Mid-year plan change, accumulators do carry

**Adjudicating a Claim with Plan Design Changes and Accumulator Carryover**

My primary objective here is to accurately adjudicate a claim, taking into account a mid-year plan design change that became effective on July 1st, 2026. It's crucial to note that the plan design in effect before and after this date remains consistent in its core structure.

The key to handling this scenario lies in understanding the specific provision regarding mid-year plan changes. This provision dictates that, under normal circumstances, deductible and out-of-pocket (OOP) credits earned under the *prior* design do not carry forward. However, this particular group has strategically purchased an "accumulator carryover rider." This rider is the game-changer, as it explicitly states that *all* credits will carry forward in full.

Therefore, I can confidently confirm that the prior accumulators – a deductible credit of $1500.00 and an OOP credit of $2240.00 – are fully preserved and available for the current plan year, which commenced on July 1st, 2026. This translates directly to the current member's deductible balance being $1500.00 and their OOP balance being $2240.00.

Now, let's examine the current plan's structure for the in-network benefits. The individual deductible is $1500.00, and since the member already has a $1500.00 credit, this deductible has been fully satisfied. For out-of-pocket expenses, the maximum is $6000.00. The member has already incurred $2240.00 towards this, leaving a remaining OOP capacity of $3760.00 ($6000.00 - $2240.00).

Moving to the claim details: the date of service is August 6th, 2026. The service is an in-network outpatient surgery, subject to deductible and coinsurance. The allowed amount for this service is $2400.00.

Given that the deductible is already satisfied, no deductible will be applied to this claim. The coinsurance is structured as 20% for the member and 80% for the plan for in-network services. This means the member's coinsurance responsibility is 20% of $2400.00, which equals $480.00.

I need to verify if this $480.00 coinsurance amount exceeds the remaining OOP capacity. Since $480.00 is less than the $3760.00 available OOP, the member will indeed be responsible for the full $480.00.

Based on this analysis, I can determine the following:
*   **Deductible Applied:** $0.00 (as the deductible was already met)
*   **Coinsurance Amount:** $480.00 (20% of the $2400.00 allowed amount)
*   **Member Responsibility:** $480.00 (this is the coinsurance amount the member owes)
*   **Plan Paid:** $1920.00 (the allowed amount of $2400.00 minus the member's $480.00 responsibility)
*   **Ending Member Deductible:** $1500.00 (this remains unchanged as no new deductible was applied to this claim; the starting deductible credit was $1500.00 and it stays at that value).

I've confirmed that the total member responsibility ($480.00) plus the plan paid ($1920.00) equals the allowed amount ($2400.00), which is a critical reconciliation point. The prompt specifies that all amounts are per plan year. The deductible credited from January 1st, 2026, through June 30th, 2026, was $1500.00, and due to the rider, this carries forward in full, establishing the member's starting deductible balance as $1500.00, and it remains at that figure. The coinsurance amount calculation is accurate. All required output keys align with my findings. There's no copay applicable for this specific service as described.

**My Thought Process on Handling a Mid-Year Plan Change with Accumulator Carryover**

Alright, let's break down this claim scenario. The core issue here is a mid-year plan design change, which can always introduce complexity, but thankfully, this group has foresight – they've purchased the accumulator carryover rider. This is the critical piece of information.

My initial understanding is that the plan design itself, the Bluebonnet PPO 1500, remains consistent both before and after the 2026-07-01 effective date. The prompt explicitly states that without the carryover rider, any credits earned under the old design wouldn't transfer. However, because this group *has* the rider, I know with certainty that all accumulated deductible and out-of-pocket credits will carry forward in their entirety. This simplifies things considerably, as I don't need to prorate or perform any complex calculations regarding the transition.

So, as of the cut-off date for the old design (2026-06-30), I'm seeing that the individual deductible has already been fully satisfied at $1500.00. Similarly, the out-of-pocket maximum contributions have reached $2240.00. These are the starting points for this claim.

Now, for the claim itself, dated 2026-08-06, involving in-network outpatient surgery with an allowed amount of $2400.00. The services include deductible and coinsurance components.

My first step is to consider the deductible. Since the individual deductible was already fully met ($1500.00), there's no remaining deductible balance for this claim. Therefore, the deductible applied to this specific service is $0.00.

Next, I move to the coinsurance. The plan dictates a 20% member / 80% plan split for in-network services after the deductible has been met. Given that the deductible has been satisfied, the entire allowed amount of $2400.00 is now subject to coinsurance. My calculation here is straightforward: $2400.00 * 20% equals $480.00.

I then perform a crucial check against the out-of-pocket maximum (OOPM). The OOPM for this plan is $6000.00. The current accumulated out-of-pocket contributions are $2240.00. Adding the calculated coinsurance of $480.00 brings the total to $2720.00. This is well below the $6000.00 OOPM, so the full coinsurance amount is indeed the member's responsibility for this claim.

So, my total member responsibility for this claim is the sum of the deductible applied (which is $0.00) and the coinsurance amount ($480.00), resulting in a total member responsibility of $480.00.

Consequently, the plan's paid amount is the allowed amount minus the member's responsibility: $2400.00 - $480.00 = $1920.00.

Finally, for the ending member deductible, since it was already fully satisfied at $1500.00 and no deductible was applied to this claim, it remains at $1500.00.

To confirm, I'll quickly re-verify the key figures:
*   **Deductible applied:** $0.00 (as it was already met)
*   **Coinsurance amount:** $480.00 (20% of $2400.00, since deductible was met)
*   **Member responsibility:** $480.00 (deductible $0 + coinsurance $480)
*   **Plan paid:** $1920.00 ($2400 allowed - $480 member responsibility)
*   **Ending member deductible:** $1500.00 (remains at its fully satisfied level)

Everything appears to be in order. The presence of the accumulator carryover rider was indeed the deciding factor, making this a standard processing of a claim against an already met deductible and within OOPM limits.

**Understanding the Impact of a Mid-Year Plan Design Change with Accumulator Carryover**

Here’s how I’m processing this scenario involving a group that’s made a mid-year plan design change, specifically considering the implications of their purchased accumulator carryover rider.

