Key Takeaways

  • While Medicare Part C (Medicare Advantage) plans offer attractive extras, such as dental and vision benefits, they come with restrictions that may limit your provider access and out-of-network care.

  • For Postal Service Health Benefits (PSHB) enrollees, integrating Medicare with your PSHB plan requires careful consideration, especially if you are thinking about switching to or from Medicare Advantage.

What Medicare Part C Promises—And Why It Appeals to So Many

Medicare Part C, known as Medicare Advantage, is popular for one reason: it seems to offer everything in one package. These plans are offered by private insurance companies approved by Medicare and bundle together Medicare Part A (hospital insurance), Part B (medical insurance), and usually Part D (prescription drug coverage). On top of that, they often include dental, vision, hearing, and fitness benefits.

For someone evaluating Medicare options, especially during Open Season or when turning 65, the idea of having fewer bills and a “complete” package is understandably appealing. The extras are what draw most people in—but it’s the limitations beneath those extras that can significantly affect your experience and costs.

What You Might Not Realize About Network Restrictions

Unlike Original Medicare, Medicare Advantage plans typically use networks. These networks include a list of doctors, hospitals, and specialists you can see without incurring higher costs.

Here’s what that means for you:

  • Limited Provider Access: You must use providers within the plan’s network to receive full coverage. Out-of-network care can result in significantly higher costs or may not be covered at all unless it’s an emergency.

  • Geographic Constraints: Many plans are designed to serve specific regions. If you split time between locations (for example, different states), coverage may not travel well.

  • Referrals and Authorizations: Some plans require referrals from a primary care provider (PCP) to see specialists, or pre-authorization for certain procedures. This adds another layer of administration to your care.

For PSHB participants, these limitations can clash with the freedom you might be accustomed to under the Federal Employees Health Benefits (fehb) system, which has historically offered broader provider choice.

The Trade-Off Between Predictable Costs and Flexibility

One reason Medicare Advantage plans draw attention is their built-in out-of-pocket limits. In 2025, the maximum out-of-pocket (MOOP) limit for in-network care is $9,350. While this offers financial protection, the trade-off is that every medical decision may be tied to plan rules and provider networks.

Under the PSHB system, when you pair your health plan with Original Medicare (Parts A and B), you typically get:

  • Nationwide Access: You can see any provider who accepts Medicare without worrying about networks.

  • Secondary Payer Benefits: Your PSHB plan often pays what Medicare doesn’t, including deductibles and coinsurance.

With Medicare Advantage, you may pay less upfront but have more exposure to hidden costs and care restrictions later.

What Happens If You Switch From PSHB to Medicare Advantage?

Some Medicare Advantage plans may entice you with additional benefits, but enrolling in one means you must drop your PSHB plan. That decision is irreversible for the remainder of the year and has long-term implications:

  • You can’t have both PSHB and Medicare Advantage at the same time.

  • Once you leave PSHB, you must wait until the next Open Season to re-enroll—assuming you’re still eligible.

  • You may lose access to benefits like coordinated prescription drug coverage through PSHB’s Medicare Part D Employer Group Waiver Plan (EGWP).

That’s a considerable shift in your healthcare strategy and should be weighed carefully, especially if you rely on PSHB for comprehensive family coverage.

Why Prescription Drug Coverage Works Differently

Most Medicare Advantage plans include drug coverage, but this coverage is subject to a formulary (a list of covered medications) that varies from plan to plan. These formularies are often narrower than what PSHB’s integrated Part D EGWP offers.

With PSHB and Original Medicare:

  • You receive automatic drug coverage through your PSHB plan’s Part D integration.

  • You benefit from the new $2,000 annual out-of-pocket cap on drug spending in 2025.

  • You may also qualify for monthly payment options under the Medicare Prescription Payment Plan, allowing you to spread costs throughout the year.

Medicare Advantage plans may or may not offer the same financial flexibility or formulary breadth. It depends entirely on the specific plan’s design, which adds uncertainty.

Supplemental Benefits: What’s Actually Covered?

The most commonly advertised extras in Medicare Advantage plans are dental, vision, hearing, transportation, and over-the-counter allowances. But the details matter:

  • Dental: May include only basic cleanings—not crowns or implants.

  • Vision: Often covers one eye exam annually and limited allowance toward glasses.

  • Hearing: Might cover hearing aids, but only through specific vendors.

  • Transportation: Usually limited to a set number of rides per year for medical appointments.

If you already have PSHB coverage, you may find that your existing benefits, especially when combined with Original Medicare, are more robust and predictable than those offered under a Medicare Advantage plan.

Care Coordination and Administrative Burden

Medicare Advantage plans often use managed care models like HMOs or PPOs. While these models aim to coordinate your care, they may also add complexity:

  • You may need a referral to see a specialist.

  • You might face delays due to prior authorization requirements.

  • You must follow plan rules closely to avoid unexpected charges.

With PSHB and Original Medicare, the coordination tends to be simpler. You maintain control over which doctors you see and when. For retirees and annuitants who value direct access and less bureaucracy, this can make a substantial difference.

Costs Can Be Less Predictable Than They Appear

At first glance, Medicare Advantage may look more affordable, especially with premiums that appear low. But costs under these plans can add up through:

  • Copayments for each doctor visit, specialist, test, or hospital stay

  • Higher out-of-network charges (if coverage is allowed at all)

  • Additional costs for non-covered services

These costs often vary depending on where you live and the plan you choose. With PSHB and Original Medicare, cost-sharing is usually more stable and outlined in the plan brochure.

Evaluating Medicare Advantage Within the PSHB Framework

Since 2025 is the first year Postal Service annuitants and employees transition from FEHB to the Postal Service Health Benefits Program, understanding your full range of options is more important than ever.

Before you make a move toward Medicare Advantage, consider the following:

  • Are you willing to give up PSHB coverage for the remainder of the year?

  • Can you afford out-of-pocket expenses if your Medicare Advantage plan’s network is restrictive or your medications aren’t fully covered?

  • Are the extra benefits worth the administrative trade-offs and possible coverage gaps?

If you’re eligible for Medicare Part B and remain enrolled in PSHB, many plans offer cost-sharing reductions or even partial Part B premium reimbursements. These options can preserve flexibility without sacrificing benefits.

A Long-Term Choice With Annual Consequences

Enrollment decisions made now will shape your healthcare experience all year. You can change your Medicare Advantage plan—or return to Original Medicare—during Medicare Open Enrollment from October 15 to December 7 each year. But that won’t automatically restore your PSHB coverage unless you also act during the PSHB Open Season, which runs from November to December.

Missing that window could mean a full year without PSHB coverage, which may impact:

  • Your ability to see certain providers

  • Your prescription drug coverage

  • Your total out-of-pocket liability

Knowing What You’re Trading Can Help You Decide Wisely

Medicare Advantage offers benefits that are easy to highlight: extras, cost limits, and all-in-one convenience. But those features come with restrictions on access, flexibility, and provider choice.

When you already have access to PSHB and are eligible for Original Medicare, you’re in a strong position to balance affordability with comprehensive care—without locking yourself into a limited network.

Before deciding, consider speaking with a licensed agent listed on this website who understands both Medicare and the Postal Service Health Benefits Program. They can help you compare your options based on your specific needs.