Key Takeaways

• Medicare Advantage plans may limit your provider choices and require prior authorizations, which can reduce the flexibility you had under PSHB paired with Original Medicare.

• While these plans offer additional benefits, they also come with managed care restrictions, network limitations, and regional coverage concerns that can affect your access to timely care.

Understanding the Basics: Medicare Advantage vs PSHB + Original Medicare

If you’re enrolled in a Postal Service Health Benefits (PSHB) plan and turning 65, you might be considering how Medicare changes your coverage. One major decision is whether to stay with Original Medicare and keep your PSHB plan as secondary, or switch to a Medicare Advantage plan. On paper, the latter might seem appealing because of added perks and bundled coverage. But there’s a major tradeoff that deserves attention: flexibility.

Medicare Advantage, or Medicare Part C, replaces your federal Medicare Parts A and B with a privately administered plan. You still pay the Part B premium, but you now operate within a specific plan’s rules, network, and coverage structure. Unlike the broad access offered by Original Medicare, Medicare Advantage comes with certain limitations that can directly affect how and when you get care.

Network Limitations: Your Choice of Providers Shrinks

One of the first things you’ll notice when switching to a Medicare Advantage plan is that provider flexibility changes significantly.

Under Original Medicare and your PSHB plan, you can usually:

• See any doctor or specialist who accepts Medicare

• Receive care nationwide without referrals or network barriers

• Avoid network penalties if you need out-of-area care

With Medicare Advantage:

• You are generally restricted to a network of doctors, hospitals, and specialists

• Some plans may not cover out-of-network services except in emergencies

• Finding a preferred provider or specialist can be challenging in some areas

This can be especially limiting if you live in a rural area, travel frequently, or need specialized care not available within your plan’s network. In contrast, PSHB plans paired with Original Medicare offer more freedom to choose providers across the country.

Prior Authorization: A Barrier to Timely Treatment

Another key restriction in Medicare Advantage plans is the frequent requirement for prior authorizations. Before receiving a range of services, you often need plan approval, which can delay treatment or result in denials.

Services that commonly require prior authorization include:

• Diagnostic imaging (MRIs, CT scans)

• Durable medical equipment (wheelchairs, home oxygen)

• Skilled nursing facility stays

• Certain outpatient procedures

This level of oversight can be frustrating, particularly for individuals managing chronic or complex conditions who are used to the streamlined process under PSHB + Original Medicare.

Geographical Coverage: Your Plan May Not Travel With You

Medicare Advantage plans are regionally based. What this means for you:

• Plans are generally designed to serve specific counties or regions

• Out-of-network coverage is minimal or nonexistent except in emergencies

• Long-term travel or relocation can disrupt your access to care

This can be a concern for retirees who split time between two locations or those who may move in the future. PSHB plans coordinated with Original Medicare continue to offer national coverage, making them more flexible in addressing healthcare needs regardless of where you are.

Referral Requirements: Extra Layers of Permission

In many Medicare Advantage plans, especially Health Maintenance Organizations (HMOs), you’ll need referrals to see specialists. This adds extra steps:

• Visit your primary care provider first

• Obtain a referral

• Wait for approval before scheduling specialist care

These administrative layers can delay needed care and add stress, especially when dealing with complex health issues. With PSHB and Original Medicare, referrals are rarely required, so access to specialists is generally faster and simpler.

Formularies and Medication Access: Prescription Coverage Can Be Restrictive

While PSHB plans integrate prescription coverage, Medicare Advantage plans include drug coverage that is plan-specific. Each plan has its own formulary:

• Drug lists vary widely, and not all medications are covered

• You may need step therapy or prior authorization for certain drugs

• Formularies can change annually, impacting access to long-term medications

This lack of consistency can create challenges, especially for those with chronic prescriptions. In contrast, PSHB plans combined with Original Medicare typically offer broader and more stable drug coverage options.