First, I've noted the new plan design elements effective July 1, 2026: an individual in-network deductible of $1,500 and an out-of-pocket maximum (OOPM) of $6,000. For family coverage, these figures are $3,000 and $12,000, respectively.

The critical piece of information here is the mid-year plan change provision. It explicitly states that without the accumulator carryover rider, credits earned under the prior design *do not* carry forward. However, this group *has* purchased that rider. This is a crucial detail, as it means all previously accumulated amounts for deductibles and OOPMs will carry forward in full.

Now, let's look at the prior accumulators before July 1, 2026: the member had accumulated $1,500 towards their deductible and $2,240 towards their OOPM.

Since the credits carry forward in full due to the rider, as of July 1, 2026, the member effectively has a $1,500 deductible credit and a $2,240 OOPM credit already in place.

Now, for the claim dated August 6, 2026, for an in-network outpatient surgery with an allowed amount of $2,400. The claim is subject to both deductible and coinsurance.

Let's break down the deductible application:
The new individual deductible is $1,500.
The member already has a $1,500 credit from the prior plan.
Therefore, the remaining deductible is $1,500 (new deductible) - $1,500 (credited amount) = $0.00.
This means $0.00 of the deductible is applied to this claim.

Next, the coinsurance:
The plan has a 20% member coinsurance.
The coinsurance amount is 20% of the allowed amount: $2,400 * 0.20 = $480.00.

Before applying this coinsurance amount, I need to check the OOPM.
The new individual OOPM is $6,000.
The member has already accumulated $2,240 towards their OOPM.
The remaining OOPM is $6,000 (new OOPM) - $2,240 (credited amount) = $3,760.00.
Since the $480.00 coinsurance amount is less than the remaining OOPM of $3,760.00, the member will be responsible for the full $480.00 in coinsurance.

So, the member's total responsibility for this claim is $480.00 (from coinsurance) + $0.00 (from deductible) = $480.00.
The plan's payment will be the allowed amount minus the member's responsibility: $2,400.00 - $480.00 = $1,920.00.

Finally, let's consider the ending member deductible.
The member started with $1,500 credited towards their deductible.
Since $0.00 was applied from this claim, the ending member deductible for the year-to-date remains $1,500.00. This means the deductible has been met.

Based on this analysis, the key figures to report are:
*   `deductible_applied`: $0.00
*   `coinsurance_amount`: $480.00 (this is the member's share of coinsurance)
*   `member_responsibility`: $480.00
*   `plan_paid`: $1,920.00
*   `ending_member_deductible`: $1,500.00

I’ve double-checked the logic. The mid-year change provision, coupled with the accumulator carryover rider, correctly means the prior credits are maintained. The deductible is fully satisfied, so only coinsurance applies. The coinsurance amount is within the remaining OOPM, making the member responsible for that portion. The member responsibility and plan paid correctly sum to the allowed amount. The ending member deductible reflects the year-to-date total, which remains at the full $1,500 credited at the start of the new plan year. The wording of "coinsurance_amount" as the member's share is clear, and all calculations align.

**My Thought Process on Processing the Claim**

Alright, let's break down this claim based on the provided plan details and the service date.

First, I'm establishing the context: the plan year runs from January 1, 2026, to December 31, 2026. For an individual in this plan, the in-network deductible is $1,500, and the out-of-pocket maximum (OOPM) is $6,000. The structure is "embedded," which is important for how individual deductibles and OOPMs are handled within a family plan. We also have coinsurance: the member pays 20%, and the plan pays 80% in-network.

A critical piece of information is the mid-year plan change provision. I note that the group *has* purchased the accumulator carryover rider. This means that any deductible or OOPM credits accumulated before the plan change date (implicitly July 1, 2026, based on the accumulator status provided) will carry forward in full. This is confirmed by the accumulator status provided: the member has already satisfied their *individual deductible* with $1,500 credited towards it (reaching the $1,500 threshold) and has $2,240 credited towards their *individual OOPM* for the period of January 1, 2026, to June 30, 2026.

Now, I'm looking at the specific claim: a service on August 6, 2026 (well after the plan change date), which was an in-network outpatient surgery subject to deductible and coinsurance. The allowed amount for this service is $2,400.

I need to determine how much of this $2,400 the member is responsible for.

My first step is to check the deductible. The member's starting deductible accumulator is $1,500, and their individual deductible threshold is also $1,500. Since the accumulator is already at the threshold, the individual deductible is satisfied. Therefore, no portion of this $2,400 allowed amount will be applied to satisfy the deductible. So, `deductible_applied` is $0.00.

With the deductible satisfied, I move to coinsurance. The remaining amount for coinsurance calculation is the full allowed amount, $2,400, since the deductible applied was $0.00. The member's coinsurance rate is 20%. So, the coinsurance amount for the member is $2,400 * 0.20 = $480.00. This is my `coinsurance_amount`.

Next, I need to calculate the total `member_responsibility` for this claim. This will be the sum of the deductible applied and the coinsurance amount. Since the deductible applied is $0.00 and the coinsurance is $480.00, the total `member_responsibility` is $480.00.

Before finalizing the plan's payment, I must verify this member responsibility against the OOPM. The member's starting OOPM accumulator is $2,240. Adding the current claim's responsibility ($480.00) brings the new OOPM total to $2,240.00 + $480.00 = $2,720.00. The individual OOPM threshold is $6,000. Since $2,720.00 is less than $6,000.00, the OOPM limit is not reached, and the full $480.00 coinsurance applies.

The `plan_paid` amount is the allowed amount minus the member's responsibility: $2,400.00 - $480.00 = $1,920.00.

Finally, I need to determine the `ending_member_deductible`. Since the deductible was already satisfied at the beginning of this claim ($1,500.00 credited), and $0.00 was applied to it, the year-to-date accumulator for the deductible remains at its satisfied amount. So, the `ending_member_deductible` is $1,500.00.

I've also double-checked the logic on copays not crediting the deductible but crediting the OOPM. This detail explains why the initial OOPM ($2,240) was higher than the deductible ($1,500) but doesn't directly impact this claim, as there was no copay involved in the outpatient surgery service itself. The mid-year rider was correctly applied to ensure continuity of these accumulators. The math is clean, no complex rounding issues, and the member responsibility plus plan paid equals the allowed amount ($480.00 + $1,920.00 = $2,400.00). The output keys match the required structure.

