# Medigap or Medicare Advantage Plan?



## Glinda

Which do you prefer and why?


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## Butterfly

I have a great Medicare Advantage plan.  It's tied to our biggest and best hospital and healthcare group, and with a  huge network of providers.  I don't pay anything for it, except the regular Medicare premium.  Low co-payments and great coverage.  I wouldn't consider anything else.


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## JustBonee

Medicare Advantage for myself.   It's no charge with Medicare,  and it works for me.  I'm not dealing with any  health issues at  present and don't want to pay for something I don't need.   
On the other hand, Medigap can get very expensive.   My late husband had to have that coverage due to heart issues and he could only see his heart specialists thru Medigap coverage. .. 
So for me, it all comes down to what kind of coverage do you need, and how much do you want to pay for it.


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## Glinda

Are there any other 64-year-olds on SF trying to sort this stuff out?  I find it very confusing . . .


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## SeaBreeze

My husband is Glinda, and also needs to find out certain things before he enrolls in Medicare.  We're both on Kaiser plans in the ACA, so that will need to be handled also.  He plans to use a Medicare supplement plan from Kaiser.  But he hasn't begun to research, getting a lot of offers in the junk mail though, funny how many people know how old you are. 

Guess we'll be applying for ACA separately this time, as I'm not Medicare age yet.  We used a free agent for the Affordable Care Act plan last year, since we had some bumps with the website, she's already contacted us to say she'll help us do what's necessary when we see her again.


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## Happyflowerlady

I have a Medicare Advantage, and I really like it. My co-pays are low, and it covers a fitness membership with Silver and Fit, so we can go to the fitness center as often as we want to. I enjoy the swimming and cardio exercises, but they also have a complete fitness center with all of the workout machines here. 
If you live in a place where there is no fitness center close, or are not interested in that; then this feature would not help you much, but otherwise, it is terrific. 
I totally recommend finding an independant agent when you choose your supplement. 
It is like going to the grocery store for a can of beans. The beans are all the same, but each store will charge a different price for the same item. 
An independant agent can find out what your needs are, and then find the company that offers that plan for the best price. 

Agents are not allowed to discuss Advantage plans unless you ask about them, so when you talk to an agent, be sure to ask about the advantage plans as well as the regular medicare supplement plans.


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## spot

SeaBreeze, I'm in this same place. My wife and I have ACA insurance , I'm 64 she will be 59 soon. Lots to learn about this, I hope to find an ACA navigator soon to help us and my CPA.


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## Butterfly

I would say don't fail to check into the Advantage plans.  Many are wonderful, some not so much so.  Mine falls into the wonderful category, but is only available here, because it is tied to a large hospital and huge medical group.


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## Manatee

We have had Medicare Advantage with 3 different companies in 2 different states.  Never had a reason to consider medigap.

I went from a regular HMO when I was working to the same coverage under Cobra, to Medicare Advantage when I turned 65.


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## QuickSilver

I just like the idea of being able to see any doctor or go to any hospital... I don't like the restrictions of an HMO.. which is what Medicare Advantage is.  It's not Medicare.. it's private insurance, and they will call the shots.


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## Ken N Tx

QuickSilver said:


> I just like the idea of being able to see any doctor or go to any hospital... I don't like the restrictions of an HMO.. which is what Medicare Advantage is.  It's not Medicare.. it's private insurance, and they will call the shots.



..Do your homework!!!


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## QuickSilver

Ken N Tx said:


> View attachment 21583..Do your homework!!!



Over the years, I have seen far to many families surprised when medical care was refused at the hospital they were taken to.   For example.. Grandma falls and breaks her hip.  She is taken to the nearest hospital.  The family is shocked to hear that Grandma has to be transported clear across town for her hip surgery.  "But She has Medicare!!"   they say.    Sadly, I have had to inform them that even though she has a Medicare card, and pays her premiums... she does NOT have Medicare.  She has a private HMO and they will decide exactly where she will receive care... and by who.     

As you said Ken... people need to do their homework..  If they are happy limiting themselves to the doctor and the hospital covered under their plan.. then that's fine..  They need to understand that they cannot go anywhere else or see any doctor they choose as they can with traditional Medicare.  These plans sound very good.. but as you said.. folks need to know what they are getting before they sign away their Medicare.

That said... I don't think HMO's are all bad.. Usually they cost less. Some of the plans have no co-pay or offer prescription drugs.  If you know for certain you can limit your healthcare to their preferred providers and are happy with the choices given, then the Advantage plans are fine.


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## Grumpy Ol' Man

I'm really confused!!!  (Wife says I have been for many years!)  We both currently covered under each of our employer's medical group plans.  It appears we will both be finally retiring at the end of 2015.  So, we need to pick up our "Part B" and "Part F"... or at least that's what I thought. It appears the Part F covers all the deductibles from Part A and Part B, so has very little out of pocket.  Part F is available in a Medicare Advantage plan and that is the direction we planned on heading.

Now, a couple posters said their Advantage plans cost them nothing.  Huh??!!??  I've priced a number of the Advantage plans and they run from ~$130/month and up.  Part B is a standard cost item which is around $115/month.  So, I assumed we would be out the $115... the $130... and our Part D (Prescription Plan), $40 for a total of about $300/month for each of us.

Where have I erred in that analysis?  How do I find Advantage plans that have zero cost??


