Key Takeaways

• Before selecting a Medicare Advantage plan as a Postal Service Health Benefits (PSHB) enrollee, it is essential to understand the trade-offs, especially when it comes to network restrictions, out-of-pocket costs, and Part B coordination.

• Asking the right questions now can help you avoid higher expenses and limited access to care in the future, particularly if you are approaching or past age 65 and Medicare-eligible.

Why Asking the Right Questions Upfront Matters

If you are enrolled in the PSHB Program and considering Medicare Advantage in 2025, the decisions you make now can significantly affect your healthcare quality, access, and financial stability. With Medicare Part B coordination becoming a major factor for many retirees and annuitants under PSHB, you must evaluate any plan with a clear understanding of how it fits into the larger picture.

Unlike Original Medicare, which is federally managed, Medicare Advantage plans are administered by private companies. While they often advertise added benefits, they also come with their own limitations. The PSHB structure integrates Medicare Part B into its benefits framework, so making a change to a Medicare Advantage plan should not be taken lightly. Below are key questions to ask before making anything official.

1. Will My Providers Still Be in Network?

One of the biggest distinctions of Medicare Advantage is its network restrictions. Unlike Original Medicare, which offers access to any provider accepting Medicare, most Medicare Advantage plans operate within Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) frameworks.

Under PSHB, many plans are structured to allow access to a broader provider network when paired with Medicare Part B. If you switch to a Medicare Advantage plan:

• You may lose access to your current doctors unless they are in the new plan’s network.

• Out-of-network visits can result in significantly higher costs.

• Specialist referrals may be required, depending on the plan.

Before enrolling, you should contact your primary care provider and any specialists you regularly see to confirm if they accept the plan you’re considering.

2. How Will My Prescription Drug Coverage Change?

In 2025, PSHB enrollees who are Medicare-eligible are automatically enrolled in a Medicare Part D Employer Group Waiver Plan (EGWP) that provides prescription drug coverage. This integration often includes:

• A $2,000 annual cap on out-of-pocket drug costs

• $35 copays for insulin

• Access to an expanded pharmacy network

If you opt into a Medicare Advantage plan that includes its own prescription drug coverage (MAPD), you could be removed from the PSHB-integrated drug plan. That could mean:

• Losing EGWP advantages such as the annual cap and cost-sharing subsidies

• Higher out-of-pocket expenses depending on the MAPD plan’s tiered formulary

• Difficulty switching back to PSHB drug coverage if you opt out

Carefully compare formularies and costs, and ask whether your current medications are covered under the new plan.

3. Will I Lose PSHB-Specific Benefits?

PSHB is designed to work best when paired with Medicare Part B. In this setup, many PSHB plans offer enhanced cost-sharing benefits, such as:

• Waived deductibles

• Lower copays and coinsurance

• Possible premium reimbursements for Medicare Part B

When you choose a Medicare Advantage plan, you may give up access to these features. Additionally, if you disenroll from PSHB entirely and rely solely on a Medicare Advantage plan, you could lose federal contribution support and eligibility to re-enroll outside of qualifying life events.

It is essential to understand that PSHB and Medicare are meant to complement each other. Exiting this coordinated structure has long-term implications.

4. What Happens If I Move?

Medicare Advantage plans are generally tied to specific service areas. If you relocate, particularly to a rural or underserved region, the plan may not be available.

Under PSHB with Original Medicare, your coverage follows you anywhere Medicare is accepted. But if you rely on a regional Medicare Advantage plan:

• You could be forced to switch plans or pay higher out-of-network fees

• There may be gaps in provider access in your new area

• Emergency coverage may be limited

Ask yourself if you plan to move within the next few years, especially in retirement. If there is any uncertainty, a nationally portable solution like PSHB plus Medicare Parts A and B might provide more flexibility.

5. How Will My Out-of-Pocket Costs Compare Long-Term?

While some Medicare Advantage plans appear to offer low premiums, they typically have structured copays, coinsurance, and out-of-pocket maximums.

