Key Takeaways

• Medicare Advantage plans may offer lower upfront costs, but their limited provider networks can leave you exposed to high out-of-pocket expenses if you need care outside those networks.

• PSHB enrollees who coordinate Medicare with their PSHB plan generally retain wider access to providers and more predictable healthcare expenses.

Understanding Medicare Advantage and Its Network Limitations

When you consider a Medicare Advantage plan, it often appears to offer an all-in-one solution: hospital care, doctor visits, and sometimes even prescription drugs in one package. But what these plans don’t emphasize enough is how they limit your provider choices. That limitation becomes glaringly obvious if you find yourself needing care that isn’t within the plan’s network.

In 2025, Medicare Advantage plans still operate as private alternatives to Original Medicare. These plans typically have Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) structures. Both rely on provider networks, and the more restrictive the network, the more costly or inaccessible out-of-network care becomes.

What It Means to Be “In-Network”

With Medicare Advantage, being “in-network” means using doctors, hospitals, and facilities that contract with your plan. These contracts help insurers control costs, but they also limit your freedom. If you need care while traveling or your specialist leaves the network, you might find yourself without coverage or facing high out-of-pocket costs.

• HMO plans generally do not cover any out-of-network care except emergencies.

• PPO plans may offer some out-of-network coverage, but at a much higher cost.

Even if you live in a city with many providers, not all of them will accept your Medicare Advantage plan. And if you reside in a rural area or travel frequently, these network rules can severely restrict your access to timely, quality care.

PSHB and Medicare Work Together Differently

Unlike Medicare Advantage, PSHB plans in 2025 are designed to coordinate more flexibly with Original Medicare. If you’re a Medicare-eligible Postal Service annuitant enrolled in both Medicare Parts A and B, your PSHB plan will generally waive or reduce deductibles, copayments, and coinsurance. You don’t need to worry about staying in-network just to avoid surprise bills.

With PSHB + Medicare:

• You can see any provider who accepts Medicare nationwide.

• There’s no gatekeeping through a primary care physician.

• You avoid high cost-sharing for out-of-network care.

That flexibility becomes essential in emergencies, specialized treatment situations, or while traveling.

Common Situations That Reveal the Limits of Advantage Plans

Medicare Advantage plans can be restrictive in ways that don’t show up during routine care. It’s often when you face urgent or complex health situations that the disadvantages become apparent:

• Out-of-State Travel: Most Medicare Advantage plans do not extend full coverage outside your plan’s local service area.

• Specialty Care Needs: If a specialist you need is out-of-network, you could be denied coverage or face steep fees.

• Hospital Choice: Your preferred hospital may not be in your plan’s network, limiting where you can receive care.

• Provider Departure: If your current doctor leaves the network mid-year, you might have to change doctors or face higher out-of-pocket costs.

These limitations can cause disruptions in care, create financial stress, and limit your treatment options when you need them most.

Out-of-Network Coverage Isn’t Just More Expensive—It’s Often Unavailable

Even in PPO Medicare Advantage plans that advertise out-of-network coverage, the reality is often frustrating. While technically allowed, out-of-network providers may refuse to accept your plan, meaning you must pay up front and request reimbursement later—if it’s even granted.

Other complications include:

• Prior authorization requirements that delay treatment.

• Lack of reimbursement for services the plan deems unnecessary.

• Billing disputes that leave you stuck in the middle.

With PSHB plans paired with Original Medicare, these issues are rare. You have the backing of Medicare’s broad national coverage, along with the supplemental protections and coordination offered by PSHB plans.

Financial Risk from Unexpected Care Needs

In 2025, Medicare Advantage plans are required to cap your out-of-pocket costs for in-network care at $9,350 per year. However, that cap only applies to services provided by in-network providers. Once you go out-of-network, that financial protection erodes quickly.

Some enrollees find themselves facing thousands of dollars in surprise medical bills, simply because they:

• Needed emergency care while traveling

• Were referred to an out-of-network specialist

• Required a procedure not pre-approved by the plan

PSHB enrollees with Medicare typically have more consistent financial protection, even if they need unexpected or complex care.

Emergency Situations Don’t Always Mean Full Coverage

It’s a common misunderstanding that all emergency care is covered equally. Under Medicare Advantage, emergency room visits may be covered nationwide, but follow-up care or inpatient hospital stays may not be.

For instance:

• You’re stabilized at an out-of-network hospital but need continued care.

• Your plan may require you to transfer to an in-network facility or pay most of the cost.

• You might be discharged early because extended out-of-network care is not authorized.

PSHB enrollees with Original Medicare usually don’t face this restriction. Medicare pays its share regardless of location, and your PSHB plan coordinates coverage without imposing network barriers.

Provider Directories Can Be Outdated or Misleading

Another hidden issue in Medicare Advantage plans is the accuracy of provider directories. What looks like a large network on paper may be far smaller in reality.

Common problems include:

• Providers listed who no longer accept the plan

• Incorrect contact or location information

• Specialists shown as available but not accepting new patients

As a result, you might spend hours trying to find an in-network provider who is truly accessible.

In contrast, with Original Medicare and a PSHB plan, you don’t rely on a narrow or outdated directory. You have access to nearly any doctor or specialist who takes Medicare—which includes the vast majority of providers nationwide.

Medicare Enrollment Deadlines Still Matter

If you’re a PSHB enrollee approaching age 65 or already eligible for Medicare, it’s important to understand the timing rules. In 2025:

• The Initial Enrollment Period (IEP) spans 7 months: 3 months before, the month of, and 3 months after your 65th birthday.

• Missing this window may lead to late penalties or coverage delays.

• A Special Enrollment Period (SEP) may apply if you’re still covered by employer-based PSHB when you turn 65.

Enrolling in Medicare Parts A and B allows your PSHB plan to function more like a comprehensive supplement, eliminating many of the network problems Medicare Advantage plans face.

Choosing PSHB with Medicare Keeps You in Control

Medicare Advantage plans work well for some people who stay within network boundaries and rarely travel or require specialists. But for many PSHB enrollees, especially retirees, the flexibility of staying with Original Medicare plus a PSHB plan is worth preserving.

The benefits include:

• Nationwide access to doctors and hospitals

• Fewer hurdles to getting care

• Consistent coordination between Medicare and your PSHB plan

When you have a health emergency or complex condition, this combination often leads to faster treatment and fewer financial surprises.

Flexibility and Freedom Matter More Than Ever

In 2025, healthcare needs are increasingly unpredictable. Whether it’s routine checkups or sudden medical events, knowing you can receive care from almost any provider gives you peace of mind. That’s exactly what the pairing of Medicare with PSHB offers—flexibility, security, and choice.

If you’re evaluating your coverage during the November to December Open Season, it’s essential to think beyond premiums. Consider how the plan supports you when life becomes complicated.

Your Coverage Should Work When You Need It Most

Relying on a Medicare Advantage plan might seem like a simple choice—until you need care outside its network. At that point, you could find yourself paying more, waiting longer, or traveling farther than expected.

Pairing your Medicare benefits with a PSHB plan gives you broader access and more dependable coverage. It eliminates the worry of whether a doctor is in-network and helps reduce the chance of costly surprises.

If you have questions or want to explore which option fits your situation best, speak with a licensed agent listed on this website for personalized help.