Claude Haiku 4.5

This is a complex claim ledger processing task. I need to carefully process each claim in order, tracking deductibles and out-of-pocket maximums for each member and for the family.

Let me start by understanding the plan:
- Individual in-network deductible: 2500.00
- Family in-network deductible: 5000.00
- Structure: EMBEDDED (individual can satisfy their own, family also satisfies once family total reaches 5000)
- Out-of-network individual deductible: 5000.00
- Individual OOPM in-network: 5500.00
- Family OOPM in-network: 11000.00
- Individual OOPM out-of-network: 11000.00
- In-network coinsurance: 30% member / 70% plan (after deductible)
- Out-of-network coinsurance: 50% member / 50% plan (after deductible)
- Copays: PCP $25, Specialist $50, Urgent care $60, ER $300 (waived if admitted), Generic pharmacy $10
- Copays credit both deductible and OOPM
- Preventive care: 100% covered, no cost share

Initial accumulators:
- A: ded 0.00, oopm 0.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 1150.72, oopm 1150.72
- Family: ded 2895.39, oopm 3051.40

Let me process each line:

**Line 1: Claim 1 - 2026-01-18 - D (child)**
- Service: Emergency department visit, in-network
- Allowed: 3295.94
- Disposition: Treated and released
- ER copay applies: $300, since not admitted the waiver doesn't apply
- D's ded balance before: 1150.72, individual remaining 1348.28, family remaining 2104.61
- Copay counts toward deductible and OOPM for this member since deductible not yet met

Copay applied: min(300, 1348.28, 2104.61) = 300.00
- Updated: member ded 1450.72, family ded 3195.39
- Remaining ded: member 1049.28, family 1804.61
- Applying to allowed 3295.94: min(3295.94, 1049.28, 1804.61) = 1049.28
- Member ded now fully satisfied at 2500.00, family ded now 4244.67
- Remaining allowed after copay+deductible to process next

ay applied toward deductible: 300.00
Member deductible now: 1150.72 + 300.00 = 1450.72, leaving 1049.28 remaining
Family deductible remaining: 5000.00 - 2895.39 - 300.00 = 1804.61

From remaining 2995.94, deductible applied = min(1049.28, 1804.61) = 1049.28

After deductible: 2995.94 - 1049.28 = 1946.66, subject to 30% coinsurance
Coinsurance: 1946.66 * 0.30 = 583.998 → 584.00
Plan portion: 1946.66 - 584.00 = 1362.66

Member total: 300.00 + 1049.28 + 584.00 = 1933.28
Verify: 1933.28 + 1362.66 = 3295.94 ✓

Still need to check against OOPM.

D's OOPM: 1150.72 + 1933.28 = 3084.00
Family OOPM: 3051.40 + 1933.28 = 4984.68

Updated accumulators after Line 1:
- A: ded 0.00, oopm 0.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 2500.00, oopm 3084.00
- Family: ded 4244.67, oopm 4984.68

Moving to Line 2 - Claim 2, D's urgent care visit (in-network), allowed 182.07, $60 copay. D's deductible is already satisfied at 2500.00, so need to determine how copay interacts with coinsurance once deductible is met.

Looking at the plan rules again, copays credit the deductible when applicable, but since D's deductible is already exhausted, this copay generates no additional deductible credit — it still counts toward OOPM though.

So for D: no deductible applied, copay = 60.00 credits OOPM, remaining allowed (182.07 - 60.00 = 122.07) goes to coinsurance.

30% coinsurance: 122.07 × 0.30 = 36.62, plan pays 85.45. Member owes 60.00 + 36.62 = 96.62 total (checks out against 182.07).

D's OOPM becomes 3084.00 + 96.62 = 3180.62; family OOPM updates to 5081.30.

Updated accumulators: C at ded 1744.67/oopm 1900.68, D at ded 2500.00/oopm 3180.62, family ded 4244.67/oopm 5081.30 (A and B still zero).

Moving to Line 3 - Claim 3, dated 2026-02-09 for subscriber A: an out-of-network inpatient admission with surgery, allowed amount 25881.03. Out-of-network deductible is 5000.00, with 50/50 coinsurance split. Checking A's deductible status — in-network individual is 0.00, out-of-network individual is 5000.00, and these accumulate together.

A's deductible starts at 0.00, so the full 5000.00 out-of-network deductible remains. Applying it against the 25881.03 allowed amount uses up the entire 5000.00, leaving 20881.03 subject to 50% coinsurance — that's 10440.52 member share, 10440.51 plan paid. Total member responsibility: 5000.00 + 10440.52 = 15440.52, which checks out against the plan's 10440.51 (summing to 25881.03).

For OOPM tracking, the out-of-network individual max is 11000.00, but I need to check whether family accumulators apply here. Re-reading the plan language: out-of-network claims only count against the out-of-network individual threshold, not the family amounts (which are in-network only). However, the out-of-network claim's credits still flow into both the member's and family's overall balance tracking.

So does A's balance get capped at 11000.00, or does it just track the raw 15440.52? Checking the accumulator rules — a balance is simply the running total, uncapped. Since out-of-network thresholds are higher, claims can push a member's balance past the in-network limits, and past the family limits too; balances aren't capped at th...

e in-network amounts. So while the raw balance isn't capped, once it reaches the applicable limit the plan starts paying 100%.

A's deductible: 5000.00. A's OOPM: 15440.52, against an 11000.00 out-of-network limit — already satisfied.

Family OOPM: 5081.30 + 15440.52 = 20521.82, but the 11000.00 family limit is in-network only and doesn't govern out-of-network claims. Out-of-network claims are checked only against the individual out-of-network threshold — family amounts don't limit them, though the claim still credits both the member's and family's balances.

I just need to track running balances and note which limits apply to each.

After Line 3:
- A: ded 5000.00, oopm 15440.52 (out-of-network limit 11000.00, exceeded)
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 2500.00, oopm 3180.62
- Family: ded 4244.67 (in-network only), oopm 20521.82

Now I need to check whether out-of-network deductible credits count toward the family deductible. In-network and out-of-network credits accumulate to a single member deductible balance, with the out-of-network threshold used for out-of-network measurement — but the family deductible section only lists in-network figures.

So member A's deductible balance is 5000.00 total after Line 3, but the family deductible likely only accrues from in-network credits. The plan structure is EMBEDDED: an individual satisfies their own deductible independently, and the family deductible is satisfied once total family credits reach the family amount, whichever comes first.

The wording "total family credits" doesn't specify in-network only, which makes me reconsider whether out-of-network counts too. But since the plan lists "Family (in-network)" specifically, I lean toward it being in-network only. The accumulators note that out-of-network claims can push balances past the in-network amounts without being capped there — suggesting out-of-network claims do affect the family balance, not just the individual one.

Looking at the deductible table, there's no separate "Out-of-network (family)" line — only "Out-of-network (individual) ... 5000.00". So the out-of-network deductible seems to apply per-individual only, with no family-level out-of-network deductible. "Total family credits" then likely refers to summed in-network credits across family members.

Under this reading, A's out-of-network claim wouldn't count toward the family deductible for Line 3, keeping it at 4244.67. But the accumulators' mention of out-of-network claims carrying balances past in-network family amounts complicates this and needs more thought.

I'll go with: family deductible tracks in-network only, out-of-network deductible is individual-only, though out-of-network member responsibility still feeds the family OOPM total (even without a family limit).

Updated accumulators after Line 3:
- A: ded 5000.00, oopm 15440.52
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 2500.00, oopm 3180.62
- Family: ded 4244.67, oopm 20521.82

Moving to Line 4 (C, urgent care, in-network, allowed 290.40, $60 copay): C's remaining deductible is 755.33, matching family's remaining 755.33 exactly.

The copay credits toward deductible: min(60.00, 755.33, 755.33) = 60.00. C's deductible → 1804.67, family → 4304.67.

Remaining allowed 230.40 all applies to deductible since both C and family have room (695.33 each): applied = 230.40. C's deductible → 2035.07, family → 4535.07.

No coinsurance since deductible absorbed the full remaining amount. Member pays 290.40 total (60 copay + 230.40 deductible), plan pays 0.00.

C's OOPM → 2191.08, family OOPM → 20812.22.

Accumulators after Line 4:
- A: ded 5000.00, oopm 15440.52
- B: ded 0.00, oopm 0.00
- C: ded 2035.07, oopm 2191.08
- D: ded 2500.00, oopm 3180.62
- Family: ded 4535.07, oopm 20812.22

Now onto Line 5, a claim for A on 2026-03-07.

Urgent care visit, in-network, allowed 175.00, copay $60. A's single deductible balance sits at 5000.00, satisfied for out-of-network purposes, but the in-network threshold is only 2500.00. Since the balance already exceeds that in-network limit, A's deductible is effectively satisfied for this in-network claim too.

So the copay of $60 doesn't apply toward deductible, no deductible amount applies, and coinsurance (30%) applies to the remaining allowed amount (175-60=115): 34.50 coinsurance, plan pays 80.50.

Member owes 94.50 total, pushing A's OOPM to 15535.02 — but wait, A's out-of-network OOPM (11000.00) was already exceeded back at Line 3, meaning further claims should be paid 100%. I need to track in-network and out-of-network OOPMs separately rather than combining them.

A's in-network OOPM tracker is still at 0.00 going into Line 5, since Line 3 was out-of-network. So Line 5's 94.50 responsibility applies fully against the in-network limit of 5500.00, landing at 94.50 — not yet satisfied.

The plan document's 100%-after-OOPM rule likely applies separately to each network type given their distinct limits. So in-network OOPM sits at 94.50/5500.00 (unmet) while out-of-network sits at 11000.00 (met). Future in-network claims still have cost-sharing; future out-of-network claims should be 100% plan-paid.

This also means Line 3 was miscalculated — the member's responsibility of 15440.52 blew past the 11000.00 out-of-network cap, so the member should have only been charged up to that limit.

er's actual responsibility for this claim: 11000.00 - 0.00 = 11000.00
- Plan paid: 25881.03 - 11000.00 = 14881.03

So the deductible and coinsurance figures get reduced proportionally, or the coinsurance is simply capped so the total member share doesn't exceed the OOPM. Either way, plan payment = allowed amount - actual member responsibility (capped at OOPM).

Checking the out-of-network OOPM language more carefully — the plan pays 100% once the 11000.00 threshold is met, and family accumulators don't apply to out-of-network claims, only individual out-of-network thresholds do.

With member responsibility calculated at 15440.52 (5000.00 deductible + 10440.515 coinsurance), this exceeds the 11000.00 OOPM cap. So the member's actual responsibility gets capped at 11000.00, meaning plan paid = 25881.03 - 11000.00 = 14881.03.

Breaking down Line 3: deductible applied stays 5000.00, but coinsurance applied becomes min(10440.52, 11000.00 - 5000.00) = 6000.00, bringing total member responsibility to exactly 11000.00.

I'll report deductible_applied as 5000.00, coinsurance_amount as 6000.00 (capped by OOPM rather than the raw 10440.52), member responsibility as 11000.00, and plan paid as 14881.03. A's OOPM accumulator now reaches 11000.00 after this line.

Updating accumulators post-Line 3: A has ded 5000.00/oopm 11000.00, B unchanged at 0/0, C at 1744.67/1900.68, D at 2500.00/3180.62. For family, I need to check how the out-of-network claim affects the family OOPM balance — the accumulator rules state out-of-network claims are measured against individual OON thresholds only, not family in-network amounts, but the credits generated still flow into the family balance.

Since there's no separate family OOPM for out-of-network, I'll treat the family OOPM as in-network only: 5081.30 + 11000.00 = 16081.30.

That number seems too high though. Let me re-examine the OOPM rule itself: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." This implies once OOPM is hit, all future costs are covered fully — but I still need to determine how a single claim that pushes past the OOPM threshold gets split between member and plan. Presumably the member owes only up to the remaining OOPM room, and the plan covers the rest of that claim.

For Line 3: member's raw cost share is 5000.00 + 10440.52 = 15440.52, but capped at the OOPM limit of 11000.00. So member pays 11000.00, plan pays 25881.03 - 11000.00 = 14881.03, and the member's OOPM balance moves from 0.00 to 11000.00.

Now I need to redo the accumulator tracking with this correction, including how the family OOPM interacts with out-of-network claims. The out-of-network claim is measured against the out-of-network individual threshold only — family in-network amounts don't cap it — but the resulting credits still flow into the family balance.

Family balance after Line 3: 5081.30 + 11000.00 = 16081.30, even though the in-network family OOPM limit of 11000.00 doesn't apply as a cap here since this is an out-of-network claim.

Member responsibility: 11000.00, Plan paid: 25881.03 - 11000.00 = 14881.03, which checks out: 11000.00 + 14881.03 = 25881.03.

Breakdown: deductible 5000.00, coinsurance 6000.00, member total 11000.00, plan paid 14881.03.

Restarting the ledger more carefully, I need to confirm how the OOPM works - copays credit both deductible and OOPM per the glossary, and deductibles/coinsurance also credit the OOPM. Once OOPM is met, the plan covers 100% of allowed amounts going forward.

For claims where cost share would exceed remaining OOPM, the member only pays up to the remaining OOPM cap.

For Line 3 (out-of-network): allowed 25881.03, raw cost share = 5000.00 deductible + 10440.52 coinsurance = 15440.52. With OOPM starting at 0.00 and limit 11000.00, capped OOPM = 11000.00, so member pays 11000.00 and plan pays 14881.03.

Breaking this into components: full deductible (5000.00) applies first, then coinsurance is capped at the remaining OOPM room: min(10440.52, 11000.00-5000.00) = 6000.00. Total member responsibility = 11000.00.

So deductible applied: 5000.00, coinsurance: 6000.00, member responsibility: 11000.00.

Now starting over to process the ledger from the beginning, tracking accumulators carefully.

Initial accumulators:
- A: ded 0.00, oopm 0.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 1150.72, oopm 1150.72
- Family: ded 2895.39, oopm 3051.40

For Line 1 (Claim 1, member D, in-network ER visit, allowed 3295.94), the ER copay is 300.00 and applies since the visit was "Treated and released."

D's individual deductible remaining is 1348.28, family remaining is 2104.61, so the lesser embedded value (1348.28) governs. The 300.00 copay credits toward deductible in full, bringing D to 1450.72 and family to 3195.39.

Remaining allowed after copay: 2995.94. New deductible remainders: D at 1049.28, family at 1804.61 — the limiting value is D's 1049.28, which gets applied, satisfying D's individual deductible at 2500.00 and pushing family deductible to 3195.39 + 1049.28.

Remaining balance after deductible: 1946.66, coinsurance at 30% = 584.00. Member owes 300.00 + 1049.28 + 584.00 = 1933.28; plan pays 1362.66. Verified against 3295.94 total.

D's OOPM updates to 3084.00, family OOPM to 4984.68.

Updated accumulators:
- C: ded 1744.67, oopm 1900.68
- D: ded 2500.00, oopm 3084.00
- Family: ded 4244.67, oopm 4984.68

For Line 2 (Claim 2, member D, urgent care, allowed 182.07), copay is 60.00. Since D's deductible is already satisfied, the copay doesn't apply toward it — deductible applied is 0.00.

Remaining allowed after copay: 122.07, coinsurance at 30% = 36.62. Member responsibility totals 96.62, plan pays 85.45.

D's OOPM becomes 3180.62; family OOPM updates to 4984.68 + 96.

ne 3:
- A: ded 5000.00, oopm 11000.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 2500.00, oopm 3180.62
- Family: ded 4244.67, oopm 16081.30

But wait - family OOPM tracks in-network amounts, and out-of-network claims aren't limited by family thresholds, though they still credit toward the family balance. So A's out-of-network OOPM is satisfied at 11000.00, and the family OOPM balance rises to 16081.30, exceeding the in-network family limit of 11000.00 - but that limit simply doesn't cap this claim.

Line 4: Claim 4 - C - urgent care, in-network, allowed 290.40, copay 60.00.

C's deductible remaining: 2500 - 1744.67 = 755.33; family remaining: 5000 - 4244.67 = 755.33. Copay credits deductible first: min(60, 755.33, 755.33) = 60.00. C's deductible → 1804.67, family → 4304.67.

Remaining allowed 230.40 goes to deductible: min(230.40, 695.33, 695.33) = 230.40. C's deductible → 2035.07, family → 4535.07. Nothing left for coinsurance.

Member responsibility = 290.40, plan paid = 0.00.
C's OOPM → 2191.08, family OOPM → 16371.70.

Accumulators: A ded 5000.00/oopm 11000.00, B 0/0, C ded 2035.07/oopm 2191.08, D ded 2500.00/oopm 3180.62, family ded 4535.07/oopm 16371.70.

**Line 5: Claim 5 - A - urgent care, in-network, allowed 175.00, copay 60.00**

A's deductible balance of 5000.00 exceeds the in-network limit, so A's in-network deductible is already satisfied — copay doesn't credit it further.

Remaining allowed after copay: 175.00 - 60.00 = 115.00. Coinsurance: 115.00 * 0.30 = 34.50.

Member responsibility: 60.00 + 34.50 = 94.50. A's in-network OOPM remaining (5500.00) easily covers this, no cap triggered.

Plan paid: 115.00 - 34.50 = 80.50.

A's in-network OOPM → 94.50, family OOPM → 16466.20.

I need to keep A's in-network and out-of-network OOPM tracked separately since they have distinct limits (5500 in-network, 11000 out-of-network).

But the output field is "ending_oopm_a" — singular, not separate in/out fields. So I need to decide how to represent a single combined balance while still respecting separate limits internally, since credits from either network type accumulate together toward the member/family total per the accumulator rules.

For A, this means summing across both types: 11000.00 (out-of-network from Line 3) + 94.50 (in-network from Line 5) = 11094.50 as the ending_oopm_a.

**Line 6: Claim 6 - C - Outpatient procedure, in-network, allowed 7641.96**
No copay applies, so deductible then coinsurance.

C's remaining deductible: 464.93, family remaining: 464.93 — both get satisfied with 464.93 applied.
- C deductible: 2500.00 (met)
- Family deductible: 5000.00 (met)

Remaining balance: 7641.96 - 464.93 = 7177.03
Coinsurance at 30%: 2153.11

C's in-network OOPM remaining: 3308.92. Member responsibility before cap: 464.93 + 2

153.11 = 2618.04, which stays under the 3308.92 remaining, so no cap needed.

Plan paid: 5023.92. C's OOPM updates to 4809.12, family OOPM to 19084.24.

**Line 7: Claim 7 - A - Physical therapy, in-network, allowed 894.21**
A's deductible is already satisfied, so coinsurance applies directly: 894.21 * 0.30 = 268.26.

A's remaining in-network OOPM is 5405.50, well above 268.26, so no cap triggers.

Plan pays 625.95. A's OOPM becomes 11362.76, family OOPM reaches 19352.50.

**Line 8: Claim 8 - D - Inpatient admission, in-network, allowed 25110.74**
D's deductible is met. Coinsurance calculates to 7533.22, but D only has 2319.38 left before hitting the 5500.00 in-network OOPM cap, so member responsibility caps at 2319.38.

Plan pays 22791.36. This pushes D's OOPM to exactly 5500.00 (fully satisfied), and family OOPM climbs to 21671.88.

**Line 9: Claim 9 - D - Physical therapy, in-network, allowed 646.70**
With D's

This is a complex plan year ledger task. Let me break down the rules:

1. Process lines in order, updating accumulators as we go
2. Embedded deductible: individual deductible is satisfied on its own; family deductible is also satisfied once total family credits reach family amount
3. In-network deductible: 2500 individual, 5000 family
4. Out-of-network deductible: 5000 individual (same balance as in-network)
5. In-network coinsurance: 30% member / 70% plan (after deductible)
6. Out-of-network coinsurance: 50% member / 50% plan (after deductible)
7. Emergency room: 300 copay, WAIVED if results in inpatient admission (then subject to deductible and coinsurance)
8. Urgent care: 60 copay
9. Other copays: PCP 25, specialist 50, generic pharmacy 10
10. Copays DO credit the deductible and OOPM
11. Preventive services: 100% covered, no cost share, don't move accumulators
12. Once OOPM reached, plan pays 100% for covered in-network services

Starting accumulators:
- A: deductible 0.00, OOPM 0.00
- B: deductible 0.00, OOPM 0.00
- C: deductible 1744.67, OOPM 1900.68
- D: deductible 1150.72, OOPM 1150.72
- Family: deductible 2895.39, OOPM 3051.40

Let me process each claim:

**Line 1 — Claim 1 — 2026-01-18 — D (child)**
Service: Emergency department visit, in-network, treated and released.
Allowed: 3295.94, copay: 300.00 (not waived, no admission).

D's individual deductible remaining: 2500.00 - 1150.72 = 1349.28
Family deductible remaining: 5000.00 - 2895.39 = 2104.61
Applicable deductible: 1349.28 (lesser of the two)

The 300.00 copay credits toward D's deductible, updating D's balance accordingly.

895.39 = 2104.61, so deductible_applied = min(1349.28, 2104.61) = 1349.28.

Deductible_applied against allowed amount (3295.94) = 1349.28. Remaining balance subject to coinsurance: 3295.94 - 1349.28 = 1946.66, giving coinsurance of 1946.66 × 30% = 583.99.

But the plan waives the ER copay if it results in inpatient admission—need to check whether that applies here.

For this treated-and-released claim, the 300.00 copay applies instead, and copays credit the deductible. So the copay uses 300.00 of D's remaining deductible (1349.28), leaving 1049.28 individual / 1804.61 family remaining. The remaining allowed amount after copay (2995.94) then gets applied: first toward the 1049.28 deductible, then coinsurance on what's left.

But I need to reconsider—deductible_applied should be measured against the allowed amount directly, not calculated after subtracting the copay. Let me re-check the accumulator rules for how copay, deductible, and coinsurance interact on this claim.

Individual deductible room: 1349.28, family room: 2104.61. Embedded rule takes min(allowed, min(individual, family)) = min(3295.94, 1349.28) = 1349.28 for deductible_applied.

Now for copay and coinsurance ordering—copay credits both deductible and OOP max, so I need to determine if it stacks before or alongside the deductible calculation.

Applying copay first: D's deductible becomes 1150.72+300=1450.72, family becomes 2895.39+300=3195.39. D's OOPM becomes 1450.72, family OOPM becomes 3351.40.

New remaining deductible room: D=1049.28, family=1804.61. Then I need to figure out how the copay factors into the remaining allowed amount calculation.

Actually, let me reconsider the whole structure. The member's cost consists of deductible, copay, and coinsurance layered together. The copay is a flat amount that also credits toward the deductible and OOPM simultaneously - it's not separate from those limits, it counts within them. So after the 300 copay is applied, I still need to work out what portion of the remaining $3295.94 allowed amount goes to deductible vs coinsurance, using the updated remaining deductible room (1049.28 for D, 1804.61 for family).

Then coinsurance applies at 30% on whatever's left after deductible is exhausted. I need to check the accumulators section more carefully to confirm how deductible_applied is calculated relative to allowed amount and remaining deductible room.

's other cost shares.

Let me reconsider the breakdown: member_responsibility = deductible_applied + copay_amount + coinsurance_amount, with the sum plus plan_paid equaling the allowed amount. But copay and deductible crediting might overlap in a service that has both a copay and deductible requirement.

"Copay credits the deductible" likely means the copay dollars also reduce the remaining deductible balance. So if D has $1349.28 remaining deductible and pays a $300 copay, the remaining deductible drops to $1049.28.

For Claim 1 (allowed $3295.94, copay $300): after crediting, remaining deductible is $1049.28, and I need to work out how the rest of the allowed amount applies to deductible and coinsurance.

- Copay: $300.00 (paid by member)
- Deductible applied: $1049.28 (satisfies remaining deductible)
- Remaining allowed: 3295.94 - 300 - 1049.28 = $1946.66
- Coinsurance at 30%: 1946.66 × 0.3 = $583.99

Total member cost: 300 + 1049.28 + 583.99 = $1933.27

I need to double-check this "credits the deductible" interpretation—standard insurance terminology usually treats copay and deductible as separate, non-overlapping costs, so I should verify which model applies here.

deductible—the copay itself remains a separate out-of-pocket expense.

Applying this to Claim 1: allowed amount 3295.94, copay 300 (paid by member). Remaining deductible for D drops to 1349.28 - 300 = 1049.28 since the copay credits it. Deductible applied against the remaining allowed (2995.94) is min(2995.94, 1049.28) = 1049.28. After that, 1946.66 remains, subject to 30% coinsurance = 583.99.

Total: 300 + 1049.28 + 583.99 = 1933.27.

Components: copay_amount 300.00, deductible_applied 1049.28, coinsurance_amount 583.99. Plan pays 3295.94 - 1933.27 = 1362.67, verified by summing all parts back to 3295.94.

Now for accumulators, I need to figure out whether D's deductible balance includes the copay. Checking my logic: deductible balance likely equals cumulative deductible_applied plus deductible-crediting copays, so D's balance updates accordingly.

deductible_applied is capped at 0.00 once the threshold is met, "including for a copay that would otherwise credit the deductible" — implying copay counts toward deductible too.

So the required output fields (deductible_applied, copay_amount, coinsurance_amount) might not be mutually exclusive buckets. Possibly deductible_applied already folds in the copay, or copay_amount is reported separately while still being part of what reduces the deductible room. I need to figure out which interpretation the schema expects: deductible_applied as total credited amount vs. deductible_applied as leftover after subtracting copay.

For Claim 1: copay=300, remaining deductible after copay=1049.28, remaining allowed after copay=2995.94, so deductible_applied=1049.28, coinsurance=(2995.94-1049.28)*30%=583.99.

Still unsure if copay should reduce the allowed amount before applying deductible math — need to confirm "credit the deductible" means copay dollars count against the deductible balance.

from the remaining deductible before calculating deductible_applied.

So with a 300 copay against a 1349.28 remaining deductible: remaining becomes 1049.28. Deductible_applied = min(3295.94, 1049.28) = 1049.28, leaving 1946.66 subject to 30% coinsurance = 583.99. Total member responsibility = 300 + 1049.28 + 583.99 = 1933.27, plan pays 1362.67. This approach lines up correctly.

Updating accumulators: D's deductible goes from 1150.72 to 1150.72 + 1049.28 + 300 = 2500.00 ✓. Family deductible: 2895.39 + 1049.28 + 300 = 4244.67. D's OOPM: 1150.72 + 1933.27 = 3084.00 (equivalent to adding copay + coinsurance).

Confirming copays credit OOPM per the rules given: 1150.72 + 300 + 583.99 = 2034.71 for D. Family OOPM: 3051.40 + 300 + 583.99 = 3935.39.

Moving to Claim 2, dated 2026-01-28 for D (child).

Urgent care visit, in-network, allowed 182.07, copay 60.00. D's deductible is already satisfied (2500.00), so copay doesn't touch deductible—just applies as member cost share directly.

Remaining after copay goes to coinsurance: 182.07 - 60 = 122.07, coinsurance at 30% = 36.62.

Total member owes: 60 + 36.62 = 96.62. Plan pays: 182.07 - 96.62 = 85.45.

D's accumulators: deductible stays 2500.00, OOPM becomes 2034.71 + 96.62 = 2131.33.

Family: deductible stays 4244.67, OOPM becomes 3935.39 + 96.62 = 4031.01.

Since D's deductible is already met, the copay shouldn't credit toward it - deductible_applied is 0.00 for Claim 2. The member pays both copay and coinsurance, both counting toward OOPM.

For Claim 2's math: copay 60.00 + coinsurance on the remaining allowed amount. If coinsurance applies to (182.07 - 60) × 30% = 36.62, but I need to verify whether copay reduces the coinsurance base in standard insurance logic - typically copay is separate from the deductible/coinsurance calculation entirely, not subtracted from the allowed amount.

Checking the plan's urgent care line: "Urgent care...60.00 copay" - no explicit mention of additional coinsurance on top, which suggests the copay alone might be the full cost share for this service type.

But then coinsurance may still apply separately. Given the plan text: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum" - this treats copays as distinct from deductible/coinsurance mechanics.

So the likely calculation: copay applies first, then remaining allowed amount goes through deductible/coinsurance if the service also has coinsurance listed separately.