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## QuickSilver

I also plan to retire at the end of next year.  At that point I will pick up Medicare part B and also purchase a Blue Cross Medicare supplement to pick up everything part A and B do not.. I will still have traditional Medicare and be able to go anywhere and see any doctor I choose.


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## Ken N Tx

QuickSilver said:


> I also plan to retire at the end of next year.  At that point I will pick up Medicare part B and also purchase a Blue Cross Medicare supplement to pick up everything part A and B do not.. I will still have traditional Medicare and be able to go anywhere and see any doctor I choose.



The above is what my 94 year young MIL has. She pays $203 a Month for the BC&BSof Illinois. Has United Healthcare for drug plan, not sure what the premium amount is as it is deducted by MC.

She does not pay any deductibles or Co-pays to anyone. 

She has had these plans for YEARS and we are well pleased..


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## Butterfly

Grumpy Ol' Man said:


> I'm really confused!!!  (Wife says I have been for many years!)  We both currently covered under each of our employer's medical group plans.  It appears we will both be finally retiring at the end of 2015.  So, we need to pick up our "Part B" and "Part F"... or at least that's what I thought. It appears the Part F covers all the deductibles from Part A and Part B, so has very little out of pocket.  Part F is available in a Medicare Advantage plan and that is the direction we planned on heading.
> 
> Now, a couple posters said their Advantage plans cost them nothing.  Huh??!!??  I've priced a number of the Advantage plans and they run from ~$130/month and up.  Part B is a standard cost item which is around $115/month.  So, I assumed we would be out the $115... the $130... and our Part D (Prescription Plan), $40 for a total of about $300/month for each of us.
> 
> Where have I erred in that analysis?  How do I find Advantage plans that have zero cost??



Well here where I live, there are two medicare advantage plans that cost nothing additional over the $104 that we pay for Medicare.  I have one of them, pay NOTHING in addition to the medicare premium, and I am extremely pleased with the plan.  Both the plans available here are local and tied to large hospitals and medical groups in the area.  I don't know where else to look, as I never tried looking for anything else because this is such a good deal for me.


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## Dudewho

QuickSilver said:


> I just like the idea of being able to see any doctor or go to any hospital... I don't like the restrictions of an HMO.. which is what Medicare Advantage is.  It's not Medicare.. it's private insurance, and they will call the shots.




Check for a PPO. It has IN and OUT of network benefits.


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## Dudewho

Glinda said:


> Which do you prefer and why?



Many Advantage plans have benefits that original Medicare does not. Plans may have dental, vision, over the counter coverage, prescription drug coverage and or health clue memberships. All with a lower premium the Medigap plans. The trade off is you have small copays when you see health care providers.


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## Dudewho

Check with your local SHIP representative. You can usually find them in the local senior center if you have one.
If Humana is in you area, they have employee sales representatives that will come out explain all the A's B's and C's of Medicare to you.


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## Dudewho

Grumpy Ol' Man said:


> I'm really confused!!!  (Wife says I have been for many years!)  We both currently covered under each of our employer's medical group plans.  It appears we will both be finally retiring at the end of 2015.  So, we need to pick up our "Part B" and "Part F"... or at least that's what I thought. It appears the Part F covers all the deductibles from Part A and Part B, so has very little out of pocket.  Part F is available in a Medicare Advantage plan and that is the direction we planned on heading.
> 
> Now, a couple posters said their Advantage plans cost them nothing.  Huh??!!??  I've priced a number of the Advantage plans and they run from ~$130/month and up.  Part B is a standard cost item which is around $115/month.  So, I assumed we would be out the $115... the $130... and our Part D (Prescription Plan), $40 for a total of about $300/month for each of us.
> 
> Where have I erred in that analysis?  How do I find Advantage plans that have zero cost??



Medicare advantage plans are  administered by private insurance companies. The plans all differ basically by county or ZIP Code. When you enroll in a Medicare advantage plan Medicare pays the plan monthly for your health care whether you go to the doctor or not. So basically, the Insurance company collects money for everybody on the plan you are on in you area the money is pooled together and the plan is administered from there. The more people you have on the plan the lower the premium. So some plans and a problem zero premium.
You will soon be getting your Medicare and you book in the mail. Your book will be able to tell you how many plans are available in your area, the Medicare star rating (A grading system Medicare gives to all 
plans) and what the premiums are.


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## Ken N Tx

For me, coverage is more important than premium!! 

For the past 4 years I have paid what some consider a high premium, but I have never paid out a dime for doctors or hospitals!!

You get what you pay for...


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## Dudewho

Ken N Tx said:


> For me, coverage is more important than premium!!
> 
> For the past 4 years I have paid what some consider a high premium, but I have never paid out a dime for doctors or hospitals!!
> 
> You get what you pay for...



You may have spent more in premium (Medicare Supplement and Part D) than the maximum out of pocket that the Medicare Advantage plan has. 
If I add up the $$ saved in over the counter coverage, my YMCA membership, Part D premium, vision w/ eye glass coverage, dental and mail order Rx for free. All for ZERO $$ a month. I'll gladly pay the $15 doctor copay.


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## Ken N Tx

Dudewho said:


> You may have spent more in premium (Medicare Supplement and Part D) than the maximum out of pocket that the Medicare Advantage plan has.
> If I add up the $$ saved in over the counter coverage, my YMCA membership, Part D premium, vision w/ eye glass coverage, dental and mail order Rx for free. All for ZERO $$ a month. I'll gladly pay the $15 doctor copay.



