Key Takeaways

• Enrolling in a Medicare Advantage plan without fully understanding how it interacts with PSHB coverage can lead to gaps, duplicate benefits, or denied claims.

• In 2025, certain PSHB enrollees must have Medicare Part B to keep full PSHB benefits. Medicare Advantage is optional, but its impact on your PSHB plan can be more significant than you think.

What Makes Medicare Advantage Different from Original Medicare

Medicare Advantage, also known as Medicare Part C, combines the benefits of Medicare Part A (hospital insurance) and Part B (medical insurance), often with additional coverage such as vision, dental, and prescription drugs. Unlike Original Medicare, these plans are offered through private insurers and may feature network-based restrictions, prior authorizations, or referral requirements.

Medicare Advantage sounds like a comprehensive alternative, and in some cases, it is. But if you’re a Postal Service Health Benefits (PSHB) enrollee, you need to consider more than just added perks.

Why PSHB Works Best with Original Medicare

The PSHB program is structured to coordinate most efficiently with Original Medicare. In 2025, if you are a Medicare-eligible annuitant or family member, enrolling in Medicare Part B is required to maintain full PSHB benefits—unless you fall under certain exemptions.

Here’s how the integration works:

• Medicare pays primary for covered services

• Your PSHB plan pays secondary, often covering costs that Medicare doesn’t, like deductibles or coinsurance

• Many PSHB plans waive cost-sharing altogether for members enrolled in both Part A and Part B

This synergy doesn’t always carry over when you enroll in a Medicare Advantage plan.

Where Medicare Advantage and PSHB Can Clash

Choosing Medicare Advantage may seem attractive, but it introduces a few potential issues when layered with your PSHB coverage:

1. Duplicate Coverage

Medicare Advantage plans already bundle hospital and medical coverage, and often include drug benefits. But if your PSHB plan also provides drug and medical benefits, you’re essentially paying for two overlapping coverages.

PSHB does not automatically cancel out or adjust when you enroll in Medicare Advantage. You’re responsible for both premiums, and there’s no automatic discount for having both.

2. Network Restrictions

Original Medicare allows you to visit any provider that accepts Medicare. But most Medicare Advantage plans use a provider network. If you choose a Medicare Advantage plan that limits your provider options, and your preferred doctor or specialist isn’t in-network, your PSHB coordination may suffer.

Your PSHB plan may still offer wraparound coverage, but it won’t override Medicare Advantage’s restrictions. You could be denied care or charged higher out-of-network rates.

3. Prior Authorization and Claims Confusion

Many Medicare Advantage plans require prior authorizations for certain procedures or services. Original Medicare typically does not.

If your PSHB plan assumes Medicare is paying primary and the Medicare Advantage plan denies the claim due to lack of prior authorization, your secondary PSHB plan may also deny it. That could leave you stuck with the bill.

The 2025 PSHB-Medicare Mandate: What You Must Know

As of January 1, 2025, many Medicare-eligible Postal Service annuitants and family members must enroll in Medicare Part B to keep full PSHB coverage. This rule applies if:

• You are a Postal Service annuitant (or family member of one)

• You turn 65 on or after January 1, 2025

• You live in the U.S. and are eligible for Medicare

If you don’t enroll in Part B when required, your PSHB coverage may be reduced or terminated.

But Medicare Advantage enrollment is not required. It’s optional, and for many PSHB enrollees, it may not be the best choice.

Who Might Be Exempt from the Part B Requirement

You are exempt from the Medicare Part B requirement for PSHB if:

• You retired from the Postal Service on or before January 1, 2025

• You were an active Postal employee and age 64 or older on January 1, 2025

• You permanently reside overseas

• You are enrolled in benefits from the Indian Health Service or Department of Veterans Affairs

Even if you fall into one of these groups, Medicare Advantage enrollment still carries the same compatibility issues with PSHB.

Prescription Drug Coverage: Double Is Not Always Better

Many Medicare Advantage plans include prescription drug coverage (MAPD). But PSHB plans already offer robust prescription benefits.