For Claim 2 with allowed $182.07:
- Deductible already met, so full remaining amount subject to coinsurance
- Coinsurance: 182.07 × 30% = $54.62
- Plus copay: $60.00

That gives $114.62 total, only 63% of allowed — doesn't match the expected split. Maybe the copay reduces what's left before coinsurance applies:
- Member pays copay: $60
- Remaining: 182.07 - 60 = $122.07
- Coinsurance would apply to this remaining balance if deductible isn't met

Actually, deductible is met for D, so coinsurance applies directly: 122.07 × 30% = $36.62. Total member owes: 60 + 36.62 = $96.62, plan pays $85.45. That reconciles cleanly to the allowed amount.

Claim 2 breakdown: copay $60.00, deductible applied $0.00, coinsurance $36.62.

This updates D's OOPM to 2034.71 + 96.62 = $2131.33.

Checking whether copay reduces the base for coinsurance—the plan states cost share is calculated from the allowed amount, supporting that coinsurance applies to the remainder after copay: 122.07 × 30% = $36.62, member total $96.62.

I'll finalize this approach: copay is flat, coinsurance calculated on remaining allowed amount after copay is subtracted.

Now reconsidering the ER copay logic from Claim 1: the plan states $300 copay, waived only if admission occurs, in which case deductible/coinsurance applies instead. This implies ER visits normally use copay only—not both copay and coinsurance/deductible together. Admission swaps the payment method entirely rather than adding to it. I need to check the disposition for Claim 1 to see if admission occurred.

deductible/coinsurance can coexist, with the copay reducing the amount subject to deductible/coinsurance.

For Claim 1 (ER, treated and released), charge is 3295.94:
- Copay: 300
- Remaining: 2995.94
- Deductible applied: 1349.28 (remaining deductible)
- Remaining for coinsurance: 1646.66
- Coinsurance at 30%: 493.99
- Total member owes: 300 + 1349.28 + 493.99

Wait, actually the rule states deductible_applied is the lesser of the allowed amount and remaining deductible room — meaning it's based on the full allowed amount, not allowed minus copay. So for Claim 1: deductible_applied = min(3295.94, 1349.28) = 1349.28. This figure represents both what the member covers toward deductible and what the plan eventually covers.

The member also owes a copay of 300, and copays credit the deductible, reducing the remaining balance. So coinsurance applies to the leftover: (3295.94 - 1349.28) × 30% = 1946.66 × 30% = 583.99. Total member cost: 300 + 1349.28 + 583.99 = 2233.27.

I need to pin down whether the copay reduces the deductible-subject amount itself or just the remaining deductible balance — these give different results, and "credit the deductible" is ambiguous on this point.

Treating copay and deductible as separately paid amounts: copay 300, remaining allowed after copay 2995.94, remaining deductible after copay 1049.28, so deductible paid = min(2995.94, 1049.28) = 1049.28, leaving 1946.66 for coinsurance at 30% = 583.99. Total so far: 300 +

1049.28 + 583.99 = 1933.27, plan pays 3295.94 - 1933.27 = 1362.67, confirming my original figure for Claim 1.

For Claim 2, deductible's already met, so copay 60 leaves 122.07 for 30% coinsurance = 36.62, total member cost 96.62, plan pays 85.45 — also matching my earlier result.

Now let me lay out all four accumulators before processing starts: A and B at zero, C with 1744.67 deductible/1900.68 OOPM, D with 1150.72/1150.72, and family at 2895.39/3051.40. Moving into Line 1, Claim 1 for D's ER visit — allowed 3295.94, copay 300, with D's remaining deductible at 1349.28 and family's at 2104.61, using embedded logic to take the minimum applicable amount.

The copay of 300 reduces the remaining deductible target to 1049.28, so deductible applied comes out to that same 1049.28. That leaves 1946.66 subject to 30% coinsurance, totaling 583.99. Adding it up: member pays 300 + 1049.28 + 583.99 = 1933.27, plan covers 1362.67. This maxes out D's deductible to 2500.00, and pushes D's OOPM to 2034.99.

Family deductible climbs to 4244.67, family OOPM to 3935.39.

For claim 2, D's urgent care visit: deductible's already satisfied, so the 60 copay doesn't touch it. Coinsurance applies to 122.07 (allowed minus copay) at 30%, giving 36.62. Member owes 96.62 total, plan pays 85.45. Deductible stays at 2500.00 for D.

D's OOPM: 2034.71 + 60 + 36.62 = 2131.33. Family OOPM: 3935.39 + 96.62 = 4031.01.

Moving to claim 3, A's inpatient admission with surgery, this one's out-of-network. A hasn't touched the OON deductible yet, so the full 5000 applies against the 25881.03 allowed amount.

Remaining after deductible: 25881.03 - 5000 = 20881.03, coinsurance at 50% OON = 10440.52. Member owes 5000 + 10440.52 = 15440.52. Plan pays 10440.51.

Updating accumulators: A's deductible now 5000, A's OOPM (OON) at 15440.52. Family deductible climbs to 9244.67, but family OOPM stays at 4031.01 since OON amounts don't count toward the in-network OOPM tracker — need to double-check this assumption though.

Rereading the OOPM section: individual OON OOPM is 11000, separate from the in-network family figures. The plan explicitly states OON claims are measured only against individual OON thresholds — family in-network amounts don't cap them, though the credits still flow into both member and family balances.

So OON costs credit the family OOPM tally even though that family figure only governs in-network limits. Practically: once a member's OON spend hits 11000, that member's OON cost-sharing stops, regardless of whether the family total has been reached.

For Claim 3 (A, OON, allowed 25881.03): A's OON OOPM starts at 0, so this claim pushes A to 15440.52 if fully cost-shared - but that exceeds the 11000 cap. So A's OON responsibility is capped at 11000, and plan pays the remaining 25881.03 - 11000 = 14881.03.

52, 11000) = 11000, so the member's actual out-of-pocket is capped at their OOPM.

Plan pays: 25881.03 - 11000 = 14881.03

Checking the ACCUMULATORS section - balances keep accumulating past the OOPM threshold for tracking purposes, but once OOPM is hit, plan covers 100% going forward. So member's true cost share here is 11000 (the OOPM cap), and the plan absorbs the remainder: 14881.03.

Verifying: member_responsibility + plan_paid = allowed amount → 11000 + 14881.03 = 25881.03 ✓

The OOPM balance caps at the max itself (11000), not the raw calculated amount, since the member can't owe more than the plan maximum. For any future claims after hitting OOPM, member_responsibility drops to 0 for covered in-network services.

For OON claims specifically, coinsurance keeps applying until the separate OON OOPM is reached. Tracking cumulative member cost share: starting balance 0, this claim's raw cost share 15440.52, but capped at the remaining 11000 OON OOPM — so member pays exactly 11000, and that becomes the new OOPM balance.

The member_responsibility should break down into deductible_applied plus copay_amount plus the applicable coinsurance piece, all summing to that capped 11000.

Deductible gets applied first: 5000. That leaves 6000 of OOPM room. Coinsurance then gets capped at that remaining 6000 rather than the full 10440.52. So: deductible_applied 5000, copay 0, coinsurance_amount 6000, totaling 11000 member responsibility. Plan_paid becomes 25881.03 - 11000 = 14881.03.

Updating Claim 3 with this logic — allowed 25881.03, deductible 5000, coinsurance calculated at 50% of 20881.03 = 10440.52, but capped by remaining OOPM of 11000 (since A's OON OOPM starts fresh at 0 used).

So member pays: deductible 5000 + coinsurance min(10440.52, 6000) = 6000, totaling 11000. Plan pays the rest: 25881.03 - 11000 = 14881.03.

New accumulators:
- A deductible: 5000
- A OOPM: 11000 (met)
- Family deductible: 4244.67 + 5000 = 9244.67
- Family OOPM: need to check whether OON amounts count toward family OOPM per plan rules — checking the credit language now.

The rule states OON claim credits still accumulate to both the member's balance and the family balance, though family in-network thresholds don't limit OON claim cost-sharing. So Family OOPM becomes 4031.01 + 11000 = 15031.01, while the family in-network amounts remain irrelevant to how this OON claim's member responsibility is calculated.

exceeds the family in-network OOPM of 11000, meaning the family has effectively hit its in-network cap through this one OON claim.

That raises the question of subsequent claims from other family members — once family OOPM hits 11000, in-network claims should be paid at 100% for everyone else. The OON claim's contribution pushes the family over that threshold even though it's an out-of-network claim.

So:
- A OOPM: 11000
- Family OOPM: 15031.01 (though capped at 11000 for triggering the 100% in-network benefit)

The accumulator rules confirm balances aren't capped even if payment thresholds are.

Moving to claim 4 — C, urgent care, in-network:
- Allowed 290.40, copay 60.00
- C's remaining deductible: 2500 - 1744.67 = 755.33
- Family remaining deductible: 5000 - 9244.67 = already exceeded, so $0 remains

Since family deductible is already met, embedded structure dictates C's deductible is satisfied too, regardless of individual accumulation. Copay applies (60), then coinsurance on the rest: 230.40 × 30% = 69.12. Member owes 129.12 total, plan pays 161.28.

Updating trackers: C's OOPM climbs to 2029.80, family OOPM to 15160.13. Family deductible stays at 9244.67.

Now for claim 5 — A's urgent care visit. Allowed amount 175, copay 60. A's deductible is already satisfied (family met at 5000, well past the 2500 individual mark). After copay, 115 remains, coinsurance takes 34.50, so A pays 94.50 and plan covers the full 175.

I need to separate in-network and OON OOPM tracking — they're distinct pools per the plan terms. In-network individual OOPM is 5500, family in-network is 11000, and OON individual OOPM is a separate 11000. So A's in-network OOPM balance (starting at 0) absorbs this claim's 94.50, leaving 5405.50 remaining toward that specific cap.

For the family side, I'm uncertain whether OON claims contribute to the family in-network OOPM total or stay separate. Re-reading: "credits an out-of-network claim generates still accumulate to the member's balance and to the family balance" — this suggests there's just one shared family OOPM, not split by network status, even though individual OOPMs are split.

So the family OOPM cap of 11000 covers everything combined. Before Claim 3

This is a complex health plan ledger processing task. I need to process all 28 lines in order, tracking individual and family deductibles and out-of-pocket maximums, handling adjustments and voids properly.

Let me set up the key facts:
- Plan year 2026
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Out-of-network individual deductible: 3000.00 (but on same balance as in-network)
- Embedded structure (individual threshold of 1500, family threshold of 3000)
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Out-of-network individual OOPM: 12000.00
- In-network coinsurance: 20% member / 80% plan
- Out-of-network coinsurance: 40% member / 60% plan
- Primary care copay: 30.00
- Specialist copay: 60.00
- Urgent care copay: 75.00
- ER copay: 400.00 (waived if admission)
- Generic pharmacy copay: 15.00
- Preventive services: 100% covered, no cost share

I'll track:
- Member deductible balance (single balance for both in and out of network)
- Member OOPM balance
- Family deductible balance
- Family OOPM balance

Let me process each line:

**Line 1 — Claim 1 — 2026-01-23 — D (child) — Outpatient procedure, in-network**
- Allowed: 9156.86
- In-network, so deductible is 1500 individual / 3000 family (embedded)
- D has no deductible applied yet
- Deductible applied: min(9156.86, 1500, 3000) = 1500.00
- Remainder 8656.86 hits 20% coinsurance = 1731.37
- Member owes 1500 + 1731.37 = 3231.37, plan pays 5925.49

Running totals after this claim: D's deductible maxed at 1500.00, D's OOPM at 3231.37, family deductible at 1500 toward the 3000 threshold.

Moving to claim 2 for E, a $205.32 primary care visit with a $30 copay. Since copays don't touch deductible but do count toward OOPM, I just need to confirm whether the allowed amount beyond the copay is subject to deductible or if the copay is the full cost-share for this visit type.

Copay is a flat per-service charge — E pays $30, plan covers the remaining $175.32. No deductible applies here since copays bypass deductible entirely.

- Member owes: $30.00 copay
- Plan pays: $175.32
- Deductible applied: $0.00
- Coinsurance: $0.00

Running totals now: B's deductible sits at $0.00 remaining toward E-level, OOPM at $30.00; D's deductible at $1500.00, OOPM at $3231.37; family deductible $1500.00, OOPM $3261.37.

For claim 3 (B, outpatient imaging, allowed $1054.17), no copay applies so coinsurance kicks in. B has $1500.00 individual deductible remaining, family has $1500.00 remaining. Deductible applied = min(1054.17, 1500, 1500) = $1054.17, fully absorbing the allowed amount with $0 left over.

No coinsurance owed; member owes the full $1054.17, plan pays $0.

Updated after Line 3: B deductible $1054.17/OOPM $1054.17; D unchanged at $1500.00/$3231.37; E unchanged at $0.00/$30.00; family deductible climbs to $2554.17, OOPM to $4315.54.

Claim 4 covers E's inpatient surgery, out-of-network, allowed $16325.03. Out-of-network coinsurance splits 40% member/60% plan. E hasn't touched deductible yet, and the out-of-network individual threshold is $3000.00 — applied independently of family totals since this is out-of-network. Deductible applied: min(16325.03, 3000) = $3000.00, leaving $13325.03 subject to coinsurance. Member's 40% share comes to $5330.01, making total member responsibility $3000.00 + $5330.01 = $8330.01.

Plan pays the difference: $16325.03 - $8330.01 = $7995.02.

After Line 4: E's deductible sits at $3000.00, OOPM climbs to $8360.01. Family deductible now totals $5554.17 — exceeding the stated family threshold of $3000.00, though I'll keep tracking it. Family OOPM reaches $12645.55.

I need to double-check how out-of-network deductible interacts with the single balance system. The plan specifies one shared deductible balance per member, with different thresholds depending on network status — $1500 in-network, $3000 out-of-network. So for E's out-of-network claim, the relevant threshold is $3000, not $1500.

Since E entered Line 4 with $0.00 applied, the deductible owed is min(16325.03, 3000 - 0) = $3000.00.

For the family side, the ACCUMULATORS section clarifies: in-network uses the embedded approach — the smaller of individual remainder and family remainder. Out-of-network only checks the individual remainder against that same single balance, ignoring the family remainder entirely.

For E's line 4 (out-of-network):
- E's balance: 0.00, individual remainder: 3000.00
- Deductible applied: min(16325.03, 3000.00) = 3000.00
- E's balance becomes 3000.00

But does this feed into the family total? The plan states out-of-network credits still accumulate to both the member's balance and the family balance, even though family thresholds don't limit out-of-network claims. So after this line, family balance also increases by 3000.00.

Wait - checking the family OOPM would push it above 12000.00, but that limit is in-network only per the ACCUMULATORS language. Out-of-network claims are measured solely against the individual out-of-network thresholds (12000.00 each), so the family cap doesn't constrain this claim regardless of what the family running total shows.

So each member has 6000.00 in-network / 12000.00 out-of-network individual OOPM, with a 12000.00 family in-network OOPM. E's out-of-network claim is checked only against E's own 12000.00 threshold, unaffected by the family accumulation shown above.

's tracking shows in-network OOPM of 6000.00 and out-of-network OOPM of 12000.00. After line 4, E's in-network OOPM sits at 30.

.00, out-of-network OOPM at 8330.01, and family in-network OOPM at 4315.54 (out-of-network doesn't contribute here).

The plan language about out-of-network credits accumulating to member and family balance applies specifically to the deductible, not the OOPM. So for line 4, E's deductible balance updates to 0.00 + 3000.00 = 3000.00, and E out-of

y refer to the family deductible balance and family in-network OOPM. So the out-of-network claim counts toward the family deductible and the member's own out-of-network OOPM, but not the family in-network OOPM.

So my original approach was correct. Continuing from Line 4:
- A deductible: 0

.00, OOPM: 0.00
- B deductible: 1054.17, OOPM: 1054.17
- C deductible: 0.00, OOPM: 0.00
- D deductible: 1500.00, OOPM: 3231.37
- E deductible: 3000.00, out-of-network OOPM: 8330.01, in-network OOPM: 30.00
- Family deductible: 5554.17, in-network OOPM: 4315.54

But wait - can the family deductible balance actually exceed 3000.00? With embedded deductibles, once the family deductible cap is hit, no further deductible applies to anyone, even if individual members haven't hit theirs yet. I need to check the plan rules on this.

The plan states the family deductible is satisfied once total family credits reach 3000.00, whichever comes first (individual or family threshold). So once family credits hit that cap, all subsequent claims stop applying deductible at the family level.

For in-network claims, the deductible applied per claim is the minimum of: the allowed amount, the member's remaining individual deductible (1500 minus their balance), and the family's remaining deductible (3000 minus family balance).

For out-of-network claims, each member has a threshold of 3000.00 on the same shared balance—there's no separate family out-of-network cap mentioned. The applied amount is the lesser of the claim's allowed amount and the member's remaining balance against that 3000 threshold, and it still counts toward the family total.

But the plan specifies deductible credits accumulate into a single member balance, not split by network status. So in-network and out-of-network claims share one running total per member—meaning out-of-network claims, with their higher threshold, can push a member's balance past their in-network individual cap.

Similarly, family balances aren't capped at in-network amounts—out-of-network claims can drive the family total past 3000 (the family's in-network threshold) since out-of-network claims are only measured against individual thresholds, not family ones. That raises a question: if the family deductible is already met but a member submits an out-of-network claim, does deductible still apply since family caps don't govern out-of-network claims?

So for embedded in-network deductibles, a member pays toward deductible up to min(individual remaining, family remaining), stopping once either cap is hit. For out-of-network, since there's no stated family threshold specifically for out-of-network, deductible applies up to the member's own 3000 individual out-of-network cap, and those credits still flow into both the member and family balances even though the family cap doesn't constrain them.

This means:
- In-network deductible applied = min(allowed, member's individual remaining, family remaining)
- Out-of-network deductible applied = min(allowed, member's individual out-of-network remaining)

Both types still increment the member's and family's tracked balances.

Now looking at Claim 4 — E's inpatient admission, out-of-network, allowed 16325.03, with E's deductible balance at 0.00.

E's out-of-network individual threshold is 3000.00, so remaining is 3000.00. Deductible applied = min(16325.03, 3000.00) = 3000.00. Remaining after deductible: 13325.03, coinsurance at 40% = 5330.01. Member responsibility = 3000.00 + 5330.01 = 8330.01, plan paid = 7995.02.

Updating accumulators: E's deductible balance becomes 3000.00, family deductible becomes 2554.17 + 3000.00 = 5554.17 — exceeding the family threshold of 3000.00. This confirms out-of-network claims can push balances past the in-network caps since balances aren't capped at those amounts.

So deductible stops applying once a threshold is reached: for in-network claims, both the member's 1500 threshold and the family's 3000 threshold gate the deductible; for out-of-network claims, only the member's 3000 threshold applies (family in-network threshold is irrelevant here), though the amount still accumulates into the shared family balance.

After Line 4, E's deductible balance sits at 3000.00 and the family balance at 5554.17 — meaning the family threshold of 3000 is already exceeded, so subsequent in-network claims for any member will have deductible_applied = 0 due to the family cap. Out-of-network claims still apply per-member up to their own 3000 threshold.

Moving to Line 5 (E, outpatient rehab, in-network, allowed 2923.30): I need E's individual in-network threshold remaining. E's balance of 3000 came from an out-of-network claim, so I'm unsure whether that balance counts against E's in-network threshold or if separate tracking applies —

Re-reading the plan: deductibles use a single member balance that accumulates both in-network and out-of-network credits, with different thresholds depending on claim type — in-network individual 1500, in-network family 3000, out-of-network individual 3000. For in-network claims, deductible_applied is the lesser of the allowed amount and the room remaining under the smaller of the member's individual remainder and the family remainder.

With the member's balance already at 3000 from the prior out-of-network claim, individual remainder = 1500 - 3000 = negative, so effectively 0. Family remainder = 3000 - 5554.17, also negative, so 0. That means deductible_applied = min(2923.30, 0, 0) = 0 for Line 5 — no deductible applies since both thresholds are already exceeded.

This means coinsurance kicks in instead, since the individual deductible is satisfied. I need to nail down what "remainder" means once the balance surpasses the threshold — typically it just floors at zero rather than going negative.

Given deductible = 0, coinsurance applies to the full allowed amount: 2923.30 * 20% = 584.66 member responsibility, leaving plan paid = 2923.30 - 584.66 = 2338.64.

After Line 5, E's deductible sits at 3000.00, in-network OOPM climbs to 614.66, out-of-network OOPM to 8330.01, and family deductible/OOPM update to 5554.17 / 4900.20.

Line 6 is a preventive screening mammography for A — no cost share, no accumulator movement, so member owes 0.00 and plan pays 1220.47 in full.

Line 7 involves D's inpatient admission, allowed 19176.22, in-network. D's deductible balance from Line 1 was 1500.00, so I need D's remaining individual threshold against the 1500 cap and check against family's 3000 threshold too.

D's remainder comes out to 0, family remainder is also 0, so deductible applied is 0.00. The full allowed amount hits coinsurance: 20% of 19176.22 = 3835.24, matching member responsibility. Plan pays 15340.98.

After this, D's OOPM rises to 7066.61, family in-network OOPM to 8735.44.

Line 8 covers A's inpatient admission with surgery, allowed 15812.18. A's deductible balance is 0.00, individual remainder 1500, but family remainder is 0 — so deductible applied stays 0.00 since family cap is exhausted, pushing the full amount into coinsurance calculation.

family in-network OOPM threshold is 12000.00, and this is now exceeded.

Once the family OOPM is reached, the plan pays 100% for in-network services. Let me reconsider Line 9 with this in mind: remaining family OOPM before this claim is 12000.00 - 8735.44 = 3264.56, so member owes min(coinsurance amount, 3264.56) rather than the full 4762.15. I need to check the ACCUMULATORS section for exact balance tracking rules.

The out-of-pocket balance tracks member_responsibility, not deductible + coinsurance separately. Once family OOPM balance hits 12000.00, plan pays 100% for remaining services in the year.

Calculating member responsibility for Line 9 without OOPM cap: deductible applied 0.00, coinsurance 4762.15, totaling 4762.15. Adding to prior balance of 8735.44 gives 13497.59, which exceeds 12000.00 — confirming the OOPM cap must be applied to limit the actual member cost.

is capped: min(4762.15, 12000.00 - 8735.44) = 3264.56, so plan_paid = 23810.73 - 3264.56 = 20546.17.

After Line 9: E deductible 3000.00, in-network OOPM 3879.22, out-of-network OOPM 8330.01; family deductible 5554.17, in-network OOPM hits the 12000.00 cap.

Line 10, E's diagnostic lab panel (846.74, in-network) — family OOPM already maxed, so plan pays 100%, member owes 0.00, plan pays 846.74 in full. Balances stay the same except plan payment.

Moving to Line 11, A's outpatient rehab claim (8259.39, in-network), A's deductible balance is 0.00, checking family status next.

the family OOPM limit applies. The balance is 12000.00, already at the limit, so the plan should pay 100% of the allowed amount rather than applying the copay.

Copays credit the OOPM per plan rules, so once the OOPM is met, no further member cost-sharing applies—including copays.

For Line 13:
- Family in-network OOPM balance: 12000.00 (at limit)
- Plan pays 100% of allowed amount
- Member responsibility: 0.00
- Plan paid: 208.35

ponsibility: 0.00, plan pays allowed amount in full, no copay/coinsurance/deductible applies.

Line 13 confirmed:
- Member responsibility: 0.00
- Plan paid: 208.35
- Deductible: 0.00, Copay: 0.00, Coinsurance: 0.00

Running totals after Line 13:
- C: deductible 0.00, OOPM 0.00
- Family: deductible 5554.17, in-network OOPM 12000.00

Moving to Line 14 — ADJUSTMENT to Claim 8, dated 2026-05-31, for A (subscriber).

Original allowed 15812.18 → adjusted allowed 13440.35, with original member responsibility 3162.44.

To process the adjustment, I first back out the original claim's credits from accumulators:
- A's in-network OOPM: 3162.44 - 3162.44 = 0.00
- Family in-network OOPM: 12000.00 - 3162.44 = 8837.56
- No deductible was applied originally, so nothing to remove there

Then re-adjudicate with corrected allowed amount:
- A's deductible balance before claim: 0.00; family deductible balance: 5554.17
- A's remainder: max(0, 1500-0)=1500; family remainder: max(0, 3000-5554.17)=0
- Deductible applied: min(13440.35, 1500, 0) = 0.00
- Coinsurance at 20%: 13440.35 * 0.20 = 2688.07
- Member responsibility: 2688.07
- Plan paid: 13440.35 - 2688.07 = 10752.28

This is lower than the original 3162.44 responsibility. Adding back the corrected credits:
- A's OOPM: 0.00 + 2688.07 = 2688.07
- Family OOPM: 8837.56 + 2688.07 = 11525.63

Checking whether claims between the original and adjustment need reprocessing — Lines 9-13 (Claims 9-13 for E, A, A, C) fall in between. Per the rule, claims processed between the original and adjustment are NOT reprocessed and stand as first adjudicated. So I only adjust Claim 8's own credits, not the intervening ones.

Also confirming: "An adjustment or void affects only the claim it names" — meaning Claim 8 alone gets touched.

So the process is: remove Claim 8's original credits, re-adjudicate at corrected values against current accumulator state, then add the corrected credits back.

I need to double-check my running family OOPM total since I may have miscalculated:
- Line 1: 3231.37
- Line 2: 3261.37
- Line 3: 4315.54
- Line 4: unchanged (out-of-network)
- Line 5: 4900.20
- Line 6: unchanged (preventive)
- Line 7: 8735.44
- Line 8: 8735.44 + 3162.44

I need to recheck whether OOPM tracking is cumulative or capped per-claim. The plan states that once the OOPM is met, the plan covers 100% for the rest of the year, and balances are running totals of member responsibility. So each service adds its member responsibility until the balance hits the threshold, then any excess gets capped so the balance lands exactly at the max, with the plan absorbing the remainder.

For Line 9: family in-network OOPM sits at 11897.88 before this claim, with an uncapped member responsibility of 4762.15. Adding that would push the balance to 16660.03, well past 12000.00 — so I cap it at 12000.00 - 11897.88 = 102.12, meaning plan paid = 23810.73 - 102.12 = 23708.61.

That contradicts my earlier number, so I need to retrace the family OOPM accumulation from the start:
- Line 1 (D): 3231.37
- Line 2 (E): 3261.37
- Line 3 (B): 4315.54
- Line 4 (E, OON): unchanged, 4315.54
- Line 5 (E): 4900.20
- Line 6 (A, preventive): unchanged
- continuing through subsequent lines to confirm the balance right before Line 9.

This makes me realize I should be tracking OOPM at both the individual and family level, not just family — since the plan sets individual in-network OOPM at 6000.00 and family at 12000.00, with 100% coverage kicking in once either threshold is hit for that member.

So each service's member responsibility should be the minimum of: the standard cost share, the remaining individual OOPM, and the remaining family OOPM. I need to check if the plan language supports individual and family maxes working independently (embedded) rather than just family-only tracking.

The family OOPM at 12000 being exactly 2x the individual 6000 suggests standard embedded accumulator logic — once any one member hits 6000, that member is done, and once family hits 12000 combined, everyone stops paying. Out-of-network claims only count against the out-of-network individual threshold, not the in-network family amounts.

For each in-network service, I'll apply min(cost_share, member_remaining_oopm, family_remaining_oopm). After Line 8, totaling individual accumulators: A=3162.44, B=1054.17, C=0, D=7066.61, E=614.66, giving family total 11897.88.

Line 9 (E): remaining member OOPM 5385.34, remaining family OOPM only 102.12 - this becomes the binding constraint. Member pays 102.12, plan covers 23708.61. Family hits 12000.00 exactly.

Line 10 (E): Family is now at limit, remaining 0.00, so member responsibility becomes min(cost_share, member_remaining, 0.00) = 0.00 - fully covered by plan.

Since family OOPM stays maxed at 12000.00, Lines 11-13 (A, A, C) all follow the same pattern: member pays 0.00, plan pays 8259.39, 5987.22, and 208.35 respectively.

Verifying Line 9 against the post-Line-8 tally: A=3162.44, B=1054.17, C=0.00, D=7066.61, E=614.66, summing to family total 11897.88 - confirms the 102.12 gap driving Line 9's calculation.

Now I need to circle back and adjust Line 8's calculatio

Let me work through this carefully, processing each claim in order and tracking the accumulators.

