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In This Chapter

^ Understanding the differences between traditional Medicare and Medicare’s private health plans

^ Picking between traditional Medicare and private plans

^ Comparing and choosing among private Medicare health plans

Hoices, choices, choices. Part D has an abundance of them, and for many people, selecting just one drug plan seems a daunting task. But before you begin comparing drug plans (which Chapter 10 delves into), you really need to be clear about how you want your Medicare Medical Benefits delivered. This is a critical first step in the Part D plan selection process — and one that affects and automatically narrows your drug coverage options.

Broadly, Medicare medical benefits are available through two very different delivery systems:

Traditional Medicare: The original government system, in place since 1966, traditional Medicare works on a Fee for service Basis — Medicare directly pays a portion of the costs of any medical service it covers to any provider that accepts Medicare patients. You, the patient, pay a percentage of the cost, or in some cases a fixed amount, for each covered service you receive.

Private Medicare health plans: Collectively known as the Medicare Advantage (MA) program, these plans provide alternatives to the traditional system and are run by private, Medicare-approved insurers. Medicare pays each plan a monthly amount for each enrollee’s medical care. You receive your medical benefits through the plan of your choice and pay the charges required by the plan. Because plans vary greatly in their costs and benefits, you need to compare them carefully to pick the one that most suits your needs.

Whichever type of coverage you choose, you’re still part of Medicare. But be aware that traditional Medicare and private Medicare health plans have big differences. Oh yeah, and then there are all the variations among the five types of Medicare Advantage plans — Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Medicare Medical Savings Accounts (MSAs), and Special Needs Plans (SNPs). Not to mention yet another type of plan that isn’t strictly part of the Medicare Advantage program — an HMO known as a Medicare Cost plan. Complicating matters further, Medicare even has rules about which kind of drug coverage you can choose depending on how you receive your Medicare medical benefits.

If you’re already sure you want either traditional Medicare or a private Medicare health plan for your medical benefits — or are already in one or the other and want to remain in it — pass this chapter over and head straight to Chapter 10, which explains how to compare drug plans. But if you’re undecided, read on.

In this chapter, I explain the differences between traditional Medicare and the various kinds of health plans that fall under the Medicare Advantage umbrella, as well as a few other individual programs. I also suggest items to consider when making a choice between traditional Medicare and a private Medicare health plan. And finally, if you opt for the Medicare Advantage system, I explain how to compare the MA plans available in your area to find the one that suits you best.

The Features of Traditional Medicare and Medicare’s Private Health Plans

Your choice of medical care directly affects how you receive drug coverage:

You can choose a stand-alone Part D plan — the kind that provides coverage only for prescription drugs — if you’re enrolled in one of the following:

• Traditional Medicare

• A Private Fee-for-Service (PFFS) plan that doesn’t offer drug coverage

• A Medicare Savings Account (MSA) plan

• A Medicare Cost plan that doesn’t offer drug coverage

I You can choose a Medicare HMO, PPO, SNP, PFFS, or Cost plan that provides both medical care and prescription drug coverage in a single package.

I You can’t have a stand-alone Part D plan while you’re enrolled in a Medicare HMO or PPO plan, Even if it doesn’t provide drug coverage.

Your choice of medical care also reduces the quantity of your drug coverage choices. For example, if your area offers 50 stand-alone Part D plans and 50 Medicare Advantage (MA) plans that include drug coverage (by no means an uncommon scenario in urban areas), your options are instantly halved.

Good news: Nobody’s going to ask you to take a quiz on all of this information! But you do need to do some homework to make an informed decision about getting your healthcare from either traditional Medicare or a private health plan — and, if you choose the latter, about the kind of Medicare Advantage plan you prefer. The more thoroughly you understand the differences among all of these choices, the more likely you’ll be content with the one you pick.

Table 9-1 shows at a glance the main differences among traditional Medicare and the three types of private health plans most commonly chosen by Medicare beneficiaries. The following sections go further, with detailed information on all the plan choices available to you. In each case, I explain how each type of plan works with prescription drug coverage, to what extent you can choose the doctors and hospitals you go to, the eligibility rules, whether extra benefits (more than traditional Medicare covers) may be available, and what kind of out-of-pocket expenses to expect.

Table 9-1 Key Questions When Comparing Traditional

Medicare and the Main Types of Private Medicare Advantage Health Plans

That doesn’t offer drugs.

(continued)

Table 9-1 (continued)

Costs and covers a few extra benefits.

Traditional Medicare

Also known as Original Medicare, Traditional Medicare is the program you’re in, unless you opt for one of the private plans I describe later in this chapter.

Eligibility: You must have Medicare Part A (hospital care) or Part B (outpatient care) or both, as explained in Chapter 1. To receive services, you can live anywhere in the United States or its territories.

I Choice of doctors and hospitals: You can go to any doctor or hospital that accepts Medicare patients (and is accepting new ones) anywhere in the country. You don’t need a referral from a primary care doctor to see a specialist. (To find a doctor enrolled in Medicare, visit www. Medicare. gov and click "Find a Doctor" on the home page. You can use this tool to search for a doctor by name, area, or specialty. Or you can always call Medicare at 800-633-4227 and ask for a list to be mailed to you.)

I Out-of-pocket costs: For outpatient care, you pay the standard Part B monthly premium ($96.40 in 2008 for most people; higher if your income is above $82,000 a year in 2008), annual deductible ($135 in 2008) and a percentage of the cost (20 percent in most cases, but possibly higher) of each Medicare-covered service. For hospital care, you pay a deductible ($1,024 in 2008) for each stay up to 60 days in a benefit period and co-pays for extra days, as explained in Chapter 1. There’s no limit on out-of-pocket costs. You can buy private Medigap supplementary insurance for

An extra premium to cover deductibles and co-pays in full or in part (see Chapter 1 for more about Medigap).

I Extra benefits: Traditional Medicare covers many kinds of healthcare, but by no means does it cover all the services you’re likely to need. For example, it doesn’t cover routine vision, hearing, and dental care. Medigap insurance may provide a few extra benefits, such as emergency care abroad and limited preventive care, depending on the policy you purchase.

I Prescription drugs: Traditional Medicare solely covers drugs used in hospitals or administered in doctors’ offices and clinics. You need to join a private stand-alone Part D plan, for an additional premium, to get coverage for outpatient drugs.

Medicare Advantage plans

You can choose among several very different types of plans within the Medicare Advantage program. Some types, such as HMOs and PPOs, have been part of Medicare for many years. (You’ll be familiar with the way these work if you’ve previously been in an HMO or PPO sponsored by an employer.) Other types of MA plans are much newer: Private Fee-for-Service (PFFS) plans, though available earlier, only became widespread from 2006 onward. Medicare Medical Savings Accounts (MSAs) and Special Needs Plans (SNPs) have been available in Medicare only since 2004. The following sections explain the key features of each type of MA plan.

Health Maintenance Organizations (HMOs)

Health Maintenance Organizations (HMOs) offer Managed care. This is a healthcare delivery system designed to hold down costs, typically by requiring primary care doctors to act as gatekeepers in referring patients to specialists and other services. HMOs operate locally in limited geographical service areas — usually a county or even a zip code. The same HMO may offer costs and benefits different in one service area than in another that may be right next to it. Following are the main features of HMOs:

I Eligibility: You must have Medicare Part A and Part B and live within the service area of the plan you select. You can’t join an HMO if you have end-stage renal disease (ESRD) — but if you develop it when already enrolled, you can remain in the plan.

I Choice of doctors and hospitals: You must be treated by doctors and hospitals within the plan’s network of contracted providers in the service area, except in an emergency or if you urgently need care. You usually need a referral from your primary care doctor to see a specialist. (If the plan offers a Point of Service Option, however, you can go out of network for a higher co-pay.) An HMO can supply you with its list of providers to help you find out in advance whether it covers your preferred hospitals and doctors.

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U Out-of-pocket costs: Whether you pay a premium in addition to the Part B premium depends on the plan. Co-pays for specific services are often less, but sometimes higher, than those in traditional Medicare. Some plans set a limit on out-of-pocket spending in the year, usually on specified services. If you go outside of the plan’s provider network (unless you have a Point of Service agreement), you’re responsible for the full cost of treatment, except in emergencies.

U Extra benefits: Some plans offer vision, hearing, and/or dental services (though the extent of this coverage varies a great deal among plans); routine checkups; and other extras, like health club memberships. These bonuses are usually reflected in higher premiums.

U Prescription drugs: Not all HMOs offer prescription drug coverage. If you join a plan that doesn’t, you can’t get coverage from a stand-alone Part D plan.

Preferred Provider Organizations (PPOs)

MA plans that offer managed care with fewer restrictions than HMOs are known as Preferred Provider Organizations (PPOs). Regional PPOs cover large areas, maybe several states. Local PPOs operate within smaller areas, such as in one or several adjacent counties. Their features include the following:

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U Eligibility: Like HMOs, you must have Medicare Parts A and B and live within the service area of your selected plan. You can’t join a plan if you have end-stage renal disease (ESRD), but you can stay in a plan if you develop this illness after enrollment.

U Choice of doctors and hospitals: You can go to a doctor or hospital outside of the plan’s provider network — but, if you do, it’ll cost you more in co-pays. You don’t need a referral to see a specialist. A PPO can give you its list of network providers so you can see in advance whether your preferred doctors and hospitals are covered.

U Out-of-pocket costs: The plan you select determines whether you pay a premium in addition to the Part B premium. Co-pays for specific services are different from those in traditional Medicare (often less, but sometimes higher). Some plans set a limit on out-of-pocket spending in the year, usually on specified services. Naturally, going to out-of-network providers (except in emergencies or for urgently needed care) costs more, often a lot more, though typically not the full cost.

U Extra benefits: Some plans offer vision, hearing, and/or dental services (though the extent of this coverage varies a great deal among plans); routine checkups; and other extras, like health club memberships. These are usually reflected in higher premiums.