Have you had a major hospital stay??


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## QuickSilver

Ken N Tx said:


> Have you had a major hospital stay??



That's for sure...  That will be an eye-opener...   I like the idea of being able to go ANYWHERE I choose and see ANY doc I want... You can't have that with the HMO plans.


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## Dudewho

Ken N Tx said:


> Have you had a major hospital stay??



Two day stay last year $520.00.


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## QuickSilver

Dudewho said:


> Two day stay last year $520.00.




That was what you paid out of pocket?    Because with Traditional Medicare part A and a medicare supplement.. there would be $0 out of pocket for any hospital stay... no matter how long.   Plus.. you get to pick which hospital you want to be in.


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## MJC-56

Medicare seems confusing at first, but after you learn the lingo it's not difficult.  Certainly, sit down and do the research.
What I consider on Medicare Advantage vs.  Original Medicare + a Medigap Plan-- don't just look at monthly premium.  Look at Maximum Out of Pocket risk.  That is what gets people.  
Do you travel?  Advantage plans have a limited area / network.  Original Medicare does not
For Medicare to cover something it must be deemd medically neccessary. With Original Medicare, your doctor determines that.  With an Advantage plan the insurance company makes the determination.
Look up the Medicare Facebook page and read peoples comments.  You get lots of input from there

my 2 cents


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## QuickSilver

Here's another tidbit..   Medicare part A is for inpatient hospital stay only.   Medicare part B is for outpatient services..  When you are hospitalized, you will be required to satisfy a Medicare deductible of $1,260.  Your Medicare supplement will cover this deductible.   You will not be required to pay one single penny out of pocket for an inpatient stay since Medicare pays hospitals by DRG (diagnostic related group)..  In other words.. medicare assigns a payment amount for each diagnosis..  It will pay the hospital the same dollar amount whether you are hospitalized for 2 days or 22 days..  not one penny more.  If a hospital chooses to be a medicare provider, they have agreed to treat that diagnosis for the amount given.. and not a penny more.  You are not responsible for paying the hospital ANYTHING...   If you stay out of the hospital 61 days and re readmitted,  you will then be charged another deductible of $1,260.   If you are rehospitalized under 60 days time.. you do not owe another deductible. 

Part B covers 80% of you outpatient services... Your Medicare supplement will pick up the other 20%... however, it will NOT pay for anything that Medicare doesn't cover.


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## MJC-56

All it takes is one serious battle with cancer to make a person curse the day they chose Medicare Advantage.
Medicare pays 80% of most chemotherapy.  A supplement will  cover the rest.  You pay $0
With most Medicare Advantage plans, they pay 80% of Chemo you pay the rest.  This can run into many thousands.
The maximum out-of-pocket for most Med Advantage plans I have seen $6,700 / year + additional Max out-of-pocket for prescriptions.


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## Dudewho

QuickSilver said:


> That was what you paid out of pocket?    Because with Traditional Medicare part A and a medicare supplement.. there would be $0 out of pocket for any hospital stay... no matter how long.   Plus.. you get to pick which hospital you want to be in.



I don't pay monthly for my plan and it includes Rx coverage. I don't pay for that either.


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## QuickSilver

MJC-56 said:


> All it takes is one serious battle with cancer to make a person curse the day they chose Medicare Advantage.
> Medicare pays 80% of most chemotherapy.  A supplement will  cover the rest.  You pay $0
> With most Medicare Advantage plans, they pay 80% of Chemo you pay the rest.  This can run into many thousands.
> The maximum out-of-pocket for most Med Advantage plans I have seen $6,700 / year + additional Max out-of-pocket for prescriptions.



I know that I would never give up my traditional Medicare for an Advantage plan..   I have seen far too may horror stories to consider it.


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## Ken N Tx

MJC-56 said:


> Medicare seems confusing at first, but after you learn the lingo it's not difficult.  Certainly, sit down and do the research.
> What I consider on Medicare Advantage vs.  Original Medicare + a Medigap Plan-- don't just look at monthly premium.  Look at Maximum Out of Pocket risk.  That is what gets people.
> Do you travel?  Advantage plans have a limited area / network.  Original Medicare does not
> For Medicare to cover something it must be deemd medically neccessary. With Original Medicare, your doctor determines that.  With an Advantage plan the insurance company makes the determination.
> Look up the Medicare Facebook page and read peoples comments.  You get lots of input from there
> 
> my 2 cents





QuickSilver said:


> Here's another tidbit..   Medicare part A is for inpatient hospital stay only.   Medicare part B is for outpatient services..  When you are hospitalized, you will be required to satisfy a Medicare deductible of $1,260.  Your Medicare supplement will cover this deductible.   You will not be required to pay one single penny out of pocket for an inpatient stay since Medicare pays hospitals by DRG (diagnostic related group)..  In other words.. medicare assigns a payment amount for each diagnosis..  It will pay the hospital the same dollar amount whether you are hospitalized for 2 days or 22 days..  not one penny more.  If a hospital chooses to be a medicare provider, they have agreed to treat that diagnosis for the amount given.. and not a penny more.  You are not responsible for paying the hospital ANYTHING...   If you stay out of the hospital 61 days and re readmitted,  you will then be charged another deductible of $1,260.   If you are rehospitalized under 60 days time.. you do not owe another deductible.
> 
> Part B covers 80% of you outpatient services... Your Medicare supplement will pick up the other 20%... however, it will NOT pay for anything that Medicare doesn't cover.





