An "accident" is a sudden and unforeseen event that occurs at a specific time and place, and results in bodily injury. It is independent of illness other than infection of a cut or wound received in an accident.

"Aetna" is the organization contracted by the county to administer medical services for KingCare^SM, its self-insured medical plan, and for the life insurance plan. (Aetna isn't affiliated with Express Scripts.)

"Aexcel Designated Preferred Care Specialists" are Aetna Preferred Care Providers who have met designation criteria for thresholds for performance and effectiveness, as established by Aetna. They're listed in the provider directory and on DocFind as Aexcel Designated Preferred Care Specialists for the specialty care involved for the class of employees who are plan members.

An "alveolar ridge" is one of the two jaw ridges either on the roof of the mouth or on the bottom of the mouth containing the sockets (alveoli) of the teeth.

An "amalgam" is a silver filling.

"Amblyopia," commonly known as lazy eye, is a disorder of the eye characterized by poor or blurry vision in an eye that is otherwise physically normal without an apparent change in eye structure.

"Anisometropia" is unequal refractive power in the two eyes.

An "annual deductible" is the amount you pay each calendar year before the plan (other than Group Health) pays benefits. The annual deductible doesn't apply to any out-of-pocket maximums.

An "annual open enrollment" is the annual period when benefit-eligible employees may join a plan, change plans, add or increase accidental death and dismemberment (AD&D) insurance coverage, and add family members for coverage within the limits of each benefit plan. The annual open enrollment also gives benefit-eligible employees the opportunity to enroll or re-enroll in a flexible spending account (FSA).

An "anti-reflective coating" is a coating that goes on both sides of an eyeglass lens, and on the backside of a sunglass lens, to allow light to pass more freely through the lens.

"Apicoectomy" is the amputation of the tip or end of the root of a tooth.

A "bifocal lens" is a single lens divided by a visible line into two viewing areas, each with a different prescription. The lower section is for reading and for viewing objects up close, and the upper section is for viewing objects in the distance.

A "bitewing X-ray" is an X-ray taken of the crowns of teeth to check for decay.

A "blended lens" is a multifocal lens without the usual dividing line that exists with normal multifocal lenses.

"Body Mass Index" is a practical marker that is used to assess the degree of obesity. It's calculated by dividing the weight in kilograms by the height in meters squared.

A "brand-name drug" is a trademarked drug patented for a limited period by a single pharmaceutical company.

A "bridge" is a non-removable tooth replacement attached to adjoining natural teeth when one or a few teeth are missing.

"Caries" is tooth decay, which leads to a cavity.

A "caries susceptibility test" is performed, usually by measuring the concentration of certain bacteria in the mouth, to determine how likely someone is to develop tooth decay.

A "carrier" is a licensed insurance company or health maintenance organization that operates as a health care plan or a third-party administrator that processes claims on behalf of a self-insured organization.

"Cast restoration" is a procedure that uses a model of the tooth (an impression) to make a casting that replaces a missing part. A crown is an example of a casting restoration.

"Chemical dependency" is a psychological and/or physical dependence on alcohol or a state-controlled substance. The pattern of use must be so frequent or intense that the user loses self-control over the amount and circumstances of use, develops symptoms of tolerance and, if use is reduced or discontinued, shows symptoms of physical and/or psychological withdrawal. The result is that health is substantially impaired or endangered, or social or economic function is substantially disrupted.

"Chiropractic care" is the manipulation of the spine or extremities to correct a subluxation (that is, incomplete or partial dislocation) identified on an X-ray. The subluxation must be consistent with the patient's neuromusculoskeletal symptoms, and treatment must be within the limits of a specific documented treatment plan. Services must be provided by a state-licensed chiropractor or osteopath. (Chiropractors are restricted by law to manipulation of the spine; osteopaths are licensed to perform manipulative therapy to all parts of the body.)

A "coating" is one of a variety of compounds that can be applied to the exterior of a lens or absorbed by a lens.

"COBRA" stands for the Consolidated Omnibus Budget Reconciliation Act of 1986. COBRA allows plan members to continue health care coverage on a self-pay basis under certain circumstances for a limited time. The county offers all required COBRA rights to employees, their spouses/domestic partners and their children covered at the time coverage is lost.