**Processing a Claim with Mid-Year Plan Changes and Accumulator Carryover**

As I review this claim, my primary objective is to accurately determine the member's and the plan's financial responsibility, taking into account a mid-year plan design change that included an accumulator carryover rider.

The plan year is January 1, 2026, to December 31, 2026. For the initial period, the individual deductible was $1,500, and the individual Out-of-Pocket Maximum (OOPM) was $6,000, with a 20% member / 80% plan cost-sharing structure after the deductible was met, all for in-network services.

A crucial point is the mid-year change effective July 1, 2026. The group purchased an "accumulator carryover rider." This is critical because, without it, credits earned under the prior plan design typically wouldn't transfer. With the rider, however, all prior credits carry forward in full.

As of June 30, 2026 (before the new plan design fully takes effect, but with the rider already purchased for the *entire* plan year's benefit calculation for the carryover), the member's accumulators were:
*   Deductible Credited: $1,500. This means the individual deductible of $1,500 was already satisfied.
*   OOPM Credited: $2,240.

Now, I'm processing a service that occurred on August 6, 2026. This is an in-network outpatient surgery, subject to the deductible and coinsurance. The allowed amount for this service is $2,400.

My thought process for calculating the claim is as follows:

1.  **Deductible Application:** I first check if the deductible applies. The individual deductible is $1,500, and the member already has $1,500 credited. Since the deductible is fully satisfied due to the carryover and the individual limit being met, no portion of the $2,400 allowed amount will be applied to the deductible. Therefore, `deductible_applied` is $0.00.

2.  **Remaining Amount for Coinsurance:** With $0 applied to the deductible, the full allowed amount of $2,400 remains to be considered for coinsurance.

3.  **Coinsurance Calculation:** The cost-sharing is 20% for the member and 80% for the plan.
    *   Member Coinsurance: $2,400 * 0.20 = $480.00. So, `coinsurance_amount` is $480.00.
    *   Plan Coinsurance: $2,400 * 0.80 = $1,920.00. This is the `plan_paid` amount.

4.  **Out-of-Pocket Maximum (OOPM) Check:** I need to ensure this member coinsurance does not push the member over their individual OOPM limit.
    *   Current OOPM accumulator: $2,240.
    *   Member responsibility for this claim (coinsurance): $480.
    *   Projected new OOPM total: $2,240 + $480 = $2,720.
    *   The individual OOPM limit is $6,000. Since $2,720 is well below $6,000, the coinsurance is applied as calculated.

5.  **Total Member Responsibility:** The total member responsibility for this claim is the sum of amounts applied to the deductible and coinsurance. Since $0 was applied to the deductible, the `member_responsibility` is solely the coinsurance amount: $0.00 + $480.00 = $480.00.

6.  **Ending Deductible Accumulator:** The `ending_member_deductible` reflects the total credited towards the deductible for the plan year. Since the deductible was already met at $1,500 and no new deductible was applied from this claim, the accumulator remains at $1,500.00.

7.  **Final Plan Payment:** The plan pays the allowed amount minus the member's responsibility: $2,400 - $480.00 = $1,920.00. This aligns with the plan coinsurance calculated earlier.

I've also confirmed a few specific rules:
*   Copays do not credit the deductible, but this service is not subject to a copay, only deductible/coinsurance.
*   The embedded structure means an individual satisfying their individual deductible is the relevant threshold here.
*   The mid-year change and the accumulator carryover rider were correctly applied, ensuring prior credits were preserved.

Therefore, the key values for this claim processing are:
*   `deductible_applied`: 0.00
*   `coinsurance_amount`: 480.00
*   `member_responsibility`: 480.00
*   `plan_paid`: 1920.00
*   `ending_member_deductible`: 1500.00

**My Thought Process on Processing a Health Insurance Claim**

Alright, let's break down this claim. The plan year is set for January 1st, 2026, to December 31st, 2026. For an individual, the in-network deductible is $1,500, and the out-of-pocket maximum (OOPM) is $6,000. When it comes to coinsurance, I know it's a 20% member / 80% plan split after the deductible has been met.

A crucial detail here is that the group *did* purchase the accumulator carryover rider. This means that any amounts accumulated towards the deductible and OOPM as of June 30th, 2026, will carry forward after the mid-year plan change on July 1st.

Looking at the year-to-date (YTD) figures as of June 30th, the individual deductible has already been satisfied – that's a full $1,500 credited. The YTD OOPM is $2,240.

Now, let's look at the current service. It's an in-network outpatient surgery on August 6th, 2026, which is after the mid-year plan change, but remember, the credits carry over due to that rider. The allowed amount for this service is $2,400.

Since the individual deductible of $1,500 was already met by June 30th, no deductible will be applied to this claim. That's $0.00 deductible applied.

Because the deductible is satisfied, the member will be responsible for the 20% coinsurance on the allowed amount. The amount subject to coinsurance is the full allowed amount, $2,400, since no deductible was applied. So, the coinsurance comes out to 20% of $2,400, which is $480.

Now, I need to consider the OOPM. The current YTD OOPM is $2,240, and the OOPM ceiling is $6,000. The remaining amount until the OOPM is reached is $6,000 - $2,240 = $3,760. The member's cost share for this claim is $480, which is well below the remaining $3,760. Therefore, this $480 will contribute to the OOPM.

So, to summarize the member's responsibility for this specific claim:
*   Deductible applied: $0.00 (since it was already met)
*   Coinsurance: $480.00
*   Total Member Responsibility for this claim: $480.00

The plan's responsibility will be the allowed amount minus the member's responsibility: $2,400.00 - $480.00 = $1,920.00.

Now, let's look at the accumulators:
*   Deductible applied for this claim: $0.00. The YTD deductible remains at its satisfied level. The "ending member deductible" figure reflects the cumulative amount met, which was $1,500.00.
*   Coinsurance amount for this claim: $480.00.
*   Total member responsibility for this claim: $480.00.
*   Plan paid for this claim: $1,920.00.
*   Ending member deductible accumulator: $1,500.00 (it remains at the satisfied threshold because no further deductible was applied).