MJC-56 said:


> All it takes is one serious battle with cancer to make a person curse the day they chose Medicare Advantage.
> Medicare pays 80% of most chemotherapy.  A supplement will  cover the rest.  You pay $0
> With most Medicare Advantage plans, they pay 80% of Chemo you pay the rest.  This can run into many thousands.
> The maximum out-of-pocket for most Med Advantage plans I have seen $6,700 / year + additional Max out-of-pocket for prescriptions.





QuickSilver said:


> I know that I would never give up my traditional Medicare for an Advantage plan..   I have seen far too may horror stories to consider it.



...
*All top notch advise!!!!!
*
It is not how your medical condition is now, but what will happen down the road!!!


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## MJC-56

Grumpy Ol' Man said:


> I'm really confused!!!  (Wife says I have been for many years!)  We both currently covered under each of our employer's medical group plans.  It appears we will both be finally retiring at the end of 2015.  So, we need to pick up our "Part B" and "Part F"... or at least that's what I thought. It appears the Part F covers all the deductibles from Part A and Part B, so has very little out of pocket.  Part F is available in a Medicare Advantage plan and that is the direction we planned on heading.
> 
> Now, a couple posters said their Advantage plans cost them nothing.  Huh??!!??  I've priced a number of the Advantage plans and they run from ~$130/month and up.  Part B is a standard cost item which is around $115/month.  So, I assumed we would be out the $115... the $130... and our Part D (Prescription Plan), $40 for a total of about $300/month for each of us.
> 
> Where have I erred in that analysis?  How do I find Advantage plans that have zero cost??



One thing I noticed in your comment that is probably the root of some of the confusion:  "Part F is available in a Medicare Advantage plan and that is the direction we planned on heading."  That is incorrect.   You can have Medicare Part A + Part B and a Supplement plan like F or G .   OR You can have a Medicare Advantage plan.  You cannot have a Medicare Advantage plan + a Supplement.  Medicare Advantage plans are roughly equivalent to Medicare Part A + Part B, but are not near the coverage of Medicare + a Supplement.

Some areas have great Medicare Advantage plans.  Some do not.    Some have Advantage Plans with no premium, but if you get sick you pay $6,700 / year to $10,000 (this is called a maximum out-of-pocket risk).  Some Advantage plans have a premium, but the maximum out-of-pocket risk is much smaller.

If you choose Medicare A + B and a Supplement, you get to also choose your own Part D drug plan.  Go to Medicare.gov and shop for the best one each year based on your prescriptions.  This feature alone can save a lot of money because with a Medicare Advantage plan you take whatever prescription plan they offer..and they are not all the same.

Lastly -  Compare Plan F and Plan G and Plan N if you choose a supplement.


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## Ken N Tx

MJC-56 said:


> One thing I noticed in your comment that is probably the root of some of the confusion:  "Part F is available in a Medicare Advantage plan and that is the direction we planned on heading."  That is incorrect.   You can have Medicare Part A + Part B and a Supplement plan like F or G .   OR You can have a Medicare Advantage plan.  You cannot have a Medicare Advantage plan + a Supplement.  Medicare Advantage plans are roughly equivalent to Medicare Part A + Part B, but are not near the coverage of Medicare + a Supplement.
> 
> Some areas have great Medicare Advantage plans.  Some do not.    Some have Advantage Plans with no premium, but if you get sick you pay $6,700 / year to $10,000 (this is called a maximum out-of-pocket risk).  Some Advantage plans have a premium, but the maximum out-of-pocket risk is much smaller.
> 
> If you choose Medicare A + B and a Supplement, you get to also choose your own Part D drug plan.  Go to Medicare.gov and shop for the best one each year based on your prescriptions.  This feature alone can save a lot of money because with a Medicare Advantage plan you take whatever prescription plan they offer..and they are not all the same.
> 
> Lastly -  Compare Plan F and Plan G and Plan N if you choose a supplement.


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## Thorn

I've seen some complaints in here about Medicare Advantage plans that are HMOs.  I plan on getting a PPO Medicare Advantage plan from Blue Cross.   I don't like HMOs in any flavor, I'd rather just pay more to have the freedom.  Does anyone in here have any experience with Medicare Advantage PPO plans?


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## QuickSilver

Thorn said:


> I've seen some complaints in here about Medicare Advantage plans that are HMOs.  I plan on getting a PPO Medicare Advantage plan from Blue Cross.   I don't like HMOs in any flavor, I'd rather just pay more to have the freedom.  Does anyone in here have any experience with Medicare Advantage PPO plans?



I was not aware that there were PPO Advantage plans...  If they cost more... why not just keep Traditional Medicare and a supplement?


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## MJC-56

Thorn said:


> I've seen some complaints in here about Medicare Advantage plans that are HMOs.  I plan on getting a PPO Medicare Advantage plan from Blue Cross.   I don't like HMOs in any flavor, I'd rather just pay more to have the freedom.  Does anyone in here have any experience with Medicare Advantage PPO plans?