After you've met your annual deductible, you begin paying a percentage—"coinsurance"—of the allowed amount for most medical services and supplies until you reach the annual out-of-pocket maximum. Coinsurance doesn't apply to prescription drugs.

A "companion" is a person whose presence as a companion or caregiver is necessary to enable an NME patient:

A "composite" is a tooth-colored filling made of plastic resin or porcelain.

A "contracted professional/contracted specialist" is a network provider who is under contract to Group Health.

A "copay" is the fixed amount you pay at the time a covered service is received.

A "coping" is a thin thimble of a crown with no anatomic features. It is placed on teeth before placement of either an overdenture or a large span bridge to allow for the removal and modification (if the tooth is lost) of the bridge without requiring a major remake of the bridgework.

A "crown" is an artificial covering for a tooth with metal, porcelain or porcelain fused to metal. A crown, sometimes referred to as a cap, covers a tooth weakened by decay or severely damaged or chipped.

"Curettage" is a deep scaling of the portion of the tooth below the gum line to remove calculus and infected gum tissue.

"Custodial or convalescent care" is care that primarily assists the patient in activities of daily living, including inpatient care mainly to support self-care and provide room and board. Examples are helping the participant to walk, get in and out of bed, bathe, get dressed, eat or prepare special diets or take medication that is normally self-administered.

"Dental care" is care of, or related to, the mouth, gums, teeth, mouth tissues, upper or lower jaw bones or attached muscle, upper or lower jaw augmentation or reduction procedures, orthodontic appliances, dentures and any care generally recognized as dental. This also includes related supplies and devices, but not prescription drugs.

A "denture" is a removable set of artificial teeth in a plastic base that rests directly on the gums. A denture may be partial or complete depending on the number of missing natural teeth.

A "dependent" is a member of your immediate family who is eligible for medical, dental and vision benefits through your county plans. The following family members are considered dependents:

Parents and other relatives are not considered "dependents."

"DESI (Drug Efficacy Study Implementation) drugs" are drugs that lack substantial evidence of effectiveness according to the FDA; but since they've been used and accepted for many years without significant safety problems, they continue to be used today. Examples include Donnatal, Naldec Syrup and Tigan suppositories.

A "disability" is a condition determined to be disabling by the Social Security Administration, Washington State Department of Retirement Systems or the county-sponsored long-term disability plan.

A "domestic partner" is an individual who is in an established domestic partnership in which both individuals:

"Durable medical equipment" is mechanical equipment that:

An "emergency" is the sudden, unexpected onset of a medical condition that threatens loss of life or limb, or may cause serious harm to the patient's health if not treated immediately.

"Evidence of insurability (EOI)" is any statement or proof of a person's physical condition, occupation or other factor affecting his/her acceptance for insurance.

An "exclusion" is a service or supply not covered under a plan.

An "experimental or investigational service/supply" is any treatment, procedure, facility, equipment, drug, drug usage, medical device or supply that meets any of the following criteria at the time it is or will be provided to the plan member:

In determining whether a service or supply is experimental or investigational, the following sources of information are relied upon exclusively:

If two or more services or supplies are part of the same plan of treatment or diagnosis, all are excluded if one is experimental or investigational. KingCare^SM or Group Health should consult the appropriate professional staff and then use the previously specified criteria to decide if a particular service or supply is experimental or investigational.

"Express Scripts" is Express Scripts, Inc., the organization contracted by the county to administer prescription benefits for KingCare^SM, its self-insured medical plan. (Express Scripts isn't affiliated with Aetna.)

"FDA" stands for the U.S. Food and Drug Administration, which enforces laws regulating the manufacture and distribution of food, drugs and cosmetics.

A "filling" is the material used to fill a cavity or replace part of a tooth.

A "fissure" is a break in the tooth enamel.

"Fluoride" is a chemical agent used to strengthen teeth to prevent cavities.

A "fluoride varnish" is a fluoride treatment contained in a varnish base, which is applied to the teeth to reduce acid damage from the bacteria that cause tooth decay. It remains on the teeth longer than regular fluoride and is considered more effective than other fluoride delivery systems.

