GLM-5.3

Let me carefully work through this ledger.

Plan: Pecos Select 2500, plan year 2026.

Deductibles:
- Individual in-network: 2500.00
- Family in-network: 5000.00
- Structure: EMBEDDED
- Out-of-network individual: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The out-of-network threshold (5000) is measured against that single balance when service is OON.

OOPM:
- Individual in-network: 5500.00
- Family in-network: 11000.00
- Individual out-of-network: 11000.00

Cost share:
- Coinsurance after deductible in-network: 30% member
- Coinsurance after deductible out-of-network: 50% member
- Primary care copay 25, specialist 50, urgent care 60, ER 300 (waived if admitted → subject to deductible and coinsurance), generic pharmacy 10.
- Copays DO credit the deductible. Copays always credit the OOPM.

Accumulator rules:
- deductible_applied = lesser of allowed amount and room left under the applicable threshold.
  - In-network: smaller of member's individual remainder and family remainder (embedded).
  - Out-of-network: the OON individual remainder (5000 threshold), measured against member's same single deductible balance. Family amounts do not limit OON claims. But credits still accumulate to member's balance and family balance.
- Once threshold met, deductible_applied = 0.00.
- Deductible balance = running total of deductible_applied. OOP balance = running total of member_responsibility.
- Balances not capped at in-network amounts.

OOPM: Once member reaches OOPM, plan pays 100% of allowed amount for covered services for remainder of plan year. There's an individual OOPM and family OOPM. Hmm — how does the family OOPM interact? Typically, once family OOPM is reached, all members' cost share stops. The plan document says "Individual (in-network) 5500, Family (in-network) 11000, Individual (out-of-network) 11000. 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."

The rules say "Once reached, the plan pays 100% of the allowed amount for covered in-network services." The glossary says OOPM is the ceiling on member cost share for the plan year.

I think we need to consider: a member's OOPM is presumably the individual OOPM applicable to the network of the service? Or is there a single OOPM balance like the deductible? The plan document doesn't explicitly say in-network and OON OOPM accumulate to a single balance, unlike the deductible. Hmm.

Actually, let me think. The deductible explicitly says a single member deductible balance shared between networks. For OOPM, the document lists individual in-network 5500, family in-network 11000, individual OON 11000. It doesn't say they accumulate to a single balance. But typically in these harness problems, the OOPM accumulates as a single balance too, and the applicable threshold depends on the network of the service: in-network services measured against min(individual in-network remainder, family remainder?) — hmm, actually for family OOPM, is it embedded or aggregate?

Let me think about this carefully. The deductible is explicitly EMBEDDED. For OOPM, the document doesn't specify embedded/aggregate. But typically family OOPM works similarly embedded: each member's individual OOPM counts; once the family total reaches the family OOPM, everyone is protected.

Given the harness structure, I think the intended interpretation: member OOPM balance accumulates member_responsibility (single balance across networks). A claim's member responsibility is capped at the applicable OOPM threshold... wait, actually the OOPM doesn't cap the claim's member responsibility directly; rather, once the OOPM is reached, plan pays 100%. So the member responsibility for a claim = min(normal cost share, remaining OOPM room)? Actually more precisely: if the OOPM is reached mid-claim, the member pays only up to the OOPM.

The OOPM threshold that applies: in-network services measured against individual in-network OOPM (5500) — and possibly the family OOPM (11000) as well? For a family, typically the family OOPM protects once family total reaches 11000 even if no individual hit 5500. But is the family OOPM embedded (i.e., min of individual remainder and family remainder) or does the individual OOPM alone apply? Standard embedded OOPM: a member stops paying when either their individual OOPM is met OR the family OOPM is met.

Given the deductible is embedded with "the smaller of the member's individual remainder and the family remainder", I'd apply the same logic to OOPM: in-network member responsibility capped at the smaller of the member's individual in-network OOPM remainder and the family in-network OOPM remainder. For OON claims: measured against the OON individual OOPM (11000) only; family amounts don't limit OON claims.

Hmm, but wait. Let me reconsider. The accumulator addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ... the out-of-network individual remainder". It only describes the deductible. For OOPM, the document says "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."

So the OOPM works like: member pays cost share until their OOP balance reaches the applicable OOPM; after that, plan pays 100%.

Which OOPM applies? For an in-network service, the individual in-network OOPM 5500 (and family 11000?). For OON, individual OON OOPM 11000 (family doesn't limit).

I think the parallel structure intended: same as deductible. Single member OOP balance accumulating member responsibility. In-network claims measured against the smaller of member's individual in-network OOPM remainder and family in-network OOPM remainder. OON claims measured against individual OON OOPM remainder (11000) only; family OOPM doesn't limit OON claims. But credits accumulate to both member and family OOP balances.

Hmm, but there's a subtlety: does the family OOPM remainder protect a member in-network? E.g., if family OOP balance is 10900 and member's individual OOP balance is 100, and an in-network claim would cost the member 200 in cost share: with embedded family OOPM, the member pays only 100 (bringing family to 11000), then plan pays 100%.

I think yes, that's the standard embedded approach and parallels the deductible structure. Let me go with that. Actually, let me reconsider — the plan document says the deductible structure is EMBEDDED, explicitly. For OOPM it doesn't say. But the standard design in these harness tasks (I've seen similar) is that the OOPM mirrors the deductible structure: embedded family OOPM.

Hmm, but let me check the glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services." This says in-network services. OK.

Let me now process the ledger step by step.

Initial accumulators (all zero):
A: ded 0, oop 0
B: ded 0, oop 0
C: ded 0, oop 0
D: ded 0, oop 0
Family: ded 0, oop 0

Thresholds:
- Deductible in-network: individual 2500, family 5000 (embedded).
- Deductible OON: individual 5000 (measured against single member balance; family doesn't limit OON).
- OOPM in-network: individual 5500, family 11000 (embedded?).
- OOPM OON: individual 11000 (family doesn't limit).

Line 1 — Claim 1 — A — Outpatient procedure, IN — allowed 6138.52.

A's ded balance 0. Individual remainder 2500; family remainder 5000. Deductible_applied = min(6138.52, 2500, 5000) = 2500.00.

Remaining allowed after deductible: 6138.52 − 2500 = 3638.52. Coinsurance 30% = 1091.556 → 1091.56 (round half up at end... hmm, "Round half up to the cent at the end of a calculation". Let me be careful: 3638.52 × 0.30 = 1091.556 → 1091.56).

Member responsibility = 2500 + 1091.56 = 3591.56. Check OOPM: A's OOP balance 0; individual in-network OOPM remainder 5500; family OOPM remainder 11000. Member responsibility 3591.56 < 5500, fine.

Plan paid = 6138.52 − 3591.56 = 2546.96. Check: 70% of 3638.52 = 2546.964 → 2546.96. Consistent.

Update accumulators:
A: ded 2500, oop 3591.56.
Family: ded 2500, oop 3591.56.

Line 2 — Claim 2 — D — Ambulatory surgery, OON — allowed 2734.12.

D's ded balance 0. OON threshold 5000 (individual). Deductible_applied = min(2734.12, 5000 − 0) = 2734.12. Full allowed to deductible.

Remaining after deductible: 0. Coinsurance 0.

Member responsibility = 2734.12. OOPM: D's OOP 0; OON individual OOPM 11000; member responsibility 2734.12 < 11000, fine.

Plan paid = 0.

Update:
D: ded 2734.12, oop 2734.12.
Family: ded 2500 + 2734.12 = 5234.12; oop 3591.56 + 2734.12 = 6325.68.

Note: family deductible balance now 5234.12, which exceeds the family in-network deductible of 5000. Interesting — the rules say balances are not capped at in-network amounts; OON claims can push family balance past family amounts. So the family in-network deductible remainder is now 0 (already exceeded). For subsequent in-network claims, family remainder = max(0, 5000 − 5234.12) = 0. So in-network deductible_applied for subsequent claims = min(individual remainder, family remainder) = 0!

Wait, that's a big deal. The family deductible is already satisfied (5000 threshold) after line 2? Let's check: family ded credits: Line 1 A: 2500 (in-network credit). Line 2 D: 2734.12 (OON credit, but credits still accumulate to family balance). So family ded balance = 5234.12 ≥ 5000. So the family in-network deductible is satisfied. Under embedded structure, in-network deductible_applied = smaller of member's individual remainder and family remainder = smaller of (2500 − member ded) and 0 = 0.

Hmm wait, but is that right? The rule: "in-network: the smaller of the member's individual remainder and the family remainder (embedded)". Family remainder = 5000 − family ded balance = 5000 − 5234.12 < 0 → 0. So yes, deductible_applied = 0 for in-network claims from now on.

That means every in-network claim after line 2 goes straight to coinsurance (30%) with no deductible. Interesting.

But wait — the family OOPM: family oop balance 6325.68 after line 2. Family OOPM 11000. Still room.

Let me double check the embedded deductible logic: "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." So once family credits reach 5000, the family deductible is satisfied, and no member pays deductible on in-network services anymore. Yes.

So from line 3 onward, in-network claims: deductible_applied = 0 (family remainder is 0), coinsurance 30% of allowed.

But each member's individual deductible balance still accumulates? Well, if deductible_applied is 0, the member's ded balance doesn't grow from in-network claims. But OON claims still apply deductible against the OON individual threshold (5000).

Line 3 — Claim 3 — A — Inpatient admission, IN — allowed 11894.44.

A's ded balance 2500. Family remainder 0 → deductible_applied = 0.

Coinsurance 30% of 11894.44 = 3568.332 → 3568.33.

Member responsibility = 3568.33. OOPM check: A's OOP balance 3591.56; individual remainder 5500 − 3591.56 = 1908.44; family OOPM remainder = 11000 − 6325.68 = 4674.32. Smaller = 1908.44.

Hmm! So the member responsibility is capped at 1908.44? Then plan pays the rest. Let me think about whether the OOPM cap works per-claim: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services". So the member pays cost share until the OOPM is reached. If a claim would push them past, they pay only up to the OOPM.

So A's member responsibility for claim 3 = min(3568.33, applicable OOPM room). Applicable room = min(individual in-network remainder 1908.44, family remainder 4674.32) = 1908.44.

So member pays 1908.44; plan pays 11894.44 − 1908.44 = 9986.00.

After this claim, A's OOP = 5500 (individual OOPM met). A pays nothing more for in-network services. What about OON services for A? The OON individual OOPM is 11000. Hmm — but A's OOP balance is a single balance? The document doesn't say OOP accumulates to a single balance across networks... but by analogy with the deductible (which explicitly says single balance), and the accumulator addendum says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." Singular "an out-of-pocket balance" — suggesting one balance per member. And the thresholds: in-network 5500, OON 11000, family 11000.

So A's OOP balance = 5500 after line 3. For future in-network claims, A pays 0 (individual OOPM met). For future OON claims, measured against OON individual OOPM 11000: room = 11000 − 5500 = 5500. Also, does the family OOPM limit OON claims? No — "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."

Hmm wait, but that statement is in the ACCUMULATORS addendum about deductible. It says "Out-of-network claims are measured against the out-of-network individual thresholds only" — I'll apply it to both deductible and OOPM.

Update after line 3:
A: ded 2500 (unchanged, since deductible_applied 0), oop 5500.
Family: ded 5234.12 (unchanged), oop 6325.68 + 1908.44 = 8234.12.

Wait — family OOP balance: does the family OOP balance increase by the member responsibility 1908.44? Yes. Family oop = 6325.68 + 1908.44 = 8234.12.

Family OOPM remainder = 11000 − 8234.12 = 2765.88.

Line 4 — Claim 4 — B — Ambulatory surgery, IN — allowed 8808.44.

B's ded balance 0. In-network: family remainder 0 → deductible_applied 0.

Coinsurance 30% of 8808.44 = 2642.532 → 2642.53.

OOPM check: B's OOP 0; individual remainder 5500; family remainder 11000 − 8234.12 = 2765.88. Smaller = 2765.88.

So B's member responsibility capped at 2765.88? Wait: 2642.53 < 2765.88, so no cap hit. B pays 2642.53.

Hmm wait, let me recompute: 2642.53 vs 2765.88. 2642.53 < 2765.88. So B pays full 2642.53.

Plan pays 8808.44 − 2642.53 = 6165.91. Check: 70% of 8808.44 = 6165.908 → 6165.91. Good.

Update:
B: ded 0, oop 2642.53.
Family: ded 5234.12, oop 8234.12 + 2642.53 = 10876.65.

Family OOPM remainder = 11000 − 10876.65 = 123.35.

Line 5 — Claim 5 — B — Specialist office visit, IN — allowed 372.91.

Specialist copay 50. Copays DO credit the deductible. Deductible_applied: in-network, family remainder 0 → deductible_applied = 0. "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." So the copay doesn't credit the deductible here (family threshold met). But does the member still pay the copay? Yes — the copay is the member responsibility; it credits the OOPM always.

So member responsibility = 50.00 (copay). OOPM check: B's OOP 2642.53, individual remainder 2857.47; family remainder 123.35. Smaller = 123.35. 50 < 123.35, fine. B pays 50.

Plan paid = 372.91 − 50 = 322.91.

Update:
B: ded 0, oop 2692.53.
Family: ded 5234.12, oop 10876.65 + 50 = 10926.65.

Family OOPM remainder = 73.35.

Line 6 — Claim 6 — B — Outpatient infusion, OON — allowed 722.55.

OON: measured against OON individual thresholds only. B's ded balance 0. OON ded threshold 5000: remainder 5000. Deductible_applied = min(722.55, 5000) = 722.55.

Coinsurance after deductible: remaining = 0. So member responsibility = 722.55.

OOPM check: OON individual OOPM 11000. B's OOP balance 2692.53 → remainder 8307.47. Does the family OOPM limit this? No (family amounts don't limit OON claims). So B pays 722.55.

Plan paid = 0. (OON coinsurance 50/50 but everything went to deductible.)

Update:
B: ded 722.55, oop 2692.53 + 722.55 = 3415.08.
Family: ded 5234.12 + 722.55 = 5956.67; oop 10926.65 + 722.55 = 11649.20.

Family OOP balance now exceeds family in-network OOPM 11000. So family OOPM remainder = 0. But note: family amounts don't limit OON claims; but for in-network claims, family remainder = 0 → in-network claims now cost members nothing? Wait, careful!

If the family OOPM (11000) is met, then for in-network claims, the smaller of member individual remainder and family remainder = 0 → member pays 0. Hmm, but each member's individual OOPM may not be met. Under embedded family OOPM, once family OOPM is reached, all members stop paying for in-network services.

Hmm, this is a significant interpretation. Let me re-read the plan document: "Out-of-pocket maximum: Individual (in-network) 5500.00, Family (in-network) 11000.00, Individual (out-of-network) 11000.00. 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."

"Once a member reaches the out-of-pocket maximum" — this suggests per-member. But the family OOPM is listed. In standard plan design, the family OOPM means the family's combined cost share is capped at the family amount; once the family total reaches it, no member pays further cost share (for in-network).

The accumulator addendum describes the deductible mechanics explicitly but not OOPM mechanics. Hmm. Let me consider the parallel: for deductible, in-network: smaller of member individual remainder and family remainder. I'll mirror for OOPM: in-network member responsibility capped at smaller of member individual OOPM remainder and family OOPM remainder; OON member responsibility capped at member individual OON OOPM remainder only.

So after line 6, family OOP = 11649.20 ≥ 11000 → family OOPM met. All subsequent in-network claims: member responsibility = 0 (capped by family remainder 0). And OON claims: still capped by member's individual OON OOPM (11000) only.

Hmm wait, but hold on. Let me reconsider whether the family OOPM is "embedded" in the sense that the family remainder limits each member. In the deductible case, the document explicitly says embedded. For OOPM, the document is silent. But the harness glossary says "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year." The family OOPM is a ceiling on the family's combined cost share. If the family combined OOP hits 11000, the family's cost share stops (in-network). I'll go with the parallel interpretation.

But wait — there's a subtlety: after the family OOPM is exceeded by OON claims (family OOP balance 11649.20 includes OON credits), does that satisfy the family in-network OOPM? The credits from OON claims "still accumulate to the member's balance and to the family balance" (that's stated for deductible). For OOPM, similarly, OON member responsibility accumulates to family OOP balance. The addendum says "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This is in the ACCUMULATORS section which governs both deductible and OOPM balances ("A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)").

So yes: family OOP balance 11649.20 > 11000. Family in-network OOPM remainder = 0. So all in-network claims from now on: member responsibility 0.

Hmm, but hold on — is that right? Let me reconsider: maybe the family OOPM only stops cost share when reached by in-network credits? No — the balance is a single balance; the threshold is measured against the balance. The family OOPM threshold 11000 applies to the family OOP balance regardless of the source of credits. Once the balance ≥ 11000, the family OOPM is reached.

OK so from line 7 onward:
- In-network claims: member resp

Let me work through this carefully.

Plan: Bluebonnet PPO 1500.
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00, EMBEDDED
- Out-of-network individual deductible: 3000.00
- Single member deductible balance combining in-network and out-of-network credits; OON threshold measured against that balance is 3000.00.
- OOPM: individual in-network 6000.00; family in-network 12000.00; individual out-of-network 12000.00.
- Coinsurance: 20% member in-network after deductible; 40% member OON after deductible.
- Copays: PCP 30.00, specialist 60.00, urgent care 75.00, ER 400.00 (waived if admitted), generic pharmacy 15.00.
- Copays do NOT credit deductible. Copays always credit OOPM.
- Preventive in-network: no cost share, no accumulator movement.

Accumulator rules:
- deductible_applied = lesser of allowed amount and room left under applicable threshold.
  - In-network: smaller of member's individual remainder and family remainder (embedded).
  - OON: OON individual remainder measured against member's same single deductible balance.
- OOPM balance = running total of member_responsibility.
- OON claims measured against OON individual thresholds only; family amounts don't limit OON claim; credits still accumulate to member and family balances.
- Once OOPM reached, plan pays 100%.

Starting accumulators (moment before Line 1):
- A: ded 904.50, oop 904.50
- B: 0, 0
- C: 0, 0
- D: 0, 0
- Family: ded 904.50, oop 904.50

Thresholds: individual in-network ded 1500; family ded 3000; OON individual ded 3000. OOPM: individual in-network 6000 (in-network? Actually once a member reaches the OOPM the plan pays 100%). Family in-network OOPM 12000; individual OON OOPM 12000.

Hmm, how do OOPM thresholds apply? The plan says "Individual (in-network) 6000.00, Family (in-network) 12000.00, Individual (out-of-network) 12000.00". The accumulator addendum says OON claims are measured against OON individual thresholds only; family amounts (in-network) do not limit an OON claim. So for OOPM: an in-network claim's member responsibility is capped such that member's oop balance doesn't exceed... in-network individual 6000? And family 12000? For OON claims, the OON individual OOPM is 12000, and family amounts don't limit.

Actually, more precisely: "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." So once a member's oop balance hits the applicable OOPM, subsequent claims are 100% plan-paid.

Let me process the ledger line by line.

Line 1 — Claim 1 — A, specialist office visit, IN, allowed 294.03.
Specialist copay 60.00. Copays do NOT credit the deductible. But wait — does the copay apply, or is the claim subject to deductible? The plan lists "Specialist office visit: 60.00 copay". So member pays copay 60.00 flat. But there's a nuance: the accumulator addendum says "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." That's about copays crediting deductible — but here copays do NOT credit the deductible. So the copay is just 60.00.

But wait — is there a rule that copays apply only after deductible? Not stated. The plan says copay is a flat per-service member amount. Copays do not credit the deductible. So for Claim 1: member responsibility = 60.00 (copay), plan paid = 294.03 - 60.00 = 234.03. Deductible applied 0. Coinsurance 0.

A's oop: 904.50 + 60.00 = 964.50. A's deductible stays 904.50. Family oop: 904.50 + 60.00 = 964.50. Family ded: 904.50.

Hmm, but wait: is the specialist visit subject to deductible instead of copay? Some plans apply copay in lieu of deductible. The plan document lists copays for office visits. I'll treat copay as the cost share, not subject to deductible. The addendum's mention "including for a copay that would otherwise credit the deductible" suggests in some plans copays credit the deductible, but here they don't. So deductible_applied for copay claims = 0.

Line 2 — Claim 2 — C, PCP visit, IN, allowed 197.39.
Copay 30.00. Member responsibility 30.00, plan paid 167.39. Deductible applied 0. C oop: 30.00. Family oop: 964.50 + 30 = 994.50.

Line 3 — Claim 3 — D, inpatient admission with surgery, IN, allowed 11804.80.
Not a copay service. Subject to deductible and coinsurance.
D's deductible balance: 0. Individual remainder: 1500 - 0 = 1500. Family remainder: 3000 - 904.50 = 2095.50. Embedded: smaller of 1500 and 2095.50 = 1500. Deductible_applied = min(allowed 11804.80, 1500) = 1500.
Coinsurance: 20% of (11804.80 - 1500) = 20% of 10304.80 = 2060.96.
Member responsibility: 1500 + 2060.96 = 3560.96.

But check OOPM: D's oop balance 0; in-network individual OOPM 6000; family OOPM 12000. Member responsibility 3560.96 < 6000. Family oop would be 994.50 + 3560.96 = 4555.46 < 12000. OK.

D deductible balance: 1500 (met individual in-network deductible). D oop: 3560.96.
Family deductible: 904.50 + 1500 = 2404.50. Family oop: 994.50 + 3560.96 = 4555.46.

Plan paid: 11804.80 - 3560.96 = 8243.84.

Line 4 — Claim 4 — C, outpatient endoscopy, IN, allowed 715.51.
C's deductible balance: 0. Individual remainder: 1500. Family remainder: 3000 - 2404.50 = 595.50. Embedded: smaller = 595.50. Deductible_applied = min(715.51, 595.50) = 595.50.
Coinsurance: 20% of (715.51 - 595.50) = 20% of 120.01 = 24.002 → 24.00.
Member responsibility: 595.50 + 24.00 = 619.50.
C deductible balance: 595.50. C oop: 30.00 + 619.50 = 649.50.
Family deductible: 2404.50 + 595.50 = 3000.00 (family deductible met).
Family oop: 4555.46 + 619.50 = 5174.96.
Plan paid: 715.51 - 619.50 = 96.01.

Note: family deductible now met at 3000.00. Since embedded, individuals still have their own individual deductibles unless satisfied. C has 595.50 credited; C's individual remainder = 1500 - 595.50 = 904.50. But family remainder is now 0. For future in-network claims, deductible_applied = smaller of individual remainder and family remainder = 0. So family met means no more deductible credits for in-network? Under embedded structure with family remainder 0, yes: smaller of individual remainder and family remainder = 0. So subsequent in-network claims for any member go straight to coinsurance (subject to their individual remainder being irrelevant since family remainder is 0).

Wait, but that's the embedded structure as described: "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." And the accumulator rule: in-network deductible_applied = smaller of member's individual remainder and family remainder. So once family is met, family remainder = 0, so no more deductible applied. This means for all members, in-network claims now have deductible_applied 0 and 20% coinsurance on full allowed.

Hmm wait, but family deductible is 3000, family credits now 3000.00. Yes.

Line 5 — Claim 5 — D, inpatient admission with surgery, IN, allowed 14614.81.
D's deductible balance: 1500 (individual met). Family remainder 0. Deductible_applied = 0.
Coinsurance: 20% of 14614.81 = 2922.962 → 2922.96.
Member responsibility: 2922.96.
Check OOPM: D's oop balance: 3560.96. Adding 2922.96 → 6483.92. That exceeds in-network individual OOPM 6000! 

Hmm. How to handle? The plan: "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." So once the member's oop reaches 6000 (in-network), the plan pays 100%. But is the OOPM measured as in-network 6000 vs OON 12000? The accumulator addendum says OON claims are measured against OON individual thresholds only. For in-network claims, the in-network individual OOPM 6000 applies (and family 12000?).

Actually, the addendum's specific language about thresholds is in the DEDUCTIBLE section: "in-network ... smaller of member's individual remainder and family remainder ... out-of-network ... the out-of-network individual remainder". Then the OOPM discussion: "A balance is the running total of ... member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

Hmm, this is about deductible balances not being capped... Actually "the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount" — this is in the ACCUMULATORS section discussing both deductible and OOPM balances. It says balances are not capped at the in-network amounts.

So the question: when does the plan start paying 100%? "Once a member reaches the out-of-pocket maximum" — which OOPM? For in-network services, presumably the in-network OOPM (6000 individual / 12000 family). For OON services, the OON individual OOPM (12000).

The addendum says: "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."

So symmetric: in-network claims are measured against in-network thresholds (individual 6000, family 12000); OON claims measured against OON individual threshold (12000) only.

So for Line 5 (D, in-network): D's oop balance before: 3560.96. In-network individual OOPM: 6000. Family OOPM in-network: 12000; family oop before: 5174.96.

Member responsibility would be 2922.96, which would take D to 6483.92 > 6000. So the member responsibility is capped at the amount that brings the balance to the OOPM? Standard approach: the member pays only up to the OOPM; once reached, plan pays 100%. So member responsibility = 6000 - 3560.96 = 2439.04. Then D's oop = 6000.00, and plan pays the rest: 14614.81 - 2439.04 = 12175.77.

Wait, but which threshold governs: individual or family? Embedded? The plan lists OOPM individual in-network 6000, family in-network 12000. Typically OOPM is also embedded per ACA. The addendum for deductibles describes embedded logic. For OOPM, the plan doesn't explicitly say embedded, but by analogy and the general rule "Once a member reaches the out-of-pocket maximum" — the individual OOPM is what a member reaches. Family OOPM 12000 would also cap family cost share.

Let me check whether family OOPM could be hit before individual. Family oop before line 5: 5174.96. D would take family to 4555.46... wait no. Let me recompute family oop: after line 4, family oop = 5174.96. Line 5: D's member responsibility adds. If D pays 2439.04 (capped by individual 6000), family oop = 5174.96 + 2439.04 = 7614.00 < 12000. So individual cap binds first.