According to Medicare & You handbook, Advantage plans come in lots of flavors including HMO. PPO, Regional PPO, PFFS, POS and so on.  
What Advantage plan is available to you depends on where you live. 
Original Medicare and all the Supplements are available to you wherever you live.
In my opinion, it's not the type of Advantage Plan that is the issue.  It is the fact that when you decide to go the Medicare Advantage route instead of staying with Original Medicare you are giving up your rights to an insurance company.   Original Medicare makes it very clear that YOUR doctor is the primary director of what is medically necessary.  With an Advantage plan, the insurance company tells you what is Medically necessary.  Medicare only covers what is Medically Necessary.  So, guess what happens way too often…the service you and your doctor say you need is deemed not necessary and therefore the insurance company will not pay for it.  

Ta Da!  Instantly reduce medical costs and build profit.


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## QuickSilver

MJC-56 said:


> According to Medicare & You handbook, Advantage plans come in lots of flavors including HMO. PPO, Regional PPO, PFFS, POS and so on.
> What Advantage plan is available to you depends on where you live.
> Original Medicare and all the Supplements are available to you wherever you live.
> In my opinion, it's not the type of Advantage Plan that is the issue.  It is the fact that when you decide to go the Medicare Advantage route instead of staying with Original Medicare you are giving up your rights to an insurance company.   Original Medicare makes it very clear that YOUR doctor is the primary director of what is medically necessary.  With an Advantage plan, the insurance company tells you what is Medically necessary.  Medicare only covers what is Medically Necessary.  So, guess what happens way too often…the service you and your doctor say you need is deemed not necessary and therefore the insurance company will not pay for it.
> 
> Ta Da!  Instantly reduce medical costs and build profit.



That's is the main thing..   Who do you want making your medical decisions... Your Doctor... Or your insurance company..


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## MJC-56

I found this on Youtube.  It's old, but the story is repeated even as we speak.  in fact, all anyone needs to do is go on the Facebook and find the "Medicare" page.  Read peoples comments about services their doctors request being denied.  

https://www.youtube.com/watch?t=6&v=H8erunWFyT4


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## Dudewho

QuickSilver said:


> I was not aware that there were PPO Advantage plans...  If they cost more... why not just keep Traditional Medicare and a supplement?



HMOs, PPOs and PFFS  (private fee for service) plans. plan choices vary by geographical area.


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## Thorn

QuickSilver said:


> I was not aware that there were PPO Advantage plans...  If they cost more... why not just keep Traditional Medicare and a supplement?



Traditional Medicare and HMOs are the same thing, they both require you to have a primary doctor whose choices rule your healthcare.  While I do trust my doctor, I want to have the freedom to see anyone I please about anything I feel needs attention.  That's going to cost more, and I know that, but I'll pay for it.  With a PPO I am only limited by the policy itself, it's coverage percentages, and my deductibles which are spelled out in my plan.


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## MJC-56

Thorn -  Did you mean to say "Traditional Medicare and HMO's are *NOT* the same thing?   that would be correct.   
Traditional Medicare is Part A inpatient care and Part B outpatient care.  You can go to any doctor or hospital in the U.S. that takes Medicare (99% of doctors and hospitals).  You do not need a primary care doctor. 

Add a Supplement like Plan F or Plan G and you can do all that with an annual out of pocket maximum risk of between $0 to $147. 

With a PPO you are going to have a maximum out of pocket risk of between $6,700 and $10,000 depending on if you are in network or not.  PPO's still have a network like an HMO.
Some PPO's also have a monthly premium approx equal to a Medicare Supplement and have a reduced maximum out of pocket risk to around $3,500 in network, more out of network.  
Please see page 17 and pp 67-73 of this 2015 Medicare & You handbook  https://www.medicare.gov/Pubs/pdf/10050.pdf  See page 83 for general information on PPO's.  

I too much prefer PPO's to an HMO.   I truly dislike the idea of having to get permission / referral from a primary care doctor to see a specialist.  
Some PPO's are called Regional PPO's and have a very large in-network area.   Here in Florida there is even a PPO for snowbirds that has in-network care both locally and the state where they spend their summer months.   I have no idea if other states offer that benefit.


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## Thorn

MJC-56 -  Actually, except for my Mom, I've never known anyone on Medicare.  And as far as I can remember, she's had this Advantage plan that works like an HMO, which I just hate the idea of.   I've never even looked at straight Medicare because I've seen to many little notices in office doors in medical buildings saying "No New Medicare" patients are being accepted.  Medicare is giving doctors and hospitals a hard time right now.  Whether it's justified or not, I don't know.  In any case, I want no part of it.  Blue Cross has a Medicare Advantage PPO for $50 a month, which looks pretty much like the PPO I have from them right now.


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## MJC-56

I am sure you'll like the PPO more than the HMO.  FYI -when they say "No New Medicare Patients"  they mean both Original Medicare and the PPO / Advantage Plans.  
Whoever sells you a PPO policy should go over that with you.


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## Dudewho

MJC-56 said:


> Thorn -  Did you mean to say "Traditional Medicare and HMO's are *NOT* the same thing?   that would be correct.
> Traditional Medicare is Part A inpatient care and Part B outpatient care.  You can go to any doctor or hospital in the U.S. that takes Medicare (99% of doctors and hospitals).  You do not need a primary care doctor.
> 
> Add a Supplement like Plan F or Plan G and you can do all that with an annual out of pocket maximum risk of between $0 to $147.
> 
> With a PPO you are going to have a maximum out of pocket risk of between $6,700 and $10,000 depending on if you are in network or not.  PPO's still have a network like an HMO.
> Some PPO's also have a monthly premium approx equal to a Medicare Supplement and have a reduced maximum out of pocket risk to around $3,500 in network, more out of network.
> Please see page 17 and pp 67-73 of this 2015 Medicare & You handbook  https://www.medicare.gov/Pubs/pdf/10050.pdf  See page 83 for general information on PPO's.
> 
> I too much prefer PPO's to an HMO.   I truly dislike the idea of having to get permission / referral from a primary care doctor to see a specialist.
> Some PPO's are called Regional PPO's and have a very large in-network area.   Here in Florida there is even a PPO for snowbirds that has in-network care both locally and the state where they spend their summer months.   I have no idea if other states offer that benefit.