I've double-checked:
*   The mid-year change is accounted for because the carryover rider was purchased, meaning the YTD balances are the correct starting point.
*   The in-network coinsurance rate of 20% was used correctly.
*   The deductible was indeed satisfied as of the claim date.
*   The OOPM is not reached; the new total will be $2,240 + $480 = $2,720, which is still under the $6,000 limit.
*   The math checks out: 20% of $2,400 is $480, and the plan pays $1,920.
*   The definition of "ending member deductible" is clear – it's the running YTD total met. Since $1,500 was met and $0 was applied, it remains $1,500.
*   The plan documents confirm that in-network and out-of-network credits contribute to a single member deductible balance, and since the credits ($1,500) meet or exceed the threshold ($1,500), the deductible is satisfied.
*   The fact that copays don't credit the deductible is understood, but this service isn't a copay-based service.

Everything looks consistent and correctly calculated based on the provided plan details.

Alright, let's break down this adjudication. My primary task here is to process a single claim for a member who already has some accumulator balances from earlier in the plan year. This means I need to consider how the plan works, what the member has already paid towards their deductibles and out-of-pocket maximums, and how that interacts with this new claim.

First and foremost, I need to thoroughly understand the plan design. The plan year runs from January 1st to December 31st, 2026. For in-network services, there's an individual deductible of $1500 and a family deductible of $3000. Importantly, this is an "embedded" deductible structure. What this tells me is that an individual within the family can satisfy their $1500 deductible independently, or the family as a whole can reach the $3000 threshold. Beyond the deductible, the in-network coinsurance is split 20% for me (the member) and 80% for the plan. I also note that copays don't count towards the deductible but *do* count towards the out-of-pocket maximum (OOPM).

A critical piece of information is the "mid-year plan change" with a rider that allows existing accumulators to carry forward. This is crucial for this specific adjudication.

Now, let's look at where the member stands *before* this claim is processed. The prompt tells me this is an individual claim, so I'll primarily focus on the individual accumulators, though family ones might come into play if the individual ones weren't met.

For the period from January 1st to June 30th, 2026, the member had already met their individual deductible, specifically $1500.00, which is the full amount. This is my starting point for the deductible accumulator. Their out-of-pocket maximum accumulator for the same period was $2240.00. Thanks to that rider, these figures carry forward.

So, at the moment this new claim comes in, the member's individual deductible is completely satisfied (1500.00 out of 1500.00). Their individual OOPM accumulator is at $2240.00, with a limit of $6000.00.

Now, to adjudicate the claim itself. The date of service is August 6th, 2026. The service is in-network outpatient surgery, which the plan document specifies is subject to both deductible and coinsurance. The allowed amount for this service is $2400.00.

Let's walk through the calculations step-by-step:

**Deductible:**
The individual deductible required is $1500.00.
The individual deductible already paid is $1500.00.
This leaves $0.00 remaining on the individual deductible for this claim.
Even though the prompt doesn't provide family accumulator details, since the individual deductible is met, the plan will proceed directly to coinsurance for this member regardless of the family's status.
Therefore, the `deductible_applied` for this specific claim is $0.00.

**Coinsurance:**
Since the deductible has been met, the entire allowed amount of $2400.00 is now subject to coinsurance.
My coinsurance responsibility (the member's share) is 20%.
So, my `coinsurance_amount` for this claim is $2400.00 multiplied by 0.20, which equals $480.00.

**Out-of-Pocket Maximum Check:**
I need to ensure that adding this $480.00 coinsurance doesn't push me over my individual OOPM.
My current OOPM accumulator stands at $2240.00.
Adding the cost share from this claim ($480.00) would bring my total to $2240.00 + $480.00 = $2720.00.
My individual OOPM limit is $6000.00.
Since $2720.00 is well below $6000.00, the full $480.00 coinsurance amount is indeed my responsibility.

**Member Responsibility:**
My total `member_responsibility` for this claim is the sum of any applied deductible and coinsurance.
`member_responsibility` = `deductible_applied` + `coinsurance_amount`
`member_responsibility` = $0.00 + $480.00 = $480.00.

**Plan Paid:**
The amount the plan will pay is the allowed amount minus my responsibility.
`plan_paid` = `Allowed Amount` - `member_responsibility`
`plan_paid` = $2400.00 - $480.00 = $1920.00.
I can double-check this by looking at the plan's coinsurance share: 80% of $2400.00 is $1920.00, so this matches perfectly.

**Ending Accumulators:**
Now, to update the accumulators for the future.
For the deductible:
Starting individual deductible accumulator: $1500.00.
Deductible applied on this claim: $0.00.
So, my `ending_member_deductible` remains at $1500.00.

For the OOPM (though not explicitly requested in the final output, it's important for my process):
Starting OOPM accumulator: $2240.00.
Cost share applied on this claim: $480.00.
My `ending_member_OOPM` becomes $2240.00 + $480.00 = $2720.00.

Finally, I need to ensure I've correctly identified all the required output keys:
`deductible_applied`: $0.00
`coinsurance_amount`: $480.00
`member_responsibility`: $480.00
`plan_paid`: $1920.00
`ending_member_deductible`: $1500.00

Everything seems to line up logically and computationally based on the provided plan details and the member's prior activity. The key here was recognizing the carry-over provision and the fact that the individual deductible was already met, moving the claim straight into the coinsurance calculation.

Alright, let's break down this claim adjudication. My primary task is to process a single claim for a member who already has some accumulator balances from earlier in the plan year.

First, I need to thoroughly understand the input data. I have the member's plan details: it's the "Bluebonnet PPO 1500" plan, and we're looking at the 2026 plan year, which runs from January 1st to December 31st. I've noted the in-network deductible for an individual is $1500, with a family deductible of $3000, and these are embedded, meaning the individual deductible counts towards the family one. The individual out-of-pocket maximum (OOPM) is $6000, and the family OOPM is $12000. The coinsurance for in-network services, after the deductible is met, is 20% for the member and 80% for the plan. I also see there are copays, but they aren't relevant for this particular claim, as copays don't count towards the deductible, though they do count towards the OOPM.

Crucially, I've identified that there was a mid-year plan change on July 1st, 2026. However, the plan design itself remained the same. The existence of an "accumulator carryover rider" is vital here, as it means any credits accumulated before the plan change are still valid and carry forward.

