A major medical policy denies a claim for care provided primarily to help an elderly member bathe, dress, and eat, with no skilled treatment being given. This denial is generally valid because major medical plans:

Why A is correct

Major medical insurance covers medically necessary care for injury or illness. Custodial care — assistance with activities of daily living such as bathing, dressing, and eating — does not require skilled medical treatment and is a standard exclusion from these policies. Such care is addressed by long-term care insurance or, after a spend-down of assets, by Medi-Cal. Agents should explain this limitation so customers understand the scope of what their major medical policy will pay.

Why the other options are wrong

• B) Custodial care is not covered merely because it happens in a hospital; the test is whether skilled, medically necessary treatment is being provided.
• C) Medically necessary home health care such as skilled nursing or therapy is often covered; the exclusion targets non-skilled custodial assistance.
• D) A 90-day elimination period is a disability income concept, not a route to custodial coverage under major medical.

Memory hook

Custodial care = help with daily living, not skilled treatment — and not covered by major medical.

Why A is correct

Major medical policies cover care that is medically necessary and directed at treating an illness or injury. Custodial care — help with the activities of daily living such as bathing, dressing, and eating when no skilled treatment is being provided — is a standard exclusion because it is maintenance rather than medical treatment. The distinction is deliberately drawn to keep comprehensive medical insurance focused on acute care. This is exactly why long-term care insurance exists as a separate product: it pays for the custodial and maintenance care that major medical policies do not cover. The exam tests this boundary between medical care and custodial care.

Why the other options are wrong

• B) Custodial long-term care is not an essential health benefit; the EHB categories center on medical services such as hospitalization and physician care, so no plan is required to cover it.
• C) Custodial care is generally excluded entirely rather than reimbursed at the skilled nursing level, which requires active medical treatment by skilled professionals.
• D) Even when ordered or rendered by a health professional, non-medical custodial care remains outside typical major medical coverage because the service itself is maintenance rather than treatment.

Memory hook

Custodial care keeps a person comfortable; major medical treats a disease. Different jobs, different policies.

Why A is correct

Major medical policies cover medically necessary treatment and exclude custodial care — assistance with activities of daily living such as bathing, dressing, and feeding that does not require skilled medical services. A physician's order does not convert custodial care into a covered benefit, because the policy pays for treatment of sickness or injury, not for maintenance care. This exclusion is one reason long-term care insurance exists: major medical stops where custodial care begins. Agents must therefore distinguish skilled care, which major medical covers, from custodial maintenance, which it does not, when counseling older clients about their coverage needs.

Why the other options are wrong

• B) A physician's order cannot make custodial care medically necessary; the nature of the care, not the order, determines coverage.
• C) Meeting the deductible affects cost-sharing, not whether the service is a covered expense in the first place.
• D) Custodial care is not a preventive essential health benefit; preventive services are clinical screenings and immunizations.

Memory hook

Custodial = comfort and chores, not cures. Major medical heals; it does not do housekeeping.