Key Takeaways

  • Medicare Advantage features can appear appealing in PSHB plan summaries but may shift after enrollment—especially when it comes to provider access, out-of-pocket costs, and referral requirements.

  • As a Postal Service worker or retiree, your experience with Medicare Advantage under PSHB depends heavily on how the plan integrates with your Medicare Part B enrollment and how the benefits function throughout the calendar year.

Why Those Flashy Benefits Deserve a Second Look

If you’re enrolled in a Postal Service Health Benefits (PSHB) plan and considering adding a Medicare Advantage plan, you’ve probably noticed the enticing perks: dental, vision, hearing, gym memberships, and promises of low out-of-pocket costs. At first glance, these benefits look comprehensive and cost-efficient. But what happens once you actually enroll?

The truth is, Medicare Advantage can behave differently once you’re in the plan, especially in how it coordinates with your PSHB coverage and your Medicare Part B benefits. Understanding these differences now can save you from unexpected bills and access issues later.

How PSHB and Medicare Advantage Interact in 2025

Starting January 1, 2025, Postal Service retirees and annuitants must be enrolled in a PSHB plan to maintain coverage. If you’re also eligible for Medicare, you may find that some PSHB plans include or encourage enrollment in a Medicare Advantage plan.

But integration doesn’t mean simplicity. While PSHB aims to coordinate benefits smoothly, Medicare Advantage plans can change key elements that matter to you:

  • Referral requirements

  • Network restrictions

  • Prior authorization demands

  • Cost-sharing responsibilities

These shifts may not be obvious in brochures or enrollment packets.

1. The Provider Network Isn’t What You May Expect

One major shift that many enrollees encounter is limited provider access. Medicare Advantage plans often work within Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) models. That means:

  • You may need to choose from a smaller list of in-network doctors.

  • Seeing a specialist often requires prior authorization or a referral.

  • Out-of-network care may not be covered—or could cost significantly more.

If you’re used to broader access under Original Medicare combined with FEHB or PSHB, this change can feel restrictive.

2. Costs Shift Throughout the Year

One of the most misunderstood elements of Medicare Advantage is how costs evolve. You may start the year with manageable copayments, but they can accumulate fast—especially if:

  • You require ongoing specialist care

  • You experience an inpatient hospital stay

  • You use brand-name prescriptions

While there is a federally mandated annual out-of-pocket limit, in 2025 that amount can be up to $9,350 for in-network services, with combined in/out-of-network caps reaching $14,000. These amounts don’t include what you may still pay for services that aren’t covered.

3. Extra Benefits Aren’t Guaranteed or Always Useful

Many Medicare Advantage plans highlight supplemental benefits like dental, vision, hearing aids, and wellness incentives. But the availability, quality, and usability of these benefits can vary dramatically. In some cases:

  • Services may be limited to specific providers or locations

  • There may be caps on how much the plan pays annually

  • You may need to complete certain wellness requirements before you can access other benefits

In 2025, plan flexibility has slightly decreased. Fewer plans offer transportation or over-the-counter allowances compared to 2024. This trend may continue, so you shouldn’t base your decision solely on extras that may not serve your actual needs.

4. Coverage Rules Can Be Stricter Than You Realize

Unlike Original Medicare, Medicare Advantage plans can impose stricter rules about how and when care is delivered. For example:

  • Hospital admissions may require prior authorization

  • Skilled nursing stays may be covered differently than you expect

  • You might need plan approval before getting certain imaging tests or surgeries

Under PSHB, these conditions might still apply if your plan is offering Medicare Advantage as a feature. That can add time, paperwork, or even denial of care if you’re not familiar with the requirements.

5. Changes Can Occur Annually Without Much Notice

Each fall, Medicare Advantage plans can change their cost structures, provider networks, and benefits. These changes take effect on January 1 of the following year.

Even if you enroll in a Medicare Advantage plan under PSHB in 2025 and everything looks good now, next year might bring:

  • Increased premiums

  • Reduced coverage areas

  • Higher copays or deductibles

  • Removal of specific providers from the network

If you don’t actively review your Annual Notice of Change (ANOC) each fall, you may not catch these adjustments until they affect your care.

6. Drug Coverage Can Still Be a Minefield

While PSHB plans include Medicare Part D drug coverage through an Employer Group Waiver Plan (EGWP), some Medicare Advantage options may bundle drug coverage differently—or require you to opt out of your current plan.

Even within PSHB, making changes or declining the integrated drug plan can have consequences:

  • You could lose drug coverage under PSHB

  • Re-enrollment might not be allowed until the next Open Season

  • You may face late enrollment penalties or coverage gaps

In 2025, the out-of-pocket cap on drug costs is $2,000, which is a welcome relief. But be cautious—how and when that cap applies may vary depending on your specific Medicare Advantage arrangement.

7. Medicare Part B Is Still a Must for PSHB Enrollees

If you’re a Medicare-eligible postal retiree, PSHB rules now require you to enroll in Medicare Part B to maintain your PSHB coverage—unless you’re exempt.

Medicare Advantage plans are built on top of Part B, so skipping Part B means you’re ineligible for the Medicare Advantage plan and could risk your PSHB benefits.

You’ll continue paying the standard Part B premium, which in 2025 is $185 per month (higher if you’re subject to income-related adjustments). If a Medicare Advantage plan appears to “replace” Part B or make it unnecessary, that’s misleading. In all cases under PSHB, your Medicare Part B coverage remains foundational.

8. Appeals and Grievances Take More Time

One of the advantages of Original Medicare is that appeals are relatively straightforward. Under Medicare Advantage, however, the appeals process can be slower and involve more steps. If your care is denied or delayed:

  • You must appeal through the plan first

  • Timelines vary depending on the type of appeal (e.g., expedited vs. standard)

  • Further escalation to Medicare may take weeks or months

If you’re dealing with a chronic illness or urgent health need, these delays can feel like barriers to care.

What to Ask Before You Enroll

Before committing to a Medicare Advantage plan within your PSHB coverage, take the time to ask the following questions:

  • Will my current doctors and hospitals accept this plan?

  • Are prior authorizations or referrals required?

  • What is the total out-of-pocket maximum for the year?

  • How are drug costs handled with this plan?

  • What are the conditions for using supplemental benefits?

You should also read through the Summary of Benefits and the Evidence of Coverage (EOC) for the plan you’re considering, as this is where most of the fine print lives.

The Big Picture on PSHB and Medicare Advantage

Combining PSHB with a Medicare Advantage plan might seem like a strong move for retirement coverage. But the reality is more nuanced. Once enrolled, you may find the care process more controlled, the network narrower, and the promised perks more conditional than advertised.

Don’t assume what’s printed in the marketing materials will translate seamlessly into everyday care. Take the time to understand what changes after you enroll—and whether those changes fit the way you prefer to receive care.

If you’re unsure about the best path forward, get in touch with a licensed agent listed on this website. They can walk you through the plan details, help evaluate your Medicare Part B status, and explain what to expect long term.