**Plan Details:**
- Individual (in-network) deductible: 2500.00
- Family (in-network) deductible: 5000.00
- Structure: EMBEDDED (individual can satisfy individual deductible on their own; family threshold is also satisfied once total family credits reach family amount)
- Out-of-network deductible (individual): 5000.00
- In-network and out-of-network deductibles accumulate to SINGLE member deductible balance
- Individual (in-network) OOPM: 5500.00
- Family (in-network) OOPM: 11000.00
- Individual (out-of-network) OOPM: 11000.00
- In-network coinsurance: 30% member / 70% plan
- Out-of-network coinsurance: 50% member / 50% plan
- Specialist copay: 50.00
- Generic pharmacy copay: 10.00
- Emergency room copay: 300.00 (waived if admitted as inpatient, then subject to deductible and coinsurance)
- Copays credit the deductible
- Copays credit the OOPM
- Preventive services: no cost share, no deductible, no accumulator movement

**Initial State:**
All deductibles and OOPMs are at 0.00 for all members and family.

Let me process each line:

**Line 1 — Claim 1 — 2026-01-18 — A (subscriber)**
- Service: Outpatient procedure, in-network
- Allowed: 6138.52
- This is in-network, subject to deductible and coinsurance
- A's individual deductible remainder: 2500.00
- Family deductible remainder: 5000.00
- Deductible applied: min(6138.52, 2500.00, 5000.00) = 2500.00
- Remaining after deductible: 3638.52, coinsurance at 30% = 1091.56
- Member owes 2500.00 + 1091.56 = 3591.56, plan covers the rest, 2546.96

Updating accumulators: A hits 2500.00 deductible/3591.56 oopm, family matches at 2500.00/3591.56, B/C/D untouched.

Moving to Line 2, claim for D on 2026-01-23, ambulatory surgery out-of-network, allowed 2734.12. This falls under D's out-of-network deductible, remainder 5000.00, so full 2734.12 applies toward deductible.

With no remaining balance after deductible, coinsurance is 0.00, making D's total responsibility 2734.12 and plan payment 0.00.

Updated: D deductible/oopm both 2734.12, family deductible 5234.12, family oopm 6325.68.

I need to double-check how family deductible accumulates across in-network and out-of-network buckets since the plan is embedded—should verify whether out-of-network credits count separately from the family threshold.

The plan document clarifies: out-of-network claims measure against out-of-network individual thresholds, not family amounts (which are in-network), but the credits still flow into the member's and family's balance. So D's 2734.12 out-of-network credit adds to family deductible: 2500.00 + 2734.12 = 5234.12, exceeding the 5000.00 family threshold — family deductible is now satisfied.

Moving to Line 3, Claim 3, dated 2026-02-03, for subscriber A.

Inpatient admission, in-network, allowed 11894.44. A's individual deductible remainder is 0.00 (already met), and family deductible is also satisfied (5234.12 exceeds 5000.00), so no deductible applies here. Coinsurance at 30% gives 3568.33, all falling to member responsibility since deductible is already exhausted. Plan pays 8326.11.

Updated accumulators: A's deductible stays at 2500.00, oopm rises to 7159.89 (3591.56 + 3568.33). B and C remain untouched at zero. D's deductible holds at 2734.12, oopm carries forward unchanged.

Family totals: deductible 5234.12, oopm climbs to 9894.01 (6325.68 + 3568.33).

Though A's OOPM limit is 5500.00, the running total of 7159.89 exceeds it — this is acceptable since accumulators can continue past the in-network threshold per the document.

Moving to Claim 4 — B's ambulatory surgery on 2026-02-10, in-network, allowed 8808.44. B's individual deductible remainder is the full 2500.00, but family deductible is already satisfied at 0 remaining. Embedded deductible logic takes the minimum of these figures, applying 0.00. Full allowed amount carries to coinsurance: 8808.44 × 30% = 2642.53.

.00 = 322.91, coinsurance 30% = 96.87, member owes 50.00 + 96.87 = 146.87, plan pays 226.04.

Accumulators after Line 5:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 0.00, oopm 2789.40
- C: deductible 0.00, oopm 0.00
- D: deductible 2734.12, oopm 2734.12
- Family: deductible 5234.12, oopm 12683.41

Line 6, Claim 6, 2026-02-27, B (spouse): outpatient infusion, out-of-network, allowed 722.55. B's individual out-of-network deductible remainder is 5000.00.

Deductible absorbs the full 722.55, leaving nothing for coinsurance. Member owes 722.55, plan pays 0.

Updated: B deductible 722.55, oopm 3511.95; others unchanged.

Family total: deductible 5956.67 (exceeds 5000 family max), oopm 13405.96.

**Line 7 — Claim 7 — 2026-03-12 — B (spouse)**
Ambulatory surgery, in-network, allowed 7877.07. B's remaining individual deductible is 1777.45, but family deductible is already met (5956.67 > 5000), so applied deductible = 0.00. Full 7877.07 moves to coinsurance.

Coinsurance at 30%: 2363.12, so member owes 2363.12 total, plan covers 5513.95.

Updated totals:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 722.55, oopm 5875.07
- C: deductible 0.00, oopm 0.00
- D: deductible 2734.12, oopm 2734.12
- Family: deductible 5956.67, oopm 15769.08

**Line 8 — Claim 8 — 2026-03-26 — C (child)**
Inpatient admission with surgery, in-network, allowed 14673.

oopm = 15769.08 + 4401.99 = 20171.07

**Line 9 — Claim 9 — 2026-04-05 — D (child)**
- Service: Inpatient admission with surgery, in-network
- Allowed: 12574.38
- D's deductible already exceeded (2734.12 > 2500.00), remainder 0
- Family deductible also satisfied, remainder 0
- Deductible applied: 0.00
- After deductible: 12574.38
- Co

insurance (30%): 12574.38 × 0.30 = 3772.31, plan paid 8802.07

Accumulators after Line 9:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 722.55, oopm 5875.07
- C: deductible 0.00, oopm 4401.99
- D: deductible 2734.12, oopm 6506.43
- Family: deductible 5956.67, oopm 23943.38

**Line 10 — ADJUSTMENT to Claim 5 — 2026-04-09 — B (spouse)**
Reviewing the original Claim 5 to apply this correction.

Original Claim 5: allowed 372.91, member responsibility 146.87 (copay 50.00 + coinsurance 96.87), deductible applied 0.00.

Adjustment corrects allowed to 223.75. I need to reprocess using accumulators as they stood right before Claim 5, which were after Line 4: B deductible 0.00, oopm 2642.53; family deductible 5234.12 (satisfied), oopm 12536.54.

Reprocessing with allowed = 223.75, checking B's remaining individual deductible of 2500.00 against the family deductible already being satisfied.

Since family deductible is already met, deductible applied stays at 0.00. Copay 50.00, then coinsurance on the remaining 173.75 at 30% = 52.13. Member responsibility totals 102.13, plan paid = 223.75 - 102.13 = 121.62.

Comparing to original: member responsibility drops from 146.87 to 102.13 (44.74 credit to member), plan paid drops from 226.04 to 121.62 (104.42 charge back to plan).

Now I need to unwind this original claim's impact on the running accumulators and reapply the corrected version before continuing forward through subsequent claims.

Before line 10, accumulators sit at: A ded 2500.00/oopm 7159.89, B ded 722.55/oopm 5875.07, C ded 0.00/oopm 4401.99, D ded 2734.12/oopm 6506.43, family ded 5956.67/oopm 23943.38.

Removing original Claim 5's contribution: since it applied 0.00 deductible, B and family deductibles stay unchanged. Subtract the 146.87 member responsibility from B's oopm (→5728.20) and family oopm (→23796.51). Then reapply the corrected claim with the new deductible/copay/coinsurance figures.

At the new allowed amount of 223.75, deductible applied is still 0.00 (family already met), member responsibility comes to 102.13. Add this back: B's oopm becomes 5830.33, family oopm becomes 23898.64. Deductibles remain unchanged at 722.55/5956.67.

So after processing through line 10: A stays 2500.00/7159.89, B is now 722.55/5830.33, C stays 0.00/4401.99, D stays 2734.12/6506.43, family stands at 5956.67/23898.64.

Lines 6-9 fall between claim 5 and claim 10 but shouldn't need reprocessing—I should double check the adjustment instructions to confirm this.

= 23898.64

Accumulators after Line 10:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 722.55, oopm 5830.33
- C: deductible 0.00, oopm 4401.99
- D: deductible 2734.12
- Family oopm: 23898.64

Checking deductible status at adjustment time: family deductible was already met when the original Claim 5 was processed, so deductible applied was 0.00 both before and after — no change there.

**Line 11 — Claim 11 — 2026-04-14 — C (child)**
- Service: Inpatient admission, in-network
- Allowed: 16484.33
- C's individual deductible remainder: 2500.00
- Family deductible: already met (0 remainder)

Deductible applied: 0.00, coinsurance 30% of 16484.33 = 4945.30, plan pays 11539.03.

Updated accumulators:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 722.55, oopm 5830.33
- C: deductible 0.00, oopm 9347.29
- D: deductible 2734.12, oopm 6506.43
- Family: deductible 5956.67, oopm 28843.94

**Line 12 — Claim 12 — 2026-04-20

Specialty pharmacy administration for spouse B, out-of-network, allowed 6655.34. B's remaining out-of-network individual deductible: 5000.00 - 722.55 = 4277.45, fully applied. Remainder: 6655.34 - 4277.45 = 2377.89, coinsurance 50% = 1188.95. Member owes 4277.45 + 1188.95 = 5466.40, plan pays 1188.94.

Plan paid: 6655.34 - 5466.40 = 1188.94

Check: 5466.40 + 1188.94 = 6655.34 ✓

Updating accumulators after Line 12:
- A unchanged: deductible 2500.00, oopm 7159.89
- B: deductible 722.55 + 4277.45 = 5000.00 (met), oopm 5830.33 + 5466.40 = 11296.73
- C unchanged: deductible 0.00, oopm 9347.29
- D unchanged: deductible 2734.12, oopm 6506.43
- Family: deductible 5956.67 + 4277.45 = 10234.12, oopm 28843.94 + 5466.40 = 34310.34

**Line 13 —

Claim 13 — 2026-05-02 — A (subscriber)**, inpatient admission with surgery, in-network, allowed 14802.53. A's individual deductible already met (0 remainder), family deductible also satisfied — deductible applied 0.00. Coinsurance at 30%: 14802.53 × 0.30 = 4440.76, so member owes 4440.76 and plan pays 14802.53 - 4440.76 = 10361.77.

Updating A's oopm to 7159.89 + 4440.76 = 11600.65; B, C, D remain unchanged.

D: deductible = 2734.12, oopm =
6506.43
- Family: deductible = 10234.12, oopm = 34310.34 + 4440.76 = 38751.10

But A's OOPM limit is only 5500.00, and the accumulator has ballooned to 11600.65 — clearly exceeding the cap. Checking back, A's accumulator already surpassed 5500.00 after Line 3 (7159.89), meaning A hit the OOPM earlier than this line. I need to revisit the OOPM rule to see how overages should be handled.

Once reached, the plan pays 100% for covered in-network services, and premiums/non-covered services don't count. So any claims after A's accumulator crosses 5500.00 should have zero member cost share. Going back to Line 3: after Line 1, A's OOPM was 3591.56, leaving 1908.44 remaining before the cap. Member responsibility on Line 3 should be capped at that remaining amount, with the plan covering everything beyond.

Redoing Line 3 with 30% coinsurance on 11894.44 gives 3568.33, but capping this against the 1908.44 remaining OOPM means the member owes only 1908.44, and the plan pays 9986.00. This brings A's accumulator to exactly 5500.00 — the limit. Updated totals: A hits 5500.00 for both deductible and OOPM combined tracking, D remains at 2734.12, and the family OOPM rises to 8234.12.

Family: deductible = 5234.12, oopm = 8234.12

Now for Line 4, B's OOPM isn't capped yet, so a normal calculation applies. But I should track both per-member and family OOPM caps together — A's in-network limit is 5500.00, family limit is 11000.00.

For Line 3, before this claim A's OOPM sits at 3591.56, leaving 1908.44 of room; family OOPM also sits at 3591.56, leaving 7408.44. The claim's raw member responsibility is 3568.33, but capped by A's remaining room it becomes 1908.44, and family cap doesn't tighten it further. So member responsibility = 1908.44, plan paid = 11894.

After this claim, A's OOPM accumulator hits exactly 5500.00 (the individual max), and family accumulator reaches 5500.00 too.

Now I need to check whether the family OOPM applies per-member or as an aggregate ceiling. The plan defines OOPM as the ceiling on cost share, then lists separate individual and family limits (5500 / 11000). This suggests once A hits their individual cap, A pays $0 going forward — but the family OOPM is a separate aggregate threshold across all members that, once met, would also zero out everyone's cost share.

So the logic per claim: compute normal cost share, cap by remaining individual OOPM, cap further by remaining family OOPM.

Continuing through B, C, D's earlier claims (both at 0), D at 2734.12, family total still 5500.00.

For B's ambulatory surgery claim: normal cost share is 2642.53, B has full 5500 remaining individually, and family has 11000-5500=5500 remaining — so responsibility is min of these values.

This gives B's OOPM at 2642.53, pushing family total to 8142.53. Continuing through subsequent claims for B, tracking running totals for both B and family after each line, accumulating amounts like 146.87, 722.55, and 2363.12 sequentially.

But adding 2363.12 straight through would push family OOPM to 11375.07, exceeding the 11000.00 cap. Need to cap Line 7's contribution: B's remaining room is 5500.00 - 3511.95 = 1988.05, and family's remaining room is also 1988.05 - so the member responsibility caps at 1988.05 rather than the full 2363.12.

This brings B's OOPM to exactly 5500.00 and family OOPM to exactly 11000.00, hitting both limits simultaneously.

With the family OOPM now maxed out, Line 8 for C becomes fully plan-paid - member responsibility drops to 0.00, and the plan covers the entire 14673.31. C's individual OOPM stays at 0.00 since nothing was charged to them.

Line 9 for D follows the same pattern - family OOPM is exhausted, so despite D having 2765.88 in remaining personal OOPM room, responsibility is 0.00 and the plan pays the full 12574.38.

After these lines: D's OOPM sits at 2734.12, family remains at 11000.00.

Now I need to handle the adjustment at Line 10. Claim 5's original member responsibility was 146.87. Before touching Line 10, let me note the accumulator state after Line 9: A=5500.00, B=5500.00, C=0.00, D=2734.12, Family=11000.00.

First, reverse the original Claim 5 amount from B and Family:
- B: 5500.00 - 146.87 = 5353.13
- Family: 11000.00 - 146.87 = 10853.13

Then reapply Claim 5 with the corrected allowed amount of 223.75.

B's normal cost share comes out to 102.13. Checking against remaining room: B has 146.87 left (5500 - 5353.13), Family also has 146.87 left (11000 - 10853.13). Since 102.13 is less than both, member responsibility is just 102.13.

Updated totals: B = 5353.13 + 102.13 = 5455.26, Family = 10853.13 + 102.13 = 10955.26.

This is getting intricate — I want to double-check whether family OOPM still applies once individual OOPM caps in. Yes, it should — family OOPM is an independent limit, so responsibility gets capped by whichever is smaller between individual and family remaining room.

Revisiting Line 7 under this framework: B's cost share is 2363.12, with B's remaining room at 5500-3511.95=1988.05 and family's remaining room identically at 11000-9011.95=1988.05 — so B's OOPM caps the responsibility here.

Applying min(2363.12, 1988.05, 1988.05) = 1988.05 — B and family exhaust OOPM simultaneously.

Given this complexity, I'll restart the whole calculation from scratch, tracking OOPM caps carefully from the beginning.

**Line 1 — Claim 1 — A**
Allowed 6138.52, deductible 2500 applied, coinsurance 30% on remainder (1091.56), giving raw cost share 3591.56. Since A's and family's OOPM remaining (5500/11000) both exceed this, full 3591.56 applies. Plan pays 2546.96.

Updated: A deductible=2500, oopm=3591.56; family deductible=2500, oopm=3591.56 — all others at zero.

**Line 2 — Claim 2 — D**
Out-of-network allowed 2734.12, entirely deductible with no coinsurance applied. Checking against D's and family's 11000 OOPM caps — well under, so full 2734.12 stands. Plan pays $0.

Updated: D deductible=2734.12, oopm=2734.12; family deductible=5234.12, oopm=6325.68.

**Line 3 — Claim 3 — A**
Allowed 11894.44, deductible already met, so moving to coinsurance calculation.

**Line 3 — Claim 3 — A**
30% coinsurance gives 3568.33, but A's remaining OOPM room is only 1908.44 (5500 - 3591.56), which is tighter than the family's 4674.32 remaining. Member owes 1908.44, plan covers 9986.00 — A hits their $5500 OOPM cap exactly.

Updated: A deductible=2500.00, oopm=5500.00 (maxed); family deductible=5234.12, oopm=8234.12.

**Line 4 — Claim 4 — B**
Allowed 8808.44

Family deductible already met, so no deductible for B. Coinsurance is 8808.44 × 0.30 = 2642.53. Checking OOPM limits: B has full 5500.00 remaining, family has 2765.88 left (11000 - 8234.12). Both exceed 2642.53, so member pays the full coinsurance amount. Plan pays 6165.91.

Updated: B deductible=0.00, oopm=2642.53; family deductible=5234.12, oopm=10876.65.

**Line 5 — Claim 5 — B**
Allowed 372.91, copay 50.00. No deductible needed. Coinsurance portion: (372.91-50.00)×0.30=96.87, total member cost 146.87. B's OOPM room is 2857.47, but family OOPM room is only 123.35 (11000-10876.65) — this is now the binding constraint. Member pays 123.35, plan pays 249.56.

Family hits the OOPM cap exactly at 11000.00 after this claim.

Updated totals after Line 5:
- A: deductible 2500.00, oopm 5500.00
- B: deductible 0.00, oopm 2765.88
- C: deductible 0.00, oopm 0.00
- D: deductible 2734.12, oopm 2734.12
- Family: deductible 5234.12, oopm 11000.00 (capped)

The plan absorbs the extra 23.52 that would have pushed the family past the OOPM. I should double-check the plan document's exact wording on how the family OOPM cap interacts with individual member cost share to confirm this interpretation.

pool—once the combined family cost share hits $11,000, every member gets 100% coverage, even if no single person maxed out their individual OOPM. But then I need to figure out how that interacts with the per-member

So a member can hit their individual OOPM even while the family total hasn't reached $11,000—like A hitting their cap at Line 3 while the family sits at $8234.12. From there, A's own claims pay 100%, but B still accrues against the family OOPM until that's exhausted too. So cost share per claim gets capped by whichever remaining limit applies—individual first, family as backstop. Still need to check how out-of-network OOPM factors in separately.

claims accumulate to the family balance, they should still be limited by it—unless the accumulation happens without the cap applying. Re-reading: the credits go to both the member's and family's balance, but the claim itself isn't capped by the family in-network threshold, only by the member's out-of-network threshold.

For D's out-of-network claim (Line 2), I need D's remaining out-of-network OOPM of 11000.00, and D's member cost share of 2734.12 applies without being capped by the family in-network balance.

Updated accumulators after Line 2:
- A: deductible 2500.00, oopm 3591.56
- B, C: still zero
- D: deductible/oopm 2734.12 (out-of-network)
- Family: deductible 5234.12, oopm 6325.68

Now I need to check whether B's out-of-network claims later get capped by the family in-network OOPM, given this same rule about credits accumulating without capping.

For B's out-of-network infusion, I need to track B's own out-of-network deductible/OOPM thresholds separately from the in-network ones, since out-of-network claims measure only against out-of-network individual limits, not family in-network amounts.

Working through Line 1 (Claim 1 — A): with allowed 6138.52, deductible 2500.00 applied, coinsurance 1091.56, total member cost 3591.56 — A's in-network OOPM drops to 5500.00, family in-network OOPM to 11000.00.

Capping: min(3591.56, 5500.0

Let me work through this carefully, processing each line in order and tracking accumulators.

**PLAN DOCUMENT KEY POINTS:**
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 5000.00
- In-network and out-of-network deductibles accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance (in-network): 30% member / 70% plan
- Coinsurance (out-of-network): 50% member / 50% plan
- Specialist copay: 50.00
- Copays credit the deductible and OOPM
- Preventive services have no cost share

Let me track each member's and the family's accumulators:

Initial state:
- A: deductible 0.00, oopm 0.00
- B: deductible 0.00, oopm 0.00
- C: deductible 0.00, oopm 0.00
- D: deductible 0.00, oopm 0.00
- Family: deductible 0.00, oopm 0.00

---

**LINE 1: Claim 1 — 2026-01-18 — A (subscriber)**
Service: Outpatient procedure, in-network
Allowed amount: 6138.52

For in-network, deductible is applied before coinsurance.
- Deductible_applied = min(6138.52, 2500.00 - 0.00, 5000.00 - 0.00) = min(6138.52, 2500.00, 5000.00) = 2500.00
- Remaining after deductible: 3638.52, coinsurance at 30%: 1091.56
- Member owes: 2500.00 + 1091.56 = 3591.56, plan pays 2547.96
- No copay applies here since this is an outpatient procedure

After Line 1:
- A: deductible 2500.00, oopm 

3591.56
- B, C, D: deductible 0.00, oopm 0.00
- Family: deductible 2500.00, oopm 3591.56

For claim 2 (D, ambulatory surgery, out-of-network, allowed 2734.12), the out-of-network deductible threshold is 5000.00.
- Full allowed amount goes to deductible: 2734.12 applied
- Nothing left after deductible, so coinsurance is $0
- Member responsibility: 2734.12 total

After Line 2:
- A: deductible 2500.00, oopm 3591.56
- D: deductible 2734.12, oopm 2734.12
- Family: deductible 5234.12, oopm 6325.68

For claim 3 (A, inpatient admission, in-network, allowed 11894.44), A's individual deductible is already met (0 remaining) and family deductible is already exceeded (5234.12 > 5000.00 threshold). So deductible applied is $0, and the full amount moves to coinsurance at 30%.

Coinsurance: 11894.44 × 0.30 = 3568.33
Member responsibility: 3568.33
Plan paid: 11894.44 - 3568.33 = 8326.11

Running totals: A's oopm hits 7159.89, family oopm hits 9894.01. But I realize I need to double check the family deductible cap — it shouldn't exceed $5000 exactly, so Line 2's calculation of family deductible needs reworking since 2500 + 2734.12 already overshoots 5000.

Reconsidering Line 2: D's individual remainder is 2500.00, family remainder is also 2500.00 (5000 - 2500 already applied by A). Using embedded logic, deductible applied = min(2734.12, min(2500, 2500)) = 2500.00, split between D's individual and family deductible equally.

Remaining balance 234.12 hits coinsurance at 50%: 117.06. Member owes 2500 + 117.06 = 2617.06, plan pays 117.06.

Updated running totals after Line 2: A stays at deductible 2500, oopm 3591.56; B and C untouched; D's deductible now fully met at 2500 with oopm 2617.06.

**LINE 3 — Claim 3, A (subscriber):**
A's remainder and family remainder are both zero already, so no deductible applies here. Full allowed amount 11894.44 goes to coinsurance at 30%: 3568.33, which becomes member responsibility (plan pays 8326.11).

Updated totals: A's oopm climbs to 7159.89; family oopm to 9776.95.

**LINE 4 — Claim 4, B (spouse):**
Ambulatory surgery, in-network, allowed 8808.44. Need to check B's individual deductible remainder against the family remainder next.

reached, plan pays 100% going forward. So I track the accumulator, and once it hits 11000.00, member cost share becomes zero on later claims.

Continuing through the lines with this OOPM cap logic applied whenever the family or individual OOPM is exceeded.

After Line 4:
- A: deductible 2500.00, oopm 7159.89
- B: deductible 0.00, oopm 2642.53
- C: deductible 0.00, oopm 0.00
- D: deductible 2500.00, oopm 2617.06
- Family: deductible 5000.00, oopm sum 9776.95+2642.53=12419.48, exceeds 11000.00 cap, so family OOPM is reached after this line.

Moving to Line 5 (Claim 5, B, specialist visit, allowed 372.91), since family OOPM is already met, member responsibility should just be whatever remains to reach the 11000.00 cap, likely zero given it's already exceeded.

's individual OOPM of 5500.00 caps how much they pay total. So Line 3 should trigger the cap: once A hits 5500.00, the plan covers the rest at 100% for that individual. I need to track cumulative amounts per member and per family, and once either cap is hit, stop applying member cost-share for that scope.

For Line 3: A's OOPM accumulator sits at 3591.56 after Line 1. Coinsurance would be 11894.44 * 0.30 = 3568.33, pushing A to 7159.89 — over the 5500.00 cap. So A only pays the remaining room: 5500.00 - 3591.56 = 1908.44, and the plan absorbs the difference (3568.33 - 1908.44 = 1659.89).

Total plan paid: 11894.44 - 1908.44 = 9985.99. Member responsibility: 0.00 deductible + 1908.44 coinsurance = 1908.44 total.

This conflicts with an earlier attempt, so I need to double-check the order of operations — deductible first, then coinsurance capped by remaining OOPM room, with any excess coinsurance shifted onto the plan.

For Line 3: deductible already met, coinsurance = 11894.44 × 0.30 = 3568.33, but OOPM room remaining = 5500.00 - 3591.56 = 1908.44, so member pays min(3568.33, 1908.44) = 1908.44 and plan pays 9985.99.

Updated totals after Line 3: A's OOPM hits the 5500.00 cap; family OOPM reaches 8117.06.

Moving to Line 4 (Claim 4, spouse B, 2026-02-10, allowed 8808.44): B's remaining deductible is 2500.00, but family deductible is already fully met at 5000.00, so I need to determine deductible_applied accordingly.

50.00

Remaining after copay: 372.91 - 50.00 = 322.91, all going to deductible since B has plenty of room left (2450.00).

Total deductible_applied: 372.91

Nothing left over for coinsurance since the full allowed amount was absorbed by copay+deductible.

Member responsibility: 50.00, plan paid: 322.91

OOPM check: B's room is 2857.47, well above the 50.00 owed, so full amount counts.

Updated B totals: deductible 372.91, oopm 2692.53

Family totals: oopm 10809.59, other members unchanged from Line 5.

---

**LINE 6: Claim 6 — 2026-02-27 — B (spouse)**
Out-of-network infusion, allowed 722.55, deductible 5000.00, coinsurance 50%.

B's out-of-network deductible remaining: 5000.00 - 372.91 = 4627.09
Full 722.55 applies to deductible, leaving 0.00 for coinsurance.

Member responsibility: 722.55 +

0.00 = 722.55, plan pays 0.00.

For OOPM, out-of-network uses individual threshold of 11000.00 rather than the shared family accumulator — the plan document confirms family amounts are in-network only and don't cap out-of-network claims, though credits still flow into both member and family balances.

Checking further, the out-of-network individual OOPM is separate at 11000.00 versus the in-network 5500.00/11000.00 split. The accumulators track balances as running totals, and out-of-network thresholds being higher suggests they're tracked independently from in-network progress.

Once a member hits their out-of-pocket max, the plan covers 100% of allowed amounts for the rest of the plan year. Out-of-network claims only count against the out-of-network individual threshold—the family amounts (which are in-network figures) don't cap them.

So individually: in-network OOPM is 5500.00, out-of-network is 11000.00. For family, in-network OOPM is 11000.00, but I'm unclear if there's a separate family out-of-network figure.

Re-reading the accumulators section: balances just track running totals of deductible_applied or member_responsibility, and since out-of-network thresholds run higher, those claims can push a member's balance past the in-network individual figure, and family balances past the family figure too—nothing caps these balances at in-network levels. Out-of-network claims only measure against the out-of-network individual thresholds.

This means there's actually just one member balance per category (deductible, OOPM) covering both in-network and out-of-network claims together. The in-network threshold sits at 5500.00 but out-of-network activity can carry it higher, up toward the 11000.00 out-of-network threshold. Similarly, family balance aggregates both types, but the family threshold of 11000.00 only governs in-network claims—out-of-network claims don't get limited by the family cap.

So the logic seems to be: an individual's out-of-network claims stop costing them once their balance hits 11000.00, in-network claims stop once balance hits 5500.00, and for the family, once bala

it, the family OOPM only applies to in-network claims — out-of-network amounts still accumulate to the family balance but aren't capped by that 11000.00 threshold.

So the family balance tracks both types, but only in-network claims get capped when the balance hits 11000.00. Out-of-network claims keep accruing without triggering that cap. After Line 5, the family balance stands wherever it landed, and Line 6 (out-of-network) just adds to it without a ceiling.

