Key Takeaways

• Medicare continues to cover essential healthcare services in 2025, but certain out-of-pocket expenses remain your responsibility, especially when coordinating with PSHB.

• Understanding where Medicare stops and your PSHB plan starts is critical to avoid unexpected bills and to fully optimize your benefits.

Medicare’s Role in 2025: What It Still Covers

Medicare remains a vital foundation for healthcare in 2025, especially for postal retirees and workers now navigating the PSHB landscape. Here’s a breakdown of what Medicare Parts A and B continue to cover:

Medicare Part A

• Inpatient Hospital Stays: Medicare covers inpatient care after you meet the deductible of $1,676 per benefit period.

• Skilled Nursing Facility Care: After a qualifying hospital stay, Medicare covers up to 20 days fully. From days 21 to 100, you are responsible for a daily coinsurance of $209.50.

• Hospice Care: Full coverage is provided for hospice services related to terminal illness.

• Some Home Health Care: Limited to medically necessary part-time or intermittent skilled nursing care and therapy.

Medicare Part B

• Outpatient Services: Includes doctor visits, lab tests, surgeries, and preventive services.

• Durable Medical Equipment (DME): Covers medically necessary equipment like wheelchairs or oxygen.

• Mental Health Services: Covers outpatient mental health treatment and partial hospitalization services.

• Annual Wellness Visits: One wellness visit every year to update or create a personalized prevention plan.

The Limits of Medicare: Where You Begin Paying

While Medicare covers a large portion of medical expenses, it does not cover everything. Here’s where you’re expected to step in:

Out-of-Pocket Costs

• Part A Deductible: $1,676 for each hospital stay.

• Part A Coinsurance: $419 per day for hospital stays beyond 60 days.

• Part B Premium: $185 per month for most beneficiaries.

• Part B Deductible: $257 annually.

• Part B Coinsurance: Typically 20% of Medicare-approved charges after the deductible.

Services Not Covered by Medicare

• Prescription Drugs: Unless you have separate Part D coverage or drug coverage integrated with PSHB.

• Routine Vision, Dental, and Hearing Care: Services like eye exams, hearing aids, and dental cleanings are not covered.

• Long-Term Care: Custodial care in nursing homes or assisted living facilities is generally not covered.

• Overseas Care: Medicare usually does not cover medical care outside the U.S.

How PSHB Plans Step In

Postal Service Health Benefits (PSHB) plans are designed to coordinate with Medicare, helping you fill in the gaps.

• Cost-Sharing Reductions: Many PSHB plans reduce or eliminate your deductibles and coinsurance if you are enrolled in both Medicare Parts A and B.

• Drug Coverage: Your PSHB plan typically integrates a Medicare Part D Employer Group Waiver Plan (EGWP), ensuring continued access to prescription medications.

• Additional Benefits: PSHB plans may offer limited dental, vision, and hearing coverage, but coverage levels vary significantly.

Important Timeframes You Must Know

In 2025, paying attention to timelines is more important than ever:

• Medicare Part B Enrollment: If you are required to enroll under PSHB rules, failure to do so can result in loss of your PSHB medical and prescription coverage.

• Open Season: Runs from November to December annually. This is your window to review and adjust your PSHB plan if necessary.

• Out-of-Pocket Drug Cap: Starting January 1, 2025, Medicare Part D plans, including those integrated into PSHB, cap annual out-of-pocket drug costs at $2,000.

How Cost Sharing Works Between Medicare and PSHB

Understanding how your two coverages interact can save you thousands each year.

• Primary vs Secondary Payer: Medicare pays first. Your PSHB plan usually pays second, covering many remaining expenses.

• No Double Deductibles: When you have both Medicare and PSHB, your PSHB plan often waives or significantly reduces your in-network deductible.

• Prescription Drugs: Even though PSHB plans cover drugs through an EGWP, you must remain enrolled in Medicare Part B to maintain this benefit.

Common Misunderstandings to Avoid

Even with both Medicare and PSHB, some myths can trip you up. Here are clarifications:

• Myth: “Medicare covers all my healthcare costs.”

  Reality: You still have deductibles, coinsurance, and uncovered services.

• Myth: “PSHB automatically covers what Medicare doesn’t.”

  Reality: PSHB reduces many costs, but not all services are covered fully.

• Myth: “I can ignore Medicare Part B because I have PSHB.”

  Reality: Opting out of Part B when required can cause you to lose PSHB coverage.

Costs You Might Still Face Even With Both Coverages

While you are in a better position with both Medicare and PSHB, you might still face:

• Copayments: For specialty care, urgent care, and emergency room visits.

• Out-of-Network Costs: Higher costs if you see providers outside your PSHB network.

• Service Caps: Limits on the number of visits for services like physical therapy or mental health treatment.

Tips to Minimize Your Costs in 2025

Being strategic helps maximize your benefits and minimize your financial responsibility.

• Always Use In-Network Providers: Staying in-network ensures lower costs and better coordination between Medicare and PSHB.

• Schedule Preventive Services: Medicare covers most preventive services at no cost, saving you money long-term.

• Monitor Prescription Drug Spending: With the $2,000 cap, track your expenses carefully to avoid surprise costs.

• Review Annual Changes: PSHB plan benefits and Medicare rules can shift every year. Reviewing updates during Open Season is critical.

• Seek Help When Needed: Licensed agents listed on this website can explain your options based on your unique situation.

Special Considerations for 2025

This year introduces some unique dynamics that retirees and workers must factor into their planning:

• Mid-Year Notification: Medicare Advantage enrollees receive mid-year notifications if they haven’t used certain supplemental benefits — but this does not apply to traditional Medicare + PSHB setups.

• Income-Related Monthly Adjustment Amount (IRMAA): Higher earners pay more for Medicare Part B and Part D, affecting total health spending.

• Changing Plan Benefits: PSHB plans are fine-tuning benefits, especially in how they integrate with Medicare Part D. Check your plan’s ANOC (Annual Notice of Changes).

Why It’s Critical to Review Your Health Plan Annually

Failing to review your health coverage each year can lead to:

• Unexpected out-of-pocket costs.

• Loss of coverage for medications you need.

• Missing out on newer benefits or programs that could save you money.

Even if you’re satisfied with your coverage today, future plan changes could impact your costs or benefits significantly. Taking a fresh look every year during Open Season ensures you’re never caught off guard.

Taking Control of Your Healthcare in 2025

Managing healthcare under Medicare and PSHB requires proactive attention in 2025. By understanding your coverages, staying alert to timelines, and actively managing your healthcare choices, you can ensure strong protection without unnecessary costs.

If you feel unsure about how your Medicare and PSHB benefits work together or want to explore ways to reduce your healthcare expenses, reach out to a licensed insurance agent listed on this website. They can help you evaluate your situation and find a solution tailored to your needs.