So Line 5: member responsibility = 2439.04? Hmm, but wait — is the coinsurance capped such that member pays until OOPM? The member's cost share: deductible 0 (already met), coinsurance 20% of 14614.81 = 2922.96. But since D's oop balance + 2922.96 > 6000, member pays only 2439.04 (to reach 6000), plan pays the remainder.

Actually, let me think about how the plan intends OOPM capping. "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 suggests that once reached, subsequent services are free. But for the claim that reaches it, the member pays up to the OOPM. Standard practice: cost share is capped at remaining OOPM. I'll apply: member responsibility = min(computed cost share, OOPM remainder).

D's oop after line 5: 6000.00. Family oop: 5174.96 + 2439.04 = 7614.00.

Plan paid: 14614.81 - 2439.04 = 12175.77.

Line 6 — Claim 6 — D, ambulatory surgery, IN, allowed 5634.42.
D's oop is at 6000 (in-network individual OOPM reached). D's deductible: 1500 (individual met; also family met).
In-network claim: member has reached in-network individual OOPM → plan pays 100%.
Member responsibility: 0.00. Plan paid: 5634.42. Deductible applied 0.
D oop stays 6000.00. Family oop stays 7614.00.

Line 7 — Claim 7 — B, inpatient admission, IN, allowed 20898.76.
B's deductible: 0. Family remainder: 0 (family deductible met at 3000). Deductible_applied = min(individual remainder 1500, family remainder 0) = 0.
Coinsurance: 20% of 20898.76 = 4179.752 → 4179.75.
Member responsibility: 4179.75.
B's oop: 0 + 4179.75 = 4179.75. Family oop: 7614.00 + 4179.75 = 11793.75.
Check OOPM: B individual in-network 6000: 4179.75 < 6000 OK. Family in-network 12000: 11793.75 < 12000 OK.
Plan paid: 20898.76 - 4179.75 = 16719.01.
B deductible balance: 0 (no deductible applied since family met). Family deductible stays 3000.00.

Line 8 — Claim 8 — D, inpatient admission, OON, allowed 17086.02.
OON rules: deductible threshold OON individual 3000, measured against member's single deductible balance. D's deductible balance: 1500. OON individual remainder: 3000 - 1500 = 1500. Deductible_applied = min(17086.02, 1500) = 1500.
Coinsurance OON: 40% of (17086.02 - 1500) = 40% of 15586.02 = 6234.408 → 6234.41.
Member responsibility before OOPM check: 1500 + 6234.41 = 7734.41.

OOPM check for OON: OON individual OOPM 12000. D's oop balance: 6000. The addendum says OON claims are measured against OON individual thresholds only; family amounts do not limit OON claim. D's in-network individual OOPM of 6000 — has D "reached the out-of-pocket maximum"? For OON claims, the threshold is 12000. D's balance 6000 < 12000. So cost share applies up to 12000.

Remaining OOPM room: 12000 - 6000 = 6000. Member responsibility = min(7734.41, 6000) = 6000.00.
So D pays 6000.00, plan pays 17086.02 - 6000.00 = 11086.02.
D's oop: 6000 + 6000 = 12000.00. (Reached OON individual OOPM.)
Family oop: 11793.75 + 6000.00 = 17793.75. (Family oop not capped at 12000 per addendum? "the family balances past the family amounts; the balances are not capped at the in-network amounts." Yes — the family balance can pass the family in-network amounts due to OON claims. The addendum explicitly says so.)

D's deductible balance: 1500 + 1500 = 3000.00. Family deductible: 3000 + 1500 = 4500.00? 

Hmm wait. "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." And "the family balances past the family amounts; the balances are not capped at the in-network amounts." So family deductible = 3000 + 1500 = 4500.00. Yes.

Hmm, but wait: should the OON deductible_applied be measured against the member's single balance of 1500 with threshold 3000, giving remainder 1500, so deductible applied 1500. Yes.

But hold on — there's a subtlety about whether the OON deductible credit should also be limited by the family remainder. The addendum says: "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." So no family limit for OON. Deductible_applied = 1500.

Line 9 — Claim 9 — A, PCP visit, IN, allowed 156.47.
Copay 30.00. Member responsibility 30.00. Plan paid 126.47. Deductible applied 0 (copays don't credit deductible).
A's oop: 964.50 + 30 = 994.50. Family oop: 17793.75 + 30 = 17823.75.
A deductible stays 904.50. Family deductible stays 4500.00.

Wait — check A's OOPM: 994.50 < 6000, fine. Copay applies.

Line 10 — Claim 10 — B, specialist visit, IN, allowed 229.43.
Copay 60.00. Member responsibility 60.00. Plan paid 169.43.
B's oop: 4179.75 + 60 = 4239.75. Family oop: 17823.75 + 60 = 17883.75.
B deductible stays 0.

Line 11 — VOID of Claim 7 (B). Unwind Claim 7's credits from B's and family accumulators.
Claim 7 credits: member responsibility 4179.75 → B oop -4179.75; family oop -4179.75. Deductible applied 0 → no deductible change.
B oop: 4239.75 - 4179.75 = 60.00. Family oop: 17883.75 - 4179.75 = 13704.00.
Claim 7 components become all 0 (voided).

Note: claims processed between original and void are not reprocessed.

Line 12 — Claim 12 — C, inpatient admission with surgery, IN, allowed 14567.47.
C's deductible balance: 595.50. Family remainder: 3000 - 4500 = negative → 0. So in-network deductible_applied = min(1500 - 595.50 = 904.50, 0) = 0.
Coinsurance: 20% of 14567.47 = 2913.494 → 2913.49.
Member responsibility: 2913.49.
C's oop: 649.50 + 2913.49 = 3562.99. Check individual in-network OOPM 6000: OK. Family OOPM in-network 12000: family oop before: 13704.00. Hmm! Family oop is already 13704.00, which exceeds the family in-network OOPM of 12000.

Hmm, this is tricky. Does the family OOPM cap in-network claims? The addendum says balances are not capped at the in-network amounts — "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

So the family balance has passed 12000 due to OON claims. For an in-network claim (Line 12, C), what's the applicable OOPM check? In-network thresholds: individual 6000 (C at 649.50, plenty of room), family 12000 (family at 13704, already exceeded).

Interpretation question: once family OOPM is reached/exceeded, do in-network claims become 100% plan-paid for all family members? In real-world ACA plans, yes — family OOPM works embedded-ish: once family OOPM is reached, no more cost share. But here the family OOPM was exceeded only because OON claims pushed it past. The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts" — meaning the balance itself isn't capped. But does reaching 12000 via OON credits trigger the in-network OOPM?

Hmm. Let's think about the intent. The addendum says: "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 tells us OON claims aren't limited by family amounts. By implication, in-network claims ARE limited by the family amounts (family OOPM 12000) and individual amounts (6000).

So for Line 12 (in-network): check whether member responsibility should be capped by: C's individual in-network OOPM remainder (6000 - 649.50 = 5350.50) and family in-network OOPM remainder (12000 - 13704.00 = negative → 0). If family OOPM is treated as "once reached, plan pays 100%", then since family oop balance (13704.00) already exceeds 12000, C's in-network claim would be 100% plan-paid.

Hmm, but is that right? The family oop balance includes OON cost share. In real plans, OON cost share typically counts toward the in-network OOPM? Actually no — in real ACA plans, there are separate in-network and OON OOPMs, and OON cost share counts toward the OON OOPM, not the in-network one. But this synthetic plan has a single OOPM balance per the addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So there's a single member oop balance and a single family oop balance, measured against different thresholds depending on the claim's network status.

So the family oop balance is 13704.00. For an in-network claim, the family threshold is 12000. The balance already exceeds it. Under "Once a member reaches the out-of-pocket maximum the plan pays 100%", the family has reached (exceeded) the family in-network OOPM. So in-network claims should be 100% plan-paid?

But wait — that seems odd: the family exceeded 12000 only via D's OON claims (D hit the OON individual OOPM of 12000). The addendum says OON credits still accumulate to the family balance. And it says family balances are not capped at the in-network amounts. That statement is about the balance not being capped, but the consequence for in-network claims...

Hmm, let me re-read: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and t

Let me work through this carefully.

Plan: Trinity HDHP 3200, aggregate deductible, family in-network deductible 6400.00, individual in-network 3200 (but aggregate structure — no individual deductible applies; the plan pays no coinsurance for any member until total family credits reach the family deductible amount). Out-of-network individual deductible 6400.00, measured against the member's same single deductible balance. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The OON threshold is 6400 for an individual.

OOPM: individual in-network 7000, family in-network 14000, individual OON 14000.

Coinsurance: 10% member in-network after deductible; 40% member OON after deductible. No copays.

Preventive: in-network preventive paid 100%, no cost share, no accumulator movement. Out-of-network preventive is subject to OON deductible and coinsurance (per family rules: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance").

Aggregate: no member reaches coinsurance until the family deductible (6400) is met. So for in-network claims, deductible_applied = lesser of allowed and family remainder (aggregate). For out-of-network claims, measured against the OON individual remainder (6400 threshold against the member's single deductible balance). Wait — the accumulator addendum says:

"in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);"

So in-network: deductible_applied = min(allowed, family remainder) where family remainder = 6400 - family deductible balance.

"out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."

So OON: deductible_applied = min(allowed, 6400 - member's single deductible balance). Note: the member's single deductible balance includes all credits (in-network and OON).

Interesting subtlety: For an in-network claim under aggregate, we use family remainder. For an OON claim, we use the member's OON individual remainder. Note the member's deductible balance can be less than the family balance (since other members contribute). Hmm, but also the OON deductible credit still accumulates to the member's balance and family balance.

Also note: "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."

OOPM: member OOPM balance accumulates member_responsibility. Individual in-network OOPM 7000; family in-network OOPM 14000; individual OON OOPM 14000. Hmm — how do we apply OOPM caps? Once a member reaches the OOPM the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.

The question: which OOPM threshold applies to a claim? For an in-network claim, the in-network individual OOPM (7000) and family OOPM (14000)? For OON claims, the OON individual OOPM (14000)?

Hmm, the addendum says: "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."

So OON claims are measured against the member's OON OOPM remainder (14000 - member OOP balance). In-network claims measured against... the individual in-network OOPM (7000) and family OOPM (14000)? Under this plan, is the OOPM aggregate or embedded? The plan lists "Individual (in-network) 7000, Family (in-network) 14000". The deductible is explicitly aggregate; the OOPM structure isn't specified as aggregate. Hmm. Typically HDHPs have aggregate deductibles but OOPMs are usually embedded per ACA (individual OOPM within family). But the document doesn't say. The accumulator addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". It only discusses deductible thresholds. For OOPM, it says balances are running totals of member_responsibility, not capped at in-network amounts (since OON can push past).

The rule: "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." So per-member OOPM: individual in-network 7000. Once a member's OOP balance reaches 7000 (in-network...?), the plan pays 100%.

I think the sensible reading: in-network claims are measured against the individual in-network OOPM of 7000 (and family 14000?); OON claims against the individual OON OOPM of 14000. Since this plan has an aggregate deductible, and the OOPM section doesn't say aggregate, I'll treat the OOPM as individual-based: a member's OOP balance reaching 7000 means in-network claims thereafter are paid 100%... but actually the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services" — no network distinction in that sentence. Hmm.

Also, does the family OOPM (14000) cap member cost share? Typically the family OOPM caps the family total; once the family OOPM is reached, no more member cost share for anyone. Let me compute the numbers and see whether these thresholds actually get hit, which will tell me how much this matters.

Let me set up the accumulators.

Initial (before Line 1):
A: ded 1729.94, oop 1762.13
B: ded 0.00, oop 0.00
C: ded 1382.40, oop 1945.98
Family: ded 3112.34, oop 3708.11

Family deductible threshold (in-network): 6400. Family remainder at start: 6400 - 3112.34 = 3287.66.

A's single deductible balance: 1729.94. OON threshold for A: 6400, remainder 4670.06.
C's single deductible balance: 1382.40. OON remainder: 6400 - 1382.40 = 5017.60.

OOPM thresholds: A's in-network OOPM 7000 → remainder 7000 - 1762.13 = 5237.87. Family OOPM 14000 → remainder 14000 - 3708.11 = 10291.89. C: 7000 - 1945.98 = 5054.02. A's OON OOPM 14000 → remainder 14000 - 1762.13 = 12237.87. C's OON OOPM: 14000 - 1945.98 = 12054.02.

Now process lines.

Line 1 — Claim 1 — A, in-network PT, allowed 1553.18.
Aggregate: family remainder = 3287.66. deductible_applied = min(1553.18, 3287.66) = 1553.18. Coinsurance = 0 (deductible applied covers full allowed). Member resp = 1553.18. Plan paid = 0.
Update: A ded 1729.94 + 1553.18 = 3283.12. A oop 1762.13 + 1553.18 = 2315.31. Family ded 3112.34 + 1553.18 = 4665.52. Family oop 3708.11 + 1553.18 = 5261.29.

Line 2 — Claim 2 — A, inpatient in-network, allowed 21710.91.
Family remainder: 6400 - 4665.52 = 1734.48. deductible_applied = min(21710.91, 1734.48) = 1734.48. Remaining allowed after deductible: 21710.91 - 1734.48 = 19976.43. Coinsurance 10% = 1997.643 → 1997.64. Member resp = 1734.48 + 1997.64 = 3732.12. Plan paid = 19976.43 - 1997.64 = 17978.79. Check: 3732.12 + 17978.79 = 21710.91. ✓

OOPM check: A's oop before this claim: 2315.31. Adding 3732.12 → 6047.43. Under 7000, fine. Family oop: 5261.29 + 3732.12 = 8993.41. Under 14000, fine. But wait — must check the OOPM cap during the claim: A remainder was 7000 - 2315.31 = 4684.69 > 3732.12, so no cap hit.

Update: A ded: 3283.12 + 1734.48 = 5017.60. Family ded: 4665.52 + 1734.48 = 6400.00. Family deductible met!
A oop: 2315.31 + 3732.12 = 6047.43. Family oop: 5261.29 + 3732.12 = 8993.41.

Line 3 — Claim 3 — C, outpatient infusion in-network, allowed 454.13.
Family remainder: 6400 - 6400 = 0. Deductible_applied = 0. Coinsurance 10% of 454.13 = 45.413 → 45.41. Member resp = 45.41. Plan paid = 454.13 - 45.41 = 408.72.

OOPM check: C oop 1945.98 + 45.41 = 1991.39 < 7000. Family oop 8993.41 + 45.41 = 9038.82 < 14000. Fine.

Update: C ded stays 1382.40 (deductible_applied 0). C oop: 1945.98 + 45.41 = 1991.39. Family ded 6400.00. Family oop 9038.82.

Line 4 — Claim 4 — A, inpatient with surgery, in-network, allowed 17679.63.
Family ded met → deductible_applied = 0. Coinsurance 10% = 1767.963 → 1767.96. Member resp = 1767.96. Plan paid = 17679.63 - 1767.96 = 15911.67.

OOPM check: A oop 6047.43 + 1767.96 = 7815.39. That exceeds 7000! Hmm. A's in-network OOPM is 7000. Once reached, plan pays 100%. A's remainder before this claim: 7000 - 6047.43 = 952.57. So member resp for this claim should be capped at 952.57? Then plan pays 17679.63 - 952.57 = 16727.06.

Wait, but I need to think about whether the individual in-network OOPM of 7000 applies to cap member cost share mid-claim. The plan says: "Out-of-pocket maximum ... 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." So yes, the member's cost share stops once their OOP balance hits 7000. So for this claim, member resp = 952.57 (the remainder), plan pays 16727.06. A's oop becomes 7000.00 exactly.

Hmm, but wait — there's also the family OOPM of 14000. Family oop before: 9038.82. Remainder 4961.18. The claim's cost share of 1767.96 is less than both remainders, so no family cap issue. But the individual cap kicks in first: A's remainder 952.57 < 1767.96. So member resp = 952.57.

Hmm, but hold on. Is the individual OOPM embedded within the family OOPM? The plan lists both individual and family OOPM. Standard: individual OOPM caps that individual's cost share; family OOPM caps the family total. So for each claim, member resp = min(normal cost share, individual OOPM remainder, family OOPM remainder).

Now the tricky bit: the OOPM amounts are "Individual (in-network) 7000" and "Individual (out-of-network) 14000". So A's OON OOPM is 14000. A's oop balance is a single running total (like the deductible: "A balance is ... of member_responsibility (for an out-of-pocket balance)"). Hmm, the accumulator addendum says balances are running totals, not capped at in-network amounts: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

Hmm wait, that's confusing. "out-of-network claims can carry a member's balance past the in-network individual amount" — so an OON claim can push the member's OOP balance past 7000. That means for an OON claim, the applicable OOPM threshold is 14000 (the OON individual threshold), and it can push the balance past 7000. Similarly family balance can go past 14000 due to OON claims.

But then, once a member's balance is above 7000, would a subsequent in-network claim be paid 100%? "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Which OOPM? I think for in-network claims, the in-network OOPM (7000 individual / 14000 family) applies; for OON claims, the OON individual OOPM (14000) applies, and family amounts don't limit OON claims.

So the reading: 
- In-network claim cost share capped by: individual in-network OOPM remainder (7000 - member oop) and family in-network OOPM remainder (14000 - family oop).
- OON claim cost share capped by: individual OON OOPM remainder (14000 - member oop). Family does not limit OON claims.

That's consistent with the addendum: "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."

Hmm, but there's an ambiguity: for an in-network claim, if the member's oop balance is already above 7000 (because OON claims pushed it there), then the in-network individual remainder is negative/zero → plan pays 100%. I think that's right: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." So if balance ≥ 7000, in-network claims are free. And if balance ≥ 14000, OON claims are free too.

But also, is the individual in-network OOPM the cap for in-network claims even under an aggregate deductible plan? Yes — OOPM section lists individual and family amounts; nothing says aggregate. And the ground rule about embedded vs aggregate was in the "deductible" definition context... Actually the glossary defines OOPM as "the ceiling on member cost share for the plan year." The plan lists individual OOPMs. I'll go with: individual in-network OOPM 7000 caps each member's in-network cost share; family 14000 caps family total in-network cost share; OON claims capped only by individual OON 14000.

Wait, but actually, should the family OOPM of 14000 cap in-network member cost share cumulatively? Once family oop reaches 14000, in-network claims for anyone are paid 100%. Let me just compute and see if it's reached.

Let me now recompute Line 4 with the cap.

Line 4 — A, in-network, allowed 17679.63. Deductible met (family). Coinsurance 10% = 1767.96. Caps: A individual in-network OOPM remainder = 7000 - 6047.43 = 952.57. Family remainder = 14000 - 9038.82 = 4961.18. Member resp = min(1767.96, 952.57, 4961.18) = 952.57. Plan paid = 17679.63 - 952.57 = 16727.06.

A oop: 6047.43 + 952.57 = 7000.00. Family oop: 9038.82 + 952.57 = 9991.39.

Line 5 — Claim 5 — C, annual wellness visit, OUT-OF-NETWORK, allowed 771.12.
Per the family rules: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." So this is not free; it's subject to OON deductible and 40% coinsurance.

C's single deductible balance: 1382.40. OON individual threshold: 6400. Remainder = 6400 - 1382.40 = 5017.60. deductible_applied = min(771.12, 5017.60) = 771.12. Coinsurance = 0 (fully absorbed by deductible). Member resp = 771.12. Plan paid = 0.

OOPM check for OON claim: C's OON OOPM remainder = 14000 - 1991.39 = 12008.61 > 771.12. Fine. (Family doesn't limit OON.)

Update: C ded: 1382.40 + 771.12 = 2153.52. C oop: 1991.39 + 771.12 = 2762.51. Family ded: 6400.00 + 771.12 = 7171.12. Family oop: 9991.39 + 771.12 = 10762.51.

Hmm wait — family deductible was at 6400 (met). OON credits still accumulate to family balance, so family ded = 7171.12. That's fine per "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

Line 6 — Claim 6 — A, inpatient admission, OUT-OF-NETWORK, allowed 25351.30. (Later adjusted to 36759.38 at Line 16; but first adjudicate as of Line 6.)

A's single deductible balance: 5017.60. OON threshold 6400. Remainder = 6400 - 5017.60 = 1382.40. deductible_applied = min(25351.30, 1382.40) = 1382.40. Remaining allowed: 25351.30 - 1382.40 = 23968.90. Coinsurance 40% = 9587.56. Member resp = 1382.40 + 9587.56 = 10969.96. Plan paid = 23968.90 - 9587.56 = 14381.34. Check sum: 10969.96 + 14381.34 = 25351.30 ✓.

OOPM check (OON): A's OON OOPM remainder = 14000 - 7000.00 = 7000.00. Member resp 10969.96 > 7000. So cap: member resp = 7000.00? Hmm. A's oop balance is 7000.00 (in-network OOPM reached). For an OON claim, the applicable ceiling is the OON individual OOPM 14000, remainder 7000. So member resp capped at 7000.00. Plan paid = 25351.30 - 7000.00 = 18351.30.

Hmm, wait. Let me reconsider. Is the cap applied as "member resp = min(uncapped resp, OON OOPM remainder)"? Yes, that's how OOPM works: the member pays until their balance hits the OOPM, then plan pays 100%.

So member resp for Claim 6 = 7000.00, plan paid = 18351.30. Deductible_applied: how does the OOPM cap interact with deductible credit? The member still paid 7000.00. Does all of that credit the deductible? The deductible remainder was 1382.40, so deductible_applied = 1382.40 (the amount credited to the deductible). The rest, 5617.60, is coinsurance (or rather, excess). Hmm, but coinsurance component would be 7000 - 1382.40 = 5617.60.

Wait, but there's a subtlety: when the OOPM cap truncates cost share, how much counts as deductible credit? The deductible_applied should still be the amount applied to the deductible, which is min(allowed, deductible remainder) = 1382.40. The member responsibility is capped at 7000, so the coinsurance portion = 7000 - 1382.40 = 5617.60. That seems right: the deductible was satisfied (A's single balance goes to 6400, meeting the OON threshold), and the rest of what the member paid is coinsurance (capped).

Update: A ded: 5017.60 + 1382.40 = 6400.00. A oop: 7000.00 + 7000.00 = 14000.00. Family ded: 7171.12 + 1382.40 = 8553.52. Family oop: 10762.51 + 7000.00 = 17762.51.

Hmm, family oop now 17762.51, which is above the family in-network OOPM of 14000. Per the addendum, family balances are not capped at in-network amounts because OON claims can push them past. OK.

But now — subsequent in-network claims: family oop balance is 17762.51 > 14000. Does that mean in-network claims for anyone are now paid 100% (family OOPM reached)? And A's oop is 14000 > 7000, so A's in-network claims are 100% covered. For B and C, their individual in-network OOPM (7000) hasn't been reached, but the family in-network OOPM (14000) — has it been "reached"? The family balance is 17762.51, which exceeds 14000. Hmm, but the addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts". This suggests the family balance exceeding 14000 due to OON claims does NOT trigger the in-network family OOPM? Or does it?

Hmm, this is genuinely ambiguous. Let me think about the intent of the addendum. The addendum says: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

I read this as: the balances (running totals) are not artificially capped at 7000/14000 — they keep accumulating. It doesn't directly say whether crossing the in-network threshold via OON claims triggers 100% payment for in-network claims.

But logically, per the plan document: "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." If the member's OOP balance is 14000, they have certainly reached the in-network individual OOPM of 7000 (and the OON one of 14000). So in-network claims would be paid 100%. For family: if family balance ≥ 14000, the family OOPM is reached, so... in-network claims for all members paid 100%?

Hmm wait, but actually, let me reconsider. Maybe the intended design is simpler: the OOPM check for in-network claims uses the in-network thresholds (7000 individual, 14000 family) against the running balances (which include OON credits). Since the balances include all credits, once the balance exceeds the threshold, the OOPM is "reached".

Actually, let me reconsider whether the intended reading is that separate balances are tracked... No — the addendum explicitly says the balances are single running totals not capped at in-network amounts. And "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." For OOP: "A balance is the running total ... of member_responsibility (for an out-of-pocket balance)."

So the member OOP balance is a single number. For an in-network claim, the applicable OOPM ceiling is 7000 (individual) — if balance ≥ 7000, plan pays 100%. For an OON claim, ceiling 14000 — if balance ≥ 14000, plan pays 100%.

For family: family OOP balance is a single number. For in-network claims, ceiling 14000. Family balance is 17762.51 > 14000. So family OOPM reached → in-network claims for any member paid 100%?? 

Hmm, that would make Lines 7, 8, 10, etc. free for C. And B's claims (13, 17, 19) free. And Line 12 (A) free. And Claim 15 (C) free — but we need Claim 15's components!

Hmm, wait. But hold on. Let me reconsider. Is that the intended design? The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." This sentence exists precisely to tell us that OON claims push family balance past 14000 and that's OK. If the intent were that crossing 14000 via OON claims triggers free in-network care for the whole family, that would be a big deal and probably not intended.

Let me carefully work through this ledger.

Plan: Pecos Select 2500
- Individual in-network deductible: 2500.00
- Family in-network deductible: 5000.00
- Structure: EMBEDDED — 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.
- OON individual deductible: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold that balance is measured against: 2500 in-network, 5000 out-of-network.
- OOPM: individual in-network 5500, family in-network 11000, individual out-of-network 11000.
- Coinsurance: IN 30% member / 70% plan; OON 50%/50%.
- Copays: PCP 25, specialist 50, urgent care 60, ER 300 (waived if admitted → subject to deductible and coinsurance), generic retail pharmacy 10.
- Copays DO credit the deductible. Copays always credit the OOPM.
- Preventive care in-network: paid 100%, no cost share, no accumulator movement.

