Key Takeaways

  • Medicare Advantage plans often include coverage restrictions, prior authorizations, and network limitations that aren’t obvious until a claim is denied or care is delayed.

  • As a Postal Service Health Benefits (PSHB) enrollee, understanding how Medicare integrates with your PSHB plan can help you avoid surprise denials and out-of-pocket costs.

How Medicare Advantage Plans Really Work Behind the Scenes

Medicare Advantage, also known as Medicare Part C, is often marketed as an all-in-one solution that combines hospital, medical, and sometimes prescription drug coverage. While these plans must cover everything Original Medicare covers, they can—and often do—set their own rules about how you get that coverage.

What many enrollees don’t realize until they file a claim is that these rules can be far more restrictive than those under Original Medicare. Claims may be denied not because the service isn’t covered, but because it wasn’t approved in advance, wasn’t performed by a network provider, or didn’t meet the plan’s specific criteria.

Why Claims Get Denied More Often Than You Think

One of the most common surprises with Medicare Advantage plans is how often prior authorization is required. This means your doctor must get approval from your plan before providing certain services.

This requirement applies to:

  • MRIs and CT scans

  • Skilled nursing facility care

  • Durable medical equipment

  • Inpatient hospital stays

In 2025, prior authorization continues to be one of the leading causes of claim denials. If the authorization wasn’t obtained—or if the plan determines the service isn’t “medically necessary” according to its own standards—the claim may be denied. Even if your doctor believes the service is appropriate.

The Network Trap: It’s Not Just Who You See, But Where You Go

Unlike Original Medicare, which allows you to see any provider that accepts Medicare, Medicare Advantage plans usually restrict you to a defined network. Going outside that network, even by accident, can mean paying the full cost out of pocket.

This network limitation can especially impact you if:

  • You travel out of state

  • You split time between locations

  • You need care while visiting family or during emergencies

Even in-network providers can become out-of-network during the plan year, leaving you vulnerable unless you constantly monitor your plan’s provider directory.

What the PSHB-Medicare Combo Changes—and What It Doesn’t

If you’re a Postal Service annuitant or employee with Medicare Part A and Part B, you may already know that many PSHB plans integrate with Medicare. This integration can include:

  • Reduced or waived deductibles

  • Lower copayments for Medicare-covered services

  • Prescription drug coverage through a Medicare Part D plan (EGWP)

However, if you opt into a standalone Medicare Advantage plan that is not coordinated with PSHB, you may lose these PSHB-specific benefits. Worse, you could be responsible for:

  • Higher out-of-pocket costs due to plan-specific rules

  • No coverage for services not pre-approved by the Advantage plan

  • Lack of access to your full PSHB pharmacy network

Medicare’s Coverage Rules vs. Advantage Plans: Not the Same

In Original Medicare, a doctor’s order is often sufficient to authorize a test, procedure, or specialist referral. But in Medicare Advantage, that order usually triggers a multi-step review:

  • The plan reviews the service for its definition of “medical necessity”

  • The plan may request additional documentation

  • Approval may be delayed, modified, or denied

This process can delay needed care or lead you to pay out of pocket for something that would have been covered under Original Medicare plus PSHB.

What Happens If a Claim Is Denied?

If a Medicare Advantage claim is denied, you have the right to appeal. But the process can be time-consuming and involves multiple steps:

  1. Initial denial: You receive a Notice of Denial of Medical Coverage.

  2. First-level appeal: You file a request for reconsideration.

  3. Second-level review: If denied again, the appeal goes to an independent review entity.

  4. Further levels: You may escalate to an Administrative Law Judge, Medicare Appeals Council, or federal court.

Many people don’t have the time, energy, or expertise to navigate this appeals process. Meanwhile, their health needs go unmet, or they pay out of pocket to avoid delays.

The 2025 Advantage Plan Landscape: What’s Changing

For 2025, there are a few structural updates to Medicare Advantage plans, but the core issues around claims and access remain. Key points:

  • The out-of-pocket prescription drug cost cap is now $2,000 annually, but only for integrated Part D coverage.

  • Some Advantage plans offer enhanced benefits like dental or hearing, but these vary widely.

  • Prior authorization remains common and, in many plans, unchanged from 2024 levels.

Even with minor improvements, the burden of plan-specific rules still rests on the enrollee—especially if you’re managing multiple conditions or need care across state lines.

What PSHB Offers That Standalone Advantage Plans May Not

The PSHB program was created specifically for Postal Service employees and retirees. When paired with Medicare, many PSHB plans offer:

  • Nationwide coverage with fewer network restrictions

  • Coordination of benefits to reduce your share of costs

  • Direct Medicare Part B integration, often with premium reimbursement options

You don’t have to give up your PSHB plan just because you qualify for Medicare. In fact, staying with PSHB while adding Medicare Part A and B usually provides broader protection than shifting entirely into a standalone Medicare Advantage plan.

Coordination of Benefits Can Save You From Surprise Costs

If you stay enrolled in a PSHB plan and add Medicare Parts A and B, Medicare becomes your primary payer, and PSHB is secondary. That means:

  • Medicare pays first

  • Your PSHB plan covers some or all of the remainder

  • You often avoid deductibles and coinsurance

But if you switch to a Medicare Advantage plan not tied to PSHB, your benefits are bundled, and you lose that dual-payer safety net. You’re also subject to the Advantage plan’s rules—many of which aren’t transparent until something goes wrong.

What You Should Do Before Enrolling in Medicare Advantage

Before making a change, consider these steps:

  • Review your PSHB plan’s Medicare coordination benefits: Many PSHB plans provide detailed brochures that outline what happens when you enroll in Medicare.

  • Compare what’s covered: Look at how Original Medicare plus PSHB stacks up against Medicare Advantage plans.

  • Think beyond monthly premiums: Consider access to care, prior authorizations, and appeals processes—not just costs.

  • Talk to a licensed agent listed on this website: They can walk you through the implications and help you understand how your choices impact your PSHB benefits.

Your Health Decisions in 2025 Should Be Based on Clarity, Not Surprises

You’ve earned your Postal Service health benefits through years of work. As you reach Medicare eligibility, it’s essential to make informed choices that reflect your needs—not just marketing messages.

The reality is that Medicare Advantage plans are not one-size-fits-all. Some may work for your situation. Others may deny care when you need it most.

That’s why reviewing your PSHB plan, understanding how it works with Medicare, and weighing your options before switching to a Medicare Advantage plan can help you avoid denied claims, higher costs, and delayed treatment.

If you’re unsure about your next step, speak to a licensed agent listed on this website. They’re here to provide you with personalized help so your benefits work for you—not against you.