The Humana PPO is a National Network. 
Some HMOs do not need referrals. But they vary by area.


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## Dudewho

MJC-56 said:


> I am sure you'll like the PPO more than the HMO.  FYI -when they say "No New Medicare Patients"  they mean both Original Medicare and the PPO / Advantage Plans.
> Whoever sells you a PPO policy should go over that with you.



If a doctor is contracted with a Hospital, chances are they accept the local Medicare Advantage plans.


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## Dudewho

The simple fact is that there is "not" a one size fits all plan out there. A husband may like original Medicare and his spouse may get a better deal from a Medicare Advantage plan. Everyone should do their due diligence and figure out what is available in that area for them. Sicker individuals may want to keep a Medicare supplement policy to keep the their medical cost down, Vs a healthier individual may want to keep their premium down because you don't need as much medical coverage. Either way you're only going to know what's best for you if you do your due diligence.

Medicare time frame:

October 1 to October 14-Medicare Pre annual enrollment.- you may start to look up 2016 plans to see what's right for you.

October 15th to December 7-Medicare annual enrollment.- this is when you make your choices for plans I will start January 1.
during this timeframe if you choose a plan and think you made a wrong decision you can choose a second plan and the last application and takes effect Jan.1st

January 1 of February 14-annual disenrollment period.- during this timeframe you can disenroll from a Medicare advantage prescription drug plan or a prescription drug plan and go back to original Medicare.

February 15 through January 31- this is the lock in period when you can not make any plan changes (in most cases).
In some scenarios you may be able to make changes in the locked in. Anybody who has a low income subsidy known as LiS gets help with your prescription drug cost can make plan changes to their drug program all your long. Those who are dual eligible which means they have both Medicare and Medicaid can also make changes to drug plans or Medicare Advantage plans all year long. Your area may also have SNP plans or "special needs plans" that have an open election all year long to help treat chronic conditions.

If you choose a Medicare advantage plan for the "first time" and throughout the year and do not like it you can return at any time to original Medicare. This can only be done by calling Medicare.


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## QuickSilver

I see there is a lot of misinformation about what Traditional Medicare is and does... and what an insurance company managed Medicare substitute is and does..  People need to get the facts before making a decision.


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## Thorn

Well then, glad I signed up here.  I'm learning something.


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## Dudewho

QuickSilver said:


> That's is the main thing..   Who do you want making your medical decisions... Your Doctor... Or your insurance company..



With an HMO your primary care physician ascts as your health care Cordinator. Not the insurance company. That's why you pick them with an HMO


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## QuickSilver

Dudewho said:


> With an HMO your primary care physician ascts as your health care Cordinator. Not the insurance company. That's why you pick them with an HMO




It's the Insurance company that decides what it will pay for.. and what medical care you can have... not your primary care physician..   With traditional Medicare.. it's your doctor that makes that decision.   This is why HMO's are inferior to Medicare.


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## Underock1

My wife was hospitalized for two months in three different facilities, including hospice in the hospital. Had every test you could think of. We had AARP Medi-Gap, and never paid a dime except for ambulance bills.


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## Butterfly

My medicare Advantage plan pays for anything Medicare covers.  Medicare decides what it will cover -- your doctor does not.  For Medicare to cover, it has to be medically necessary, also.  Medicare doesn't just give you a blank check, it decides what it will cover and what it will not.  So it acts as your insurance company.  

My Advantage plan (for which I pay nothing in addition to the regular Medicare premium) also pays for prescriptions, vision, etc., and several things Medicare does not.  The HMO I am in is huge, and most of the doctors here either accept it, or the other major Advantage plan here, or both.  My sister and I both had hip surgeries, and we used the same surgeon.  She had one Advantage plan, and I had the other.  Here, at least, the restrictions on doctors you can choose is not a problem. 

As to the out of pocket caps -- I had two hip replacements in 2013, for which I paid a grand total of $100 to the surgeon (for all the visits together, and the surgeries) and about $600 in hospital co-pays (for both surgeries together).  I paid nothing to the anesthesiologist, or for diagnostic tests, or home PT, or anything else.  And I had no Advantage premiums.   My sister had the same scenario, but her payments were a little different (negligible difference) because she was on the other plan.

I saved a heck of a lot of money for two VERY expensive operative procedures and a total of 5 days in the best hospital in the region.

They all work differently.