"FMLA" stands for the Family and Medical Leave Act of 1993. FMLA allows you to take up to 12 weeks of unpaid, job-protected leave for certain family and medical reasons if you meet eligibility requirements.

A "formulary" is an authorized list of generic and brand-name prescription drugs approved for use by the FDA.

"Fringe Benefits Management Company (FBMC)" is the organization contracted by the county to administer its flexible spending accounts, COBRA benefits and retiree medical benefits.

"General anesthesia" is a drug or gas that produces unconsciousness and insensibility to pain.

A "generic drug" is a medication that isn't a trademarked drug but is chemically equivalent to the brand-name drug.

"Gingivitis" is an inflammation or infection of the gingiva (gum tissue)—the initial stage of gum disease.

"Group Health" is Group Health Cooperative, the organization contracted by the county to provide employees with its HMO medical plan option.

"HIPAA" stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA restricts the extent to which group health plans may impose preexisting condition limits and protects the personal health information of plan members.

"HMO" stands for health maintenance organization. HMO members usually pay a specified fee for comprehensive care, including inpatient and outpatient care, through a network of physicians and hospitals. Group Health is the county's HMO, with the county in effect paying the membership fee for employee and dependent coverage.

A "home health care agency" is an agency that:

A "home health care plan" is a plan that provides for care and treatment of a disease or injury. The care and treatment must be:

A "hospice" is a private or public agency or organization with a hospice agency license which administers or provides hospice care.

"Hospice care" is a coordinated program of supportive care provided by a team of professionals and volunteers for a dying person.

A "hospital" is an institution licensed by the state and primarily engaged in providing diagnostic and therapeutic facilities for surgical and/or medical diagnosis, as well as treatment and care of injured or ill persons by or under the supervision of staff physicians. The institution also continuously provides 24-hour nursing service by or under the supervision of registered nurses, or is any other licensed institution with which the medical plans have an agreement to provide hospital services. Skilled nursing facilities, nursing homes, convalescent homes, custodial homes, health resorts, hospices or places for rest, for the aged or for the treatment of pulmonary tuberculosis are not hospitals.

An "implant" is a support for a bridge or denture that has been surgically placed into bone.

An "inlay" is a solid filling cast to fit the missing portion of a tooth and cemented into place. An inlay covers one or more teeth.

"Inpatient services" refers to the care provided to a patient who is hospitalized or in hospice.

"Intravenous sedation" is a form of sedation where the patient experiences a lowered level of consciousness but is still awake and can respond.

An "ionomer" is a filling made of a mixture of glass and an organic acid, sometimes called glass ionomer concrete.

"KCFML" stands for King County Family and Medical Leave. Passed by King County Ordinance 13377 in 1998 and adopted by most, but not all, labor unions representing county employees, it allows you to take up to 18 weeks of unpaid, job-protected leave with medical benefits for certain family and medical reasons if you meet certain eligibility requirements.

"Keratoconus" is an hereditary, degenerative corneal disease affecting vision, characterized by generalized thinning and cone-shaped protrusion of the central cornea, usually in both eyes.

"KingCare^SM" is the county's self-insured medical plan. Medical services are provided by Aetna, and prescription services are provided by Express Scripts.

A "lenticular lens" is a single convex lens that magnifies light through a prism effect.

A "lifetime maximum" is the maximum benefit amount you may receive from your medical plan or for a given benefit during your lifetime.

"Limitations" are restricting conditions such as age, time covered and waiting periods, which affect the level of benefits.

"Low vision" is a term usually used to indicate vision of less than 20/200 and requiring special lenses.

"Malocclusion" is the improper alignment of biting or chewing surfaces of upper and lower teeth.

"Medically necessary" refers to health care services, supplies, treatments or settings considered appropriate and necessary according to generally accepted principles of good medical practice to diagnose or treat a medical condition. Services, supplies, treatments or settings must meet all of these requirements:

The plan member is responsible for the cost of services and supplies that aren't medically necessary.

KingCare^SM and Group Health reserve the right to determine whether a service, supply, treatment or setting is medically necessary. The fact that a physician or other provider has prescribed, ordered, recommended or approved a service, supply, treatment or setting doesn't, in itself, make it medically necessary.

A "mental condition" is a condition classified as such by the most current edition of the Diagnostic and Statistical Manual of Mental Disorders.