For individual members though, out-of-network claims are measured against each person's own out-of-network OOPM (11000.00 for B), separate from the shared family in-network threshold.

So Line 6 revised: B's oopm becomes 2692.53 + 722.55 = 3415.08, with deductible 372.91. Family deductible sits at 5000.00, and I need to reconsider whether family oopm should really jump to 11532.14 or stay tracked separately.

Actually I suspect family OOPM tracking needs to be split into distinct in-network and out-of-network accumulators, similar to individuals - in-network capped at 11000.00, out-of-network possibly unlimited or unspecified. After Line 5, only B's in-network claim of 50.00 would count toward the family in-network accumulator.

Checking the plan text confirms: individual in-network OOPM 5500.00, family in-network OOPM 11000.00, individual out-of-network OOPM 11000.00, with no family out-of-network OOPM listed. The accumulators section clarifies that out-of-network claims only apply against individual out-of-network thresholds - family in-network amounts don't limit them at all.

But then another passage says out-of-network credits still accumulate to both the member's balance and the family balance, contradicting the first statement. So which applies - does family in-network OOPM get affected by out-of-network claims or not?

Tracking individually: member A's in-network balance sits at 3591.56 after line 1, feeding the family in-network total to the same figure. Line 2 puts D's out-of-network balance at 2617.06 - if the exclusion rule holds, family in-network stays at 3591.56 unaffected by this.

Given the accumulator language suggests both in-network and out-of-network claims add to the individual and family balances, but each threshold (individual in-network, individual out-of-network, family in-network) checks against its own claim type's contribution, I'll proceed with:

**LINE 1: Claim 1 — 2026-01-18 — A (subscriber)**
In-network, allowed 6138.52: deductible 2500.00 applied, coinsurance 3638.52 × 0.30 = 1091.56, member owes 3591.56, plan pays 2547.96.

Individual A in-network balance: 3591.56. Family in-network balance updates to match.

**LINE 2: Claim 2 — 2026-01-23 — D (child)**
Out-of-network, allowed 2734.12: deductible applies 2500.00 to shared family deductible, coinsurance 234.12 × 0.50 = 117.06, member owes 2617.06, plan pays 117.06.

D's individual out-of-network balance: 2617.06. Family in-network balance stays 3591.56 since this claim is out-of-network.

However, the shared deductible concept means after these two claims, the family deductible total should be 5000.00 (2500.00 from each claim), since in-network and out-of-network credits combine into one deductible balance per member and presumably per family too.

This matters because the family's in-network threshold (5000.00) would now be met, while D still has room under the out-of-network individual threshold (5000.00) — leaving 2500.00 left there. I need to check the accumulator rules for how deductible_applied is computed as the lesser of allowed amount and room left under whichever threshold applies.

Applying the out-of-network formula to Line 2: with D's balance at 0.00, the remainder is 5000.00, so deductible_applied = min(2734.12, 5000.00) = 2734.12. D's new balance becomes 2734.12, and the family's balance climbs to 5234.12 — exceeding the family's 5000.00 in-network threshold, meaning that limit is now satisfied. D's out-of-network threshold still has 2265.88 remaining. So the deductible tracks two separate thresholds depending on network status.

Redoing Line 1: A's in-network claim of 6138.52, with A's remainder at 2500.00 and family's at 5000.00, gives deductible_applied = 2500.00. Remaining 3638.52 gets 30% coinsurance = 1091.56, so member owes 3591.56 total, plan pays 2547.96.

A's balance updates to 2500.00, family in-network balance also hits 2500.00. A's OOPM balance becomes 3591.56, family in-network OOPM matches at 3591.56.

**LINE 2: Claim 2 — D (child), out-of-network, allowed 2734.12**
D's out-of-network remainder is full 5000.00, so deductible_applied = 2734.12 entirely — nothing left for coinsurance. Member responsibility: 2734.12, plan pays 0.00.

D's deductible balance: 2734.12. Family's balance, if combining in/out-of-network, would be 5234.12, but this doesn't affect anything since it's an out-of-network claim. D's out-of-network OOPM: 2734.12. Family in-network OOPM stays unchanged at 3591.56 since this claim is out-of-network.

I need to reconsider whether the accumulator structure treats in-network and out-of-network deductibles as separate pools or shared.

Per the ACCUMULATORS section, out-of-network claims still credit the member's balance and family balance. So I'll track three types of balances: individual in-network, individual out-of-network, and a shared family balance that both feed into. Caps: individual in-network member responsibility stops accruing at 5500.00, individual out-of-network stops at 11000.00, and family in-network...

Wait, re-reading again: "the family amounts, which are in-network amounts, do not limit an out-of-network claim." So the family threshold only ever caps in-network claims - an out-of-network claim is never limited by the family balance, only by the individual out-of-network threshold. Meanwhile, both claim types still add to the family balance for tracking purposes, but capping logic differs by network type.

Revising Claim 2 for D (out-of-network, child):
- Individual out-of-network OOPM: 11000.00, room: 11000.00
- Member responsibility: min(2734.12, 11000.00) = 2734.12, plan paid: 0.00
- D's out-of-network balance: 2734.12
- Family balance: 3591.56 + 2734.12 = 6325.68 (uncapped, since out-of-network claims aren't limited by family threshold)

Still unsure whether family balance should even include out-of-network amounts.

Re-reading the spec more carefully: balances track running totals of deductible_applied/member_responsibility and are NOT capped at in-network amounts — out-of-network claims can push both individual and family balances past in-network thresholds. Out-of-network claims are measured only against individual out-of-network thresholds; the family (in-network) amount doesn't limit them. But their credits still flow into both the member's and family's balance.

So the family balance does accumulate out-of-network contributions, just isn't used to cap out-of-network claims themselves.

Applying this to D's claim: out-of-network OOPM starts at 0.00, allowed member responsibility 2734.12 stays uncapped since it's under 11000.00 individual threshold, plan pays 0.00. D's running out-of-network OOPM becomes 2734.12, added to family balance (3591.56 + 2734.12 = 6325.68).

State after Line 2:
- A: deductible 2500.00, in-network OOPM 3591.56
- B, C: all zero
- D: deductible 2734.12, out-of-network OOPM 2734.12
- Family: deductible 5234.12, OOPM balance 6325.68

Moving to Line 3, A's in-network claim on 2026-02-03 with allowed amount 11894.44.

A's deductible is already met (0.00 remainder), and family deductible is also already exceeded (5234.12 > 5000.00), so no deductible applies here.

Coinsurance at 30%: 11894.44 * 0.30 = 3568.33

Checking A's individual OOPM room: 5500.00 - 3591.56 = 1908.44, which caps the coinsurance responsibility to 1908.44 rather than the full 3568.33.

Family OOPM room is 11000.00 - 6325.68 = 4674.32, well above 1908.44, so the individual cap governs.

Member responsibility: 1908.44, plan pays 11894.44 - 1908.44 = 9985.99

A's in-network OOPM hits the max: 3591.56 + 1908.44 = 5500.00
Family balance grows to 6325.68 + 1908.44 = 8234.12

State after Line 3:
- A: deductible 2500.00 (met), in-network OOPM 5500.00 (maxed)
- B, C: still zero
- D: deductible 2734.12, out-of-network OOPM 2734.12
- Family: continuing to accumulate toward the 11000.00 cap

Moving to Line 4, B's spouse claim on 2026-02-10, in-network, allowed amount 8808.44. B's individual deductible remainder is 2500.00, but since family deductible is already exceeded, deductible_applied is 0.00.

Coinsurance: 8808.44 * 0.30 = 2642.53

B has full OOPM room available (5500.00), and family room is 11000.00 - 8234.12 = 2765.88, so the family cap of 2765.88 is what limits things, but since 2642.53 is smaller, that's the actual responsibility.

Plan pays 8808.44 - 2642.53 = 6165.91
B's OOPM becomes 2642.53, family balance rises to 8234.12 + 2642.53 = 10876.65

Post-line-4 status: A (deductible 2500.00, OOPM 5500.00), B (deductible 0.00, OOPM 2642.53), C (deductible 0.00, OOPM 0.00), D (deductible 2734.12, out-of-network OOPM 2734.12), Family (deductible 5234.12, balance 10876.65).

Line 5: another B claim, 2026-02-21, in-network, allowed amount 372.91, specialist copay 50.00. Since copays credit the deductible, I apply the copay toward B's remaining deductible (2500.00 room), fully using the 50.00. Remaining balance after copay is 322.91, and B's deductible room is now 2450.00, so this full 322.91 also applies toward the deductible.

Total deductible applied: 372.91, leaving 0.00 for coinsurance calculation. Coinsurance comes out to 0.00, meaning total member responsibility is just the 50.00 copay, and plan pays 322.91.

But I should double check the copay rule since I want to make sure I'm interpreting "copays credit the deductible" correctly — does that mean the copay amount reduces the deductible, or is it counted separately?

family room 11000-10876.65=123.35, so member owes 50.00.

B updates: deductible 372.91, OOPM 2692.53. Family balance climbs to 10926.65.

Tallying totals after Line 5: A unchanged at 2500/5500, B at 372.91/2692.53, C untouched, D holds 2734.12 out-of-network, family combined 10926.65. B still has 2127.09 of in-network deductible room remaining since their cap is 2500.00. Need to keep straight that in-network and out-of-network deductibles are tracked separately (2500 individual/5000 family in-network vs 5000 individual out-of-network), and not conflate the two buckets when summing family totals.

deductible balance after: 2500.00 + 2734.12 = 5234.12, which exceeds the family threshold of 5000.00 — so the family deductible was already met partway through Line 2.

That means the family limit constrains D's deductible_applied too, since family remainder was only 5000.00 - 2500.00 = 2500.00. So deductible_applied for Line 2 is min(2734.12, 5000.00, 2500.00) = 2500.00, not the full amount.

Let me redo: D's deductible balance after = 0.00 + 2500.00 = 2500.00; family balance after = 2500.00 + 2500.00 = 5000.00 (exactly met). Remaining allowed amount after deductible: 2734.12 - 2500.00 = 234.12, subject to coinsurance.

Once the family deductible is satisfied, all subsequent in-network 

Let me work through this ledger step by step, tracking the accumulators for each member and the family.

Initial state (before Line 1):
- A (subscriber): deductible 1729.94, OOPM 1762.13
- B (spouse): deductible 0.00, OOPM 0.00
- C (child): deductible 1382.40, OOPM 1945.98
- Family: deductible 3112.34, OOPM 3708.11

Plan rules:
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- AGGREGATE structure: family deductible must be satisfied before any member gets coinsurance
- Out-of-network individual deductible: 6400.00
- Single deductible balance for in-network and out-of-network
- In-network coinsurance: 10% member / 90% plan
- Out-of-network coinsurance: 40% member / 60% plan
- Individual OOPM in-network: 7000.00
- Family OOPM in-network: 14000.00
- Individual OOPM out-of-network: 14000.00
- Preventive services in-network: 100% covered, no cost share
- Preventive services out-of-network: subject to deductible and coinsurance

Let me process each line:

**Line 1 — Claim 1 — A (subscriber)**
- Service: Physical therapy course, in-network
- Allowed: 1553.18
- Network: In-network
- Family deductible remaining: 6400.00 - 3112.34 = 3287.66
- Deductible applied: min(1553.18, 3287.66) = 1553.18
- After deductible applied, remaining allowed: 0.00
- No coinsurance applies since the full amount went to deductible
- Member owes the full 1553.18, plan pays 0.00
- New A deductible: 1729.94 + 1553.18 = 3283.12
- New A OOPM: 1762.13 + 1553.18 = 3315.31
- New Family deductible: 3112.34 + 1553.18 = 4665.52
- Family OOPM updates similarly with the same amount added

Now for Claim 2, subscriber A's inpatient admission at 21710.91 allowed, in-network. Family deductible has 1734.48 remaining (6400 - 4665.52), which gets fully applied. The rest, 19976.43, hits 10% coinsurance = 1997.64. Total member cost is 3732.12, with plan paying the remaining 19976.43 minus coinsurance.

Updating totals: A's deductible reaches 5017.60, A's OOPM hits 7047.43. Family deductible caps out at 6400.00, family OOPM climbs to 8993.41.

Moving to Claim 3 for child C — outpatient infusion at 454.13 allowed, in-network. Since family deductible is already met, C only owes 10% coinsurance: 45.41, with plan covering the balance.

.413 = 408.717 ≈ 408.72
Accumulators update: C deductible stays at 1382.40 (unaffected since family deductible cleared), C OOPM rises to 1991.39, family OOPM to 9038.82.

Claim 4 for A: inpatient surgery admission, in-network, allowed 17679.63. With deductible satisfied, coinsurance applies at 10% — A owes 1767.96, plan pays 15911.67.

Updating: A OOPM reaches 8815.39, family OOPM climbs to 10806.78.

Claim 5 involves C's annual wellness visit, but out-of-network — meaning it loses preventive status and falls under out-of-network deductible/coinsurance per plan terms, so I need to check C's remaining deductible against the out-of-network threshold.

C's deductible gap is 5017.60, but the allowed amount of 771.12 is smaller, so it all applies to deductible with nothing left over for coinsurance. Member owes the full 771.12, plan pays nothing.

Updated totals: C deductible reaches 2153.52, C OOPM hits 2762.51, family OOPM climbs to 11577.90 while family deductible holds steady at 6400.00 (already maxed).

Moving to claim 6 — A's inpatient admission, out-of-network, allowed amount 25...

OOPM in-network: 14000.00
- Individual OOPM out-of-network: 14000.00

Out-of-network claims measure against the out-of-network individual threshold only, since family amounts are in-network specific and don't limit an out-of-network claim.

The addendum clarifies balances are running totals of deductible_applied or member_responsibility, not capped at in-network amounts. Out-of-network thresholds being higher means claims can push a member past the in-network individual figure and family balances past the family amounts. So for this claim: deductible threshold is 6400.00 (out-of-network individual), OOPM threshold is 14000.00, and credits still accumulate to both the member's and family's balances.

I want to double-check by looking at the actual OOPM numbers in the plan section rather than guessing.

Individual in-network OOPM is 7000.00, family in-network OOPM is 14000.00, and individual out-of-network OOPM is 14000.00.

The accumulator rules match the deductible pattern: out-of-network claims only get compared against the 14000.00 individual out-of-network threshold, not the family in-network figures. Still, credits from an out-of-network claim flow into both the member's individual balance and the family balance.

So each member effectively tracks two separate OOPM ceilings — 7000.00 for in-network care and 14000.00 for out-of-network care. Once either ceiling is hit, that category of care becomes fully covered for the rest of the year.

Checking A after Line 5: the balance is 8815.39, past the 7000.00 in-network cap, meaning in-network services should now be 100% covered going forward. Line 4 was already paid though, so I need to figure out whether that overage applies retroactively or only to subsequent claims.

Restarting the OOPM check from Line 1 for A: member responsibility 1553.18, OOPM goes from 1762.13 before... wait, that doesn't match—A's opening balance should start lower. Recomputing carefully: A OOPM before Line 1 is some starting value, after applying 1553.18 it lands at 1762.13.

Line 2 adds another 3732.12, pushing A's OOPM to 7047.43, which exceeds the 7000.00 individual cap. So from that point forward, A's in-network claims should be paid at 100%.

Line 3 belongs to C, so it doesn't touch A's accumulator.

Line 4 is A's next claim after crossing the threshold — since A already hit the OOPM, this claim should be covered fully at 100%, not at the standard coinsurance rate.

But I need to double check whether the OOPM applies specifically to in-network vs out-of-network. The plan lists separate thresholds: 7000.00 in-network and 14000.00 out-of-network, with out-of-network claims measured only against the out-of-network threshold. So hitting the in-network OOPM only guarantees 100% coverage on in-network claims going forward — out-of-network claims would still need to hit their own separate 14000.00 cap.

Given that, since Line 2 pushed A's balance to 7047.43, exceeding the in-network 7000.00 threshold, Line 4 being in-network should trigger 100% coverage, meaning A's cost share on Line 4 should be zero.

Rereading the OOPM section again for clarity: individual in-network is 7000.00, family in-network is 14000.00, individual out-of-network is 14000.00, and once a member hits their max, the plan covers 100% for the rest of the year. This implies separate tracking - in-network accumulations count toward the 7000.00 cap, out-of-network accumulations count toward the 14000.00 cap, and each type triggers 100% coverage independently once reached.

Applying this to A: in-network OOPM cap of 7000.00, out-of-network cap of 14000.00, tracked separately by service type.

Running the numbers - after Line 1, A's in-network balance sits at 3315.31. After Line 2, it climbs to 7047.43, already surpassing the 7000.00 cap. Since Line 4 is also in-network, A has effectively maxed out before this claim even hits. That means Line 4 should be covered at 100%, member owes 0.00, and the plan pays the full allowed amount of 17679.63. I'm noticing the billed charge on Line 4 is 32707.32 versus an allowed amount of 17679.63 - normally the gap between billed and allowed wouldn't fall on the member, since cost-sharing applies only to the allowed amount, not billed charges.

et maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year," and premiums/non-covered services never count toward it.

Out-of-network claims measure against out-of-network thresholds only, but credits still accumulate to both the member's overall balance and the family balance.

So there's a single cumulative OOPM balance per member. For in-network services, once that balance crosses the in-network cap, the plan covers 100% going forward.

Tracking A: after Line 1, balance = 3315.31; after Line 2, balance = 7047.43. Line 4 is in-network, and the balance already exceeds 7000.00 in-network cap - so this should be fully covered. But Line 2's cost share of 3732.12 pushed the balance past the cap, meaning some of that contribution may have exceeded what should count toward the in-network threshold.

Rereading the task spec: balance is simply the running total of member_responsibility, not split by network type. The key insight is that out-of-network thresholds being higher means out-of-network claims can carry a balance past the in-network cap without contradiction - the caps just determine when each type of claim stops requiring cost-sharing.

So there's one balance per member/family. For in-network claims, check against the in-network cap (7000/14000); for out-of-network claims, check against the out-of-network cap (14000/28000). If the balance already exceeds the relevant cap, the plan pays 100%.

Applying this to A: after Line 1, balance = 3315.31 (below 7000 in-network cap, so cost-sharing applies as normal).

After Line 2, balance = 7047.43, which crosses the 7000.00 in-network threshold.

For Line 4 (in-network), since A's balance is already above 7000.00, the plan should pay 100% and member responsibility = 0.00, plan paid = 17679.63, balance unchanged at 7047.43. This seems consistent — once the cap is reached, the member owes nothing more for that network type going forward, and the balance simply tracks accumulated costs without resetting.

's balance stays at 7047.43 since member pays 0% going forward.

Wait, let me check the initial OOPM: 1762.13, well under 7000.00. After Line 1: 1762.13 + 1553.18 = 3315.31, still under cap. After Line 2: 3315.31 + 3732.12 = 7047.43, exceeding the cap mid-claim. This raises the question of whether Line 2's cost share should be capped so the balance lands exactly at 7000.00, or whether it's allowed to overshoot.

Testing the capping approach: A could only take 7000.00 - 3315.31 = 3684.69 more on Line 2, with the plan covering the remaining (1767.96 + 1997.643) - 3684.69 = 80.913. That number seems off, so I need to check how the family deductible interacts with the 21710.91 allowed amount on Line 2.

Deductible applied: 1734.48, leaving 19976.43 for coinsurance at 10% = 1997.643, giving member responsibility 3732.123. A's running balance before this line is 3315.31, which would push post-line balance to 7047.43 - exceeding the 7000.00 OOPM cap by 47.43. So A's contribution caps at 3684.69, and plan paid becomes 21710.91 - 3684.69 = 18026.22.

To split this properly: deductible (1734.48) still counts fully toward OOPM, leaving only 1950.21 (3684.69 - 1734.48) available for coinsurance. Since 1950.21 < 1997.643, coinsurance caps here too, meaning plan absorbs the remaining 47.433 of coinsurance beyond member's capped share.

Recalculating plan payment: 19976.43 - 1950.21 = 18026.22.

The plan pays the remaining allowed amount minus whatever the member actually pays. Deductible (1734.48) + capped coinsurance (1950.21) = 3684.69, matching the OOP max. So plan payment = 19976.43 - 1950.21 = 18026.22.

Once the OOPM cap hits, the plan covers 100% of everything remaining. On Line 2 (allowed 21710.91), the deductible of 1734.48 applies first, counting toward OOPM.

With remaining allowed of 19976.43, normal coinsurance would be 1997.643 at 10%. A's OOPM balance sits at 5049.79 with cap 7000.00, leaving room for 1950.21. So member coinsurance is capped at 1950.21, and the plan absorbs the remaining 47.433 of that coinsurance amount, since the member can't be charged past the cap.

Plan pays: 19976.43 - 1950.21 = 18026.22
Total member responsibility this line: 1734.48 + 1950.21 = 3684.69
Check: 3684.69 + 18026.22 = 21710.91 ✓

A's balance after this line: 3315.31 + 3684.69 = 7000.00, exactly hitting the in-network OOPM.

Now I need to rebuild the entire ledger with this corrected logic from the start.

Initial deductible/OOPM figures: A at 1729.94/1762.13, B at 0/0, C at 1382.40/1945.98, family at 3112.34/3708.11.

Line 1, A's PT claim, allowed 1553.18, entirely absorbed by remaining family deductible (3287.66), so member owes full 1553.18, plan pays nothing.

Updated totals: A deductible 3283.12/OOPM 3315.31, family deductible 4665.52/OOPM 5261.29.

Line 2, A's inpatient admission, allowed 21710.91. Remaining family deductible is 1734.48, applied fully. A's OOPM remaining before coinsurance is 3684.69, with 19976.43 left to allocate under normal coinsurance rules.

Coinsurance at 10% would be 1997.643, but capped by the remaining OOPM room of 1950.21, so member owes 1734.48 + 1950.21 = 3684.69 total, hitting A's OOPM exactly. Plan pays 18026.22.

Accumulators after Line 2: A deductible 5017.60, OOPM 7000.00 (maxed). Family deductible 6400.00 (maxed), OOPM 8945.98.

Moving to Line 3, C's outpatient infusion claim.

% since A's OOPM is maxed—member responsibility 0.00, plan pays the full 17679.63.

Accumulators after Line 4:
- A: deductible 5017.60, OOPM stays 7000.00
- Family: deductible 6400.00, OOPM stays 8991.39 since A didn't contribute anything this time

That checks out — family OOPM only moves when someone actually pays.

But wait, A hitting the in-network OOPM cap doesn't cap out-of-network exposure. A's out-of-network OOPM is a separate 14000.00 limit. So a future out-of-network claim for A could still generate member cost-sharing.

Looking back at the OOPM section:
"Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00"

This raises the question of whether in-network and out-of-network OOPMs are tracked independently, or whether hitting one affects the other.

Out-of-network claims are measured against the individual out-of-network threshold only—the family amount (which is in-network) doesn't apply here.

So A has two separate caps: 7000.00 for in-network, 14000.00 for out-of-network. In-network OOPM for A hits 7000.00 after Line 2, but out-of-network OOPM stays at 0.00. Line 4 being in-network means 100% coverage since A's already at the in-network cap—out-of-network OOPM remains untouched at 0.00.

**Line 5 — Claim 5 — C (child)**
- Annual wellness visit, out-of-network, allowed 771.12
- Preventive but out-of-network means deductible/coinsurance still apply
- C's deductible balance: 1382.40, remaining out-of-network deductible: 6400.00 - 1382.40 = 5017.60
- Deductible applied: 771.12 (full amount), remaining allowed: 0.00
- Member pays 771.12, plan pays 0.00

Updated accumulators: C's deductible reaches 2153.52, out-of-network OOPM reaches 2762.51. Family deductible stays 6400.00, family out-of-network OOPM climbs to 9762.51.

I need to reconsider how I'm tracking in-network vs out-of-network OOPM — there's likely a single accumulator per member where in-network costs count only toward the in-network cap (7000.00), while out-of-network costs count toward both that cap and the out-of-network cap (14000.00). Once a cap is reached, claims of that type get 100% coverage. So after Line 2, A's balance hit 7000.00 (in-network cap), meaning Line 4's in-network claim should get full coverage rather than requiring further cost-sharing. I'll apply this logic going forward.

For C after Line 5, the OOPM balance becomes 1991.39 + 771.12 = 2762.51.

Line 6 is A's inpatient admission, out-of-network, allowed at 25351.30. A's deductible balance is 5017.60, leaving 1382.40 of out-of-network deductible (6400.00 - 5017.60). This full amount applies as deductible. A's OOPM sits at 7000.00 before this claim, with 7000.00 remaining toward the 14000.00 out-of-network cap. After deductible, 23968.90 remains — coinsurance at 40% would be 9587.56, but capped at the OOPM remaining minus deductible already applied (7000.00 - 1382.40 = 5617.60). Total member responsibility comes to 1382.40 + 5617.60 = 6999.

not limit out-of-network claims themselves. They just add to the balances.

So:
- Out-of-network claims aren't capped by the family in-network amount
- OON claims still add credits to member and family balances

A "balance" is a running total, not a threshold. Deductible/OOPM caps are the thresholds (7000, 14000, etc.), while balances track accumulation toward them. Family deductible balance accumulates deductible_applied across members up to 6400.00, family OOPM balance accumulates member_responsibility up to 14000.00.

Both member and family accumulators move together on every claim generating cost share. Under an embedded structure, a member's deductible is met by whichever remainder is smaller—individual or family. Under an aggregate structure, no one gets coinsurance until the family total is fully met.

For out-of-network claims specifically: only individual OON thresholds apply—family amounts (which are in-network) never limit an OON claim. So the family deductible (6400.00) and family OOPM (14000.00) don't cap or restrict an OON claim, though credits still accumulate to the member's own running totals.

After Line 6, the family OOPM balance would climb to 9762.51 + 7000.00 = 16762.51, well past 14000.00, but this cap isn't a limiting factor for OON claims. The family deductible stays at 6400.00 since it's already met and doesn't grow further once reached. I need to check the deductible section to confirm this aggregate cap behavior.

the in-network OOPM cap applies specifically to in-network cost share accumulation, capping it at 14000.00 once reached. Out-of-network claims still add to the running family OOPM balance but don't trigger the in-network cap.

So after Line 5: family OOPM balance = 8991.39
Line 6 is out-of-network, adding 7000.00: 8991.39 + 7000.00 = 15991.39

This exceeds the 14000.00 cap, but that cap governs in-network accumulation only—there's no separate family out-of-network OOPM cap specified, so out-of-network cost share just keeps accumulating without a ceiling.

Given this, after Line 5 the family in-network OOPM balance sits at 8991.39. Line 6 being out-of-network doesn't touch this in-network balance—it stays at 8991.39, while a separate out-of-network running total would be 7000.00 from just that claim.

But "ending_family_oopm" implies one combined number. So likely there's a single family OOPM tracking all cost shares together, with the 14000.00 cap applying specifically to the in-network portion.

That gives 8991.39 + 7000.00 = 15991.39, but that exceeds 14000.00, which contradicts what a cap should do. The rule stating family in-network amounts don't limit out-of-network claims suggests out-of-network claims aren't checked against this cap at all when processing them.

So the family balance keeps accumulating (both in-network and out-of-network credits contribute), even past 14000.00 — that ceiling only governs when in-network member cost shares stop being charged. Out-of-network cost shares keep applying regardless of what the family balance shows, since the individual out-of-network cap (14000.00) is what actually governs those specific claims.

Let me reconsider the OOPM structure: individual in-network 7000.00, family in-network 14000.00, individual out-of-network 14000.00. Each cap applies to its own category, so a family balance exceeding 14000.00 from mixed claims doesn't automatically waive out-of-network cost sharing — only hitting the individual out-of-network max would do that for that specific member.

own 7000.00 cap when their balance hits that mark, while the family caps out at 14000.00 combined. Out-of-network works differently - no family cap exists there, just the individual 14000.00 threshold. So in-network coverage stops at whichever comes first: the member's 7000.00 or the family's 14000.00. Checking Line 4, A already maxed their in-network 7000.00, triggering 100% coverage - but I still need to verify the family total against 14000.00, which s

Let me work through this carefully, processing each line in order and tracking accumulators.

