Qwen3.7 Max

Let me carefully process this ledger step by step.

**Plan Details:**
- Plan year: 2026
- Deductible:
  - Individual (in-network): 3200.00
  - Family (in-network): 6400.00
  - Structure: AGGREGATE — no member reaches coinsurance until total family credits reach 6400.00
  - Out-of-network (individual): 6400.00
  - Single deductible balance for in-network and out-of-network
- OOPM:
  - Individual (in-network): 7000.00
  - Family (in-network): 14000.00
  - Individual (out-of-network): 14000.00
- Coinsurance:
  - In-network: 10% member / 90% plan (after deductible)
  - Out-of-network: 40% member / 60% plan (after deductible)
- No copays
- Preventive care in-network: 100% plan, no cost share, no accumulator movement

**Initial Accumulators (before Line 1):**
- A: deductible = 1729.94, OOPM = 1762.13
- B: deductible = 0.00, OOPM = 0.00
- C: deductible = 1382.40, OOPM = 1945.98
- Family total: deductible = 3112.34, OOPM = 3708.11

Since this is AGGREGATE structure, the family deductible is 6400.00. No member reaches coinsurance until family deductible is met.

Wait, let me re-read the deductible rules:
- "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."
- So there's only a family deductible of 6400.00 for in-network.
- For out-of-network: individual deductible of 6400.00

Wait, the accumulator rules say:
- in-network: "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, deductible_applied is limited by family remainder (6400.00 - family_deductible_accumulator).
For out-of-network claims, deductible_applied is limited by out-of-network individual remainder (6400.00 - member's single deductible balance).

Wait, but the single deductible balance accumulates both in-network and out-of-network deductible credits. So the member's deductible balance is a single number.

Let me re-read: "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."

So there's one deductible balance per member. For in-network, it's measured against family deductible (6400). For out-of-network, it's measured against individual out-of-network deductible (6400).

But wait, in aggregate structure, there's no individual deductible for in-network. So what's the "member deductible" tracking? Let me think...

The family deductible accumulator is the sum of all members' deductible credits. The individual member deductible accumulators track how much each member contributed.

For in-network claims under aggregate:
- deductible_applied = min(allowed_amount, family_deductible_remainder)
- The credit goes to both the member's deductible balance and the family deductible balance.

For out-of-network claims:
- deductible_applied = min(allowed_amount, out_of_network_individual_remainder)
- out_of_network_individual_remainder = 6400.00 - member's single deductible balance
- The credit goes to the member's deductible balance and the family deductible balance.

Wait, but "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

Let me re-read the accumulator rules more 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 aggregate in-network:
- deductible_applied = min(allowed_amount, family_remainder)
- family_remainder = 6400.00 - family_deductible_accumulator

For out-of-network:
- deductible_applied = min(allowed_amount, OON_individual_remainder)
- OON_individual_remainder = 6400.00 - member's single deductible balance

And the credits go to:
- Member's single deductible balance
- Family deductible balance

Let me also think about OOPM:
- Individual (in-network): 7000.00
- Family (in-network): 14000.00
- Individual (out-of-network): 14000.00

Wait, what about family OOPM for out-of-network? The plan doc says:
"Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ............ 14000.00"

There's no family out-of-network OOPM listed. 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 out-of-network claims are only measured against the individual out-of-network OOPM (14000.00). The family OOPM doesn't apply to out-of-network.

Wait, but the credits still accumulate to the family balance. Let me think about this more carefully.

Actually, 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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

So the family OOPM balance can go past 14000.00 due to out-of-network claims, but the family OOPM threshold of 14000.00 only applies to in-network claims.

Let me think about how OOPM works:
- A member's OOPM balance accumulates member_responsibility (deductible + coinsurance + copay).
- For in-network claims, once member's individual OOPM (7000) or family OOPM (14000) is reached, plan pays 100%.
- For out-of-network claims, once member's individual OON OOPM (14000) is reached, plan pays 100%.

Wait, but under aggregate deductible, there's no individual deductible. Is there an individual OOPM?

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."

So there IS an individual OOPM of 7000 (in-network). Let me think about how this interacts with aggregate deductible.

Under aggregate deductible:
- Family deductible must be met (6400) before any coinsurance kicks in.
- But individual OOPM of 7000 still applies.
- So once a member's OOPM balance reaches 7000, plan pays 100% for that member's in-network services.
- And once family OOPM reaches 14000, plan pays 100% for all members' in-network services.

For out-of-network:
- Individual OON OOPM of 14000 applies.
- No family OON OOPM.

Let me now think about how the OOPM check works. When processing a claim:
1. First, apply deductible (if not met).
2. Then, apply coinsurance to the remainder.
3. But cap member responsibility at OOPM remainder.

Actually, let me think about this more carefully. The member_responsibility for a claim is:
- deductible_applied (goes to deductible and OOPM accumulators)
- coinsurance_amount (goes to OOPM accumulator)
- copay_amount (goes to OOPM accumulator, but this plan has no copays)

Total member_responsibility = deductible_applied + coinsurance_amount + copay_amount

And the member's OOPM balance increases by member_responsibility.

But wait, what if applying the full member_responsibility would push the member past their OOPM? Then we need to cap it.

Let me think about the order of operations:
1. Determine deductible_applied.
2. Determine coinsurance on the remaining allowed amount.
3. Check if total member_responsibility would exceed OOPM remainder.
4. If so, cap member_responsibility at OOPM remainder, and plan pays the rest.

Actually, I think the OOPM cap applies to the total member cost share. Let me work through this step by step.

For an in-network claim:
- deductible_applied = min(allowed, family_deductible_remainder)
- remaining = allowed - deductible_applied
- If family deductible is met (after this claim or before), coinsurance applies to remaining.
  - But wait, under aggregate, coinsurance only applies AFTER the family deductible is fully met.
  - So if family_deductible_remainder > 0 after applying deductible, no coinsurance.
  - If family_deductible is met by this claim, coinsurance applies to the portion of remaining that is after the deductible is met.

Wait, actually, let me re-read: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount."

So if the family deductible is not yet met, ALL of the allowed amount goes to the deductible (up to the family remainder). No coinsurance.

If the family deductible IS met (either before this claim or by this claim), then:
- deductible_applied = min(allowed, family_remainder) [could be 0 if already met]
- remaining_after_deductible = allowed - deductible_applied
- coinsurance on remaining_after_deductible: member pays 10%, plan pays 90%

But wait, what if the family deductible is met DURING this claim? E.g., family remainder is 500, allowed is 1000.
- deductible_applied = 500
- remaining = 500
- coinsurance on 500: member pays 10% = 50, plan pays 90% = 450
- Total member responsibility = 500 + 50 = 550
- Plan paid = 450

Yes, that's how it works. The deductible is applied first, then coinsurance on the remainder.

Now for OOPM:
- After calculating member_responsibility (deductible + coinsurance), check if it would push member's OOPM balance past the OOPM threshold.
- If member OOPM (in-network: 7000) or family OOPM (in-network: 14000) would be exceeded, cap member_responsibility.

Actually, I need to think about which OOPM applies. For in-network claims:
- Member's individual in-network OOPM: 7000
- Family in-network OOPM: 14000

The member is protected by BOTH. If EITHER is reached, plan pays 100%.

Wait, under aggregate deductible, is the individual OOPM still meaningful? Let me think...

Yes, the plan doc says: "Individual (in-network) ................ 7000.00" and "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 if member A's OOPM balance reaches 7000, plan pays 100% for A's in-network services, even if family OOPM hasn't reached 14000.

For out-of-network claims:
- Member's individual OON OOPM: 14000
- No family OON OOPM mentioned.

So for OON claims, only the member's individual OON OOPM of 14000 applies.

But wait, "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 means for OON claims:
- Deductible: measured against OON individual deductible (6400) using the member's single deductible balance.
- OOPM: measured against OON individual OOPM (14000).
- Family amounts don't limit OON claims.

But OON claims still accumulate to family balances.

Now let me think about the OOPM check more carefully. For an in-network claim:
- The member's OOPM balance increases by member_responsibility.
- If member's OOPM balance would exceed 7000 (individual) OR family OOPM balance would exceed 14000 (family), we cap.
- The cap is: member_responsibility = min(calculated_member_responsibility, min(7000 - member_OOPM_balance, 14000 - family_OOPM_balance))

Wait, but the member_responsibility also increases the family OOPM balance. So we need to check both.

Actually, let me think about this differently. The member_responsibility is capped by:
- member_OOPM_remainder = 7000 - member_OOPM_balance (for in-network)
- family_OOPM_remainder = 14000 - family_OOPM_balance (for in-network)
- effective_OOPM_remainder = min(member_OOPM_remainder, family_OOPM_remainder)

If calculated_member_responsibility > effective_OOPM_remainder:
- member_responsibility = effective_OOPM_remainder
- plan_paid = allowed - member_responsibility

For out-of-network claims:
- member_OOPM_remainder = 14000 - member_OOPM_balance (OON individual)
- No family OOPM check for OON.
- If calculated_member_responsibility > member_OOPM_remainder:
  - member_responsibility = member_OOPM_remainder
  - plan_paid = allowed - member_responsibility

Wait, but does the OON claim's member_responsibility also accumulate to the family OOPM? The plan doc says "the family amounts, which are in-network amounts, do not limit an out-of-network claim." But do OON credits accumulate to family OOPM?

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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

This suggests that OON member_responsibility DOES accumulate to the family OOPM balance, and can push it past 14000. But the family OOPM of 14000 doesn't limit OON claims.

OK wait, let me re-read more carefully. "the family balances past the family amounts" - this means the family OOPM balance can exceed 14000 due to OON claims. But does the family OOPM balance affect in-network claims after being pushed past 14000 by OON claims?

I think the family OOPM balance is a single running total, and once it reaches 14000, all in-network claims are paid at 100%. If OON claims push it past 14000, then in-network claims would definitely be at 100%.

Let me just track all the accumulators and process each claim.

Let me define the accumulators:
- A_ded: A's single deductible balance
- A_oop: A's OOPM balance (single, used for both IN and OON)
- B_ded: B's single deductible balance
- B_oop: B's OOPM balance
- C_ded: C's single deductible balance
- C_oop: C's OOPM balance
- fam_ded: Family deductible balance
- fam_oop: Family OOPM balance

Wait, are the OOPM balances single or separate for IN and OON?

The plan doc says:
"Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ............ 14000.00"

And: "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."

I think there's a single OOPM balance per member and a single family OOPM balance. The IN OOPM threshold is 7000 (individual) and 14000 (family). The OON OOPM threshold is 14000 (individual).

For an in-network claim, we check if member OOPM balance >= 7000 OR family OOPM balance >= 14000. If either, plan pays 100%.

For an out-of-network claim, we check if member OOPM balance >= 14000. If so, plan pays 100%.

Wait, but what if a member's OOPM balance is 8000 (due to OON claims pushing it past 7000)? For an in-network claim, 8000 > 7000, so plan pays 100%. For an OON claim, 8000 < 14000, so member still has cost share.

That makes sense. The single OOPM balance is measured against different thresholds depending on network status.

OK wait, I need to re-read the initial accumulators:
"A (subscriber)   deductible   1729.94   out-of-pocket   1762.13"

So A has a single deductible balance of 1729.94 and a single OOPM balance of 1762.13.

Let me also check: the initial accumulators show "Family total deductible 3112.34, out-of-pocket 3708.11".
1729.94 + 0.00 + 1382.40 = 3112.34. Yes, family deductible = sum of member deductibles.
1762.13 + 0.00 + 1945.98 = 3708.11. Yes, family OOPM = sum of member OOPMs.

Great, so the accumulators are consistent.

Now let me process each claim.

**Starting Accumulators:**
- A_ded = 1729.94, A_oop = 1762.13
- B_ded = 0.00, B_oop = 0.00
- C_ded = 1382.40, C_oop = 1945.98
- fam_ded = 3112.34, fam_oop = 3708.11

**Line 1 — Claim 1 — A — In-network — Allowed: 1553.18**

Family deductible remainder = 6400.00 - 3112.34 = 3287.66
deductible_applied = min(1553.18, 3287.66) = 1553.18
remaining = 1553.18 - 1553.18 = 0.00
coinsurance = 0.00
member_responsibility = 1553.18

Check OOPM:
- A_oop_remainder = 7000.00 - 1762.13 = 5237.87
- fam_oop_remainder = 14000.00 - 3708.11 = 10291.89
- effective_OOPM_remainder = min(5237.87, 10291.89) = 5237.87
- 1553.18 <= 5237.87, so no cap.

member_responsibility = 1553.18
plan_paid = 0.00
deductible_applied = 1553.18
coinsurance_amount = 0.00
copay_amount = 0.00

Update accumulators:
- A_ded = 1729.94 + 1553.18 = 3283.12
- A_oop = 1762.13 + 1553.18 = 3315.31
- fam_ded = 3112.34 + 1553.18 = 4665.52
- fam_oop = 3708.11 + 1553.18 = 5261.29

**Line 2 — Claim 2 — A — In-network — Allowed: 21710.91**

Family deductible remainder = 6400.00 - 4665.52 = 1734.48
deductible_applied = min(21710.91, 1734.48) = 1734.48
remaining = 21710.91 - 1734.48 = 19976.43

Family deductible is now met (fam_ded = 6400.00).
Coinsurance on remaining: 10% member, 90% plan.
coinsurance_member = 19976.43 * 0.10 = 1997.643
Let me keep precision: 19976.43 * 0.10 = 1997.643

member_responsibility_before_cap = 1734.48 + 1997.643 = 3732.123

Check OOPM:
- A_oop = 3315.31
- A_oop_remainder = 7000.00 - 3315.31 = 3684.69
- fam_oop = 5261.29
- fam_oop_remainder = 14000.00 - 5261.29 = 8738.71
- effective_OOPM_remainder = min(3684.69, 8738.71) = 3684.69
- 3732.123 > 3684.69, so cap at 3684.69

member_responsibility = 3684.69
plan_paid = 21710.91 - 3684.69 = 18026.22

How to split member_responsibility between deductible and coinsurance?
deductible_applied = 1734.48
coinsurance_amount = 3684.69 - 1734.48 = 1950.21

Wait, let me double-check: member_responsibility = deductible_applied + coinsurance_amount + copay_amount
3684.69 = 1734.48 + coinsurance_amount + 0
coinsurance_amount = 3684.69 - 1734.48 = 1950.21

Let me verify: 1734.48 + 1950.21 = 3684.69. Yes.

Update accumulators:
- A_ded = 3283.12 + 1734.48 = 5017.60
- A_oop = 3315.31 + 3684.69 = 7000.00
- fam_ded = 4665.52 + 1734.48 = 6400.00
- fam_oop = 5261.29 + 3684.69 = 8945.98

A has reached individual OOPM of 7000.00.

**Line 3 — Claim 3 — C — In-network — Allowed: 454.13**

Family deductible is met (fam_ded = 6400.00).
deductible_applied = 0.00
remaining = 454.13
coinsurance_member = 454.13 * 0.10 = 45.413

member_responsibility_before_cap = 45.413

Check OOPM:
- C_oop = 1945.98
- C_oop_remainder = 7000.00 - 1945.98 = 5054.02
- fam_oop = 8945.98
- fam_oop_remainder = 14000.00 - 8945.98 = 5054.02
- effective_OOPM_remainder = min(5054.02, 5054.02) = 5054.02
- 45.413 <= 5054.02, so no cap.

member_responsibility = 45.41 (rounded to 2 decimal places at the end)

Wait, I should keep precision until the end. Let me use exact values.

coinsurance_member = 454.13 * 0.10 = 45.413

member_responsibility = 45.413
plan_paid = 454.13 - 45.413 = 408.717

Rounding at the end:
member_responsibility = 45.41 (45.413 rounds to 45.41)
plan_paid = 408.72 (408.717 rounds to 408.72)

Wait, but member_responsibility + plan_paid should equal allowed amount.
45.41 + 408.72 = 454.13. Yes.