Accumulators addendum:
- deductible_applied = LESSER of allowed amount and room left under the deductible threshold that applies:
  - in-network: smaller of member's individual remainder and family remainder (embedded)
  - out-of-network: OON individual remainder measured against member's same single deductible balance.
- Once threshold met, deductible_applied = 0.00, including for a copay that would otherwise credit the deductible.
- Balance = running total of deductible_applied (deductible) or member_responsibility (OOP).
- OON claims measured against OON individual thresholds only; family amounts don't limit OON claims. Credits still accumulate to member balance and family balance.
- OOPM: individual in-network 5500, family in-network 11000, individual out-of-network 11000.

Wait, there's a subtlety with the OOPM. The plan says "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." There are separate in-network and out-of-network OOPM thresholds, but the addendum says "A balance is the running total of ... member_responsibility (for an out-of-pocket balance)." It doesn't explicitly say there's a single OOP balance measured against different thresholds, but by analogy with the deductible ("In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."), it seems the same structure applies to the OOPM: single member OOP balance, measured against 5500 for in-network claims and 11000 for OON claims. Similarly family OOP balance measured against 11000 (family in-network) — for in-network claims. Hmm, the OOPM section says "Individual (in-network) 5500, Family (in-network) 11000, Individual (out-of-network) 11000". There's no family OON OOPM. The deductible addendum explicitly covers OON claims being measured against individual OON thresholds only. For the OOPM, I think we should treat analogously: an OON claim is measured against the member's OON individual OOPM (11000); in-network claims measured against min(member's IN individual OOPM remainder, family OOPM remainder). The addendum for OON says "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."

Actually, that sentence appears in the ACCUMULATORS addendum generally: "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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This is in the context of deductibles but says "thresholds" and "balances" — I'll apply it to both deductible and OOPM balances, since OOPM is described as a balance/threshold too.

Hmm, but actually let me think. The OOPM addendum statement: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This confirms: single balance per member, single family balance; OON thresholds are higher; balances not capped at IN amounts. So for OOPM: member's OOP balance accumulates all member responsibility; when adjudicating an IN claim, cost share is capped so the member's OOP balance doesn't exceed... hmm, wait. Actually the OOPM works differently from the deductible. The OOPM caps the member's total cost share: once the member's OOP balance reaches the OOPM, the plan pays 100%. So for a claim, the member responsibility is limited by the remaining room under the applicable OOPM.

Let me think about how the OOPM applies per claim: member_responsibility = deductible_applied + copay + coinsurance. If the member's OOP balance + this claim's member responsibility would exceed the OOPM threshold (the applicable one for this claim's network), then the member responsibility is capped at the room remaining under that threshold, and the plan pays the rest.

For in-network claims: applicable OOPM threshold = min(member's IN individual OOPM remainder, family OOPM remainder)? Hmm. Embedded OOPM... The plan says OOPM individual in-network 5500, family in-network 11000. It's a family plan, so presumably the family OOPM works like an embedded structure similar to deductible: a member's cost share is capped at the lesser of their individual OOPM remainder and the family OOPM remainder.

For OON claims: threshold = individual OON OOPM 11000 only (family amounts don't limit OON claims).

OK, let me now process the ledger line by line. I need to be extremely careful.

Initial accumulators (before Line 1):
- A: ded 0.00, oop 0.00
- B: ded 0.00, oop 0.00
- C: ded 1744.67, oop 1900.68
- D: ded 1150.72, oop 1150.72
- Family: ded 2895.39, oop 3051.40

Check family totals: 0+0+1744.67+1150.72 = 2895.39 ✓. OOP: 0+0+1900.68+1150.72 = 3051.40 ✓.

Thresholds:
- Deductible: individual IN 2500, family IN 5000, individual OON 5000.
- OOPM: individual IN 5500, family IN 11000, individual OON 11000.

Line 1 — Claim 1 — D — ED visit, in-network, treated and released. Allowed 3295.94.
ER copay 300 (not admitted, so copay applies). ED visit treated and released: $300 copay. But wait — how does an ER copay interact with the deductible? The plan says copays DO credit the deductible. And the accumulators addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

Hmm, so for a claim with a copay, what is deductible_applied? Is it the copay amount (credited to the deductible), or the allowed amount? Let me think. "Copays DO credit the deductible." So the copay counts toward the deductible. But the addendum says deductible_applied = lesser of allowed amount and room left. Hmm, that would mean for a copay claim, the deductible credit is the copay amount (the member's payment), not the whole allowed amount. But the addendum says "LESSER of its allowed amount and the room left". Hmm.

Wait, let me re-read: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... the smaller of the member's individual remainder and the family remainder (embedded)...; out-of-network ... the out-of-network individual remainder... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

Hmm, "including for a copay that would otherwise credit the deductible" — this suggests copays do generate deductible_applied. But how much? If deductible_applied = lesser of allowed amount and room left, then for an ER visit with a $300 copay and allowed 3295.94, deductible_applied would be the full room left under the deductible... That seems odd but might be the intended mechanic: the deductible_applied is based on allowed amount regardless of cost-share structure, and then the member responsibility = deductible_applied + coinsurance on the remainder + copay?

Hmm wait, but then member responsibility could exceed the allowed amount. Let's compute: D's deductible IN: individual remainder = 2500 - 1150.72 = 1349.28. Family remainder = 5000 - 2895.39 = 2104.61. Smaller = 1349.28. Allowed = 3295.94. deductible_applied = 1349.28. Coinsurance = 30% × (3295.94 - 1349.28) = 30% × 1946.66 = 583.998 → 584.00. Plus copay 300? That would make member responsibility = 1349.28 + 584.00 + 300 = 2233.28. Hmm, that's less than allowed 3295.94 (plan paid would be 1062.66). But is the ER copay in addition to deductible/coinsurance? Typically, an ER copay replaces the deductible/coinsurance, or is applied like: member pays copay, and the rest is... Hmm.

The plan document says: "Emergency room ... 300.00 copay, WAIVED if the visit results in an inpatient admission, in which case the visit is subject to the deductible and coinsurance." So the ER copay applies when treated and released; when admitted, the copay is waived and the visit is subject to deductible and coinsurance. So for a treated-and-released ED visit, member pays $300 copay, and the plan pays the rest of allowed? But then what about "Copays DO credit the deductible" — the $300 copay credits the deductible.

But then the addendum's rule "deductible_applied is the LESSER of its allowed amount and the room left" conflicts with a copay-only structure. Unless for copay claims, deductible_applied is the copay amount (the "amount that credits the deductible"), and the "allowed amount" language is for deductible/coinsurance claims. Hmm.

Let me re-read again: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". Hmm, but for a copay claim, the member pays the copay; the copay credits the deductible. If deductible_applied were the lesser of allowed and room, then the member would pay the deductible_applied (as deductible) — but the member only paid a copay. That doesn't work for the requirement "member_responsibility plus plan_paid equals the allowed amount" — well, it still works, but member responsibility would include a "deductible" component the member didn't pay under a copay structure.

Hmm, wait. Let me think about how these harness problems usually structure it. There are separate keys: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount. So member_responsibility = deductible_applied + copay_amount + coinsurance_amount presumably. And plan_paid = allowed - member_responsibility.

For a copay claim (e.g., urgent care): allowed 182.07, copay 60. What's deductible_applied? If the rule is "lesser of allowed amount and room left", then for urgent care: D's remainder at line 2... this would make the member pay deductible + copay + coinsurance, which is weird for a flat-copay service. Typically urgent care = $60 copay, no deductible/coinsurance. But this plan has "Copays DO credit the deductible", which is unusual (most plans copays don't credit the deductible; here they do).

So the intended mechanic might be: for a copay claim, member pays copay; the copay credits the deductible (deductible_applied = copay amount, if room remains); coinsurance = 0; plan pays allowed - copay. That makes "Copays DO credit the deductible" meaningful. And the addendum "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible" — i.e., a copay claim still has its copay, but if the deductible is already met, deductible_applied = 0.00 (the copay doesn't credit the deductible since it's full, but the copay still counts toward OOPM).

That reading makes sense: deductible_applied for a copay claim = the copay amount (limited by room left under the threshold). The "LESSER of its allowed amount and the room left" clause then applies to non-copay claims (deductible/coinsurance claims). Hmm, but the copay amount is never more than the allowed amount anyway... Actually wait, could the copay exceed the allowed amount? Urgent care allowed 175.00, copay 60 — no. ER allowed 2801.55, copay 300 — no. So "lesser of allowed and room" for a copay claim: if we interpret "the amount subject to deductible" as the copay, then deductible_applied = min(copay, room). Hmm.

Alternatively, maybe the intended mechanic is that ALL claims are subject to deductible + coinsurance, and copays are... no, that can't be, because the copay is a flat per-service member amount.

Let me think about "Member cost share" section: "Coinsurance after deductible, in-network 30% member / 70% plan; ... Primary care office visit 25.00 copay; Specialist office visit 50.00 copay; Urgent care 60.00 copay; Emergency room 300.00 copay, WAIVED if ... admitted ...; Generic retail pharmacy 10.00 copay. Copays DO credit the deductible. Copays always credit the out-of-pocket maximum."

So the structure: certain service types have copays instead of deductible/coinsurance. The copay is the member's cost share for that service. The copay credits the deductible and the OOPM.

So for a copay claim:
- copay_amount = the copay (e.g., 60 for urgent care)
- deductible_applied = min(copay, room under applicable threshold) — the copay credits the deductible
- coinsurance_amount = 0
- member_responsibility = copay
- plan_paid = allowed - copay

And per the addendum: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." So if the deductible is met, the copay still applies (member pays it), but deductible_applied = 0.00.

Hmm wait, but actually there's another possibility: the copay claim is also subject to deductible and coinsurance beyond the copay. Some plans have "copay after deductible". But the plain reading of "Urgent care 60.00 copay" is a flat copay with no deductible. And the OOPM addendum says "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold" — hmm, this is the sticking point. Let me consider: maybe for copay claims, since the member's payment is the copay, the deductible credit is the copay. The "allowed amount" in that sentence is for claims whose cost share is deductible/coinsurance-based.

Actually, hold on. Let me reconsider. Maybe the intended mechanic for ALL claims (including copay claims) is: deductible_applied = min(allowed, room). Then coinsurance = 30% of (allowed - deductible_applied). Then member_responsibility = deductible_applied + coinsurance + copay. This would make "Copays DO credit the deductible" redundant/wrong. And "WAIVED if the visit results in an inpatient admission, in which case the visit is subject to the deductible and coinsurance" — this implies that when NOT admitted, the visit is NOT subject to deductible and coinsurance; it's subject only to the copay. That's strong evidence: the ER copay case is copay-only; the admitted case is deductible+coinsurance (no copay). So for copay claims, cost share = copay only.

Therefore for copay claims: deductible_applied = min(copay, room under applicable threshold); coinsurance = 0; member_responsibility = copay (capped by OOPM room, presumably); plan_paid = allowed - member_responsibility.

Now the "LESSER of its allowed amount and the room left" — for copay claims, hmm. The copay is part of the allowed amount... I think the cleanest consistent interpretation:

- For a deductible/coinsurance claim: deductible_applied = min(allowed, room). coinsurance = member% × (allowed - deductible_applied). member_resp = deductible_applied + coinsurance.
- For a copay claim: member_resp = copay. deductible_applied = min(copay, room) (the copay credits the deductible; if no room, 0). coinsurance = 0.

The addendum's sentence "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible" supports this: a copay "would otherwise credit the deductible" — i.e., copays credit the deductible up to the room; once met, 0.00.

OK so with that interpretation, let's also handle: what about a copay claim where the copay exceeds the room left? Then deductible_applied = room left, and the rest of the copay... doesn't credit the deductible but still is member responsibility and credits OOPM. Fine.

Also, OOPM capping: once the member's OOP balance reaches the applicable OOPM threshold, the plan pays 100%. For a claim, member_resp is capped at the room under the applicable OOPM threshold. Let's keep track.

Also note: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." Not relevant here (Claim 24 is a screening colonoscopy in-network — preventive, no polyp removed, in-network → 100% paid, no cost share, no accumulator movement).

Let me now process.

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

Line 1 — Claim 1 — D — ED visit, IN, treated and released. Allowed 3295.94.
ER copay 300 (not admitted). 
Deductible room for D (in-network): individual remainder = 2500 - 1150.72 = 1349.28; family remainder = 5000 - 2895.39 = 2104.61. min = 1349.28.
deductible_applied = min(copay 300, room 1349.28) = 300.00.
coinsurance = 0.
member_resp = 300.00.
plan_paid = 3295.94 - 300 = 2995.94.
OOPM check: D's OOP = 1150.72; applicable threshold for IN claim: min(individual IN OOPM remainder = 5500 - 1150.72 = 4349.28, family OOPM remainder = 11000 - 3051.40 = 7948.60) → room = 4349.28. 300 < room, fine.

Update:
- D: ded 1150.72 + 300 = 1450.72; oop 1150.72 + 300 = 1450.72.
- Family: ded 2895.39 + 300 = 3195.39; oop 3051.40 + 300 = 3351.40.

Line 2 — Claim 2 — D — Urgent care, IN. Allowed 182.07. Copay 60.
D deductible room: individual remainder = 2500 - 1450.72 = 1049.28; family remainder = 5000 - 3195.39 = 1804.61. min = 1049.28.
deductible_applied = min(60, 1049.28) = 60.00.
member_resp = 60.00. plan_paid = 182.07 - 60 = 122.07.
Update:
- D: ded 1450.72 + 60 = 1510.72; oop 1450.72 + 60 = 1510.72.
- Family: ded 3195.39 + 60 = 3255.39; oop 3351.40 + 60 = 3411.40.

Line 3 — Claim 3 — A — Inpatient admission with surgery, OON. Allowed 25881.03.
OON: deductible threshold = OON individual 5000, measured against A's single deductible balance (0.00). Remainder = 5000 - 0 = 5000. deductible_applied = min(25881.03, 5000) = 5000.00.
Coinsurance OON = 50% × (25881.03 - 5000) = 50% × 20881.03 = 10440.515 → 10440.52 (round half up at end; 10440.515 → 10440.52). Hmm, careful: 20881.03 × 0.5 = 10440.515. Round half up → 10440.52.

Wait, but OOPM: A's OOP = 0. OON individual OOPM = 11000. Room = 11000. Member_resp would be 5000 + 10440.52 = 15440.52 > 11000. So capped at OOPM? The plan says once member reaches OOPM, plan pays 100%. So member_resp = min(15440.52, room under OOPM). Room = 11000 - 0 = 11000. But wait — do we also consider family OOPM for OON? No — "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts... do not limit an out-of-network claim."

So member_resp = 11000.00. Plan_paid = 25881.03 - 11000 = 14881.03.

Now, how do the components break down? deductible_applied = 5000.00, coinsurance_amount = 10440.52, but member_resp capped at 11000. So the member pays 5000 deductible + 6000 of coinsurance (capped). Coinsurance_amount on the books = 11000 - 5000 = 6000.00. Plan e

Let me work through this carefully.

Plan: Bluebonnet PPO 1500.
- In-network individual deductible: 1500.00; family: 3000.00; embedded.
- Out-of-network individual deductible: 3000.00. In- and out-of-network deductible credits accumulate to a SINGLE member deductible balance; the threshold measured against for OON is 3000.00.
- OOPM: individual in-network 6000.00; family in-network 12000.00; individual out-of-network 12000.00.
- Coinsurance: 20% member in-network after deductible; 40% member OON after deductible.
- Copays: PCP 30, specialist 60, urgent care 75, ER 400 (waived if admitted → then deductible + coinsurance), generic pharmacy 15.
- Copays do NOT credit deductible; copays always credit OOPM.
- Preventive in-network: 100% allowed, no cost share, no accumulator movement.
- Member cost share from allowed amount.
- Deductible applied = lesser of allowed amount and room left under applicable deductible threshold. In-network: smaller of member's individual remainder and family remainder (embedded). OON: the OON individual remainder measured against the member's single balance.
- OON claims measured against OON individual thresholds only; family amounts do not limit an OON claim. Credits still accumulate to member and family balances. Balances not capped at in-network amounts.
- OOPM: once a member reaches OOPM the plan pays 100% of allowed for covered services for remainder of year. Family OOPM: 12000 in-network... Hmm, what about family OOPM for OON? The plan lists family in-network OOPM 12000 and individual OON 12000. The addendum says OON claims are measured against OON individual thresholds only; family amounts don't limit an OON claim. For OOPM, presumably similar: the member's OOPM is 12000 for OON? Actually "Individual (out-of-network) 12000.00". And family OOPM in-network 12000. Hmm, family in-network OOPM is also 12000. So the family OOPM is 12000.

Wait, but the addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts" — for deductibles. For OOPM, the rule is once a member reaches OOPM, plan pays 100%. Family OOPM: once family OOPM reached, plan pays 100% for everyone? The plan doc says "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." It mentions member only, but there is a family OOPM listed. Typically once family OOPM is reached, all members are protected. Hmm, but the plan text only says "a member reaches the OOPM". Let me consider: with family OOPM 12000, once family total reaches 12000, presumably the plan pays 100% for all family members. I need to decide.

Actually, let me just carefully compute and see whether these thresholds matter.

Initial accumulators (before Line 1):
- A: ded 0.00, oop 0.00
- B: ded 710.81, oop 710.81
- C: ded 331.32, oop 331.32
- D: ded 0.00, oop 0.00
- Family: ded 1042.13, oop 1042.13

Family deductible threshold in-network: 3000.00. Family remainder: 3000 - 1042.13 = 1957.87.

Embedded: in-network claims apply lesser of member individual remainder and family remainder.

A's individual remainder: 1500 - 0 = 1500.
B's: 1500 - 710.81 = 789.19.
C's: 1500 - 331.32 = 1168.68.
D's: 1500.

Let me process each line.

Line 1 — Claim 1 — A — ED visit in-network, admitted → ER copay waived; subject to deductible and coinsurance. Allowed 1970.69.
A in-network: deductible_applied = min(1970.69, A indiv remainder 1500, family remainder 1957.87) = min(1970.69, 1500) = 1500.00.
Remaining after deductible: 1970.69 - 1500.00 = 470.69. Coinsurance 20% = 94.138 → 94.14 (round half up at end; let's keep precision: 94.138).
Member responsibility = 1500.00 + 94.138 = 1594.138 → 1594.14.
Plan paid = 1970.69 - 1594.138 = 376.552 → 376.55. Let's compute: 1970.69 - 1594.14 = 376.55. Good.
A ded becomes 1500.00 (individual met). Family ded: 1042.13 + 1500.00 = 2542.13.
A oop: 0 + 1594.138 = 1594.138 → 1594.14. Family oop: 1042.13 + 1594.138 = 2636.268 → 2636.27.

Hmm, rounding: I'll keep track with full precision and round at the end. But accumulators... The rule says round half up to the cent at the end of a calculation, not at each intermediate step. For accumulators, it's a running total; I think we should keep cents at each step since money is in cents. Let me compute each line's member responsibility rounded to cents, then add to accumulators (that's standard claims processing). The instruction "round half up to the cent at the end of a calculation, not at each intermediate step" — each claim's adjudication is a calculation; accumulators are sums of claim amounts. I'll round each claim's components to cents, and add those to accumulators. That seems most defensible and matches typical adjudication.

Actually, let me think about the family OOPM question later; first compute.

Line 2 — Claim 2 — C — outpatient endoscopy in-network, allowed 654.68. Not preventive (endoscopy). Subject to deductible and coinsurance.
C indiv remainder: 1500 - 331.32 = 1168.68. Family remainder: 3000 - 2542.13 = 457.87.
deductible_applied = min(654.68, 1168.68, 457.87) = 457.87.
Wait — embedded: the member satisfies individual deductible on their own; the family deductible is also satisfied once total family credits reach family amount. So in-network deductible applied is smaller of individual remainder and family remainder: 457.87.
After deductible: 654.68 - 457.87 = 196.81. Coinsurance 20% = 39.362 → 39.36.
Member resp = 457.87 + 39.36 = 497.23. Plan paid = 654.68 - 497.23 = 157.45.
C ded: 331.32 + 457.87 = 789.19. Family ded: 2542.13 + 457.87 = 3000.00 → family deductible met!
C oop: 331.32 + 497.23 = 828.55. Family oop: 2636.27 + 497.23 = 3133.50.

Hmm wait, family deductible is now met at 3000.00. But under embedded structure, the individual deductibles still apply for members who haven't met their individual 1500. Since family is met, subsequent in-network claims for any member: the smaller of individual remainder and family remainder. Family remainder is 0, so deductible_applied = 0? Wait no — under embedded, once the family deductible is satisfied, no further deductible applies for anyone (the smaller of the two remainders; family remainder = 0 → deductible applied 0). Yes: "A member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Once family remainder is 0, deductible is satisfied for all members. So after Line 2, family ded met → all in-network claims go straight to coinsurance for the deductible part.

But wait — does family deductible being met also mean members' individual deductibles are considered satisfied? Under embedded, yes, effectively: the deductible applied is min(indiv remainder, family remainder) = 0. So all members' in-network deductible is effectively met.

But careful: the OON deductible threshold is 3000 individual measured against the member's single balance. The family amounts "do not limit an out-of-network claim". So for OON claims, deductible applied = min(allowed, OON individual remainder) where OON remainder = 3000 - member's current ded balance. Family met doesn't matter for OON.

Hmm, but what if a member's balance is already ≥ 3000? Then OON deductible is met.

Line 3 — Claim 3 — C — routine immunisation in-network — preventive. Paid 100%, no cost share, no accumulator movement. Member resp 0, plan paid 733.65. No accumulator change.

Line 4 — Claim 4 — C — screening mammography in-network — preventive (screening mammography is preventive). Paid 100%, no accumulator movement. Member resp 0, plan 338.32. (This will be voided later; void removes credits — but it generated no credits anyway.)

Note: "Routine immunisation" and "screening mammography" are preventive services. In-network → no cost share, no accumulator movement.

Line 5 — Claim 5 — B — cardiac stress test in-network, allowed 2159.40. Not preventive. Family deductible already met (3000.00). So in-network deductible applied = min(indiv remainder 789.19, family remainder 0) = 0. So deductible_applied = 0.
Coinsurance 20% of 2159.40 = 431.88.
Member resp = 431.88. Plan paid = 1727.52.
B ded stays 710.81. B oop: 710.81 + 431.88 = 1142.69. Family oop: 3133.50 + 431.88 = 3565.38.

Wait — but B hasn't met their individual deductible of 1500. Under embedded with family met, deductible_applied = min(789.19, 0) = 0. Yes, per the addendum: "in-network: the smaller of the member's individual remainder and the family remainder (embedded)". Family remainder is 0 → 0. So deductible no longer applies. Correct.

Line 6 — Claim 6 — A — inpatient admission with surgery, in-network, allowed 11020.18. Deductible applied 0 (family met). Coinsurance 20% = 2204.036 → 2204.04.
Member resp = 2204.04. Plan = 11020.18 - 2204.04 = 8816.14.
A oop: 1594.14 + 2204.04 = 3798.18. Family oop: 3565.38 + 2204.04 = 5769.42.
A ded stays 1500.00.

Check A's OOPM: individual in-network OOPM 6000. A at 3798.18 — not yet.

Line 7 — Claim 7 — A — diagnostic laboratory panel in-network, allowed 1959.89. Deductible applied 0. Coinsurance 20% = 391.978 → 391.98.
Member resp = 391.98. Plan = 1959.89 - 391.98 = 1567.91.
A oop: 3798.18 + 391.98 = 4190.16. Family oop: 5769.42 + 391.98 = 6161.40.

Note: This claim is later adjusted (Line 22): allowed corrected to 2547.86. So the final components on the books for Claim 7 are from the adjustment. We'll compute at Line 22. But we must process in order, and the original adjudication affects accumulators until the adjustment unwinds it.

Line 8 — Claim 8 — B — inpatient admission in-network, allowed 24984.17. Deductible applied 0. Coinsurance 20% = 4996.834 → 4996.83.
Member resp = 4996.83. Plan = 24984.17 - 4996.83 = 19987.34.
B oop: 1142.69 + 4996.83 = 6139.52. That exceeds B's individual OOPM of 6000! So B reaches OOPM during this claim. Once reached, plan pays 100% for remainder. The member responsibility is capped at OOPM.

How to handle: B's oop before claim: 1142.69. OOPM individual in-network: 6000. Room: 6000 - 1142.69 = 4857.31. So member resp for Claim 8 = 4857.31 (capped), plan = 24984.17 - 4857.31 = 20126.86.
B oop becomes 6000.00 → B has reached OOPM. Family oop: 6161.40 + 4857.31 = 11018.71.

Wait — need to also check family OOPM: 12000. Family at 11018.71 — not yet.

Hmm, but wait: does the family OOPM matter here? Family oop 12000. After B's claim: 11018.71. Not reached. OK.

Line 9 — VOID of Claim 4 — C. Claim 4 was preventive: no cost share, no credits. Void removes nothing. C's accumulators unchanged. Family unchanged.

Line 10 — Claim 10 — D — inpatient admission with surgery, in-network, allowed 12032.63. Deductible: family met → applied 0. Coinsurance 20% = 2406.526 → 2406.53.
Member resp = 2406.53. Plan = 12032.63 - 2406.53 = 9626.10.
D oop: 0 + 2406.53 = 2406.53. Family oop: 11018.71 + 2406.53 = 13425.24.

Family OOPM is 12000 (in-network). Family oop now 13425.24 > 12000. Hmm! Did the family OOPM get reached during this claim? Before claim 10: family oop 11018.71. Room to family OOPM: 12000 - 11018.71 = 981.29. If family OOPM caps cost share, D's member resp would be 981.29, plan pays the rest, and then all family members have 100% coverage for the rest of the year (like standard family OOPM).

But the plan document says: "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." It says "a member". But the OOPM section lists family OOPM 12000. Typically, family OOPM means once the family accumulates 12000 in cost share, no more cost share for anyone.

Hmm, this is a crucial decision. The addendum says for deductibles: "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." And "the balances are not capped at the in-network amounts" — for deductible balances.

For OOPM: individual in-network 6000, family in-network 12000, individual OON 12000. Hmm, the plan lists no family OON OOPM.

The question: does the family OOPM of 12000 cap member cost share across the family?

Let me think about what the harness intends. The plan document: "Out-of-pocket maximum — Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. 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."

The glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."

"Once reached" — by whom? The family OOPM is a family-level ceiling. I think the intended reading: family OOPM 12000 is a ceiling on total family cost share; once family accumulates 12000, plan pays 100% for covered services for all members. This is standard embedded OOPM.

But then the interesting wrinkle: OON claims are "measured against the out-of-network individual thresholds only; the family amounts... do not limit an out-of-network claim". This is stated in the ACCUMULATORS addendum about deductible balances: "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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

That paragraph is in the ACCUMULATORS addendum, which is about deductible_applied and balances. It clarifies deductible logic. For OOPM, the analogous question: does the family OOPM (in-network 12000) limit an OON claim? And does the OON individual OOPM 12000 apply to OON claims?

Let me look at the plan doc OOPM section again: "Individual (in-network) 6000.00; Family (in-network) 12000.00; Individual (out-of-network) 12000.00." Then "Once a member reaches the out-of-pocket maximum the plan pays 100%..."

Given the addendum's treatment of deductibles (OON measured against OON individual thresholds only; family amounts don't limit OON claims), I suspect the harness intends a parallel structure for OOPM: in-network claims are capped by the smaller of the member's individual in-network OOPM remainder and family OOPM remainder? Hmm, but the addendum doesn't say that explicitly for OOPM. The addendum's ACCUMULATORS section is specifically about deductibles ("A claim's deductible_applied is...").

Hmm, let me think about this more carefully, because it drastically changes the answer. Let's consider both interpretations and see which produces a "cleaner" set of answers.

Interpretation 1 (family OOPM caps all cost share): Once family OOPM (12000) is reached, all cost share stops. Family reached 12000 during Line 10 (D's inpatient surgery): room 981.29, so D pays 981.29, plan pays 11051.34. Family oop = 12000. Then all subsequent claims (11-23) have zero member responsibility... except OON claims? Under interpretation 1, does family OOPM apply to OON claims too? The plan says family OOPM is in-network 12000. The addendum says family amounts don't limit OON claims (in the deductible context). If parallel for OOPM, OON claims would be measured against OON individual OOPM (12000) only. Members B, A, D have OOPM balances well below 12000.

Interpretation 2 (each member capped by own individual OOPM only; family OOPM applies to in-network claims as a family ceiling but... hmm).

Actually, let's re-read the glossary definition: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services. Premiums and non-covered services never count toward it."

And the plan document: "Out-of-pocket maximum — Individual (in-network) 6000.00, Family (in-network) 12000.00, Individual (out-of-network) 12000.00. 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."

Note the family OOPM is listed under a structure parallel to the deductible: individual and family amounts, embedded. The deductible section explicitly describes EMBEDDED structure. The OOPM section doesn't say embedded or aggregate, but lists family amounts.

Hmm. The task's whole point may be to test the family OOPM logic. Let me think about which claims would be affected.

Under interpretation where family OOPM caps in-network cost share at 12000 total: Line 10 is where family crosses 12000. Before Line 10, family oop = 11018.71. So D's cost share for Claim 10 = 981.29 (capped). Family oop = 12000. Then for all subsequent in-network claims, member responsibility = 0 for everyone. OON claims: measured against OON individual OOPM 12000 — each member's oop balance is way below 12000, so OON cost share still applies... but wait, B's oop is 6000 (individual in-network OOPM met). Does meeting in-network OOPM stop OON cost share? The plan says once a member reaches the OOPM, plan pays 100% of allowed for covered services. Which OOPM? There are separate in-network and OON OOPMs. Standard ACA plans have a single combined OOPM. Here it's split. Hmm.

Actually wait. Let me reconsider. Maybe the harness intends a simpler model: the OOPM that applies to a claim is based on the network of that claim: in-network claims are capped by the in-network individual OOPM (6000) and family in-network OOPM (12000); OON claims are capped by the OON individual OOPM (12000). The addendum for deductibles says OON claims are measured against OON individual thresholds only, family amounts don't limit OON claims, but credits accumulate to family balances. Parallel for OOPM: OON claims are capped by the OON individual OOPM (12000) only; the family OOPM (in-network) doesn't limit OON claims; but the credits accumulate to family oop balance.

Under that model:
- In-network claims: member cost share capped so that member's oop ≤ 6000 (individual in-network OOPM) and family oop ≤ 12000 (family in-network OOPM)? Hmm, but is the family OOPM a cap on in-network claims? The plan says "Family (in-network) 12000.00". I think yes: in-network family OOPM caps total family in-network cost share at 12000.

Hmm wait, but there's a subtlety: the deductible balances combine in- and out-of-network credits into a single member balance, and OON claims are measured against OON thresholds. For OOPM, the plan lists in-network individual 6000, family 12000, OON individual 12000. There's a single "out-of-pocket" running total per member (and family). In-network claims are measured against... which threshold? The in-network individual 6000 and family 12000. OON claims measured against OON individual 12000 only.

Actually, hold on. Let me reconsider — maybe simpler: the harness intends the family OOPM to function like family deductible: in-network claims capped by min(member's individual in-network OOPM remainder, family OOPM remainder); OON claims capped by member's OON individual OOPM remainder only.

Let me now also reconsider: is the family OOPM even reached before the end? Let's compute under the "no family OOPM cap on... hmm.

Let me carefully compute both scenarios fully and see which gives cleaner numbers. Actually, the required outputs: Claim 7 (adjusted at Line 22), Claim 16 (D, OON sleep study), Claim 23 (C, PCP office visit), and ending accumulators.

Claim 23 is a PCP office visit: 30.00 copay, in-network. Copays credit OOPM but not deductible. If family OOPM is reached (interpretation 1), then... does the copay still apply? "Once reached, the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." If family OOPM reached, copay waived → member resp 0. If not reached, member resp = 30.00 copay.

Claim 16 is D's OON sleep study: subject to OON deductible (3000 individual measured against D's single deductible balance) and 40% coinsurance, capped by D's OON OOPM 12000. D's deductible balance: unde

Let me carefully work through this ledger.

Plan: Bluebonnet PPO 1500.
- Deductible: Individual in-network 1500.00; Family in-network 3000.00; EMBEDDED structure. Out-of-network individual 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance; the OON threshold (3000) applies when the service is OON.
- OOPM: Individual in-network 6000.00; Family in-network 12000.00; Individual OON 12000.00.
- Coinsurance after deductible: in-network 20% member; out-of-network 40% member.
- Copays: PCP 30, specialist 60, urgent care 75, ER 400 (waived if admitted), generic pharmacy 15.
- Copays do NOT credit deductible. Copays DO credit OOPM.
- Preventive in-network: no cost share, no accumulator movement. Out-of-network preventive: subject to OON deductible and coinsurance.

Accumulator rules:
- deductible_applied = LESSER of allowed amount and room left under the deductible threshold that applies:
  - in-network: smaller of member's individual remainder (1500 - member deductible balance) and family remainder (3000 - family deductible balance) (embedded).
  - out-of-network: OON individual remainder (3000 - member's same single deductible balance).
- Once threshold met, deductible_applied = 0.
- Deductible balance = running total of deductible_applied. OOP balance = running total of member_responsibility.
- OON claims measured against OON individual thresholds only; family amounts (in-network) do not limit an OON claim. Credits still accumulate to member and family balances.

Hmm, there's a subtlety: For OOPM, when does the OOPM stop cost share? "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." The OOPM individual in-network is 6000, OON individual is 12000. Family in-network OOPM is 12000. Hmm — how do we apply OOPM limits for a claim? Similar to deductible: for in-network claims, the smaller of the member's individual in-network OOPM remainder and family OOPM remainder? The accumulator section only spells out the deductible_applied logic in detail. For OOPM, presumably analogous: an in-network claim's member responsibility is capped so that the member's OOP balance doesn't exceed the applicable threshold(s): individual in-network 6000 and family 12000 (embedded? the plan doesn't say embedded for OOPM, but typically family OOPM with embedded individual). And for OON claims, the OON individual OOPM is 12000.

Hmm, but the plan document says "Out-of-pocket maximum: Individual (in-network) 6000.00; Family (in-network) 12000.00; Individual (out-of-network) 12000.00." The addendum says for deductibles, OON claims are measured against OON individual thresholds only; family amounts do not limit an OON claim. Presumably similar for OOPM: OON claims are measured against the OON individual OOPM (12000) only; family OOPM (12000, in-network) doesn't limit OON claims... though they're the same number here (12000). Family in-network OOPM is 12000 and individual OON is 12000. Hmm.

For in-network claims, is the family OOPM a cap on member responsibility? The plan structure for deductible is explicitly embedded. For OOPM, the plan doesn't state embedded vs aggregate. Hmm. Under the ACA, OOPM for family plans must be embedded. The deductible section says "Structure ... EMBEDDED". The OOPM section doesn't say. I think the intended interpretation: individual OOPM 6000 caps a member's in-network cost share; family 12000 caps the family total in-network cost share. Let's compute and see whether these matter.

Let me process the ledger line by line.

Start: all accumulators 0.

Family deductible remainder = 3000. Individual in-network deductible remainder = 1500 each.

Line 1 — Claim 1 — D — Outpatient procedure, in-network, allowed 9156.86.
Deductible_applied = min(allowed, min(individual remainder 1500, family remainder 3000)) = 1500.00.
Remaining after deductible: 9156.86 - 1500 = 7656.86. Coinsurance 20% = 1531.372 → 1531.37. Plan pays 80% = 6125.488 → 6125.49. Member responsibility = 1500 + 1531.37 = 3031.37. Check: 1500 + 1531.37 = 3031.37; plan 6125.49; total = 9156.86. ✓.

OOPM check: D's OOP balance before = 0. Individual in-network OOPM 6000. 3031.37 < 6000, fine. Family OOPM 12000 fine.

Update: D deductible = 1500.00; D OOP = 3031.37. Family deductible = 1500.00; family OOP = 3031.37.

Line 2 — Claim 2 — E — PCP office visit, in-network, allowed 205.32. Copay 30.00. Copays don't credit deductible. Member responsibility = 30.00, plan pays 175.32.

Update: E deductible = 0; E OOP = 30.00. Family deductible = 1500; family OOP = 3061.37.

Line 3 — Claim 3 — B — Outpatient imaging, in-network, allowed 1054.17.
Deductible_applied = min(1054.17, min(indiv remainder 1500, family remainder 3000-1500=1500)) = 1054.17. Full allowed to deductible. Coinsurance = 0. Member = 1054.17; plan = 0.
Update: B deductible = 1054.17; B OOP = 1054.17. Family deductible = 1500 + 1054.17 = 2554.17; family OOP = 3061.37 + 1054.17 = 4115.54.

Line 4 — Claim 4 — E — Inpatient admission with surgery, out-of-network, allowed 16325.03.
OON deductible: individual OON threshold 3000, measured against member's single deductible balance. E's deductible balance = 0. OON individual remainder = 3000 - 0 = 3000. Family remainder does not limit OON claims. Deductible_applied = min(16325.03, 3000) = 3000.00.
Remaining: 16325.03 - 3000 = 13325.03. Coinsurance 40% member = 5330.012 → 5330.01. Plan 60% = 7995.018 → 7995.02. Member = 3000 + 5330.01 = 8330.01. Check sum: 8330.01 + 7995.02 = 16325.03 ✓.

OOPM check: E OOP before = 30. OON individual OOPM = 12000. After this claim, E OOP = 30 + 8330.01 = 8360.01 < 12000, OK. Family OOP = 4115.54 + 8330.01 = 12445.55. Hmm, family OOPM is 12000 in-network. Does the family OOPM cap OON credits? The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." So family OOP balance can exceed 12000 due to OON claims. The family OOPM (in-network) applies to in-network claims. Let me hold that thought; we'll deal with it when in-network claims come.

Update: E deductible = 3000.00; E OOP = 8360.01. Family deductible = 2554.17 + 3000 = 5554.17. Family OOP = 4115.54 + 8330.01 = 12445.55.

Note: E's deductible balance (3000) now exceeds the in-network individual threshold (1500), so E's in-network claims are past deductible. Family deductible (5554.17) exceeds 3000, so family in-network deductible remainder is 0 → all in-network claims have deductible_applied = 0 (family remainder 0).

Line 5 — Claim 5 — E — Outpatient rehab, in-network, allowed 2923.30.
In-network: deductible_applied = min(2923.30, min(indiv remainder 1500-3000 → negative → 0, family remainder 3000-5554.17 → negative → 0)) = 0.
Coinsurance 20% member = 584.66. Plan = 2338.64. Member = 584.66.
OOPM: E OOP = 8360.01. Individual in-network OOPM 6000 — but E's balance is 8360.01 already (driven by OON). Hmm! The in-network individual OOPM is 6000. E's OOP balance is already 8360.01 > 6000. So for an in-network claim, has E reached the in-network OOPM?

This is the tricky part. The OOP balance is a single running total of member_responsibility (both in-network and OON credits). The thresholds: individual in-network 6000, individual OON 12000. The addendum says for deductibles: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." And "Out-of-network claims are measured against the out-of-network individual thresholds only."

So how do we measure whether the OOPM is reached for an in-network claim? I think the intended logic, mirroring the deductible logic: an in-network claim's member responsibility is capped by the smaller of the member's in-network individual OOPM remainder and the family OOPM remainder. But what is the member's "in-network individual OOPM remainder" when the balance includes OON credits? Hmm.

Let me think about the deductible analogy precisely, because the addendum spells that out:

"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network: the smaller of the member's individual remainder and the family remainder (embedded)...; out-of-network: the out-of-network individual remainder, measured against the member's same single deductible balance."

So for a deductible, the "member's individual remainder" for an in-network claim = 1500 - member's deductible balance (which includes OON credits). "Once the applicable threshold is met, deductible_applied is 0.00." So E's in-network deductible remainder = 1500 - 3000 < 0 → 0. E is past the in-network individual deductible even though all their credits came from an OON claim. That's how Line 5 works: deductible_applied = 0.

By analogy, for OOPM: an in-network claim's member responsibility would be capped so that... hmm, but the structure differs. For OOPM, cost share isn't "applied" like a deductible — the whole member responsibility counts toward OOPM. The cap works as: member responsibility cannot push the OOP balance past the applicable threshold. So for an in-network claim, the applicable threshold would be the smaller of (individual in-network OOPM 6000 - member OOP balance) and (family in-network OOPM 12000 - family OOP balance). If the remainder is ≤ 0, member responsibility = 0? That seems to be the implication: E's OOP balance is 8360.01 > 6000, so for in-network claims E pays nothing more? Hmm, but wait — is that right? E's OOP balance of 8360.01 came from an OON claim. Under a real plan, the in-network OOPM and OON OOPM are separate accumulators typically. But this synthetic plan says "Accumulator: the running year-to-date total" — a single OOP balance per member ("A balance is the running total ... of member_responsibility (for an out-of-pocket balance)").

Hmm, but the addendum says balances are not capped at the in-network amounts, and OON claims can carry a balance past the in-network individual amount. This strongly suggests the intended model: single OOP balance per member; thresholds are checked per claim based on network status. For an in-network claim, the thresholds are the in-network individual (6000) and family (12000); if the balance is already at/past those, the plan pays 100% for in-network claims.

But wait — that seems to create a weird situation where OON spending triggers 100% coverage for in-network services. But that's actually how some plans work when they have a single combined OOPM... Actually no. In real ACA plans, there's one OOPM per network tier. But this synthetic plan explicitly describes a single balance with different thresholds per network. The addendum's language: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This says OON claims CAN carry the balance past those amounts (i.e., we don't cap the balance at 6000 for OON claims). It doesn't explicitly say what happens to subsequent in-network claims when the balance exceeds 6000.

Hmm. Let me think about what interpretation the task designer intended. The parallel with the deductible is strong: for the deductible, E's OON claim (3000 deductible credit) puts E past the 1500 in-network individual deductible, so E's subsequent in-network claims have deductible_applied = 0 and go straight to coinsurance. The addendum explicitly describes this. For OOPM, the parallel would be: E's balance 8360.01 > 6000 in-network individual OOPM, so E's subsequent in-network claims have member responsibility 0 (plan pays 100%)?

Hmm, but wait. Let me re-read: "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." The question is which OOPM applies. Let me look at the family OOPM: 12000 in-network. Family OOP balance after Line 4 = 12445.55 > 12000. So under this interpretation, ALL family members' in-network claims after Line 4 would be paid 100%. That would make most of the rest of the ledger trivial (member responsibility 0), except OON claims measured against individual OON OOPM 12000.

Hmm, that seems like it might actually be the intended design! Let me check: this is a task family "PLAN-YEAR LEDGER" with lots of claims; if the OOPM interpretation zeroes out everything after Line 4, then the answers for claims 13, 20, 28 would be... let's see.

Wait, but let me reconsider. Let me re-read the OOPM section: "Out-of-pocket maximum: Individual (in-network) 6000.00; Family (in-network) 12000.00; Individual (out-of-network) 12000.00. 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."

And the accumulators addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. 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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

OK so the addendum tells us:
1. Balances are single running totals (member and family) including OON credits.
2. OON claims are measured against OON individual thresholds only (3000 deductible, 12000 OOPM); family thresholds don't limit them.
3. In-network claims are presumably measured against in-network thresholds: individual 1500/6000 and family 3000/12000, embedded (smaller of member individual remainder and family remainder).

The phrase "the balances are not capped at the in-network amounts" clarifies that we shouldn't stop crediting OON claims at 6000/12000 — they keep going up to the OON thresholds (12000 individual OOPM).

So for in-network claims: the applicable OOPM remainder = min(individual in-network OOPM 6000 - member balance, family OOPM 12000 - family balance). If ≤ 0 → plan pays 100%, member responsibility 0.

For OON claims: applicable OOPM remainder = 12000 - member balance (individual OON OOPM). Family doesn't limit. If ≤ 0 → member pays 0.

Hmm wait, but there's a question about whether for in-network claims the family OOPM caps member responsibility. The deductible is explicitly embedded; the OOPM section doesn't say embedded or aggregate. The addendum's OOPM-specific language: "out-of-network claims can carry ... the family balances past the family amounts" — this refers to the family OOP balance passing 12000. If the family OOPM didn't cap anything for in-network claims, that sentence would be pointless — the fact that they mention family balances passing family amounts suggests that family amounts DO matter for in-network claims (otherwise why track the family OOP balance at all?). So yes, family OOPM (12000) caps in-network member responsibility, embedded with individual 6000 (whichever is hit first, by analogy with the deductible).

Hmm, but actually wait. Is the family OOPM embedded? The deductible says "Structure EMBEDDED". For OOPM, under the ACA, family OOPM must be embedded (each member capped at individual OOPM). The plan lists "Individual (in-network) 6000.00, Family (in-network) 12000.00". I'll treat the OOPM as embedded too: a member's in-network cost share stops at min(individual 6000 remainder, family 12000 remainder).

OK let me now recompute carefully with this model. Let me be careful about the order and adjustments.

Actually, wait. Let me reconsider whether the OOPM check for an in-network claim is based on the single combined balance or something else. The problem is the answer depends heavily on this. Let me think about which interpretation the designer intended, given the numbers.

After Line 4: family OOP = 12445.55 > 12000. If family OOPM caps in-network claims, then every in-network claim from Line 5 onward has member responsibility 0. Then:
- Line 5 (E, in-network rehab): member 0, plan 2923.30.
- Line 6 (A, preventive mammography, in-network): 0/0 anyway.
- Line 7 (D, inpatient, in-network): 0, plan 19176.22.
- Line 8 (A, inpatient surgery, in-network): 0, plan 15812.18.
- Line 9 (E, inpatient surgery, in-network): 0, plan 23810.73.
- Line 10 (E, lab): 0, plan 846.74.
- Line 11 (A, rehab): 0, plan 8259.39.
- Line 12 (A, ambulatory surgery): 0, plan 5987.22.
- Line 13 (C, urgent care): copay 75 but OOPM reached → 0? "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." That's about deductible. For OOPM: if the OOPM is reached, plan pays 100%, so copay would be 0 too.
- Line 14: adjustment to Claim 8 — unwind credits (which were 0), re-adjudicate at 13440.35 → member 0, plan 13440.35.
- etc.

Then the answers for 13 and 20 would be trivially 0 and the task would be pointless for testing copay/deductible interactions... but not necessarily; the task might be designed so that the family OOPM is NOT exceeded, or the interpretation is different.

Hold on. Let me recompute family OOP after Line 4 more carefully. Line 1: D member 3031.37. Line 2: E 30. Line 3: B 1054.17. Line 4: E 8330.01. Total = 3031.37 + 30 + 1054.17 + 8330.01 = 12445.55. Yes, > 12000.

Hmm, that's suspicious. The designer chose numbers such that after 4 lines the family OOP exceeds 12000? That would make lines 5-28 mostly trivial. That seems unlikely to be intended — the ledger has 28 lines with lots of detail (copays, adjustments, voids), and the task asks for claim 13 and 20 components (copay amounts, coinsurance amounts). If everything were zero after line 4, the "copay_amount" and "coinsurance_amount" fields would all be 0 and the adjustments/voids would only matter for deductible balances... which also would be mostly settled.

Wait, but actually let me reconsider: maybe the intended OOPM model is different. Maybe each member's OOP balance is compared to their individual OOPM based on the network of the current claim, and the family OOPM caps the family... Hmm, same thing.

Alternative interpretation: Maybe OOP balances are tracked separately for in-network and OON? No — the addendum says "A balance is the running total of ... member_responsibility (for an out-of-pocket balance)" — single balance. And "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" (deductible). For OOPM it doesn't explicitly say single, but "the balances are not capped at the in-network amounts" implies single balances.

Hmm, wait. Let me reconsider. Maybe the OOPM check for in-network claims uses ONLY the individual in-network OOPM (6000) and the family in-network OOPM (12000), and the question is whether OON credits count toward reaching those. The addendum says OON claims can carry a member's balance past the in-network individual amount (6000) — i.e., we don't cap the balance. But does an OON-driven balance above 6000 mean in-network claims are now free?

Think about the deductible analogy: E's OON deductible credit of 3000 puts E's deductible balance at 3000, past the 1500 in-network threshold. The addendum's deductible rule explicitly says in-network claims measure against "the smaller of the member's individual remainder and the family remainder" — the remainder computed from the single balance. So E's in-network claims: individual remainder = 1500 - 3000 = negative → treated as met → deductible_applie

Let me carefully work through this ledger.

Plan: Trinity HDHP 3200.
- Deductible: Individual in-network 3200.00, Family in-network 6400.00, AGGREGATE structure — no member reaches coinsurance until family credits reach 6400.00.
- Out-of-network individual deductible 6400.00 (single member deductible balance, in-network and out-of-network credits accumulate to a single member deductible balance; the OON threshold is 6400 measured against that balance).
- OOPM: Individual in-network 7000, Family in-network 14000, Individual OON 14000.
- Coinsurance after deductible: in-network 10% member; OON 40% member.
- No copays.
- Preventive in-network: 100% paid, no accumulator movement.

Key rules from the ACCUMULATORS addendum:
- deductible_applied = lesser of allowed amount and room left under the deductible threshold that applies:
  - in-network: family remainder alone (aggregate)
  - out-of-network: OON individual remainder measured against the member's same single deductible balance.
- "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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

Hmm, this is tricky. Let me parse carefully.

So for an in-network claim: deductible_applied = min(allowed, family remainder). Family remainder = 6400 - family deductible balance. Under aggregate, no individual threshold.

Wait, but also the member's own single deductible balance matters? For in-network claims, the threshold is the family remainder alone (aggregate). But wait — could a member's balance exceed... Hmm. Under aggregate, the in-network threshold is the family amount. But what if the member's own balance is already above 3200 due to OON claims? The rule says in-network: "the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". So in-network aggregate: family remainder alone.

But hold on — the member's deductible balance is a single balance for both IN and OON. The OON threshold is 6400 (individual OON). The in-network threshold is family 6400 aggregate. Interesting — they're the same number here: family in-network 6400, individual OON 6400.

Wait, but there's a subtlety: for an in-network claim, do we also need to check the member's own single balance against... no, the rule says family remainder alone for aggregate. But hmm, what about a member whose single balance exceeds 6400 due to OON claims? Then the family balance would also be high... Actually the family balance includes all members' credits, so family balance >= any member's balance. So if a member's balance is >= 6400, family is too. OK.

But wait — the OON threshold is the individual OON deductible of 6400 measured against the member's single deductible balance. The in-network threshold is family remainder (6400 - family balance). These could differ: a member with a low personal balance but family balance high.

Hmm, actually let me re-read: "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."

So for an OON claim: deductible_applied = min(allowed, OON individual remainder) = min(allowed, 6400 - member's single deductible balance).

For an in-network claim: deductible_applied = min(allowed, family remainder) = min(allowed, 6400 - family deductible balance).

Hmm wait, but that creates a weird situation: if family remainder is small but the member's own balance is far from 6400... e.g., family balance 6000, member balance 1000. In-network claim for that member: family remainder = 400, so deductible applied = min(allowed, 400). After that, family = 6400, and everyone is at coinsurance. OK, that's aggregate behavior.

If family balance = 6400 already (family deductible met), then in-network claims have deductible_applied = 0, coinsurance.

For OON claims: member's single balance vs 6400. Note the member's balance could be less than the family balance. E.g., member C has balance 0 but family at 6400. OON claim for C: remainder = 6400 - 0 = 6400, so deductible applied = min(allowed, 6400). That's harsher. Per the rule, "Out-of-network claims are measured against the out-of-network individual thresholds only". So yes.

Hmm, but wait — that seems odd relative to "aggregate" but the addendum is explicit. Let me follow it exactly.

Also OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once a member reaches the OOPM the plan pays 100% for covered services for the remainder of the year.

Hmm, which OOPM applies to a claim? Presumably similar logic: in-network claims measured against... hmm. The addendum says "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

So the OOP balance is a single running total per member (of member_responsibility), and per family. For an in-network claim, the applicable OOPM threshold... Hmm. Let's think. For in-network claims, presumably individual in-network OOPM 7000 and family in-network OOPM 14000 apply. For OON claims, individual OON OOPM 14000 applies.

Actually wait. Let's think about how the OOPM works with the claim adjudication. The member responsibility for a claim = deductible_applied + coinsurance, but capped so that the member's OOP balance doesn't exceed the applicable OOPM. Once reached, plan pays 100%.

For an in-network claim: the applicable thresholds are individual 7000 / family 14000. Hmm, but is the family OOPM applied to in-network claims only, or to all? The OON thresholds are individual-only (14000 individual OON). The addendum says "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."

So for an OON claim, the cap is the member's individual OON OOPM of 14000 (measured against member's OOP balance). Family OOPM doesn't limit OON claims.

For an in-network claim, the cap is min(individual in-network remainder, family in-network remainder)? Hmm, embedded vs aggregate for OOPM? The plan document doesn't say the OOPM is aggregate. It just lists individual and family OOPM. Hmm.

Typically, family OOPM works such that once the family total reaches the family OOPM, no more cost share for anyone. And individual OOPM such that once an individual reaches 7000 (in-network), that member pays no more. The addendum says for deductibles the structure is aggregate. For OOPM, it says nothing about aggregate/embedded. Hmm.

Let me re-read the OOPM section: "Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. 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."

"Once a member reaches the out-of-pocket maximum" — member-level. And the family OOPM: once family total reaches 14000, no member pays more (for in-network). I think the natural reading: in-network claims are capped by both the member's individual in-network OOPM remainder and the family in-network OOPM remainder; OON claims are capped by the member's OON OOPM (14000) remainder only.

Given the deductibles are aggregate, maybe OOPM also effectively... Actually, since the family OOPM is exactly 2x individual, and there are 4 members, the family limit could bind first in some cases. Let me just compute and see whether it matters.

Actually, let me consider: does the family OOPM apply to OON claims' credits? "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." That's about deductible credits. For OOP, member responsibility always accumulates to both member OOP balance and family OOP balance (per the general rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share").

OK. Let me now just carefully process the ledger.

Initial accumulators (before Line 1):
- A: ded 2120.26, oop 2618.28
- B: ded 1996.73, oop 2173.25
- C: ded 0.00, oop 0.00
- D: ded 662.41, oop 1267.18
- Family: ded 4779.40, oop 6058.71

Check: 2120.26+1996.73+0+662.41 = 4779.40. Yes. OOP: 2618.28+2173.25+0+1267.18 = 6058.71. Yes.

Plan thresholds:
- In-network deductible threshold: family 6400 (aggregate). Family remainder = 6400 - family ded balance.
- OON deductible threshold: individual 6400 vs member's single ded balance.
- In-network OOPM: individual 7000, family 14000.
- OON OOPM: individual 14000.

Coinsurance: IN 10% member of (allowed - deductible_applied). OON 40% member.

Now the OOPM capping: For each claim, member_responsibility = deductible_applied + coinsurance, but if the member's OOP balance + this amount would exceed the applicable OOPM, cap it at the remainder; plan pays the rest. Also, hmm, when does the deductible stop applying because OOPM reached? If OOPM already reached, member pays 0.

But careful: if the OOPM is reached mid-claim, the member responsibility is capped, and the deductible credit... Hmm. The deductible_applied is defined as the lesser of allowed and room under the deductible threshold. But if the OOPM caps the member responsibility below deductible_applied, does the deductible still get credited? Hmm. This is a subtle interaction.

In real HDHP administration, if OOPM is reached, the claim is paid 100% and typically no deductible credit is needed (it doesn't matter). But here the deductible balance could matter for... nothing after OOPM is reached, since the member pays nothing more. But the family deductible could matter for other members! Under aggregate, the family deductible matters for all members. Hmm, but if a member hits their individual OOPM, they pay nothing more, but other members still face the family deductible.

Hmm, wait. Actually, let's think about whether the OOPM will even bind in this scenario. Let me compute and see.

Let me process line by line.

**Line 1 — Claim 1 — A — ED visit, IN — allowed 3722.46**

Family ded balance: 4779.40. Family remainder = 6400 - 4779.40 = 1620.60.
In-network claim: deductible_applied = min(3722.46, 1620.60) = 1620.60.
Coinsurance: allowed - deductible_applied = 3722.46 - 1620.60 = 2101.86 × 10% = 210.186 → 210.19 (round half up at end; let me keep precision: 210.186).

Hmm, rounding: "Round half up to the cent at the end of a calculation, not at each intermediate step." The coinsurance for a claim is a final reported number for that claim... but also feeds into accumulators. I'll round each claim's component to cents when posting, since money is posted in cents. Actually, "at the end of a calculation" — the claim's coinsurance is a calculation. Let me compute precisely and round to cent: 210.186 → 210.19.

Member responsibility = 1620.60 + 210.19 = 1830.79. Plan paid = 3722.46 - 1830.79 = 1891.67.

Check OOPM: A's OOP balance 2618.28 + 1830.79 = 4449.07 < 7000 (individual IN). Family OOP: 6058.71 + 1830.79 = 7889.50 < 14000. OK, no cap.

Update:
- A: ded 2120.26 + 1620.60 = 3740.86; oop 2618.28 + 1830.79 = 4449.07.
- Family: ded 4779.40 + 1620.60 = 6400.00; oop 6058.71 + 1830.79 = 7889.50.

Family deductible is now exactly met (6400.00). So subsequent in-network claims for anyone: deductible_applied = 0 (family remainder = 0), coinsurance 10%.

Interesting. And OON claims: measured against member's individual single balance vs 6400.

**Line 2 — Claim 2 — C — Allergy testing, IN — allowed 783.25**

Family remainder = 0. Deductible_applied = 0. Coinsurance = 783.25 × 10% = 78.325 → 78.33 (round half up: 78.325 → 78.33). Hmm, 78.325 rounds to 78.33 (half up). Member resp = 78.33. Plan = 783.25 - 78.33 = 704.92.

OOP check: C oop 0 + 78.33 = 78.33. Family oop 7889.50 + 78.33 = 7967.83.

Update: C: ded 0, oop 78.33. Family: ded 6400.00, oop 7967.83.

**Line 3 — Claim 3 — C — Outpatient rehab, IN — allowed 7147.73**

Family remainder = 0. Deductible_applied = 0. Coinsurance = 7147.73 × 10% = 714.773 → 714.77. Member resp = 714.77. Plan = 7147.73 - 714.77 = 6432.96.

OOP: C: 78.33 + 714.77 = 793.10. Family: 7967.83 + 714.77 = 8682.60.

Update: C: ded 0, oop 793.10. Family ded 6400.00, oop 8682.60.

(Note: Claim 3 will be adjusted at Line 15 to allowed 6075.57.)

**Line 4 — Claim 4 — C — Specialist office visit, OON — allowed 362.74**

OON claim: measured against member's individual OON deductible 6400 vs C's single ded balance (0.00). Remainder = 6400 - 0 = 6400. Deductible_applied = min(362.74, 6400) = 362.74.

Hmm wait — but the family deductible is already met (6400). Does an OON claim still apply deductible because the member's individual balance is 0? Per the addendum: "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." So the OON claim is not limited by the family amount — meaning the family remainder doesn't cap... hmm, wait. "do not limit" — the family amount doesn't limit the OON claim. Hmm, but here the family remainder is 0, which would limit it to 0. The rule says family amounts don't limit OON claims. So we use the OON individual threshold: 6400 - C's balance (0) = 6400. Deductible_applied = 362.74.

Hmm, but wait — is that right? Let me re-read the ACCUMULATORS addendum:

"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
  in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
  out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."

So for OON: room left = OON individual remainder = 6400 - member's single ded balance. For C: 6400 - 0 = 6400. Deductible_applied = min(362.74, 6400) = 362.74.

Then coinsurance: OON 40% of (allowed - deductible_applied) = 40% × 0 = 0. Member resp = 362.74. Plan = 0.

OOP: C oop 793.10 + 362.74 = 1155.84. Family oop 8682.60 + 362.74 = 9045.34.

Ded credits: C ded 0 + 362.74 = 362.74. Family ded: 6400.00 + 362.74 = 6762.74. (Family balance not capped at in-network amounts — explicitly stated.)

Update: C: ded 362.74, oop 1155.84. Family: ded 6762.74, oop 9045.34.

**Line 5 — Claim 5 — B — PT course, IN — allowed 913.55**

Family remainder (in-network aggregate) = 6400 - 6762.74 = negative → 0 room. Deductible_applied = 0. Coinsurance = 913.55 × 10% = 91.355 → 91.36 (half up: 91.355 → 91.36). Hmm, 91.355 — the digit after 5 is exactly 5, round half up → 91.36. Member resp = 91.36. Plan = 913.55 - 91.36 = 822.19.

OOP: B: 2173.25 + 91.36 = 2264.61. Family: 9045.34 + 91.36 = 9136.70.

Update: B: ded 1996.73, oop 2264.61. Family: ded 6762.74, oop 9136.70.

**Line 6 — Claim 6 — D — Outpatient procedure, IN — allowed 2887.42**

Family remainder = 0 (family ded 6762.74 ≥ 6400). Deductible_applied = 0. Coinsurance = 2887.42 × 10% = 288.742 → 288.74. Member resp = 288.74. Plan = 2887.42 - 288.74 = 2598.68.

OOP: D: 1267.18 + 288.74 = 1555.92. Family: 9136.70 + 288.74 = 9425.44.

Update: D: ded 662.41, oop 1555.92. Family: ded 6762.74, oop 9425.44.

(Note: Claim 6 will be voided at Line 24.)

**Line 7 — Claim 7 — D — Urgent care, IN — allowed 280.31**

Deductible_applied = 0. Coinsurance = 28.031 → 28.03. Member resp = 28.03. Plan = 252.28.

OOP: D: 1555.92 + 28.03 = 1583.95. Family: 9425.44 + 28.03 = 9453.47.

Update: D: ded 662.41, oop 1583.95. Family: ded 6762.74, oop 9453.47.

**Line 8 — Claim 8 — A — Cardiac stress test, IN — allowed 1889.97**

Deductible_applied = 0. Coinsurance = 188.997 → 189.00 (half up: 188.997 → 189.00). Member resp = 189.00. Plan = 1889.97 - 189.00 = 1700.97.

OOP: A: 4449.07 + 189.00 = 4638.07. Family: 9453.47 + 189.00 = 9642.47.

Update: A: ded 3740.86, oop 4638.07. Family: ded 6762.74, oop 9642.47.

**Line 9 — Claim 9 — A — Annual wellness visit, IN — allowed 1650.40**

Preventive in-network: paid 100%, no cost share, no accumulator movement. Member resp = 0, plan = 1650.40. (Will be voided at Line 20 anyway; void unwinds credits — there are none.)

No changes.

**Line 10 — Claim 10 — C — PT course, OON — allowed 867.11**

OON: C's single ded balance = 362.74. OON individual remainder = 6400 - 362.74 = 6037.26. Deductible_applied = min(867.11, 6037.26) = 867.11. Coinsurance = 40% × 0 = 0. Member resp = 867.11. Plan = 0.

OOP: C: 1155.84 + 867.11 = 2022.95. Family: 9642.47 + 867.11 = 10509.58.

Ded: C: 362.74 + 867.11 = 1229.85. Family: 6762.74 + 867.11 = 7629.85.

Update: C: ded 1229.85, oop 2022.95. Family: ded 7629.85, oop 10509.58.

**Line 11 — Claim 11 — B — Outpatient rehab, OON — allowed 4991.99**

OON: B's single ded balance = 1996.73. OON individual remainder = 6400 - 1996.73 = 4403.27. Deductible_applied = min(4991.99, 4403.27) = 4403.27. Coinsurance = 40% × (4991.99 - 4403.27) = 40% × 588.72 = 235.488 → 235.49. Member resp = 4403.27 + 235.49 = 4638.76. Plan = 4991.99 - 4638.76 = 353.23.

OOP check: B oop 2264.61 + 4638.76 = 6903.37. OON individual OOPM = 14000. Not reached. Family OOP: 10509.58 + 4638.76 = 15148.34. Hmm — family OOPM in-network is 14000. Does the family OOPM cap this OON claim? The addendum says OON claims are measured against OON individual thresholds only; family amounts don't limit OON claims. So no cap. Family OOP balance = 15148.34 (not capped at in-network amounts — explicitly allowed: "the family balances past the family amounts; the balances are not capped at the in-network amounts").

Ded: B: 1996.73 + 4403.27 = 6400.00. Family: 7629.85 + 4403.27 = 12033.12.

Update: B: ded 6400.00, oop 6903.37. Family: ded 12033.12, oop 15148.34.

Hmm wait, now family OOP balance is 15148.34, above the family in-network OOPM of 14000. Does that mean in-network claims for anyone now pay 100%? Hmm. This is a question: the family OOPM is 14000 (in-network). Once family OOP reaches 14000, the plan pays 100% for covered services. But the addendum says balances aren't capped at in-network amounts — meaning the balance can exceed, but the threshold still triggers.

Hmm, but wait. Let me think about this more carefully. The OOPM section: "Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. 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."

The family OOPM of 14000 — once the family total reaches 14000, presumably no more in-network cost share for anyone. But OON claims continue to be capped by individual OON OOPM 14000.

Hmm, but hold on: is the family OOPM aggregate or embedded? For OOPM, typically once family OOP reaches family OOPM, everyone stops. Also each individual stops at their individual OOPM.

But here's a subtlety: when the family OOP balance exceeded 14000 due to OON claims (which are measured against OON individual thresholds only, not limited by family amounts), does that trigger the family in-network OOPM for subsequent in-network claims? Hmm.

The addendum says: "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 is about how OON claims are adjudicated (they're not capped by family thresholds). It doesn't say the family balance stops counting toward the family OOPM.

And: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

So

Let me carefully work through this ledger.

Plan document:
- Deductible individual in-network: 1500.00
- Family in-network: 3000.00
- EMBEDDED structure
- Out-of-network individual deductible: 3000.00
- Single member deductible balance for both in and out of network. The threshold measured against depends on the service network.
- OOPM individual in-network: 6000.00
- Family in-network: 12000.00
- Individual OON: 12000.00
- Coinsurance in-network: 20% member / 80% plan
- Coinsurance OON: 40% member / 60% plan
- Copays: PCP 30.00, Specialist 60.00, Urgent care 75.00, ER 400.00, Generic pharmacy 15.00
- Copays do NOT credit the deductible, but always credit the OOPM.
- Preventive in-network: no cost share, no accumulator movement.

Accumulator rules:
- deductible_applied = LESSER of allowed amount and room left under the deductible threshold that applies:
  - in-network: smaller of member's individual remainder and family remainder (embedded)
  - out-of-network: the OON individual remainder, measured against member's same single deductible balance.
- Deductible balance = running total of deductible_applied.
- OOP balance = running total of member_responsibility.
- OON claims measured against OON individual thresholds only; family amounts don't limit an OON claim. But credits accumulate to member balance and family balance.

OOPM: Once a member reaches the OOPM the plan pays 100% of allowed for covered services. The individual in-network OOPM is 6000, family 12000, OON individual 12000. Hmm, but the OOPM thresholds: which applies? Similar to deductible: in-network claims measured against smaller of individual in-network OOPM remainder and family OOPM remainder? The plan document says "Once a member reaches the out-of-pocket maximum the plan pays 100%...". The accumulators addendum says "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." and "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."

So for OOPM:
- In-network claims: measured against the smaller of the member's individual in-network OOPM remainder (6000 - member OOP) and family OOPM remainder (12000 - family OOP). Once reached, plan pays 100%.
- OON claims: measured against OON individual OOPM remainder (12000 - member OOP). Family OOPM doesn't limit.

Hmm, but wait — the OOPM section in the accumulators addendum only explicitly discusses the deductible. Let me re-read.

"ACCUMULATORS (addendum to the plan document)
  A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: ..."

The addendum is about deductible_applied. For OOPM, the plan document says "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."

The question is how the OOPM caps member responsibility on a claim. Presumably member_responsibility is capped at the room left under the applicable OOPM threshold, similar to deductible. Let me think about whether that matters in this ledger.

Let me process the ledger step by step.

Initial state:
- A: ded 904.50, oop 904.50
- B: ded 0, oop 0
- C: ded 0, oop 0
- D: ded 0, oop 0
- Family: ded 904.50, oop 904.50

Thresholds:
- Individual in-network ded: 1500; family ded: 3000 (embedded).
- OON individual ded: 3000.
- Individual in-network OOPM: 6000; family OOPM: 12000; OON individual OOPM: 12000.

Line 1 — Claim 1 — A (subscriber), specialist office visit, in-network, allowed 294.03.
Specialist copay = 60.00. Copays do not credit deductible, always credit OOPM.
Does a specialist visit copay apply, or is it subject to deductible? The plan says "Specialist office visit ... 60.00 copay". Typically copay applies after deductible or instead. The plan lists cost share: coinsurance after deductible, and copays for specific services. I think the intent: office visits have copays (not subject to deductible). Copays do NOT credit the deductible. So claim 1: member responsibility = 60.00 copay, plan pays 294.03 - 60.00 = 234.03.
Wait — but is the copay the full member responsibility? Yes: copay flat per-service member amount. Member responsibility = 60.00. Plan paid = 234.03.
Deductible applied = 0.00 (copays don't credit deductible).
A oop: 904.50 + 60.00 = 964.50. Family oop: 904.50 + 60 = 964.50.
A ded stays 904.50; family ded stays 904.50.

Line 2 — Claim 2 — C, primary care office visit, in-network, allowed 197.39.
PCP copay 30.00. Member resp = 30.00, plan paid = 167.39. Deductible applied 0.
C oop: 30.00. Family oop: 964.50 + 30 = 994.50.
C ded 0; family ded 904.50.

Line 3 — Claim 3 — D, inpatient admission with surgery, in-network, allowed 11804.80.
No copay for inpatient. Subject to deductible then coinsurance.
D's individual deductible remainder: 1500 - 0 = 1500. Family remainder: 3000 - 904.50 = 2095.50. Embedded: smaller of member remainder and family remainder = 1500.00. Deductible applied = min(11804.80, 1500) = 1500.00.
Remaining allowed after deductible: 11804.80 - 1500 = 10304.80. Coinsurance 20% = 2060.96. Member resp = 1500 + 2060.96 = 3560.96. Plan paid = 11804.80 - 3560.96 = 8243.84.
OOPM check: D's oop before = 0. Individual OOPM in-network 6000; remainder 6000. Family OOPM remainder = 12000 - 994.50 = 11005.50. Smaller = 6000. Member resp 3560.96 < 6000, so no cap.
D ded: 1500.00. D oop: 3560.96.
Family ded: 904.50 + 1500 = 2404.50. Family oop: 994.50 + 3560.96 = 4555.46.

Line 4 — Claim 4 — C, outpatient endoscopy, in-network, allowed 715.51.
C's ded = 0. Individual remainder 1500. Family remainder: 3000 - 2404.50 = 595.50. Embedded: smaller = 595.50. Deductible applied = min(715.51, 595.50) = 595.50.
After deductible: 715.51 - 595.50 = 120.01. Coinsurance 20% = 24.002 → 24.00. Member resp = 595.50 + 24.00 = 619.50. Plan paid = 715.51 - 619.50 = 96.01.
OOPM: C oop before = 30.00. Individual remainder 5970. Family remainder 12000 - 4555.46 = 7444.54. Smaller 5970. 619.50 < 5970 fine.
C ded: 595.50. C oop: 30 + 619.50 = 649.50.
Family ded: 2404.50 + 595.50 = 3000.00 (family deductible now met!). Family oop: 4555.46 + 619.50 = 5174.96.

Note: Claim 4 is later voided (Line 15). So its components will be unwound and nothing replaces them. Final components on the books for Claim 4: all 0.00. The task says "Where it was voided, every component is 0.00." So claim_4_member_responsibility = 0.00, claim_4_plan_paid = 0.00, claim_4_deductible_applied = 0.00, claim_4_copay_amount = 0.00, claim_4_coinsurance_amount = 0.00.

But I still need to process it in order because it affects subsequent claims.

Line 5 — Claim 5 — D, inpatient admission with surgery, in-network, allowed 14614.81.
D ded = 1500. Individual remainder = 0 (since D's ded balance is 1500 and individual in-network ded is 1500). Family remainder = 3000 - 3000 = 0. Deductible applied = 0.
Coinsurance 20% of 14614.81 = 2922.962 → 2922.96. Member resp = 2922.96. Plan paid = 14614.81 - 2922.96 = 11691.85.
OOPM check: D oop before = 3560.96. Individual remainder = 6000 - 3560.96 = 2439.04. Family remainder = 12000 - 5174.96 = 6825.04. Smaller = 2439.04. Member resp 2922.96 > 2439.04? Yes! 2922.96 exceeds the room left under the OOPM. So member resp capped at 2439.04, plan pays the rest.

Hmm wait. Does the OOPM cap member responsibility mid-claim? "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." So the member pays up to the OOPM, and beyond that the plan pays 100%. The member responsibility on this claim would be capped at the room left: 2439.04. Plan paid = 14614.81 - 2439.04 = 12175.77.

Hmm, but wait — the deductible addendum says "Because the out-of-network thresholds are higher..." — that's about deductibles. For OOPM, similar logic should apply: in-network claims measured against smaller of individual in-network OOPM remainder and family OOPM remainder. Since OOPM is "the ceiling on member cost share for the plan year. Once reached, the plan pays 100%".

So D reaches individual in-network OOPM of 6000 on this claim. D oop after = 6000.00.

Actually, let me double check: does the OOPM cap the member responsibility such that the coinsurance is reduced? Yes — once the OOPM is reached, plan pays 100%. So on the claim where it's reached, member pays only up to the OOPM remainder, plan pays the rest.

So Claim 5: deductible applied = 0.00, coinsurance amount = 2439.04? Hmm, what would the coinsurance_amount field be? The member's responsibility consists of deductible + coinsurance (+ copay). If capped by OOPM, the coinsurance paid is capped. Let me define coinsurance_amount as the portion of member responsibility attributable to coinsurance = 2439.04.

Actually, let me reconsider. The components: member_responsibility = deductible_applied + copay_amount + coinsurance_amount, and member_responsibility + plan_paid = allowed amount. If the OOPM caps, then coinsurance_amount would be the capped amount. I'll go with that.

D oop = 6000.00 (reached individual in-network OOPM). D ded stays 1500.
Family oop: 5174.96 + 2439.04 = 7614.00. Family ded stays 3000.

Line 6 — Claim 6 — D, ambulatory surgery, in-network, allowed 5634.42.
D ded = 1500, individual remainder 0; family remainder 0. Deductible applied = 0.
D has reached individual in-network OOPM (6000). Plan pays 100%. Member resp = 0.00. Plan paid = 5634.42.
OOPM: is there a family OOPM consideration? D reached individual OOPM, so plan pays 100% for D's covered services. Member resp = 0. Coinsurance would have been 20% but waived.
D oop stays 6000. Family oop stays 7614.00.

Hmm wait, but I should double check whether the OOPM cap on claim 5 is right. Let me reconsider whether in-network claims are measured against "smaller of individual and family OOPM remainders". The addendum explicitly describes this for the deductible. For OOPM, the plan document just says individual 6000 in-network, family 12000, individual OON 12000. The natural reading in this harness: same embedded structure — a member's OOPM is the individual amount; once the member's cost share reaches 6000 (in-network), the plan pays 100% for that member. The family OOPM of 12000: once total family cost share reaches 12000, the plan pays 100% for everyone? Actually family OOPM typically means once the family total reaches the family OOPM, no member pays further cost share.

In this case, D reaches 6000 individually on Claim 5. So for Claim 6, D pays 0.

Let me continue.

Line 7 — Claim 7 — B, inpatient admission, in-network, allowed 20898.76.
B ded = 0. Individual remainder 1500. Family remainder 0 (family ded met). Embedded: smaller of member remainder (1500) and family remainder (0) = 0. Deductible applied = 0.

Hmm, this is the embedded rule: "in-network ..... the smaller of the member's individual remainder and the family remainder (embedded)". Family remainder = 3000 - 3000 = 0. So deductible_applied = 0. Once the family deductible is met, no member pays deductible anymore (in-network). Correct under embedded: once family deductible met, everyone has satisfied.

Coinsurance 20% of 20898.76 = 4179.752 → 4179.75. Member resp = 4179.75. Plan paid = 20898.76 - 4179.75 = 16719.01.
OOPM check: B oop before = 0. Individual remainder 6000. Family remainder = 12000 - 7614.00 = 4386.00. Smaller = 4386.00. Member resp 4179.75 < 4386.00, so no cap. B oop = 4179.75.
Family oop: 7614.00 + 4179.75 = 11793.75.

Note: Claim 7 is later voided (Line 11). I'll track it anyway.

Line 8 — Claim 8 — D, inpatient admission, OUT-OF-NETWORK, allowed 17086.02.
OON: deductible threshold = OON individual 3000, measured against D's single deductible balance (currently 1500). OON individual remainder = 3000 - 1500 = 1500. Family amounts don't limit OON claims. Deductible applied = min(17086.02, 1500) = 1500.00.
After deductible: 17086.02 - 1500 = 15586.02. Coinsurance OON 40% = 6234.408 → 6234.41. Member resp = 1500 + 6234.41 = 7734.41.
OOPM check: OON claims measured against OON individual OOPM threshold only: 12000. D's oop before = 6000. Remainder = 12000 - 6000 = 6000. Member resp 7734.41 > 6000? Yes. Capped at 6000.00. Plan paid = 17086.02 - 6000.00 = 11086.02.

Hmm wait — but D already reached the in-network individual OOPM of 6000. Does that mean the plan pays 100% for D even for OON services? The plan document: "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." But there are separate OOPMs: individual in-network 6000, individual OON 12000. The typical design: in-network OOPM applies to in-network cost share; OON services accumulate toward the OON OOPM (and often toward combined). This plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" — for deductibles. For OOPM, it doesn't say single balance explicitly, but the accumulators addendum says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount...". So there's a single OOP balance per member, measured against different thresholds depending on the claim's network: in-network claims measured against 6000 (individual) / 12000 (family); OON claims measured against 12000 (OON individual).

So for D on Claim 8: OON individual OOPM remainder = 12000 - 6000 = 6000. Member resp capped at 6000. D oop = 12000. Plan paid = 11086.02.

So Claim 8: deductible applied 1500, coinsurance = 4500 (6000 - 1500)? Member resp 6000.00 = 1500 deductible + 4500 coinsurance. Plan paid 11086.02.

D ded: 1500 + 1500 = 3000.00. D oop: 6000 + 6000 = 12000.00.
Family ded: 3000 + 1500 = 4500.00. Family oop: 11793.75 + 6000 = 17793.75.

Hmm wait, family deductible: OON credits accumulate to the family balance. Family ded was 3000 (met). Now 4500. The family in-network threshold is 3000, already met. The family balance is not capped. OK.

Line 9 — Claim 9 — A, primary care office visit, in-network, allowed 156.47.
PCP copay 30.00. Member resp = 30.00, plan paid = 126.47. Deductible applied 0 (copays don't credit deductible).
A oop: 964.50 + 30 = 994.50. Family oop: 17793.75 + 30 = 17823.75.
A ded stays 904.50. Family ded stays 4500.

Line 10 — Claim 10 — B, specialist office visit, in-network, allowed 229.43.
Specialist copay 60.00. Member resp 60.00, plan paid 169.43.
OOPM check: copays credit OOPM. B oop before = 4179.75. Individual remainder = 6000 - 4179.75 = 1820.25. Family remainder = 12000 - 17823.75... wait family oop is 17823.75 which is above 12000. Hmm. Family in-network OOPM is 12000. Family oop balance = 17823.75 > 12000. So family OOPM met? Then would B pay anything?

Hold on. This is getting complicated. Let me think about the family OOPM. Family OOPM in-network = 12000. The family OOP balance includes all members' member responsibility, including OON claims' credits ("The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance"). The family balance is now 17823.75, past 12000. The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." So the family OOPM (12000) has been passed due to OON claims.

Now, for in-network claims, is the member's cost share capped by the family OOPM? Under the embedded-like structure for OOPM: "in-network ..... the smaller of the member's individual remainder and the family remainder". If family remainder is 0 (family OOPM met), then in-network member responsibility would be 0 — plan pays 100%.

Hmm, but that seems to conflict with the intent... Let me reconsider. Actually, let's think about what the family OOPM means: "the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services." So once the family OOPM (12000) is reached by total family cost share, the plan pays 100% of covered in-network services for all family members.

In this ledger, the family OOP balance crosses 12000 during Claim 8 (D's OON claim): before claim 8, family oop = 11793.75; claim 8 adds 6000 → 17793.75. So the family OOPM is reached during Claim 8.

So for subsequent in-network claims, does the plan pay 100%? Claim 9 (A, PCP): family OOPM already met. Would A's copay be waived?

Hmm. This is a crucial interpretation question. Let me re-read the plan document.

"Out-of-pocket maximum
  Individual (in-network) ................ 6000.00
  Family (in-network) .................... 12000.00
  Individual (out-of-network) ............ 12000.00
  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."

"Once a member reaches..." — it says member. The family OOPM: the family amount is the ceiling for the family. Typically, once the family OOPM is reached, no family member pays more cost share.

But there's tension: the family balance includes OON credits, and the family OOPM is an in-network amount. The addendum says OON claims are measured against OON individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. This means an OON claim's member responsibility is not capped by the family OOPM remainder. But it doesn't say whether the family OOPM, once crossed by the running total, waives in-network cost share for members.

Hmm, let me think about the standard interpretation of family OOPM: it's a cap on total family cost share. Once the family accumulates 12000 in cost share, the plan pays 100% for everyone (in-network). Under a typical plan, yes.

But this harness's addendum says "the balances are not capped at the in-network amounts" — meaning the balance keeps accumulating past 12000 (because OON claims can push it past). It doesn't say the family OOPM stops applying once crossed.

Let me reconsider: the OOPM logic for a claim, in-network:
- member's cost share for the claim is capped at min(individual OOPM remainder, family OOPM remainder). Once either is 0, plan pays 100%.

That mirrors the deductible logic exactly. The deductible logic: embedded, in-network: smaller of member individual remainder and family remainder. Once family ded met, deductible_applied = 0 for everyone in-network.

So symmetric OOPM logic: in-network claim's member responsibility capped at smaller of (individual in-network OOPM remainder, family in-network OOPM remainder). Once family OOPM met, in-network claims have zero member responsibility.

But wait — the plan says copays always credit the OOPM. If the OOPM is met, is the copay waived? "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." Yes, copays would be waived once OOPM reached.

Hmm, but the addendum for deductible says: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." Wait, that's odd — "including for a copay that would otherwise credit the deductible" — but copays never credit the deductible in this plan ("Copays do NOT credit the deductible"). Hmm, that clause seems to be a general statement for other plan designs maybe. In this plan copays don't credit the deductible anyway.

OK so let me think again about the OOPM application carefully, because it drastically changes the answers.

Key question 1: For an in-network claim, is member responsibility capped by min(individual in-network OOPM remainder, family in-network OOPM 

Let me work through this carefully.

Plan: Pecos Select 2500, plan year 2026.
- Individual in-network deductible: 2500.00
- Family in-network deductible: 5000.00, EMBEDDED
- Out-of-network individual deductible: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The out-of-network threshold (5000) is what the balance is measured against for OON services; the in-network threshold (2500) for INN services.
- OOPM: individual in-network 5500, family in-network 11000, individual out-of-network 11000.
- Coinsurance after deductible: INN 30% member / 70% plan; OON 50/50.
- Copays: PCP 25, specialist 50, urgent care 60, ER 300 (waived if admitted), generic pharmacy 10.
- Copays credit the deductible. Copays always credit the OOPM.
- Preventive INN: no cost share. OON preventive: subject to OON deductible and coinsurance.

Accumulator rules:
- deductible_applied = lesser of allowed amount and room left under the applicable deductible threshold:
  - in-network: min(member's individual remainder (in-network individual 2500 minus member balance? — measured how?), family remainder (5000 minus family balance))
  - out-of-network: OON individual remainder, measured against the member's same single deductible balance.
- Once applicable threshold met, deductible_applied = 0.
- Balances are running totals of deductible_applied (deductible) and member_responsibility (OOP). Balances not capped at in-network amounts; OON claims measured against OON thresholds only; family amounts don't limit OON claims (family remainder doesn't apply to OON). But credits still accumulate to member and family balances.

Initial accumulators (before Line 1):
- A: ded 60.69, oop 60.69
- B: ded 383.93, oop 924.55
- C: ded 1524.34, oop 2116.83
- Family: ded 1968.96, oop 3102.07

Let me process each line.

Line 1 — Claim 1 — C (child) — Inpatient admission with surgery, INN. Allowed 10074.70.
C's deductible balance: 1524.34. Individual INN remainder: 2500 - 1524.34 = 975.66. Family remainder: 5000 - 1968.96 = 3031.04. Deductible applied = min(10074.70, 975.66, 3031.04) = 975.66.
Coinsurance: 30% of (10074.70 - 975.66) = 30% of 9099.04 = 2729.712 → 2729.71.
Member responsibility = 975.66 + 2729.71 = 3705.37.
Check OOPM: C's OOP balance before: 2116.83. Individual INN OOPM 5500. Remainder: 5500 - 2116.83 = 3383.17. Member responsibility 3705.37 exceeds remainder? Hmm — need to handle OOPM cap. Once OOPM reached, plan pays 100%.

Wait, but the plan document says OOPM individual in-network 5500, family 11000, individual OON 11000. There's an embedded question: does the family OOPM limit apply? The document lists family in-network OOPM 11000. It says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." The accumulator addendum says OON claims are measured against OON individual thresholds only; the family amounts don't limit OON claims. So for INN claims, family OOPM does apply presumably (family remainder matters?). Hmm, the addendum speaks specifically about deductibles: "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."

For OOPM, the plan doc says individual in-network 5500, family in-network 11000, individual OON 11000. For OON claims, presumably measured against OON individual OOPM 11000 only. For INN claims, presumably measured against min of individual remainder and family remainder? The doc says "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." It doesn't explicitly say the family OOPM works embedded like the deductible. Hmm.

The task family rules say: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Under an aggregate structure no member reaches coinsurance until the family amount is met."

That's about deductibles. For OOPM, the plan document says family OOPM 11000. Typically family OOPM works like: once family OOPM total reached, no more cost share for anyone. And individual OOPM: each member capped at individual. So member cost share is capped at min(individual remainder, family remainder)? Similar embedded logic. Given the harness describes "Embedded deductible" concept, and the plan says family OOPM 11000, I think the intended treatment: member's OOP is capped by their individual OOPM (5500 INN / 11000 OON) and also by the family OOPM (11000 INN).

Hmm, but the addendum only says for OON claims the family amounts don't limit. For OOPM OON: individual OON OOPM 11000. For INN claims: individual INN OOPM 5500, family 11000.

Let me just carefully compute with these rules and see whether any OOPM caps get hit.

Also note: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". For a copay claim: copay credits deductible. So deductible_applied for a copay claim = the copay amount, capped by room left. And "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So for office visit copays: member responsibility = copay (50 or 60 etc.), deductible_applied = min(copay, room). Coinsurance = 0. Plan paid = allowed - copay? Wait: "member_responsibility plus plan_paid equals the allowed amount of the claim being reported". So for a copay claim, plan_paid = allowed - member_responsibility. Hmm, but that would mean the copay is the only member responsibility and the plan pays the rest. Yes, typical: copay replaces coinsurance; plan pays allowed minus copay.

But wait — do copays apply only after deductible? The plan says "Copays DO credit the deductible" — meaning copays are the member's responsibility regardless of deductible status, and they credit the deductible. There's no "deductible then copay" for office visits. So member responsibility for a specialist visit = 50.00 copay, and that 50 credits the deductible if room remains.

OOPM: copays credit OOPM.

Now, what about the OOPM cap mid-claim: member responsibility capped at OOPM remainder; plan pays the rest.

Let me now process.

Initial:
A: ded 60.69, oop 60.69
B: ded 383.93, oop 924.55
C: ded 1524.34, oop 2116.83
Fam: ded 1968.96, oop 3102.07

Line 1 — Claim 1 — C — INN inpatient surgery, allowed 10074.70.
- Deductible: C individual remainder: 2500 - 1524.34 = 975.66. Family remainder: 5000 - 1968.96 = 3031.04. deductible_applied = min(10074.70, 975.66, 3031.04) = 975.66.
- Coinsurance base: 10074.70 - 975.66 = 9099.04. Member coins 30% = 2729.712 → 2729.71.
- Member responsibility before OOPM check: 975.66 + 2729.71 = 3705.37.
- OOPM: C oop before = 2116.83. Individual INN OOPM 5500 remainder = 3383.17. Family OOPM 11000 remainder = 11000 - 3102.07 = 7897.93. Member resp 3705.37 < 3383.17? No! 3705.37 > 3383.17. So C hits individual OOPM on this claim. Member responsibility capped at 3383.17. Plan pays 10074.70 - 3383.17 = 6691.53.

Hmm wait — but then the deductible credit: does the full deductible_applied still credit? The member responsibility is capped at OOPM. The deductible_applied... Let me think. The claim's member responsibility = 3705.37 but capped by OOPM remainder 3383.17. So member pays 3383.17, plan pays 6691.53.

What about the deductible credit? The member's deductible balance: the amount they actually paid toward deductible... Hmm. The accumulator addendum says "A balance is the running total of deductible_applied (for a deductible)". The claim's deductible_applied = 975.66. But the member didn't pay all of it? Actually the member responsibility of 3383.17 covers the deductible portion 975.66 plus 2407.51 of coinsurance. So the deductible is fully credited (975.66) since member responsibility exceeds deductible_applied. So deductible balance C becomes 1524.34 + 975.66 = 2500.00 (individual deductible met). Family ded: 1968.96 + 975.66 = 2944.62.

OOP: C oop: 2116.83 + 3383.17 = 5500.00 (OOPM met). Family oop: 3102.07 + 3383.17 = 6485.24.

Hmm, wait. Let me double check the coinsurance rounding: 9099.04 * 0.30 = 2729.712 → 2729.71 (round half up at end of calculation). Member resp = 975.66 + 2729.71 = 3705.37. Cap at 3383.17. So member pays 3383.17.

Actually, hold on. Let me reconsider whether OOPM remainder uses family too. Family remainder 7897.93 > individual remainder 3383.17, so min = 3383.17. Cap applies either way.

Components for claim 1 (not asked, but for accumulators):
- deductible_applied: 975.66
- member_responsibility: 3383.17
- plan_paid: 6691.53
- copay: 0, coinsurance: hmm, if capped, coinsurance amount would be 3383.17 - 975.66 = 2407.51.

Now, when OOPM is reached, plan pays 100% of allowed for covered services for remainder of plan year. So C has met their individual INN OOPM (5500). For subsequent INN claims by C, member responsibility = 0. But for OON claims, the OON individual OOPM is 11000 — so C still has room under OON OOPM (11000 - 5500 = 5500 more?). Hmm, wait. The member's OOP balance is a single running total. The OON threshold is 11000 measured against the same balance. So for an OON claim, member responsibility is capped at 11000 - oop balance. And for INN claims, capped at 5500 - oop balance (if positive).

Also deductible: single balance; INN threshold 2500, OON threshold 5000. C's deductible balance is now 2500, so INN deductible met; OON deductible remainder = 5000 - 2500 = 2500 more for OON claims.

Line 2 — Claim 2 — A — specialty pharmacy administration, INN, allowed 4603.57. Not a copay service (specialty pharmacy administration — not listed copay; generic retail pharmacy is the copay one). So deductible + coinsurance.
A ded balance: 60.69. Individual INN remainder: 2500 - 60.69 = 2439.31. Family remainder: 5000 - 2944.62 = 2055.38. deductible_applied = min(4603.57, 2439.31, 2055.38) = 2055.38.
Coinsurance: 30% of (4603.57 - 2055.38) = 30% of 2548.19 = 764.457 → 764.46.
Member resp: 2055.38 + 764.46 = 2819.84.
OOPM: A oop 60.69, individual INN remainder 5500 - 60.69 = 5439.31. Family remainder: 11000 - 6485.24 = 4514.76. Member resp 2819.84 < min(5439.31, 4514.76). No cap.
A ded: 60.69 + 2055.38 = 2116.07. A oop: 60.69 + 2819.84 = 2880.53.
Fam ded: 2944.62 + 2055.38 = 5000.00 → family deductible met! Fam oop: 6485.24 + 2819.84 = 9305.08.

Line 3 — Claim 3 — B — specialist office visit, INN, allowed 339.69. Copay 50.
B ded balance 383.93. Individual remainder: 2500 - 383.93 = 2116.07. Family remainder: 5000 - 5000 = 0.00. Deductible applied = min(50, 2116.07, 0) = 0.00 (family deductible met, so no more deductible applies for INN claims — embedded: satisfied by lesser... once family met, deductible_applied 0).

Hmm wait — is that right? Under embedded, an individual satisfies their individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. Family deductible is now met (5000). So for all members, INN deductible is satisfied. deductible_applied = 0.

Member responsibility: copay 50.00. OOPM: B oop 924.55; remainder large. Member resp = 50.00.
Plan paid = 339.69 - 50.00 = 289.69.
deductible_applied = 0.00. copay_amount = 50.00. Coinsurance = 0.00.
B ded stays 383.93. B oop: 924.55 + 50 = 974.55. Fam ded stays 5000.00. Fam oop: 9305.08 + 50 = 9355.08.

Line 4 — Claim 4 — B — inpatient admission, OON, allowed 15484.21.
OON: deductible measured against OON individual threshold 5000, using member's single balance. B ded balance: 383.93. OON remainder: 5000 - 383.93 = 4616.07. deductible_applied = min(15484.21, 4616.07) = 4616.07. (Family amounts don't limit OON claims.)
Coinsurance OON: 50% of (15484.21 - 4616.07) = 50% of 10868.14 = 5434.07.
Member resp: 4616.07 + 5434.07 = 10050.14.
OOPM check: B oop before: 974.55. Individual OON OOPM: 11000. Remainder: 11000 - 974.55 = 10025.45. Family remainder (11000 - 9355.08 = 1644.92)? Hmm — does family OOPM limit an OON claim? The addendum says "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." So for OON claims, only the OON individual threshold (11000) applies; family OOPM does NOT limit. So remainder = 10025.45.

Member resp 10050.14 > 10025.45. Cap at 10025.45. Plan pays 15484.21 - 10025.45 = 5458.76.

Deductible credit: B pays 10025.45 total; deductible_applied 4616.07 — member responsibility covers deductible fully. B ded: 383.93 + 4616.07 = 5000.00. (OON deductible met.)
B oop: 974.55 + 10025.45 = 11000.00. (OON OOPM met.)
Fam ded: 5000.00 + 4616.07 = 9616.07. Fam oop: 9355.08 + 10025.45 = 19380.53.

Hmm, family OOPM 11000 is way exceeded (19380.53). The addendum says balances are not capped at in-network amounts; OON claims can carry balances past family amounts. OK.

Note: family deductible balance 9616.07 — but family deductible threshold is 5000, already met. The balance just keeps growing (running total of deductible_applied). That's fine per addendum: "the balances are not capped at the in-network amounts."

Now B has met OON OOPM 11000. So for B, subsequent OON claims: member resp 0? Yes, since balance 11000 ≥ 11000. And INN claims: individual INN OOPM 5500 — B's oop balance 11000 > 5500, so INN OOPM also met (balance exceeds). So B pays nothing more this year for covered services.

Line 5 — Claim 5 — B — urgent care, INN, allowed 181.01. Copay 60.
B oop balance 11000 ≥ 5500 (INN OOPM) → plan pays 100%. Member resp = 0.00. Plan paid = 181.01.
deductible_applied = 0.00 (copay would credit deductible, but OOPM met → no member responsibility at all; also deductible thresholds met).
copay_amount: hmm. The copay is waived? The member pays 0. The copay amount... The claim is a copay claim but member responsibility is 0 due to OOPM. I'd report copay_amount 0.00 and member_responsibility 0.00. Actually let me think: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." So member responsibility 0. The copay doesn't apply. copay_amount = 0.00.
Accumulators: no movement (member resp 0, deductible applied 0).
B ded stays 5000.00, B oop stays 11000.00. Fam stays ded 9616.07, oop 19380.53.

Line 6 — Claim 6 — A — urgent care, INN, allowed 213.67. Copay 60.
A ded balance 2116.07. Individual INN remainder: 2500 - 2116.07 = 383.93. Family remainder: 0 (met). deductible_applied = 0.00.
Member resp = copay 60.00. OOPM: A oop 2880.53, remainder large. Member resp = 60.00.
Plan paid: 213.67 - 60.00 = 153.67.
A oop: 2880.53 + 60 = 2940.53. A ded: 2116.07 + 0 = 2116.07 (no deductible credit since family met; the copay credits deductible only if room — there's no room, so 0).
Wait, "Copays DO credit the deductible." — but "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." The applicable threshold for an INN claim is min(individual remainder, family remainder). Family remainder is 0. So deductible_applied = 0.00. Yes.
Fam ded: 9616.07. Fam oop: 19380.53 + 60 = 19440.53.

Claim 6 original components: member resp 60.00, plan paid 153.67, ded applied 0.00, copay 60.00, coins 0.00.

Line 7 — Claim 7 — C — specialist office visit, INN, allowed 330.22. Copay 50.
C oop balance: 5500 (met individual INN OOPM). So member resp = 0. Plan paid 330.22. Ded applied 0. copay 0.
Accumulators unchanged. C ded 2500.00, C oop 5500.00. Fam unchanged: ded 9616.07, oop 19440.53.

Wait — but C's OOPM met at 5500 for INN. But what about the family OOPM? Family oop balance is 19440.53 which exceeds 11000 anyway. Fine.

Hmm, actually wait. Let me reconsider: when C hit their individual OOPM at claim 1, family oop was 6485.24. Family OOPM 11000 not yet met. Individual OOPM met → C pays nothing more for INN. For OON, C's OON OOPM 11000: remainder 11000 - 5500 = 5500. So C can still owe on OON claims.

Line 8 — Claim 8 — C — sleep study, OON, allowed 1805.31.
OON: deductible measured against OON individual threshold 5000 on C's balance 2500.00. Remainder: 5000 - 2500 = 2500.00. deductible_applied = min(1805.31, 2500.00) = 1805.31.
Coinsurance OON 50%: 50% of (1805.31 - 1805.31) = 0.
Member resp = 1805.31.
OOPM: OON individual remainder: 11000 - 5500 = 5500. Member resp 1805.31 < 5500. No cap.
C ded: 2500 + 1805.31 = 4305.31. C oop: 5500 + 1805.31 = 7305.31.
Fam ded: 9616.07 + 1805.31 = 11421.38. Fam oop: 19440.53 + 1805.31 = 21245.84.

Line 9 — ADJUSTMENT to Claim 6 — allowed corrected to 277.77.
Unwind Claim 6's credits: member resp 60.00 (A oop: 2940.53 - 60 = 2880.53; fam oop: 19440.53 - 60 = 19380.53). Deductible applied was 0, so no deductible change. A ded stays 2116.07, fam ded stays 9616.07.

Re-adjudicate Claim 6 at allowed 277.77 against accumulators as they stand:
A ded balance 2116.07. Individual INN remainder: 2500 - 2116.07 = 383.93. Family remainder: 5000 - 9616.07 → negative → 0 (family met). deductible_applied = 0.
Member resp = copay 60.00. OOPM: A oop 2880.53 → fine.
Plan paid = 277.77 - 60.00 = 217.77.
Components now: member resp 60.00, plan paid 217.77, ded applied 0.00, copay 60.00, coins 0.00.
Accumulators: A oop: 2880.53 + 60 = 2940.53. Fam oop: 19380.53 + 60 = 19440.53.

So after Line 9, same as after Line 7 state (A oop 2940.53, fam oop 19440.53).

Line 10 — Claim 10 — C — ambulatory surgery, OON, allowed 8945.95.
C ded balance 4305.31. OON remainder: 5000 - 4305.31 = 694.69. deductible_applied = min(8945.95, 694.69) = 694.69.
Coinsurance OON 50% of (8945.95 - 694.69) = 50% of 8251.26 = 4125.63.
Member resp: 694.69 + 4125.63 = 4820.32.
OOPM: C oop 7305.31. OON individual remainder: 11000 - 7305.31 = 3694.69. Member resp 4820.32 > 3694.69 → cap at 3694.69.
Plan paid: 8945.95 - 3694.69 = 5251.26.
Deductible credit: member resp 3694.69 ≥ ded applied 694.69 → full credit. C ded: 4305.31 + 694.69 = 5000.00 (OON deductible met).
C oop: 7305.31 + 3694.69 = 11000.00 (OON OOPM met).
Fam ded: 11421.38 + 694.69 = 12116.07. Fam oop: 21245.84 + 3694.69 = 24940.53.

Now C has met OON OOPM 11000. So C pays nothing more this year (INN OOPM 5500 also exceeded).

Line 11 — ADJUSTMENT to Claim 6 (again) — allowed corrected to 277.77. Same as line 9's values.

Hmm, interesting — a second adjustment to Claim 6 with the same corrected allowed amount. So we unwind Claim 6's current credits (member resp 60.00, ded applied 0) and re-adjudicate at 277.77.

Unwind: A oop: 2940.53 - 60 = 2880.53. Fam oop: 19440.53 - 60 = 19380.53. Ded unchanged (0 credit).

Re-adjudicate at allowed 277.77: A ded balance 2116.07, individual remainder 383.93, family remainder 0 (fam ded balance 12116.07 > 5000). deductible_applied 0. Member resp = 60.00 copay. Plan paid = 217.77.
A oop: 2880.53 + 60 = 2940.53. Fam oop: 19380.53 + 60 = 19440.53.

Final Claim 6 components (after adjustment): member resp 60.00, plan paid 217.77, ded applied 0.00, copay 60.00, coins 0.00.

Line 12 — Claim 12 — C — inpatient admission, INN, allowed 23123.73.
C oop balance 11000 ≥ 5500 (INN OOPM met) → member resp 0.00. Plan paid 23123.73. Ded applied 0. No accumulator movement.
C ded 5000.00, C oop 11000.00. Fam ded 12116.07, fam oop 19440.53.

Wait — family oop: no movement since member resp 0. Fam oop stays 19440.53. Yes.

Hmm wait, after line 11, fam oop = 19440.53. Claim 12: member resp 0 → fam oop unchanged 19440.53.

Line 13 — Claim 13 — A — outpatient procedure, INN, allowed 5196.38.
A ded balance 2116.07. INN individual remainder: 2500 - 2116.07 = 383.93. Family remainder: 0 (met). deductible_applied = 0.00.
Coinsurance: 30% of 5196.38 = 1558.914 → 1558.91.
Member resp: 1558.91. OOPM: A oop 2940.53; INN individual remainder 5500 - 2940.53 = 2559.47. 1558.91 < 2559.47. OK.
Plan paid: 519

Let me carefully work through this ledger.

Plan: Trinity HDHP 3200.
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- Structure: AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
- Out-of-network (individual) deductible: 6400.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The OON threshold is 6400.00 measured against that balance when the service is OON.

OOPM:
- Individual in-network: 7000.00
- Family in-network: 14000.00
- Individual OON: 14000.00
- Once a member reaches the OOPM, plan pays 100% of allowed for covered services for remainder of plan year.

Coinsurance: 10% member in-network after deductible; 40% member OON after deductible. No copays.

Preventive: in-network preventive at 100% allowed, no cost share. OON preventive subject to OON deductible and coinsurance.

Accumulator rules:
- deductible_applied = LESSER of allowed amount and room left under the deductible threshold that applies:
  - in-network: family remainder alone (aggregate)
  - out-of-network: the OON individual remainder, measured against the member's same single deductible balance.
- Once applicable threshold met, deductible_applied = 0.00.
- A balance is running total of deductible_applied (deductible) or member_responsibility (OOPM).
- OON claims measured against OON individual thresholds only; family amounts don't limit an OON claim. But OON credits still accumulate to member's balance and family balance.

Hmm, wait. Let me re-read carefully:

"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
    in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
    out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."

So for in-network claims under aggregate: deductible_applied = min(allowed, family remainder) where family remainder = 6400 - family deductible balance.

For OON claims: deductible_applied = min(allowed, OON individual remainder) where OON individual remainder = 6400 - member's single deductible balance. Note: this is measured against the member's single deductible balance which includes both in-network and OON credits. So the member's balance is compared against 6400 for OON.

Important nuance: For in-network claims under aggregate structure, is the deductible_applied limited by the member's individual amount? The doc says "There is no individual deductible under this structure." So no — in-network claims are limited only by the family remainder (6400 - family balance). Interesting: so a single member could satisfy the entire family deductible alone. Under a true aggregate, yes.

But wait — the OON claims: "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." So for an OON claim, the limit is the OON individual remainder = 6400 - member's single deductible balance. Hmm, but does the family remainder also limit an OON claim? The text says the family amounts do not limit an OON claim. So OON claim's deductible_applied = min(allowed, 6400 - member balance).

Hmm, but there's a subtlety: under aggregate structure, no member reaches coinsurance (in-network) until family deductible met. But an OON claim is measured against the member's OON individual threshold of 6400. So a member with an OON claim could hit coinsurance on that OON claim once their own balance reaches 6400, even if the family balance is less than 6400? Wait, but the family balance includes all members' credits. If member A's balance is 6400, the family balance is at least 6400 (since family balance is the sum of member balances). Actually yes — family total = sum of member totals. So if A's balance reaches 6400, family balance ≥ 6400, so family deductible met anyway.

But could a member's OON claim exceed the family in-network remainder? E.g., family balance is 3112.34, family remainder = 3287.66. A's balance is 1729.94, A's OON remainder = 6400 - 1729.94 = 4670.06. If A has an OON claim of allowed 4670.06+, the deductible_applied would be 4670.06 (the OON remainder), which pushes family balance past 6400. That's what the doc says: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

OK. Now OOPM: "Individual (in-network) 7000.00; Family (in-network) 14000.00; Individual (out-of-network) 14000.00. Once a member reaches the out-of-pocket maximum the plan pays 100%..."

Question: which OOPM threshold applies to a claim? For in-network claims, presumably the individual 7000 and family 14000 thresholds. For OON claims... the individual OON threshold is 14000. Hmm, and family OON? Not specified — only "Family (in-network) 14000.00". The OOPM section lists: Individual in-network 7000, Family in-network 14000, Individual OON 14000.

The deductible addendum says OON claims are measured against OON individual thresholds only. Does a similar rule apply for OOPM? The OOPM addendum isn't given explicitly beyond the plan document. Hmm.

Let me think about how OOPM works here. The OOPM is a ceiling on member cost share. Once a member reaches the OOPM, plan pays 100%. Also family OOPM: once family OOPM reached... typically, once the family OOPM is reached, no further member cost share for anyone. The plan says "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."

So member-level: a member's cost share is capped so that their OOP balance doesn't exceed the applicable OOPM. For in-network services, applicable OOPM = 7000 individual; for OON = 14000? Hmm, but typically in real HDHPs, there's a single combined OOPM. Here the plan separates: individual in-network 7000, individual OON 14000.

But note the glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year." And "Accumulator: the running year-to-date total of a member's deductible or OOPM."

The addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

Hmm — so the OOP balance is the running total of member_responsibility across all claims (in-network and OON). The question is what threshold caps it. For a member, the in-network individual OOPM is 7000; the OON individual OOPM is 14000.

For an in-network claim, member cost share is capped so that member's OOP balance ≤ 7000? And also the family OOP balance ≤ 14000 (family in-network OOPM)? Hmm.

Actually, let's think. Family OOPM 14000 (in-network). Once the family OOPM is reached, the plan pays 100% for everyone (that's the standard meaning). The plan document says "Once a member reaches the out-of-pocket maximum..." — it frames it member-wise. But the family OOPM presumably works similarly: once family accumulations reach 14000, no more member cost share for in-network services for any member.

For OON claims: individual OON OOPM is 14000. There's no family OON OOPM listed. Hmm. So an OON claim's member responsibility is capped by the member's OON individual OOPM (14000 - member OOP balance)? And the family in-network OOPM of 14000 — does it limit OON claims? The deductible addendum says family amounts are in-network amounts and do not limit OON claims (for deductibles). Maybe similar logic for OOPM? That's not explicitly stated for OOPM though.

Let me just process the ledger and see whether these edge cases matter.

Initial accumulators (before Line 1):
A: deductible 1729.94, OOP 1762.13
B: deductible 0.00, OOP 0.00
C: deductible 1382.40, OOP 1945.98
Family: deductible 3112.34, OOP 3708.11

Note: family deductible 3112.34 = 1729.94 + 1382.40 ✓. Family OOP 3708.11 = 1762.13 + 1945.98 ✓.

Family deductible remainder (in-network): 6400 - 3112.34 = 3287.66.

Line 1 — Claim 1 — A — PT, in-network, allowed 1553.18.
Aggregate: deductible_applied = min(1553.18, family remainder 3287.66) = 1553.18. Member responsibility = 1553.18 (all deductible). Plan paid = 0.
A deductible: 1729.94 + 1553.18 = 3283.12. A OOP: 1762.13 + 1553.18 = 3315.31.
Family deductible: 3112.34 + 1553.18 = 4665.52. Family OOP: 3708.11 + 1553.18 = 5261.29.
Family remainder now: 6400 - 4665.52 = 1734.48.

Line 2 — Claim 2 — A — inpatient, in-network, allowed 21710.91.
Deductible_applied = min(21710.91, 1734.48) = 1734.48. Remainder of allowed after deductible: 21710.91 - 1734.48 = 19976.43. Coinsurance 10% = 1997.643 → 1997.64 (round half up at end; let me be careful: 1997.643 rounds to 1997.64).

Member responsibility = 1734.48 + 1997.64 = 3732.12. Plan paid = 21710.91 - 3732.12 = 17978.79.

Check OOPM: A's OOP before = 3315.31. Adding 3732.12 → 7047.43. That exceeds A's in-network individual OOPM of 7000! So we need to cap.

Hmm wait — A's OOP balance before claim 2 is 3315.31. In-network individual OOPM = 7000. Remaining room = 7000 - 3315.31 = 3684.69. Member responsibility would be 3732.12 > 3684.69. So cap member responsibility at 3684.69? Then plan pays the rest.

But wait — should the OOPM cap apply to the deductible portion too? The OOPM is a ceiling on member cost share total. Yes — once the member's OOP balance hits the OOPM, the plan pays 100% of allowed. So member responsibility is capped at the room remaining under the OOPM.

But then how does this interact with the deductible credit? Hmm. If member responsibility is capped by OOPM, does the deductible still get credited fully? This is a tricky interaction. The deductible_applied is defined as min(allowed, room under deductible threshold). The OOPM cap reduces the member's payment. Hmm.

Let me think about how real adjudication works: when a member's OOPM is reached mid-claim, the member pays only up to the OOPM, and the plan pays the rest. The deductible credit... typically the deductible credit is the amount the member actually paid toward deductible. If the OOPM caps the payment, then the deductible credit would be limited too.

But the addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

So deductible balance = sum of deductible_applied, and OOP balance = sum of member_responsibility. These are separate accumulators. The deductible_applied is defined as min(allowed, room under deductible threshold) — it doesn't mention OOPM capping.

Hmm, but if the member's OOPM is reached, the plan pays 100%, and the member pays nothing more. If we still credit the deductible with amounts the member didn't pay, that's weird but the addendum's definition is mechanical.

Wait, let's check whether the OOPM actually gets hit before the deductible. In an HDHP, the deductible (3200 individual/6400 family) is much lower than the OOPM (7000 individual/14000 family), so normally the deductible is satisfied before the OOPM. But with coinsurance at 10%, after the family deductible of 6400, remaining to family OOPM 14000 is 7600 of coinsurance at 10% member... For A individually: A's OOP balance 3315.31; individual OOPM 7000. A's cost share on claim 2 = 3732.12, which would take A to 7047.43 > 7000.

Hmm interesting — A reaches the individual in-network OOPM on claim 2 (mid-claim). Let me reconsider: is the individual OOPM applicable given the aggregate structure? The plan document lists "Individual (in-network) OOPM 7000" and "Family (in-network) 14000". The glossary says once reached, plan pays 100% of allowed for covered in-network services. The plan document says "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."

So yes, individual OOPM applies per member. A hits it on claim 2.

So on claim 2: A's OOP room = 7000 - 3315.31 = 3684.69. The calculated cost share = 3732.12 (1734.48 deductible + 1997.64 coinsurance). Capped at 3684.69. So member responsibility = 3684.69, plan paid = 21710.91 - 3684.69 = 18026.22.

Now what about the deductible credit? The claim generated deductible_applied of 1734.48 per the formula. But the member only paid 3684.69 total, of which... how do we split? If the member pays 3684.69, and the deductible portion is 1734.48, coinsurance portion = 3684.69 - 1734.48 = 1950.21 (less than the 1997.64 calculated). Hmm, that's one way: deductible is credited first, then coinsurance capped.

Alternatively, the deductible credit is reduced. Hmm.

The addendum defines deductible_applied mechanically as min(allowed, room under threshold). It doesn't mention OOPM. And it says "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." It's silent on OOPM interaction with deductible credits.

Hmm, but there's a real tension: if A's OOPM is reached, A pays nothing more for the rest of the year (in-network). Then deductible credits for A afterwards would be... the deductible balance would stop mattering for A's in-network claims (since A pays 0). But the deductible balance still matters for the family aggregate (other members' claims) and for A's OON claims? Wait, if A reached the in-network individual OOPM of 7000, does that mean A pays nothing for OON claims either? The OON individual OOPM is 14000. Hmm — "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services" — which OOPM? If in-network and OON accumulate to a single OOP balance (like the deductible single balance), then the thresholds differ: 7000 for in-network services, 14000 for OON services? That parallels the deductible structure: single balance, different thresholds by network.

Actually the plan document lists separate OOPMs: individual in-network 7000, individual OON 14000. The deductible section explicitly says in-network and OON credits accumulate to a SINGLE member deductible balance, with the OON amount being the threshold when the service is OON. The OOPM section doesn't say that explicitly, but by analogy, the OOP balance is a single running total of member_responsibility, and the threshold applied depends on the network of the service being adjudicated: 7000 for in-network, 14000 for OON.

Hmm, but the glossary says "Once reached, the plan pays 100% of the allowed amount for covered in-network services." That suggests the OOPM applies to in-network services.

Let me now check: does A reach 7000 in-network OOPM on claim 2? A's OOP balance before claim 2 = 3315.31 (which includes the PT claim and prior accumulations). Yes, 3315.31 + 3732.12 = 7047.43 > 7000. So capped at 3684.69 → A's OOP = 7000.00 exactly.

After that, A pays nothing for in-network services for the rest of the year (claims 4, 9, 12, 18, 20 for A in-network; claim 6 is OON; claim 16 is adjustment to claim 6).

For A's OON claim 6: threshold is the OON individual OOPM 14000. A's OOP balance = 7000. Room = 7000. So A can still pay up to 14000 total for OON services.

Hmm wait, but hold on. Let me reconsider whether the individual in-network OOPM applies to A, given the aggregate deductible. Yes, OOPM is separate from deductible structure. Individual OOPM 7000 applies per member.

But also the family OOPM 14000 (in-network). Family OOP before claim 2 = 5261.29. Adding A's 3684.69 → 8945.98. Not yet 14000.

Hmm, wait. Let me reconsider. Actually, let me reconsider whether the OOPM cap on claim 2 changes the deductible credit. This matters a lot downstream because the family deductible determines coinsurance for other members (B and C), and the adjustment/void mechanics.

Let me think about what's most defensible mechanically per the addendum:

"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it."

For claim 2 (in-network, aggregate): room left under family deductible = 1734.48. So deductible_applied = 1734.48. This is mechanical and doesn't reference the OOPM.

"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

So deductible balance moves by deductible_applied regardless of OOPM capping? That would mean A's deductible balance and family deductible balance both increase by 1734.48 even though A only paid 3684.69 total (with the deductible portion... hmm).

But wait — if the OOPM caps the member's payment at 3684.69, and the deductible_applied is 1734.48, then the coinsurance portion = 3684.69 - 1734.48 = 1950.21. The plan pays 21710.91 - 3684.69 = 18026.22. The components: deductible 1734.48, coinsurance 1950.21, copay 0.

Hmm, but is that right? Alternative: the OOPM cap applies to the coinsurance portion only? No — the OOPM is a ceiling on total member cost share including deductible.

Alternatively: the deductible credit should be reduced to what the member actually paid. If the member pays 3684.69 and the deductible room is 1734.48... the member's payment covers the deductible first (1734.48), then 1950.21 of coinsurance. So the deductible credit is fully paid by the member anyway. So no tension here! The member's payment of 3684.69 > 1734.48, so the deductible is fully credited. The only reduction is in coinsurance (1997.64 → 1950.21).

OK so claim 2: deductible_applied = 1734.48, coinsurance = 1950.21, member resp = 3684.69, plan paid = 18026.22.

After claim 2:
A: deductible 1729.94 + 1553.18 + 1734.48 = 5017.60. OOP 1762.13 + 1553.18 + 3684.69 = 7000.00.
Family: deductible 3112.34 + 1553.18 + 1734.48 = 6400.00. OOP 3708.11 + 1553.18 + 3684.69 = 8945.98.

Family deductible is now exactly 6400.00 — met! So all subsequent in-network claims for any member have deductible_applied = 0 and just 10% coinsurance (subject to OOPM).

A's in-network OOPM (7000) is met — A pays nothing for in-network services henceforth.

Line 3 — Claim 3 — C — outpatient infusion, in-network, allowed 454.13.
Family deductible met → deductible_applied = 0. Coinsurance 10% = 45.413 → 45.41. Member resp = 45.41. Plan paid = 454.13 - 45.41 = 408.72.
C OOP before: 1945.98. C's individual in-network OOPM = 7000. Room plenty. Family OOP: 8945.98 + 45.41 = 8991.39 < 14000. OK.
C: deductible stays 1382.40, OOP = 1945.98 + 45.41 = 1991.39.
Family OOP = 8991.39.

Line 4 — Claim 4 — A — inpatient with surgery, in-network, allowed 17679.63.
Family deductible met → deductible 0. Coinsurance would be 10% = 1767.963 → 1767.96. But A's OOPM is met (7000). So member resp = 0.00, plan paid = 17679.63.
A: no change. Family: no change.

Hmm — but wait. Does A's OOPM being met mean the claim's member responsibility is 0? Yes: "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."

So claim 4: member resp 0.00, plan paid 17679.63, deductible 0, coinsurance 0.

Line 5 — Claim 5 — C — annual wellness visit, OON, allowed 771.12.
Preventive but OON → subject to OON deductible and coinsurance (per family rules: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance.").

OON deductible: member's single deductible balance measured against 6400. C's deductible balance = 1382.40. OON individual remainder = 6400 - 1382.40 = 5017.60. Allowed 771.12 < 5017.60, so deductible_applied = 771.12. Member resp = 771.12 (all deductible; no coinsurance since deductible threshold... wait, the OON threshold is 6400 and C's balance is 1382.40, so the deductible isn't met; the entire allowed goes to de

Let me carefully work through this ledger.

Plan: Pecos Select 2500
- Individual in-network deductible: 2500.00
- Family in-network deductible: 5000.00
- EMBEDDED
- Out-of-network individual deductible: 5000.00 (measured against same single member deductible balance)
- OOPM: Individual in-network 5500.00; Family in-network 11000.00; Individual out-of-network 11000.00
- Coinsurance after deductible: in-network 30% member / 70% plan; out-of-network 50/50
- Copays: PCP 25, specialist 50, urgent care 60, ER 300 (waived if admitted → then deductible+coinsurance), generic retail pharmacy 10
- Copays DO credit the deductible. Copays always credit OOPM.
- Preventive in-network: 100% allowed, no cost share, no accumulator movement.
- Member cost share from ALLOWED amount.
- deductible_applied = lesser of allowed amount and room left under applicable threshold. Once threshold met, deductible_applied 0.00.
- For in-network: embedded — smaller of member individual remainder and family remainder.
- Out-of-network: out-of-network individual remainder measured against member's same single deductible balance.
- OOPM balance: running total of member_responsibility. Balances not capped at in-network amounts.
- Out-of-network claims measured against OON individual thresholds only; family amounts don't limit OON claim. Credits still accumulate to member and family balances.

Wait — but for family OOPM, is there a family OOPM check? The plan says family OOPM 11000 in-network. The accumulator rules mention deductible thresholds with family remainder; for OOPM, once member reaches OOPM, plan pays 100%. What about family OOPM? Typically once family OOPM reached, all members are protected. The plan document says "Out-of-pocket maximum: Individual (in-network) 5500, Family (in-network) 11000, Individual (out-of-network) 11000. 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."

Hmm, the family OOPM — does reaching family OOPM protect all members? The document lists family OOPM of 11000. The addendum says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." and "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

The question is whether a claim's member responsibility is capped by the family OOPM. Typically, family OOPM works like aggregate: once family OOPM is reached, no more member cost share for anyone. The document lists family OOPM 11000, which strongly implies it functions. The addendum's statement that balances are "not capped at the in-network amounts" refers to balances (the accumulators) being able to exceed, not that thresholds don't apply.

But the addendum explicitly describes how deductible_applied is computed with thresholds, and for OOPM it says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." It says "a member". Hmm, but family OOPM of 11000 — when family total reaches 11000, presumably all members' cost share ends.

Let me think about whether this matters in the computation. Let's process the ledger and see.

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

Family deductible remainder initially: 5000 − 2895.39 = 2104.61.
Family OOPM remainder initially: 11000 − 3051.40 = 7948.60.

Individual deductible in-network: 2500 each.

Line 1 — Claim 1 — D — ED visit in-network, treated and released. Allowed 3295.94. ER copay 300 (not admitted). Copays DO credit deductible. So the claim: copay 300.00, then deductible? Hmm — how does an ER visit with copay work with deductible? The ER copay is 300. Does the ER visit also subject to deductible/coinsurance? Typically ER copay applies, and the rest of allowed amount... hmm. Let me think.

Plan says "Emergency room: 300.00 copay, WAIVED if the visit results in an inpatient admission, in which case the visit is subject to the deductible and coinsurance."

So if not admitted: 300 copay. Is the remainder of allowed amount subject to deductible and coinsurance? The plan doesn't say the ER visit is subject to deductible+coinsurance in addition to copay. Common plan designs: ER copay plus coinsurance, but the document as given just lists a copay schedule. The simplest reading: ER visit not admitted → member pays 300 copay (plus presumably nothing else? or deductible/coinsurance on the rest?).

Hmm. This is a designed task; the intended interpretation matters. Let's consider the design: "Copays DO credit the deductible." So the copay credits the deductible. The accumulator rule: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So for a copay claim: deductible_applied = lesser of allowed amount and room left. For a copay-only claim (like urgent care), member responsibility = copay (60). deductible_applied = lesser of allowed (182.07) and room left. Hmm, but then does the member responsibility get reduced by deductible credit? For copay claims, the member responsibility IS the copay. The deductible_applied is the credit to the deductible balance.

Wait, but there's a subtlety: is the copay reduced/absorbed by the deductible? "Copays DO credit the deductible" — meaning the copay amount paid counts toward the deductible balance. And "deductible_applied is the LESSER of its allowed amount and the room left... including for a copay that would otherwise credit the deductible. Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So for a copay claim, deductible_applied = min(allowed, room). But the member responsibility is the copay amount regardless (60), unless OOPM caps it.

Hmm wait, but that seems odd: if room left is 10 and copay is 60, deductible_applied = 10? Or deductible_applied = copay amount (60) but capped at room? Let me re-read: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it". For a copay claim, allowed amount is e.g. 182.07, room left maybe large, so deductible_applied = 182.07? That would credit the full allowed amount to the deductible, not just the copay. Hmm, that seems to be what the rule says: deductible_applied is lesser of allowed amount and room left. So a copay claim credits min(allowed, room) to the deductible.

Hmm, that's a strange plan design but it's what the rule says. Let's go with the mechanical rule: deductible_applied = min(allowed amount, room left under applicable threshold).

Actually wait. Let me reconsider. For ER not admitted: is member responsibility just 300 copay, or 300 copay plus deductible/coinsurance on the rest? The plan lists "Emergency room: 300.00 copay, WAIVED if the visit results in an inpatient admission, in which case the visit is subject to the deductible and coinsurance." The phrase "in which case the visit is subject to the deductible and coinsurance" implies that in the non-admitted case, the visit is NOT subject to deductible and coinsurance — just the copay. That's the natural reading: copay waived if admitted; if admitted, subject to deductible and coinsurance instead.

So ER treated and released: member responsibility = 300 copay. Deductible credit: min(allowed, room).

But hold on — does the whole allowed amount credit the deductible for a copay claim? Per the accumulator rule, yes: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... including for a copay that would otherwise credit the deductible."

Hmm, "including for a copay that would otherwise credit the deductible" — meaning even when the threshold is met, a copay claim's deductible_applied is 0.00. And when not met, the copay claim's deductible_applied = min(allowed, room). So yes, the full allowed amount (up to room) credits the deductible.

Wait, but that creates a weird situation: a 60 copay on a 182.07 allowed urgent care visit credits 182.07 to deductible. Then when the deductible is met, the member starts paying coinsurance. Hmm, but the member has only paid 60 toward it. That's generous to the member but mechanically it's what the rule says. Let me double check with the "member_responsibility plus plan_paid equals the allowed amount" rule: For a copay claim, member responsibility 60, plan paid 122.07, allowed 182.07. OK.

Hmm, but wait. Actually let me reconsider whether the plan intends the copay claim to also charge deductible+coinsurance beyond the copay. Common real-world design: "ER copay 300 plus coinsurance" or "after deductible". But this synthetic plan seems designed with the accumulator rule to make copay claims credit the full allowed amount to the deductible. That's the design that makes "deductible_applied is the LESSER of its allowed amount and the room left" coherent — the deductible_applied for a copay claim is based on allowed amount.

Hmm, actually, maybe for copay claims, deductible_applied should be min(copay, room)? "Copays DO credit the deductible" — the copay credits the deductible. So the credit = copay amount. But then "deductible_applied is the LESSER of its allowed amount and the room left" — for a copay claim... hmm.

Let me think about which interpretation the task designers intended. The sentence: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." This tells us that even when the deductible is met, a copay claim still charges the copay (member responsibility = copay), but credits 0 to the deductible. So "a copay that would otherwise credit the deductible" = the copay normally credits the deductible, but when threshold met, deductible_applied = 0.

So for copay claims, the credit to deductible = copay amount? Or allowed amount? The general rule says "LESSER of its allowed amount and the room left". Hmm.

Consider: urgent care allowed 182.07, copay 60. Room left 2104.61. If deductible_applied = 182.07, the deductible balance jumps by 182.07 even though member paid 60. If deductible_applied = 60, then "lesser of allowed amount and room" doesn't fit because 60 ≠ min(182.07, 2104.61).

The rule explicitly says "its allowed amount". So deductible_applied = min(allowed, room). I think the designers intend the full allowed to credit. This is a synthetic plan; the mechanics are as stated. Let me go with deductible_applied = min(allowed, room) for all claims, including copay claims.

Hmm wait, but actually, let me reconsider. Is that right? "Copays DO credit the deductible." Maybe the meaning is just that copay claims are not exempt from the deductible (unlike typical plans where copays don't count). And the mechanism is the accumulator rule: the claim's deductible_applied = min(allowed, room left). For a copay claim, since the member pays only the copay, but the allowed amount credits the deductible... Hmm, that's weird but consistent with the rule text.

Actually, hold on. Let me reconsider the ER case. If ER copay claim credits full allowed to deductible, then... Line 1: D, ED visit, allowed 3295.94, copay 300. D's deductible balance: 1150.72. Individual remainder: 2500 − 1150.72 = 1349.28. Family remainder: 5000 − 2895.39 = 2104.61. Embedded: smaller = 1349.28. deductible_applied = min(3295.94, 1349.28) = 1349.28. D's ded balance → 2500.00 (individual met). Family ded → 2895.39 + 1349.28 = 4244.67.

Member responsibility: 300 copay. OOPM: D oop 1150.72 + 300 = 1450.72. Family oop 3051.40 + 300 = 3351.40.

Plan paid: 3295.94 − 300 = 2995.94.

OK. Under the alternative interpretation (member responsibility = copay, and deductible credit = copay), D's ded would be 1150.72 + 300 = 1450.72, and family 3195.39. Hmm.

Which interpretation? Let me look at the OOPM rule for guidance: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So the deductible balance = sum of deductible_applied amounts. And deductible_applied = min(allowed, room). The rule is uniform across claims. So yes, copay claims credit min(allowed, room) to the deductible.

I'm fairly confident: deductible_applied = min(allowed amount, room left under applicable threshold), for every claim (copay or not), and member responsibility is the copay for copay claims (subject to OOPM cap).

Hmm, but wait — for a copay claim, should member responsibility be reduced if... no. Copay claims: member pays copay. Unless OOPM reached, then 0.

What about a claim that's subject to deductible+coinsurance: member responsibility = deductible_applied + coinsurance on (allowed − deductible_applied). And once deductible met, member responsibility = coinsurance on allowed. Once OOPM met, member responsibility = 0.

Also, what about the ER copay claim when the member's OOPM is reached mid-year — member responsibility 0.

Now, does the OOPM cap apply per-claim (whole claim becomes 0 once OOPM already met) or does a claim straddling the OOPM threshold charge only up to the remainder? Standard: the member pays up to the OOPM; once the OOPM is reached, plan pays 100%. If a claim would push the member past the OOPM, the member pays the remainder up to OOPM and the plan pays the rest. The rule: "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." So the member responsibility is capped at the OOPM remainder. I'll apply that: member responsibility = min(claim's natural cost share, OOPM remainder) where OOPM remainder = threshold − current oop balance.

But which threshold? Individual OOPM in-network 5500 vs out-of-network 11000. The addendum says "Out-of-network claims are measured against the out-of-network individual thresholds only". So for an OON claim, the member's cost share is capped by the OON individual OOPM (11000) remainder, not the in-network 5500. And family OOPM 11000 (in-network) — does it cap anything? The addendum says for OON claims, family amounts don't limit. For in-network claims, does the family OOPM limit? Hmm.

The plan document lists family OOPM 11000 in-network. The addendum describes balances but doesn't explicitly say how family OOPM caps claims. Let me think about the design. The addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."

So balances can exceed in-network amounts. The question is whether the family OOPM (11000) caps member responsibility on in-network claims when the family total is near 11000. In typical plans, yes — family OOPM works like an aggregate stop-loss. The document says "Once a member reaches the out-of-pocket maximum the plan pays 100%". It says "a member", but family OOPM is listed, so presumably when family OOPM is reached, everyone is protected.

Hmm, but the addendum is careful about thresholds: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network: the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network: the out-of-network individual remainder". Note: for deductible, in-network uses min(individual remainder, family remainder).

By analogy, for OOPM on in-network claims: the cap would be min(member's individual OOPM remainder, family OOPM remainder). For OON claims: OON individual OOPM remainder (11000 − member's oop balance)... and family doesn't limit.

Hmm, wait. But there's a subtlety: the member's oop balance is a single balance (in-network and out-of-network credits accumulate to it? The plan says in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. For OOPM, there's individual in-network 5500 and individual OON 11000. Presumably a single OOPM balance too, measured against different thresholds depending on the claim's network.)

Actually the plan says: "Out-of-pocket maximum: Individual (in-network) 5500. Family (in-network) 11000. Individual (out-of-network) 11000. 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." And the addendum: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the innaires amounts."

So a member's oop balance is single, and it can exceed 5500 (if driven by OON claims). Then for a subsequent in-network claim, if the member's balance is already above 5500 (say 6000), is the member protected for in-network claims? The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." — ambiguous which OOPM. Hmm. This is a designed scenario; let me see if it matters.

Let me now also consider: does the family OOPM cap matter in this scenario? Let's compute and see whether family oop approaches 11000.

Let me carefully process all 26 lines with adjustments. I need ending accumulators for all members and the family, plus final components for claims 7 (adjusted at line 23), 19, and 26.

Let me set up notation. Member balances: ded_A, ded_B, ded_C, ded_D; oop_A, oop_B, oop_C, oop_D; family ded_F, oop_F. Initially:
ded_A=0, ded_B=0, ded_C=1744.67, ded_D=1150.72, ded_F=2895.39
oop_A=0, oop_B=0, oop_C=1900.68, oop_D=1150.72, oop_F=3051.40

Check: 1744.67+1150.72 = 2895.39 ✓. 1900.68+1150.72 = 3051.40 ✓.

Thresholds:
- In-network deductible: individual 2500, family 5000. Embedded: min(individual remainder, family remainder).
- OON deductible: individual 5000, measured against member's single ded balance. Family doesn't limit OON claims.
- OOPM: individual in-network 5500, family in-network 11000, individual OON 11000.

Key question 1: For in-network claims, is member responsibility capped by min(individual OOPM remainder, family OOPM remainder)?

Key question 2: For OON claims, capped by OON individual OOPM remainder (11000 − oop_member)? And family OOPM doesn't limit OON claims.

Key question 3: Deductible_applied for in-network claims: min(allowed, individual ded remainder, family ded remainder). For OON: min(allowed, OON individual remainder = 5000 − ded_member). Family doesn't limit.

Hmm wait, actually, for the OON deductible: "the out-of-network individual remainder, measured against the member's same single deductible balance". So OON remainder = 5000 − ded_member. Note ded_member includes in-network credits. And in-network remainder = 2500 − ded_member. Interesting: since in-network threshold 2500 < OON 5000, once ded_member ≥ 2500, in-network claims pay no deductible; OON claims still owe deductible until ded_member ≥ 5000.

Also embedded family: for in-network claims, room = min(2500 − ded_member, 5000 − ded_F).

Now the OOPM cap on member responsibility. Let me think about whether the designers intended a family OOPM cap. The addendum says balances "are not capped at the in-network amounts" — that's about balances. The plan document lists family

Let me work through this carefully.

Plan: Bluebonnet PPO 1500, plan year 2026.

Deductible:
- Individual in-network: 1500.00
- Family in-network: 3000.00
- Structure: EMBEDDED — individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
- OON individual: 3000.00
- In-network and OON deductible credits accumulate to a SINGLE member deductible balance. OON threshold is measured against that same balance.

OOPM:
- Individual in-network: 6000.00
- Family in-network: 12000.00
- Individual OON: 12000.00
- Once member reaches OOPM, plan pays 100%.

Member cost share:
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance OON: 40% member / 60% plan
- PCP copay: 30.00
- Specialist copay: 60.00
- Urgent care: 75.00
- ER: 400.00 copay, WAIVED if visit results in inpatient admission, in which case visit is subject to deductible and coinsurance
- Generic retail pharmacy: 15.00 copay
- Copays do NOT credit the deductible. Copays always credit OOPM.

Preventive: in-network preventive = 100% allowed, no deductible/coins/copay, moves no accumulator.

Accumulators addendum:
- deductible_applied = lesser of allowed amount and room left under applicable threshold:
  - in-network: smaller of member's individual remainder and family remainder (embedded)
  - OON: OON individual remainder, measured against member's same single deductible balance.
- Once threshold met, deductible_applied = 0.00, including for a copay that would otherwise credit the deductible. (Copays don't credit deductible anyway.)
- Balance is running total of deductible_applied (deductible) or member_responsibility (OOP balance). Balances not capped at in-network amounts.
- OON claims measured against OON individual thresholds only; family amounts don't limit an OON claim. OON credits still accumulate to member's balance and family balance.

Starting accumulators (before Line 1):
- A: ded 0.00, oop 0.00
- B: ded 710.81, oop 710.81
- C: ded 331.32, oop 331.32
- D: ded 0.00, oop 0.00
- Family: ded 1042.13, oop 1042.13

Note family total = 710.81 + 331.32 = 1042.13. Consistent.

Now process lines in order.

Initial state:
- A ded bal: 0.00; A oop: 0.00
- B ded: 710.81; B oop: 710.81
- C ded: 331.32; C oop: 331.32
- D ded: 0.00; D oop: 0.00
- Fam ded: 1042.13; Fam oop: 1042.13

Embedded: individual deductible in-network = 1500.00; family = 3000.00.

For in-network claims: deductible_applied = min(allowed, member individual remainder, family remainder), where individual remainder = 1500.00 − member's ded balance, family remainder = 3000.00 − family ded balance.

For OON claims: deductible_applied = min(allowed, OON individual remainder) where OON individual remainder = 3000.00 − member's ded balance. Family doesn't limit OON.

Member responsibility = deductible_applied + copay + coinsurance. Coinsurance = coinsurance rate × (allowed − deductible_applied) if deductible fully satisfied... wait, actually coinsurance applies after deductible satisfied. Let me think: if deductible_applied is partial (claim amount less than remainder), then the rest of the claim is subject to coinsurance? Standard: deductible applies to first dollars, coinsurance to remainder. Here deductible_applied = lesser of allowed and room left. So if room left < allowed, then the remainder (allowed − deductible_applied) is subject to coinsurance. Actually, careful: "Once the applicable threshold is met, deductible_applied is 0.00" — meaning if there's no room left, deductible_applied = 0 and the whole claim is coinsurance. If there's some room, deductible_applied = min(allowed, room), and the remainder is coinsurance.

Also OOPM: once member reaches OOPM, plan pays 100%. So member responsibility capped by remaining OOPM. Let me handle that as we go.

Also note: is there an individual OOPM cap at 6000 in-network? Individual OOPM in-network: 6000. OON individual: 12000. Family in-network: 12000. Hmm, how do the OOPM thresholds interact? "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." The plan has both in-network and OON individual OOPMs. Presumably a single OOP balance per member (like the deductible), measured against 6000 in-network and 12000 OON depending on the service. And family OOPM 12000 in-network limits in-network claims. The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts" for deductible. For OOPM, similar logic likely: in-network claims measured against smaller of individual in-network OOPM remainder and family OOPM remainder; OON claims measured against OON individual OOPM (12000) only.

Let me just carefully process.

Line 1 — Claim 1 — A (subscriber), ED visit in-network, allowed 1970.69, admitted as inpatient.
ER copay 400 WAIVED because admitted; visit subject to deductible and coinsurance.

A ded bal = 0.00. Individual remainder (in-net) = 1500 − 0 = 1500. Family remainder = 3000 − 1042.13 = 1957.87.
deductible_applied = min(1970.69, 1500, 1957.87) = 1500.00.
Coinsurance: 20% of (1970.69 − 1500.00) = 20% × 470.69 = 94.138 = 94.14.
Member responsibility = 1500.00 + 94.14 = 1594.14.
Plan paid = 1970.69 − 1594.14 = 376.55.
OOPM check: A oop = 0, individual OOPM 6000, remainder large. Fine.

Update:
- A ded: 0 + 1500 = 1500.00; A oop: 0 + 1594.14 = 1594.14.
- Fam ded: 1042.13 + 1500 = 2542.13; Fam oop: 1042.13 + 1594.14 = 2636.27.

Line 2 — Claim 2 — C, outpatient endoscopy in-network, allowed 654.68. Not preventive? Endoscopy — could be colonoscopy screening... but it says "Outpatient endoscopy" — not labeled preventive. Only lines 3 and 4 are labeled immunization and screening mammography — preventive. Line 17 is another endoscopy for B. So treat as regular medical service, subject to deductible and coinsurance (no copay listed for these).

C ded bal = 331.32. Individual remainder = 1500 − 331.32 = 1168.68. Family remainder = 3000 − 2542.13 = 457.87.
deductible_applied = min(654.68, 1168.68, 457.87) = 457.87.
Hmm wait — family remainder limits. 457.87 < 654.68. So deductible_applied = 457.87.
Coinsurance: 20% × (654.68 − 457.87) = 20% × 196.81 = 39.362 = 39.36.
Member resp = 457.87 + 39.36 = 497.23.
Plan paid = 654.68 − 497.23 = 157.45.
Update: C ded: 331.32 + 457.87 = 789.19. C oop: 331.32 + 497.23 = 828.55.
Fam ded: 2542.13 + 457.87 = 3000.00. Fam oop: 2636.27 + 497.23 = 3133.50.

Family deductible now satisfied (3000.00). Interesting.

Line 3 — Claim 3 — C, routine immunization, in-network, allowed 733.65. Preventive: in-network preventive paid 100%, no cost share, no accumulator movement.
Member resp = 0, plan paid = 733.65, ded applied 0, copay 0, coins 0.
No accumulator changes.

Line 4 — Claim 4 — C, screening mammography, in-network, allowed 338.32. Preventive: 100% plan paid, no cost share, no accumulator movement.
No changes.

Line 5 — Claim 5 — B, cardiac stress test in-network, allowed 2159.40.
B ded bal = 710.81. Individual remainder = 1500 − 710.81 = 789.19. Family remainder = 3000 − 3000 = 0.
Embedded: deductible_applied = min(2159.40, 789.19, 0) = 0.
So family deductible is met; even though B's individual isn't, the family deductible being satisfied means... wait. Embedded structure: "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." So once family deductible is met, all members have met deductible. So B's deductible is satisfied. deductible_applied = 0.
Coinsurance: 20% × 2159.40 = 431.88.
Member resp = 431.88. Plan paid = 2159.40 − 431.88 = 1727.52.
Update: B ded stays 710.81 (deductible_applied = 0, so no credit... wait, but deductible is "satisfied"? The balance doesn't move since deductible_applied = 0). B oop: 710.81 + 431.88 = 1142.69.
Fam ded stays 3000.00. Fam oop: 3133.50 + 431.88 = 3565.38.

Hmm, but conceptually once family deductible met, member deductibles are considered satisfied. B's deductible balance remains 710.81 but effectively satisfied. For reporting "ending_deductible_b" — the balance is the running total of deductible_applied. So it stays at 710.81 unless further deductible credits occur. Since family ded is met, no more in-network deductible credits. OON claims could still credit (measured against OON individual threshold of 3000).

Line 6 — Claim 6 — A, inpatient admission with surgery, in-network, allowed 11020.18.
A ded bal = 1500 (individual met). Family ded met. deductible_applied = 0.
Coinsurance: 20% × 11020.18 = 2204.036 = 2204.04.
Member resp = 2204.04. Plan paid = 11020.18 − 2204.04 = 8816.14.
OOPM check: A oop before = 1594.14. Individual OOPM in-net 6000: remainder 6000 − 1594.14 = 4405.86. 2204.04 < 4405.86, OK.
Update: A oop: 1594.14 + 2204.04 = 3798.18. Fam oop: 3565.38 + 2204.04 = 5769.42.
A ded stays 1500. Fam ded stays 3000.

Line 7 — Claim 7 — A, diagnostic laboratory panel, in-network, allowed 1959.89. (Later adjusted at Line 22 to allowed 2547.86.)
Original adjudication:
A ded met. deductible_applied = 0.
Coinsurance 20% × 1959.89 = 391.978 = 391.98.
Member resp = 391.98. Plan paid = 1959.89 − 391.98 = 1567.91.
OOPM check: A oop = 3798.18 + 391.98 = 4190.16. Under 6000. OK.
Update: A oop: 3798.18 + 391.98 = 4190.16. Fam oop: 5769.42 + 391.98 = 6161.40.

But this claim gets adjusted at Line 22, so its final components will be re-adjudicated then. Let me note original credits: member resp 391.98, ded applied 0. These will be unwound at Line 22.

Line 8 — Claim 8 — B, inpatient admission, in-network, allowed 24984.17.
B ded satisfied (family met). deductible_applied = 0.
Coinsurance 20% × 24984.17 = 4996.834 = 4996.83.
OOPM check: B oop before = 1142.69. Individual in-net OOPM 6000: remainder = 6000 − 1142.69 = 4857.31. Coinsurance 4996.83 > 4857.31. So member responsibility capped at 4857.31 (reaching OOPM). Once reached, plan pays 100% for remainder.

So member resp = 4857.31. Plan paid = 24984.17 − 4857.31 = 20126.86.
Hmm — but wait, does the family OOPM matter? Family in-net OOPM 12000. Family oop before = 6161.40. Family remainder = 12000 − 6161.40 = 5838.60. Individual remainder 4857.31 is smaller. So cap = 4857.31.

Actually, how does the OOPM cap work with coinsurance? The member responsibility = min(what cost share would be, remaining OOPM). The member's cost share before cap: 4996.83. Cap at 4857.31 (individual remainder, smaller than family remainder 5838.60). So member resp = 4857.31, and B has now hit individual in-network OOPM of 6000.

Update: B oop: 1142.69 + 4857.31 = 6000.00. Fam oop: 6161.40 + 4857.31 = 11018.71.
B ded stays 710.81. Fam ded stays 3000.00.

Hmm, one consideration: once B hits OOPM, plan pays 100% for covered services for remainder of plan year (in-network). But OON claims are measured against OON OOPM 12000. So B could still have cost share on OON claims until OON OOPM (12000) is reached? The single OOP balance is 6000 for B. For an OON claim, threshold is 12000. So B's OON remainder = 12000 − 6000 = 6000. So OON claims can still generate cost share up to that.

Wait, but there's a subtlety: does "Once a member reaches the out-of-pocket maximum the plan pays 100%" apply across the board, or only per network tier? The plan lists separate individual OOPMs for in-network (6000) and OON (12000). The single-balance concept (from deductible addendum) suggests: one balance, measured against different thresholds depending on service network. So for in-network services, B is at OOPM (6000 reached), so in-network covered services are 100% paid. For OON services, threshold is 12000, so B still has room: 6000 remaining.

Line 9 — VOID of Claim 4 (C). Claim 4 was preventive with no cost share and no accumulator movement. So voiding it removes nothing. "A voided claim has no member responsibility and no plan payment." Claim 4 components become 0.00 (not asked, but fine). No accumulator changes.

Line 10 — Claim 10 — D, inpatient admission with surgery, in-network, allowed 12032.63.
D ded bal = 0. But family ded met (3000). Embedded: family deductible satisfied → D's deductible satisfied. deductible_applied = min(12032.63, individual remainder 1500, family remainder 0) = 0.
Coinsurance 20% × 12032.63 = 2406.526 = 2406.53.
OOPM check: D oop before = 0. Individual in-net OOPM remainder 6000. Family OOPM remainder = 12000 − 11018.71 = 981.29. Coinsurance 2406.53 > 981.29? Family remainder 981.29 is smaller than individual remainder 6000. So member responsibility capped at 981.29.

So D member resp = 981.29. Plan paid = 12032.63 − 981.29 = 11051.34.
Family OOPM now reached: Fam oop = 11018.71 + 981.29 = 12000.00.
D oop = 981.29.

Hmm wait — family OOPM is 12000. Once family OOPM reached, plan pays 100% for covered in-network services for all family members? "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." The family OOPM is the ceiling on family cost share. Typically once family OOPM is hit, all family members' in-network cost share ends. So after Line 10, no more in-network cost share for anyone. OON claims still measured against OON individual thresholds (12000 per member).

Hmm, but careful: is family OOPM a real cap in this harness? The addendum says "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 implies family amounts DO limit in-network claims. So yes, family OOPM 12000 caps in-network cost share.

But note: family oop balance can exceed 12000 via OON credits ("the balances are not capped at the in-network amounts" — that's stated for deductible, and presumably applies to OOP too... it says "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This is in the ACCUMULATORS addendum, speaking about balances generally — deductible and OOP both. So OON claims can push family OOP past 12000.)

Line 11 — Claim 11 — B, inpatient admission with surgery, OON, allowed 18900.86.
B ded bal = 710.81. OON individual deductible threshold = 3000. OON remainder = 3000 − 710.81 = 2289.19. (Family doesn't limit OON.)
deductible_applied = min(18900.86, 2289.19) = 2289.19.
Coinsurance OON: 40% × (18900.86 − 2289.19) = 40% × 16611.67 = 6644.668 = 6644.67.
OOPM check for OON: B's oop balance = 6000.00. OON individual OOPM = 12000. OON remainder = 12000 − 6000 = 6000. Member cost share before cap = 2289.19 + 6644.67 = 8933.86. Capped at 6000. So member resp = 6000.00.
Plan paid = 18900.86 − 6000.00 = 12900.86.
Update: B oop: 6000 + 6000 = 12000.00. B ded: 710.81 + 2289.19 = 3000.00. Fam ded: 3000 + 2289.19 = 5289.19. Fam oop: 12000 + 6000 = 18000.00.

Hmm wait — the deductible_applied was 2289.19 even though OOPM capped the member responsibility. The deductible credit is still 2289.19 (it's part of member responsibility paid). Yes — the member paid 6000, which includes the 2289.19 deductible portion and 3710.81 of coinsurance. Deductible credit stands at 2289.19.

B's OOP balance now 12000 = OON individual OOPM. So B has hit OON OOPM. For in-network, B hit 6000 earlier. Family oop 18000 — but that's fine, not capped.

Actually wait — I need to double-check the family OOPM cap interaction at Line 11. B's OON claim: measured against OON individual OOPM only; family amounts don't limit OON claims. So cap = 12000 − 6000 = 6000. Correct.

Line 12 — Claim 12 — D, ambulatory surgery, in-network, allowed 3444.66.
D ded: family met → deductible satisfied. deductible_applied = 0.
Coinsurance 20% × 3444.66 = 688.932 = 688.93.
OOPM: D oop = 981.29. Family OOPM met (12000). In-network cost share → 0 (plan pays 100%).

So member resp = 0.00. Plan paid = 3444.66.
No accumulator changes.

Line 13 — Claim 13 — B, generic retail pharmacy fill, in-network, allowed 89.29. Copay 15.00.
Copays credit OOPM. But B's in-network OOPM is met (6000 reached), and family OOPM met (12000). In-network covered services → plan pays 100%. Does the copay still apply? Once OOPM reached, plan pays 100% of allowed for covered services. The pharmacy copay is cost share for a covered service. Since B (and the family) reached the in-network OOPM, the copay is waived → member resp 0.

Hmm — but wait, B's OOP balance is 12000, which equals the OON individual OOPM too. So even for OON, B is maxed. Anyway in-network: family OOPM met → 0.

Member resp = 0.00, plan paid = 89.29. No accumulator movement.

Hmm, actually let me reconsider. Is it right that once family OOPM is met, individual members pay nothing for in-network services? Standard plan design: yes. The plan document: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered in-network services." (OOPM section: "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.") Family OOPM 12000 — the family's total cost share ceiling. Once the family accumulates 12000, the family has reached the OOPM. I think yes, in-network cost share ends for everyone.

But hold on — should I be more careful here? The family OOPM is listed as "Family (in-network) 12000.00". The addendum says family amounts are in-network amounts that don't limit OON claims. This confirms family amounts DO limit in-network claims. After Line 10, family oop = 12000. So all subsequent in-network claims: member responsibility 0.

Line 14 — ADJUSTMENT to Claim 1 — A. Allowed corrected downward to 1418.90.
Unwind Claim 1's credits: original member resp 1594.14 (ded 1500.00, coins 94.14), ded credit 1500.00.
Remove from A: A ded −1500 → 1500 − 1500 = 0.00. A oop −1594.14 → 4190.16 − 1594.14 = 2596.02.
Fam ded: 3000 − 1500 = 1500.00. Fam oop: 18000 − 1594.14 = 16405.86.

Wait, I need to track family oop carefully. Let me recompute family oop at each step. Let me list all accumulator updates so far:

Initial: A ded 0, oop 0; B ded 710.81, oop 710.81; C ded 331.32, oop 331.32; D ded 0, oop 0; Fam ded 1042.13, oop 1042.13.

L1 (A): ded +1500, oop +1594.14 → A ded 1500, oop 1594.14; Fam ded 2542.13, oop 2636.27.
L2 (C): ded +457.87, oop +497.23 → C ded 789.19, oop 828.55; Fam ded 3000.00, oop 3133.50.
L3 (C): preventive, no change.
L4 (C): preventive, no change.
L5 (B): ded 0, oop +431.88 → B oop 1142.69; Fam oop 3565.38.
L6 (A): ded 0, oop +2204.04 → A oop 3798.18; Fam oop 5769.42.
L7 (A): ded 0, oop +391.98 → A oop 4190.16; Fam oop 6161.40.
L8 (B): ded 0, oop +4857.31 → B oop 6000.00; Fam oop 11018.71.
L9: void of preventive claim, no change.
L10 (D): ded 0, oop +981.29 → D oop 981.29; Fam oop 12000.00.
L11 (B): ded +2289.19, oop +6000.00 → B ded 3000.00, oop 12000.00; Fam ded 5289.19, oop 18000.00.
L12 (D): no change (family OOPM met).
L13 (B): no change.

L14 (Adjustment to Claim 1, A): unwind ded 1500, oop 1594.14.
A ded: 1500 − 1500 = 0.00. A oop: 4190.16 − 1594.14 = 2596.02.
Fam ded: 5289.19 − 1500 = 3789.19. Fam oop: 18000 − 1594.14 = 16405.86.

Re-adjudicate Claim 1 at allowed 1418.90 against accumulators as they stand now:
A ded bal = 0. Individual in-net remainder = 1500 − 0 = 1500. Family remainder = 3000 − 3789.19 = negative → 0 (family deductible met? Fam ded balance 3789.19 > 3000, so family remainder = 0). Embedded: min(1418.90, 1500, 0) = 0.
deductible_applied = 0.
Coinsurance 20% × 1418.90 = 283.78.
OOPM: A oop = 2596.02. Family OOPM met? Fam oop = 16405.86 > 12000. In-network → family OOPM met → plan pays 100%? Hmm!

Wait, this is tricky. The re-adjudication happens "against the accumulators as they stand at the adjustment." Family OOPM is already met (16405.86 > 12000). So for in-network