Initial state:
- A (subscriber): deductible 0.00, oopm 0.00
- B (spouse): deductible 0.00, oopm 0.00
- C (child): deductible 0.00, oopm 0.00
- Family: deductible 0.00, oopm 0.00

Key plan details:
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED (individual satisfies their own, family satisfied once total family reaches 3000)
- Out-of-network individual deductible: 3000.00
- In-network OOPM individual: 6000.00
- In-network OOPM family: 12000.00
- Out-of-network OOPM individual: 12000.00
- In-network coinsurance: 20% member / 80% plan
- Out-of-network coinsurance: 40% member / 60% plan
- Preventive care: 100% covered, no deductible/coinsurance/copay
- Urgent care copay: 75.00
- Copays do NOT credit deductible, but DO credit OOPM

Line 1: Claim 1 — 2026-01-19 — C (child)
Service: Screening colonoscopy (PREVENTIVE)
Network: In-network
Allowed: 920.67

Preventive in-network: 100% covered, no cost share
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 0.00
- member_responsibility: 0.00
- plan_paid: 920.67

Accumulators after Line 1:
- C: deductible 0.00, oopm 0.00
- Family: deductible 0.00, oopm 0.00

Line 2: Claim 2 — 2026-02-04 — B (spouse)
Service: Inpatient admission with surgery
Network: In-network
Allowed: 15770.22

Not preventive, so subject to deductible and coinsurance. B's deductible remaining is 1500.00, family remaining is 3000.00. Embedded structure means deductible_applied = min(B's remainder, family remainder) = min(1500.00, 3000.00).

After 1500.00 deductible, 14270.22 subject to coinsurance: member pays 2854.04, plan pays 11416.18.

member_responsibility = 1500.00 + 2854.04 = 4354.04, plan_paid = 11416.18. Sum checks out to 15770.22.

B's accumulators update to deductible 1500.00, oopm 4354.04.

Post-Line 2 totals: A untouched (0/0), B at 1500.00/4354.04, C untouched (0/0), Family deductible 1500.00, oopm 4354.04.

Moving to Line 3: Claim 3, 2026-02-15, C (child), urgent care visit, in-network, allowed 227.43. Copay 75.00, leaving 227.43 subject to deductible/coinsurance.

C's deductible remaining is 1500.00, family remaining is 3000.00 - 1500.00 = 1500.00. So deductible_applied = min(1500.00, 1500.00) = 1500.00 — but copays don't credit deductible, only OOPM, so I need to reconsider how the remaining 227.43 applies since the copay was already carved out separately.

For this urgent care visit at 227.43 allowed:
- 75.00 copay (OOPM only, not deductible)
- Remaining 152.43 would go toward deductible/coinsurance

But wait - is the copay actually subtracted from the allowed amount first, or does deductible apply to the full amount and copay is separate entirely? Given the plan wording, the copay is the member's cost-share replacing deductible/coinsurance for this visit type - so the full 75.00 is what's owed, credited to OOPM, and deductible isn't touched at all for a copay-based service.

1500.00) = 227.43, since only that much allowed amount remains.

After deductible, no remaining balance for coinsurance.

So member owes 75.00 (copay) + 227.43 (deductible) = 302.43, but that exceeds the total allowed amount of 227.43 — plan pays nothing, which seems wrong for a $75 copay visit.

I must be misapplying the model. A copay likely substitutes for deductible/coinsurance rather than stacking with them.

Reworking: the copay is simply what the member owes for that service, and the plan covers the rest.
- Member: 75.00
- Plan: 227.43 - 75.00 = 152.43

The copay credits OOPM but not the deductible balance. Now I need to determine whether the remaining $152.43 after copay is itself subject to deductible before the plan pays it, or whether it's paid outright once the copay is satisfied.

Looking at the plan doc entry: "Urgent care ...................................... 75.00 copay" — this is a flat copay structure, not coinsurance-after-deductible. So the member simply pays 75.00, and the plan pays the rest, regardless of deductible status, since copays typically apply independent of deductible.

But then the "copays do NOT credit the deductible" language complicates this — it implies copays exist alongside deductible tracking. So possibly: pay copay ($75) which counts toward OOPM but not deductible, while the underlying claim amount still separately accrues toward deductible tracking. The ambiguity is whether the deductible/coinsurance also applies on top of the copay, or the copay simply replaces cost-sharing for this visit type entirely.

No solid example in the instructions to confirm the calculation, so I'll go with the standard model: copay is the total member responsibility for the service, plan covers the rest, copay applies to OOPM only.

Member pays $75.00, plan pays $152.43, and I'll track how this affects the OOPM accumulator without touching the deductible.

4429.04

Post-Line 3 totals:
- A: deductible 0.00, oopm 0.00
- B: deductible 1500.00, oopm 4354.04
- C: deductible 0.00, oopm 75.00
- Family: deductible 1500.00, oopm 4429.04

Line 4: Claim 4 — 2026-02-21 — A (subscriber), specialty pharmacy administration, out-of-network, allowed 8351.84.

Out-of-network deductible applies here (3000.00 individual), and A hasn't touched it yet. Family deductible doesn't apply to out-of-network claims—

network, only the individual deductible

deductible_applied = min(8351.84, 3000.00) = 3000.00

Remaining after deductible: 8351.84 - 3000.00 = 5351.84
Coinsurance 40%: 5351.84 × 0.40 = 2140.74
Plan pays 60%: 5351.84 × 0.60 = 3211.10

member_responsibility = 3000.00 + 2140.74 = 5140.74, plan_paid = 3211.10, sum checks out to 8351.84.

A's deductible becomes 3000.00, oopm (out-of-network) becomes 5140.74. Now checking whether family accumulators get touched by out-of-network claims—

the instructions confirm out-of-network credits still flow into both the member's and family's balances. But there's a nuance: in-network and out-of-network deductible credits all pool into one single member deductible balance, just measured against different thresholds depending on service type (1500.00 in-network vs 3000.00 out-of-network individual).

The family deductible itself is explicitly an in-network figure, so out-of-network claims don't cap against it - they're only compared to the out-of-network individual threshold. So for Line 4, I need to track how these credits flow while keeping the family deductible measurement tied to in-network amounts only.

Working the numbers: A's deductible balance goes from 0.00 to 3000.00. A's out-of-network OOPM moves from 0.00 to 5140.74. The family OOPM increases from 4429.04 to 9569.78, since member responsibility feeds the family OOPM regardless of network. But the family deductible stays at 1500.00 since out-of-network claims don't count against that in-network-only threshold.

Wait, I need to re-check this — that paragraph applies to both deductible and OOPM, not just OOPM. It states out-of-network claims are capped by the individual out-of-network threshold, family in-network amounts don't limit them, but credits still flow to both the member's single balance and the family balance. So out-of-network deductible payments do add to the family deductible total too — I need to reconsider whether 1500.00 stays fixed or increases.

the lesser of their individual remainder and the family remainder. So family credits pool from members toward a shared family threshold, in-network.

The ambiguous phrase about out-of-network credits accumulating to "family balance" probably points to the family OOPM rather than family deductible, since out-of-network claims are evaluated against the individual out-of-network threshold, not the family in-network deductible. Member responsibility from out-of-network claims likely feeds the family OOPM pool while deductible credits stay separate. Checking the ACCUMULATORS section definition of "balance" for clarity.

network credits also feed into the family deductible balance, but the out-of-network claim itself only gets checked against the member's out-of-network threshold (3000.00), never the family threshold.

So A's deductible balance becomes 0.00 + 3000.00 = 3000.00, and the family deductible balance becomes 1500.00 + 3000.00 = 4500.00. This feels off though, since the in-network family deductible (3000.00) is exactly equal to the sum of the two individual in-network deductibles (1500.00 each) — adding out-of-network credits on top pushes the family total past that in-network cap, which doesn't sit right.

Reconsidering: out-of-network deductible credits accumulate to the member's balance but not to the family deductible balance, since the family amounts don't limit here. Out-of-network member responsibility credits do count toward the family OOPM though.

Going with that:

Line 4:
A's deductible: 0.00 + 3000.00 = 3000.00
A's oopm (OON): 0.00 + 5140.74 = 5140.74
Family deductible: unchanged at 1500.00
Family oopm: 4429.04 + 5140.74 = 9569.78

Updated accumulators:
- A: deductible 3000.00, oopm 5140.74
- B: deductible 1500.00, oopm 4354.04
- C: deductible 0.00, oopm 75.00
- Family: deductible 1500.00, oopm 9569.78

Line 5: Claim 5 — 2026-03-02 — A (subscriber), inpatient admission with surgery, in-network, allowed 14673.74.

A has already hit the 3000.00 out-of-network deductible, but since this claim is in-network, it needs to be checked against the in-network deductible instead.

Since A's individual balance already exceeds the 1500.00 threshold, the individual deductible is fully met regardless of remaining family room. That means deductible_applied = 0.00 for this claim.

Checking the embedded rule confirms this: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." A's own accumulator being satisfied is enough to trigger deductible waiver, independent of the family's 1500.00 remaining room. The ACCUMULATORS section also notes both the member's own and family accumulators move together with each claim.

So Line 5 deductible_applied is 0.00 since A's individual threshold is already met.

Coinsurance base: 14673.74 - 0 = 14673.74
Member owes 20%: 2934.75
Plan pays 80%: 11739.19 (rounding 11739.192)

Checking: 2934.75 + 11739.19 = 14673.94, but allowed is 14673.74 — off by 0.20 due to independent rounding of each piece.

Better approach: round only one value directly, then derive the other by subtraction so they sum exactly to the allowed amount.

Member coinsurance = 14673.74 × 0.20 = 2934.748 → rounds to 2934.75
Plan paid = 14673.74 - 2934.75 = 11739.19 (derived by subtraction, guaranteeing the totals match)

= 11738.99, confirming 2934.75 + 11738.99 = 14673.74 ✓.

So plan_paid = 11738.99, member = 2934.75.

The "round half up at the end" instruction likely just means compute one value directly and derive the other by subtraction, rather than rounding both independently—ensuring member_responsibility + plan_paid always equals the allowed amount exactly.

For Line 5:
- copay: 0.00
- deductible_applied: 0.00
- coinsurance: 2934.75
- member_responsibility: 2934.75
- plan_paid: 11738.99

Updating A's accumulators: deductible stays 3000.00 (already met, no change),

oopm 5140.74 + 2934.75 = 8075.49. Family deductible stays 1500.00, oopm 9569.78 + 2934.75 = 12504.53.

Snapshot after Line 5: A(3000.00, 8075.49), B(1500.00, 4354.04), C(0.00, 75.00), Family(1500.00, 12504.53).

Moving to Line 6: Claim 6 — 2026-03.

Colonoscopy screening for B, in-network preventive service, allowed 1881.87 — fully covered at 100%, no cost sharing. Deductible, copay, coinsurance, and member responsibility all 0.00; plan pays 1881.87. Accumulators stay unchanged from before.

Snapshot after Line 6 remains: A(3000.00, 8075.49), B(1500.00, 4354.04), C(0.00, 75.00), Family(1500.00, 12504.53).

Now Line 7: Claim 7 — 2026-03-27 — A.

Diagnostic lab panel, in-network, allowed 1676.10. A's deductible is already exhausted (satisfied at 1500.00), so no deductible applies here despite family room remaining at 1500.00.

With deductible_applied = 0.00, the full 1676.10 goes to coinsurance at 20%: member owes 335.22, plan pays 1340.88 — sum checks out to 1676.10.

Updating A's accumulators: deductible stays 3000.00, oopm rises to 8075.49 + 335.22 = 8410.71. Family deductible stays at 1500.00, family oopm climbs to 12504.53 + 335.22 = 12839.75.

Snapshot after Line 7: A (3000.00 / 8410.71), B (1500.00 / 4354.04), C (0.00 / 75.00), Family (1500.00 / 12839.75).

Moving to Line 8: Claim 8, 2026-04-01, A the subscriber — inpatient admission with surgery, in-network, allowed 22767.73. A's individual deductible is already fully

 in-network OOPM of 6000.00. In-network claims total 3270.00 (Claim 5: 2934.75 + Claim 7: 335.22), well under the limit.

The out-of-network claim (5140.74) shouldn't count toward the in-network OOPM—these tracks seem separate. The instructions confirm: out-of-network claims measure against out-of-network thresholds only, and family in-network amounts don't limit out-of-network claims.

That said, credits from out-of-network claims still flow into the member's overall balance and the family balance. So each member likely has distinct in-network individual, out-of-network individual, and family in-network OOPMs, but member responsibility accumulates across all claims toward these applicable buckets simultaneously.

Once a member's OOPM for a given network status is reached, the plan starts paying 100% for that network status going forward. The two limits function independently, with the family limit only applying to in-network accumulation.

So for A: in-network accrued is 3270.00 (Claims 5+7) against a 6000.00 cap, leaving 2730.00 of room. Out-of-network accrued is 5140.74 (Claim 4) against a 12000.00 cap.

Now for Line 8, checking whether Claim 4's out-of-network cost-sharing also counts toward A's in-network OOPM, or whether the two tracks stay fully separate.

and the threshold shifts by network mix: all in-network hits 6000.00, all out-of-network hits 12000.00. For mixed claims, the applicable OOPM is unclear.

Most likely setup: in-network claims accrue toward a 6000.00 in-network OOPM, out-of-network claims accrue toward a 12000.00 out-of-network OOPM, separately for individual and family. But the document only lists "Family (in-network) 12000.00" with no out-of-network family figure specified.

So the family OOPM applies only to in-network claims. That gives A: 6000.00 in-network OOPM, 12000.00 out-of-network OOPM, and Family in-network OOPM of 12000.00 — with out-of-network costs not counting toward the family in-network total.

This means my earlier Line 4 family OOPM calculation (4429.04 + 5140.74 = 9569.78) is wrong if out-of-network doesn't count toward it — it should stay at 4429.04. Checking the instructions confirms: out-of-network claims are measured only against out-of-network individual thresholds, and family (in-network) amounts don't limit them.

But there's tension with "credits accumulate to the member's balance and to the family balance." I resolve this by treating deductible as shared regardless of network, while OOPM stays split — out-of-network member responsibility feeds the individual's out-of-network OOPM only, not the family in-network OOPM.

So after Line 4: family deductible = 1500.00 (unaffected by out-of-network), family OOPM = 4429.04 (out-of-network doesn't count).

Reconsidering "accumulate to the family balance" — maybe this refers to a separate family out-of-network OOPM track. I'll commit to: out-of-network deductible stays separate from family deductible, and out-of-network responsibility only builds A's individual out-of-network OOPM, giving A's OOPM after Line 4 as 5140.74.

For Line 8, A's in-network OOPM (6000.00) accumulates only in-network claims: Claim 5 (2934.75) + Claim 7 (335.22) = 3270.00, keeping out-of-network responsibility separate from this track.

Remaining room: 6000.00 - 3270.00 = 2730.00.

A's deductible is met, so 20% coinsurance applies on the 22767.73 allowed amount: 4553.55. But this exceeds remaining OOPM room, so member responsibility caps at 2730.00.

plan_paid = 22767.73 - 2730.00 = 20037.73

That means A hits the OOPM exactly at 2730.00 more in member costs, then the plan covers 100% of the rest of the allowed amount for this line.

So member pays 2730.00, plan pays 22767.73 - 2730.00 = 20037.73. Actually this is the same calc I did before—I need to check if it's actually correct rather than assuming it's wrong. The confusion was treating this as invalid without verifying against the OOPM definition itself.

By definition, once member responsibility hits the OOPM limit, plan covers 100% of remaining allowed amount. With 2730.00 left before the cap, that's the member's payment; plan covers the rest.

Since deductible is already met, the full 2730.00 is coinsurance, not deductible.

So: copay 0.00, deductible applied 0.00, coinsurance 2730.00 (OOPM-capped), member responsibility 2730.00, plan paid 20037.73.

For A's updated accumulators: deductible stays 3000.00. In-network OOPM moves from 3270.00 to 6000.00 (hitting the cap). Out-of-network OOPM remains untouched at 5140.74 since this claim is in-network.

But "ending_oopm_a" implies a single combined OOPM value, not separate in/out-of-network tracking. Maybe the OOPM limit itself shifts depending on whether prior services were in-network (6000.00 cap), out-of-network (12000.00 cap), or a mix (likely defaulting to the higher 12000.00 cap). The cleanest read is a single OOPM tracker overall.

Under this model, member cost-sharing accumulates from every claim regardless of network, but the applicable ceiling depends on the service type. Once accumulated spend passes 6000.00, in-network services get paid 100% by the plan; passing 12000.00 does the same for out-of-network.

Checking A after Line 7: total accumulated is 8410.71, already surpassing the 6000.00 in-network threshold. This means Line 8 (in-network) should have the plan cover the full cost.

This 8410.71 total is the sum of the out-of-network claim (5140.74) plus two in-network claims (2934.75 and 335.22) — confirming A blew past the in-network cap.

20037.73.

Updated accumulators for A: deductible stays at 3000.00, in-network OOPM hits exactly 6000.00 (3270.00 + 2730.00), out-of-network OOPM remains 5140.74. Family deductible unchanged at 1500.00.

For the family OOPM, the pre-claim accumulated amount was already 12839.75, which exceeds the 12000.00 family limit. That's odd - it suggests the family had already surpassed the OOPM cap before this claim, meaning services should have been paid at 100% already.

So for Line 8, the plan should pay 100% and A's responsibility should be 0.00, since the family maximum has been met. But A's individual OOPM tracker hasn't hit 6000.00 yet - does that matter?

Looking back at the plan language: once a member reaches the OOPM (individual or family), the plan covers 100% for the rest of the year. This means either A's individual accumulation or the family's shared accumulation triggering the cap is enough to zero out cost-sharing.

I need to verify how the family OOPM reached 12839.75 by Line 8. Tracing through prior claims: preventive visits contribute 0, in-network claims and copays accumulate normally, and I need to check whether out-of-network claim 4 (5140.74) counts toward the in-network family OOPM or has its own separate out-of-network limit.

If out-of-network amounts don't accrue to the in-network family OOPM (since the plan document only specifies an in-network limit), the running total after Line 7 would be 7699.01, not 12839.75. This leaves 4300.99 of room before hitting the 12000.00 cap for Line 8, which needs to be checked against A's individual OOPM room and coinsurance owed.

A's individual in-network OOPM: 6000.00 - 3270.00 = 2730.00 remaining.

Member r

This is a complex plan year ledger exercise. I need to process each claim in order, tracking deductible and OOPM accumulators for each member and the family. Let me work through this carefully.

Plan details:
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Structure: EMBEDDED (individual can satisfy their own, family threshold is separate)
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductibles accumulate to SINGLE member deductible balance
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Individual out-of-network OOPM: 12000.00
- Coinsurance: 20% member/80% plan (in-network), 40% member/60% plan (out-of-network)
- Various copays for specific services
- Copays do NOT credit the deductible but DO credit the OOPM
- Preventive in-network services carry no cost share
- Emergency room copay ($400) is waived if results in inpatient admission

Key rules for embedded deductible:
- A member's deductible is satisfied by the lesser of their individual remainder and the family remainder
- Once a member or the family reaches their threshold, deductible_applied = 0

Let me process each line:

**Line 1 — Claim 1 — D (child)**
Service: Outpatient procedure, in-network
Allowed: 9156.86
Network: In-network
- D's individual deductible remainder: 1500.00
- Family deductible remainder: 3000.00
- deductible_applied = min(1500.00, 3000.00) = 1500.00
- After deductible, remaining amount: 9156.86 - 1500.00 = 7656.86
- Coinsurance (20%): 7656.86 * 0.20 = 1531.37
- member_responsibility = 1500.00 + 1531.37 = 3031.37, plan_paid = 6125.49
- D deductible/OOPM balances → 1500.00 / 3031.37; family deductible/OOPM → 1500.00 / 3031.37

**Line 2 — Claim 2 — E (child)**
Primary care visit, in-network, allowed 205. Need to apply copay rules for PCP visits since this typically has a fixed copay rather than deductible/coinsurance treatment — checking plan copay schedule for office visit type.

ices unless explicitly stated.
- But the plan explicitly separates the two mechanisms - copays and deductibles work independently, so I need to figure out which one actually applies here.
- Typically, a copay service means you just pay that flat fee and the deductible doesn't apply. But this plan's language is ambiguous enough to make me second-guess that assumption.
- The two possibilities: either the copay is the entire member responsibility, or the deductible is checked first and coinsurance kicks in after.

Given standard insurance conventions, copays usually apply regardless of deductible status - you pay the flat $30 for a primary care visit and that's it, no interaction with deductible progress.

The plan pays 205.32 - 30.00 = 175.32, with the copay only counting toward OOPM.

Services explicitly listed with copays follow this fixed-payment structure, while everything else (outpatient procedures, imaging, etc.) falls under the standard deductible-then-coinsurance model. Need to double check this against the actual plan language though.

Line 2, primary care visit: member owes the $30 copay, plan covers 175.32, deductible untouched, OOPM increases by 30.

E's OOPM balance moves to 30.00, deductible stays at 0.00. Family OOPM climbs to 3061.37, family deductible remains 1500.00 unchanged.

Moving to Line 3, B's outpatient imaging claim - allowed amount 1054.17, with individual and family deductible remainders both still open to apply against.

Since the full allowed amount fits within remaining deductible space, the whole 1054.17 goes toward deductible, leaving nothing for coinsurance. Member owes the full allowed amount, plan pays zero. B's deductible and OOPM balances both jump to 1054.17. Family deductible rises to 2554.17, family OOPM to 4115.54.

For Line 4, E's out-of-network inpatient surgery claim with allowed amount 16325.03 - applying E's out-of-network deductible cap of 3000.00 first, then 40% coinsurance on the remainder of 13325.03, giving coinsurance of 5330.01. Total member responsibility comes to 8330.01, with plan paying the rest.

Checking the family OOPM limit of 12000.00 against my running total gives 12445.55, which exceeds it - I need to review the out-of-network rules more carefully. The plan doc states out-of-network claims measure against out-of-network individual thresholds only, not family in-network amounts, but the credits still flow into member and family balances. I should also verify whether the individual/family OOPM figures I'm using are correctly split between in-network and out-of-network categories, since the plan lists separate OOPM values for each.

tal OOPM stays at 12000.00 in-network, with out-of-network tracked separately but still feeding into the family balance.

Reading again: the out-of-network claim gets checked against E's own out-of-network threshold, not the family in-network number. But whatever E owes still adds to both E's balance and the family's overall balance—so it's a one-way accumulation rather than a limiting factor.

For E's claim: member responsibility of 8330.01 goes to E's out-of-network OOPM (0 + 8330.01 = 8330.01) and also to family OOPM (4115.54 + 8330.01 = 12445.55). That pushes the family total past the 12000.00 cap, which seems like it should trigger capping behavior on the family side even though the claim itself was evaluated against E's individual out-of-network limit.

There's no separate family out-of-network OOPM listed in the plan—only individual in-network (6000), family in-network (12000), and individual out-of-network (12000). So the family accumulator being exceeded by an out-of-network claim needs clarification on whether it caps there or just tracks past it.

Out-of-network dollars still feed into both the member's own accumulator and the family total, even without a distinct family out-of-network cap. Once a member hits their in-network OOPM, in-network services become fully covered—but the plan doesn't clearly state that reaching the out-of-network OOPM triggers 100% coverage for out-of-network services too, which is a gap I need to work through.

mounts don't limit an out-of-network claim, but doesn't say the reverse—that out-of-network costs are excluded from the family accumulator.

So I'll settle on: out-of-network member costs still add to the family balance total, but when checking whether an out-of-network claim should be limited, only the out-of-network individual OOPM matters, not the family in-network OOPM.

For accumulator tracking I need each member's in-network OOPM, each member's out-of-network OOPM (if separate), and the family in-network OOPM—summing all member costs regardless of network status into the family total.

Deductible works differently: copays never touch the deductible, but they always hit the OOPM. So the OOPM accumulator captures every dollar of member responsibility, in-network and out-of-network alike, while the deductible tracks only non-copay costs. Once a member's OOPM hits 6000.00 for in-network care, they get full coverage on future in-network claims.

But out-of-network has its own ceiling of 12000.00, and the 100%-coverage language specifically calls out "in-network services" — it doesn't say anything about out-of-network kicking in at 100% once the in-network cap is hit. So these look like two separate tracks: an in-network OOPM (6000.00) that unlocks free in-network care, and a higher out-of-network OOPM (12000.00) that presumably unlocks free out-of-network care once reached, independently.

For the family, the 12000.00 figure is likely the combined in-network cap across all members.

So I need three accumulators: in-network OOPM per member, out-of-network OOPM per member, and family in-network OOPM. But the task only asks for a single "ending_oopm_a" per member — so maybe I should just track one combined number after all, summing whatever member_responsibility comes from either network type, capped appropriately depending on claim type as I process each claim.

ily OOPM covers everyone combined, while individual OOPM caps one person's spend. Once a member hits their max, they owe nothing more for the year in that category; same for the family cap.

So in-network stops at 6000.00 per person or 12000.00 total family, whichever comes first. Out-of-network stops at 12000.00 per person, tracked separately from the family in-network cap. The tricky part is whether in-network and out-of-network spending combine into one running total per member, or stay in separate buckets - that determines whether hitting one limit affects the other.

Given the note that family in-network amounts don't limit out-of-network claims, it seems like out-of-network costs are subject only to the individual 12000.00 out-of-network limit, not counted against the family in-network cap at all.

The mention of "family balance" separately from "family OOPM limit" clarifies things - family balance is just the accumulated total across members, while the OOPM limit is the trigger point (12000.00) that only responds to in-network spending. Out-of-network dollars still credit to the family balance, but don't count toward reaching that 12000.00 trigger.

So the tracking structure becomes:
- Individual in-network accumulator (caps at 6000.00)
- Individual out-of-network accumulator (caps at 12000.00)
- Family in-network accumulator (caps at 12000.00, triggers 100% coverage for all members' in-network claims)

For reporting purposes I'll need each member's in-network ending balance.

family OOPM is a global cap of 12000.00 total. So once the family total hits that, everyone gets 100% in-network coverage, regardless of individual amounts. But a member also gets 100% once their own individual accumulator hits 6000.00.

This mirrors how deductibles typically work in embedded plans - individual and family limits both apply, and whichever is reached first triggers the benefit. If member A pays 1500.00 and member B pays 1500.00, the family deductible of 3000.00 is satisfied even though neither individual has hit their own 1500.00 limit... wait, actually in this case each did hit it individually too. Let me think of a clearer case: if two members each pay 1000.00 toward a 1500.00 individual/3000.00 family deductible, neither has met their individual deductible, but combined they've only hit 2000.00, still short of family 3000.00.

For OOPM: if member A pays 5000.00 and member B pays 7000.00, that's 12000.00 family total, satisfying the family OOPM even though member A hasn't hit their individual 6000.00 - so member A gets 100% coverage from that point forward too.

Out-of-network works differently - individual OOPM there is 12000.00 with no stated family limit, and those out-of-network dollars don't count toward the in-network family OOPM.

For adjudication: compute deductible applied, coinsurance, member responsibility, plan paid amount, then update the OOPM accumulators accordingly.

For in-network claims, add member responsibility to both member's and family's OOPM. For out-of-network, only update the member's own accumulator. Then check caps - member hits 6000.00 individual or family hits 12000.00 triggers 100% in-network coverage going forward; out-of-network individual cap is 12000.00.

The tricky part is whether reaching the cap affects the current claim. Reading "once a member reaches" suggests this applies after the threshold is crossed - so a claim that pushes someone from 5999.99 to 6000.99 would still have them pay normally on that transaction (the last dollar under the cap), with 100% coverage starting on the next claim.

But actually, if someone's accumulator is at 5000.00 and a claim would add 2000.00, logically they should only owe 1000.00 (reaching exactly 6000.00) with the plan covering the rest of that same claim - the cap should be applied within the claim itself, not just prospectively to future claims. So I need to cap member_responsibility at the remaining OOPM room for the current claim, then set future coinsurance to 0% once the accumulator hits the limit.

