Key Takeaways

• A Medicare Advantage plan may include rules or provider networks that conflict with your PSHB plan’s benefits, especially when both plans attempt to manage your care.

• If you are required to enroll in Medicare Part B to keep PSHB coverage, enrolling in a Medicare Advantage plan separately may lead to misaligned coverage or denied claims.

Understanding the Core Conflict

As a Postal Service annuitant or employee transitioning to the Postal Service Health Benefits (PSHB) Program in 2025, your healthcare options have shifted. A major aspect of this shift is the integration with Medicare, particularly Part B. What often causes confusion, however, is how a separate Medicare Advantage plan might interfere with your PSHB benefits.

Medicare Advantage (also known as Medicare Part C) is offered by private companies approved by Medicare. While these plans must provide at least the same coverage as Original Medicare, they often come with different provider networks, prior authorization rules, and cost-sharing structures. These differences can directly clash with what your PSHB plan already covers.

Why the PSHB and Medicare Advantage Combination Can Be Problematic

The PSHB Program is structured with Medicare coordination in mind—specifically with Original Medicare (Parts A and B). Here’s where conflicts can begin:

PSHB Plans Assume You Have Original Medicare

Your PSHB plan coordinates benefits with Medicare Part A and Part B. That means:

• Your PSHB plan becomes the secondary payer once Medicare pays first.

• You benefit from waived deductibles, lower copayments, and expanded provider access.

• Some PSHB plans even reimburse a portion of your Medicare Part B premium.

However, when you enroll in a Medicare Advantage plan, Medicare pays the private insurer to manage your care. Your Original Medicare is no longer the primary payer—your Medicare Advantage plan is.

This creates a breakdown in coordination. Your PSHB plan cannot function as a proper secondary payer if it doesn’t receive a claim from Medicare first. In many cases, Medicare Advantage won’t send claims to your PSHB plan, leading to out-of-pocket expenses you weren’t expecting.

Coverage Restrictions and Provider Networks

Medicare Advantage plans are built on managed care models. This often includes:

• Limited provider networks (HMOs or PPOs)

• Referral requirements for specialists

• Pre-authorization for services

In contrast, PSHB plans—especially when paired with Original Medicare—usually offer broader access to providers nationwide. When you enroll in a Medicare Advantage plan:

• You may be restricted to a narrow network that does not include your usual PSHB providers.

• Your access to specialists may be delayed by referral requirements.

• Pre-authorization delays can hold up treatment that would otherwise be approved under your PSHB plan.

Drug Coverage Discrepancies in 2025

With the rollout of the PSHB Program, prescription coverage is integrated through a Medicare Part D Employer Group Waiver Plan (EGWP) if you are Medicare-eligible and enrolled in Part B. This EGWP:

• Offers enhanced benefits compared to standard Part D

• Includes a $2,000 cap on out-of-pocket prescription drug costs for the year

• Is automatically included with your PSHB plan for eligible annuitants

If you instead enroll in a standalone Medicare Advantage plan with drug coverage (MAPD), it could replace your PSHB plan’s EGWP drug coverage. Worse, if you opt out of the PSHB’s Part D EGWP, you may not be able to re-enroll later unless you meet strict exceptions.

This leads to two major risks:

• You lose access to your PSHB plan’s integrated drug benefits

• You risk duplicating coverage and still facing higher costs or limited pharmacy networks

Confusion Over Claims Processing

In PSHB coordination with Original Medicare, claims processing follows a standard workflow:

1. Medicare pays first (primary)

2. PSHB plan pays second (secondary)

When a Medicare Advantage plan is involved, that pattern is broken. Medicare pays the plan, and the plan may or may not forward claims to PSHB. This breakdown can mean:

• You may be responsible for full costs upfront

• PSHB may deny reimbursement if it doesn’t receive the proper coordination data

• Disputes may arise over who should have paid and when

This complexity is not just a hassle—it can result in thousands of dollars in unanticipated costs if claims go unpaid.

Timing Matters: Enrollment Requirements and Plan Conflicts

As of 2025, Medicare-eligible Postal Service annuitants (and their family members) are generally required to enroll in Medicare Part B to maintain PSHB coverage—unless you qualify for an exemption.

If you enroll in a Medicare Advantage plan instead of Original Medicare, this can fulfill the Part B enrollment requirement, but it won’t maintain the same coordination benefits. And depending on how your Advantage plan is structured:

• It may interfere with how your PSHB plan processes claims

• You may unintentionally disenroll from the PSHB drug coverage

• You may limit access to providers you’ve relied on for years

No True Secondary Coverage With Medicare Advantage

This is a key misunderstanding. Once you’re in a Medicare Advantage plan, that plan becomes your primary and often your only plan. It rarely coordinates with other coverage in the same way Original Medicare does.

Your PSHB plan is designed to wrap around Medicare Part B. If you take yourself out of that model, your PSHB plan can’t supplement it the way it was meant to. Instead, you could end up paying more, having to follow new rules, and losing access to preferred providers.

What If You Already Enrolled in a Medicare Advantage Plan?

If you’ve already joined a Medicare Advantage plan and are also enrolled in a PSHB plan, you may still be able to make a change during the Medicare Advantage Open Enrollment Period (January 1 – March 31).

During this window, you can:

• Disenroll from your Medicare Advantage plan

• Switch back to Original Medicare (Parts A and B)

• Restore proper coordination with your PSHB coverage

Outside of this period, you must wait for Medicare Open Enrollment (October 15 – December 7) unless you qualify for a Special Enrollment Period (SEP).

2025 Medicare Part B Still Matters

In 2025, the standard Medicare Part B premium is $185 per month. While this may feel like an additional burden, it unlocks access to better integration with your PSHB plan.

Your PSHB plan may even offer partial reimbursement for Part B premiums and lower out-of-pocket costs overall when paired correctly. Choosing Medicare Advantage may seem cheaper on the surface, but without proper alignment, it can cost more in the long run.

Long-Term Impact on Retirement Health Planning

As you look toward the next decade of retirement, making the right Medicare choice is foundational to how your PSHB plan works for you. Here are a few final factors to consider:

• Coordination: PSHB plans are built to coordinate with Original Medicare, not Medicare Advantage.

• Access: Original Medicare with PSHB gives you broader national provider access.

• Flexibility: You can see specialists and use providers without strict gatekeeping.

• Continuity: You avoid disruptions from switching plan networks annually.

Get PSHB Working the Way It Was Designed

The PSHB Program is designed to provide stable, comprehensive healthcare in retirement—when it’s used as intended with Medicare Parts A and B. The moment you shift to a private Medicare Advantage plan, that coordination is jeopardized.

Don’t let confusion cost you access, money, or peace of mind. Talk to a licensed agent listed on this website to get personalized help reviewing your current plan and exploring how to align your Medicare enrollment to keep PSHB working as intended.