Actually, let me be more careful about rounding. The instructions say "Round half up to the cent at the end of a calculation, not at each intermediate step."

So I should compute member_responsibility and plan_paid precisely, then round at the end.

member_responsibility = 45.413 → rounds to 45.41
plan_paid = 454.13 - 45.413 = 408.717 → rounds to 408.72

But 45.41 + 408.72 = 454.13. Good.

Actually wait, I should think about whether to round the accumulator updates too. The accumulators should probably be updated with the rounded member_responsibility.

Let me use rounded values for accumulator updates to keep things consistent.

member_responsibility = 45.41
plan_paid = 408.72
deductible_applied = 0.00
coinsurance_amount = 45.41

Update accumulators:
- C_ded = 1382.40 + 0.00 = 1382.40
- C_oop = 1945.98 + 45.41 = 1991.39
- fam_ded = 6400.00 (no change)
- fam_oop = 8945.98 + 45.41 = 

Let me carefully process each claim line by line, tracking accumulators for each member and the family.

Plan details:
- Deductible: Individual 3200, Family 6400, AGGREGATE structure
- Out-of-network deductible (individual): 6400
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- OOPM: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000
- Coinsurance after deductible, in-network: 10% member / 90% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- No copays
- Preventive care in-network: 100% paid, no cost share, no deductible credit

AGGREGATE structure: "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."

So the family deductible is 6400. No member gets coinsurance until the family deductible (6400) is met.

Wait, let me re-read: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount."

And for deductible_applied:
- in-network: "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, deductible_applied is the lesser of the allowed amount and the family remainder.
For out-of-network claims, deductible_applied is the lesser of the allowed amount and the out-of-network individual remainder (6400 minus the member's single deductible balance).

Wait, but the family deductible is 6400 and the out-of-network individual deductible is also 6400. Let me re-read.

"Deductible
  Individual (in-network) ................ 3200.00
  Family (in-network) .................... 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) ............ 6400.00
  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."

So:
- For in-network: family deductible is 6400. Since aggregate, no individual deductible. Deductible_applied = lesser of allowed amount and family remainder.
- For out-of-network: individual deductible is 6400. Measured against the member's single deductible balance (which includes both in-network and out-of-network credits).

Wait, but how does the family deductible interact with out-of-network? Let me re-read the accumulator rules:

"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."

So out-of-network claims:
- Deductible_applied = lesser of allowed amount and (6400 - member's single deductible balance)
- These credits also add to the family deductible balance

And for in-network claims:
- Deductible_applied = lesser of allowed amount and (family deductible remainder)
- But wait, in aggregate structure, does the member's own balance matter? Let me re-read.

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

So for aggregate: deductible_applied for in-network = lesser of allowed amount and family remainder.

But what about the member's own deductible balance? In aggregate, there is no individual deductible. So the member's balance just tracks credits but doesn't limit anything for in-network.

Actually wait - for out-of-network, the threshold is 6400 for the individual. So a member needs their own single deductible balance to reach 6400 before they get coinsurance on out-of-network services.

For in-network, the family deductible is 6400 (aggregate). Once the family total reaches 6400, all members get coinsurance on in-network services.

Let me also think about OOPM:
- Individual (in-network): 7000
- Family (in-network): 14000
- Individual (out-of-network): 14000

OOPM tracks member_responsibility. Once a member's OOPM is reached, plan pays 100%.

For in-network, member's OOPM is 7000. Family OOPM is 14000.
For out-of-network, member's OOPM is 14000.

Wait, but there's only one OOPM balance per member? Or separate in-network and out-of-network?

The plan says:
"Out-of-pocket maximum
  Individual (in-network) ................ 7000.00
  Family (in-network) .................... 14000.00
  Individual (out-of-network) ............ 14000.00"

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

I think there's a single OOPM balance per member, and it's measured against different thresholds depending on network status. Similar to how the deductible works - single balance, different thresholds.

Actually wait, 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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

So there's a single OOPM balance per member. For in-network services, it's measured against 7000 (individual) and 14000 (family). For out-of-network, it's measured against 14000 (individual).

Hmm, but actually, I need to think about this more carefully. When does a member reach OOPM for in-network? When their member_responsibility total reaches 7000. For out-of-network? When their member_responsibility total reaches 14000.

So if a member has accumulated 6500 in member_responsibility, they haven't reached either OOPM. If they then have an in-network claim, they could be capped at 7000. If out-of-network, they continue until 14000.

Let me also consider the family OOPM. "Family (in-network) 14000". So once the family total of member_responsibility reaches 14000, all members get 100% for in-network.

OK let me now process each claim.

INITIAL STATE:
A: ded=0, oopm=0
B: ded=0, oopm=0
C: ded=0, oopm=0
D: ded=0, oopm=0
E: ded=0, oopm=0
Family: ded=0, oopm=0

---

LINE 1: Claim 1 — 2026-01-07 — A (subscriber)
Generic retail pharmacy, in-network
Allowed: 74.87

In-network, aggregate structure.
Family deductible remainder = 6400 - 0 = 6400
Deductible_applied = min(74.87, 6400) = 74.87
All goes to deductible.
Member responsibility = 74.87
Plan paid = 0.00

A: ded = 0 + 74.87 = 74.87, oopm = 0 + 74.87 = 74.87
Family: ded = 0 + 74.87 = 74.87, oopm = 0 + 74.87 = 74.87

---

LINE 2: Claim 2 — 2026-01-17 — C (child)
Inpatient admission, out-of-network
Allowed: 10883.95

Out-of-network.
C's single deductible balance = 0
Out-of-network individual deductible = 6400
C's deductible remainder = 6400 - 0 = 6400
Deductible_applied = min(10883.95, 6400) = 6400.00

Remaining after deductible = 10883.95 - 6400 = 4483.95
Coinsurance (out-of-network, 40% member): 4483.95 * 0.40 = 1793.58
Plan coinsurance: 4483.95 * 0.60 = 2690.37

Member responsibility = deductible_applied + coinsurance = 6400 + 1793.58 = 7793.58
Plan paid = 2690.37

Wait, but does the family deductible also get credited? "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So C's ded balance: 0 + 6400 = 6400
Family ded balance: 74.87 + 6400 = 6474.87

Wait, the family deductible is 6400. So family ded is now 6474.87, which exceeds 6400. That's fine, balances are not capped.

C's oopm: 0 + 7793.58 = 7793.58
Family oopm: 74.87 + 7793.58 = 7868.45

Now, since family deductible (6400) is met (6474.87 > 6400), future in-network claims will have deductible_applied = 0.

Wait, but I need to check: C's out-of-network deductible is met (6400 reached). So C's future out-of-network claims will have deductible_applied = 0.

Let me re-check the out-of-network deductible_applied calculation. The out-of-network individual deductible is 6400, and C's balance is now 6400. So C has met their out-of-network deductible.

Actually wait - the deductible_applied for out-of-network was 6400, which is exactly the threshold. So C's balance is now 6400, and the remainder is 0.

Let me reconsider: does C's deductible_applied of 6400 also count toward the family deductible? Yes, per the rules: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So family deductible balance is now 74.87 + 6400 = 6474.87.

But wait, for the family deductible, the threshold is 6400 (aggregate). Since 6474.87 > 6400, the family deductible is met.

Now let me also check C's OOPM. C's OOPM balance is 7793.58.
- For in-network, C's individual OOPM threshold is 7000. Since 7793.58 > 7000, C has met their in-network OOPM.
- For out-of-network, C's individual OOPM threshold is 14000. Since 7793.58 < 14000, C has NOT met their out-of-network OOPM.

Family OOPM: 7868.45. Family in-network OOPM threshold is 14000. Not met.

---

LINE 3: Claim 3 — 2026-02-01 — C (child)
Diagnostic laboratory panel, out-of-network
Allowed: 967.99

Out-of-network.
C's deductible balance = 6400. Out-of-network threshold = 6400. Remainder = 0.
Deductible_applied = 0.00

Remaining = 967.99
Coinsurance (40% member): 967.99 * 0.40 = 387.196 → 387.20
Plan coinsurance: 967.99 * 0.60 = 580.794 → 580.79

Wait, let me be more careful with rounding. The task says "Round half up to the cent at the end of a calculation."

967.99 * 0.40 = 387.196. Rounded half up to cent: 387.20.
967.99 * 0.60 = 580.794. Rounded half up to cent: 580.79.

Check: 387.20 + 580.79 = 967.99. Yes.

Member responsibility = 0 + 387.20 = 387.20
Plan paid = 580.79

C: ded = 6400, oopm = 7793.58 + 387.20 = 8180.78
Family: ded = 6474.87, oopm = 7868.45 + 387.20 = 8255.65

Wait, does deductible_applied of 0 add to the deductible balance? No, 0 adds 0.

But wait - C's OOPM for in-network is 7000. C has already passed that (7793.58). So if this were in-network, C would pay 0. But this is out-of-network, and C's out-of-network OOPM is 14000. C's balance is 8180.78, which is less than 14000. So C still pays coinsurance for out-of-network.

But wait, should I check the OOPM before applying coinsurance? 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."

So the OOPM check should limit the member responsibility. Let me think about this.

For out-of-network, C's OOPM threshold is 14000. C's current OOPM balance is 7793.58. The coinsurance amount is 387.20. 7793.58 + 387.20 = 8180.78 < 14000. So no capping needed.

---

LINE 4: Claim 4 — 2026-02-15 — A (subscriber)
Urgent care visit, in-network
Allowed: 255.34

In-network, aggregate.
Family deductible balance = 6474.87. Family threshold = 6400. Remainder = 0 (since 6474.87 > 6400).
Deductible_applied = 0.00

Remaining = 255.34
Coinsurance (in-network, 10% member): 255.34 * 0.10 = 25.534 → 25.53
Plan: 255.34 * 0.90 = 229.806 → 229.81

Check: 25.53 + 229.81 = 255.34. Yes.

Now check A's OOPM. A's OOPM balance = 74.87. Threshold for in-network = 7000.
74.87 + 25.53 = 100.40 < 7000. No capping.

Member responsibility = 25.53
Plan paid = 229.81

A: ded = 74.87, oopm = 74.87 + 25.53 = 100.40
Family: ded = 6474.87, oopm = 8255.65 + 25.53 = 8281.18

---

LINE 5: Claim 5 — 2026-03-01 — A (subscriber)
Emergency department visit, in-network
Allowed: 3545.18

In-network, aggregate.
Family deductible remainder = 0 (already met).
Deductible_applied = 0.00

Remaining = 3545.18
Coinsurance (10% member): 3545.18 * 0.10 = 354.518 → 354.52
Plan: 3545.18 * 0.90 = 3190.662 → 3190.66

Check: 354.52 + 3190.66 = 3545.18. Yes.

A's OOPM balance = 100.40. Threshold = 7000.
100.40 + 354.52 = 454.92 < 7000. No capping.

Member responsibility = 354.52
Plan paid = 3190.66

A: ded = 74.87, oopm = 100.40 + 354.52 = 454.92
Family: ded = 6474.87, oopm = 8281.18 + 354.52 = 8635.70

---

LINE 6: Claim 6 — 2026-03-07 — A (subscriber)
Allergy testing, in-network
Allowed: 911.89

In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00

Remaining = 911.89
Coinsurance (10%): 911.89 * 0.10 = 91.189 → 91.19
Plan: 911.89 * 0.90 = 820.701 → 820.70

Check: 91.19 + 820.70 = 911.89. Yes.

A's OOPM = 454.92. 454.92 + 91.19 = 546.11 < 7000.

Member responsibility = 91.19
Plan paid = 820.70

A: ded = 74.87, oopm = 454.92 + 91.19 = 546.11
Family: ded = 6474.87, oopm = 8635.70 + 91.19 = 8726.89

---

LINE 7: Claim 7 — 2026-03-19 — B (spouse)
Ambulatory surgery, in-network
Allowed: 7845.50

In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00

Remaining = 7845.50
Coinsurance (10%): 7845.50 * 0.10 = 784.55
Plan: 7845.50 * 0.90 = 7060.95

Check: 784.55 + 7060.95 = 7845.50. Yes.

B's OOPM = 0. 0 + 784.55 = 784.55 < 7000.

Member responsibility = 784.55
Plan paid = 7060.95

B: ded = 0, oopm = 784.55
Family: ded = 6474.87, oopm = 8726.89 + 784.55 = 9511.44

Wait, does B's deductible balance change? Deductible_applied is 0, so B's ded balance stays 0.

Actually, wait. Let me reconsider the deductible for B. In aggregate structure, the family deductible is 6400. B hasn't personally contributed to the deductible, but the family has met it. So B gets coinsurance on in-network. That's correct.

But what about B's own deductible balance? It stays 0. For out-of-network purposes, B's single deductible balance is 0, and the out-of-network threshold is 6400.

---

LINE 8: Claim 8 — 2026-03-28 — D (child)
Ambulatory surgery, in-network
Allowed: 6750.63

In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00

Remaining = 6750.63
Coinsurance (10%): 6750.63 * 0.10 = 675.063 → 675.06
Plan: 6750.63 * 0.90 = 6075.567 → 6075.57

Check: 675.06 + 6075.57 = 6750.63. Yes.

D's OOPM = 0. 0 + 675.06 = 675.06 < 7000.

Member responsibility = 675.06
Plan paid = 6075.57

D: ded = 0, oopm = 675.06
Family: ded = 6474.87, oopm = 9511.44 + 675.06 = 10186.50

---

LINE 9: Claim 9 — 2026-04-11 — B (spouse)
Inpatient admission, in-network
Allowed: 12250.27

In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00

Remaining = 12250.27
Coinsurance (10%): 12250.27 * 0.10 = 1225.027 → 1225.03
Plan: 12250.27 * 0.90 = 11025.243 → 11025.24

Check: 1225.03 + 11025.24 = 12250.27. Yes.

B's OOPM = 784.55. 784.55 + 1225.03 = 2009.58 < 7000.

Member responsibility = 1225.03
Plan paid = 11025.24

B: ded = 0, oopm = 2009.58
Family: ded = 6474.87, oopm = 10186.50 + 1225.03 = 11411.53

---

LINE 10: Claim 10 — 2026-04-27 — D (child)
Inpatient admission, in-network
Allowed: 12224.51

In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00

Remaining = 12224.51
Coinsurance (10%): 12224.51 * 0.10 = 1222.451 → 1222.45
Plan: 12224.51 * 0.90 = 11002.059 → 11002.06

Check: 1222.45 + 11002.06 = 12224.51. Yes.

D's OOPM = 675.06. 675.06 + 1222.45 = 1897.51 < 7000.

Member responsibility = 1222.45
Plan paid = 11002.06

D: ded = 0, oopm = 1897.51
Family: ded = 6474.87, oopm = 11411.53 + 1222.45 = 12633.98

---

LINE 11: Claim 11 — 2026-05-10 — D (child)
Annual wellness visit, out-of-network
Allowed: 664.62

Out-of-network. "Annual wellness visit" - is this preventive care?

The plan says: "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

And from the rules: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."

An annual wellness visit is a preventive service. Since it's out-of-network, it IS subject to deductible and coinsurance.