U Prescription drugs: Not all PPOs offer prescription drug coverage. If you join a plan that doesn’t, you can’t purchase coverage from a stand-alone Part D plan.

Private Fee-for-Service (PFFS) plans

Private Fee-for-Service (PFFS) plans don’t offer managed care. They directly pay providers for each covered service, similar to the way traditional Medicare works (which sometimes leads consumers to confuse the two). Here are the main features of PFFS plans:

U Eligibility: You must have Medicare Part A and Part B and live in the service area of the plan you select. You can’t join a plan if you have end-stage renal disease (ESRD) — but if you develop it when already enrolled, you can remain in the plan.

U Choice of doctors and hospitals: You can go to any doctor or hospital that accepts the plan’s conditions and payment rates, anywhere in the country, and you don’t need a referral to see a specialist. But many providers don’t accept PFFS plans, and it isn’t easy to find out in advance which do, except by asking doctors and hospitals directly. (However, starting in 2011, PFFS plans must have written contracts with providers.) In addition, providers are allowed to accept or reject the plan for each service visit. So if the plan covers your care from a particular doctor or hospital once, there’s no guarantee that you’ll be covered next time.

U Out-of-pocket costs: Whether you pay a premium in addition to the Part B premium depends on the plan. Co-pays for specific services may be different from those in traditional Medicare — either lower or higher. Some plans set a limit on out-of-pocket costs in the year, usually on specified services. If you’re treated by a provider who doesn’t accept the PFFS plan’s payment rates, you’re responsible for the full cost of treatment, except in emergencies.

U Extra benefits: Some plans offer vision, hearing, and/or dental services (though the extent of this coverage varies a great deal among plans); routine checkups; and other extras, such as health club memberships. These add-ons are usually reflected in higher premiums.

U Prescription drugs: Not all PFFS plans offer prescription drug coverage. If you join a plan that doesn’t, you can enroll in a stand-alone Part D plan to obtain coverage (unlike HMOs and PPOs).

Medicare Medical Savings Account (MSA) plans

Medicare Medical Savings Account (MSA) plans work very differently from other Medicare Advantage plans. Medicare gives an MSA plan a certain amount of money for each of its enrollees; the plan then deposits a portion of this money into a special health savings account for you. You draw on the money in the account to pay for medical care. If you use up the entire amount, you then pay 100 percent of your medical costs until you’ve reached the plan’s deductible limit. Beyond that limit, the plan pays all of your costs for Medicare-covered services for the rest of the year.

MSAs offer the following features:

U Eligibility: You must have Medicare Part A and Part B. You can’t enroll in an MSA if

• You have health coverage through Medicaid, the Department of Veterans Affairs (VA or CHAMPVA benefits), the Department of Defense (TRICARE military benefits), or the Federal Employees Health Benefits program

• You have other heath coverage (like a retiree plan) that would cover all or part of the MSA deductible

• You have end-stage renal disease (ESRD)

• You’ve already chosen to receive Medicare hospice care for a terminal illness (which is covered under Part A; see Chapter 1)

• You’ll live in the U. S. for fewer than 183 days in the year

U Choice of doctors and hospitals: You can go to any doctor and hospital, but the cost may be lower if you choose a provider that has a contract with the MSA plan to treat its enrollees. If the MSA offers this option (and not all do), you can ask the plan for a list of providers.

U Out-of-pocket costs: This type of Medicare Advantage plan has no premium (aside from the Part B premium) and no co-pays. You pay the full cost of a medical service out of the money deposited in your health savings account. After this money is used up, you pay 100 percent out of pocket until you meet your deductible. The account deposit and deductible amounts vary from plan to plan. For example, if the deposit is $1,500 and the deductible is $4,000, your maximum out-of-pocket expenses in the year would be $2,500. (Some other examples for account deposits/deductibles in 2008 include: $1,000/$2,750; $1,250/$2,275; $1,300/$3,000; $1,575/$5,000.)

As long as you use the money in your account to pay for services that are covered by traditional Medicare, they count toward your deductible. After meeting the deductible, you pay no more for the rest of the year. If you don’t use all the money in your account, the balance rolls over and is yours to use the following year — regardless of whether you enroll in the same plan or another plan.

U Extra benefits: You’re free to use the money in your account for

Services not covered by Medicare (for example, routine eye and hearing exams), but these payments don’t count toward your deductible.

U Taxes: MSA accounts aren’t taxed, as long as they’re used for what the IRS calls "qualified medical expenses." Each year you must report your account withdrawals to the IRS, using Forms 1040 and 8853, even if you aren’t otherwise required to file an income tax return.

U Prescription drugs: MSA plans don’t cover prescription drugs. You can enroll in a stand-alone Part D plan to receive drug coverage. You can use your MSA account to pay for your Part D premiums and co-pays, but these expenses don’t count toward your MSA deductible.

Special Needs Plans (SNPs)

Special Needs Plans are relatively new additions to the Medicare Advantage program and aren’t available in all areas. They’re similar in structure to HMOs or PPOs (which I describe earlier in this chapter), but each individual SNP serves people in only one of the following specific categories:

U People who live in institutions (such as nursing homes)

U People who are eligible for both Medicare and Medicaid

U People who have at least one chronic or disabling condition (such as congestive heart failure, mental illness, diabetes, or HIV/AIDS)

I cover SNPs in more detail in Chapter 18. Here are their key features:

U Eligibility: You must have Medicare Parts A and B and live in the service area of your selected plan. To be accepted into an SNP, you must fall into the single category (one of the three previously described) that the plan serves. You can’t join an SNP if you have end-stage renal disease (ESRD), unless the plan specifically offers care for this condition.

U Choice of doctors and hospitals: If the SNP works like an HMO, you must go to the doctors and hospitals within the plan’s provider network, except in emergencies or for urgently needed care, and you need a primary care doctor to refer you to a specialist. If the SNP works like a PPO, you can go out-of-network for a higher cost and don’t need a referral to see a specialist. The plan may assign a care manager to help coordinate your needs for healthcare and other services in the community.

U Out-of-pocket costs: The plan you select determines whether you pay a premium in addition to the Part B premium. Co-pays for specific services are often less, but sometimes higher, than those in traditional Medicare. Some plans set a limit on out-of-pocket spending in the year, usually on specified services. If your plan requires you to see only in-network providers, going outside of it would make you responsible for the full cost of treatment, except in emergencies or for urgently needed care. If you have Medicaid as well as Medicare, your Medicaid program may not pay the SNP’s premium (if it has one), and you may pay different co-pays than those charged in traditional Medicare and Medicaid.

U Extra benefits: SNPs come with a built-in extra benefit in that they focus on your special circumstances or health condition and coordinate the services you need accordingly. Some plans offer vision, hearing, and/ or dental services (though the extent of this coverage varies a great deal among plans); routine checkups; and other extras, like health club memberships or fitness classes. These bonuses are usually reflected in higher premiums.

U Prescription drugs: All SNPs must offer prescription drug coverage.

Three other types of Medicare health plans

Three types of plans don’t fall within traditional Medicare or the Medicare Advantage program and aren’t available in all parts of the country:

W Medicare Cost plans: These plans work like HMOs (which I describe earlier in this chapter), but, unlike MA plans, you can join a Medicare Cost plan if you have only Medicare Part B. If you go to doctors and hospitals outside of the plan’s provider network for Medicare-covered services, traditional Medicare pays for your services, leaving you responsible for paying the usual costs and deductibles that apply in traditional Medicare. You can join a Medicare Cost plan at any time (if it’s accepting new members), and you can also disenroll from it and return to traditional Medicare at any time. If the plan doesn’t offer prescription drugs, you can enroll in a stand-alone Part D plan.

U Programs of All-Inclusive Care for the Elderly (PACE): These plans combine medical, social, and long-term care for frail people age 55 and older who are eligible for nursing home care but live in the community. All of them cover prescription drugs. PACE programs are covered in more detail in Chapter 18.

U Medicare demonstration and pilot programs: These are special projects that Medicare uses from time to time in specific parts of the country to test improvements in Medicare health coverage. If you want to know whether any demos or pilots are available in your area and how they work, call Medicare or your State Health Insurance Assistance Program (SHIP). See Appendix B for contact information.

Deciding between Traditional Medicare and a Private Medicare Health Plan

Knowing the key differences among Medicare’s various health delivery systems — the traditional program and each type of private health plan, as described in the previous section — is essential in deciding which one to choose. Only you can make that decision. However, in the following sections, I highlight broader points to keep in mind when considering whether traditional Medicare or a private health plan is right for you. (I exclude PACE plans and demonstration or pilot programs here because their availability is limited.) I also touch on a situation that may not allow you a personal choice — being in a specific health plan chosen by an employer or union.

Weighing the systems

When you join Medicare and intend to rely on it for your medical needs (that is, if you aren’t going to be receiving full benefits from elsewhere, such as an employer or union health plan), you automatically receive your care from the traditional Medicare program Unless You specifically choose to switch to one of Medicare’s private health plans. Similarly, if you’re already in either traditional Medicare or one of the private health plans, you remain in that plan Unless You take action to switch. In other words, you make the call.

Usually you can make this switch only during the annual open enrollment period from January 1 to March 31. (If you have Part D drug coverage, you also have from November 15 to December 31, as explained in Chapter 17.) Medicare allows some special circumstances for changing at other times of the year (see Chapter 17 for details). Also, you may have an opportunity to change your mind about the plan you join in certain situations, which I cover later in this chapter. Otherwise, you may find yourself locked into your choice, whether traditional Medicare or a private plan, for a whole year. So taking some time to consider which system you want is invaluable.

When making your decision, it may help to consider a wider perspective — how traditional Medicare and the Medicare Advantage program stack up generally in delivering healthcare. I take a big picture standpoint in the next several sections to touch on a range of issues: overall costs, premiums, co-pays, the long-term stability of costs and care, choice of providers and whether care is coordinated, extra benefits, and geographical service areas.