In 2025:

• Medicare Advantage plans have an in-network out-of-pocket maximum of $9,350

• If out-of-network costs apply, the cap may reach up to $14,000

On the other hand, many PSHB plans with Medicare coordination cap out-of-pocket costs much lower:

• $7,500 for Self Only

• $15,000 for Self Plus One and Self and Family

These figures are essential to factor in, especially if you anticipate regular healthcare usage or chronic conditions.

6. What Are the Rules for Re-Enrollment in PSHB?

Leaving PSHB to enroll in a standalone Medicare Advantage plan may not be reversible outside of Open Season or a Qualifying Life Event (QLE). Even during Open Season, returning to PSHB is only possible if you meet eligibility requirements.

This means:

• If your Medicare Advantage plan underperforms, switching back may be delayed

• You risk being locked out of certain cost-saving options integrated in PSHB

• You may have to wait up to a year for re-enrollment unless you qualify for a Special Enrollment Period (SEP)

Ask the plan administrator whether disenrolling from PSHB and joining Medicare Advantage will limit future flexibility.

7. Am I Required to Keep Medicare Part B?

If you’re a Medicare-eligible annuitant or family member under PSHB in 2025, you are required to enroll in Medicare Part B unless you meet one of the following exceptions:

• You retired on or before January 1, 2025, and are not already enrolled

• You were age 64 or older as of January 1, 2025

• You live overseas or qualify under Indian Health Services or VA coverage

If you forgo Part B and enroll in a Medicare Advantage plan that includes Part B coverage, you could face late enrollment penalties later if you return to Original Medicare. Coordination issues may also arise with your PSHB plan if you try to combine coverage improperly.

Always confirm your eligibility and responsibilities to avoid coverage gaps or financial penalties.

8. How Will Emergencies Be Handled?

Under PSHB and Original Medicare, emergency care is broadly covered across the United States. Medicare Advantage plans, however, may limit emergency services outside their network or require prior authorization in some circumstances.

Ask the following:

• Are out-of-network emergency services covered at the same cost?

• What counts as an emergency under this plan?

• Are ambulance and hospital services subject to prior approval?

For annuitants who travel or live in multiple locations throughout the year, PSHB with Medicare may offer more predictable emergency protection.

9. Does the Plan Offer Mid-Year Benefit Tracking?

Starting in 2025, Medicare Advantage plans are required to send a “Mid-Year Enrollee Notification of Unused Supplemental Benefits.” This alert helps you identify unused dental, vision, hearing, or OTC benefits.

However, this new rule does not guarantee full transparency on copays, authorizations, or provider usage.

Under PSHB, you may have access to more comprehensive tracking tools through your plan administrator. Be sure to ask:

• How often benefit usage updates are sent

• What digital tools are available for benefit management

• Whether real-time cost estimators are provided

Understanding your usage patterns can help you avoid overpaying or missing care.

10. What Support Is Available if I Have Issues with the Plan?

If you enroll in a Medicare Advantage plan, your primary support will come from the private company administering it. Appeals, prior authorizations, and grievances must go through their system.

With PSHB and Medicare Parts A and B, you benefit from federal protections and broader support structures.

Ask how the following are handled:

• Appeals and denials

• Prior authorization requirements

• Annual Notice of Change (ANOC) reviews

Also confirm if your current providers offer billing support for the plan you’re considering.

Smart Decisions Begin with Better Questions

Before enrolling in a Medicare Advantage plan, especially as a PSHB enrollee, it’s crucial to evaluate more than just the premium. Ask questions about provider access, out-of-pocket caps, travel flexibility, and prescription drug integration. Once you commit, the flexibility to switch back may be limited.

If you’re unsure about how Medicare Advantage fits into your PSHB options, speak with a licensed agent listed on this website. They can help you weigh your options, understand eligibility rules, and make informed decisions before Open Season ends.