Now, I've got the member's starting accumulator balances as of June 30th, 2026: their deductible accumulator was already at $1500, and their OOPM accumulator was at $2240.

Then, I've examined the claim details: it occurred on August 6th, 2026, for an in-network outpatient surgery. This type of service is subject to both the deductible and coinsurance. The allowed amount for this service is $2400.

With this information in hand, I can proceed with adjudicating the claim.

**Adjudication Steps:**

1.  **Deductible Application:** The claim is for an in-network outpatient surgery, so it first needs to satisfy the deductible. The member's individual in-network deductible is $1500. Looking at their starting accumulator, it's already $1500. This means the individual deductible was already fully met *before* this claim. Since the plan is embedded, once the individual deductible is satisfied, the plan starts paying coinsurance for that member, even if the family deductible hasn't been met yet. Therefore, the deductible applied to *this specific claim* is $0.00.

2.  **Coinsurance Application:** Since the deductible is already satisfied, the entire allowed amount of $2400 becomes subject to coinsurance. The member's coinsurance responsibility is 20%. So, the member's coinsurance amount for this claim is $2400.00 multiplied by 0.20, which equals $480.00.

3.  **Total Member Responsibility:** The total amount the member is responsible for on this claim is the sum of the deductible applied and the coinsurance amount. In this case, it's $0.00 (deductible) + $480.00 (coinsurance) = $480.00.

4.  **Out-of-Pocket Maximum (OOPM) Check:** I need to ensure this member responsibility doesn't exceed the OOPM. The member's starting OOPM accumulator was $2240. Adding the current claim's responsibility of $480.00 brings their total OOPM accumulator to $2720.00 ($2240 + $480). This is well below the individual OOPM limit of $6000.00, so the calculated member responsibility of $480.00 is correct and not capped by the OOPM.

5.  **Plan Payment Calculation:** The amount the plan pays is the allowed amount minus the member's responsibility. So, $2400.00 (allowed) - $480.00 (member responsibility) = $1920.00. Alternatively, the plan pays the coinsurance portion, which is 80% of the $2400.00 allowed amount, also resulting in $1920.00. Both calculations align.

6.  **Ending Accumulator Calculation:**
    *   **Ending Member Deductible:** The starting deductible accumulator was $1500. Since $0.00 was applied towards the deductible from this claim, the ending member deductible accumulator remains $1500.00.
    *   **Ending OOPM:** While not explicitly requested for the output, it's good practice to track. The starting OOPM accumulator was $2240. Adding the $480.00 member responsibility from this claim, the ending OOPM accumulator becomes $2720.00.

Finally, I've reviewed all these calculations. The mid-year plan change with accumulator carryover was a critical factor ensuring the prior balances were correctly applied. The service type, deductible status, coinsurance calculation, OOPM check, and the final plan payment all appear sound. I'm confident in these figures.

Therefore, the output values are:
*   `deductible_applied`: 0.00
*   `coinsurance_amount`: 480.00
*   `member_responsibility`: 480.00
*   `plan_paid`: 1920.00
*   `ending_member_deductible`: 1500.00

Alright, let's break down this adjudication. My primary task is to process a single claim under the 'Bluebonnet PPO 1500' plan. I need to be precise with the plan details, the member's status, and how the mid-year plan change affects things.

First, I'm reviewing the 'Bluebonnet PPO 1500' plan specifics for the 2026 plan year (January 1st to December 31st). I've noted the in-network individual deductible is $1500 and the family deductible is $3000. The structure is embedded. The individual Out-of-Pocket Maximum (OOPM) is $6000, and the family OOPM is $12000. Coinsurance is set at 20% for the member and 80% for the plan. I also see a crucial note about copays: they *don't* count towards the deductible but *do* credit towards the OOPM.

A significant factor here is the mid-year plan change on July 1st, 2026. While the plan design itself remains the same, this change impacts accumulators. The good news for the member is that the group *did* purchase the Accumulator Carryover Rider. This means all accumulated credits from before the plan change will carry forward in full.

Now, let's look at the member's situation *before* this current claim, keeping in mind the date of service is August 6th, 2026, which falls *after* the mid-year change.
For the period from January 1st to June 30th, 2026, the member had already credited $1500 towards their deductible and $2240 towards their OOPM.

Because of the Accumulator Carryover Rider, these prior credits are transferred directly to the new period. So, as of July 1st, 2026, the member's starting accumulators are:
*   **Starting Individual Deductible Accumulator:** $1500.00
*   **Starting Individual OOPM Accumulator:** $2240.00

Now I'll process the claim itself.
The claim details are:
*   **Date of Service:** 2026-08-06 (after the mid-year change)
*   **Service:** In-network outpatient surgery, subject to deductible and coinsurance.
*   **Allowed Amount:** $2400.00

Here's my step-by-step adjudication:

1.  **Deductible Calculation:**
    *   The individual in-network deductible is $1500.
    *   The member's starting deductible accumulator is already $1500.
    *   Since $1500 (accumulated) is greater than or equal to $1500 (required), the individual deductible is already met.
    *   Therefore, I will apply $0.00 towards the deductible for this claim. (`deductible_applied` = 0.00).

2.  **Coinsurance Calculation:**
    *   With the deductible satisfied, the claim is now subject to coinsurance.
    *   The service is in-network, so the coinsurance split is 20% member / 80% plan.
    *   The coinsurance is calculated on the *full allowed amount* of $2400, as the deductible has already been met.
    *   The member's coinsurance portion is 20% of $2400, which is $480.00. (`coinsurance_amount` = 480.00).

3.  **Member Responsibility Calculation:**
    *   My total member responsibility is the sum of deductible applied and coinsurance amount.
    *   `member_responsibility` = $0.00 (deductible) + $480.00 (coinsurance) = $480.00.

4.  **OOPM Check:**
    *   I need to ensure this member responsibility doesn't push them over their OOPM.
    *   The individual in-network OOPM is $6000.
    *   The member's starting OOPM accumulator was $2240.
    *   Adding the current claim's member responsibility ($480.00) brings their total OOPM credit to $2240 + $480 = $2720.00.
    *   Since $2720.00 is well below the $6000 OOPM limit, the full $480.00 calculated as member responsibility stands.