Cost Predictability: You May Face More Out-of-Pocket Surprises

Medicare Advantage plans often advertise lower upfront costs, but they can lead to unpredictable out-of-pocket spending due to:

• Copayments for nearly every service

• High out-of-pocket maximums (up to $9,350 for in-network care in 2025)

• Additional costs if you go out of network or need uncovered services

With PSHB and Original Medicare, your cost structure tends to be more transparent. You may pay premiums and deductibles, but many plans reduce or eliminate coinsurance for services once Medicare pays its share.

Appeals and Denials: Administrative Burdens Increase

Medicare Advantage plans have the authority to deny services based on their internal guidelines. While you have the right to appeal, the process can be time-consuming and stressful:

• Multiple levels of appeal are often required

• You may need additional documentation or provider support

• Appeals can take days or weeks to resolve

PSHB enrollees who stick with Original Medicare generally experience fewer service denials and less red tape.

Annual Changes: Plan Rules and Coverage Can Shift Yearly

Every year, Medicare Advantage plans can change:

• Provider networks

• Covered services

• Copayments and coinsurance

• Out-of-pocket limits

• Drug formularies

You’ll receive an Annual Notice of Change (ANOC), but staying on top of these shifts is essential to avoid unexpected costs or disruptions in care. In contrast, PSHB plans offer greater long-term consistency, particularly when paired with Medicare.

Supplemental Benefits: Extras Come with Strings

Medicare Advantage plans often promote supplemental benefits such as:

• Dental, vision, and hearing coverage

• Fitness memberships

• Over-the-counter (OTC) allowances

However, these extras come with conditions:

• Usage may be limited by network, service area, or vendor restrictions

• Benefits may be reduced mid-year or not renew in future plan years

• OTC benefits require you to use plan-approved items and vendors

While these add-ons may seem attractive, they shouldn’t overshadow the core coverage limitations that can restrict your flexibility. PSHB plans may offer similar benefits without the managed care constraints.

Enrollment and Disenrollment Rules: Timing Matters

Once enrolled in a Medicare Advantage plan, changing your mind isn’t always simple. Key enrollment periods include:

• Initial Enrollment Period (IEP): When you first become eligible for Medicare (usually at 65)

• Annual Enrollment Period (AEP): October 15 to December 7 each year

• Medicare Advantage Open Enrollment Period (MA OEP): January 1 to March 31, but limited to one change

Outside these windows, changes are only allowed for qualifying life events (Special Enrollment Periods). This makes it critical to carefully evaluate your decision before committing to a Medicare Advantage plan.

Returning to Original Medicare Can Be Complicated

If you leave a PSHB plan and enroll in Medicare Advantage, then decide to return:

• You may be subject to late enrollment penalties if you delayed Part D or Medigap coverage

• Not all PSHB plans will accept you back at the same level

• There may be delays in coverage restoration

Remaining with PSHB and Original Medicare from the outset helps avoid these complications and preserves access to familiar benefits and support systems.

Why Flexibility Matters More Than Ever in 2025

As healthcare needs become more individualized and complex with age, flexibility is no longer a luxury—it’s a necessity. In 2025, the health system continues to shift toward value-based and managed care models. While these offer efficiency, they also limit patient autonomy.

By staying enrolled in your PSHB plan and using it alongside Original Medicare, you retain national provider access, fewer barriers to care, and more reliable drug coverage. You avoid the frustration of navigating approvals, denials, and restrictive networks.

Protecting Your Coverage Choices Starts with Education

Choosing between Medicare Advantage and sticking with your PSHB plan isn’t just about benefits—it’s about control. If you value the ability to choose your providers, travel without healthcare disruption, and avoid red tape, PSHB with Original Medicare remains a strong option.

Before you make any change, review the differences thoroughly and ask detailed questions. Speak with a licensed agent listed on this website to understand your specific situation and how each option will affect your healthcare access long term.