Definitions for mutual benefit societies

As used in this article: "Health care expenditures" means claims incurred. "Managed hospital payment basis" means agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of services. "Member" means an individual who is covered by a mutual benefit society. "Net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt. "Operating expenses" means claims adjustment, administrative, soliciting, and reinsurance allowances. "Society" means mutual benefit society. "Uncovered expenditures" means the costs to the mutual benefit society for health care services that are the obligation of the mutual benefit society, for which a member may be liable in the event of the mutual benefit society's insolvency, and for which no alternative arrangements have been made that are acceptable to the commissioner. Uncovered expenditures include but are not limited to out-of-area services, referral services, and hospital services. Uncovered expenditures do not include expenditures for services when a provider has agreed not to bill the member even though the provider is not paid by the mutual benefit society, or for services that are guaranteed, insured, or assumed by a person or organization other than a mutual benefit society.