5.  **Plan Paid Calculation:**
    *   The amount the plan will pay is the allowed amount minus the member's responsibility.
    *   `plan_paid` = $2400.00 (allowed amount) - $480.00 (member responsibility) = $1920.00.
    *   Alternatively, I can verify this with the plan's coinsurance share: 80% of $2400.00 is indeed $1920.00.

6.  **Ending Accumulator Calculation:**
    *   **Ending Member Deductible:** The member started with $1500 towards their deductible, and $0.00 was applied on this claim. So, the ending deductible accumulator remains $1500.00. (`ending_member_deductible` = 1500.00).
    *   **Ending Member OOPM (for my own tracking):** The member started with $2240.00 towards their OOPM, and $480.00 was added from this claim. The ending OOPM accumulator is $2720.00.

So, based on my analysis and the application of the mid-year plan change provision with the carryover rider, the required output fields are:

*   `deductible_applied`: 0.00
*   `coinsurance_amount`: 480.00
*   `member_responsibility`: 480.00
*   `plan_paid`: 1920.00
*   `ending_member_deductible`: 1500.00

I've double-checked all the numbers and the logic. The key was recognizing that the deductible was already met due to the prior credits carrying over, which then directly applied the coinsurance calculation to the full allowed amount. The OOPM was not affected on this claim as the member is still far from the maximum.

Let me work through this claim adjudication step by step.

**Plan Details:**
- Individual deductible (in-network): $1,500.00
- Family deductible (in-network): $3,000.00
- Structure: Embedded
- Individual OOPM (in-network): $6,000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Copays do NOT credit the deductible. Copays always credit the OOPM.

**Mid-year change provision:**
- Group changed plan design effective 2026-07-01.
- The group HAS purchased the accumulator carryover rider, so all credits carry forward in full.

**Accumulators as of 2026-06-30 (carried forward):**
- Deductible credited: $1,500.00 (individual satisfied)
- OOPM credited: $2,240.00

**Claim:**
- Date of service: 2026-08-06
- Service: In-network outpatient surgery, deductible and coinsurance
- Allowed: $2,400.00

**Step 1: Deductible**
The individual deductible is $1,500.00 and it has already been fully satisfied ($1,500.00 credited). So no deductible applies to this claim.

- deductible_applied = 0.00

**Step 2: Coinsurance**
Since the deductible is satisfied, coinsurance applies. The allowed amount is $2,400.00.
- Member coinsurance = 20% of $2,400.00 = $480.00
- Plan coinsurance = 80% of $2,400.00 = $1,920.00

- coinsurance_amount = 480.00

**Step 3: Member Responsibility**
- deductible_applied + coinsurance_amount = 0.00 + 480.00 = 480.00

- member_responsibility = 480.00

**Step 4: Plan Paid**
- plan_paid = allowed - member_responsibility = 2,400.00 - 480.00 = 1,920.00

**Step 5: Ending Member Deductible**
- Starting deductible credited: $1,500.00
- Deductible applied on this claim: $0.00
- Ending member deductible: $1,500.00

- ending_member_deductible = 1500.00

Let me also verify OOPM:
- Starting OOPM: $2,240.00
- This claim adds $480.00 to OOPM
- Ending OOPM: $2,720.00
- Individual OOPM is $6,000.00, so not reached. No adjustment needed.

Everything checks out.

Let me work through this claim adjudication step by step.

**Member's accumulator status as of 2026-06-30:**
- Individual deductible: 1,500.00 credited (individual satisfied, since individual deductible is 1,500.00)
- Out-of-pocket: 2,240.00 credited

**Plan details:**
- Individual deductible (in-network): 1,500.00
- Family deductible (in-network): 3,000.00
- Structure: Embedded
- Individual OOPM (in-network): 6,000.00
- Family OOPM (in-network): 12,000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan

**Mid-year plan change:**
- Effective 2026-07-01
- The group HAS purchased the accumulator carryover rider, so all credits carry forward in full.
- The plan design applies both before and after the change; only accumulators are affected.

So as of 2026-07-01, the member's accumulators are:
- Individual deductible credited: 1,500.00 (satisfied)
- OOPM credited: 2,240.00

**Claim details:**
- Date of service: 2026-08-06 (after mid-year change)
- Service: In-network outpatient surgery, deductible and coinsurance
- Allowed: 2,400.00

**Adjudication:**

1. **Deductible:** The individual deductible is already satisfied (1,500.00 credited against 1,500.00 threshold). So no deductible applies to this claim.
   - deductible_applied = 0.00

2. **Coinsurance:** Since the deductible is satisfied, coinsurance applies.
   - In-network coinsurance: 20% member / 80% plan
   - Coinsurance amount = 20% of 2,400.00 = 480.00
   - coinsurance_amount = 480.00

3. **Member responsibility:** deductible_applied + coinsurance_amount = 0.00 + 480.00 = 480.00
   - member_responsibility = 480.00

4. **Plan paid:** allowed - member_responsibility = 2,400.00 - 480.00 = 1,920.00
   - plan_paid = 1,920.00

5. **Ending member deductible:** The deductible was already at 1,500.00 and no additional deductible was applied, so it stays at 1,500.00.
   - ending_member_deductible = 1500.00

Let me verify: member_responsibility (480.00) + plan_paid (1920.00) = 2,400.00 = allowed amount. ✓

The OOPM accumulator would update to 2,240.00 + 480.00 = 2,720.00, but that's not asked for.

All checks pass.

Let me work through this claim adjudication step by step.

**Member status before the claim (2026-08-06):**
- The group changed plan design effective 2026-07-01.
- The group HAS purchased the accumulator carryover rider, so all credits carry forward in full.
- Deductible credited 2026-01-01 through 2026-06-30: 1,500.00 (individual satisfied)
- Out-of-pocket credited over the same period: 2,240.00

So at the start of this claim:
- Individual deductible accumulator: 1,500.00 (individual deductible of 1,500.00 is satisfied)
- Individual OOPM accumulator: 2,240.00 (out of 6,000.00)

**The claim:**
- Date of service: 2026-08-06
- Service: In-network outpatient surgery, deductible and coinsurance
- Allowed: 2,400.00

**Step 1: Deductible**
The individual deductible is 1,500.00 and has already been fully satisfied (accumulator = 1,500.00). So no deductible applies to this claim.