A "mental disorder" is any mental, emotional, behavioral, psychological, personality, cognitive, mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of cause, including any biological or biochemical disorder or imbalance of the brain. Mental disorder includes, but is not limited to, bipolar affective disorder, organic brain syndrome, schizophrenia, psychotic illness, manic depressive illness, depression and depressive disorders, and anxiety and anxiety disorders.

A "multifocal lens" is a lens with multiple lens corrections so you can see objects at varying distances through the same lens. A bifocal lens offers two different viewing fields (near and far). Progressive and trifocal lenses offer three different viewing fields (near, intermediate and far).

A "mutual aid agreement" is an agreement that allows certain benefits to continue while you're away from the county if you're needed to work temporarily for another agency.

"Network benefits" refers to the level of benefits you receive when you see a network provider. Network benefits are generally higher than out-of-network benefits.

A "network provider" is a person, group, organization or facility under contract with a benefit plan to furnish covered services to plan members.

An "NME patient" is a person who:

"NME" stands for the symptom of necrolytic migratory erythema observed in patients with glucagonoma.

A "non-preferred brand" is a brand-name prescription drug that isn't on the formulary list because it's considered no more effective than preferred brands and generic drugs, but in general costs more.

An "occlusal adjustment" is a modification of the surfaces of opposing teeth to improve how the teeth interact with each other.

An "occlusal guard," usually worn at night, is a device that lessens the impact of biting, chewing or grinding on the surfaces of the upper and lower teeth.

An "onlay" is a cast gold or porcelain filling that covers one or all of a tooth's cusps.

An "ophthalmologist" is a medical doctor specializing in vision care, who can perform vision examinations and recommend lens options, fit contact lenses, prescribe medications, test for and treat eye diseases, treat eye injuries and perform eye surgery.

An "optometrist" is a doctor of optometry specializing in vision examinations and recommending lens options. An optometrist can test for eye diseases, fit contact lenses and, in many states, diagnose and treat certain eye conditions with medication.

An "oral health assessment" helps determine the most appropriate dental treatment for you based on your oral health, as well as your overall health.

"Orthodontics" is a specialized branch of dentistry that corrects malocclusion and restores teeth to proper alignment and function. There are several different types of appliances used in orthodontics, one of which is commonly referred to as braces.

"Orthoptics" is a discipline dealing with the diagnosis and treatment of defective eye coordination, binocular vision and functional amblyopia by non-medical and non-surgical methods, such as glasses, prisms and exercises.

"Out-of-network benefits" refers to the level of benefits you receive when you see an out-of-network provider.

An "out-of-network provider" is a person, group, organization or facility not under contract with a plan to furnish covered services to plan members. Though some benefit plans allow use of out-of-network providers, they still must be licensed, registered or certified to provide covered services by the state in which they operate.

"Outpatient services" refers to the care provided to a patient who isn't hospitalized but who receives treatment, including surgery, at a licensed medical facility.

An "overbite" is a condition in which the upper teeth excessively overlap the lower teeth when the jaw is closed. This condition can be corrected with orthodontics.

An "overdenture" is a prosthetic device supported by implants or the roots of at least two natural teeth to provide better stability for the denture.

"Palliative" refers to treatment that relieves pain but is not curative.

A "partial denture" is a removable appliance used to replace one or more lost teeth.

"Periodontal" refers to the treatment of the gums, tissue and bone that support the teeth.

"Periodontal scaling/root planing" is treatment of periodontal disease that involves scraping and planing the exposed root surfaces of a tooth to remove all calculus, plaque and infected tissue.

A "physician" is a provider licensed by the State of Washington in which he/she practices as a:

KingCare^SM and Group Health also cover eligible services provided by providers licensed as a physician or osteopath's assistant, certified as a nursing assistant, or licensed as a practical nurse or registered nurse's assistant, when that provider works with or is supervised by one of the above physicians.

A "plano lens" is an eyeglass lens with no prescription.

A "pontic" is an artificial tooth used in a bridge to replace a missing tooth.

"Preauthorization" is medical plan approval for services or supplies before the patient receives them.

A "preferred brand" is a brand-name prescription drug that is on the formulary list because of its clinical and economic value to the plan and its members. Preferred-brand drugs are considered equally effective as non-preferred brands, but cost less.