Thinking through these issues, and applying your personal preferences, enables you to settle on the Medicare system that works best for you. If you choose to go with a private health plan, see the later section "Comparing Medicare’s Private Health Plans and Making Your Pick" for details on comparing individual plans in your area. You can also use the online search tool suggested in that section to compare the details of individual plans with traditional Medicare’s standard offerings.

Overall costs

On the whole, most private plans offer lower costs to the consumer — sometimes charging no extra premiums — than traditional Medicare, for two reasons:

U Managed care plans (HMOs, PPOs, SNPs, and Medicare Cost plans) keep costs low by restricting care to their provider networks or by charging enrollees more to go out of those networks. They may also require enrollees to ask for prior authorization before covering certain kinds of treatment.

U Since a change in the law in 2003, Medicare has paid the private plans more on average for enrollees’ care than it pays for people enrolled in the traditional system. The extra payments allow the plans to charge enrollees less and/or offer better benefits than traditional Medicare.

(This fact accounts for most of the advantages in the Medicare Advantage system, but these extras could be much reduced if Congress acts to remove the extra payments, as some lawmakers and consumer groups are pushing for. I touch on this possibility in Chapter 21.)

JttNG/ However, Medicare’s private plans may not be a less expensive option for everyone. The Government Accountability Office, which investigates public spending for Congress, recently reported that private plans generally charge enrollees more than traditional Medicare for services used by people with greater healthcare needs — those who require more (or longer) stays in hospitals and skilled nursing facilities or who use home healthcare services.

Premium costs

Many people in traditional Medicare pay three premiums: one for Part B, one for prescription drug coverage (Part D), and one for a Medigap supplemental insurance policy (see Chapter 1 for the basics of Medigap). Medigap insurance can’t be used to cover out-of-pocket expenses in private plans, so dropping that premium to join one may save you money. But unless you have a private health plan that provides drug coverage and charges no premium of its own (as some do), you still pay three premiums — for Part B, for Part D, and for the health plan itself.

Co-pay costs

Private plans usually charge fixed dollar co-pays for doctor visits, which may be less expensive and more convenient than the percentage of the cost that traditional Medicare charges. But in comparing all plans, look carefully at the hospital co-pays. Traditional Medicare has a standard Deductible ($1,024 in 2008), which is the limit you’d pay whether you’re in the hospital for one day or up to 60 days in a benefit period. (I explain hospital benefit periods in Chapter 1.) The private plans usually charge a daily co-pay for a certain number of days in the hospital and often no co-pays between that number and up to 90 days or more. If you’re in the hospital for five days and your plan charges a co-pay of $100 a day for the first six days, your bill would be $500 — or less than half what you’d pay under traditional Medicare at 2008 rates. But if the plan charges $250 a day, the bill for five days would be $1,250 — or $226 more than traditional Medicare.

Furthermore, if you need to go back into the hospital within 60 days of being discharged, you won’t pay anything under traditional Medicare, because the deductible you’ve already paid for this benefit period covers your readmission stay. But under a private plan, you’re charged new daily co-pays for the number of days specified by the plan.

You can purchase a Medigap supplementary policy that pays your hospital deductible, Part B deductible, and co-pays in traditional Medicare, making your costs more predictable. Under Medicare rules, you can’t use Medigap to cover out-of-pocket expenses in a private health plan.

Cost and benefit stability

Private plans can change their costs and benefits each year — for better or for worse. Traditional Medicare is more stable, but it increases the Part B and hospital deductibles each year, and the 20 percent coinsurance it charges for most services also tends to rise as healthcare costs in general go up. Services that traditional Medicare covers generally don’t change, although from time to time new ones are added.

Care stability

JttNG/ Traditional Medicare is there, year after year. Private health plans can choose annually whether to stay in Medicare or withdraw, or whether to enter or exit a particular service area. Occasionally Medicare doesn’t renew a particular plan’s contract. If any such changes occur, affected enrollees are notified in advance and can switch to another private plan or to traditional Medicare, but this change can be a disrupting experience.

Provider choice

The main reason people give for choosing traditional Medicare (or staying in it) is that they can go to any doctor or hospital they please. Or at least any that accept Medicare patients, and most providers still do. In contrast, the Medicare Advantage plans that offer managed care limit the choice of providers to those in their networks. However, this may be considered a benefit rather than a restriction if care is properly coordinated, as explained in the next section.

The growth of PFFS plans in recent years offers an alternative to managed care in that PFFS plans allow you to go to any doctors or hospitals that accept their payment terms. That’s fine if all the providers you want in your area accept the terms. But not all do, and it’s not easy to find out which ones accept a PFFS plan’s terms in advance of joining it.

Care coordination

Managed care has generally gotten a bad rap, because many people see it as too restrictive, especially in terms of provider choice. But when care is coordinated properly, as it’s supposed to be in HMOs, SNPs, and Medicare Cost plans, it can be of great benefit to the consumer. Because your care is handled and monitored by a single local system, you’re more likely to be encouraged to get tests and screenings early enough to prevent serious health problems later on, and less likely to be prescribed drugs that may interact badly with each other, for example. PPOs may offer elements of coordinated care, but not if you exercise your right to go to out-of-network providers or see specialists without a referral. Traditional Medicare, PFFS, and MSA plans don’t feature coordination of care.

Extra benefits

All private plans must provide the same medical services as traditional Medicare. But they can also include extra benefits in their packages that are well worth having. Some plans with these extras don’t charge higher premiums, but most do — often quite a lot more. Look at any extra benefits carefully when comparing plans, because some provide significant coverage and others are very limited.

Geographical area

Considering your geographic location is important if you travel a lot or live in another state for part of the year. Traditional Medicare covers you anywhere in the U. S.; so do PFFS plans (at least in theory) and MSAs. However, HMOs, local PPOs, SNPs, and Medicare Cost plans require you to either go to providers within their local service areas or get preapproval to go outside the network. In a regional PPO, you can go to providers throughout the service region (sometimes several adjacent states) or get preapproval to go outside the network. Fortunately, all plans must cover emergency treatment or urgently needed care anywhere in the country. Some Medigap policies and health plans also cover emergency care abroad.

Recognizing when you may not have a choice

You may not be free to make a choice — either between traditional Medicare and the private plan system or among the private plans themselves — if you have health coverage from a current or former employer or union. Following are some of the ways this limitation can occur:

W Your current plan is a special one offered only to employees or retirees of the employer or union that sponsors it.

U Your current plan pays the premiums for a Medigap supplementary insurance policy. (This type of policy can be used only with traditional Medicare, not with a Medicare Advantage plan.)

Your current plan gives you coverage under a specific Medicare Advantage plan — an HMO, PPO, PFFS, or an MSA plan — meaning you can’t also be enrolled in the traditional Medicare program or any other MA plan.

JttNG/ Be aware that if you enroll in an alternative plan (unless it’s an alternative specifically offered by your employer or union) you may automatically lose your current coverage for you and your dependents and may not be able to get it back. Always check with your current plan’s benefits administrator before taking this step so you know the consequences.

Some people in this situation are faced with a real dilemma. For example, an increasing number of employers and unions are contracting with Medicare PFFS plans to cover their retirees. This move makes sense to sponsoring organizations with retirees all over the country, because in theory PFFS enrollees can go to doctors or hospitals anywhere. But some retirees have found that the only providers that accept their PFFS plan are far from their homes. If this Catch-22 happens to you, you can either put up with the plan or give up the retiree health benefit you’ve paid into for years. But first, why not holler loudly to the administrators of your employer or union plan to let them know what’s going on and see whether they can fix it?

Comparing Medicare’s Private Health Plans and Making Your Pick

The different types of Medicare private health plans (see the earlier section "Medicare Advantage plans" for details on each) aren’t just single plans. Rather, each type is offered by a number of different insurers. And a single insurer may offer several plans in one or more of these categories. The result? A lot of different plans to choose from, each with its own mix of costs and benefits.

I’m not going to pretend that making this choice is necessarily easy. If you’ve had experience making two or three plan choices under employer coverage in the past, you know the score. Well, sort of — deciding between two or three plans pales before the choices in Medicare. And if you’ve never had to choose a plan before, the number and range of choices may come as a big shock. After all, you’re not comparing apples to apples here. I mean, how do you compare one plan’s flat dollar co-pay for visiting a doctor with another plan’s percentage of the cost? How do you figure the trade-off between a relatively high co-pay for a hospital stay against a low premium?

Still, the difficulty of making that choice is no argument for not comparing plans. Whichever plan you choose may be a bit of a gamble, but insurance always is. And taking a hard look at the differences among the plans available to you makes your final decision an informed one. Regardless of the outcome, you can know you gave it your best shot.

In the following sections, I delve into how many private health plan choices you may face. Then I explain how to compare the details of the ones that interest you — either by making an online search that I walk you through, step by step, or by obtaining personal help. I also suggest ways of using this information to choose a final plan. Finally, I explain three circumstances in which you may be able to change your mind after enrollment and switch to traditional Medicare.

Determining how many plan choices you have

The number of Medicare private health plans for you to choose from depends very much on where you live. If you live in a heavily populated place, you probably have at least 50 plans available to you, including all the different types of Medicare plans. If you live in a very rural area, fewer than 15 plans may be available, and you may have far less choice among plan types. Rural areas often have no HMOs, local PPOs, or SNPs. They generally have one or two regional PPOs, one MSA plan, and a vast majority of PFFS plans.

Not all of these plans include drug coverage, so if you’re looking for a plan that combines medical and drug benefits in one package, this preference reduces your number of plan choices.

You can get a very rough idea of how many Medicare health plans are available to you by looking at your Medicare & You Handbook that Medicare sends out to all beneficiaries in October with information for the following year. Flip toward the back of the book to find a list of health plans in your state. (You can also read Medicare & You Online at Www. medicare. gov.)

