LOMA 281 Module 2 Lesson 4 UPDATED
Questions and CORRECT Answers
medical expense coverage - CORRECT ANSWER - A type of health insurance coverage
that provides benefits to pay for the treatment of an insured's illnesses and injuries.
long-term care (LTC) coverage - CORRECT ANSWER - Health insurance that provides
benefits for medical and other services to insureds who need care for an extended period in their
own homes or in a qualified facility.
disability income coverage - CORRECT ANSWER - Health insurance coverage that
provides income replacement benefits to an insured who is unable to work because of sickness or
injury.
major medical coverage - CORRECT ANSWER - Medical expense insurance coverage
that provides substantial benefits for (1) basic hospital, surgical, and physician expenses, (2)
additional medical services related to illness or injuries, and (3) preventive care. Most common
type.
exclusions of medical expense coverage - CORRECT ANSWER - Cosmetic surgery (other
than required corrective surgery), Illness or injury during military service or acts of war,
Intentionally self-inflicted injuries, Routine dental treatments, eye exams, and corrective lenses
coinsurance - CORRECT ANSWER - An expense participation requirement imposed by
many medical expense plans; the requirement generally is a specified percentage of all allowable
expenses that remain after the insured has paid the deductible and that must be paid by the
insured.
maximum out-of-pocket provision - CORRECT ANSWER - A major medical expense
insurance policy provision which states that the policy will cover 100 percent of allowable
medical expenses after the insured has paid a specified amount out of pocket to satisfy deductible
and coinsurance requirements. Also known as stop-loss provision.
, Affordable Care Act (ACA) - CORRECT ANSWER - In the U.S., a law that requires
insurance companies to accept all applicants for medical expense coverage and restricts insurers
from basing premium rates on preexisting conditions.
dread disease coverage - CORRECT ANSWER - Supplemental medical expense insurance
coverage that provides benefits in a lump-sum or installments for medical expenses incurred by
the insured who has contracted a specified disease. Also known as critical illness (CI) coverage.
provider networks - CORRECT ANSWER - A group of physicians, hospitals, and ancillary
services providers that a specific managed care plan has contracted with to deliver health care
services to plan insureds for negotiated fees.
primary care providers (PCPs) - CORRECT ANSWER - A member of a provider network
who coordinates insureds' medical care and treatment. Also known as a primary care physician.
managed care plan - CORRECT ANSWER - An arrangement that integrates the financing
and management of health care with the delivery of health care services to a group of individuals
who have enrolled in the plan.
Health Maintenance Organization (HMO) - CORRECT ANSWER - A health care
financing and delivery system that provides comprehensive health care services to plan
members, often referred to as subscribers, in a particular geographic area.
preferred provider organization (PPO) - CORRECT ANSWER - A health care benefit
arrangement that provides incentives for plan members to use network providers, but also
provides at least some coverage for services rendered by non-network providers.
point of service (POS) plans - CORRECT ANSWER - A managed care plan that combines
features of HMOs and PPOs; plan members who need medical care choose, at the point of
service, whether to seek care in-network or out-of-network.
copayment - CORRECT ANSWER - A specified, fixed amount paid by a managed care
plan member to a network provider when she receives services from the provider.
Questions and CORRECT Answers
medical expense coverage - CORRECT ANSWER - A type of health insurance coverage
that provides benefits to pay for the treatment of an insured's illnesses and injuries.
long-term care (LTC) coverage - CORRECT ANSWER - Health insurance that provides
benefits for medical and other services to insureds who need care for an extended period in their
own homes or in a qualified facility.
disability income coverage - CORRECT ANSWER - Health insurance coverage that
provides income replacement benefits to an insured who is unable to work because of sickness or
injury.
major medical coverage - CORRECT ANSWER - Medical expense insurance coverage
that provides substantial benefits for (1) basic hospital, surgical, and physician expenses, (2)
additional medical services related to illness or injuries, and (3) preventive care. Most common
type.
exclusions of medical expense coverage - CORRECT ANSWER - Cosmetic surgery (other
than required corrective surgery), Illness or injury during military service or acts of war,
Intentionally self-inflicted injuries, Routine dental treatments, eye exams, and corrective lenses
coinsurance - CORRECT ANSWER - An expense participation requirement imposed by
many medical expense plans; the requirement generally is a specified percentage of all allowable
expenses that remain after the insured has paid the deductible and that must be paid by the
insured.
maximum out-of-pocket provision - CORRECT ANSWER - A major medical expense
insurance policy provision which states that the policy will cover 100 percent of allowable
medical expenses after the insured has paid a specified amount out of pocket to satisfy deductible
and coinsurance requirements. Also known as stop-loss provision.
, Affordable Care Act (ACA) - CORRECT ANSWER - In the U.S., a law that requires
insurance companies to accept all applicants for medical expense coverage and restricts insurers
from basing premium rates on preexisting conditions.
dread disease coverage - CORRECT ANSWER - Supplemental medical expense insurance
coverage that provides benefits in a lump-sum or installments for medical expenses incurred by
the insured who has contracted a specified disease. Also known as critical illness (CI) coverage.
provider networks - CORRECT ANSWER - A group of physicians, hospitals, and ancillary
services providers that a specific managed care plan has contracted with to deliver health care
services to plan insureds for negotiated fees.
primary care providers (PCPs) - CORRECT ANSWER - A member of a provider network
who coordinates insureds' medical care and treatment. Also known as a primary care physician.
managed care plan - CORRECT ANSWER - An arrangement that integrates the financing
and management of health care with the delivery of health care services to a group of individuals
who have enrolled in the plan.
Health Maintenance Organization (HMO) - CORRECT ANSWER - A health care
financing and delivery system that provides comprehensive health care services to plan
members, often referred to as subscribers, in a particular geographic area.
preferred provider organization (PPO) - CORRECT ANSWER - A health care benefit
arrangement that provides incentives for plan members to use network providers, but also
provides at least some coverage for services rendered by non-network providers.
point of service (POS) plans - CORRECT ANSWER - A managed care plan that combines
features of HMOs and PPOs; plan members who need medical care choose, at the point of
service, whether to seek care in-network or out-of-network.
copayment - CORRECT ANSWER - A specified, fixed amount paid by a managed care
plan member to a network provider when she receives services from the provider.