- deductible_applied = 0.00

**Step 2: Coinsurance**
Since the deductible is satisfied, coinsurance applies. In-network coinsurance is 20% member / 80% plan.

The allowed amount is 2,400.00.
- Member coinsurance = 20% × 2,400.00 = 480.00
- Plan coinsurance = 80% × 2,400.00 = 1,920.00

- coinsurance_amount = 480.00

**Step 3: Check OOPM**
Current OOPM accumulator: 2,240.00
Adding member cost share from this claim: 480.00
New OOPM accumulator: 2,240.00 + 480.00 = 2,720.00

The individual OOPM is 6,000.00. 2,720.00 < 6,000.00, so the OOPM is not reached. The full coinsurance applies.

**Step 4: Member responsibility and plan paid**
- member_responsibility = deductible_applied + coinsurance_amount = 0.00 + 480.00 = 480.00
- plan_paid = allowed - member_responsibility = 2,400.00 - 480.00 = 1,920.00

Check: member_responsibility + plan_paid = 480.00 + 1,920.00 = 2,400.00 = allowed. ✓

**Step 5: Ending member deductible**
The deductible was already satisfied at 1,500.00. No additional deductible was applied, so it stays at 1,500.00.

- ending_member_deductible = 1500.00

Let me double-check everything:
- deductible_applied: 0.00 (deductible already met)
- coinsurance_amount: 480.00 (20% of 2400)
- member_responsibility: 480.00
- plan_paid: 1920.00
- ending_member_deductible: 1500.00

All looks correct.

Let me work through this.

Plan: Bluebonnet PPO 1500, plan year 2026. Embedded deductible, individual in-network 1500, family 3000. In-network OOPM individual 6000, family 12000.

Mid-year plan change effective 2026-07-01; the group has the accumulator carryover rider, so all credits carry forward in full.

Pre-change credits:
- Deductible credited 2026-01-01 through 2026-06-30: 1,500.00 (individual satisfied)
- OOP credited: 2,240.00

Claim: DOS 2026-08-06, in-network outpatient surgery, deductible and coinsurance apply. Allowed 2,400.00.

Deductible: individual deductible 1500 is already satisfied (credited 1500). So deductible applied on this claim = 0.00.

Wait — but need to check family deductible? Under embedded structure, individual deductible satisfied on its own. The member's individual deductible is satisfied (1500 credited). So no deductible applies.

Coinsurance: 20% member of allowed 2400 = 480.00.

OOPM check: member OOP credited 2240. Individual in-network OOPM 6000. 2240 + 480 = 2720 < 6000. So full coinsurance applies.

Member responsibility = 0 (deductible) + 480 (coinsurance) = 480.00.
Plan paid = 2400 - 480 = 1920.00.

Ending member deductible = 1500.00 (unchanged, since no deductible applied). The deductible credit is 1500, which equals individual deductible; nothing more accrues since no deductible applied. Ending member deductible = 1500.00.

Hmm, "ending_member_deductible" — the accumulated deductible credited after this claim. Since deductible is satisfied and no deductible applied, it stays at 1500.00.

Wait — but should I consider whether the family deductible matters? The task says "an individual satisfies the individual deductible on their own". Individual deductible credited = 1500, which satisfies the individual in-network deductible of 1500. So no deductible applied.

Also check whether coinsurance of 480 would push OOPM — no, 2240+480=2720 < 6000.

So:
- deductible_applied: 0.00
- coinsurance_amount: 480.00
- member_responsibility: 480.00
- plan_paid: 1920.00
- ending_member_deductible: 1500.00

Check: member_responsibility + plan_paid = 480 + 1920 = 2400 = allowed. ✓

Note the coinsurance credits OOPM (copays always credit OOPM; coinsurance also counts toward OOPM as cost share). 2240 + 480 = 2720, below 6000.

Rounding: 480.00 exactly.

Output JSON with exactly these keys.

Let me work through this.

Plan: Bluebonnet PPO 1500, plan year 2026. Individual deductible in-network 1500.00, family 3000.00 embedded. The member has deductible credited 1500.00 through 2026-06-30 (individual satisfied). OOP credited 2240.00.

Mid-year plan change: accumulator carryover rider purchased, so all credits carry forward in full.

Claim: DOS 2026-08-06, in-network outpatient surgery, allowed 2400.00, subject to deductible and coinsurance.

Deductible applied: the member's individual deductible (1500.00) is already satisfied (credited 1500.00 carries forward due to rider). So deductible applied = 0.00.

Coinsurance: 20% of allowed amount after deductible. Deductible is fully satisfied, so coinsurance applies to full 2400.00 = 480.00.

Check OOPM: individual in-network OOPM 6000.00. Credited 2240.00 + 480.00 = 2720.00, below 6000. So no cap.

Member responsibility = 0.00 + 480.00 = 480.00.
Plan paid = 2400.00 - 480.00 = 1920.00.

Ending member deductible = 1500.00 (individual threshold, satisfied; credits don't exceed threshold... well, deductible applied was 0, so ending deductible balance credited = 1500.00).

Wait — should I consider the family deductible? The prompt only gives individual information: "Deductible credited 2026-01-01 through 2026-06-30 .... 1,500.00 (individual satisfied)". Under embedded structure, the member's deductible is satisfied by the lesser of their individual remainder and family remainder. Individual remainder = 0. Family remainder unknown, but lesser of 0 and family remainder is 0. So deductible satisfied regardless. Good — the family accumulator doesn't matter here because individual remainder is already 0. So the answer is determinate.

Ending member deductible: the running year-to-date deductible credit. It was 1500.00, claim applied 0.00 more (since satisfied), so ending = 1500.00.

So:
- deductible_applied: 0.00
- coinsurance_amount: 480.00
- member_responsibility: 480.00
- plan_paid: 1920.00
- ending_member_deductible: 1500.00

Check member_responsibility + plan_paid = 480 + 1920 = 2400 = allowed. ✓

OutputJSON only.

Let me work through this.

Plan: Bluebonnet PPO 1500, plan year 2026. Deductible individual in-network 1500.00, embedded. OOPM individual in-network 6000.00.