However, you can’t always tell from the handbook which plans are available in your neck of the woods. Plans’ service areas may be described as being in select counties, or in a particular region of your state without specifying its borders. In other words, some of the plans listed may not operate in your zip code at all. What’s more, the handbook’s list gives only scant details about the plans — far too little info to make a reasoned choice among them. Fortunately, a better resource exists. Keep reading!

Finding a list of plans online

The fastest and most effective way of finding out your Medicare health plan options is to go to the Web site Medicare provides for this purpose. This useful tool allows to you compare plans head-to-head. (If you don’t have access to the Internet, fast-forward to the section "Getting personal help to compare plans" later in this chapter.)

To navigate the Web site, follow these steps, which represent consecutive pages on-screen:

1. On the Www. medicare. gov home page, under Search Tools, click "Compare Health Plans and Medigap Policies in Your Area."

2. In the box on the left-hand side, click "Find & Compare Health Plans."

3. Click "Begin General Plan Search" on the right.

4. Enter your zip code, ignore the request for age and health status, answer the following questions, and click "Continue."

5. Read this page if you want to review the details you’ve provided or see the general information offered, then click "Continue."

6. Click "Continue to Plan List" to compare only the health plans’ medical benefits at this stage. You can compare the plans’ drug coverage later.

7. Examine the list of all the Medicare health plans available in your area by scrolling down the page.

The total number of available plans appears at the top. Table 9-2 gives a few examples of the kind of broad information, labeled Plan Summary, you’ll encounter.

Table 9-2 Sample Plan Summary from Medicare’s

Plan Comparison Tool

As you can see in Table 9-2, the Plan Summary page gives a quick snapshot of each plan. The page shows at a glance the plan’s name, its type, its premium (in addition to the Part B premium), and whether it includes drug coverage, restricts doctor choice, or covers vision/dental services and physical exams.

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One column that appears in the Plan Summary on-screen, but is excluded in Table 9-2, is headed "Estimated Annual Cost for People Like You." This is a very rough estimate based on any information you give as to your age and health status in Step 4 of the previous list. A dollar amount is shown, even if you haven’t provided this detail. This tool doesn’t (and can’t!) provide a reliable guide to your out-of-pocket medical expenses over the year in any plan.

The plan descriptions in Table 9-2 are only examples. Plenty of plans within each type charge premiums higher or lower than those shown, or vary in their inclusion of drug coverage and extra benefits. The only type that’s always the same is the Original Medicare row, which shows details that are standard to the traditional Medicare program.

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If you want, you can cut down the number of plans on-screen to show only the kind you’re looking for. Go to the top of the page and click the "Show" button next to Select Criteria to Reduce Number of Plans Shown (optional). A menu of options will appear. Click the small box next to each kind of plan you want to see — for example, "Plans that include drug coverage." Then click "Apply Limits."

Be cautious of using this device to lessen the number of plans. For example, if you indicate that you want to see only plans that include drug coverage, you automatically exclude the traditional Medicare program from the list — yet it may be very useful to know what this program offers, as a kind of yardstick, when you’re comparing specific medical benefits among plans. Similarly, if you specify a premium limit, you exclude all plans with premiums over that dollar amount. So you don’t see plans that overall may give you a better deal — for example, somewhat higher premiums but lower co-pays. However, if you’re looking specifically for an SNP or an MSA, checking those options reduces the number of plans that appear on-screen to those you wish to see.

Digging for plan details

After obtaining your Medicare plan options (see the preceding section for tips on doing so), you’re now ready to look at the nitty-gritty details necessary to compare plans properly. These details include what the plan charges for visits to a primary care doctor or specialist, stays in a hospital, having an X-ray, or using an ambulance. Clicking any of the plan names in the left-hand column on the list brings up all of these details, and many more, for that plan.

Each details page provides a lot of information. Here are some guidelines to help you sort through it all:

V Comparing plans’ benefits side by side is useful. Fortunately, you can do so for up to three plans at a time. On the main list page, click the little box that appears alongside the name of each plan you want to see, then click "Compare" at the top or bottom of the page.

The three-plan comparison device is also very useful for comparing details of the traditional Medicare program (always called Original Medicare on this site) with some of the private health plans you’re considering. Scroll down the main plan list until you see Original Medicare and click the box beside it.

V The first chunk of information you see for any private plan is a quality assessment titled Plan Ratings. This section features stars, ranging from one (poor) to five (excellent), to grade how well the plan performs in categories like Getting Care from Your Doctors and Specialists and Managing Chronic Conditions. Select the "Click to view more details on Plan Ratings" link to see how Medicare arrived at these ratings.

This information can be useful in deciding which plans to avoid or in breaking a tie after whittling down your plan options to just two or three.

V In the next section, headed Important Information, you can see the plan’s monthly premium, as well as if you have a choice of doctors and hospitals, need a referral to see a specialist, or must limit yourself to the plan’s provider network. Look to see if the plan sets a cap on your out-of-pocket expenses — but be aware that this limit may apply only to certain services. You need to call the plan to find out which ones count.

V Pay special attention to the section headed Inpatient Care. Plans vary a great deal in the co-pays they charge for hospital stays — sometimes by hundreds of dollars. You should also compare these charges with the hospital deductible required under traditional Medicare. Look to see if you or your doctor must notify the plan before checking into the hospital for a nonemergency surgery or treatment.

V The Outpatient Care section gives details of costs to visit doctors and specialists, have outpatient surgery, or use an ambulance. It also states whether the payment method is a flat co-pay or a percentage of the cost. The following section gives similar details for outpatient tests, X-rays, lab services, and medical equipment (like wheelchairs). Look to see if you’re required to ask the plan for prior authorization before receiving any of the services listed in this section.

V If the plan includes Part D prescription drug coverage in its package, details appear in the Additional Benefits section. You can see lots of stuff here about the plan’s formulary, deductible, and co-pays for different kinds of drugs.

Here’s a special tip: Ignore these details! It’s impossible to tell what your drugs will cost under the plan from this information, or if they’ll be covered. Instead, you need to do a different search according to the Specific Drugs you take. You can do this by going back and entering your drugs, their dosages, and frequency in Step 6, and then clicking on "View Drug Benefits" at the top of the main page. Or you can follow the more detailed instructions for comparing drug plans on Medicare’s Part D plan finder tool that I walk you through in Chapter 10. Either way, you’ll find out more precisely what your out-of-pocket drug expenses would be over the whole year in a plan.

V If the plan includes coverage for extra services — such as dental, hearing, and eye care — these details appear at the bottom of the Additional Benefits list. You may notice that some co-pays are given for Medicare-covered services. Traditional Medicare provides for a few medically justified services in these areas — for example, eye exams for people who have diabetes or are at high risk for glaucoma; eye glasses for people who’ve had cataract surgery; hearing tests for people who may need medical treatment as a result; and dental work required for a medical procedure, such as jaw surgery after an accident. But the private plan may offer checkups and procedures (like teeth cleaning) that aren’t covered by traditional Medicare.

Getting personal help to compare plans

If you don’t have access to the Internet, or just don’t feel up to doing an online search yourself, you can still get the information you need to compare Medicare health plans properly. These alternatives include the following:

V Asking a family member or a friend to do an online search for you

V Calling the Medicare help line, your State Health Insurance Assistance Program (SHIP), or your Area Agency on Aging — which all give free help

V Talking to trained volunteers from a consumer group or senior center

These sources are the same as the ones I explain in Chapter 10′s "Finding Personal Help to Compare Plans" section. So go there for details and contact information.

Watching out for hard-sell marketing pressures and scams

Of course, you can obtain details in ways other than the options I mention in the previous sections. For example,

V You may receive advertising materials from Medicare health plans through the mail.

V You may chat with a sales representative by phone or at a pharmacy, shopping mall, or senior center.

V You may consult an independent insurance agent or broker.

Just remember that fancy direct mail pieces and energetic sales reps are pitching the health plan they’re supposed to sell. They’re not going to compare their plan point by point with their competitors’ plans! The same is true for some independent insurance agents, because they’re paid

Higher commissions for some plans than others. So the plan they pitch may not be the right one for you.

JttNG/ Selling Medicare health plans is a ferociously competitive business — so stay on your guard against being pressured into buying a plan you don’t want or don’t understand fully. Yes, regrettably, you can be persuaded into buying a plan that’s not right for you! That’s why I urge you to read Chapter 11, in which I explain how to protect yourself against unethical hard-sell tactics, as well as downright illegal scams. There, I break down Medicare’s marketing rules for plans, a list of matters to think about and check out before enrolling in a plan, and actions you can take if you’re misled into joining a plan you don’t want or understand.

Asking questions before you make your final choice

If you’re here, I’m assuming you’ve now decided on a Medicare health plan for your medical care rather than traditional Medicare, and also that you’ve narrowed your plan choices to a manageable two, three, or four. Now all you need to do is get down to that final one.

Getting all of your information in order helps a great deal. If you research plans using Medicare’s online comparison tool, you can print out the details of the few that interest you. If you call the Medicare help line at 800-633-4227 for the same information, you can ask the customer representative to mail you printouts for the plans you want to consider. You can also call the plans to ask for their info packets or visit their Web sites.

After you have this information, notice how the options can become tons clearer when you write down the key details alongside each other. The following questions are also reproduced in Worksheet 3 in Appendix A, along with spaces for writing out the answers for up to four plans. In the following list, I explain what action to take to find out specific answers to some of the questions. In all other cases, you can find the answers in your Medicare printouts, in the plan’s info packet, or on its Web site.

Dive into the decision-making process by asking the following:

V Will the providers (doctors and hospitals) that I prefer accept this plan?

You can obtain provider network lists from HMOs, PPOs, SNPs, and Medicare Cost plans by mail on request or from their Web sites. In the case of PFFS plans, you need to ask your local doctors and hospitals.

V Will this plan allow me to go to out-of-network providers for a higher co-pay?

V Will this plan cover my Nonemergency Healthcare needs outside of my home area?