A "preferred provider organization" (PPO), sometimes referred to as a participating provider organization, is a managed care organization of medical doctors, hospitals and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

A "prescription drug" is any medical substance that, under the Federal Food, Drug and Cosmetic Act (as amended), must be labeled with "Caution—Federal law prohibits dispensing without a prescription."

A "primary care physician (PCP)" is a physician who provides or coordinates care for plan members.

A "progressive lens" is a trifocal lens without visible lines separating near vision, mid-range vision and distance vision, with smooth transitions and no trifocal demarcation lines.

"Prophylaxis" is a professional cleaning to remove plaque, calculus and stains to help prevent dental disease.

A "prosthesis" is an artificial substitute to replace a missing natural body part.

"Prosthodontics" is the replacement of missing teeth with artificial materials, such as a bridge or denture.

A "provider" is a person, group, organization or facility licensed to provide health care services, equipment, supplies or drugs. For KingCare^SM and Group Health, this includes, but is not limited to, naturopaths, acupuncturists and massage therapists. The provider must be practicing within the scope of his/her license.

"Pulpotomy" is the removal of a portion of the tooth's pulp (the soft interior of the tooth).

A "Qualified Medical Child Support Order (QMCSO)" is a decree, judgment or order, including approval of a settlement agreement, from a state court or an administrative order that requires benefit plans to include a child in the employee's coverage and make any applicable payroll deductions.

"Reasonable and customary (R&C) charges" are rates that are consistent with those normally charged by the provider for the same services or supplies and within the general range of charges by other providers in the same geographic area for the same services or supplies.

"Reline" is the process of resurfacing the tissue side of a denture with a base material.

"Remineralization" is a process in which calcium, fluoride and an antimicrobial mouth rinse are combined to reduce bacteria and bond with a tooth to strengthen and rebuild the enamel.

A "resin-based composite" is a tooth-colored filling material used primarily for cosmetic purposes on front teeth.

"Respite care" is time off or a break for someone who is the main caregiver for an aged, ill or disabled adult or child.

A "root canal" is the removal of the pulp tissue of a tooth due to decay or injury.

"Root planing" is a procedure performed to smooth roughened root surfaces.

A "scratch-resistant coating" is material used to coat a plastic lens, which is relatively soft and easily scratched, to help reduce the lens' susceptibility to being scratched.

A "sealant" is a thin plastic material used to cover the biting surface of a tooth to prevent tooth decay.

A "service area" is the geographic area where a plan has arranged for covered services through agreements with various providers.

A "single vision lens" is a lens with only one use, either to see objects in the distance or for reading.

A "skilled nursing facility" is a facility that provides room and board, as well as skilled nursing care, 24 hours a day and is accredited as an extended care facility or is Medicare-certified as a skilled nursing facility. It is not a hotel, motel or place for rest or domiciliary care for the aged.

A "space maintainer" is a dental appliance that fills the space of a lost tooth or teeth and prevents the other teeth from moving into the space, primarily used in orthodontic and pediatric treatment.

A "staff member/staff specialist" is a network provider who is part of the Group Health staff.

A "stainless steel crown" is a pre-made metal crown, shaped like a tooth, primarily used to temporarily cover a seriously decayed or broken down tooth in children.

"Temporomandibular joint (TMJ) disorders" are disorders affecting the temporomandibular joint (which is just ahead of the ear and connects the mandible, or jawbone, to the temporal bone of the skull) and exhibiting any of the following characteristics:

A "tint" is a coating added to or absorbed by a lens in almost any shade or color density.

"Urgent care" refers to medical service for someone whose condition doesn't constitute a medical emergency but who needs immediate medical attention.

"USERRA" stands for the Uniformed Services Employment and Reemployment Rights Act of 1994.

"Usual, customary and reasonable (UCR) charges" are the levels of benefits payable when expenses are incurred from an out-of-network provider. Expenses are considered usual, customary and reasonable if the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies, and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies.

A "veneer" is an artificial filling material, usually plastic, composite or porcelain, that is used to provide an aesthetic covering over the visible surface of a tooth. It is primarily used on front teeth.

"Women's health care services" are health care services related to: