Page 86 - QCS.19 SPD - HSA

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child
Support Order or other court or administrative order. The Plan Administrator is responsible for determining if an
order meets the criteria of a Qualified Medical Child Support Order.

Designated Facility - a facility that has entered into an agreement with the Claims Administrator, or with an
organization contracting on behalf of the Plan to provide Covered Health Care Services for the treatment of
specified diseases or conditions. A Designated Facility may or may not be located within your geographic area.
The fact that a Hospital is a Network Hospital does not mean that it is a Designated Facility.

Designated Pharmacy - a pharmacy that has entered into an agreement with us or our pharmacy benefits
manager to provide specific prescription drug products. The fact that a pharmacy is a member pharmacy does
not mean that it is a Designated Pharmacy.

Domestic Partner - an individual of the same or opposite sex with whom you have established a domestic
partnership as described below.

A domestic partnership is a relationship between a Participant and one other person of the same or opposite sex.
Both persons must:
· not be so closely related that marriage would otherwise be prohibited;

· not be legally married to, or the Domestic Partner of, another person under either statutory or common
law;

· be at least 18 years old;
· live together and share the common necessities of life;

· be mentally competent to enter into a contract; and
· be financially interdependent.

Durable Medical Equipment (DME)- medical equipment that is all of the following:
· Ordered or provided by a Physician for outpatient use primarily in a home setting.

· Used for medical purposes.
· Not consumable or disposable except as needed for the effective use of covered DME.

· Not of use to a person in the absence of a disease or disability.
· Serves a medical purpose for the treatment of a Sickness or Injury.

· Primarily used within the home.
Eligible Person - an Employee of QUEEN CITY SKILLED CARE LLC or other person whose connection with
QUEEN CITY SKILLED CARE LLC meets the eligibility requirements shown in both the Employers' application
and the Plan. An Eligible Person must reside within the United States.
Emergency - a medical condition that manifests itself by sudden symptoms of sufficient severity, (including
severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in any of the following:
· placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her
unborn child in serious jeopardy;

· serious impairment to bodily functions; or
· serious dysfunction of any bodily organ or part.

Emergency Health Care Services - with respect to an Emergency. Emergency Health Care Services include:
· a medical screening examination, as required by federal law, that is within the capability of the emergency
department of a Hospital, including ancillary services routinely available to the emergency department, to
evaluate an Emergency medical condition; and
· such further medical examination and treatment that are required by federal law to stabilize an
Emergency medical condition and are within the capabilities of the staff and facilities available at the
Hospital, including any trauma and burn center of the Hospital.

Page 81 Section 15 - Glossary
HSA - 2017