D's single deductible balance = 0.
Out-of-network threshold = 6400.
Remainder = 6400 - 0 = 6400.
Deductible_applied = min(664.62, 6400) = 664.62

All goes to deductible.
Member responsibility = 664.62
Plan paid = 0.00

D: ded = 0 + 664.62 = 664.62, oopm = 1897.51 + 664.62 = 2562.13
Family: ded = 6474.87 + 664.62 = 7139.49, oopm = 12633.98 + 664.62 = 13298.60

---

LINE 12: Claim 12 — 2026-05-17 — B (spouse)
Generic retail pharmacy fill, out-of-network
Allowed: 30.19

Out-of-network.
B's single deductible balance = 0.
Out-of-network threshold = 6400.
Remainder = 6400.
Deductible_applied = min(30.19, 6400) = 30.19

Member responsibility = 30.19
Plan paid = 0.00

B: ded = 0 + 30.19 = 30.19, oopm = 2009.58 + 30.19 = 2039.77
Family: ded = 7139.49 + 30.19 = 7169.68, oopm = 13298.60 + 30.19 = 13328.79

---

LINE 13: Claim 13 — 2026-05-24 — D (child)
Screening colonoscopy, no polyp removed, out-of-network
Allowed: 716.51

Out-of-network. Screening colonoscopy is a preventive service. Since it's out-of-network, it's subject to deductible and coinsurance.

D's single deductible balance = 664.62.
Out-of-network threshold = 6400.
Remainder = 6400 - 664.62 = 5735.38.
Deductible_applied = min(716.51, 5735.38) = 716.51

Member responsibility = 716.51
Plan paid = 0.00

D: ded = 664.62 + 716.51 = 1381.13, oopm = 2562.13 + 716.51 = 3278.64
Family: ded = 7169.68 + 716.51 = 7886.19, oopm = 13328.79 + 716.51 = 14045.30

---

LINE 14: VOID of Claim 3 — 2026-06-06 — C (child)

Claim 3 was: C, out-of-network, allowed 967.99
Original adjudication: deductible_applied = 0, coinsurance member = 387.20, plan = 580.79
Credits to remove:
- Deductible credit: 0 (so no change to deductible balances)
- Member responsibility: 387.20 (remove from C's OOPM and family OOPM)

C: ded stays 6400, oopm = 8180.78 - 387.20 = 7793.58
Family: ded stays 7886.19, oopm = 14045.30 - 387.20 = 13658.10

Wait, let me re-read the void rule: "When a line voids an earlier claim, its credits are removed in the same way and nothing replaces them."

Claim 3 had:
- deductible_applied = 0 (no deductible credit to remove)
- member_responsibility = 387.20 (remove from C's OOPM and family OOPM)
- plan_paid = 580.79 (this is plan payment, not an accumulator credit)

So:
C's OOPM: 8180.78 - 387.20 = 7793.58
Family OOPM: 14045.30 - 387.20 = 13658.10

C's deductible stays 6400 (no deductible credit was generated by Claim 3).
Family deductible stays 7886.19.

Let me double check C's OOPM. After Claim 2, C's OOPM was 7793.58. After Claim 3, it was 8180.78. Now voiding Claim 3 brings it back to 7793.58. Correct.

Family OOPM: After Claim 2, family OOPM was 7868.45. After Claim 3, it was 8255.65. Then:
- Claim 4: +25.53 → 8281.18
- Claim 5: +354.52 → 8635.70
- Claim 6: +91.19 → 8726.89
- Claim 7: +784.55 → 9511.44
- Claim 8: +675.06 → 10186.50
- Claim 9: +1225.03 → 11411.53
- Claim 10: +1222.45 → 12633.98
- Claim 11: +664.62 → 13298.60
- Claim 12: +30.19 → 13328.79
- Claim 13: +716.51 → 14045.30

Now void Claim 3 (387.20): 14045.30 - 387.20 = 13658.10. Correct.

---

LINE 15: Claim 15 — 2026-06-18 — A (subscriber)
Outpatient endoscopy, out-of-network
Allowed: 2331.25

Out-of-network.
A's single deductible balance = 74.87.
Out-of-network threshold = 6400.
Remainder = 6400 - 74.87 = 6325.13.
Deductible_applied = min(2331.25, 6325.13) = 2331.25

All goes to deductible.
Member responsibility = 2331.25
Plan paid = 0.00

A: ded = 74.87 + 2331.25 = 2406.12, oopm = 546.11 + 2331.25 = 2877.36
Family: ded = 7886.19 + 2331.25 = 10217.44, oopm = 13658.10 + 2331.25 = 15989.35

---

LINE 16: VOID of Claim 6 — 2026-06-22 — A (subscriber)

Claim 6 was: A, in-network, allowed 911.89
Original adjudication: deductible_applied = 0, coinsurance member = 91.19, plan = 820.70
Credits to remove:
- Deductible credit: 0
- Member responsibility: 91.19

A: ded stays 2406.12, oopm = 2877.36 - 91.19 = 2786.17
Family: ded stays 10217.44, oopm = 15989.35 - 91.19 = 15898.16

---

LINE 17:

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

INITIAL ACCUMULATORS:
A: deductible 0.00, OOPM 0.00
B: deductible 0.00, OOPM 0.00
C: deductible 1744.67, OOPM 1900.68
D: deductible 1150.72, OOPM 1150.72
Family: deductible 2895.39, OOPM 3051.40

Plan details:
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- OOPM individual (in-network): 5500.00
- OOPM family (in-network): 11000.00
- Coinsurance after deductible, in-network: 30% member / 70% plan
- Copays: PCP 25, Specialist 50, Urgent care 60, ER 300 (waived if admitted), Generic retail pharmacy 10
- Copays DO credit deductible and OOPM
- Preventive care in-network: 100% paid, no cost share, no deductible/OOPM credit

Let me process each line:

LINE 1: Claim 1 — 2026-01-18 — D (child)
Service: Emergency department visit, in-network
Network: In-network
Allowed: 3295.94
Disposition: Treated and released (NOT admitted, so ER copay applies)

ER copay: 300.00 (not waived since treated and released)
Since copays credit the deductible:
D's individual deductible remaining: 2500.00 - 1150.72 = 1349.28
Family deductible remaining: 5000.00 - 2895.39 = 2104.61

Wait, for an ER visit with a copay - does the copay apply INSTEAD of deductible/coinsurance, or in addition to?

Looking at the plan document:
"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 for ER treated and released: $300 copay applies. The copay is the member's cost share.
But does the entire allowed amount go to deductible, or just the copay?

"Copays DO credit the deductible."
So the copay amount (300) credits the deductible.

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"

But for a copay service, is the deductible applied to the full allowed amount or just the copay?

Hmm, the plan says "Copays DO credit the deductible." This means the copay amount credits the deductible. So deductible_applied = copay amount (up to remaining deductible).

Actually, let me think about this more carefully. For a service with a copay:
- The member pays the copay
- The copay credits the deductible
- deductible_applied = the copay amount (since that's what credits the deductible)

Wait, but "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold." This suggests deductible_applied could be the full allowed amount if there's room. But for a copay service, the member only pays the copay, not the full allowed amount.

Let me re-read: "Copays DO credit the deductible. Copays always credit the out-of-pocket maximum."

I think for copay services:
- member_responsibility = copay amount
- deductible_applied = copay amount (since the copay credits the deductible)
- The rest is paid by the plan

Actually wait. Let me reconsider. For services with copays, the member pays just the copay. The deductible_applied would be the copay amount since that's what credits the deductible. The plan pays the rest of the allowed amount.

Let me think about this differently. The rules say:
- "member_responsibility plus plan_paid equals the allowed amount"
- For a copay service, member_responsibility = copay
- plan_paid = allowed - copay
- deductible_applied = copay (since copays credit the deductible)

Let me proceed with this interpretation.

LINE 1: Claim 1 — D — ER visit, treated and released
Allowed: 3295.94
ER copay: 300.00

D's deductible remaining (individual): 2500.00 - 1150.72 = 1349.28
Family deductible remaining: 5000.00 - 2895.39 = 2104.61

deductible_applied = min(300.00, min(1349.28, 2104.61)) = 300.00
member_responsibility = 300.00
plan_paid = 3295.94 - 300.00 = 2995.94
copay = 300.00
coinsurance = 0.00

Update accumulators:
D: deductible = 1150.72 + 300.00 = 1450.72, OOPM = 1150.72 + 300.00 = 1450.72
Family: deductible = 2895.39 + 300.00 = 3195.39, OOPM = 3051.40 + 300.00 = 3351.40

LINE 2: Claim 2 — 2026-01-28 — D (child)
Service: Urgent care visit, in-network
Allowed: 182.07
Urgent care copay: 60.00

D's deductible remaining (individual): 2500.00 - 1450.72 = 1049.28
Family deductible remaining: 5000.00 - 3195.39 = 1804.61

deductible_applied = min(60.00, min(1049.28, 1804.61)) = 60.00
member_responsibility = 60.00
plan_paid = 182.07 - 60.00 = 122.07
copay = 60.00
coinsurance = 0.00

Update accumulators:
D: deductible = 1450.72 + 60.00 = 1510.72, OOPM = 1450.72 + 60.00 = 1510.72
Family: deductible = 3195.39 + 60.00 = 3255.39, OOPM = 3351.40 + 60.00 = 3411.40

LINE 3: Claim 3 — 2026-02-09 — A (subscriber)
Service: Inpatient admission with surgery, out-of-network
Network: Out-of-network
Allowed: 25881.03

Out-of-network:
- Individual deductible (out-of-network): 5000.00
- Coinsurance: 50% member / 50% plan
- "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."

So A has a single deductible balance, currently 0.00. For out-of-network, the threshold is 5000.00.
A's deductible remaining (out-of-network): 5000.00 - 0.00 = 5000.00

deductible_applied = min(25881.03, 5000.00) = 5000.00
Remaining allowed after deductible: 25881.03 - 5000.00 = 20881.03
Coinsurance: 50% of 20881.03 = 10440.515 → 10440.52 (member)

Wait, let me check rounding. "Round half up to the cent at the end of a calculation."
20881.03 * 0.50 = 10440.515 → rounds to 10440.52

member_responsibility = 5000.00 + 10440.52 = 15440.52
plan_paid = 25881.03 - 15440.52 = 10440.51

Wait, let me recalculate: 25881.03 - 5000.00 = 20881.03
20881.03 * 0.50 = 10440.515 → 10440.52
member_responsibility = 5000.00 + 10440.52 = 15440.52
plan_paid = 25881.03 - 15440.52 = 10440.51

Check: 15440.52 + 10440.51 = 25881.03 ✓

Now, OOPM for out-of-network: Individual OOPM (out-of-network) is 11000.00.
But wait, the plan 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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So for out-of-network:
- Deductible threshold: 5000.00 (individual out-of-network)
- OOPM threshold: 11000.00 (individual out-of-network)
- The member's single deductible balance is used
- The credits accumulate to member's balance and family balance

A's OOPM balance: 0.00
OOPM threshold (out-of-network): 11000.00
OOPM remaining: 11000.00 - 0.00 = 11000.00

member_responsibility = 15440.52
This exceeds the OOPM remaining (11000.00).

So the member pays up to the OOPM:
deductible_applied = 5000.00
After deductible, remaining allowed: 20881.03
OOPM room after deductible: 11000.00 - 5000.00 = 6000.00
So coinsurance is capped at 6000.00
member_responsibility = 5000.00 + 6000.00 = 11000.00
plan_paid = 25881.03 - 11000.00 = 14881.03

Check: 11000.00 + 14881.03 = 25881.03 ✓

Update accumulators:
A: deductible = 0.00 + 5000.00 = 5000.00, OOPM = 0.00 + 11000.00 = 11000.00
Family: deductible = 3255.39 + 5000.00 = 8255.39, OOPM = 3411.40 + 11000.00 = 14411.40

Wait, but the family deductible is 5000.00 and family OOPM is 11000.00 (in-network). The out-of-network claim credits still accumulate to the family balance. So family deductible goes to 8255.39 and family OOPM goes to 14411.40.

Actually, let me re-read: "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."

So the family deductible and OOPM can exceed their in-network thresholds. They just don't cap the out-of-network claim. The out-of-network claim is only capped by the out-of-network individual thresholds.

A: deductible = 5000.00, OOPM = 11000.00
Family: deductible = 8255.39, OOPM = 14411.40

LINE 4: Claim 4 — 2026-02-22 — C (child)
Service: Urgent care visit, in-network
Allowed: 290.40
Urgent care copay: 60.00

C's deductible remaining (individual): 2500.00 - 1744.67 = 755.33
Family deductible remaining: The family deductible is 5000.00. Family balance is 8255.39. So family deductible remaining = 0 (already exceeded).

Wait, for embedded structure: "the smaller of the member's individual remainder and the family remainder"
Family remainder = max(5000.00 - 8255.39, 0) = 0

So deductible_applied = min(60.00, min(755.33, 0)) = 0.00

Hmm, but the family deductible is already met (8255.39 > 5000.00). So family remainder is 0. Under embedded, deductible_applied = min(copay, min(individual remainder, family remainder)) = min(60, min(755.33, 0)) = 0.

But wait, does the copay still apply? Let me re-read:
"Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So deductible_applied = 0.00. But the copay still applies as member responsibility? Let me think...

For a copay service, the member pays the copay. The copay credits the deductible and OOPM. But if the deductible is already met (family deductible met), then deductible_applied = 0.00.

But does the member still pay the copay? The copay is a flat per-service amount. Let me re-read the plan:
"Primary care office visit ... 25.00 copay"
"Urgent care ... 60.00 copay"

These are copays - the member pays them regardless of deductible status? Or do copays only apply before the deductible is met?

Actually, in most plans, copays apply AFTER the deductible is met, or they apply INSTEAD of the deductible for certain services. But the plan says "Copays DO credit the deductible" which implies copays are paid while the deductible is being met.

Hmm, let me think about this differently. For urgent care with a $60 copay:
- The member pays $60
- This $60 credits the deductible
- The plan pays the rest

Once the deductible is met (both individual and family), what happens? Does the member still pay the copay?

Looking at the plan document again:
"Coinsurance after deductible, in-network ......... 30% member / 70% plan"
"Urgent care ...................................... 60.00 copay"

I think the copay replaces the coinsurance for these specific services. So even after the deductible is met, the member pays the copay (not coinsurance) for urgent care visits.

But then: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So the copay is still paid, but it doesn't credit the deductible anymore. It still credits the OOPM though: "Copays always credit the out-of-pocket maximum."

So for C's urgent care:
- Family deductible is met (8255.39 > 5000.00)
- C's individual deductible is not met (1744.67 < 2500.00)
- Under embedded: deductible_applied = min(60, min(755.33, 0)) = 0.00

Wait, but if the family deductible is met, does that mean all family members have satisfied their deductible for in-network purposes? Under 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 the family deductible is met, all members are considered to have met their deductible. So C's deductible is effectively met (through the family deductible being met).

So for C:
- Deductible is met (family deductible met)
- member_responsibility = copay = 60.00
- deductible_applied = 0.00 (since deductible is met)
- plan_paid = 290.40 - 60.00 = 230.40
- copay = 60.00
- coinsurance = 0.00

OOPM: C's OOPM = 1900.68. Individual OOPM = 5500.00. OOPM remaining = 5500.00 - 1900.68 = 3599.32.
60.00 credits OOPM.

Update accumulators:
C: deductible = 1744.67 (no change since deductible_applied = 0), OOPM = 1900.68 + 60.00 = 1960.68
Family: deductible = 8255.39 (no change), OOPM = 14411.40 + 60.00 = 14471.40

Wait, I need to reconsider. If the family deductible is already met, do copays still apply? Or does coinsurance apply?

Looking at the plan: "Urgent care ... 60.00 copay". This seems to be a fixed copay for urgent care visits regardless of deductible status. The copay is the member's cost share for this service type.

Let me re-read: "Member cost share: Coinsurance after deductible, in-network ......... 30% member / 70% plan" and then lists specific copays for specific services.

I think the copays are the cost share for those specific services, and they apply whether or not the deductible is met. The deductible and coinsurance apply to services that don't have a specific copay.

So for urgent care: member pays $60 copay. This is the member's full responsibility.
deductible_applied = 0.00 (since deductible is met)
member_responsibility = 60.00
plan_paid = 290.40 - 60.00 = 230.40

Actually, wait. I need to reconsider whether copays apply before or after deductible. Let me look at the plan document more carefully.

The plan lists:
"Member cost share
  Coinsurance after deductible, in-network ......... 30% member / 70% plan
  Coinsurance after deductible, out-of-network ..... 50% member / 50% 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..."

The heading is "Member cost share" and it lists both coinsurance (after deductible) and copays. The copays seem to be separate from the deductible/coinsurance structure - they're flat amounts for specific services.

"Copays DO credit the deductible." - This means when you pay a copay, it counts toward your deductible.

So the copay is the member's cost share for that service. It credits the deductible (and OOPM). Once the deductible is met, the copay still applies (it's the cost share for that service), but it no longer credits the deductible.

OK, so my calculation for C is correct:
member_responsibility = 60.00
deductible_applied = 0.00
plan_paid = 230.40
copay = 60.00
coinsurance = 0.00

LINE 5: Claim 5 — 2026-03-07 — A (subscriber)
Service: Urgent care visit, in-network
Allowed: 175.00
Urgent care copay: 60.00

A's deductible: 5000.00 (already met - individual in-network deductible is 2500.00, and A's balance is 5000.00 which exceeds it)
Family deductible: 8255.39 (already met)

deductible_applied = 0.00
member_responsibility = 60.00
plan_paid = 175.00 - 60.00 = 115.00
copay = 60.00
coinsurance = 0.00

A's OOPM: 11000.00. Individual OOPM (in-network) = 5500.00.
Wait, A's OOPM balance is 11000.00, which already exceeds the in-network individual OOPM of 5500.00.

"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."

So A has reached the OOPM (11000.00 >= 5500.00 for in-network). The plan pays 100%.

Wait, but A's OOPM balance is 11000.00 because of the out-of-network claim. The out-of-network OOPM threshold is 11000.00, and A reached it. But for in-network services, the OOPM threshold is 5500.00. A's balance of 11000.00 exceeds 5500.00, so A has definitely reached the in-network OOPM.

So for A's in-network urgent care:
member_responsibility = 0.00 (OOPM reached)
plan_paid = 175.00
deductible_applied = 0.00
copay = 0.00
coinsurance = 0.00

Wait, but the copay is 60.00. If OOPM is reached, does the member still pay the copay?

"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 no, the member pays nothing. The plan pays 100%.

Update accumulators:
A: deductible = 5000.00 (no change), OOPM = 11000.00 (no change)
Family: deductible = 8255.39 (no change), OOPM = 14471.40 (no change)

LINE 6: Claim 6 — 2026-03-19 — C (child)
Service: Outpatient procedure, in-network
Allowed: 7641.96

This is not a copay service. It's subject to deductible and coinsurance.

C's deductible: 1744.67. Individual in-network deductible: 2500.00.
But family deductible is already met (8255.39 > 5000.00).
Under embedded: C's deductible is considered met because family deductible is met.

So deductible_applied = 0.00.
Coinsurance: 30% of 7641.96 = 2292.588 → 2292.59

C's OOPM: 1960.68. Individual OOPM: 5500.00. OOPM remaining: 5500.00 - 1960.68 = 3539.32.

member_responsibility from coinsurance = 2292.59. This is less than OOPM remaining (3539.32), so no cap needed.

member_responsibility = 2292.59
plan_paid = 7641.96 - 2292.59 = 5349.37
deductible_applied = 0.00
copay = 0.00
coinsurance = 2292.59

Update accumulators:
C: deductible = 1744.67 (no change), OOPM = 1960.68 + 2292.59 = 4253.27
Family: deductible = 8255.39 (no change), OOPM = 14471.40 + 2292.59 = 16763.99

LINE 7: Claim 7 — 2026-03-29 — A (subscriber)
Service: Physical therapy course, in-network
Allowed: 894.21

This is not a copay service (no specific copay listed for PT). Subject to deductible and coinsurance.

A's deductible is met (5000.00 > 2500.00).
A's OOPM: 11000.00. In-network OOPM: 5500.00. A has reached OOPM.

member_responsibility = 0.00
plan_paid = 894.21
deductible_applied = 0.00
copay = 0.00
coinsurance = 0.00

Update accumulators:
A: deductible = 5000.00, OOPM = 11000.00 (no change)
Family: deductible = 8255.39, OOPM = 16763.99 (no change)

LINE 8: Claim 8 — 2026-04-09 — D (child)
Service: Inpatient admission with surgery, in-network
Allowed: 25110.74

Not a copay service. Subject to deductible and coinsurance.

D's deductible: 1510.72. Individual in-network deductible: 2500.00.
Family deductible: 8255.39 (already met, > 5000.00).

Since family deductible is met, D's deductible is considered met (embedded).
deductible_applied = 0.00.

Coinsurance: 30% of 25110.74 = 7533.222 → 7533.22

D's OOPM: 1510.72. Individual OOPM: 5500.00. OOPM remaining: 5500.00 - 1510.72 = 3989.28.

Coinsurance (7533.22) exceeds OOPM remaining (3989.28).
So member_responsibility = 3989.28 (capped at OOPM).
plan_paid = 25110.74 - 3989.28 = 21121.46

deductible_applied = 0.00
copay = 0.00
coinsurance = 3989.28 (the amount that actually went to coinsurance before OOPM cap)

Wait, actually, what is coinsurance_amount? Is it the calculated coinsurance or the actual amount paid? Let me think...

member_responsibility = deductible_applied + copay + coinsurance
3989.28 = 0.00 + 0.00 + coinsurance
coinsurance = 3989.28

So coinsurance_amount = 3989.28 (the actual coinsurance the member pays, capped by OOPM).

Update accumulators:
D: deductible = 1510.72, OOPM = 1510.72 + 3989.28 = 5500.00
Family: deductible = 8255.39, OOPM = 16763.99 + 3989.28 = 20753.27

LINE 9: Claim 9 — 2026-04-25 — D (child)
Service: Physical therapy course, in-network
Allowed: 646.70

D's OOPM is 5500.00 (reached). Plan pays 100%.

member_responsibility = 0.00
plan_paid = 646.70
deductible_applied = 0.00
copay = 0.00
coinsurance = 0.00

Update accumulators:
D: deductible = 1510.72, OOPM = 5500.00 (no change)
Family: deductible = 8255.39, OOPM = 20753.27 (no change)

LINE 10: ADJUSTMENT to Claim 2 — 2026-05-09 — D (child)
Original Claim 2: Allowed 182.07, copay 60.00, deductible_applied 60.00, member_responsibility 60.00, plan_paid 122.07

Wait, I need to unwind Claim 2's credits from accumulators.

Claim 2 originally:
- deductible_applied = 60.00 (credited to D's deductible and family deductible)
- member_responsibility = 60.00 (credited to D's OOPM and family OOPM)

Unwind:
D: deductible = 1510.72 - 60.00 = 1450.72, OOPM = 5500.00 - 60.00 = 5440.00
Family: deductible = 8255.39 - 60.00 = 8195.39, OOPM = 20753.27 - 60.00 = 20693.27

Now re-adjudicate Claim 2 at corrected values:
Allowed: 264.00
Urgent care copay: 60.00

D's deductible at this point: 1450.72. Individual: 2500.00. Remaining: 1049.28.
Family deductible: 8195.39. Family: 5000.00. Already m

Let me process this ledger step by step.

**Initial Accumulators:**
- A: deductible = 60.69, OOPM = 60.69
- B: deductible = 383.93, OOPM = 924.55
- C: deductible = 1524.34, OOPM = 2116.83
- Family: deductible = 1968.96, OOPM = 3102.07

**Plan Details:**
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance in-network: 30% member / 70% plan
- Coinsurance out-of-network: 50% member / 50% plan
- Primary care copay: 25.00
- Specialist copay: 50.00
- Urgent care copay: 60.00
- ER copay: 300.00 (waived if inpatient admission)
- Generic retail pharmacy: 10.00 copay
- Copays DO credit the deductible and OOPM
- Preventive care in-network: 100% plan, no cost share, no deductible/coinsurance/copay
- Out-of-network preventive: subject to OON deductible and coinsurance

**Deductible applied rules:**
- In-network: lesser of (member individual remainder, family remainder) for embedded
- Out-of-network: OON individual remainder, measured against member's single deductible balance
- Once applicable threshold is met, deductible_applied is 0.00

Let me track accumulators carefully.

**Starting state:**
- A: ded = 60.69, oopm = 60.69
- B: ded = 383.93, oopm = 924.55
- C: ded = 1524.34, oopm = 2116.83
- Family: ded = 1968.96, oopm = 3102.07

**Line 1 — Claim 1 — C (child) — Inpatient admission with surgery, in-network**
- Allowed: 10074.70
- C's individual deductible remainder: 2500.00 - 1524.34 = 975.66
- Family deductible remainder: 5000.00 - 1968.96 = 3031.04
- Deductible applied: min(975.66, 3031.04) = 975.66
- Remaining allowed after deductible: 10074.70 - 975.66 = 9099.04
- Coinsurance (30%): 9099.04 * 0.30 = 2729.712 → 2729.71
- Member responsibility: 975.66 + 2729.71 = 3695.37 (let me verify: 975.66 + 2729.712 = 3705.372... wait let me recalculate)

Wait, let me be more careful with rounding. The plan says round half up to the cent at the end of a calculation.

- Deductible applied: 975.66
- After deductible: 10074.70 - 975.66 = 9099.04
- Coinsurance: 9099.04 * 0.30 = 2729.712 → round to 2729.71
- Member responsibility: 975.66 + 2729.71 = 3705.37
- Plan paid: 10074.70 - 3705.37 = 7369.33

Wait, let me check: member_responsibility + plan_paid = allowed amount.
3705.37 + 7369.33 = 11074.70. That's not 10074.70. Let me recalculate.

Plan paid = allowed - member_responsibility = 10074.70 - 3705.37 = 6369.33
Check: 3705.37 + 6369.33 = 10074.70. Yes.

Actually let me recalculate coinsurance:
9099.04 * 0.30 = 2729.712
Rounding half up: 2729.71

Member responsibility = deductible_applied + coinsurance = 975.66 + 2729.71 = 3705.37
Plan paid = 10074.70 - 3705.37 = 6369.33

Check: 3705.37 + 6369.33 = 10074.70 ✓

Now update accumulators:
- C: ded = 1524.34 + 975.66 = 2500.00, oopm = 2116.83 + 3705.37 = 5822.20
- Family: ded = 1968.96 + 975.66 = 2944.62, oopm = 3102.07 + 3705.37 = 6807.44

Wait, C's OOPM is 5822.20 which exceeds the individual in-network OOPM of 5500.00. But the plan says the individual OOPM in-network is 5500.00. Does this matter? 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."

So C has reached the in-network individual OOPM (5500.00). But the OOPM was exceeded during this claim. Should the claim have been capped?

Let me re-read the accumulator rules: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

So the OOPM balance is the running total of member_responsibility. C's OOPM before this claim was 2116.83. The member responsibility on this claim is 3705.37. 2116.83 + 3705.37 = 5822.20.

But wait - if C reaches the OOPM during a claim, does the plan pay 100% after that point? Let me think about this...

Actually, the OOPM is checked at the point of adjudication. If the member hasn't reached the OOPM yet at the start of the claim, the full cost share applies. But some plans cap the cost share at the OOPM. 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."

This suggests that once the OOPM is reached, future claims are paid at 100%. But what about the claim that pushes them over? I think in standard practice, the member responsibility is capped at the OOPM.

Let me re-read: "A balance is the running total of... member_responsibility (for an out-of-pocket balance)."

If the member responsibility is capped, then the balance would never exceed the OOPM. Let me think about whether the member responsibility should be capped.

Actually, I think the member responsibility on a single claim should be capped so that the total OOPM balance doesn't exceed the individual OOPM. Let me re-read the rules more carefully...

The rules say: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

This talks about the deductible threshold being met. But for OOPM, it says "Once a member reaches the out-of-pocket maximum the plan pays 100%."

I think the standard interpretation is:
- If a member's OOPM accumulator + the current claim's member responsibility would exceed the OOPM, the member responsibility is capped at (OOPM - current accumulator).

Let me re-process Claim 1 with this logic:

C's OOPM before: 2116.83
Individual in-network OOPM: 5500.00
Room under OOPM: 5500.00 - 2116.83 = 3383.17

Calculated member responsibility: 3705.37
Since 3705.37 > 3383.17, member responsibility is capped at 3383.17.
Plan paid: 10074.70 - 3383.17 = 6691.53

Check: 3383.17 + 6691.53 = 10074.70 ✓

But wait, how does the cap work with deductible and coinsurance? The deductible_applied is 975.66. The coinsurance calculated is 2729.71. Total = 3705.37. The cap is 3383.17. So the coinsurance would be reduced: 3383.17 - 975.66 = 2407.51.

So:
- deductible_applied: 975.66
- coinsurance_amount: 2407.51
- member_responsibility: 3383.17
- plan_paid: 6691.53

Update accumulators:
- C: ded = 1524.34 + 975.66 = 2500.00, oopm = 2116.83 + 3383.17 = 5500.00
- Family: ded = 1968.96 + 975.66 = 2944.62, oopm = 3102.07 + 3383.17 = 6485.24

C has met their individual in-network deductible (2500.00) and individual in-network OOPM (5500.00).

**Line 2 — Claim 2 — A (subscriber) — Specialty pharmacy administration, in-network**
- Allowed: 4603.57
- This is "Specialty pharmacy administration" - not a copay service, so it goes to deductible and coinsurance.
- A's individual deductible remainder: 2500.00 - 60.69 = 2439.31
- Family deductible remainder: 5000.00 - 2944.62 = 2055.38
- Deductible applied: min(2439.31, 2055.38) = 2055.38
- Remaining allowed after deductible: 4603.57 - 2055.38 = 2548.19
- Coinsurance (30%): 2548.19 * 0.30 = 764.457 → 764.46
- Member responsibility before OOPM cap: 2055.38 + 764.46 = 2819.84
- A's OOPM before: 60.69
- Room under individual in-network OOPM: 5500.00 - 60.69 = 5439.31
- 2819.84 < 5439.31, so no cap needed.
- Member responsibility: 2819.84
- Plan paid: 4603.57 - 2819.84 = 1783.73

Check: 2819.84 + 1783.73 = 4603.57 ✓

Update accumulators:
- A: ded = 60.69 + 2055.38 = 2116.07, oopm = 60.69 + 2819.84 = 2880.53
- Family: ded = 2944.62 + 2055.38 = 5000.00, oopm = 6485.24 + 2819.84 = 9305.08

Family deductible is now met (5000.00).

**Line 3 — Claim 3 — B (spouse) — Specialist office visit, in-network**
- Allowed: 339.69
- Specialist office visit: 50.00 copay
- B's individual deductible remainder: 2500.00 - 383.93 = 2116.07
- Family deductible remainder: 5000.00 - 5000.00 = 0.00
- Since family deductible is met, deductible_applied = 0.00
- Copay: 50.00
- Since deductible is met (family deductible met), does the copay apply?

Wait, let me re-read: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So the copay still applies, but it doesn't credit the deductible. The member pays the copay and the plan pays the rest.

Actually, for a specialist office visit with a copay, how does it work? The member pays the 50.00 copay, and the plan pays the remaining allowed amount (339.69 - 50.00 = 289.69).

Wait, but is the deductible met for B? B's individual deductible is 383.93, so B hasn't met their individual deductible. But the family deductible IS met (5000.00). Under embedded structure, once the family deductible is met, all members have their deductible satisfied.

Let me re-read: "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."

So once the family deductible is met, all members' deductibles are considered satisfied. So B's deductible is satisfied.

So for Claim 3:
- deductible_applied: 0.00
- copay: 50.00
- Member responsibility: 50.00
- Plan paid: 339.69 - 50.00 = 289.69

Check: 50.00 + 289.69 = 339.69 ✓

OOPM cap check:
- B's OOPM before: 924.55
- Room under OOPM: 5500.00 - 924.55 = 4575.45
- 50.00 < 4575.45, no cap.

Update accumulators:
- B: ded = 383.93 + 0.00 = 383.93, oopm = 924.55 + 50.00 = 974.55
- Family: ded = 5000.00 + 0.00 = 5000.00, oopm = 9305.08 + 50.00 = 9355.08

Wait, does B's deductible accumulator change? The deductible_applied is 0.00, so B's deductible balance stays at 383.93. That's fine.

**Line 4 — Claim 4 — B (spouse) — Inpatient admission, out-of-network**
- Allowed: 15484.21
- Out-of-network
- B's single deductible balance: 383.93
- OON individual deductible: 5000.00
- OON individual deductible remainder: 5000.00 - 383.93 = 4616.07
- Deductible applied: min(15484.21, 4616.07) = 4616.07
- Remaining after deductible: 15484.21 - 4616.07 = 10868.14
- Coinsurance (50% OON): 10868.14 * 0.50 = 5434.07
- Member responsibility before OOPM cap: 4616.07 + 5434.07 = 10050.14

OOPM check:
- B's OOPM before: 974.55
- B's OON individual OOPM: 11000.00
- Room under OON OOPM: 11000.00 - 974.55 = 10025.45
- 10050.14 > 10025.45, so cap at 10025.45
- Member responsibility: 10025.45
- deductible_applied: 4616.07
- coinsurance: 10025.45 - 4616.07 = 5409.38
- Plan paid: 15484.21 - 10025.45 = 5458.76

Check: 10025.45 + 5458.76 = 15484.21 ✓

Update accumulators:
- B: ded = 383.93 + 4616.07 = 5000.00, oopm = 974.55 + 10025.45 = 11000.00
- Family: ded = 5000.00 + 4616.07 = 9616.07, oopm = 9355.08 + 10025.45 = 19380.53

Wait, the family deductible is 5000.00 and it was already met. The out-of-network credits still accumulate to the member's balance and family 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."

So family deductible becomes 5000.00 + 4616.07 = 9616.07.
Family OOPM becomes 9355.08 + 10025.45 = 19380.53.

B has met their OON individual deductible (5000.00) and OON individual OOPM (11000.00).

**Line 5 — Claim 5 — B (spouse) — Urgent care visit, in-network**
- Allowed: 181.01
- Urgent care: 60.00 copay
- B has met their deductible (family deductible met, and B's own OON deductible met).
- deductible_applied: 0.00
- copay: 60.00

OOPM check:
- B's OOPM before: 11000.00
- B has reached the OON OOPM (11000.00). But this is an in-network claim.
- B's in-network OOPM: 5500.00. B's OOPM balance is 11000.00 which exceeds 5500.00.
- So B has also met the in-network OOPM.
- "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."
- Since B's OOPM balance (11000.00) exceeds the in-network OOPM (5500.00), B has met the in-network OOPM too.
- So member responsibility = 0.00? 

Wait, but the copay is 60.00. If the OOPM is met, does the copay still apply?

"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."

I think once the OOPM is met, the plan pays 100%, so no copay applies.

Actually, let me reconsider. B's OOPM balance is 11000.00. The in-network individual OOPM is 5500.00. Since 11000.00 > 5500.00, B has met the in-network OOPM.

So for this in-network claim:
- deductible_applied: 0.00
- copay: 0.00 (OOPM met)
- coinsurance: 0.00
- member_responsibility: 0.00
- plan_paid: 181.01

Update accumulators:
- B: ded = 5000.00, oopm = 11000.00 (no change)
- Family: ded = 9616.07, oopm = 19380.53 (no change)

**Line 6 — Claim 6 — A (subscriber) — Urgent care visit, in-network**
- Allowed: 213.67
- Urgent care: 60.00 copay
- A's deductible: 2116.07. Individual remainder: 2500.00 - 2116.07 = 383.93
- Family deductible is met (5000.00+), so family remainder = 0
- Deductible applied: min(383.93, 0) = 0.00 (since family deductible is met)

Wait, but the family deductible was already met at Line 2. So deductible_applied = 0.00.

Actually wait. Let me re-read: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded)"

Family remainder = 5000.00 - family_ded_accumulator. But family deductible accumulator is now 9616.07 (after the OON claim). So family remainder is 0 (or negative, but effectively 0).

So deductible_applied = 0.00.

- Copay: 60.00
- Member responsibility: 60.00

OOPM check:
- A's OOPM before: 2880.53
- Room under in-network OOPM: 5500.00 - 2880.53 = 2619.47
- 60.00 < 2619.47, no cap.

Update accumulators:
- A: ded = 2116.07 + 0.00 = 2116.07, oopm = 2880.53 + 60.00 = 2940.53
- Family: ded = 9616.07 + 0.00 = 9616.07, oopm = 19380.53 + 60.00 = 19440.53

Claim 6 components:
- deductible_applied: 0.00
- copay_amount: 60.00
- coinsurance_amount: 0.00
- member_responsibility: 60.00
- plan_paid: 213.67 - 60.00 = 153.67

**Line 7 — Claim 7 — C (child) — Specialist office visit, in-network**
- Allowed: 330.22
- Specialist: 50.00 copay
- C's deductible is met (2500.00), family deductible is met.
- deductible_applied: 0.00
- C's OOPM is 5500.00 (met). So plan pays 100%.
- member_responsibility: 0.00
- plan_paid: 330.22

Update accumulators:
- C: ded = 2500.00, oopm = 5500.00 (no change)
- Family: ded = 9616.07, oopm = 19440.53 (no change)

**Line 8 — Claim 8 — C (child) — Sleep study, out-of-network**
- Allowed: 1805.31
- Out-of-network
- C's single deductible balance: 2500.00
- OON individual deductible: 5000.00
- OON remainder: 5000.00 - 2500.00 = 2500.00
- Deductible applied: min(1805.31, 2500.00) = 1805.31
- Remaining after deductible: 1805.31 - 1805.31 = 0.00
- Coinsurance: 0.00
- Member responsibility: 1805.31

OOPM check:
- C's OOPM before: 5500.00
- C's OON OOPM: 11000.00
- Room: 11000.00 - 5500.00 = 5500.00
- 1805.31 < 5500.00, no cap.

Update accumulators:
- C: ded = 2500.00 + 1805.31 = 4305.31, oopm = 5500.00 + 1805.31 = 7305.31
- Family: ded = 9616.07 + 1805.31 = 11421.38, oopm = 19440.53 + 1805.31 = 21245.84

**Line 9 — ADJUSTMENT to Claim 6 — A (subscriber)**
- Original Claim 6: allowed 213.67, deductible_applied 0.00, copay 60.00, member_resp 60.00, plan_paid 153.67
- New allowed: 277.77

First, unwind Claim 6's credits:
- A: ded = 2116.07 - 0.00 = 2116.07, oopm = 2940.53 - 60.00 = 2880.53
- Family: ded = 11421.38 - 0.00 = 11421.38, oopm = 21245.84 - 60.00 = 21185.84

Now re-adjudicate Claim 6 with allowed = 277.77 against current accumulators:
- A (subscriber) — Urgent care visit, in-network
- Allowed: 277.77
- Urgent care: 60.00 copay
- Family deductible is met (11421.38 > 5000.00), so deductible_applied = 0.00
- Copay: 60.00
- Member responsibility: 60.00

OOPM check:
- A's OOPM: 2880.53
- Room: 5500.00 - 2880.53 = 2619.47
- 60.00 < 2619.47, no cap.

Update accumulators:
- A: ded = 2116.07 + 0.00 = 2116.07, oopm = 2880.53 + 60.00 = 2940.53
- Family: ded = 11421.38 + 0.00 = 11421.38, oopm = 21185.84 + 60.00 = 21245.84

Claim 6 adjusted components:
- deductible_applied: 0.00
- copay_amount: 60.00
- coinsurance_amount: 0.00
- member_responsibility: 60.00
- plan_paid: 277.77 - 60.00 = 217.77

**Line 10 — Claim 10 — C (child) — Ambulatory surgery, out-of-network**
- Allowed: 8945.95
- Out-of-network
- C's deductible balance: 4305.31
- OON individual deductible: 5000.00
- OON remainder: 5000.00 - 4305.31 = 694.69
- Deductible applied: min(8945.95, 694.69) = 694.69
- Remaining after deductible: 8945.95 - 694.69 = 8251.26
- Coinsurance (50% OON): 8251.26 * 0.50 = 4125.63
- Member responsibility before OOPM cap: 694.69 + 4125.63 = 4820.32

OOPM check:
- C's OOPM before: 7305.31
- C's OON OOPM: 11000.00
- Room: 11000.00 - 7305.31 = 3694.69
- 4820.32 > 3694.69, so cap at 3694.69
- Member responsibility: 3694.69
- deductible_applied: 694.69
- coinsurance: 3694.69 - 694.69 = 3000.00
- Plan paid: 8945.95 - 3694.69 = 5251.26

Check: 3694.69 + 5251.26 = 8945.95 ✓

Update accumulators:
- C: ded = 4305.31 + 694.69 = 5000.00, oopm = 7305.31 + 3694.69 = 11000.00
- Family: ded = 11421.38 + 694.69 = 12116.07, oopm = 21245.84 + 3694.69 = 24940.53

C has met OON deductible (5000.00) and OON OOPM (11000.00).

**Line 11 — ADJUSTMENT to Claim 6 — A (subscriber)**
- This is another adjustment to Claim 6, correcting to allowed = 277.77
- Wait, the allowed was already corrected to 277.77 in Line 9. And Line 11 says "corrected to 277.77" again.

Let me re-read:
Line 9: "Allowed amount .. corrected to 277.77"
Line 11: "Allowed amount .. corrected to 277.77"

So Line 11 adjusts Claim 6 to the same value it was already adjusted to. Let me process it anyway.

First, unwind Claim 6's current credits (from Line 9 adjustment):
- Claim 6 current: deductible_applied 0.00, member_resp 60.00
- A: ded = 2116.07 - 0.00 = 2116.07, oopm = 2940.53 - 60.00 = 2880.53
- Family: ded = 12116.07 - 0.00 = 12116.07, oopm = 24940.53 - 60.00 = 24880.53

Re-adjudicate Claim 6 with allowed = 277.77:
- Urgent care, in-network
- Family deductible met, so deductible_applied = 0.00
- Copay: 60.00
- Member responsibility: 60.00

OOPM check:
- A's OOPM: 2880.53
- Room: 5500.00 - 2880.53 = 2619.47
- No cap.

Update accumulators:
- A: ded = 2116.07, oopm = 2880.53 + 60.00 = 2940.53
- Family: ded = 12116.07, oopm = 24880.53 + 60.00 = 24940.53

Claim 6 components remain the same:
- deductible_applied: 0.00
- copay_amount: 60.00
- coinsurance_amount: 0.00
- member_responsibility: 60.00
- plan_paid: 277.77 - 60.00 = 217.77

**Line 12 — Claim 12 — C (child) — Inpatient admission, in-network**
- Allowed: 23123.73
- In-network
- C's deductible is met (5000.00, family met).
- C's OOPM: 11000.00. In-network OOPM: 5500.00. C's balance is 11000.00 > 5500.00, so in-network OOPM is met.
- deductible_applied: 0.00
- member_responsibility: 0.00 (OOPM met)
- plan_paid: 23123.73

Update accumulators: no change
- C: ded = 5000.00, oopm = 11000.00
- Family: ded = 12116.07, oopm = 24940.53

**Line 13 — Claim 13 — A (subscriber) — Outpatient procedure, in-network**
- Allowed: 5196.38
- In-network
- A's deductible: 2116.07. Individual remainder: 2500.00 - 2116.07 = 383.93
- Family deductible met, so family remainder = 0.
- Deductible applied: min(383.93, 0) = 0.00
- Remaining after deductible: 5196.38
- Coinsurance (30%): 5196.38 * 0.30 = 1558.914 → 1558.91
- Member responsibility before cap: 0.00 + 1558.91 = 1558.91

OOPM check:
- A's OOPM: 2940.53
- Room: 5500.00 - 2940.53 = 2559.47
- 1558.91 < 2559.47, no cap.

Member responsibility: 1558.91
Plan paid: 5196.38 - 1558.91 = 3637.47

Check: 1558.91 + 3637.47 = 5196.38 ✓

Update accumulators:
- A: ded = 2116.07 + 0.00 = 2116.07, oopm = 2940.53 + 1558.91 = 4499.44
- Family: ded = 12116.07, oopm = 24940.53 + 1558.91 = 26499.44

**Line 14 — Claim 14 — B (spouse) 

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

**Initial Accumulators:**
- A: deductible = 904.50, OOPM = 904.50
- B: deductible = 0.00, OOPM = 0.00
- C: deductible = 0.00, OOPM = 0.00
- D: deductible = 0.00, OOPM = 0.00
- Family: deductible = 904.50, OOPM = 904.50

**Plan Parameters:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance in-network: 20% member / 80% plan
- Coinsurance out-of-network: 40% member / 60% plan
- Primary care copay: 30.00
- Specialist copay: 60.00
- Urgent care copay: 75.00
- ER copay: 400.00 (waived if inpatient admission)
- Generic retail pharmacy: 15.00
- Copays do NOT credit deductible, but DO credit OOPM

**Line 1 — Claim 1 — A — Specialist office visit, in-network**
- Allowed: 294.03
- Specialist copay: 60.00
- Copays do NOT credit deductible. Copays DO credit OOPM.
- Deductible applied: 0.00
- Copay amount: 60.00
- Coinsurance amount: 0.00
- Member responsibility: 60.00
- Plan paid: 294.03 - 60.00 = 234.03

Accumulators after Line 1:
- A: deductible = 904.50, OOPM = 904.50 + 60.00 = 964.50
- Family: deductible = 904.50, OOPM = 904.50 + 60.00 = 964.50

**Line 2 — Claim 2 — C — Primary care office visit, in-network**
- Allowed: 197.39
- Primary care copay: 30.00
- Deductible applied: 0.00
- Copay amount: 30.00
- Coinsurance amount: 0.00
- Member responsibility: 30.00
- Plan paid: 197.39 - 30.00 = 167.39

Accumulators after Line 2:
- C: deductible = 0.00, OOPM = 0.00 + 30.00 = 30.00
- Family: deductible = 904.50, OOPM = 964.50 + 30.00 = 994.50

**Line 3 — Claim 3 — D — Inpatient admission with surgery, in-network**
- Allowed: 11804.80
- D's individual deductible remainder: 1500.00 - 0.00 = 1500.00
- Family deductible remainder: 3000.00 - 904.50 = 2095.50
- Embedded: deductible_applied = min(allowed, min(individual remainder, family remainder))
  = min(11804.80, min(1500.00, 2095.50)) = min(11804.80, 1500.00) = 1500.00
- After deductible: 11804.80 - 1500.00 = 10304.80
- Coinsurance (20%): 10304.80 * 0.20 = 2060.96
- Member responsibility: 1500.00 + 2060.96 = 3560.96
- Plan paid: 11804.80 - 3560.96 = 8243.84

Check OOPM: D's individual OOPM = 6000.00. D's OOPM balance was 0.00. 
3560.96 < 6000.00, so no cap needed.

Accumulators after Line 3:
- D: deductible = 0.00 + 1500.00 = 1500.00, OOPM = 0.00 + 3560.96 = 3560.96
- Family: deductible = 904.50 + 1500.00 = 2404.50, OOPM = 994.50 + 3560.96 = 4555.46

**Line 4 — Claim 4 — C — Outpatient endoscopy, in-network**
- Allowed: 715.51
- C's individual deductible remainder: 1500.00 - 0.00 = 1500.00
- Family deductible remainder: 3000.00 - 2404.50 = 595.50
- Embedded: deductible_applied = min(715.51, min(1500.00, 595.50)) = min(715.51, 595.50) = 595.50
- After deductible: 715.51 - 595.50 = 120.01
- Coinsurance (20%): 120.01 * 0.20 = 24.002 → 24.00 (wait, I should not round until the end)
  Actually, let me keep precision and round at the end.
  Coinsurance: 120.01 * 0.20 = 24.002
- Member responsibility: 595.50 + 24.002 = 619.502
- Plan paid: 715.51 - 619.502 = 95.008

Wait, let me think about rounding. The instructions say "Round half up to the cent at the end of a calculation, not at each intermediate step."

So coinsurance = 120.01 * 0.20 = 24.002
Member responsibility = 595.50 + 24.002 = 619.502
Plan paid = 715.51 - 619.502 = 96.008

Hmm, but member_responsibility + plan_paid must equal allowed amount.
If I round member_responsibility to 619.50, then plan_paid = 715.51 - 619.50 = 96.01.
If I round member_responsibility to 619.50 (round half up: 619.502 → 619.50), then plan_paid = 96.01.

Wait, 619.502 rounds to 619.50 (since the third decimal is 2, which is less than 5, so round down).
Plan paid = 715.51 - 619.50 = 96.01.

Actually, let me reconsider. The coinsurance is 24.002. If I round that to 24.00, then:
Member responsibility = 595.50 + 24.00 = 619.50
Plan paid = 715.51 - 619.50 = 96.01

Let me keep things as: deductible_applied = 595.50, coinsurance = 24.00 (rounded from 24.002), member responsibility = 619.50, plan paid = 96.01.

Wait, 24.002 rounds to 24.00. Yes.

Actually, I need to be more careful. Let me compute coinsurance precisely:
120.01 * 0.20 = 24.002
Round half up to cent: 24.00 (since 2 < 5)

Member responsibility = 595.50 + 24.00 = 619.50
Plan paid = 715.51 - 619.50 = 96.01

Check OOPM: C's OOPM was 30.00. 30.00 + 619.50 = 649.50 < 6000.00. OK.

Accumulators after Line 4:
- C: deductible = 0.00 + 595.50 = 595.50, OOPM = 30.00 + 619.50 = 649.50
- Family: deductible = 2404.50 + 595.50 = 3000.00, OOPM = 4555.46 + 619.50 = 5174.96

Family deductible is now met (3000.00).

**Line 5 — Claim 5 — D — Inpatient admission with surgery, in-network**
- Allowed: 14614.81
- D's individual deductible remainder: 1500.00 - 1500.00 = 0.00 (already met)
- Family deductible remainder: 3000.00 - 3000.00 = 0.00 (already met)
- Deductible applied: 0.00
- Coinsurance (20%): 14614.81 * 0.20 = 2922.962 → 2922.96
- Member responsibility: 0.00 + 2922.96 = 2922.96
- Plan paid: 14614.81 - 2922.96 = 11691.85

Check OOPM: D's OOPM was 3560.96. 3560.96 + 2922.96 = 6483.92
D's individual OOPM (in-network) = 6000.00.
6483.92 > 6000.00, so we need to cap.

Room left under D's OOPM: 6000.00 - 3560.96 = 2439.04
So member responsibility is capped at 2439.04.
Plan paid = 14614.81 - 2439.04 = 12175.77

Wait, but what about the family OOPM?
Family OOPM was 5174.96. Family OOPM limit is 12000.00.
5174.96 + 2439.04 = 7613.00 + ... wait let me recalculate.

Actually, the OOPM cap: member responsibility cannot exceed what would push the member past their individual OOPM.

D's OOPM before this claim: 3560.96
Room left: 6000.00 - 3560.96 = 2439.04

So member responsibility is capped at 2439.04.
But wait, the deductible is already 0, so the uncapped member responsibility would be 2922.96 (all coinsurance).
Since 2922.96 > 2439.04, we cap at 2439.04.

Member responsibility: 2439.04
Plan paid: 14614.81 - 2439.04 = 12175.77

Accumulators after Line 5:
- D: deductible = 1500.00, OOPM = 3560.96 + 2439.04 = 6000.00
- Family: deductible = 3000.00, OOPM = 5174.96 + 2439.04 = 7614.00

**Line 6 — Claim 6 — D — Ambulatory surgery, in-network**
- Allowed: 5634.42
- D's deductible already met, family deductible already met.
- Deductible applied: 0.00
- D's OOPM is already at 6000.00 (max). So plan pays 100%.
- Member responsibility: 0.00
- Plan paid: 5634.42

Accumulators after Line 6:
- D: deductible = 1500.00, OOPM = 6000.00
- Family: deductible = 3000.00, OOPM = 7614.00

**Line 7 — Claim 7 — B — Inpatient admission, in-network**
- Allowed: 20898.76
- B's individual deductible remainder: 1500.00 - 0.00 = 1500.00
- Family deductible remainder: 3000.00 - 3000.00 = 0.00 (already met)
- Embedded: deductible_applied = min(20898.76, min(1500.00, 0.00)) = 0.00
- Coinsurance (20%): 20898.76 * 0.20 = 4179.752 → 4179.75
- Member responsibility: 4179.75
- Plan paid: 20898.76 - 4179.75 = 16719.01

Check OOPM: B's OOPM was 0.00. 0.00 + 4179.75 = 4179.75 < 6000.00. OK.

Accumulators after Line 7:
- B: deductible = 0.00 + 0.00 = 0.00, OOPM = 0.00 + 4179.75 = 4179.75
- Family: deductible = 3000.00, OOPM = 7614.00 + 4179.75 = 11793.75

**Line 8 — Claim 8 — D — Inpatient admission, out-of-network**
- Allowed: 17086.02
- Out-of-network. 
- D's single deductible balance: 1500.00 (from in-network)
- Out-of-network individual deductible threshold: 3000.00
- Out-of-network deductible remainder: 3000.00 - 1500.00 = 1500.00
- Deductible applied: min(17086.02, 1500.00) = 1500.00
- After deductible: 17086.02 - 1500.00 = 15586.02
- Coinsurance (40% out-of-network): 15586.02 * 0.40 = 6234.408 → 6234.41
- Uncapped member responsibility: 1500.00 + 6234.41 = 7734.41

Check OOPM: D's OOPM is at 6000.00 (in-network max already reached).
But wait, D's out-of-network OOPM is 12000.00.
D's OOPM balance is 6000.00. 
Room left under out-of-network OOPM: 12000.00 - 6000.00 = 6000.00
7734.41 > 6000.00, so cap at 6000.00.

Member responsibility: 6000.00
Plan paid: 17086.02 - 6000.00 = 11086.02

Wait, let me reconsider. The out-of-network OOPM is 12000.00 for individual. D's OOPM balance is 6000.00. So room left = 12000.00 - 6000.00 = 6000.00.

But how does the deductible_applied and coinsurance work with the cap?
Uncapped: deductible = 1500.00, coinsurance = 6234.41, total = 7734.41
Cap: 6000.00

So member_responsibility = 6000.00
But how is this split between deductible and coinsurance for accumulator purposes?

Actually, looking at the plan document: "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 accumulator gets the full deductible_applied (1500.00), and the OOPM accumulator gets the member_responsibility (capped at 6000.00).

Wait, but does the deductible_applied still count even if the OOPM cap limits the member responsibility?

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."

So the OOPM cap limits the total member responsibility for the claim. The deductible_applied is still the amount applied to the deductible.

But wait, if the member responsibility is capped at 6000.00, and the deductible_applied is 1500.00, then the coinsurance portion would be 6000.00 - 1500.00 = 4500.00.

Actually, I think the deductible_applied should still be reported as 1500.00 (it's the amount applied to the deductible), and the coinsurance_amount would be adjusted to make member_responsibility = 6000.00.

So: deductible_applied = 1500.00, coinsurance = 4500.00, member_responsibility = 6000.00, plan_paid = 17086.02 - 6000.00 = 11086.02.

Accumulators after Line 8:
- D: deductible = 1500.00 + 1500.00 = 3000.00, OOPM = 6000.00 + 6000.00 = 12000.00
- Family: deductible = 3000.00 + 1500.00 = 4500.00, OOPM = 11793.75 + 6000.00 = 17793.75

Wait, the family deductible was already at 3000.00 (in-network max). Now adding 1500.00 from out-of-network?

Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."

And: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So yes, the family deductible balance goes up. But the family deductible threshold is 3000.00 (in-network). The family balance can go past that.

Actually wait - "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:
- D's deductible balance: 1500.00 + 1500.00 = 3000.00
- Family deductible balance: 3000.00 + 1500.00 = 4500.00

And for OOPM:
- D's OOPM balance: 6000.00 + 6000.00 = 12000.00
- Family OOPM balance: 11793.75 + 6000.00 = 17793.75

**Line 9 — Claim 9 — A — Primary care office visit, in-network**
- Allowed: 156.47
- Primary care copay: 30.00
- Deductible applied: 0.00 (copays don't credit deductible)
- Copay amount: 30.00
- Coinsurance: 0.00
- Member responsibility: 30.00
- Plan paid: 156.47 - 30.00 = 126.47

Accumulators after Line 9:
- A: deductible = 904.50, OOPM = 964.50 + 30.00 = 994.50
- Family: deductible = 4500.00, OOPM = 17793.75 + 30.00 = 17823.75

**Line 10 — Claim 10 — B — Specialist office visit, in-network**
- Allowed: 229.43
- Specialist copay: 60.00
- Deductible applied: 0.00
- Copay amount: 60.00
- Coinsurance: 0.00
- Member responsibility: 60.00
- Plan paid: 229.43 - 60.00 = 169.43

Accumulators after Line 10:
- B: deductible = 0.00, OOPM = 4179.75 + 60.00 = 4239.75
- Family: deductible = 4500.00, OOPM = 17823.75 + 60.00 = 17883.75

**Line 11 — VOID of Claim 7 — B**
Claim 7 was: B, allowed 20898.76, deductible_applied 0.00, member_responsibility 4179.75, plan_paid 16719.01

Unwind Claim 7's credits:
- B's deductible: 0.00 - 0.00 = 0.00
- B's OOPM: 4239.75 - 4179.75 = 60.00
- Family deductible: 4500.00 - 0.00 = 4500.00
- Family OOPM: 17883.75 - 4179.75 = 13704.00

Accumulators after Line 11:
- B: deductible = 0.00, OOPM = 60.00
- Family: deductible = 4500.00, OOPM = 13704.00

**Line 12 — Claim 12 — C — Inpatient admission with surgery, in-network**
- Allowed: 14567.47
- C's individual deductible remainder: 1500.00 - 595.50 = 904.50
- Family deductible remainder: Family deductible is 3000.00 (in-network). But family deductible balance is 4500.00. So remainder = 0.00 (already met).
  Wait, but the family deductible threshold is 3000.00. The balance is 4500.00, so the family deductible is already met.
- Embedded: deductible_applied = min(14567.47, min(904.50, 0.00)) = 0.00
- Coinsurance (20%): 14567.47 * 0.20 = 2913.494 → 2913.49
- Member responsibility: 2913.49
- Plan paid: 14567.47 - 2913.49 = 11653.98

Check OOPM: C's OOPM was 649.50. 649.50 + 2913.49 = 3562.99 < 6000.00. OK.

Accumulators after Line 12:
- C: deductible = 595.50 + 0.00 = 595.50, OOPM = 649.50 + 2913.49 = 3562.99
- Family: deductible = 4500.00, OOPM = 13704.00 + 2913.49 = 16617.49

**Line 13 — Claim 13 — B — Urgent care visit, in-network**
- Allowed: 290.00
- Urgent care copay: 75.00
- Deductible applied: 0.00
- Copay amount: 75.00
- Coinsurance: 0.00
- Member responsibility: 75.00
- Plan paid: 290.00 - 75.00 = 215.00

Accumulators after Line 13:
- B: deductible = 0.00, OOPM = 60.00 + 75.00 = 135.00
- Family: deductible = 4500.00, OOPM = 16617.49 + 75.00 = 16692.49

**Line 14 — Claim 14 — B — Ambulatory surgery, out-of-network**
- Allowed: 5382.89
- Out-of-network.
- B's single deductible balance: 0.00
- Out-of-network individual deductible threshold: 3000.00
- Out-of-network deductible remainder: 3000.00 - 0.00 = 3000.00
- Deductible applied: min(5382.89, 3000.00) = 3000.00
- After deductible: 5382.89 - 3000.00 = 2382.89
- Coinsurance (40%): 2382.89 * 0.40 = 953.156 → 953.16
- Member responsibility: 3000.00 + 953.16 = 3953.16
- Plan paid: 5382.89 - 3953.16 = 1429.73

Check OOPM: B's OOPM was 135.00. B's out-of-network OOPM is 12000.00.
135.00 + 3953.16 = 4088.16 < 12000.00. OK.

Accumulators after Line 14:
- B: deductible = 0.00 + 3000.00 = 3000.00, OOPM = 135.00 + 3953.16 = 4088.16
- Family: deductible = 4500.00 + 3000.00 = 7500.00, OOPM = 16692.49 + 3953.16 = 20645.65

**Line 15 — VOID of Claim 4 — C**
Claim 4 was: C, allowed 715.51, deductible_applied 595.50, member_responsibility 619.50, plan_paid 96.01

Unwind Claim 4's credits:
- C's deductible: 595.50 - 595.50 = 0.00
- C's OOPM: 3562.99 - 619.50 = 2943.49
- Family deductible: 7500.00 - 595.50 = 6904.50
- Family OOPM: 20645.65 - 619.50 = 20026.15

Accumulators after Line 15:
- C: deductible = 0.00, OOPM = 2943.49
- Family: deductible = 6904.50, OOPM = 20026.15

**Line 16 — Claim 16 — A — Allergy testing, in-network**
- Allowed: 920.32
- A's individual deductible remainder: 1500.00 - 904.50 = 595.50
- Family deductible remainder: Family deductible is 3000.00 (in-network). Family deductible balance is 6904.50. So remainder = 0.00 (already met).
  Wait, but we need to think about this carefully. The family deductible threshold is 3000.00. The balance is 6904.50, which is way past 3000.00. So family deductible is met.
- Embedded: deductible_applied = min(920.32, min(595.50, 0.00)) = 0.00
- Coinsurance (20%): 920.32 * 0.20 = 184.064 → 184.06
- Member responsibility: 184.06
- Plan paid: 920.32 - 184.06 = 736.26

Check OOPM: A's OOPM was 994.50. 994.50 + 184.06 = 1178.56 < 6000.00. OK.

Accumulators after Line 16:
- A: deductible = 904.50 + 0.00 = 904.50, OOPM = 994.50 + 184.06 = 1178.56
- Family: deductible = 6904.50, OOPM = 20026.15 + 184.06 = 20210.21

Now let me compile the results.

**Claim 4 (VOIDED):**
All components are 0.00.
- 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

**Claim 13:**
- claim_13_member_responsibility: 75.00
- claim_13_plan_paid: 215.00
- claim_13_deductible_applied: 0.00
- claim_13_copay_amount: 75.00
- claim_13_coinsurance_amount: 0.00

**Claim 16:**
- claim_16_member_responsibility: 184.06
- claim_16_plan_paid: 736.26
- claim_16_deductible_applied: 0.00
- claim_16_copay_amount: 0.00
- claim_16_coinsurance_amount: 184.06

**Ending Accumulators:**

A:
- ending_deductible_a: 904.50
- ending_oopm_a: 1178.56

B:
- ending_deductible_b: 3000.00
- ending_oopm_b: 4088.16

C:
- ending_deductible_c: 0.00
- ending_oopm_c: 2943.49

D:
- ending_deductible_d: 3000.00
- ending_oopm_d: 12000.00

Family:
- ending_family_deductible: 6904.50
- ending_family_oopm: 20210.21

Wait, let me double-check the family deductible. The family deductible balance accumulates all deductible credits from all members. Let me trace it:

Initial: 904.50
Line 1 (Claim 1, A): +0.00 → 904.50
Line 2 (Claim 2, C): +0.00 → 904.50
Line 3 (Claim 3, D): +1500.00 → 2404.50
Line 4 (Claim 4, C): +595.50 → 3000.00
Line 5 (Claim 5, D): +0.00 → 3000.00
Line 6 (Claim 6, D): +0.00 → 3000.00
Line 7 (Claim 7, B): +0.00 → 3000.00
Line 8 (Claim 8, D): +1500.00 → 4500.00
Line 9 (Claim 9, A): +0.00 → 4500.00
Line 10 (Claim 10, B): +0.00 → 4500.00
Line 11 (Void Claim 7): -0.00 → 4500.00
Line 12 (Claim 12, C): +0.00 → 4500.00
Line 13 (Claim 13, B): +0.00 → 4500.00
Line 14 (Claim 14, B): +3000.00 → 7500.00
Line 15 (Void Claim 4): -595.50 → 6904.50
Line 16 (Claim 16, A): +0.00 → 6904.50

Family deductible: 6904.50 ✓

Family OOPM:
Initial: 904.50
Line 1: +60.00 → 964.50
Line 2: +30.00 → 994.50
Line 3: +3560.96 → 4555.46
Line 4: +619.50 → 5174.96
Line 5: +2439.04 → 7614.00
Line 6: +0.00 → 7614.00
Line 7: +4179.75 → 11793.75
Line 8: +6000.00 → 17793.75
Line 9: +30.00 → 17823.75
Line 10: +60.00 → 17883.75
Line 11 (Void 7): -4179.75 → 13704.00
Line 12: +2913.49 → 16617.49
Line 13: +75.00 → 16692.49
Line 14: +3953.16 → 20645.65
Line 15 (Void 4): -619.50 → 20026.15
Line 16: +184.06 → 20210.21

Family OOPM: 20210.21 ✓

Let me also double-check D's OOPM.
Initial: 0.00
Line 3 (Claim 3): +3560.96 → 3560.96
Line 5 (Claim 5): +2439.04 → 6000.00
Line 6 (Claim 6): +0.00 → 6000.00
Line 8 (Claim 8): +6000.00 → 12000.00

D's OOPM: 12000.00 ✓

Let me verify D's deductible:
Initial: 0.00
Line 3: +1500.00 → 1500.00
Line 5: +0.00 → 1500.00
Line 6: +0.00 → 1500.00
Line 8: +1500.00 → 3000.00

D's deductible: 3000.00 ✓

Let me verify A's accumulators:
Initial: deductible = 904.50, OOPM = 904.50
Line 1 (Claim 1): deductible +0.00 = 904.50, OOPM +60.00 = 964.50
Line 9 (Claim 9): deductible +0.00 = 904.50, OOPM +30.00 = 994.50
Line 16 (Claim 16): deductible +0.00 = 904.50, OOPM +184.06 = 1178.56

A's deductible: 904.50 ✓
A's OOPM: 1178.56 ✓

Let me verify B's accumulators:
Initial: 0.00, 0.00
Line 7 (Claim 7): deductible +0.00 = 0.00, OOPM +4179.75 = 4179.75
Line 10 (Claim 10): deductible +0.00 = 0.00, OOPM +60.00 = 4239.75
Line 11 (Void 7): deductible -0.00 = 0.00, OOPM -4179.75 = 60.00
Line 13 (Claim 13): deductible +0.00 = 0.00, OOPM +75.00 = 135.00
Line 14 (Claim 14): deductible +3000.00 = 3000.00, OOPM +3953.16 = 4088.16

B's deductible: 3000.00 ✓
B's OOPM: 4088.16 ✓

Let me verify C's accumulators:
Initial: 0.00, 0.00
Line 2 (Claim 2): deductible +0.00 = 0.00, OOPM +30.00 = 30.00
Line 4 (Claim 4): deductible +595.50 = 595.50, OOPM +619.50 = 649.50
Line 12 (Claim 12): deductible +0.00 = 595.50, OOPM +2913.49 = 3562.99
Line 15 (Void 4): deductible -595.50 = 0.00, OOPM -619.50 = 2943.49

C's deductible: 0.00 ✓
C's OOPM: 2943.49 ✓

Now let me re-examine some calculations more carefully.

**Line 3 — Claim 3 — D — Inpatient admission with surgery, in-network**
Allowed: 11804.80
D's individual deductible remainder: 1500.00
Family deductible remainder: 3000.00 - 904.50 = 2095.50
Embedded: min(1500.00, 2095.50) = 1500.00
Deductible applied: min(11804.80, 1500.00) = 1500.00
After

Let me carefully process this ledger step by step.

First, let me understand the plan:
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance after deductible, in-network: 30% member / 70% plan
- Coinsurance after deductible, out-of-network: 50% member / 50% 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 visit results in inpatient admission (then subject to deductible and coinsurance)
- Generic retail pharmacy: 10.00 copay
- Copays DO credit the deductible. Copays always credit the OOPM.
- Preventive care in-network: 100% paid, no cost share, no deductible/coinsurance/copay.

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

Let me process each line:

**Line 1 — Claim 1 — 2026-01-18 — D (child)**
Service: Emergency department visit, in-network
Allowed: 3295.94
Disposition: Treated and released (NOT admitted)

Since not admitted, ER copay of 300.00 applies.
Wait, but does the deductible apply first? Let me re-read: "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, it's just a 300.00 copay. But wait, does the copay apply regardless of deductible status? The plan says "Copays DO credit the deductible." So the copay is applied, and it credits the deductible.

Actually, let me think about this more carefully. For services with copays, typically the copay is the member's cost share. The copay credits the deductible and OOPM.

For D:
- Individual deductible: 1150.72 (remaining: 2500 - 1150.72 = 1349.28)
- Family deductible: 2895.39 (remaining: 5000 - 2895.39 = 2104.61)
- Embedded: deductible_applied = lesser of individual remainder and family remainder = min(1349.28, 2104.61) = 1349.28

Wait, but this is a copay service. The allowed amount is 3295.94, but the member just pays a 300.00 copay.
"Copays DO 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 service, the deductible_applied is the copay amount (since copays credit the deductible), but limited to the remaining deductible.

Actually 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"

For a copay service, is the deductible_applied the copay or the allowed amount? The rule says "the LESSER of its allowed amount and the room left." But for a copay service, the member's responsibility is the copay, not the full allowed amount (once deductible is met or for copay services).

Hmm, let me think about this differently. The plan says:
- "Copays DO credit the deductible."
- deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold.

Wait, but for a copay service, the member pays the copay. The deductible_applied would be... Let me think about what makes sense.

Actually, I think for copay services, the member just pays the copay. The copay credits the deductible. So deductible_applied = copay amount (limited to remaining deductible room).

But the rule says "deductible_applied is the LESSER of its allowed amount and the room left." For a copay service, the "allowed amount" in this context might mean the copay amount since that's what's being applied.

Actually, I think I need to be more careful. 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 service, I think the deductible_applied is the copay amount (since that's the member's cost and it credits the deductible). But the formula says "lesser of allowed amount and room left." The allowed amount is 3295.94. The room left is 1349.28 (individual) and 2104.61 (family).

Hmm, but if deductible_applied = min(3295.94, 1349.28) = 1349.28, then the member would pay 1349.28 toward deductible plus coinsurance on the rest? That doesn't make sense for a copay service.

Let me reconsider. I think for copay services:
- The member pays the copay
- The copay credits the deductible (deductible_applied = copay, limited to remaining deductible)
- The plan pays the rest of the allowed amount
- No coinsurance applies

So for Claim 1 (ER visit, not admitted, copay 300.00):
- Copay = 300.00
- D's individual deductible remaining: 2500 - 1150.72 = 1349.28
- Family deductible remaining: 5000 - 2895.39 = 2104.61
- deductible_applied = min(300.00, 1349.28, 2104.61) = 300.00 (copay credits deductible, limited to remaining)

Wait, but the rule says "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold." For a copay service, the deductible_applied should be based on the copay since that's what credits the deductible.

Actually, I think the formula "LESSER of its allowed amount and the room left" applies to services subject to the deductible (like inpatient, surgery, etc.). For copay services, the deductible_applied is the copay amount (since copays credit the deductible), limited to the room left.

Let me re-read once more: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

This confirms that for copay services, the copay credits the deductible (i.e., deductible_applied = copay), but once the deductible is met, deductible_applied = 0.00 even for copays.

So for Claim 1:
- Copay = 300.00
- D's individual deductible remaining: 1349.28
- Family deductible remaining: 2104.61
- deductible_applied = min(300.00, min(1349.28, 2104.61)) = min(300.00, 1349.28) = 300.00

Wait, for embedded: "the smaller of the member's individual remainder and the family remainder"
So room = min(1349.28, 2104.61) = 1349.28
deductible_applied = min(300.00, 1349.28) = 300.00

Member responsibility = 300.00 (copay)
Plan paid = 3295.94 - 300.00 = 2995.94
Coinsurance = 0.00
Copay = 300.00

Update accumulators:
D: deductible = 1150.72 + 300.00 = 1450.72, OOPM = 1150.72 + 300.00 = 1450.72
Family: deductible = 2895.39 + 300.00 = 3195.39, OOPM = 3051.40 + 300.00 = 3351.40

**Line 2 — Claim 2 — 2026-01-28 — D (child)**
Service: Urgent care visit, in-network
Allowed: 182.07
Copay: 60.00

D's individual deductible remaining: 2500 - 1450.72 = 1049.28
Family deductible remaining: 5000 - 3195.39 = 1804.61
Room = min(1049.28, 1804.61) = 1049.28
deductible_applied = min(60.00, 1049.28) = 60.00

Member responsibility = 60.00 (copay)
Plan paid = 182.07 - 60.00 = 122.07
Coinsurance = 0.00
Copay = 60.00

Update accumulators:
D: deductible = 1450.72 + 60.00 = 1510.72, OOPM = 1450.72 + 60.00 = 1510.72
Family: deductible = 3195.39 + 60.00 = 3255.39, OOPM = 3351.40 + 60.00 = 3411.40

**Line 3 — Claim 3 — 2026-02-09 — A (subscriber)**
Service: Inpatient admission with surgery, out-of-network
Allowed: 25881.03
Network: Out-of-network

For out-of-network:
- Out-of-network individual deductible: 5000.00
- A's single deductible balance: 0.00
- Out-of-network individual remainder: 5000 - 0 = 5000.00
- Coinsurance: 50% member / 50% plan
- Out-of-network individual OOPM: 11000.00
- A's OOPM balance: 0.00

Wait, the plan says: "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."

So A's single deductible balance is 0.00. The out-of-network threshold is 5000.00.
Remainder = 5000 - 0 = 5000.00

deductible_applied = min(25881.03, 5000.00) = 5000.00

After deductible: remaining allowed = 25881.03 - 5000.00 = 20881.03
Coinsurance (50% member): 20881.03 * 0.50 = 10440.515 = 10440.52

But wait, we need to check OOPM.
A's OOPM balance: 0.00
Out-of-network individual OOPM: 11000.00
OOPM remaining: 11000 - 0 = 11000.00

Member responsibility so far: deductible_applied (5000.00) + coinsurance (10440.52) = 15440.52
But OOPM remaining is 11000.00.

So member responsibility is capped at OOPM remaining: 11000.00
deductible_applied = 5000.00
coinsurance = 11000.00 - 5000.00 = 6000.00

Plan paid = 25881.03 - 11000.00 = 14881.03

Wait, let me reconsider. The OOPM is the ceiling on member cost share. So:
- deductible_applied = 5000.00 (this counts toward OOPM)
- coinsurance before cap = 10440.52
- Total member cost = 5000.00 + 10440.52 = 15440.52
- OOPM remaining = 11000.00
- So member cost is capped at 11000.00
- deductible_applied stays at 5000.00
- coinsurance = 11000.00 - 5000.00 = 6000.00
- Plan paid = 25881.03 - 11000.00 = 14881.03

Actually wait, I need to be more careful. Let me re-read the OOPM rules:
"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."

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

So the OOPM balance tracks member_responsibility. The member_responsibility for a claim is deductible_applied + coinsurance + copay.

For this claim:
- deductible_applied = 5000.00
- Remaining allowed = 25881.03 - 5000.00 = 20881.03
- Coinsurance at 50% = 10440.515 → 10440.52
- Total member responsibility before OOPM cap = 5000.00 + 10440.52 = 15440.52
- A's OOPM balance: 0.00, OOPM limit: 11000.00 (out-of-network)
- OOPM room = 11000.00 - 0.00 = 11000.00
- Member responsibility capped at 11000.00
- So coinsurance is reduced: 11000.00 - 5000.00 = 6000.00
- Plan paid = 25881.03 - 11000.00 = 14881.03

Wait, but the OOPM limit for out-of-network is 11000.00. The member responsibility can't exceed the OOPM room. So:
member_responsibility = min(15440.52, 11000.00) = 11000.00
plan_paid = 25881.03 - 11000.00 = 14881.03

Actually, I need to be careful about how the coinsurance is reduced. Let me think...

The member responsibility is the sum of deductible_applied, coinsurance, and copay. If the total exceeds the OOPM room, the coinsurance is reduced (since deductible and copay are fixed amounts that apply first).