Applying this to Line 1 (D, child, outpatient procedure, allowed 9156.86):
- Deductible applied: min(1500.00, 3000.00, 9156.86) = 1500.00
- Coinsurance on remaining 7656.86 at 20% = 1531.37
- Total member responsibility: 3031.37, well under D's 6000.00 OOPM cap, so no adjustment needed
- Plan pays: 9156.86 - 3031.37 = 6125.49
- D's OOPM accumulator: 3031.37; family accumulator: 3031.37

Line 2 (E, child, primary care visit, allowed 205.32):
- Copay of 30.00 applies, doesn't touch deductible
- Plan pays 175.32
- E's OOPM accumulator starts updating from this copay

ible: 16325.03 - 3000.00 = 13325.03
- Coinsurance (40%): 13325.03 * 0.40 = 5330.01
- Member responsibility: 3000.00 + 5330.01 = 8330.01
- After OOPM cap: min(8330.01, 12000.00) = 8330.01
- Plan paid: 16325.03 - 8330.01 = 5995.02
- Update E's OOPM: 30.00 + 8330.01 = 8360.01 (out-of-network counts toward individual OOPM)
- Family OOPM unchanged: 4115.54 (out-of-network doesn't count)

I need to clarify whether family OOPM tracking is separate for in/out-of-network or combined. Re-reading the rules, out-of-network claims don't count toward the in-network family OOPM limit itself, but credits still accumulate to both the member's balance and a family balance — suggesting these are tracked separately from the in-network family limit.

So the family in-network OOPM limit (12000.00) only applies to in-network costs, while out-of-network accumulates separately with no cap. The "ending_family_oopm" I report should reflect the in-network balance used against that 12000.00 limit, not a combined total.

Moving to Claim 5 for E (child), outpatient rehab, in-network, allowed 2923.30:
- E's in-network OOPM remaining: 6000.00 - 30.00 = 5970.00
- Family in-network OOPM remaining: 12000.00 - 4115.54 = 7884.46

For deductible: E has 1500.00 remaining, family has 445.83 remaining (3000.00 - 1554.17). Since family remainder is smallest, deductible_applied = 445.83. Remaining charge after deductible: 2477.47, coinsurance at 20% = 495.49. Total member responsibility = 941.32, which passes under both OOPM caps unchanged. Plan pays 1981.98.

Updated totals: E's deductible now 445.83, E's OOPM now 971.32, family deductible now 2000.00, family OOPM now 5056.86.

Claim 6 for A (subscriber) is a screening mammography, in-network — a preventive service covered at 100% with no cost-sharing, so deductible, coinsurance, and copay all stay at 0.00, member responsibility is 0.00, and plan pays the full 1220.47.

But checking the rule again — preventive in-network services also don't move any accumulator, deductible or OOPM. So no updates needed beyond recording the claim.

For Claim 7, D's inpatient admission in-network at 19176.22: D's individual deductible is already fully satisfied from Line 1, so even though family has 1000.00 remaining, D's own remaining is 0, making deductible_applied 0.00. The full charge moves to coinsurance at 20%.

Coinsurance: 19176.22 × 0.20 = 3835.24 owed by member. D's remaining in-network OOPM was 2968.63 — since 3835.24 exceeds that, member responsibility caps at 2968.63, and D's OOPM hits the 6000.00 individual limit exactly. Plan pays 19176.22 - 2968.63 = 16207.59. Family OOPM remains at 5056.86 for now.

**Line 8 — Claim 8 — A (subscriber)**
Inpatient admission, in-network, allowed 15812.18.
- A's OOPM remaining: 6000.00; family OOPM remaining: 12000.00 - 8025.49 = 3974.51
- A's deductible remaining: 1500.00; family deductible remaining: 1000.00
- deductible_applied = min(1500.00, 1000.00, 15812.18) = 1000.00
- Post-deductible: 14812.18 × 20% = 2962.44 coinsurance
- Total member responsibility: 3962.44
- Family OOPM remaining (3974.51) is the binding cap, but 3962.44 is under it, so full amount applies
- Plan pays 15812.18 - 3962.44 = 11849.74
- A's deductible now 1000.00, A's OOPM now 3962.44
- Family deductible reaches 3000.00 limit
- Family OOPM updates to 11987.93

**Line 9 — Claim 9 — E (child)**, inpatient admission with surgery, in-network...

aining: 0 (family cap reached), so plan pays 100% now.
- member_responsibility: 0.00, plan_paid: 846.74
- OOPM stays unchanged since no additional cost-share accrues once the cap is hit

**Line 11 — Claim 11 — A (subscriber)**
Service: Outpatient rehabilitation, in-network
Allowed: 8259.39
With family OOPM already exhausted, this claim is also fully covered: member_responsibility 0.00, plan_paid 8259.39, A's and family OOPM remain unchanged.

**Line 12 — Claim 12 — A (subscriber)**
Ambulatory surgery, allowed 5987.22, family cap reached → plan pays 100%, member_responsibility 0.00, plan_paid 5987.22, no accumulator changes.

**Line 13 — Claim 13 — C (child)**
Urgent care visit, allowed 208.35, copay $75 applies (doesn't touch deductible). member_responsibility 75.00, plan_paid 133.35, copay_amount 75.00. C's OOPM updates from 0 to 75.00; family OOPM stays at 12000.00 since it was already capped.

**Line 14 — ADJUSTMENT to Claim 8 — A (subscriber)**
Reviewing original Claim 8: allowed 15812.18, deductible_applied 1000.00, coinsurance 2962.44, member_responsibility 3962.44, plan_paid 11849.74 — need to check the adjustment against these figures.

Corrected allowed amount is 13440.35, requiring full recalculation. Per adjustment rules, I must first reverse the original claim's credits, then re-adjudicate the corrected amount against the resulting accumulator state.

Reversing: subtract 1000.00 deductible credit and 3962.44 OOPM credit for A. This brings A's deductible to 0, A's OOPM to 0, family deductible down to 2000.00 (3000.00 - 1000.00), and family OOPM down to 8037.56 (12000.00 - 3962.44).

With original credits stripped out, A's accumulators sit at 0/0, and I now need to re-run the corrected 13440.35 claim against this reset baseline before restoring any subsequent claims that depended on the old numbers.

reprocessed; their results stand as first adjudicated." So lines 9-13 keep their original outputs, but accumulators still need reconciling since Claim 8's numbers shifted underneath them.

My read: pull out original Claim 8's contribution, insert the corrected values, leave lines 9-13's own results untouched, then reconcile the running totals to reflect the swap.

So current accumulator state at the point of adjustment, before removing Claim 8's old credits:
- A's deductible: 1000.00 (from Claim 8)
- A's OOPM: 3962.44 (from Claim 8) plus whatever else accumulated afterward

I need to trace Lines 9-13 to see actual accumulator values, since Claim 9's outcome depended on Claim 8's prior state. Family OOPM sat at 11987.93 after Claim 8, then Claim 9 pushed it the remaining 12.07 to hit the 12000.00 cap — meaning Claim 9's result was directly shaped by Claim 8's numbers.

The rule states results from in-between claims stand as first adjudicated, so Claims 9-13's member_responsibility/plan_paid stay fixed. But this creates tension: if Claim 8's corrected values differ, the accumulator trail leading into Claim 9 changes too. I think the fix is that Claim 9-13's dollar outcomes are locked in, but the accumulators themselves get rebuilt by removing Claim 8's original contribution and adding its corrected one — even if that means the running totals no longer perfectly reconcile with what Claims 9-13 "saw" when they were adjudicated.

So Claims 9-13 stay fixed at their originally adjudicated amounts—only the accumulator state shifts based on the new Claim 8.

Before Line 14: A's deductible 1000.00, A's OOPM 3962.44, Family deductible 3000.00, Family OOPM 12000.00.

Unwinding Claim 8: A's deductible drops to 0, A's OOPM to 0, Family deductible to 2000.00, Family OOPM to 8037.56.

Re-adjudicating Claim 8 with new allowed 13440.35 gives deductible_applied 1000.00 and member_responsibility 3488.07, pushing Family deductible back to 3000.00 and Family OOPM to 11525.63.

After Line 14, A's deductible becomes 1000.00 again.

But this ignores the contributions from Claims 9-13 that occurred between original C

This is a complex plan year ledger calculation task. Let me work through this systematically.

**Plan Details:**
- Deductible: Individual in-network $1500, Family in-network $3000 (EMBEDDED)
- Out-of-network deductible: $3000 individual
- In/out-of-network deductible accumulate to SINGLE member balance
- OOPM: Individual in-network $6000, Family in-network $12000, Individual out-of-network $12000
- Coinsurance: 20% member / 80% plan (in-network), 40% member / 60% plan (out-of-network)
- Copays: PCP $30, Specialist $60, Urgent care $75, ER $400 (waived if admitted), Pharmacy $15
- Copays do NOT credit deductible, but DO credit OOPM
- Preventive services: 100% covered, no cost share, no accumulator movement

**Key Rules:**
- In embedded deductible: individual amount can be satisfied on its own, but family must also be satisfied
- Deductible applies per claim: lesser of (member individual remainder, family remainder)
- After deductible is satisfied, coinsurance applies
- Out-of-network claims use the $3000 out-of-network threshold for that member, but family amounts don't limit out-of-network claims
- Adjustments unwind previous credits and re-adjudicate
- Voids unwind credits and post nothing

Let me process each claim in order:

**Line 1 — Claim 1 — 2026-01-23 — D (child)**
Service: Outpatient procedure, in-network
Allowed: 9156.86
Network: In-network
D's individual deductible ($1500) and family deductible ($3000) are both untouched, so the applied deductible is the smaller amount, $1500 — fully satisfying D's individual portion. The remaining $7656.86 gets 20% coinsurance ($1531.37), so D owes $3031.37 total and the plan covers $6125.49.

Running totals: D deductible met $1500.00, family deductible now $1500.00, D OOPM $3031.37, family OOPM $3031.37.

Claim 2, E's primary care visit ($205.32 allowed) is a copay service — $30 flat, doesn't touch deductible but counts toward OOPM. Plan pays $175.32. E's deductible stays $0, family deductible remains $1500. E OOPM becomes $30, family OOPM climbs to $3061.37.

Claim 3 starts for B's outpatient imaging ($1054.17 allowed, in-network), with B's individual deductible remainder at $1500 and family remainder at $3000 —

The single balance rule matters here — E's deductible balance sits at 0 before this claim, so out-of-network threshold of $3000 applies fully. But family deductible tracking needs clarification: checking whether out-of-network claims measure against the out-of-network family threshold separately, or continue accumulating into the same family balance.

out-of-pocket balance) — so with higher out-of-network thresholds, an out-of-network claim can push a member's balance past the in-network individual figure, and family balances past

the family amounts; nothing caps these at the in-network levels.

So for out-of-network claims, room is measured against the out-of-network individual threshold, but the deductible_applied still credits both the member and family balances. Re-reading the definition: deductible_applied is the lesser of allowed amount and remaining room — in-network uses the smaller of individual/family remainder (embedded) or just family remainder (aggregate); out-of-network uses the individual remainder against that same single balance.

Before Line 4, E's balance is 0, so E's out-of-network remainder is 3000.00. Deductible applied = min(16325.03, 3000.00) = 3000.00, bringing E's balance to 3000.00.

Now checking whether this credits to the family deductible too — the family in-network deductible is 3000, so I need to see if out-of-network credits count toward that same family threshold, since there appear to be separate deductible structures at play.

There's the individual/family in-network deductible (1500/3000 embedded), and separately an individual out-of-network deductible (3000). Each member holds one balance tracking both, and family holds its own balance.

For in-network claims: deductible applied = min(allowed, individual remainder, family remainder).

For out-of-network claims: deductible applied = min(allowed, member's out-of-network remainder) — but credits still flow into the family balance. The key rule is that out-of-network claims are only measured against the individual out-of-network threshold; the family's in-network threshold doesn't cap an out-of-network claim, even though the payment still accumulates to the family balance.

Applying this to Claim 4 (E, child, 2026-02-22, allowed 16325.03, out-of-network):
- E's out-of-network remainder: 3000.00 - 0 = 3000.00
- Deductible applied: min(16325.03, 3000.00) = 3000.00
- Remaining: 13325.03
- Coinsurance (40%): 5330.01
- Member responsibility: 8330.01
- Plan paid: 5995.02

E's balance becomes 3000.00; family balance becomes 2554.17 + 3000.00 = 5554.17 — uncapped, since balances aren't limited to the in-network thresholds.

E's OOPM: 30.00 + 8330.01 = 8360.01
Family OOPM: 4115.54 + 8330.01 = 12445.55

Need to check whether an out-of-network family OOPM cap exists separately, since 12000 was specified for in-network.

k) that count toward both individual and family balances

For out-of-network claims:
- Deductible checked against individual out-of-network threshold (3000) only
- OOPM checked against individual out-of-network threshold (12000) only
- Family thresholds simply aren't checked, since they're in-network only

The credits from out-of-network spending still accumulate into the family balances, they just don't get compared against a family out-of-network limit since none exists. This matches the "family amounts... do not limit an out-of-network claim" rule—it's not that out-of-network spending doesn't count toward family totals, it's that family totals never cap an out-of-network claim.

So for Line 4: E OOPM balance becomes 30.00 + 8330.01 = 8360.01, checked against the 12000 individual OON threshold. The family OOPM balance updates to 4115.54 + 8330.01 = 12445.55, but this is purely for record-keeping since no family threshold applies to out-of-network claims.

I also need to double check the "100% coverage after OOPM" language — it explicitly says "for covered in-network services," so once OOPM is met, that free-ride protection doesn't extend to out-of-network claims.

The 12000 individual OON limit likely serves as its own separate cap on out-of-network spending, distinct from the in-network 100% coverage trigger, though the glossary doesn't fully clarify what happens once that OON limit itself is reached.

For calculating member responsibility: I check whether the member's accumulated OOPM plus the new claim's cost-share would exceed their threshold—if so, responsibility gets capped and the plan covers the rest. This gives structure: individual in-network OOPM of 6000, individual OON OOPM of 12000, and a family in-network OOPM of 12000 (with no separate family OON limit). In-network claims cap member responsibility against the 6000 individual threshold, while family totals cap against the family 12000 threshold.

For out-of-network claims, the individual cap is 12000, but family logic gets murkier—does the family OOPM even apply? The prompt clarifies that family amounts (in-network) don't limit OON claims, so only the individual OON OOPM of 12000 matters there.

There's also ambiguity in the OOPM completion language: general text says "covered services" while the glossary specifies "covered in-network services." I lean toward trusting the glossary's specificity—OOPM completion only applies to in-network services, not OON. Answer: B.

plan pays 100% for the rest of the year once OOPM is reached.

For claim 4 (E, child), applying deductible then coinsurance: deductible balance goes to 3000.00, OOPM balance becomes 8360.01. Since E's out-of-network OOPM is 12000, this hasn't been reached yet, so E still owes the full coinsurance amount. Family deductible balance updates to 5554.17.

Family OOPM balance: 4115.54 + 8330.01 = 12445.55

For claim 5 (E, in-network rehab, allowed 2923.30), I need to check deductible status. E's individual deductible remainder appears negative (-1500.00), meaning it's fully satisfied — but this needs verification since there's a single deductible balance shared across in/out-of-network, just measured against different thresholds depending on service type. In-network services check against the 1500 threshold, out-of-network against the higher threshold, but it's one accumulating balance.

Before Line 4, E's balance was 0. Line 4 (out-of-network) applied deductible up to the 3000 threshold, adding 3000 to E's balance. Now at Line 5 (in-network, threshold 1500), E's balance of 3000 already exceeds 1500, so no additional deductible applies — E's deductible is fully met for this in-network claim.

Coinsurance: 2923.30 * 0.20 = 584.66, plan pays 2338.64.

E deductible balance stays 3000.00. E OOPM: 8360.01 + 584.66 = 8944.67. Family deductible unchanged at 5554.17; family OOPM: 12445.55 + 584.66 = 13030.21.

Line 6, A's preventive screening mammography in-network — no cost share, no accumulator movement. Deductible applied 0, member responsibility 0.

Plan paid 1220.47, copay 0. A's deductible and OOPM balances unchanged, family balances unchanged.

Line 7, D's inpatient admission, allowed 19176.22. D's individual and family deductibles already fully satisfied, so deductible applied is 0. Coinsurance: 19176.22 * 0.20 = 3835.24, plan pays 15340.98.

Checking D's OOPM: adding 3835.24 to 3031.37 gives 6866.61, but D's individual in-network OOPM cap is 6000, so this exceeds it — I need to cap the room left at 2968 instead.

The room left is actually 2968.63, so member responsibility must be capped there rather than the full 3835.24. Plan paid adjusts to 19176.22 - 2968.63 = 16207.59, bringing D's OOPM to exactly 6000.00.

Breakdown: deductible 0, copay 0, coinsurance 2968.63. Now I need to check whether the family OOPM balance (13030.21 + 2968.63 = 16000.00) also needs capping against the family OOPM limit.

Family (in-network) is 12000.00, so adding 2968.63 to the family total would push it well past that limit. This means the family OOPM cap also constrains member responsibility here — I need to check both individual and family caps and apply whichever is more restrictive.

For member D: calculated responsibility 3835.24, individual OOPM balance before is 3031.37, leaving room of 2968.63. But the family OOPM balance before appears to be 13030.21, already exceeding the 12000 family limit, which is odd and needs checking.

Going back, family OOPM after Line 3 is 4115.54 (fine), but after Line 4 it becomes 4115.54 + 8330.01 = 12445.55, which exceeds 12000. This means the family OOPM cap was actually hit during Line 4, so that calculation needs to be revised.

Recalculating Line 4: allowed 16325.03, out-of-network. Deductible 3000.00 applied, remaining 13325.03, coinsurance at 40% = 5330.01, total member responsibility = 8330.01.

Room left in family OOPM before this claim: 12000 - 4115.54 = 7884.46, so responsibility would be capped there — except this claim is out-of-network, and the problem states in-network family amounts don't limit out-of-network claims. So the OOPM cap doesn't apply here.

Still, per the accumulator rules, out-of-network credits still accumulate to member and family balances even though they don't limit the claim itself.

So for line 4, E's responsibility is capped by E's individual out-of-network OOPM (12000), not the family in-network limit, but it still accumulates to the family balance.

E's individual out-of-network OOPM balance before: 30.00, limit 12000, room left: 12000 - 30.00 =

11970.00. Since calculated member responsibility (8330.01) is under this, no capping applies.

E's member responsibility stands at 8330.01, bringing E's OOPM balance to 8360.01 and family OOPM balance to 12445.55 — exceeding 12000, but that's fine since the family limit doesn't apply to out-of-network claims.

Moving to line 5, claim 5 for E on 2026-03-03, this is in-network. Calculated responsibility is 584.66, E's OOPM balance before is 8360.01, against an individual in-network limit of 6000. Need to determine which OOPM applies here.

I'll track separate in-network and out-of-network OOPM balances per member, since the plan lists these limits separately (6000 in-network, 12000 out-of-network). Each service counts toward its relevant limit, and once a member hits either limit, that category of service becomes fully covered.

For Line 5, E's out-of-network balance stands at 8360.01, but I need to figure out where the in-network copay from Line 2 (30) went. Copays credit the OOPM, but I'm unsure whether the plan tracks one combined balance or truly separate in-network/out-of-network balances - the document doesn't explicitly clarify this split.

ate limits with separate balances - in-network OOPM tracks in-network cost-sharing, out-of-network OOPM tracks out-of-network cost-sharing independently.

So in-network claims accumulate toward 6000, and once hit, in-network services become free. Out-of-network claims accumulate toward 12000 separately, and once hit, those become free.

Applying this: line 2 (in-network PCP, $30 copay) adds to the in-network balance, bringing it to 30. Line 4 (out-of-network inpatient) would add to the separate out-of-network balance instead.

For the family OOPM, only one figure appears: $12000 in-network. There's no separate out-of-network family limit. Rereading the problem statement, it says out-of-network credits still accumulate to the family balance, but without an out-of-network family threshold, that balance could exceed 12000 for out-of-network services. The ACCUMULATORS section clarifies that out-of-network claims only measure against individual out-of-network thresholds - family amounts (which are in-network) don't limit

So member responsibility from in-network claims caps out at the $12000 family in-network OOPM, triggering 100% coverage once reached. Out-of-network claims still add to a family balance for tracking, but since there's no cap on it, they never trigger 100% coverage - member responsibility continues regardless of accumulated total.

For each claim type:
- In-network: member responsibility limited by min(6000 individual, 12000 family) minus existing balances, updates both member and family balance
- Out-of-network: member responsibility limited by 12000 individual OOPM minus member's out-of-network balance, updates member balance and possibly the family balance for tracking only

So for line 2, an in-network PCP visit, the OOPM balance becomes 30, updating both member and family totals.

For line 4, out-of-network inpatient, the member balance hits 8330.01, family balance climbs to 12445.55 - but since family limits don't apply to out-of-network, this doesn't restrict anything.

Line 5 is in-network rehab: member balance would be 30 + 8330.01 + 584.66 = 8944.67, exceeding the 6000 in-network cap. That breaks the model - the member balance shouldn't exceed either limit.

Trying a different structure: separate OOPM balances for in-network vs out-of-network claims entirely, each accumulating independently with their own 6000/12000 caps. Line 2 gives in-network balance of 30, line 4 gives out-of-network balance of 8330.01.

For family, only in-network claims accumulate toward the 12000 family cap. Line 2: family balance 30, line 3: 1084.17, line 4 doesn't touch family (out-of-network), line 5: family balance 1668.83.

But this conflicts with the stated rule that out-of-network claims still accumulate to family balance - rereading that sentence more carefully to understand the actual intent.

Simplifying: one member OOPM balance and one family OOPM balance exist. For in-network claims, check both member (6000) and family (12000) limits. For out-of-network claims, check only the out-of-network member limit (12000) - family limit doesn't apply there. But member responsibility still adds to both balances regardless of claim type.

So line 2: member=30, family=30. Line 3: both become 1084.17. Line 4: out-of-network member responsibility 8330.01, capped at

min(12000-8360.01, 8330.01) = 3639.99... wait, need to retrace the balances since in-network and out-of-network might track separately for the member.

Actually this document is genuinely ambiguous, so I'll commit to one interpretation: each member has a single OOPM balance accumulating all responsibility, capped by (6000-balance) and (12000-family balance) for in-network, or just (12000-balance) for out-of-network. Family balance similarly accumulates everything, but the 12000 family cap only constrains in-network claims.

Redoing the ledger:

Line 1 (D, in-network): deductible 1500, coinsurance 1531.37, member resp 3031.37, plan pays 6125.49. D balance 3031.37, family balance 3031.37.

Line 2 (E, in-network copay): member resp 30.00, plan pays 175.32. E balance 30.00, family balance 3061.37.

Line 3 (B, in-network): deductible 1054.17, no coinsurance, member resp 1054.17, plan pays 0. B balance 1054.17, family balance 4115.54.

Line 4 (E, out-of-network, allowed 16325.03): deductible applied 3000...

Coinsurance 13325.03*0.40=5330.01, calculated resp 8330.01. E's out-of-network limit is 12000, room left 11970, so not capped — resp stays 8330.01, plan pays 5995.02. E balance rises to 8360.01, family balance 12445.55, but since OON claims don't count toward the family cap, this is fine.

Line 5 (E, in-network, allowed 2923.30): deductible already met, coinsurance 584.66. But E's in-network accumulator sits at 8360.01, already past the 6000 in-network limit — that seems off since it exceeds before this claim even applies, prompting me to double check whether OON and in-network track separately per person.

I realize the mistake: mixing in-network and out-of-network member responsibility into one running balance is wrong. Once someone hits the in-network OOPM, in-network claims should be free even if out-of-network costs are still accumulating separately. I need to track two distinct balances per person — in-network and out-of-network — each capped independently (6000/12000 respectively), while the family 12000 limit only restricts in-network accumulation. Restarting the calculation with this split-balance model, beginning again with claim 1 for D.

8330.01 = 8330.01
Family balance: 4115.54 + 8330.01 = 12445.55

**Line 5 — Claim 5 — 2026-03-03 — E (child)**
Allowed: 2923.30, In-network
Coinsurance: 584.66
E in-network room: 6000 - 30.00 = 5970.00
Family cap room: 12000 - 12445.55 = -445.55

Wait, family balance already exceeds 12000 due to the out-of-network claim, leaving no room for in-network. That seems off—an out-of-network claim shouldn't zero out in-network coverage. Re-reading the rules, the family limit likely refers to in-network family caps only, not applying to out-of-network claims, so I need to reconsider whether out-of-network amounts should even count toward the in-network family balance.

The problem states credits from out-of-network claims still accumulate to both member and family balances. So the family balance does include out-of-network responsibility, but the 12000 cap only gets enforced when evaluating in-network claims—out-of-network claims themselves aren't limited by it.

Applying that here: family balance before is 12445.55, cap is 12000, so room is -445.55, meaning the family cap is already exceeded and this in-network claim's member responsibility should be capped.

Since the balance already surpasses 12000, member responsibility = 0.00, plan pays 2923.30. But that's giving plan liability rather than member responsibility—I need to reconsider.

Perhaps the family balance itself should be capped at 12000 for tracking purposes once it hits that threshold, with subsequent in-network claims covered 100%. The question then is whether out-of-network claims after that point are also fully covered, or still subject to coinsurance and the separate 12000 out-of-network OOPM.

Given individual out-of-network OOPM is 12000, once E's out-o

This is a complex plan-year ledger task. I need to process each claim in order, tracking both individual and family accumulators, then handle adjustments which unwind credits and re-adjudicate.

Let me start by understanding the plan:
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- Out-of-network deductible (individual): 5000.00
- In-network and OON deductibles accumulate to a SINGLE member balance
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance in-network: 30% member / 70% plan
- Coinsurance out-of-network: 50% member / 50% plan
- Copays: PCP $25, Specialist $50, Urgent care $60, ER $300 (waived if admits), Generic pharmacy $10
- Copays credit the deductible AND the out-of-pocket maximum
- Preventive care: no cost share, no deductible or OOPM impact

Starting accumulators before Line 1:
- A: ded 0.00, oopm 0.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 1150.72, oopm 1150.72
- Family: ded 2895.39, oopm 3051.40

Let me process each line:

**Line 1 — Claim 1 — 2026-01-18 — D (child)**
ER visit, in-network, allowed 3295.94, treated and released so the $300 copay applies (not waived).

D's accumulator before: ded 1150.72, oopm 1150.72
Family before: ded 2895.39, oopm 3051.40

Copay of 300.00 applies. D's remaining deductible room is 2500.00 - 1150.72 = 1349.28, and family's remaining is 5000.00 - 2895.39 = 2104.61 — the copay gets applied against deductible here.

remaining deductible is lower, apply full copay there: D's deductible balance becomes 1150.72 + 300.00 = 1450.72.

Remaining charge: 3295.94 - 300.00 = 2995.94, subject to 30% coinsurance.
Member owes: 2995.94 * 0.30 = 898.78
Plan pays: 2995.94 * 0.70 = 2097.16

D's OOPM total: 1150.72 + 300.00 + 898.78 = 2349.50

Family deductible now 2895.39 + 300.00 = 3195.39
Family OOPM: 3051.40 + 1198.78 = 4250.18

For claim 1, I have deductible_applied 300.00, copay 300.00, coinsurance 898.78, plan_paid 2097.16 — but I should double check what member_responsibility actually represents versus just summing pieces, since deductible_applied and copay might overlap conceptually.

The rule states member_responsibility + plan_paid = allowed amount, so member_responsibility = allowed - plan_paid.

After the 300 copay satisfies part of deductible, 2995.94 remains subject to 30% coinsurance: plan pays 2097.16, member owes 898.78 in coinsurance. Total member_responsibility = 300 + 898.78 = 1198.78, and 1198.78 + 2097.16 = 3295.94 checks out.

Updated accumulators — D: ded 1450.72, oopm 2349.50; Family: ded 3195.39, oopm 4250.18.

**Line 2 — Claim 2 — 2026-01-28 — D (child)**, urgent care in-network, allowed 182.07, copay 60.00.

D's remaining deductible: 2500.00 - 1450.72 = 1049.28; family remaining: 5000.00 - 3195.39 = 1804.61. The 60.00 copay fits under both, so it applies fully to deductible, bringing D's deductible to 1510.72.

Remaining balance of 122.07 hits 30% coinsurance: member owes 36.62, plan pays 85.45.

Total member responsibility: 96.62. Updating accumulators — D: ded 1510.72, oopm 2446.12; Family: ded 3255.39, oopm 4346.80.

**Line 3 — Claim 3 — 2026-02-09 — A (subscriber)**, inpatient admission with surgery, out-of-network, allowed 25881.03.

A starts fresh with ded 0.00, oopm 0.00. Out-of-network deductible is 5000.00, so A's remaining OON deductible is the full 5000.00 - 0 = 5000.00.

so member responsibility caps at 11000.00 for OON individual OOPM, not the plan's family in-network thresholds.