In the case of HMOs, PPOs, SNPs, and Medicare Cost plans, you have to ask the plan precisely what its service area is, and in what circumstances it may cover treatment outside that region. (Information on service area boundaries isn’t given on the Medicare Web site or in the Medicare & You Handbook.) PFFS and MSA plans don’t have defined service areas.

V What will my fixed costs (monthly premium on top of Part B premium; annual deductible in the case of an MSA) be in this plan?

V Does this plan put a limit on my out-of-pocket expenses in a year?

You can get the cap amount from Medicare, the plan’s Web site, or the plan’s brochure. But you need to call the plan to find out which services count toward the cap.

V What will I pay to visit my primary care doctor in this plan?

V What will I pay to visit a specialist in this plan?

V What will I pay to stay in a hospital in this plan?

V What are this plan’s ratings for quality of care?

You can only find this information on Medicare’s online health plan

Finder or by calling the Medicare help line (800-633-4227).

V Does this plan offer benefits for vision, hearing, or dental care?

V Does this plan offer preventive care (screenings, scans, tests) that meet my needs?

V Does this plan cover routine physical exams?

Notice one question missing from this list: Does this plan cover prescription

Drugs? Yes, it’s an important question. But, as I explain earlier in this chapter, the type of Medicare health plan you choose directly affects how you can get drug coverage. So remember that

V If one or more of the health plans on your shortlist includes prescription drugs in its benefit package, you need to compare the drug coverage details separately.

V If you’re thinking about an HMO or PPO that doesn’t include drug coverage, you can’t add a stand-alone Part D plan to it. So if you want drug coverage, strike this health plan off your shortlist.

V If you’re pondering a PFFS, MSA, or Medicare Cost plan that doesn’t include drug coverage, you can enroll in a stand-alone Part D plan.

V If you’re considering traditional Medicare, which doesn’t include outpatient drugs, you can enroll in a stand-alone Part D plan.

Chapter 10 shows you how to compare drug plans effectively. Afterward, you can use Worksheet 2 in Appendix A to note the differences. Then, you can use this info together with Worksheet 3 to see which plan works best for you in terms of medical And Drug coverage. When you reach that point, it’s time to enroll, as explained in Chapter 12.

Knowing if you can make a change

What if you find, after you’re in a Medicare private health plan, that you don’t like it? Medicare allows you to switch plans outside of the regular open enrollment period only for several specific reasons, and unhappiness isn’t one of them! However, here are some escape clauses (which are all explained in more detail in Chapter 17):

V If your coverage in a Medicare health plan starts January 1: You have the right to switch to traditional Medicare or to another health plan during the first three months of the year, through March 31. However, you can’t use this opportunity to drop or add drug coverage.

V If you receive Extra Help: You can change to another Medicare health plan that offers drug coverage, or to traditional Medicare and a standalone drug plan, at any time during the year.

V If you joined a Medicare health plan as soon as you enrolled in Medicare at age 65: Medicare considers this first year in the program as a trial period. So you have the right to disenroll from the plan at any time within 12 months of first receiving coverage from it in order to switch to traditional Medicare and a stand-alone Part D plan. You also have a guaranteed right to buy a Medigap policy within 63 days of your plan coverage ending.

V If this is your first time in a Medicare health plan and you dropped a Medigap policy to join it: You have the right to return to traditional Medicare and be reinstated in Medigap at any time during your first 12 months in this plan.

V If you joined a Medicare Cost plan: You have the right to disenroll from it and switch to traditional Medicare at any time. If you received drug coverage from this plan, you can also switch to a stand-alone Part D plan at the same time.

Chapter 10

In This Chapter

Testing out your thoughts and assumptions as predictions Exploring theories and gathering information Designing and recording your experiments

■ When, CBT can seem like common sense. Behavioural experiments Are particularly good examples of the common-sense side of CBT. If you want to know whether your hunch about reality is accurate, or your way of looking at something is helpful, put it to a test in reality.

This chapter is an introduction to behavioural experiments, a key CBT strategy. We include in this chapter an overview of several behavioural experiments that you can try out for yourself. We also give you examples of these experiments in action. As with the other examples we use in this book, try to look for Anything Useful you can draw from them. Try not to home in too much on how the examples differ from your specific problem. Instead, focus on what you have in common with the examples and work from there to apply the techniques to your own problems.

Even in a ‘talking treatment’ like CBT, actions speak louder than words. Aaron Beck, founder of cognitive therapy, encourages a therapeutic perspective where client and therapist work on ‘being scientific together’. Beck emphasises that testing your thoughts in reality, rather than simply talking about them, underpins effective therapy.

Seeing (or \loursel(: Reasons (or doing Behavioural Experiments

The proof of the pudding is in the eating. The same can be said of your assumptions, behaviours, beliefs, and predictions about yourself and the world around you. Use experiments to test out the Truth About your beliefs and to assess the Usefulness Of your behaviours.

You can use behavioural experiments in the following ways:

To test the validity of a thought or belief that you hold about yourself, other people, or the world.

To test the validity of an alternative thought or belief.

To discover the effects that mental or behavioural activities have on your difficulties.

To gather evidence in order to clarify the nature of your problem.

Living according to a set of beliefs because you think they’re true and helpful is both easy and common. You can also easily stick to familiar ways of behaving because you Think That they keep you safe from feared events, or that they help you to achieve certain goals. An example of this may be holding a belief that other people are out to find fault with you – with this thought in mind, you then work hard to hide your mistakes and shortcomings.

The beauty of a behavioural experiment is that you often find that your worst imagined scenarios don’t happen, or that you deal with such situations effectively when, or even if, they do occur.

We may be stating the obvious, but change can be less daunting if you keep in mind that you can always return to your old ways of thinking about things if the new ways don’t seem any better. If your old ways seem to be the best option, nothing’s stopping you from going back to them. The trick is to prepare yourself to try out new strategies and to give them a chance before returning to your former ways. Find out what works best for you and your particular situation.

Testing Out Predictions

When testing out your predictions, strive to get Unambiguous disconfirmation, In so far as you can. Unambiguous disconfirmation means discovering Conclusively That your fears Don’t Come true, whether or not you actually do something to prevent them occurring. An example of unambiguous disconfirmation

May be finding out that your dizziness is caused by anxiety, and that you won’t collapse even if you don’t sit down or hold on to something.

Go through the following four steps to devise a behavioural experiment:

1. Describe your problem.

Write down the nature of your problem and include your Safety behaviours (things you do to try to prevent your feared catastrophe – head to Chapter 7 for loads more on safety behaviour). Phrase the problem in your own words and make a note of how the problem negatively affects your life.

2. Formulate your prediction.

Decide what you think will happen if you try out a new way of thinking or behaving in real life.

3. Execute an experiment.

Think of a way of putting a new belief or behaviour to the test in a real-life situation. Try to devise more than one way to test out your prediction.

4. Examine the results.

Look to see whether your prediction came true. If it didn’t, check out what you’ve learned from the results of the experiment.

You can rate the degree to which you believe a prediction will come true on a percentage between 0 and 100 at the start of your experiment. After you’ve done the experiment and processed your results, re-rate your conviction in the original prediction.

Take care not to use subtle ways of keeping your feared catastrophe at bay, such as doing experiments only when you feel ‘right’, are with ‘safe’ people, have Safety objects To hand (such as a mobile phone or a bottle of water), or are using safety behaviours (such as trying to control your anxiety with distraction or by gripping tightly to your steering wheel). Using these subtle safety measures during your exposure to a fear can leave you with the impression that you’ve had a narrow escape, rather than highlighting that your predicted fear didn’t come true.

For example, consider the following experiment, which Nadine initiates to examine her fear of rejection and social anxiety:

Describe the problem. Nadine’s afraid of people thinking negatively of her and of being rejected by her friends. In social situations, Nadine monitors her body language and censors what she says, taking great care not to cause offence. She often plans in advance what she’s going to say.

Formulate a prediction. Nadine predicts ‘If I express an opinion or disagree with my friends, they’ll like me less.’ She rates her conviction in this idea as 90 per cent.

Execute an experiment. For the next six social gatherings Nadine attends, she decides that she’ll speak up and try to offer an opinion. If at all possible, she’ll find a point on which to disagree with someone.

Examine the results. Nadine discovers that no one took exception to her saying more. In fact, two friends commented that it was nice to hear more about what she thought about things. Nadine re-rates her conviction in her original prediction as 40 per cent.

By conducting a behavioural experiment, Nadine observed that her feared prediction – ‘Others will like me less if I express my opinions’ – didn’t happen. This result gives Nadine the opportunity to change her behaviour according to the results of her experiment; therefore, to speak up more often. It also helps to reduce how much she believes the original prediction. Nadine can now adjust her thinking based on evidence gathered through the experiment.

Nigel used a behavioural experiment to test out his prediction that he wouldn’t enjoy engaging in social activities. Since self-isolating and disengaging from previously enjoyed activities promotes depression, Nigel really needs to understand the benefits of becoming more active. Nigel worked through an experiment as follows:

Describe the problem. Nigel’s depression typically leads to him having gloomy and pessimistic thoughts. He tends to avoid going out with his friends or doing any of his regular hobbies because he doesn’t feel like it these days. He believes that he won’t enjoy himself; therefore, there’s no point in trying any of these activities. (As we note in Chapter 10, self-isolation is one of the key ways in which depression is maintained.)

Formulate a prediction. Nigel chooses to experiment with the prediction ‘Even if I do go out, I won’t enjoy myself and I’ll end up feeling even worse once I get home.’ He rates his strength of conviction in this thought as 80 per cent.

Execute an experiment. Nigel plans to structure his week and to schedule two occasions to see friends. He also plans to spend two half-hour sessions riding his bike, which he used to enjoy. He rates each day over the next seven days in terms of his mood and of how much he enjoys his activities.

Examine the results. Nigel notices that he does get some enjoyment from seeing his friends, although less than he usually would. Although he doesn’t particularly enjoy his cycling and feels more tired than usual, he notes that he at least felt glad he had done something. He re-rates his conviction in his original prediction as 40 per cent, and decides to conduct further experiments to see whether his mood and energy levels improve over the next two weeks if he continues to be more active.

This experiment helped Nigel to see that he felt better for doing Something, Even if he didn’t enjoy cycling or socialising as much as he would when he wasn’t depressed. Noting these results can help Nigel to stick to a schedule of activity and ultimately help him to overcome his depression.

Seeking Evidence to See Which Theory Best Fits the Facts

The scientific principle known as Occam’s razor States that all things considered, the simplest theory is usually the best. Whichever theory explains a phenomenon most simply is the one a scientist adopts. When you want to test out a theory or idea you hold about yourself, others, or the world, developing an Alternative theory Is a good idea. This gives you the chance to disprove your original theory and to endorse the healthier alternative.

Some emotional problems don’t respond well to attempts to disprove a negative prediction. In such cases, you may be better off developing some Competing theories About what the problem actually is. You then devise experiments to gather more evidence and see which theory reflects reality most accurately.

For example, imagine that your boss never says a cheerful ‘good morning’ to you. You develop the following two theories:

I Theory A: ‘My boss doesn’t like me at all.’

I Theory B: ‘My boss isn’t friendly in the mornings and is a bit rude, but he’s like this to a lot of employees, not just me.’

You’re now in a position to gather evidence for whether theory A or B best explains the phenomenon of your boss failing to be cheerful towards you in the mornings.

A Theory Is just an idea or assumption that you hold, which to your mind, explains why something happens – a technical word for a simple concept.

Often, developing one additional theory to compete with your original theory is enough. However, you can develop more alternative theories if you think they may help you get to the bottom of what you’re experiencing. Taking the above example, you may have a third theory, such as ‘My boss is cheerful only with employees that he knows very well’, or even a fourth theory, such as ‘My boss is cheerful only with employees of the same rank as him or above him’.

Developing competing theories can be particularly helpful in the followings situations:

Dealing with predictions that may be months or years away from being proven. If you fear you’ll go to hell for having an intrusive thought about causing harm to someone, then this outcome is likely to be sometime away. Similarly, if you have Health anxiety And spend hours each day preoccupied with the idea that physical sensations in your body may be signs that you’ll become ill and die, you’re unlikely to know straightaway whether this will actually happen. With these kinds of catastrophic thoughts, you need to design experiments to help you gather evidence to support the theory that you have a worry or anxiety problem, rather than a damnation problem or terminal illness.

Dealing with beliefs that are impossible to prove or disprove conclusively. Perhaps you’re anxious about others having negative opinions of you. You cannot know for sure what other people think, but even if someone tells you that your fears are unfounded, you can never know with absolute certainty what he’s thinking. Similarly, if you have jealous thoughts that your partner desires someone else, but he reassures you otherwise, you may remain uncertain of his true feelings.

For both of these situations, you can employ the theory A or theory B strategy:

Design an experiment to gather evidence to support the idea that your jealous feelings are based on your jealous Thoughts (theory B), rather than on reality (theory A).

Similarly, devise an experiment to test out whether your original theory A that, ‘People don’t like me’, or alternative theory B that, ‘I often Think That people don’t like me because I’m so worried about others’ opinions of me that I end up seeing a lot of their behaviour as signs of dislike’, best explains your experiences in social situations.

Following is an example of how Alex used the competing theories approach to get a better understanding of his physical sensations. Originally, Alex assumed his theory that uncomfortable bodily sensations signalled the onset of a heart attack was correct. By testing this in practice, Alex was able to consider that an alternative theory – uncomfortable bodily sensations are a byproduct of anxiety – may be more accurate.

Describe the problem. Alex suffers from panic attacks. He feels hot and his heart races, sometimes out of the blue. When he feels these sensations, he fears he’s having a heart attack. Alex sits down to try to reduce the strain on his heart (an example of a safety behaviour). He goes out of his way to avoid situations in which he has experienced these symptoms.

Develop competing theories. Alex devises two theories about his raised heart rate:

• Theory A: ‘My heart beating quickly means I’m vulnerable to having a heart attack.’

• Theory B: ‘My heart beating quickly is a consequence of anxiety.’

Execute an experiment. Alex decides to deliberately confront situations that tend to trigger off his raised heart rate and to stay in them, Without sitting down, Until his anxiety reduces. He predicts that if theory B is correct, then his heart rate will reduce after his anxiety subsides and he can leave the situation without having come to any harm.

Examine the results. Alex finds that his heart rate does indeed reduce when he stays with his anxiety. He’s struck by what a difference this knowledge makes to his confidence, and that he’s not going to come to any harm from his raised heart rate when he resists the urge to sit down. He concludes that he can reasonably have about 70 per cent confidence in his new theory that his raised heart rate is a benign consequence of anxiety.

You can’t always prove conclusively that something isn’t so. However, you can experiment to see whether certain emotional states, and mental or behavioural activities, have a beneficial or detrimental effect on the kinds of thoughts that play on your mind.

Conducting Surveys

You can use the clipboard and pen of the survey-taker in your endeavours to tackle your problems, by designing and conducting your own survey. Surveys can be especially helpful in terms of getting more information about what the average person thinks, feels, or does.

We suggest you have more than one type of behavioural experiment in your repertoire. Surveys are very useful if you believe that your thoughts, physical sensations, or behaviours are out of the ordinary. If you have upsetting, intrusive thoughts and images, or experience urges to say socially unacceptable things (symptoms typical of obsessive-compulsive disorder, OCD), feel pulled to the edge of high places (as in vertigo), or get a sense of impending doom when you’re not in a familiar place (symptoms associated with agoraphobia), you may think that you’re the only person who ever feels this way. Use surveys to see whether other people have the same thoughts and urges. You’ll probably discover that other people experience the same things as you do. You may also discover that the symptoms you experience are actually less of a problem than the way you currently deal with them.

Henry suffers from OCD. His particular obsessional problem is related to frequent intrusive images of harm coming to his family. Henry’s convinced that he’s the only person in the world who gets such unpleasant and unwanted images entering his mind. Henry concludes that there’s something very different and wrong about him because he has such images. He tests his theory about his abnormality by conducting the following survey:

Describe the problem. Henry’s convinced that his intrusive thoughts about his family being hurt in a car accident are unusual, and mean that he has to protect his family by changing the image in his mind to them being happy at a party.

Formulate a prediction. Henry comes up with the prediction ‘No one will admit to having the kind of thoughts I Have’. He rates his strength of belief as 70 per cent.

Execute an experiment. Henry tests his perception that his images are abnormal by devising a checklist of intrusive thoughts and asking his friends and family members to tick any that they experience.

Examine the results. Henry’s surprised at the variety of thoughts that people report entering their minds. Henry concludes that perhaps his images aren’t so abnormal after all. He re-rates his conviction in his original prediction as 15 per cent. Henry also learns that other people simply discount their unpleasant images and don’t worry that they mean anything sinister.

Charlotte worries a lot about her health and the possibility of developing a life-threatening illness. Sometimes, Charlotte notices funny sensations in her body and instantly interprets them as signs of an undiagnosed disease. Charlotte assumes that no one else gets unusual bodily sensations from time to time.

Describe the problem. Charlotte worries that the bodily sensations she experiences are a sign of disease. She’s unsatisfied by frequent reassurance from her family doctor and husband. Charlotte’s problems are based partly on two ideas:

• Physical sensations must have a clear medical explanation.

• Any sensible person would seek an immediate explanation for the physical sensations she’s currently experiencing.

Formulate a prediction. Charlotte makes the following prediction: ‘Most people won’t have many physical sensations, and if they do they go immediately to see their doctor.’ She rates her strength of conviction in this idea as 80 per cent.

Execute an experiment. Charlotte devises a list of physical sensations, including many of those that she worries about herself. Her checklist requires people to tick whether they’ve ever experienced the sensation and to indicate how long they might leave it before consulting their doctor about such sensations. She asks ten people to fill out her questionnaire.

Examine the results. Charlotte’s shocked that many people reported experiencing some of the bodily sensations she described and stated that they’d leave going to their doctor for several days, or even weeks. Some people reported that they probably wouldn’t bother seeing their doctor at all regarding some sensations. Charlotte concludes that perhaps she’s worrying too much about her health, and plans to delay consulting her doctor when she next has unexplained physical sensations. Her strength of belief in her original prediction reduces to 30 per cent.

Making Observations

Observations can be an easier way of getting started with doing experiments to test out the validity of your thoughts. Observations usually involve collecting evidence related to a specific thought by watching other people in action.

You may assume, for example, that no one in their right mind would admit to not understanding an important point about a work procedure. If they did, they’d no doubt be ridiculed and promptly sacked on the basis of highlighting their incompetence.

Test this assumption by observing what other people actually Do. Behave like a scientist and gather evidence of others admitting lack of understanding, asking for clarification, or owning up to mistakes. Observe whether your predication that they’ll be ridiculed or fired is accurate. Making observations to gather evidence both for and against your assumptions is another way of behaving like a scientist.

Ensuring Successful Behavioural Experiments

To get the highest level of benefit when designing and carrying out behavioural experiments, keep the following in mind:

Ensure that the type of experiment you choose is appropriate. Make your experiments challenging enough for you to gain a sense of accomplishment from conducting them. Equally, take care to devise experiments that won’t overwhelm you.

Have a clear plan about how, when, and where (and with whom, if relevant) you plan to carry out your experiment.

Be clear and specific about what you want to find out from your experiment – ‘to see what happens’ is too vague.

Decide in advance how you’ll know whether your prediction comes true. For example, what are the clues that someone’s thinking critically of you?

Plan what you’ll do if your prediction comes true. For example, how do you respond assertively if someone is actually critical of you?

Use the behavioural experiments record sheet in this chapter to plan and record your experiment.

Consider what obstacles may interrupt your experiment and how you can overcome them.

When evaluating the outcome of your experiment, check that you’re not being biased (for example, discounting the positive or mind-reading, thinking errors we describe in Chapter 2) in the way you process your results.

Consider whether you rely on any (including subtle) safety behaviours. Safety behaviours can affect the results of your experiment or determine how confident you feel about the outcome – for example, thinking that you avoided collapsing by concentrating hard, rather than discovering conclusively that your feelings of dizziness are a result of anxiety, not imminent fainting.

Plan ways to consolidate what you discover from your experiment. For example, should you repeat the experiment, devise a new experiment, change your daily activities, or some other action?

Treating your negative and unhelpful thoughts with scepticism is a key to reducing their emotional impact. Experiments can help you to realise that many of your negative thoughts and predictions are not accurate in reality. Therefore, we suggest you take many of your negative thoughts with a pinch or more of salt.

Think about therapy as an experiment, rather than a lifelong commitment, especially at the beginning. By thinking in this manner, you can feel less under pressure and more able to approach therapy with an open mind.

Keeping Records of \lour Experiments

All good scientists keep records of their experiments. If you do the same, you can look back over your results in order to:

Draw conclusions.

Decide what kind of experiment you may want to conduct next in order to gather more information.

Remind yourself that many of your negative predictions won’t come true.

To help you keep records of your experiments, photocopy Figure 4-1, and use it as often as you like, following the instructions in the figure.

= O – C —. "O _^

Behavioural Experiment Record Sheet

R Date:

Guidance on carrying out a behavioural experiment: 1. Be clear and specific about the negative and alternative predictions you are testing. Rate your strength of conviction in the prediction or theory you are testing or evaluating. 2 Decide upon your experiment, and be as clear as you can be as to howyou will measure your results. 3. Record the results of your experiment, emphasizing clear, observable outcomes. 4. Evaluate the results of your experiment. Write down what these results suggest in terms of the accuracy of your predictions, or which theory the evidence supports. 5. Consider whether a further behavioural experiment might be helpful.

Don’t take our word for it…

This book’s full of suggestions on howto reduce and overcome emotional problems. If you’re sceptical about whether CBT can workforyou, you’re in very good company. However, loads of scientific evidence shows that CBT is more effective than all other psychotherapies.

So, CBT may well workforyou, but how can you tell? The answer is to consider applying a spe-cifictool ortechnique for a period of time as an experiment to see how the technique works for you. Depending on the outcome, you can then choose to do more, modify your approach, ortry something different.

Try to have a no-lose perspective on your experiments. If you do one experiment and it goes well, then great! However, if you plan an experiment but ultimately avoid doing it, you can at least identify the thoughts that blocked you. Even if your negative predictions turn out to be accurate, you have an oppor -

Tunity to see how well you cope – and very probably that it isn’t the end of the world – and then decide whether you need to take further action. The point is, you can always gather information that you can make into a useful experience.

Chapter 5

In This Chapter

► Giving and receiving electrons in ionic bonding

► Sharing electrons in covalent bonding

► Understanding molecular orbitals

► Shaping up molecules with VSEPR theory and hybridization

► Tugging at the idea of polarity

Any atoms are prone to public displays of affection, pressing themselves against WWW Other atoms in an intimate electronic embrace called Bonding. Atoms bond with one another by playing various games with their valence electrons. In this chapter, we describe the basic rules of those games.

Because valence electrons are so important to bonding, problems involving bonding sometimes make use of Electron dot structures, Symbols that represent valence electrons as dots surrounding an atom’s chemical symbol. You should be able to draw and interpret electron dot structures for atoms as shown in Figure 5-1. This figure shows the electron dot structures for elements in the periodic table’s first two rows; notice that the valence shells progressively fill moving from left to right. To determine the electron dot structure of any element, count the number of electrons in that element’s valence shell. Then draw that number of dots around the chemical symbol for the element. Chapter 4 describes some of the factors that determine whether atoms gain or lose electrons to form ions. You should make sure to understand those patterns before attacking this chapter.

Figure 5-1:

Electron dot structures

For elements in the first

Two rows of

The periodic table.

IA IIA IIIA IVA VA VIA VIIA VIIIA H – He:

■ • • •

Li • »Be» «B« »C» SIMS JO! IF! INeJ

Pairing Charges with Ionic Bonds

Atoms of some elements, like metals, can easily lose valence electrons to form Cations (atoms with positive charge) that have stable electron configurations. Atoms of other elements, like the halogens, can easily gain valence electrons to form Anions (atoms with negative charge) with stable electron configurations. Cations and anions experience Electrostatic attraction To one another because opposite charges attract. So, a cation will snuggle up to an anion, given the chance. This event is called Ionic bonding, And it happens because the energy of the ioni-cally bonded ions is lower than the energy of the ions when they are separated.

You can think of an ionic bond as resulting from the transfer of an electron from one atom to another, as shown in Figure 5-2 for sodium and chlorine. Metals (like sodium) tend to give up their electrons to nonmetals (like chlorine) because nonmetals are much more Electronegative (they more strongly attract electrons within a bond to themselves). The greater the difference in electronegativity between the two ions, the more Ionic (or completely uneven in sharing of electrons) is the bond that forms between them.

Figure 5-2:

The transfer of an electron from sodium to

Chlorine to Na – ^~\*Cl:-Na+ IClf

Form an •• ••

Ionic bond between the Na+ cation and the Cl-anion.

Although ions are often individual, charged atoms, there are also many examples of Polyatomic ions (charged particles made up of more than one atom). Examples of common polyatomic ions are ammonium, NH4+, and sulfate, SO42-. We cover polyatomic ions in detail in Chapter 6.

When cations and anions associate in ionic bonds, they form Ionic compounds. At room temperature, most ionic compounds are solid because of the strong electrostatic forces that hold together the ions within them. The ions in ionic solids tend to pack together in a Lattice, A highly organized, regular arrangement that allows for the maximum electrostatic interaction between anions and cations. The geometric details of the packing can differ among different ionic compounds, but a simple lattice structure is shown in Figure 5-3. Flip to Chapter 6 for full details on ionic compounds.

The strong electrostatic forces that hold together ionic lattices result in the high melting and boiling points that are common among ionic compounds (see Chapter 10 for general

Information on melting and boiling points). Although it may take a great deal of thermal energy to disrupt ionic bonds, ionic compounds are usually easily dissolved in water or in other Polar solvents (fluids made up of molecules that have unevenly distributed charge). When the solvent molecules are polar, they can engage in favorable interactions with the ions that help to compensate for disrupting the ionic bonds. For example, polar water molecules can interact well with both sodium cations (Na+) and chlorine anions (Cl-). Water molecules are polar because they have distinct and separate bits of positive and negative charge. Water molecules can orient their positive bits toward Cl – and their negative bits toward Na+. Positive charges attract negative charges and vice versa, so these kinds of interactions are favorable — they require less energy. So, water dissolves solid NaCl quite well because the water-ion interactions can compete with the (Na+)-(Cl-) interactions.

Figure 5-3:

The lattice structure of an ionic solid, sodium chloride.

Cl ‘

Q.

A.

When ionic compounds are melted or dissolved, so the individual ions can move about, the resulting liquid is a very good conductor of electricity. Ionic solids, however, are often poor conductors of electricity.

Salts Are a common variety of ionic compound. A salt is formed from the reaction between a base and an acid. For example, hydrochloric acid reacts with sodium hydroxide to form the salt sodium chloride and water:

HCl(a<7) + NaOH(ag) — NaCl(aq) + H2O(l)

Note that Aq Indicates that the substance is dissolved in water, in an Aqueous Solution.

Why do metals tend to form ionic compounds with nonmetals?

Metals are much less electronegative than nonmetals, meaning that they give up valence electrons much more easily. Nonmetals (especially group VIIA and

VIA nonmetals) very easily gain new valence electrons. So, metals and non-metals tend to form bonds in which the metal atoms entirely surrender valence electrons to the nonmetals. Bonds with extremely unequal electron-sharing are called ionic bonds.

1. What is the electron dot structure of potassium fluoride?

Solve It

2. The ionic compound lithium sulfide forms between the elements lithium and sulfur. In which direction are electrons transferred to form ionic bonds, and how many electrons are transferred?

Solve It

3. Magnesium chloride is dissolved into a beaker of water and a beaker of rubbing alcohol until no more compound will dissolve. Electrical circuits are set up for each beaker in which wires lead from a battery into the solution, and a separate set of wires leads from the solution to a light bulb. The bulb connected to the aqueous solution circuit glows more brightly than the bulb connected to the alcohol solution circuit. Why?

Solve It

Sharing Charge with Covalent Bonds

.«S)MS> Sometimes the way for atoms to reach their most stable, lowest-energy states is to share valence electrons. When atoms share valence electrons, we say that they are engaged in Covalent bonding. The very word Covalent Means "together in valence." Compared to ionic bonding, covalent bonding tends to occur between atoms of similar electronegativity, most especially between nonmetals.

Just as ionic bonds tend to form in such a way that both atoms end up with completely filled valence shells, the atoms involved in covalent bonds tend to share electrons in such a way that each ends up with a completely filled valence shell. The shared electrons are attracted to the nuclei of both atoms, forming the bond. The simplest and best studied covalent bond is the one formed between two hydrogen atoms, shown in Figure 5-4. Separately, each atom has only one electron with which to fill its 1 S Orbital. By forming a covalent bond, each atom lays claim to two electrons within the molecule of dihydrogen. The figure shows various ways in which a covalent bond can be represented, explicitly depicting the valence shells (a), by using electron dot structures (b), or by signifying a shared pair of electrons with a single line (c). The latter two ways to show bonding are referred to as Lewis structures.

Figure 5-4:

Three repre-

Sentations of the formation of a,, , .. .. …..

, . (b) H* + *H ->■ H! H

Covalent

Bond in dihydrogen.

^^^^^^ (c) H* + *H -»- H-H

Atoms can share more than a single pair of electrons. When atoms share two pairs of electrons, they are said to form a Double bond, And when they share three pairs of electrons they are said to form a Triple bond. Examples of double and triple bonds are shown with electron dot and line structures in Figure 5-5.

Figure 5-5:

The formation of double bonds in carbon dioxide and triple bonds in dinitrogen.

C – + 2 -o:

-c-o:

:mi::: n: (:n – n:)

A few guidelines can help you figure out the correct Lewis structure for a molecule if you know the molecule’s formula. As an example, we work out the Lewis structure of formaldehyde, CH2O (Figure 5-6 can help you follow along):

1. Add up all the valence electrons for all the atoms in the molecule.

These are the electrons you can use to build the structure. Account for any extra or missing electrons in the case of ions. For example, if you know your molecule has +2 charge, remember to subtract two from the total number of valence electrons. In the case of formaldehyde, C has four valence electrons, each H has one valence electron, and O has six valence electrons. The total number of valence electrons is 12.

2. Pick a "central" atom to serve as the anchor of your Lewis structure.

The central atom is usually one that can form the most bonds, which is often the atom with the most empty valence orbital slots to fill. In larger molecules, some trial-and-error may be involved in this step, but in smaller molecules, some choices are obviously better than others. For example, carbon is a better choice than hydrogen to be the central atom because carbon tends to form four bonds, whereas hydrogen tends to form only one bond. In the case of formaldehyde, carbon is the obvious first choice because it can form four bonds, while oxygen can form only two, and each hydrogen can form only one.

+

3. Connect the other, "outer" atoms to your central atom using single bonds only.

Each single bond counts for two electrons. In the case of formaldehyde, attach the single oxygen and each of the two hydrogen atoms to the central carbon atom.

4. Fill the valence shells of your outer atoms. Then put any remaining electrons on the central atom.

In our example, carbon and oxygen should each have eight electrons in their valence shells; each hydrogen atom should have two. However, by the time we fill the valence shells of our outer atoms (oxygen and the two hydrogens), we have used up our allotment of 12 electrons.

5. Check whether the central atom now has a full valence shell.

If the central atom has a full valence shell, then your Lewis structure is drawn properly — it’s formally correct even though it may not correspond to a real structure. If the central atom still has an incompletely filled valence shell, then use electron dots (nonbonding electrons) from outer atoms to create double and/or triple bonds to the central atom until the central atom’s valence shell is filled. Remember, each added bond requires two electrons. In the case of our formaldehyde molecule, we must create a double bond between carbon and one of the outer atoms. Oxygen is the only choice for a double-bond partner, because each hydrogen can accommodate only two electrons in its shell. So, we use two of the electrons assigned to oxygen to create a second bond with carbon.

Sometimes a covalent bond is formed in which one atom donates both electrons to the bond, with the other atom contributing no electrons. This kind of bond is called a Coordinate cova-lent bond. Atoms with lone pairs are capable of donating both electrons to a coordinate cova-lent bond. A Lone pair Consists of two electrons paired within the same orbital that aren’t used in bonding. Even though covalent bonding usually occurs between nonmetals, metals can engage in coordinate covalent bonding. Usually, the metal receives electrons from an electron donor called a Ligand.

1. C(4 e) + H(1 e) + H(1 e) + 0(6 e) = 12 e

2. Carbon is central atom; it can form more bonds (4) than 0, H.

: 0 :

*0*

Figure 5-6: 3. H C H

Putting

Together

A Lewis " C

Structure. / \ 4. H H

Sometimes a given set of atoms can covalently bond with each other in multiple ways to form a compound. This situation leads to something called Resonance. Each of the possible bonded structures is called a Resonance structure. The actual structure of the compound is a Resonance hybrid, A sort of average of all the resonance structures. For example, if two atoms are connected by a single bond in one resonance structure, and the same two atoms are connected by a double bond in a second resonance structure, then those atoms are connected by a bond in the resonance hybrid that is worth 1>2 single bonds. A common example of resonance is found in ozone, O3, shown in Figure 5-7.

Figure 5-7: :0*j0:j0j

Resonance structures of ozone, shown in two representations.

- +

^: 0"—0=0:

10=0—0: j

-+

+

Or

+

Q.

Draw a Lewis structure for propene, C3H6.

A. First, add up the total valence electrons. Each carbon contributes 4 electrons, and each hydrogen contributes 1, for a total of 18 valence electrons. Next, pick a central atom. The best choice is a carbon atom because carbon can form four bonds, more than any hydrogen. Connect the remaining atoms to the central carbon with single bonds. To connect all the atoms into one molecule, the central carbon must be connected to each of the two other carbon atoms. These connections use up 16 of the 18 valence

Electrons, leaving 2 electrons that you can place onto one of the carbon atoms. One carbon atom in the structure still requires two additional electrons to fill its valence shell. The only way to fill this shell is to create a carbon-carbon double bond. Only one arrangement of hydrogen atoms to the three carbons allows you to fill all the carbon valence shells, as you can see in the following figure:

HH

H — C — C = C

H

/

C

\

4. Bertholite is the common name for dichlo-rine, a toxic gas that has been used as a chemical weapon. Why is bertholite most certainly a covalently bonded compound? What is the most likely electron dot structure of this compound?

Solve It

5. When aluminum chloride salt is dissolved in water, aluminum (III) cations become surrounded by clusters of six water molecules to form a "hexahydrated" aluminum cation, Al(H2O)63+. Being a group IIIA metal, aluminum easily gives up its valence electrons. The oxygen atom in water possesses two lone pairs. What kind of bonding most likely occurs between the aluminum and the hydrating water molecules?

H

H

Solve It

6. Benzene, C6H6, is a common industrial solvent. The benzene molecule is based on a ring of cova-lently bonded carbon atoms. Draw two acceptable Lewis structures for benzene. Based on the structures, describe a likely resonance hybrid structure for benzene.

Solve It

Occupying and Overlapping Molecular Orbitals

Chapter 4 describes how electrons occupy distinct orbitals within atoms. When atoms cova-lently bond to form molecules, the shared electrons are no longer constrained to those atomic orbitals, but occupy Molecular orbitals, Larger regions that form from the overlap of atomic orbitals. Just as different atomic orbitals are associated with different levels of energy, so are molecular orbitals. A stable covalent bond forms between two atoms because the energy of the molecular orbital associated with the bond is lower than the combined energies associated with the atomic orbitals of the separated atoms.

Because electrons have wave-like properties, atomic orbitals can overlap in different ways depending on the relationship between the waves of the shared electrons.

In one mode, the electron waves interact Favorably (with low energy) and together occupy a Bonding orbital.

In another mode, the electron waves interact unfavorably within a higher-energy Anti-bonding orbital.

The energy relationships between unbound atoms and different types of molecular orbitals are summarized within Molecular orbital diagrams, Such as the one shown for dihydrogen in Figure 5-8. In this figure, two hydrogen atoms each contribute a single electron from a 1 S Orbital to a sigma (o) Bonding orbital. The low-energy bonding orbital is favored over the higher-energy sigma antibonding (o*) Orbital. This illustrates a general principle: Given a choice between high – and low-energy states, molecules prefer the low-energy states. This preference for lower energy is what is meant by Favorable (low energy) versus Unfavorable (high energy).

Figure 5-8:

A molecular orbital diagram for the formation of dihydrogen.

Energy

H! H

H

H

In addition to differences in the interaction of electron waves, covalent bonds can differ based on the shape of the molecular orbitals.

When atomic orbitals overlap in such a way that the resulting molecular orbital is symmetrical with respect to the Bond axis (the line connecting the two bonded atoms), we say that a O Bond (sigma bond) Is formed.

When atomic orbitals overlap in such a way that the resulting molecular orbital is symmetric with the bond axis in only one plane, we say that a N Bond (pi bond) Is formed.

Sigma bonds are stronger than pi bonds because the electrons within sigma bonds lie directly between the two atomic nuclei. The negatively charged electrons in sigma bonds therefore experience favorable (as in, low-energy) attraction to the positively charged nuclei. Electrons in pi bonds are farther away from the nuclei, so they experience weaker attraction.

Sigma bonds form when S Or P Orbitals overlap in a head-on manner. Single bonds are usually sigma bonds. Pi bonds form when adjacent P Orbitals overlap above and below the bond axis. These situations are depicted in Figure 5-9.

Figure 5-9:

Formation of a sigma bond(o) from two S Orbitals, and formation of a pi bond (n) from two adjacent P Orbitals.

Ss

The 5th Wave Bv Rich Tennant

" 1 Tt2aUc; Don’t i-Vuntt. a simple week maeea^a Vb <$cw% -to #et rid OЈ Your VveadacVies."

In this part…

I /ou’re no doubt familiar with the famous expression, Jr "It’s better to give than to receive." And if you’re like most people, every time you’ve heard someone utter that wonderful phrase, filled as it is with such a beautiful philanthropic message, you’ve thought to yourself, "Yeah, right. I’ll take receiving any day."

But you have to admit, there’s a certain gratification that comes from giving which quite often actually makes it feel better than receiving — more meaningful, more fulfilling. And the secret to achieving that kind of fulfillment is that you have to give with your whole heart. It won’t work if you’re just going through the motions.

This is especially true for massage. Sure, you can rub some warmed almond oil on your partner’s back for 20 minutes while watching the clock out with one eye and the football game on TV with the other, but that’s not what massage is all about.

Massage is about cultivating the right attitude — the Giver’s Attitude — not just applying mechanical maneuvers, which any massage text can teach you.

But don’t worry: In this part of the book, you’re going to discover how to actually give a massage, too! And as you’ll see, it’s not that difficult. Just follow the simple instructions, and in no time, you’ll be reproducing the very same techniques you see being performed by the highly trained models in the photographs. No problem.

That’s right. You Can become one of those people about whom everyone else exclaims, "What great hands you’ve got!" Just remember to focus on your "giver’s attitude" as much as your manual skills, and you’ll do just fine.

Chapter 9