Group changed plan design effective 2026-07-01; accumulator carryover rider purchased, so all credits carry forward in full.

Deductible credited 2026-01-01 through 2026-06-30: 1,500.00 (individual satisfied). OOP credited: 2,240.00.

Claim: DOS 2026-08-06, in-network outpatient surgery, deductible and coinsurance. Allowed 2,400.00.

Deductible is satisfied (1500 credited, individual deductible 1500). So deductible_applied = 0.00.

Coinsurance: 20% member of allowed 2400.00 = 480.00.

Member responsibility = 480.00. Plan paid = 2400 - 480 = 1920.00.

OOPM check: OOP credited 2240.00 + 480 = 2720.00, well below 6000. So no cap.

Ending member deductible: the member's deductible balance — deductible credited 1500, and this claim adds 0 more deductible. So ending member deductible = 1500.00 (fully satisfied). The key "ending_member_deductible" — this likely means the credited deductible amount (running total) after the claim, i.e., 1500.00. Alternatively it could mean remaining deductible = 0.00. Hmm.

Let me think about which interpretation. "ending_member_deductible" — in this task family, adjudicate claims in order, each claim updates accumulators. The accumulator is "the running year-to-date total of a member's deductible or OOPM." Glossary: "Accumulator: the running year-to-date total of a member's deductible or OOPM." So ending_member_deductible = the running year-to-date total of deductible credited = 1500.00.

Given the glossary defines accumulator as running year-to-date total, ending_member_deductible should be 1500.00.

So:
- deductible_applied: 0.00
- coinsurance_amount: 480.00
- member_responsibility: 480.00
- plan_paid: 1920.00
- ending_member_deductible: 1500.00

Check member_responsibility + plan_paid = 480 + 1920 = 2400 = allowed. ✓

Coinsurance amount: is it the member's coinsurance share (480) or plan's? "Coinsurance after deductible, in-network: 20% member / 80% plan". coinsurance_amount should be member's coinsurance = 480.00.

Deductible applied: 0.00 since deductible already satisfied via carryover (1500 credited carried forward per rider). The carryover rider means credits carry forward in full, so deductible remains satisfied at 1500. So deductible_applied on this claim = 0.00.

Allgood.

We need answer JSON. Need solve claim adjudication with accumulators.

We have plan doc. Group changed plan design effective 2026-07-01, but design same, accumulators affected. They purchased carryover rider so all credits carry forward in full. Input says deductible credited Jan1-Jun30 1500.00 individual satisfied, OOP credited same period 2240.00.

Claim DOS 2026-08-06 in-network outpatient surgery, deductible and coinsurance. Allowed 2400.00. Need keys: deductible_applied, coinsurance_amount, member_responsibility, plan_paid, ending_member_deductible.

Need determine accumulators before claim: Member deductible credited 1500.00. Individual in-network deductible 1500, satisfied. But note in-network and out-of-network deductible credits accumulate to single member deductible balance, measured against OON threshold when OON. Here in-network. Since individual deductible satisfied, no deductible applied. OOP credited 2240.00, below OOPM individual in-network 6000. Claim subject to deductible and coinsurance. Since deductible satisfied, apply coinsurance 20% member of allowed. Member coinsurance = 0.20*2400=480. Plan pays 1920. Member responsibility = 480 (assuming no copay). OOP accumulator increases by 480, but not asked ending OOP. Deductible applied 0. Ending member deductible? Need interpret: ending_member_deductible probably ending accumulator? They ask ending_member_deductible number. Given starting deductible credited 1500 and deductible applied 0, ending member deductible = 1500? Or maybe remaining deductible? Need infer from key name. "ending_member_deductible" likely the member's deductible accumulator after claim. In these tasks, required keys include ending_member_deductible maybe year-to-date deductible credits. Starting credited 1500, claim applies 0, so ending 1500.00. Could be "ending member deductible met"? It says ending_member_deductible number. Need output plain number two decimals in JSON numeric? It says numbers plain two decimal places. JSON numbers cannot enforce decimals but can output 1500.00? JSON allows 1500.0? Actually JSON numeric representation can have 1500.00? Yes lexical can include fraction. We'll output numbers with two decimals.

Need consider mid-year plan change: design applies before/after; only accumulators affected. They have rider so credits carry forward in full. So starting deductible 1500 carries. OOP 2240 carries but irrelevant except if OOPM reached? Not reached.

Could there be family accumulator? No family details, only member. Embedded structure irrelevant.

Need ensure member_responsibility + plan_paid = allowed. 480+1920=2400.

Potential nuance: Out-of-pocket credited 2240 may include deductible? maybe yes. But not relevant. If deductible satisfied, coinsurance. If OOPM? 2240 + 480 = 2720 <6000.

Need output exactly one fenced JSON code block. No commentary. Ensure keys only required. Values numeric. Could output:
{
 "deductible_applied": 0.00,
 "coinsurance_amount": 480.00,
 "member_responsibility": 480.00,
 "plan_paid": 1920.00,
 "ending_member_deductible": 1500.00
}

Double-check if ending_member_deductible could be remaining deductible = 0. Since individual satisfied. Which is more likely? Let's examine terminology: They ask "ending_member_deductible" not "ending_member_deductible_accumulator" or "ending deductible balance". In task family rules: "Adjudicate claims in order... Each claim updates accumulators... ending_member_deductible" likely accumulator balance after claim. Also prompt gives "Deductible credited ..." not remaining. If they ask ending_member_deductible maybe amount of deductible met after claim. Starting 1500, applied 0 => 1500. If remaining, would be 0. Need choose.

Let's reason from required keys: "deductible_applied" amount applied to claim. "ending_member_deductible" likely ending accumulator for member deductible, to use for next claim. In multi-claim tasks, they'd need ending accumulator. They say "Each claim updates the accumulators the next claim is measured against". So ending_member_deductible should be accumulator total, not remaining. Also plan doc: Accumulator is running YTD total of deductible or OOPM. So ending deductible accumulator = 1500. Yes.

Need ensure if deductible satisfied before, ending_member_deductible might be capped at deductible amount? Deductible credits can exceed threshold? Here exactly 1500. If OON credits maybe single balance could exceed in-network threshold? But not here.

Final JSON only.