Recalculating: A's OOPM was 0.00, member owes 15440.52, but this exceeds the OON cap of 11000.00. So only 11000.00 counts toward member responsibility, meaning the plan absorbs the excess (15440.52 - 11000.00 = 4440.52 more than initially calculated).

A hits OON OOPM of 11000.00. Plan pays remainder: 25881.03 - 11000.00 = 14881.03.

pays 100% of allowed).

Checking A's OOPM status before Claim 3: 0.00, meaning full 11000.00 room remains.

Calculating raw member responsibility: 5000.00 deductible + 20881.03*0.50 coinsurance = 5000.00 + 10440.52 = 15440.52, which exceeds the 11000.00 room available.

So member responsibility caps at 11000.00, with plan absorbing the difference: 15440.52 - 11000.00 = 4440.52 extra.

Plan paid becomes 25881.03 - 11000.00 = 14881.03, and A's OOPM hits exactly 11000.00 (at limit now).

I need to figure out how to split that 11000.00 between deductible and coinsurance categories for reporting purposes.

bs 15440.52 - 11000.00 = 4440.52, but this doesn't work since plan should pay the remainder.

Reframing: member pays member_responsibility, plan pays plan_paid, summing to allowed. With OOPM 11000.00 capping cost share, once hit plan pays 100% after.

For Claim 3, allowed 25881.03, deductible 5000.00, coinsurance 20881.03*0.50=10440.52, total member responsibility before OOPM: 15

15440.52, plan pays 25881.03-15440.52=10440.52 before OOPM.

Applying OOPM: A has 11000.00 room, so member pays min(15440.52,11000.00)=11000.00, plan absorbs extra 4440.52, plan total 10440.52+4440.52=14881.03.

Check: 11000.00+14881.03=25881.03 ✓

A's accumulators update: deductible 5000.00, OOPM 11000.00 (maxed).

Claim 3: deductible_applied 5000.00, copay_amount 0.00.

For coinsurance_amount, need actual member-paid portion: OOPM room after deductible is 11000.00-5000.00=6000.00, so coinsurance_applied=6000.00, with 4440.52 absorbed by plan.

Copay: 0.00. Member responsibility totals 5000.00+6000.00=11000.00 (hits OOPM cap), plan pays 25881.03-11000.00=14881.03.

A's post-claim accumulators: deductible 5000.00, OOPM 11000.00.

Family totals: deductible 3255.39+5000.00=8255.39, OOPM 4346.80+11000.00=15346.80 — checking whether family OOPM caps at in-network limit, but rule states family amounts don't limit out-of-network claims, so it continues accumulating past the in-network family figure.

(D): copay 300 counts toward deductible → family ded 2895.39+300=3195.39

Claim 2 (D): urgent care copay 60 → family ded 3195.39+60=3255.39

Claim 3 (A) is OON, so it shouldn't hit the in-network family deductible bucket — need to check if OON/INN accumulate separately per the plan rules.

Re-checking: in-network and OON credits both flow into a single member deductible balance, but that balance is compared against different thresholds depending on whether the service is in-network or OON. Family deductible amounts only apply to in-network claims; OON claims are judged solely against individual OON thresholds.

So for Claim 3 (A, OON): A's balance starts at 0, OON threshold is 5000.00, so full 5000.00 applied, A's balance becomes 5000.00. This doesn't touch the family in-network deductible.

Family deductible stays at 3255.39 since Claim 3 is OON.

Moving to Claim 4 (C, in-network): C's remaining individual room is 2500.00 - 1744.67 = 755.33, family remaining is 5000.00 - 3255.39 = 1744.61. Since it's embedded, deductible applied is the smaller of these two = 755.33. Copay of 60 is fully absorbed by deductible since it's under 755.33, so 60.00 applies toward C's and family's deductible.

C's deductible: 1744.67 + 60.00 = 1804.67
Remaining charge: 290.40 - 60.00 = 230.40, coinsurance splits to 30%/70%: member owes 69.12, plan pays 161.28.
Total member responsibility: 129.12, plan paid: 161.28.

C's OOPM: 1900.68 + 129.12 = 2029.80
Family deductible: 3255.39 + 60.00 = 3315.39
Family OOPM: 15346.80 + 129.12 = 15475.92

Next: Claim 5, A's urgent care visit in-network.

Allowed: 175.00, copay: 60.00
A's accumulators show ded 5000.00, oopm 11000.00 — already at OON limit. Need to check if in-network OOPM (5500.00) is separate from the OON OOPM (11000.00), since the policy lists them individually. I'll treat network types as tracking distinct OOPMs.

For OON claims, measure against the OON threshold only; in-network claims measure against the in-network threshold. The rules confirm: once a member hits the applicable OOPM, plan pays 100% for that claim type going forward. Also, OON claims only compare against OON individual thresholds — family in-network amounts don't cap them, though OON credits still roll into both member and family balances.

Applying this to A: an OON claim would push A's balance to 11000.00 (the OON threshold reached). Then an in-network claim checks against 5500.00 — since A's balance already exceeds that, the plan pays 100% on that in-network claim too.

Alternatively the thresholds might track separately by network type rather than sharing one pool, but the phrase about OON credits still accumulating to "the member's balance" points toward a unified running total.

The cleanest reading: single OOPM balance, in-network claims stop accruing cost-share once balance hits 5500.00, OON claims stop once it hits 11000.00, but everything feeds the same pool. After Claim 3, balance sits at 11000.00 — past both thresholds. So Claim 5, being in-network, sees the balance already exceeding 5500.00, meaning the plan pays 100%. Checking Claim 5's components: copay 60.00 would normally apply, but since the member has hit the OOPM, their responsibility should be 0.

Confirming against the plan rules — once OOPM is reached, plan pays 100% of allowed for covered services rest of the year. This implies copays stop being collected too, since cost-share generally is zero at this point. Copays do credit toward OOPM, but that's about accrual before hitting the max, not after. So the logical rule: once OOPM reached, no further collection at all, plan pays 100%, member owes nothing on subsequent claims.

For Claim 5: member owes 0, plan pays 175. Deductible/copay/coinsurance applied are all 0. Accumulators after this claim: deductible stays 5000, OOPM stays at 11000 (already maxed, no further additions since no member responsibility is added).

This means the balance can keep growing past thresholds — it's not capped, just used as a checkpoint. Once the in-network threshold (5500) or OON threshold (11000) is hit, the plan pays 100% allowed for claims of that network type going forward.

For A: after Claim 3 (OON), balance hits 11000 — both thresholds are satisfied, so future in-network and OON claims pay 100%. Claim 5 (in-network) then gets member responsibility 0.00, plan paid 175.00, and A's balance stays at 11000.00.

Moving to Claim 6 for C (child), an out-of-network service on 2026-03-19.

Wait, checking again — this is an in-network procedure, allowed 7641.96. C's prior accumulators: deductible 1804.67, oopm 2029.80. Individual deductible remaining is 2500.00 - 1804.67 = 695.33, family remaining is 5000.00 - 3315.39 = 1684.61. Embedded logic takes the smaller: 695.33.

Deductible applied is 695.33, leaving 6946.63 subject to coinsurance. At 30%, member owes 2083.99, plan covers 6946.63 * 0.70.

Member total: 695.33 + 2083.99 = 2778.32
Plan paid: 4862.64

Updated accumulators — C's OOPM: 2029.80 + 2778.32 = 4808.12, still under the 5500.00 individual cap. C's deductible hits its 2500.00 cap exactly. Family deductible: 3315.39 + 695.33 = 4010.72. Family OOPM: 15475.92 + 2778.32 = 18254.24.

Claim 6: deductible 695.33, copay 0.00, coinsurance 2083.99, member responsibility 2778.32, plan paid 4862.64.

**Claim 7 — 2026-03-29 — A (subscriber)**, physical therapy, allowed 894.21. A's OOPM already at 11000.00, past the 5500.00 threshold, so plan covers fully: member responsibility 0.00, plan paid 894.21.

**Claim 8 — 2026-04-09 — D (child)**, inpatient admission with surgery, allowed 25110.74. D's prior deductible 1510.72 leaves 989.28 remaining toward the 2500.00 cap. Checking family deductible threshold next.

: 5000.00, remaining 989.28 matches individual room.

Deductible applied: 989.28, leaving 24121.46 subject to coinsurance.
Coinsurance 30%: 7236.44 owed by member, plan covers 16885.02.
Member responsibility before OOPM cap: 989.28 + 7236.44 = 8225.72.

D's OOPM room: 5500.00 - 2446.12 = 3053.88, so member pays capped at min(8225.72, 3053.

88) = 3053.88, with plan absorbing the remaining 5171.84.

Checking totals: 3053.88 + 22022.86 = 25076.74, which doesn't match 25110.74 - something's off.

Plan payment should just be allowed minus member responsibility, so let me redo this more carefully with deductible 989.28, remaining 24121.46 at 30% coinsurance = 7236.44 member share.

Total member responsibility before cap: 8225.72. With D's OOPM room of 3053.88, member pays min(8225.72, 3053.88) = 3053.88, plan absorbs 5171.84.

Total plan payment: 25110.74 - 3053.88 = 22056.86.

Breaking down member share of 3053.88: deductible 989.28 fully applied, remaining 2064.60 covers coinsurance (capped from 7236.44).

Claim 8: deductible_applied 989.28, copay 0.00, coinsurance_amount 2064.60

member_responsibility: 3053.88
- plan_paid: 22056.86

D's updated accumulators: deductible 1510.72 + 989.28 = 2500.00 (maxed), OOPM 2446.12 + 3053.88 = 5500.00 (maxed).

**Line 9 — Claim 9 — 2026-04-25 — D (child)**
Physical therapy, in-network, allowed 646.70

Since D has hit the in-network OOPM threshold, plan covers 100%. Member owes 0.00, plan pays 646.70 in full.

Claim 9: deductible_applied 0.00, copay 0

coinsurance 0.00, member_responsibility 0.00, plan_paid 646.70

**Line 10 — Adjustment to Claim 2 — 2026-05-09 — D (child)**
Allowed amount changes from 182.07 to 264.00. This requires unwinding Claim 2's original credits before re-adjudicating.

Original Claim 2 had deductible 60.00, member responsibility 96.62, plan paid 85.45. Post-claim accumulators were D: ded 1510.72/oopm 2446.12, Family: ded 3255.39/oopm 4346.80.

Reversing: D's deductible drops to 1450.72, oopm reduces by 96.62 to...

2349.50, and Family deductible falls to 3195.39, oopm to 4250.18 — giving me the baseline before Claim 2 was processed.

With D's remaining individual deductible at 1049.28 and family remaining at 1804.61, I reprocess with the new 264.00 allowed amount. The 60.00 copay applies to deductible first, bringing D's deductible to 1510.72. The remainder, 204.00, gets coinsurance at 30%, totaling 61.20 plan-side.

Plan pays 204.00 * 0.70 = 142.80. Member responsibility becomes 60.00 + 61.20 = 121.20.

So the adjusted Claim 2: deductible_applied 60.00, copay 60.00, coinsurance 61.20, member_responsibility 121.20, plan_paid 142.80.

D's updated accumulators: deductible 1510.72, oopm 2349.50 + 121.20 = 2470.70. Family: deductible 3255.39, oopm 4250.18 + 121.20 = 4371.38.

Now I need to carry these forward and reprocess claims 3 through 9 sequentially, since the adjustment at claim 2 cascades through all subsequent accumulator-dependent calculations.

Starting state before Claim 3: A (0/0), B (0/0), C (1744.67/1900.68), D (1510.72/2470.70), Family (3255.39/4371.38).

Claim 3 (A, subscriber) processes the same as originally: member responsibility 11000.00, plan paid 14881.03, bringing A to deductible 5000.00, oopm 11000.00, and updating family deductible accordingly.

Family: 8255.39 / 15371.38.

Claim 4 (C, child) also unchanged: member responsibility 129.12, plan paid 161.28. C moves to 1804.67/2029.80, family to 8315.39/15500.50.

Claim 5 (A) begins: member responsibility 0.00, plan paid 175.00.

010.72
- OOPM: 15500.50 + 2778.32 = 18278.82

**Line 7 — Claim 7 — 2026-03-29 — A (subscriber)** (re-processing)
A hit OOPM already: member 0.00, plan paid 894.21.

**Line 8 — Claim 8 — 2026-04-09 — D (child)** (re-processing with updated D oopm)
D's accumulators before: ded 1510.72, oopm 2470.70. D's deductible remaining: 2500.00 - 1510.72 = 989.28. Family deductible remaining needs checking against updated family total.

Since family deductible is already satisfied (negative remainder), family remaining is capped at 0. Deductible applied = min(individual_remaining, family_remaining) = min(989.28, 0) = 0.

So full claim amount passes through to OOPM calculation with 0 deductible applied.

Coinsurance: 25110.74 × 0.30 = 7533.22 (member share), 25110.74 × 0.70 = 17577.52 (plan share)

Member owes before OOPM check: 7533.22

D's OOPM room: 5500.00 - 2470.70 = 3029.30

Member pays min(7533.22, 3029.30) = 3029.30
Plan absorbs remainder: 7533.22 - 3029.30 = 4503.92

Total member responsibility: 3029.30
Total plan paid: 17577.52 + 4503.92 = 22081.44

Check: 3029.30 + 22081.44 = 25110.74 ✓

Claim 8 results:
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 3029.30
- member_responsibility: 3029.30
- plan_paid: 22081.44

D's updated accumulators:
- Deductible: 1510.72 (unchanged)
- OOPM: 5500.00 (hits limit)

Family updated:
- Deductible: 9010.72 (unchanged)
- OOPM: 21308.12

**Line 9

.38.

Need to unwind Claim 2's Line 10 adjustment before applying the new allowed amount.

Claim 2 at Line 10 had:
- Deductible applied: 60.00
- Member responsibility: 121.20

Reversing from current state:
- D: ded 1510.72 - 60.00 = 1450.72, oopm 5500.00 (unchanged, already at limit)

Wait, unwinding oopm: 5500.00 - 121.20 = 5378.80
- Family: ded 9010.72 - 60.00 = 8950.72, oopm 21308.12 - 121.20 = 21186.92

So prior to Claim 2, accumulators stood at:
- D: ded 1450.72, oopm 5378.80
- Family: ded 8950.72, oopm 21186.92

Now re-adjudicating with allowed 209.38: D's remaining deductible is 2500.00 - 1450.72 = 1049.28, but family's is already exceeded (8950.72 > 5000.00 threshold), giving embedded min of 0 since family deductible is fully met — deductible portion is 0, and copay 60.00 applies directly to member responsibility.

But actually, since family deductible (8950.72) already exceeds the 5000.00 family threshold, that means it was satisfied before this claim even started, so no deductible should be charged here at all — this claim should go straight to coinsurance/copay treatment, skipping deductible entirely.

So for Claim 2: family deductible remaining = 0, meaning D doesn't need to pay any further deductible even though D's individual remaining would be 1049.28. The family satisfaction takes precedence per the "whichever comes first" rule.

This raises a question about the copay - does it still credit the deductible accumulator once family deductible is already met? The plan states copays credit both deductible and OOPM, but if deductible tracking is capped at satisfaction, the copay likely just flows straight to OOPM at this point.

Reworking Claim 2:
- Deductible applied: 0.00
- Copay: 60.00 (charged, but doesn't add to deductible—already met)
- Remaining balance: 209.38 - 60.00 = 149.38
- Coinsurance (30%): 44.81
- Plan pays (70%): 104.57

Member owes: 60.00 + 44.81 = 104.81
Plan paid: 104.57
Check: 104.81 + 104.57 = 209.38 ✓

D's OOPM updates to 5483.61, family OOPM to 21291.73, deductibles unchanged.

Tracking two accumulator states (before/after adjustment) through claims 3-11 is proving unwieldy. I'll restart with a cleaner sequential approach, carefully applying adjustments as they occur.

Starting fresh:
- A: ded 0.00, oopm 0.00
- B: ded 0.00, oopm 0.00
- C: ded 1744.67, oopm 1900.68
- D: ded 1150.72, oopm 1150.72
- Family: ded 2895.39, oopm 3051.40

Line 1, Claim 1, D, Emergency dept IN: allowed 3295.94, ER copay 300 applies since treated and released.

D ded remaining = 1349.28, Fam ded remaining = 2104.61, embedded min = 1349.28.

Copay 300 applied to ded: 300 < 1349.28, so all 300 goes to ded.
Remaining allowed: 3295.94 - 300 = 2995.94
Coinsurance 30%: 898.82, member resp = 300 + 898.82 = 1198.82, plan paid = 2097.12

After claim: D ded 1450.72, D oopm 2349.54, Fam ded 3195.39, Fam oopm 4250.22

Rounding check: 2995.94 * 0.30 = 898.782 → 898.78, 2995.94 * 0.70 = 2097.158 → 2097.16
300 + 898.78 + 2097.16 = 3295.94 ✓, so use 898.78 not 898.82.

Corrected: D ded 1450.72, D oopm 1150.72+1198.78=2349.50, Fam ded 3195.39

**Claim 2 — D — Urgent care, IN**
Allowed 182.07, copay 60
D ded left: 2500-1450.72=1049.28; family ded left: 5000-3195.39=1804.61
Copay 60 goes to deductible first (60<1049.28), fully applied.
Remaining 122.07 gets 30% coinsurance: 36.62 patient, 85.45 plan.

Member owes 60+36.62=96.62; plan pays 85.45.
Updated: D ded 1510.72, D oopm

Let me work through this ledger step by step, tracking deductible and out-of-pocket accumulators for each member and for the family.

Key facts from the plan:
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- Structure: AGGREGATE - family deductible must be satisfied before ANY member gets coinsurance
- Out-of-network individual deductible: 6400.00
- Individual in-network OOPM: 7000.00
- Family in-network OOPM: 14000.00
- Individual out-of-network OOPM: 14000.00
- In-network coinsurance: 10% member / 90% plan after deductible
- Out-of-network coinsurance: 40% member / 60% plan after deductible
- In-network and out-of-network credits accumulate to a SINGLE member deductible balance
- Preventive services (in-network) carry no cost share and move no accumulator
- Out-of-network preventive services are subject to out-of-network deductible and coinsurance

Let me process each line:

**Line 1 — Claim 1 — A (subscriber) — In-network pharmacy — Allowed: 74.87**
- Family deductible balance: 0.00, needs 6400.00
- Member A deductible balance: 0.00, needs 3200.00 (aggregate, so only family matters)
- Deductible applied: min(74.87, 6400.00) = 74.87
- After deductible: 74.87 - 74.87 = 0.00
- Coinsurance: 0.00 * 10% = 0.00
- Member responsibility: 74.87 + 0.00 = 74.87
- Plan paid: 0.00
- Member A deductible: 74.87
- Family deductible: 74.87
- Member A OOPM: 74.87
- Family OOPM: 74.87

**Line 2 — Claim 2 — C (child) — Out-of-network inpatient — Allowed: 10883.95**
Family still owes 6400.00-74.87=6325.13 toward deductible. Applying 6325.13 leaves 4558.82 remaining, subject to 40% out-of-network coinsurance.

- Coinsurance: 4558.82 × 40% = 1823.53
- Member responsibility: 6325.13 + 1823.53 = 8148.66
- Plan paid: 2735.29
- Family deductible now fully met at 6400.00
- Family OOPM running total: 74.87 + 8148.66 = 8223.53

**Line 3 — Claim 3 — C (child) — Out-of-network lab — Allowed: 967.99**
Family deductible is satisfied, but member C still has 6325.13 remaining against the 6400.00 out-of-network threshold.

Deductible applied: min(967.99, 74.87) = 74.87, closing out member C's out-of-network deductible.
Remaining 893.12 hits coinsurance at 40% = 357.25.
Member responsibility: 74.87 + 357.25 = 432.12
Plan paid: 535.87
Member C OOPM: 8580.78, Family OOPM: 8655.65

Line 4 — Claim 4 — A — In-network urgent care — Allowed: 255.34
Family deductible now satisfied, so no deductible applies here.
Coinsurance: 255.34 * 10% = 25.53
Member responsibility: 25.53, Plan paid: 229.81
Member A OOPM: 100.40, Family OOPM: 8681.18

Line 5 — Claim 5 — A — In-network ED — Allowed: 3545.18
No deductible applied (family satisfied)
Coinsurance: 3545.18 * 10% = 354.52
Plan paid: 3190.66
Member A OOPM: 454.92, Family OOPM: 9035.70

Line 6 — Claim 6 — A — In-network allergy testing — Allowed: 911.89
Family deductible: 0.00

(satisfied)
Coinsurance: 911.89 * 10% = 91.19
Plan paid: 820.70
Member A OOPM: 546.11, Family OOPM: 9126.89

Line 7 — Claim 7 — B — In-network ambulatory surgery — Allowed: 7845.50, no deductible needed, coinsurance 784.55.

Plan paid: 7060.95. Member B OOPM: 784.55, Family OOPM: 9911.44.

Line 8 — Claim 8 — D — In-network ambulatory surgery — Allowed: 6750.63, coinsurance 675.06, plan paid 6075.57. Member D OOPM: 675.06, Family OOPM: 10586.50.

Line 9 — Claim 9 — B — In-network inpatient — Allowed: 12250.27, coinsurance 1225.03, plan paid 11025.24. Member B OOPM: 2009.58, Family OOPM: 11811.53.

Line 10 — Claim 10 — D — In-network inpatient — Allowed: 12224.51, deductible already satisfied, moving to coinsurance calculation.

0.00 applied, coinsurance 1222.45, plan paid 11002.06. Member D OOPM climbs to 1897.51, Family OOPM reaches 13033.98.

Line 11 — Claim 11 — D — Out-of-network wellness visit, allowed 664.62. Since this is preventive but out-of-network, it still hits the out-of-network deductible and coinsurance rather than being covered at 100%. Checking D's out-of-network deductible balance.

Actually, hold on — I need to reconsider. The plan language specifies preventive care is only covered at 100% without cost-sharing when rendered in-network. Out-of-network preventive services don't get that special treatment.

**Line 12 — Claim 12 — B (spouse) — Out-of-network pharmacy — Allowed: 30.19**
- Member B deductible balance: 0.00, out-of-network threshold: 6400.00
- Deductible applied: min(30.19, 6400.00) = 30.19
- After deductible: 0.00
- Coinsurance: 0.00
- Member responsibility: 30.19, plan paid: 0

- Member B deductible: 30.19, OOPM: 2009.58 + 30.19 = 2039.77
- Family OOPM: 13698.60 + 30.19 = 13728.79

**Line 13 — Claim 13 — D (child) — Out-of-network screening colonoscopy — Allowed: 716.51**
- Preventive service, still subject to out-of-network deductible/coinsurance
- Member D deductible balance: 664.62, threshold 6400.00
- Deductible applied: min(716.51, 5735.38) = 716.51

After deductible, remaining allowed is 0.00, so coinsurance is 0.00. Member responsibility is the full 716.51, plan pays 0.00.
- Member D deductible: 664.62 + 716.51 = 1381.13
- Member D OOPM: 2562.13 + 716.51 = 3278.64
- Family OOPM: 13728.79 + 716.51 = 14445.30

**Line 14 — VOID of Claim 3**
Recalling Claim 3's original figures: member responsibility 432.12, plan paid 535.87, deductible applied 74.87, coinsurance 357.

Reversing these amounts:
- Member C deductible: 6400.00 - 74.87 = 6325.13
- Member C OOPM: 8580.78 - 432.12 = 8148.66
- Family deductible: 6400.00 - 74.87 = 6325.13
- Family OOPM: 14445.30 - 432.12 = 14013.18

**Line 15 — Claim 15 — A (subscriber) — Out-of-network endoscopy — Allowed: 2331.25**
Member A's deductible balance is 74.87 against an out-of-network threshold of 6400.00. Applying deductible: min(2331.25, 6325.13) = 2331.25, leaving nothing after deductible, so coinsurance is 0.00.

- Member responsibility: 2331.25
- Plan paid: 0.00
- Member A deductible: 74.87 + 2331.25 = 2406.12
- Member A OOPM: 546.11 + 2331.25 = 2877.36
- Family OOPM: 14013.18 + 2331.25 = 16344.43

**Line 16 — VOID of Claim 6**
Reversing Claim 6 (member responsibility 91.19, plan paid 820.70, deductible 0.00, coinsurance 91.19):
- Member A OOPM: 2877.36 - 91.19 = 2786.17
- Family OOPM: 16344.43 - 91.19 = 16253.24

**Line 17 — Claim 17 — E (child) — Out-of-network physical therapy — Allowed: 1373.69**
Member E has no deductible met yet, threshold 6400.00. Deductible applied: min(1373.69, 6400.00) = 1373.69, so the full amount goes to deductible with nothing remaining after.

Coinsurance: 0.00. Member responsibility: 1373.69, plan paid 0.00.
- Member E deductible: 1373.69
- Member E OOPM: 1373.69
- Family OOPM: 16253.24 + 1373.69 = 17626.93

**Line 18 — Claim 18 — C (child) — Out-of-network lab — Allowed: 593.21**
Member C deductible balance at 6325.13, threshold 6400.00. Deductible applied: min(593.21, 74.87) = 74.87. Remaining 518.34 goes to 40% coinsurance = 207.34.

- Member responsibility: 74.87 + 207.34 = 282.21
- Plan paid: 311.00
- Member C deductible now hits threshold: 6400.00
- Member C OOPM: 8148.66 + 282.21 = 8430.87
- Family OOPM: 17626.93 + 282.21 = 17909.14

**Line 19 — Claim 19 — B (spouse) — In-network urgent care — Allowed: 220.46**
Checking family deductible status next.

No accumulator changes for this claim. The preventive care section confirms in-network preventive services covered without cost share are paid at 100% and excluded from deductible, coinsurance, or copay.

Routine immunization falls into this category of ACA-mandated preventive services, so it should be treated as preventive with no cost sharing applied.

Turning to the adjustment for Claim 20 on line 23 - the allowed amount was corrected downward from 1243.12 to 745.87 due to a provider appeal after contract rate review. If this claim were preventive, the adjustment wouldn't touch deductible or OOPM figures, which seems inconsistent with a typical corrective adjustment scenario. This makes me reconsider - the claim was likely processed as non-preventive, subject to normal deductible/coinsurance rules, so I'll treat it that way.

For Line 20 itself: family deductible already satisfied, so 0.00 applied. Coinsurance at 10% of 1243.12 comes to 124.31, which becomes both member responsibility and the OOPM addition. Plan pays 1118.81. Member A's OOPM rises to 2910.48, family OOPM to 18055.50.

Line 21 for member C follows the same pattern - deductible satisfied, 10% coinsurance on 3516.29 equals 351.63, plan pays 3164.66.

Deductible applied: 0.00, coinsurance 124.31, plan paid 1118.81.
- Corrected Claim 20: allowed 745.87, coinsurance 745.87*10%=74.59, member responsibility 74.59, plan paid 671.28

Need to reverse the original 124.31 member responsibility from OOPM/deductible tracking and reapply the corrected 74.59, updating Member A's running accumulators accordingly (deductible was 2406.12, OOPM 2910. before adjustment).

Removing original claim impact: Member A OOPM 2910.48 - 124.31 = 2786.17. Adding corrected impact: 2786.17 + 74.59 = 2860.76.

For the family total: 18055.50 - 124.31 + 74.59 = 18005.78.

I should verify this against the actual sequence at Line 23 (2026-09-08) - checking what accumulators looked like right before this adjustment, particularly from Line 22.

Confirming Line 22 accumulators (2026-08-23): Member A at 2910.48, Family at 19654.63.

Recalculating properly: Member A 2910.48 - 124.31 + 74.59 = 2860.76. Family 19654.63 - 124.31 + 74.59 = 19604.91.

But something's off - the family OOPM cap is 14000.00, and 19654.63 already blows past that after Line 22. That means from Line 22 onward, the plan owes 100% coverage on all covered in-network services for every family member, per the "once OOPM is met, 100% coverage for rest of plan year" rule.

I need to redo the trace from where the family in-network OOPM actually crosses 14000.00.

After Line 10, family OOPM sits at 13033.98.

Then Line 11 involves Member D's out-of-network wellness visit (664.62 allowed). Out-of-network claims use a separate OOPM track — individual out-of-network cap is 14000.00, distinct from the in-network family cap. I need to check whether out-of-network costs count toward the in-network family OOPM at all, since the plan document separates these categories explicitly.