If you are enrolled in Medicare and a PSHB plan, your prescription drug benefits are managed through a Part D Employer Group Waiver Plan (EGWP), which coordinates well with Medicare. If you enroll in a Medicare Advantage plan with drug coverage, you can’t be enrolled in both the EGWP and the Medicare Advantage drug plan at the same time.

This means one plan has to go—potentially leaving you with reduced access to pharmacies, higher copays, or formulary restrictions.

Medicare Advantage Enrollment Is Locked by Timelines

You can’t jump in and out of Medicare Advantage at will. Medicare Advantage enrollment and disenrollment is governed by fixed windows:

• Initial Enrollment Period: 3 months before, the month of, and 3 months after your 65th birthday

• Annual Enrollment Period: October 15 to December 7

• Medicare Advantage Open Enrollment Period: January 1 to March 31 (for those already enrolled in a Medicare Advantage plan)

If you choose a Medicare Advantage plan and then discover that it doesn’t work well with your PSHB coverage, you may have to wait months before switching back.

Medicare Advantage Doesn’t Count as Part B for PSHB Purposes

Some mistakenly believe that enrolling in a Medicare Advantage plan fulfills the Part B requirement under PSHB. It does not.

A Medicare Advantage plan is a private alternative to Original Medicare, but you must first be enrolled in both Medicare Part A and Part B to join a Medicare Advantage plan. So, while you need Part B to enroll in Medicare Advantage, being enrolled in Advantage alone doesn’t satisfy PSHB’s rule.

You still need to maintain your Part B enrollment to avoid losing PSHB benefits.

Can You Have Both? Yes, But It May Not Be Worth It

Technically, you can have both a Medicare Advantage plan and a PSHB plan. But here’s what you’re signing up for:

• Paying two premiums

• Managing two separate sets of rules

• Risking mismatched coverage and denied claims

It may also be unclear which plan is responsible for which costs. If the Medicare Advantage plan denies a service, your PSHB plan may follow suit.

In most cases, combining Medicare Advantage with PSHB does not offer financial or coverage advantages unless you’re extremely careful in plan selection and coordination.

Questions to Ask Before Choosing a Medicare Advantage Plan

Before enrolling in a Medicare Advantage plan, ask yourself:

• Does my provider accept the plan’s network?

• Will my PSHB plan still work the way I expect?

• Are prescription drug formularies the same?

• How do out-of-network costs compare?

• What happens if I need to disenroll midyear?

• Do I understand the prior authorization rules?

The more you know before enrolling, the less likely you are to run into surprises.

PSHB Is Designed with Original Medicare in Mind

The PSHB framework was built to integrate with Original Medicare, not private Medicare Advantage plans. It leverages the predictability and universality of Original Medicare to provide seamless, cost-effective secondary coverage.

By adding Medicare Advantage into the mix, you disrupt that balance. You may be layering plans that don’t communicate well or that create billing delays and access issues.

If you are looking for simplicity, stability, and strong coordination of benefits, Original Medicare with PSHB may be your better option.

Rethink the Appeal of Added Benefits

Many people are drawn to Medicare Advantage by promises of dental, vision, hearing, and other supplemental benefits.

But PSHB plans often offer similar or better supplemental benefits, especially when paired with Original Medicare. Before you switch for these extras, make sure you’re not already covered.

Losing the core PSHB benefits for the sake of extras could cost you far more than you expect.

Know Before You Enroll

Making Medicare decisions can feel overwhelming, especially when your PSHB benefits are tied so closely to your choices. Don’t let assumptions guide you into a plan that limits your care, duplicates your benefits, or increases your out-of-pocket costs.

Take time to understand how Medicare Advantage works with PSHB. And if you’re unsure, speak with a licensed agent listed on this website to review your personal situation.

Get Personalized Help to Avoid Coverage Mistakes

Your PSHB benefits are too important to risk by making the wrong Medicare decision. In 2025, choosing a Medicare Advantage plan without reviewing its impact on your PSHB coverage could result in claim denials, duplicate payments, and frustration during care.

Make sure your health coverage works for you, not against you. Reach out to a licensed agent listed on this website to get help reviewing your Medicare options before making any changes.