Key Takeaways

• Medicare Advantage plans may offer popular extras like dental and vision, but they also come with potential coverage restrictions, particularly around networks, referrals, and out-of-pocket limits.

• If you’re enrolled in the Postal Service Health Benefits (PSHB) Program, overlooking the limits of Medicare Advantage could expose you to higher costs or limited access to care if you don’t understand how your plans coordinate.

Why Medicare Advantage Looks Attractive at First

Many people are drawn to Medicare Advantage plans because they appear to offer more than Original Medicare. These plans often promote extra benefits like:

• Routine dental and vision coverage

• Hearing exams and hearing aid allowances

• Wellness programs

• Over-the-counter item stipends

While these added features can sound appealing, it’s crucial to look beyond the surface. For Postal Service retirees or annuitants enrolled in PSHB, those added perks are not the whole picture. The real question is: what happens when you need serious medical care or want to see a specialist?

Understanding the Trade-Offs

Medicare Advantage is not a supplement to Medicare. It’s a private plan that replaces your Original Medicare coverage and becomes your primary insurance. This structural difference introduces:

• Coverage networks: Most Medicare Advantage plans operate within Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). This means your access to care is restricted by the plan’s network.

• Referral requirements: Some plans may require referrals from a primary care provider to see specialists.

• Prior authorization: Services like hospital stays, MRIs, or skilled nursing care may require prior approval.

• Out-of-pocket caps: While these plans include annual limits, those caps can be quite high. In 2025, in-network limits can be up to $9,350, and combined in-network and out-of-network limits can reach $14,000.

These features might make it harder to access the care you need when you need it—especially if you’re used to the flexibility that PSHB plans offer when coordinated with Original Medicare.

How Medicare Advantage Interacts with PSHB

Starting in 2025, if you’re a Medicare-eligible Postal Service retiree or annuitant, you are required to enroll in Medicare Part B to maintain your PSHB plan coverage. But this doesn’t automatically mean you should enroll in a Medicare Advantage plan.

Here’s how it works under PSHB:

• You can enroll in Original Medicare (Parts A and B), and your PSHB plan will act as secondary insurance.

• Your PSHB plan may waive or reduce cost-sharing when it coordinates with Original Medicare.

• If you instead enroll in a Medicare Advantage plan, your PSHB plan does not act as secondary coverage. This means you will rely solely on the Medicare Advantage plan’s coverage and network.

For many retirees, this difference isn’t obvious until they’re faced with a hospital stay, a referral denial, or an out-of-network bill.

What’s Covered vs. What’s Restricted

Before enrolling in any Medicare Advantage plan, consider these current 2025 realities:

• Network constraints: You may not be able to see your longtime doctor unless they participate in the plan’s network.

• Emergency vs. routine coverage: Emergency care is generally covered nationwide, but routine care outside of your plan’s network might not be.

• Out-of-pocket responsibilities: Some services not covered under your plan’s guidelines may be denied, leaving you with the full bill.

• Non-Medicare benefits: Extras like vision and hearing are only as good as the plan’s limitations. For example, they might offer a set amount or only cover specific providers.

These conditions affect both access and affordability.

What the PSHB Program Offers by Comparison

If you stay with your PSHB plan and coordinate it with Original Medicare, you may experience fewer restrictions. In 2025, many PSHB plans:

• Waive deductibles and coinsurance when Medicare pays first

• Cover providers nationwide without requiring referrals

• Include prescription drug benefits through Medicare Part D Employer Group Waiver Plans (EGWPs)

• Offer optional dental and vision benefits through separate FEDVIP plans

When compared side by side, the PSHB+Original Medicare combination may offer more consistency and broader access, especially for those with complex or chronic medical needs.

Consider the Long-Term Cost Risk

A Medicare Advantage plan may initially seem cost-effective because of its extras. But over the course of a year, consider these risk factors:

• Higher out-of-pocket limits: You could pay more out of pocket if your plan has a high annual cap.

• Unexpected denials: Prior authorizations may delay or deny coverage.

• Limited provider choice: Traveling or relocating could mean starting over with new doctors.

• Loss of coordination with PSHB: You forfeit the PSHB plan’s secondary benefits when you opt into Medicare Advantage.

Choosing the wrong plan could lead to higher medical expenses and fewer care options in critical situations.

What to Ask Before You Enroll in a Medicare Advantage Plan

Before making a switch, ask the following:

• Does this plan coordinate with my PSHB coverage? (Answer: Generally, no.)

• Will I lose access to my current providers?

• Are my medications fully covered under this plan’s formulary?

• What happens if I travel or need care outside my home state?

• Are there prior authorization rules that could delay treatment?

• How high is the out-of-pocket maximum?

• What happens to my PSHB benefits if I enroll in this plan?

Carefully reviewing the plan’s Summary of Benefits and Evidence of Coverage documents can help clarify these points. But also consider how those rules apply to your personal health needs.

What If You Already Chose a Medicare Advantage Plan?

If you already enrolled in a Medicare Advantage plan and now realize it may not work well with your PSHB benefits, you do have options:

• Medicare Advantage Open Enrollment Period: Runs from January 1 to March 31 every year. You can switch to another Medicare Advantage plan or return to Original Medicare during this time.

• Annual Open Enrollment Period: From October 15 to December 7, you can change your Medicare coverage for the following year.

• Special Enrollment Periods: Certain life events may qualify you for a special enrollment window to make changes outside the regular timeframes.

Returning to Original Medicare and keeping your PSHB plan in place could be a smarter long-term move, especially if you have ongoing medical needs.

How to Avoid Coverage Gaps

The key to avoiding coverage problems is understanding how Medicare Advantage plans operate before you enroll. Here are a few preventative steps you can take:

• Review the PSHB plan brochure carefully to understand how it works with Original Medicare.

• Compare out-of-pocket maximums and provider access between PSHB+Original Medicare and any Medicare Advantage option.

• Make sure you are clear on what services require prior authorization or referrals.

• Talk with a licensed agent listed on this website for help reviewing the pros and cons based on your personal health situation.

These steps help you make a decision that protects not just your health, but your financial security.

Making the Right Choice for Your PSHB and Medicare Needs

In 2025, the decision to enroll in a Medicare Advantage plan is not just about dental benefits or gym memberships. It’s about how care is delivered, who gets to treat you, and how much you might owe when you need medical services. If you’re eligible for PSHB, pairing it with Original Medicare often results in broader access, fewer surprises, and more predictable costs.

Extras may be nice, but don’t let them distract you from the core purpose of your health coverage: protecting your access to care when it matters most.

Get in touch with a licensed agent on this website to explore which options truly align with your long-term health and financial goals.