attractive on paper, they are not standardized, and the actual value can vary widely. More importantly, they don’t offset the broader trade-offs in medical coverage, network flexibility, or federal coordination.

PSHB plans often already provide access to dental and vision benefits through separate programs like FEDVIP. Double coverage or overlapping benefits can be redundant and confusing.

9. Switching Back Isn’t Always Easy

If you leave Original Medicare and enroll in Medicare Advantage, returning to Original Medicare later isn’t always straightforward. Depending on when and how long you’ve been enrolled in Medicare Advantage, you may:

• Be subject to medical underwriting for a Medicare Supplement (Medigap) plan

• Need to wait until the next open enrollment period to switch

• Lose access to previously integrated PSHB-Medicare coordination features

Even if you do return to Original Medicare, some benefits or protections may no longer be available.

10. You Risk Losing Your PSHB Coordination Benefits

This is the most critical concern for Postal Service retirees: Medicare Advantage disrupts how your PSHB plan works with Medicare.

When you have Original Medicare and PSHB:

• Medicare pays first.

• Your PSHB plan picks up most of what Medicare doesn’t cover.

• You usually pay little to no out-of-pocket for many services.

When you replace Medicare with a private Medicare Advantage plan:

• PSHB no longer works as a true secondary payer.

• You lose cost-sharing support.

• You risk duplicating coverage or facing uncovered costs.

The 2025 PSHB program is specifically structured to integrate with Original Medicare—especially for Medicare Part B enrollees. Choosing a different path may mean walking away from some of the most valuable parts of your federal retiree coverage.

Evaluate Carefully Before You Trade Flexibility for Packaging

While Medicare Advantage can seem attractive with its bundled features and advertised extras, it may not align with how your PSHB benefits are designed to work. You must weigh the true cost—not just financially, but in terms of access, coordination, and peace of mind.

Take the time to:

• Understand how Medicare Advantage differs from Original Medicare.

• Review your PSHB plan’s benefits and how they coordinate with Medicare.

• Consider your travel, provider preferences, and prescription needs.

If you’re uncertain about which option fits best with your retirement goals, speak with a licensed agent listed on this website. They can help clarify how your PSHB coverage works with or without Medicare Advantage.