Given the wording, out-of-network claims are compared only against out-of-network individual limits, not family in-network limits. But the resulting cost-sharing still accrues to both the member's overall balance and the family's overall balance — meaning each member and the family likely track a single combined running total, even though which threshold applies depends on network status of the specific claim.

that OON payments do count toward both the individual's accumulator and the family total—they just aren't checked against the family's in-network threshold amount when determining if the claim itself hits a cap. So practically: OON claims get compared only to the OON individual threshold, but the resulting credits still add into both the member's running total and the family running total, presumably against separate OON family/individual limits if defined, or otherwise just tracked cumulatively.

So there are separate OOPM tracks: in-network individual (7000), in-network family (14000), and out-of-network individual (14000).

Out-of-network claims get measured only against the 14000 individual out-of-network threshold—the in-network family amount doesn't cap an out-of-network claim. But those out-of-network dollars still count toward both the member's individual balance and the family total.

This raises a question though: can a single member simultaneously have a 7000 in-network cap and a 14000 out-of-network cap? That would mean tracking two separate accumulators per member—one for in-network spend, one for out-of-network spend—each with its own threshold. Once a given threshold is hit, services within that network category become fully covered, while the other category keeps accumulating separately.

Family-level, the 14000 in-network OOPM likely serves as a ceiling on the combined in-network member responsibility across all family members.

I should check the ACCUMULATORS section for the precise definitions—specifically how deductible_applied is calculated as the lesser of the allowed amount and remaining room under the relevant threshold.

Embedded in-network deductibles use the smaller of the individual and family remainders, while out-of-network is measured solely against the individual's single deductible balance. Once a threshold is hit, deductible_applied drops to zero even for copays. Balances track running totals, and since out-of-network thresholds are higher, out-of-network claims can push balances past the in-network caps without being capped there.

This means there's likely a single member OOPM balance and single family OOPM balance combining both network types. In-network claims check against the in-network individual/family thresholds (7000/14000), while out-of-network claims check only against the out-of-network individual threshold (14000) — family thresholds don't constrain out-of-network claims.

Once a member's in-network balance hits 7000, in-network services become free; once out-of-network balance hits 14000, out-of-network services become free. The family in-network threshold (14000) stops in-network cost-sharing for everyone once reached, but out-of-network accumulation doesn't feed into that family cap.

Out-of-network dollars still add to both the individual and family running totals though — they just aren't checked against family limits, only against the individual's out-of-network cap. So a member's balance isn't capped at 7000 just because that's the in-network threshold; an out-of-network claim can push it higher, and correspondingly push the family total past 14000 too, since nothing caps these balances at the in-network figures.

Each member seems to track its own balance from zero. Hitting 7000 unlocks 100% coverage for that member's in-network services; hitting 14000 unlocks 100% for out-of-network services. Separately, the family in-network balance hitting 14000 unlocks 100% in-network coverage for everyone. So after an individual's OOPM is met, their in-network claims go to 100%, but out-of-network claims might still carry coinsurance until that separate threshold is reached.

But the plan document's phrasing—"pays 100% for the remainder of the plan year"—doesn't split by network, which is confusing given the two different dollar thresholds. Maybe a member's OOPM is met when they hit either threshold, whichever comes first, with in-network claims naturally hitting 7000 first unless the member is mostly out-of-network. Then again, out-of-network claims might be measured against a separate individual threshold entirely.

If a member accumulates $6000 in-network and then a $1000 out-of-network claim, that claim gets checked against the $14000 out-of-network limit, not combined with the in-network amount. This suggests OOPM is actually two separate tracked totals—one in-network (7000/14000 individual/family), one out-of-network (14000 individual)—each triggering 100% coverage independently once met. I'll proceed using this dual-tracking model.

Each member needs deductible balance (combined), plus separate in-network and out-of-network OOPM balances. Family-level tracking covers in-network deductible and OOPM only. Claims update only the matching network's balances—out-of-network claims never touch family in-network totals. Coinsurance drops to 0% once the relevant threshold (member in-network 7000, member out-of-network 14000, or family in-network 14000) is hit.

But the problem's variable naming ("ending_oopm_a") implies a single OOPM per member rather than split in/out-of-network balances, so I may need to reconsider this structure.

Perhaps a single member OOPM balance exists, with the applicable threshold depending on service type (7000 in-network, 14000 out-of-network), and once reached, that service type becomes fully covered. Family maintains one in-network OOPM balance with a 14000 threshold—so member in-network and out-of-network accumulators run separately, and hitting 7000 in-network shifts future in-network claims to 100% coverage.

Since output only asks for a single "ending_oopm_a" per member rather than split accounts, there's likely one combined accumulator, not two. Testing this: report the running total balance regardless of network type, but apply separate thresholds when checking coinsurance eligibility for each claim type based on that same combined number.

If a member accrues $6000 from in-network claims, their balance sits at $6000 - still below the $7000 in-network cutoff. Adding a $2000 out-of-network claim at 40% coinsurance contributes $800, pushing balance to $6800. In-network claims still apply coinsurance since $6800 < $7000.

This raises confusion about whether separate accumulators exist per network type or one shared balance. Assuming a single OOPM that hits the lower threshold (7000) first for all future 100% coverage doesn't explain why two different thresholds (7000 and 14000) would be specified at all.

Reconsidering the plan language: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim" - this suggests separate tracking, though the exact mechanism needs clarification.

Wait, the output fields include "ending_oopm_a", "ending_oopm_b", etc. plus "ending_family_oopm" — separate member and family accumulators confirmed. I'll track for each member: in-network balance (threshold 7000) and out-of-network balance (threshold 14000), plus one family in-network balance (threshold 14000). For reporting purposes, ending_oopm per member will just be the in-network figure since that's primary.

Preventive in-network stays cost-free and untouched by accumulators, but out-of-network preventive is subject to deductible/coinsurance and does count. Once a member's in-network OOPM hits 7000, further in-network care is 100% covered; same logic applies out-of-network at 14000. Family in-network OOPM maxing at 14000 presumably covers all members at 100% in-network going forward.

Testing this against Claim 1 (subscriber A, in-network pharmacy, $74.87 allowed): family and member deductibles start at 0, need to satisfy $6400. The full $74.87 applies to deductible, leaving $0 for coinsurance. Member A owes $74.87, plan pays nothing, and this amount lands in Member A's in-network OOPM tracker.

For Claim 2 (child C, out-of-network inpatient, $10883.95 allowed): family deductible has $6325.13 remaining after Claim 1. This entire remaining deductible applies, leaving $4558.82. Since C's out-of-network accumulator ($0) is below the $14000 threshold, 40% coinsurance kicks in on the remainder — $1823.53. Total member responsibility comes to $8148.66.

Plan pays $2735.29. Now family deductible is fully satisfied at $6400.00, C's out-of-network OOPM sits at $8148.66, while family in-network OOPM stays untouched at $74.87 since out-of-network claims don't count toward it.

Moving to Claim 3 (child C, out-of-network lab, $967.99 allowed): only $74.87 remains before hitting the $6400 out-of-network deductible threshold, so that amount applies to deductible, leaving $893.12 subject to further processing.

Plan paid: 229.81; Member A OOPM: 100.40; family OOPM: 100.40.

Claim 5, A — ED, allowed 3545.18. Both OOPM balances still under threshold, so coinsurance applies again.

10% of 3545.18 = 354.52 member owes, plan covers 3190.66. Updated OOPM for A and family: 454.92 each.

Claim 6, A — allergy testing, allowed 911.89. Still under limits, coinsurance 91.19 due, plan pays the remainder.

19 = 820.70, updating A and family OOPM to 546.11.

Claim 7 — B, ambulatory surgery, allowed 7845.50. B's OOPM starts fresh at 0, family at 546.11, both below caps. 10% coinsurance = 784.55 owed, plan pays 7060.95, pushing B's OOPM

This is a complex plan-year ledger task. Let me work through it step by step, tracking deductibles and out-of-pocket maximums.

**Plan Details:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED (individual can satisfy their own; family is also satisfied once family credits reach 3000)
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Out-of-network individual deductible: 3000.00 (single balance with in-network deductible)
- Out-of-network individual OOPM: 12000.00
- Coinsurance in-network: 20% member / 80% plan
- Coinsurance out-of-network: 40% member / 60% plan
- Specialist office visit copay: 60.00 (does NOT credit deductible, but DOES credit OOPM)
- Primary care office visit copay: 30.00 (does NOT credit deductible, but DOES credit OOPM)
- Urgent care copay: 75.00
- Ambulatory surgery: coinsurance (not copay)
- Inpatient services: subject to deductible and coinsurance

**Initial State (before Line 1):**
- A: deductible 904.50, OOPM 904.50
- B: deductible 0.00, OOPM 0.00
- C: deductible 0.00, OOPM 0.00
- D: deductible 0.00, OOPM 0.00
- Family: deductible 904.50, OOPM 904.50
---
**Line 1 — Claim 1 — 2026-01-28 — A (subscriber)**
Specialist office visit, in-network, billed 543.96, allowed 294.03. This carries the 60.00 copay structure, which doesn't touch deductible but does credit OOPM.

Since it's copay-based, no deductible is applied here — I need to reconsider using the copay amount directly rather than running the deductible math I started.

Member owes: 60.00 copay
Plan pays: 294.03 - 60.00 = 234.03

Wait, that doesn't seem right either - copays typically apply per visit regardless of deductible status, but they don't stack with deductible for the same dollar. Let me reconsider: the deductible applies to allowed amount, then copay is separate flat fee, OR copay replaces deductible+coinsurance entirely. Given "copays do NOT credit the deductible," the deductible tracking (294.03) still accrues toward the $2000 max even though member technically pays copay of $60 at point of service.

So for Claim 1: member pays 60.00 copay, plan pays 234.03. But does the deductible remaining (595.50) still get reduced by 294.03? Copays typically bypass deductible entirely - the visit is covered under copay structure, not deductible/coinsurance structure. So deductible remains untouched at 595.50, member pays flat 60.00, plan pays 234.03.

After Line 1:
- A: deductible 595.50 (unchanged), OOPM used 60.00
- Family: deductible 595.50, OOPM 60.00

**Line 2 — Claim 2 — 2026-02-11 — C (child)**
Primary care visit, in-network, billed 365.17, allowed 197.39, copay 30.00.

Same logic applies - copay bypasses deductible. C's deductible remains untouched, family deductible remains untouched. Member pays 30.00, plan pays 197.39 - 30.00 = 167.39.

After Line 2:
- C: deductible 0.00, OOPM 30.00
- Family: deductible 904.50, OOPM 994.50

**Line 3 — Claim 3 — 2026-02-17 — D (child)**
Inpatient admission with surgery, in-network, billed 21838.88, allowed 11804.80. This falls under deductible + coinsurance, not copay.

D's deductible remainder: 1500.00. Family remainder: 2095.50.

Deductible applied = min(11804.80, 1500.00, 2095.50) = 1500.00, hitting D's individual max.

Remaining allowed after deductible: 11804.80 - 1500.00 = 10304.80, subject to coinsurance next.

.00
Family deductible remainder: 3000.00 - 2404.50 = 595.50, which is the binding constraint since it's smaller.

Deductible applied: 595.50
Remaining allowed: 715.51 - 595.50 = 120.01
Coinsurance: 120.01 * 0.20 = 24.00

Member responsibility: 595.50 + 24.00 = 619.50

Plan paid: 715.51 - 619.50 = 96.01, OOPM increases by 619.50.

Updated totals after Line 4:
- C: deductible 595.50, OOPM 649.50
- Family: deductible 3000.00 (met), OOPM 5174.96

**Line 5 — Claim 5 — 2026-03-07 — D (child)**
Inpatient admission with surgery, in-network. Billed 27037.40, Allowed 14614.81.

D's deductible remainder is 0 since it's already been fully met at 1500.00. Family deductible is also fully satisfied at 3000.00.

Deductible applied: 0.00, so full 14614.81 goes to coinsurance at 20% = 2922.96.

Member owes 2922.96, plan pays 11691.85. OOPM increases by 2922.96.

After Line 5:
- D: OOPM 6483.92
- Family: OOPM 8097.92

**Line 6 — Claim 6 — 2026-03-11 — D (child)**
Ambulance service...

Billed 10423.68, allowed 5634.42, deductible already met so full amount goes to coinsurance: 5634.42 * 0.20 = 1126.88.

Member owes 1126.88, plan pays 4507.54, OOPM increases by 1126.88.

After Line 6:
- D: deductible 1500.00, OOPM 6483.92 +

1126.88 = 7610.80
- Family: deductible 3000.00, OOPM 8097.92 + 1126.88 = 9224.80

Line 7, claim 7, 2026-03-25, B (spouse): inpatient admission, in-network, billed 38662.71, allowed 20898.76. B's deductible remainder is 1500.00 but family deductible is already satisfied at 0.00 remaining, so applied deductible is 0.00 despite B not individually meeting their deductible.

Coinsurance (20%) on 20898.76 = 4179.75, all going to member responsibility since deductible is 0.
Plan paid: 16719.01. OOPM applied: 4179.75.

After Line 7: B deductible 0.00, OOPM 4179.75. Family deductible 3000.00, OOPM 9224.80 + 4179.75 = 13404.55 — but family OOPM cap is 12000.00, so I need to check this overage since responsibility can't exceed the OOPM ceiling.

Rereading the rules: balances aren't capped at in-network amounts even when out-of-network claims push them higher, but the OOPM itself acts as a ceiling on cost-sharing once reached — the plan pays 100% after. The accumulator can exceed the stated OOPM though, since it's just a running total. So once a member hits their OOPM, later claims are covered fully but the tracked balance keeps climbing regardless.

met, so no deductible applies here)

So room remaining before family OOPM cap hits: 2775.20. Member pays that much, plan covers the rest at 100%, meaning 1404.55 shifts to plan responsibility. Line 7 needs recalculating with this split applied.

Coinsurance on full claim: 20898.76 * 0.20 = 4179.75
Capped member share: min(4179.75, 2775.20) = 2775.20
Plan pays: 20898.76 - 2775.20 = 18123.56

Updating running totals for B and family after this line: B's OOPM hits 2775.20, deductible stays satisfied. Family OOPM now maxed at 12000.00, meaning any further claims should be covered 100% by the plan.

Moving to claim 8, D's inpatient admission out-of-network, billed 31609.14, allowed 17086.02. D's out-of-network deductible remainder is 3000.00 - 1500.00 = 1500.00, individual OOPM remainder 12000.00 - 6483.92 = 5516.08.

Deductible applied: 1500.00, leaving 15586.02 subject to 40% coinsurance = 6234.41. Total member cost before capping: 7734.41, but OOPM remainder caps it at 5516.08.

Member pays 5516.08, plan pays 17086.02 - 5516.08 = 11569.94. Deductible applied 1500.00, OOPM applied 5516.08.

Updating totals after Line 8: deductible now 3000.00, OOPM 12000.00 - both family limits reached.

Moving to Line 9, claim 9, 2026-04-12, subscriber A: primary care visit, billed 289.47, allowed 156.47. This is a copay service at 30.00.

Member pays 30.00, plan pays 126.47. A's OOPM sits at 964.

moving forward, checking remaining room against the 6000 individual OOPM, copay of 30.00 applies fully.

After Line 9: A's deductible stays 904.50, OOPM climbs to 994.50.

Line 10, claim 10, 2026-04-25, spouse B: specialist visit, billed 424.45, allowed 229.43, copay 60.00.

Member pays 60.00, plan pays 169.43. B's OOPM at 2775.20, well under the 6000 cap, so full copay applies.

After Line 10: B deductible 0.00, OOPM 2835.20; family deductible 3000.00, OOPM 12000.00.

Line 11 voids claim 7 — reversing B's prior OOPM credit of 2775.20 back to 0.00, and family OOPM drops from 12000.00 to 9224.80. Deductibles unaffected since claim 7 contributed none.

Since Line 10 was processed after the original claim 7 but before its void, its results stand — per the rule that intervening claims aren't reprocessed. So B's OOPM after Line 11 is 0.00 + 60.00 (from Line 10) = 60.00, not simply reset to zero.

Updated totals: A deductible 904.50, OOPM 994.50; B deductible 0.00, OOPM 60.00; C deductible 595.50, OOPM 649.50; D deductible 3000.00, OOPM 12000.00; family deductible 3000.00, OOPM 9224.80 +

.00, OOPM 12000.00
- Family: deductible 3000.00, OOPM 9284.80

Claim 12, Line 12, 2026-05-11, member C: inpatient surgery, billed 26949.82, allowed 14567.47.

C's deductible left: 904.50, but family deductible already met (0.00), so applied deductible = 0.
Remaining allowed 14567.47 goes to coinsurance at 20% = 2913.49...

913.49

C's OOPM remainder: 5350.50, so full coinsurance applies as member cost share: 2913.49.

Member responsibility this line: 2913.49; plan pays 11653.98.

Updated totals: C OOPM 649.50 → 3562.99; family OOPM 9284.80 → 12198.29, which exceeds the 12000 family OOPM cap — need to recheck and cap this properly using the family OOPM remainder before the line (12000 - 9284.80 = 2715.20) instead of C's individual remainder.

So member responsibility caps at 2715.20, plan pays 11852.27. Updated: C OOPM → 3364.70, family OOPM → 12000.00 exactly.

This reveals I need to check both individual and family OOPM limits together and use whichever is more restrictive, rather than checking them separately as I did before. I should restart this calculation with both constraints tracked simultaneously.

Going back to Line 7 for B (spouse): B's individual OOPM remainder is 6000.00 - 0.00 = 6000.00, and family OOPM remainder is 12000.00 -

Continuing with the family remainder calculation: 12000.00 - 9224.80 = 2775.20, against a coinsurance responsibility of 4179.75. The member's cost share is min(4179.75, 6000.00, 2775.20) = 2775.20, matching my earlier figure.

Moving to Line 12 for C (child): individual OOPM remainder is 6000.00 - 649.50 = 5350.50, family remainder is 12000.00 - 9284.80 = 2715.20. Coinsurance responsibility is 2913.49, so the cost share is min(2913.49, 5350.50, 2715.20) = 2715.20.

Plan paid comes to 14567.47 - 2715.20 = 11852.27. After this claim, C's OOPM reaches 3364.70, and the family OOPM hits the full 12000.00 max.

For Line 13, B's urgent care visit (billed 536.50, allowed 290.00) carries a 75.00 copay. B's individual OOPM remainder is 5940.00, but the family remainder is now 0.00 since the family met its max. The cost share is min(75.00, 5940.00

// continuing thought
, 0.00) = 0.00, meaning the plan covers this at 100% since the family OOPM has been satisfied.

So member responsibility is 0.00, plan pays the full 290.00. This makes sense — once the family OOPM cap is hit, all covered services for every family member are paid at 100% for the rest of the year, copays included. B's OOPM stays at 60.00, family remains at 12000.00.

Moving to Line 14, B has an out-of-network ambulatory surgery claim (billed 9958.35, allowed 5382.89). Same logic applies — family OOPM already met, plan pays 100%, member owes 0.00. Totals stay unchanged.

Then Line 15 voids Claim 4, requiring me to back out C's earlier credits: deductible drops from 595.50 to 0.00, OOPM reduces by 619.50 to 2745.20, and the family totals adjust downward by the same amounts — deductible to 2404.50, OOPM reduced by 619

Now the key question is whether Line 12, processed between the original Claim 4 and its void, gets reprocessed. Per the stated rule, claims between the original and the adjustment are NOT reprocessed — their results stand as first adjudicated. So Line 12's outcome remains fixed even though the accumulators it depended on have now changed retroactively. The same logic extends to Line 13, which was processed after Line 12 but before the void — since it relied on Line 12's already-locked results, Line 13's adjudication also stands unchanged.

deductible 0.00, OOPM 0.00. Claim 4 contributed 595.50 to deductible and 619.50 to OOPM, bringing them to 595.50 and 619.50. By the time Line 12 processed, C's OOPM had climbed to 3364.70. Voiding Claim 4 strips its 619.50 OOPM contribution, so OOPM becomes 3364.70 - 619.50 = 2745.20, while deductible returns to 0.00.

That's correct.

Updated after Line 15: A(904.50/994.50), B(0/60), C(0/2745.20), D(3000/12000), Family(2404.50/10760.50).

**Line 16 — Claim 16 — 2026-06-22 — A** — Allergy testing, in-network, billed 1702.59, allowed 920.32.

A's remaining deductible: 595.50, family remaining: 595.50. Deductible applied: min(920.32, 595.50, 595

.50) = 595.50, leaving 324.82 allowed, coinsurance 64.96.

A's OOPM remainder: 5005.50, family OOPM remainder: 1239.50. Total member cost share = 595.50+64.96 = 660.46, well under both caps, so full 660.46 applies.

Plan pays 920.32 - 660.46 = 259.86.

Running totals after Line 16: A deductible hits 1500.00 (fully met), A OOPM now 1654.96; family deductible hits 3000.00 (fully met).

Compiling final state:
- A: deductible 1500.00, OOPM 1654.96
- B: deductible 0.00, OOPM 60.00
- C: deductible 0.00, OOPM 2745.20
- D: deductible 3000.00, OOPM 12000.00
- Family: deductible 3000.00, OOPM 11420.96

Now extracting figures for Claims 4, 13, 16.

Claim 4 was voided at Line 15, so every component zeroes out — member responsibility, plan paid, deductible, copay, coinsurance all 0.00.

For Claim 13, family OOPM has been reached, so member_responsibility should be 0.00. Plan pays 290.00, no deductible applied. But I need to check whether copay still applies or gets waived — since OOPM is met, "the plan pays 100% of the allowed amount," which should mean no copay is charged at all, not just an extra credit toward it.

The copay is essentially the member's owed amount for this line item. If OOPM is met, member owes nothing, so copay_amount = 0.00, coinsurance_amount = 0.00.

**Claim 16:**
- member_responsibility: 660.46
- plan_paid: 259.86
- deductible_applied: 595.50
- copay_amount: 0.00 (not a copay service)
- coinsurance_amount: 64.96 (660.46 - 595.50)

Checking against the copay list — allergy testing isn't a copay-based service, so it falls under deductible/coinsurance only. This confirms Claim 16's breakdown.

Now revisiting Claim 4, which was voided...

voided, every component is 0.00.

Let me trace back through the accumulator states from the start to verify everything's consistent, starting with the initial position before Line 1: A at 904.50/904.50 (deductible/OOPM), B/C/D at 0.00, family at 904.50/904.50.

For Claim 1 (2026-01-28, A, specialist visit, allowed 294.03, copay 60.00): copay doesn't touch deductible, so member owes 60.00, plan pays 234.03. A and family OOPM both climb to 964.50, deductible stays at 904.50.

Moving to Claim 2 — 2026-02-11, C, primary care visit, allowed 197.39, copay 30.00: same logic, copay applies without deductible credit. Member responsibility 30.00, plan pays 167.39. C's OOPM becomes 30.00, family OOPM rises to 994.50, deductible unchanged at 904.50.

For Line 3, Claim 3, 2026-02-17, D's inpatient surgery, allowed 11804.80, deductible + coinsurance applies. D's remaining deductible is full 1500.00 since unused, family remaining 2095.50. Applied deductible: 1500.00, leaving 10304.80 subject to 20% coinsurance = 2060.96. Checking OOPM limits next — D remainder 6000.00, family remainder 12000.00 - 994.50

Member owes 1500.00 + 2060.96 = 3560.96, plan pays 8243.84.

Updated totals: D deductible now 1500.00, OOPM 3560.96; family deductible 2404.50, OOPM 4555.46.

Moving to Line 4, Claim 4, 2026-03-03 — C's outpatient endoscopy, allowed 715.51, deductible + coinsurance. C's deductible remainder is full 1500.00, family remainder now 595.50.

Deductible applied = min(715.51, 1500.00, 595.50) = 595.50, leaving 120.01 for 20% coinsurance = 24.00.

C's member cost: 595.50 + 24.00 = 619.50, plan pays 96.01.

Post-Line 4 state: C deductible maxed at 595.50 (family cap hit), OOPM 649.50; family deductible fully met at 3000.00, OOPM 5174.96.

**Line 5 — Claim 5 — 2026-03-07 — D**
Inpatient admission with surgery, in-network, allowed 14614.81, deductible + coinsurance.

D and family deductibles are both exhausted (0.00 remaining), so full 14614.81 goes to 20% coinsurance = 2922.96.

Member owes 2922.96, plan pays 11691.85.

State after Line 5:
- D: deductible 1500.00, OOPM 6483.92
- Family: deductible 3000.00, OOPM 8097.92

**Line 6 — Claim 6 — 2026-03-11 — D**
Ambulatory surgery, in-network, allowed 5634.42, coinsurance only.

Deductibles remain at 0.00 for both D and family.

D's OOPM already exceeds the 6000.00 cap (6483.92 > 6000), so member owes nothing here — plan covers the full 5634.42.

Member responsibility: 0.00
Plan paid: 5634.42

State after Line 6:
- D: deductible 1500.00, OOPM 6483.92
- Family: deductible

Family deductible remainder: 3000.00 - 3000.00 = 0.00 — family deductible fully met.

**Line 7 — Claim 7 — 2026-03-25 — B**
Inpatient admission, in-network, allowed 20898.76, Deductible + Coinsurance.

B's individual deductible remainder is 1500.00, but family deductible is already exhausted, so deductible applied = 0.00.
Coinsurance (20%) on 20898.76 = 4179.

Continuing: 75.

Family OOPM has only 3902.08 left (12000.00 - 8097.92), which caps member responsibility at 3902.08 despite B's own OOPM room of 6000.00.
Plan paid: 20898.76 - 3902.08 = 16996.68.

Updated state — B: deductible 0.00, OOPM 3902.08; Family: deductible 3000.00, OOPM 12000.00 (family OOPM now fully met).

Line 8, Claim 8, D, out-of-network inpatient admission, allowed 17086.02.
D's out-of-network deductible remainder: 1500.00; OOPM remainder: 5516.08.
Deductible applied: 1500.00, leaving 15586.02 subject to 40% coinsurance = 6234.41.
Member responsibility capped at OOPM remainder: 5516.08.
Plan paid: 17086.02 - 5516.08 = 11569.94.

Checking the out-of-network rule — family thresholds don't apply here, only D's individual out-of-network OOPM caps the claim. So deductible stays 1500.00, and coinsurance applied is 5516.08 - 1500.00 = 4016.08 (rather than the full 6234.41, since the cap kicks in).

After Line 8: D deductible reaches 3000.00, D out-of-network OOPM hits 12000.00. Family deductible now 3000.00, family OOPM 12000.00.

Line 9 moves to Claim 9, 2026-04-12, member A — primary care visit, in-network, allowed 156.47, copay-based (30.00). Checking A's remaining deductible: 1500.00 - 904.50 = 595.50, and reviewing family OOPM remainder.

With family OOPM now zero, plan should cover 100% — but I need to double-check whether deductible still applies once OOPM is met. Also noticing my update to A's deductible tracking wasn't quite right, so I need to revisit that line before finalizing member responsibility and plan-paid amounts.

Right, family deductible is 3000.00 after Line 8 - fully met. Line 9 doesn't add anything since it's already satisfied, so it stays at 3000.00.

Checking family OOPM: after Line 7 it hit 12000.00 (fully satisfied), stays there through Lines 8-9.

State after Line 9:
- A: deductible 904.50, OOPM 964.50
- Family: deductible 3000.00, OOPM 12000.00

**Line 10 — Claim 10 — 2026-04-25 — B**
Specialist visit, in-network, allowed 229.43, copay 60.00

Family OOPM already at max (12000.00 - 12000.00 = 0.00), so plan pays 100% regardless of copay type.

Member responsibility: 0.00
Plan paid: 229.43

State after Line 10:
- B: deductible 0.00, OOPM 3902.08
- Family: deductible 3000.00, OOPM 12000.00

**Line 11 — VOID of Claim 7**

Reversing Claim 7's contributions (0.00 deductible, 3902.08 OOPM for B/family):
- B: deductible stays 0.00, OOPM drops to 0.00
- Family: deductible stays 3000.00, OOPM drops to 8097.92

State after Line 11:
- A: deductible 904.50, OOPM 964.50

But I need to double-check — Line 10 was processed before this void, so its effects need to be preserved. B's OOPM had been sitting at 3902.08 since Line 7, unchanged through Lines 8-10. Let me verify that Line 10 truly left it untouched given the family OOPM cap was already met.

Voiding Claim 7 removes 3902.08 from B's OOPM, bringing it to 0.00. But since Line 10 shouldn't be re-adjudicated, its outcome (likely 0.00 addition since family OOPM was