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## QuickSilver

Butterfly said:


> My medicare Advantage plan pays for anything Medicare covers.  Medicare decides what it will cover -- your doctor does not.  For Medicare to cover, it has to be medically necessary, also.  Medicare doesn't just give you a blank check, it decides what it will cover and what it will not.  So it acts as your insurance company.
> 
> My Advantage plan (for which I pay nothing in addition to the regular Medicare premium) also pays for prescriptions, vision, etc., and several things Medicare does not.  The HMO I am in is huge, and most of the doctors here either accept it, or the other major Advantage plan here, or both.  My sister and I both had hip surgeries, and we used the same surgeon.  She had one Advantage plan, and I had the other.  Here, at least, the restrictions on doctors you can choose is not a problem.
> 
> As to the out of pocket caps -- I had two hip replacements in 2013, for which I paid a grand total of $100 to the surgeon (for all the visits together, and the surgeries) and about $600 in hospital co-pays (for both surgeries together).  I paid nothing to the anesthesiologist, or for diagnostic tests, or home PT, or anything else.  And I had no Advantage premiums.   My sister had the same scenario, but her payments were a little different (negligible difference) because she was on the other plan.
> 
> I saved a heck of a lot of money for two VERY expensive operative procedures and a total of 5 days in the best hospital in the region.
> 
> They all work differently.




Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have..  There is no pre-certification necessary.  If your doctor orders a test.. medicare pays for it.  unlike insurance companies.  Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation.  But isn't that understandable..  Ask me how I know...  I work with medicare every day and have for 15 years.    My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..


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## Dudewho

QuickSilver said:


> Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have..  There is no pre-certification necessary.  If your doctor orders a test.. medicare pays for it.  unlike insurance companies.  Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation.  But isn't that understandable..  Ask me how I know...  I work with medicare every day and have for 15 years.    My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..



What if you can't pass underwriting or afford a Supplement? 
What caps does Medicare have caps on spending? 
Does Medicare promote Wellness with Health memberships and OTC coverage for vitamins?
Do I need a three day stay in the Hospital to go into a Skilled Nursing facility with Medicare, I don't with  my Advantage Plan?
Will Medicare cover my prescriptions? My Advantage does.
I get my teeth cleaned, will Medicare cover that?
I wear glasses Medicare help cover them?
I wear hearing aids will Medicare help with them?
I have a chronic condition will Medicare help me with meals?
My Advantage Plan gives me diabetic shoes for free will Medicare?
I get rewards from my Advantage Plan for having my preventive services done will Medicare?


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## QuickSilver

Dudewho said:


> What if you can't pass underwriting or afford a Supplement?
> What caps does Medicare have caps on spending?
> Does Medicare promote Wellness with Health memberships and OTC coverage for vitamins?
> Do I need a three day stay in the Hospital to go into a Skilled Nursing facility with Medicare, I don't with  my Advantage Plan?
> Will Medicare cover my prescriptions? My Advantage does.
> I get my teeth cleaned, will Medicare cover that?
> I wear glasses Medicare help cover them?
> I wear hearing aids will Medicare help with them?
> I have a chronic condition will Medicare help me with meals?
> My Advantage Plan gives me diabetic shoes for free will Medicare?
> I get rewards from my Advantage Plan for having my preventive services done will Medicare?



Well that's the beauty of living in a free country...  You do and buy what you like..   I'll keep my Medicare thanks very much.


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## Thorn

With Advantage plans, do you still have the part B cost deducted from your social security checks?  I can't seem to find the answer to that.  Thanks.


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## QuickSilver

Thorn said:


> With Advantage plans, do you still have the part B cost deducted from your social security checks?  I can't seem to find the answer to that.  Thanks.




 your premiums for your part B are sent to your advantage plan.. As your advantage plan will be covering both hopspitalizations and out patient services.  So the answer is yes.


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## mathjak107

QuickSilver said:


> Unfortunately Butterfly... Medicare does NOT decide what it will pay for.. or what tests you are allowed to have..  There is no pre-certification necessary.  If your doctor orders a test.. medicare pays for it.  unlike insurance companies.  Now.. of course there are things that Medicare will not pay for... like for example cosmetic surgery or breast augmentation.  But isn't that understandable..  Ask me how I know...  I work with medicare every day and have for 15 years.    My only advise to people... DO NOT GIVE UP YOUR MEDICARE for and Advantage Plan..



this is something those with advantage plans don't realize until it is to late . nothing is ever a problem with these advantage plans-until it is a problem .

while it sounds great that your for profit insurer is supposed to pay for everything a non profit like medicare would cover that is only true until they don't .

the private for profit insurer can deny certain procedures that medicare typically would say go ahead but you don't have medicare so you have no way of ever saying what medicare would have done when your advantage plan denies you .

this is something you run in to far more often then anyone thinks .

we know someone going through this now  with their advantage plan . the surgeons want both sides of a cancerous pituitary gland removed . the for profit advantage plan said they will approve only the cancerous half and the other half which is in bad shape will have to wait until it too is cancerous .

the surgeons are blown away by this as medicare always approves this , but without having medicare you can't document what medicare would have done and the insurers know this fact . it is done all the time where these hmo's can save money at your expense .


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## mathjak107

Butterfly said:


> My medicare Advantage plan pays for anything Medicare covers.  Medicare decides what it will cover -- your doctor does not.  For Medicare to cover, it has to be medically necessary, also.  Medicare doesn't just give you a blank check, it decides what it will cover and what it will not.  So it acts as your insurance company.
> 
> .



if only this was true but it isn't . in theory advantage plans are SUPPOSED  to cover what medicare does but in practice they do not because you can never prove what medicare would have covered once the procedures are not black and white . you would actually need medicare , which you don't have , in order to prove what medicare would have done in your specific case . advantage plans are all to well aware of this fact


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## mathjak107

Dudewho said:


> Check for a PPO. It has IN and OUT of network benefits.




those out of network benefits in advantage plans can kill you financially and most people do not understand how they work .once again you learn way to late the disadvantages in an advantage plan .

i mentioned this warning in another thread .

as an example , if you go to a preferred provider, BCBS pays 85% of the doctor's charges and if you go to a non-participating provider, BCBS pays 65%, but that's not the whole story. The preferred providers have already agreed to be reimbursed a certain price from BCBS, but the non-participating providers haven't, so they can charge you anything they want. BCBS will only pay 65% of the UCR (usual, customary, & reasonable) charges. For example, a surgeon or an anesthesiologist charges $2,000, but the contracted price with BCBS knocks it down to $1,000. BCBS pays $850 (85%) and your copayment is $150. However, if the surgeon or anesthesiologist is a non-participating provider and he charges the same $2,000, BCBS will only pay $650, which is 65% of the $1,000 UCR. You are then responsible for paying not only the $350 difference between BCBS's payment and the UCR, but also the other $1,000 that the anesthesiologist billed.

So the bottom line is that your copay with the "in-network" doctor is $150, but you're copay for the out-of-network doctor is $1,350. So you see, just because BCBS will reimburse you for any doctor you see, the amount you have to pay can be quite different.


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## Vinny

I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.


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## Ken N Tx

Vinny said:


> I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.


I started out (10 years ago) with AARP United Healthcare, after the first year they wanted a $100 a month more!!! Cancelled!!!


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## mathjak107

Vinny said:


> I have a Medicare Advantage Plan and live it. $1900 cap on out of pocket costs per year. Free Doctor visits and between my wife and myself spend less than $200 a year out of pocket. Check out the AARP plans. They are good.


advantage plans are always good , that is until they are not .then you wish you had medicare and a comprehensive supplement . it turns out that way more often then not. those who rave about their advantage plans usually do so because they have not bumped the issues -yet.

if you are lucky you won't have any issues .


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## spot

FYI, I got Plan G at 65 and Plan D with Medicare A&B . I retired the first of this year and 2 months later was diagnosed with Cancer. Just took my 3rd Cemo ( glad I signed up as some on here said to do ) .


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## mathjak107

my co-worker used to brag all the time about how little his advantage plan cost . that was until his wife got breast cancer . each chemo was 4500 bucks and his out of pocket was 6500 . it happened towards year end so he got hit for 13k  with her and later in the year he was in the hospital  and it cost him even more .

they both switched to medicare. they were lucky because ny is one of the few states you can do that . most states you can switch advantage plans but without underwriting you can't go advantage plan to medicare


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## spot

mathjak107 said:


> my co-worker used to brag all the time about how little his advantage plan cost . that was until his wife got breast cancer . each chemo was 4500 bucks and his out of pocket was 6500 . it happened towards year end so he got hit for 13k  with her and later in the year he was in the hospital  and it cost him even more .
> 
> they both switched to medicare. they were lucky because ny is one of the few states you can do that . most states you can switch advantage plans but without underwriting you can't go advantage plan to medicare



FYI, my 1st cemo $38,000 total as outpatiant.


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## mathjak107

luckily the advantage plans are capped as long as you are in network


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## mathjak107

the irony is these advantage plans are used by those generally who are trying to save on the premiums because they do not have the assets to pay for medicare and a supplement . so when these gray areas hit and you reach these very high outof pockets , this 13k in the instance above is an insane amount in proportion to their assets and savings . it is usually  these very people who can afford the least to roll the dice with their health coverage .


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## Ken N Tx

mathjak107 said:


> the irony is these advantage plans are used by those generally who are trying to save on the premiums because they do not have the assets to pay for medicare and a supplement . so when these gray areas hit and you reach these very high outof pockets , this 13k in the instance above is an insane amount in proportion to their assets and savings . it is usually  these very people who can afford the least to roll the dice with their health coverage .


Ditto, I like to gamble but I enjoy the lottery or slots!!


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## mathjak107

and typically lose! very few win with those odds


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## Knight

Could be the medicare insurance carrier that makes a difference, I really don't know. What I do know is 2 ambulance transports, emergency room charges, surgical hospital room & operation, semi private hospital room, surgeon fees, private room at the rehab facility, medications, and 24 therapy sessions totalling over $700,000.00 my total out of pocket cost $680.00. The higest cost in that was the copay for the 2 ambulance transport.


AARP advantage insurance has contracts and didn't pay that amount. We quit traveling because we've gone to every place we ever wanted to go. We have no reason to go out of network so it's not about saving money it's about knowing what our advantage plan pays for. Other than the unexpected surgery that was needed our health is excellent. 


To each their own when it comes to what to choose.


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## mathjak107

lots of people have no issues with their advantage plans . but all it takes is that one time or have an emergency while traveling and it can turn it in to another outcome . it certainly will never be as secure  as you are with medicare and a supplement but that is why it cost more.here in ny you have way more going from advantage plans to medicare when they can then the other way around .


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## Stumbles

Butterfly said:


> Well here where I live, there are two medicare advantage plans that cost nothing additional over the $104 that we pay for Medicare.  I have one of them, pay NOTHING in addition to the medicare premium, and I am extremely pleased with the plan.  Both the plans available here are local and tied to large hospitals and medical groups in the area.  I don't know where else to look, as I never tried looking for anything else because this is such a good deal for me.


Don’t you have copays and large total out of pocket  you were to suddenly have major health problem?


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