So:
- deductible_applied = 5000.00
- copay = 0.00
- OOPM room = 11000.00
- Remaining OOPM room for coinsurance = 11000.00 - 5000.00 - 0.00 = 6000.00
- Coinsurance before cap = 10440.52
- Coinsurance after cap = min(10440.52, 6000.00) = 6000.00
- Member responsibility = 5000.00 + 6000.00 = 11000.00
- Plan paid = 25881.03 - 11000.00 = 14881.03

Update accumulators:
A: deductible = 0.00 + 5000.00 = 5000.00, OOPM = 0.00 + 11000.00 = 11000.00
Family: deductible = 3255.39 + 5000.00 = 8255.39, OOPM = 3411.40 + 11000.00 = 14411.40

Wait, but the family deductible is 5000.00 and family OOPM is 11000.00 (in-network). 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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So the out-of-network claim doesn't get limited by family thresholds, but the credits still go to the family balance. So:

Family deductible: 3255.39 + 5000.00 = 8255.39
Family OOPM: 3411.40 + 11000.00 = 14411.40

And A's individual deductible balance is now 5000.00 (which exceeds the in-network individual deductible of 2500.00). For future in-network claims, A's in-network individual deductible is already met (since 5000 > 2500).

Actually wait, the plan says: "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."

So A has a single deductible balance of 5000.00. For in-network services, the threshold is 2500.00. Since 5000.00 > 2500.00, A's in-network deductible is met.

For the family deductible: the family balance is 8255.39. The family deductible threshold is 5000.00. Since 8255.39 > 5000.00, the family deductible is met.

**Line 4 — Claim 4 — 2026-02-22 — C (child)**
Service: Urgent care visit, in-network
Allowed: 290.40
Copay: 60.00

C's individual deductible: 1744.67 (remaining: 2500 - 1744.67 = 755.33)
Family deductible: 8255.39 (remaining: 5000 - 8255.39 = negative, so met)

Since family deductible is met (8255.39 >= 5000), and for embedded, the room is min(individual remainder, family remainder).
Family remainder = 5000 - 8255.39 = -3255.39 → 0 (already met)

Wait, if family deductible is already met, then family remainder is 0.
Room = min(755.33, 0) = 0

So deductible_applied = min(60.00, 0) = 0.00

Since deductible is met (family deductible met means no more deductible for any member under embedded? Let me re-check.)

Under 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."

So if the family deductible is satisfied, then all members have their deductible satisfied. Let me verify: "the family deductible is also satisfied once total family credits reach the family amount." Once the family deductible is satisfied, no more deductible applies to any member.

So room = min(individual remainder, family remainder). If family remainder = 0, then room = 0.

deductible_applied = 0.00

Since deductible is met, coinsurance applies? No, this is a copay service. The member just pays the copay.

Wait, for a copay service, once the deductible is met, the member just pays the copay. The plan pays the rest.

Member responsibility = 60.00 (copay)
Plan paid = 290.40 - 60.00 = 230.40
Coinsurance = 0.00
Copay = 60.00
deductible_applied = 0.00

Update accumulators:
C: deductible = 1744.67 + 0.00 = 1744.67, OOPM = 1900.68 + 60.00 = 1960.68
Family: deductible = 8255.39 + 0.00 = 8255.39, OOPM = 14411.40 + 60.00 = 14471.40

**Line 5 — Claim 5 — 2026-03-07 — A (subscriber)**
Service: Urgent care visit, in-network
Allowed: 175.00
Copay: 60.00

A's individual deductible: 5000.00 (met, since > 2500)
Family deductible: 8255.39 (met, since > 5000)
Room = 0

deductible_applied = 0.00
Member responsibility = 60.00 (copay)
Plan paid = 175.00 - 60.00 = 115.00
Coinsurance = 0.00
Copay = 60.00

Update accumulators:
A: deductible = 5000.00, OOPM = 11000.00 + 60.00 = 11060.00

Wait, A's OOPM is already 11000.00. The in-network OOPM is 5500.00 and out-of-network is 11000.00.

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."

A's OOPM balance is 11000.00. The in-network individual OOPM is 5500.00. Since 11000.00 > 5500.00, A has already reached the in-network OOPM. So A pays nothing more for in-network services.

Wait, but the OOPM is different for in-network and out-of-network:
- Individual (in-network): 5500.00
- Individual (out-of-network): 11000.00

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 A's OOPM balance is 11000.00. For in-network services, the threshold is 5500.00. Since 11000.00 >= 5500.00, A's in-network OOPM is met.

So for this in-network urgent care visit:
- A's in-network OOPM is met
- Member responsibility = 0.00 (plan pays 100%)
- deductible_applied = 0.00
- copay = 0.00 (since OOPM is met)
- coinsurance = 0.00
- Plan paid = 175.00

Wait, but copays always credit the OOPM. But if the OOPM is already met, does the member still pay the copay?

"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 OOPM is met, plan pays 100%, member pays 0. The copay would be 0.

Member responsibility = 0.00
Plan paid = 175.00
Copay = 0.00
Coinsurance = 0.00
deductible_applied = 0.00

Update accumulators:
A: deductible = 5000.00, OOPM = 11000.00 (no change)
Family: deductible = 8255.39, OOPM = 14471.40 (no change)

**Line 6 — Claim 6 — 2026-03-19 — C (child)**
Service: Outpatient procedure, in-network
Allowed: 7641.96

C's individual deductible: 1744.67 (remaining: 2500 - 1744.67 = 755.33)
Family deductible: 8255.39 (met)
Room = min(755.33, 0) = 0

Since family deductible is met, deductible_applied = 0.00.

After deductible, coinsurance applies: 30% member / 70% plan.
Coinsurance = 7641.96 * 0.30 = 2292.588 = 2292.59

C's OOPM: 1960.68
In-network individual OOPM: 5500.00
OOPM room = 5500 - 1960.68 = 3539.32

Member responsibility before cap = 0.00 + 2292.59 = 2292.59
This is less than OOPM room (3539.32), so no cap needed.

Member responsibility = 2292.59
Plan paid = 7641.96 - 2292.59 = 5349.37
Coinsurance = 2292.59
Copay = 0.00
deductible_applied = 0.00

Update accumulators:
C: deductible = 1744.67, OOPM = 1960.68 + 2292.59 = 4253.27
Family: deductible = 8255.39, OOPM = 14471.40 + 2292.59 = 16763.99

**Line 7 — Claim 7 — 2026-03-29 — A (subscriber)**
Service: Physical therapy course, in-network
Allowed: 894.21

A's OOPM is already at 11000.00, which exceeds the in-network OOPM of 5500.00. So A pays 0.

Member responsibility = 0.00
Plan paid = 894.21
Coinsurance = 0.00
Copay = 0.00
deductible_applied = 0.00

Update accumulators:
A: deductible = 5000.00, OOPM = 11000.00
Family: deductible = 8255.39, OOPM = 16763.99

**Line 8 — Claim 8 — 2026-04-09 — D (child)**
Service: Inpatient admission with surgery, in-network
Allowed: 25110.74

D's individual deductible: 1510.72 (remaining: 2500 - 1510.72 = 989.28)
Family deductible: 8255.39 (met, > 5000)
Room = min(989.28, 0) = 0

deductible_applied = 0.00

Coinsurance: 30% member
Coinsurance = 25110.74 * 0.30 = 7533.222 = 7533.22

D's OOPM: 1510.72
In-network individual OOPM: 5500.00
OOPM room = 5500 - 1510.72 = 3989.28

Member responsibility before cap = 7533.22
OOPM room = 3989.28
Member responsibility capped at 3989.28
Coinsurance = 3989.28

Plan paid = 25110.74 - 3989.28 = 21121.46

Member responsibility = 3989.28
Coinsurance = 3989.28
Copay = 0.00
deductible_applied = 0.00

Update accumulators:
D: deductible = 1510.72, OOPM = 1510.72 + 3989.28 = 5500.00
Family: deductible = 8255.39, OOPM = 16763.99 + 3989.28 = 20753.27

D's OOPM is now 5500.00, which equals the in-network individual OOPM. So D's in-network OOPM is met.

**Line 9 — Claim 9 — 2026-04-25 — D (child)**
Service: Physical therapy course, in-network
Allowed: 646.70

D's OOPM is met (5500.00). Plan pays 100%.

Member responsibility = 0.00
Plan paid = 646.70
Coinsurance = 0.00
Copay = 0.00
deductible_applied = 0.00

Update accumulators:
D: deductible = 1510.72, OOPM = 5500.00
Family: deductible = 8255.39, OOPM = 20753.27

**Line 10 — ADJUSTMENT to Claim 2 — 2026-05-09 — D (child)**
Original Claim 2: Allowed 182.07, copay 60.00
- deductible_applied was 60.00
- member_responsibility was 60.00
- plan_paid was 122.07

New allowed: 264.00

First, unwind original Claim 2 credits:
D: deductible = 1510.72 - 60.00 = 1450.72, OOPM = 5500.00 - 60.00 = 5440.00
Family: deductible = 8255.39 - 60.00 = 8195.39, OOPM = 20753.27 - 60.00 = 20693.27

Now re-adjudicate Claim 2 at corrected values against current accumulators:
Service: Urgent care visit, in-network
Allowed: 264.00
Copay: 60.00

D's individual deductible: 1450.72 (remaining: 2500 - 1450.72 = 1049.28)
Family ded

Let me work through this step by step.

First, let me understand the plan:
- Individual deductible (in-network): $1,500.00
- Family deductible (in-network): $3,000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: $3,000.00
- Single deductible balance for in-network and out-of-network

- Individual OOPM (in-network): $6,000.00
- Family OOPM (in-network): $12,000.00
- Individual OOPM (out-of-network): $12,000.00

- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Primary care office visit: $30.00 copay
- Specialist office visit: $60.00 copay
- Urgent care: $75.00 copay
- Emergency room: $400.00 copay (waived if inpatient admission)
- Generic retail pharmacy: $15.00 copay
- Copays do NOT credit the deductible. Copays always credit the OOPM.

- Preventive care in-network: 100% paid, no cost share, no deductible, no copay.

Starting accumulators:
A: deductible 904.50, OOPM 904.50
B: deductible 0.00, OOPM 0.00
C: deductible 0.00, OOPM 0.00
D: deductible 0.00, OOPM 0.00
Family total: deductible 904.50, OOPM 904.50

Let me process each line:

**Line 1 — Claim 1 — 2026-01-28 — A (subscriber)**
Service: Specialist office visit, in-network
Allowed: 294.03

This is a specialist office visit → $60.00 copay.
Copays do NOT credit the deductible. Copays always credit the OOPM.

So:
- deductible_applied = 0.00
- copay_amount = 60.00
- coinsurance_amount = 0.00
- member_responsibility = 60.00
- plan_paid = 294.03 - 60.00 = 234.03

Accumulators after Line 1:
A: deductible 904.50, OOPM 904.50 + 60.00 = 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 0.00, OOPM 0.00
D: deductible 0.00, OOPM 0.00
Family: deductible 904.50, OOPM 964.50

**Line 2 — Claim 2 — 2026-02-11 — C (child)**
Service: Primary care office visit, in-network
Allowed: 197.39

This is a primary care office visit → $30.00 copay.
- deductible_applied = 0.00
- copay_amount = 30.00
- coinsurance_amount = 0.00
- member_responsibility = 30.00
- plan_paid = 197.39 - 30.00 = 167.39

Accumulators after Line 2:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 0.00, OOPM 0.00 + 30.00 = 30.00
D: deductible 0.00, OOPM 0.00
Family: deductible 904.50, OOPM 964.50 + 30.00 = 994.50

**Line 3 — Claim 3 — 2026-02-17 — D (child)**
Service: Inpatient admission with surgery, in-network
Allowed: 11804.80

This is an inpatient admission, in-network. Subject to deductible and coinsurance.
D's individual deductible remainder: 1500.00 - 0.00 = 1500.00
Family deductible remainder: 3000.00 - 904.50 = 2095.50
Embedded: deductible_applied = lesser of individual remainder and family remainder = min(1500.00, 2095.50) = 1500.00

After applying 1500.00 to deductible:
Remaining allowed = 11804.80 - 1500.00 = 10304.80
Coinsurance at 20% = 10304.80 * 0.20 = 2060.96

member_responsibility = 1500.00 + 2060.96 = 3560.96
plan_paid = 11804.80 - 3560.96 = 8243.84

Wait, I need to check OOPM. D's individual OOPM is 6000.00 (in-network). D's OOPM before this claim is 0.00.
member_responsibility = 3560.96. D's OOPM would become 0.00 + 3560.96 = 3560.96, which is less than 6000.00. So no capping needed.

Family OOPM: 994.50 + 3560.96 = 4555.46, which is less than 12000.00. OK.

Accumulators after Line 3:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 0.00, OOPM 30.00
D: deductible 0.00 + 1500.00 = 1500.00, OOPM 0.00 + 3560.96 = 3560.96
Family: deductible 904.50 + 1500.00 = 2404.50, OOPM 994.50 + 3560.96 = 4555.46

**Line 4 — Claim 4 — 2026-03-03 — C (child)**
Service: Outpatient endoscopy, in-network
Allowed: 715.51

This is subject to deductible and coinsurance.
C's individual deductible remainder: 1500.00 - 0.00 = 1500.00
Family deductible remainder: 3000.00 - 2404.50 = 595.50
Embedded: deductible_applied = min(1500.00, 595.50) = 595.50

Remaining allowed = 715.51 - 595.50 = 120.01
Coinsurance at 20% = 120.01 * 0.20 = 24.002 → 24.00

member_responsibility = 595.50 + 24.00 = 619.50
Wait, let me be more precise. 120.01 * 0.20 = 24.002. Round half up to cent: 24.00.

member_responsibility = 595.50 + 24.00 = 619.50
plan_paid = 715.51 - 619.50 = 96.01

Check OOPM: C's OOPM is 30.00 + 619.50 = 649.50 < 6000.00. OK.
Family OOPM: 4555.46 + 619.50 = 5174.96 < 12000.00. OK.

Accumulators after Line 4:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 0.00 + 595.50 = 595.50, OOPM 30.00 + 619.50 = 649.50
D: deductible 1500.00, OOPM 3560.96
Family: deductible 2404.50 + 595.50 = 3000.00, OOPM 4555.46 + 619.50 = 5174.96

Family deductible is now met at 3000.00.

**Line 5 — Claim 5 — 2026-03-07 — D (child)**
Service: Inpatient admission with surgery, in-network
Allowed: 14614.81

D's individual deductible remainder: 1500.00 - 1500.00 = 0.00 (already met)
Family deductible remainder: 3000.00 - 3000.00 = 0.00 (already met)
deductible_applied = 0.00

Remaining allowed = 14614.81
Coinsurance at 20% = 14614.81 * 0.20 = 2922.962 → 2922.96

member_responsibility = 0.00 + 2922.96 = 2922.96
plan_paid = 14614.81 - 2922.96 = 11691.85

Check D's OOPM: 3560.96 + 2922.96 = 6483.92 > 6000.00
So D has reached the individual OOPM!

Wait, I need to think about this more carefully. When a member hits the OOPM, the plan pays 100% for the rest. Let me recalculate.

D's OOPM before this claim: 3560.96
D's individual OOPM limit: 6000.00
Room left under OOPM: 6000.00 - 3560.96 = 2439.04

So member_responsibility is capped at 2439.04.
plan_paid = 14614.81 - 2439.04 = 12175.77

Wait, but does the family OOPM also cap? Let me check.
Family OOPM before: 5174.96
Family OOPM limit: 12000.00
Room left: 12000.00 - 5174.96 = 6825.04

The member's responsibility is 2439.04 (capped by individual OOPM). This is less than the family room. So member_responsibility = 2439.04.

Actually wait, let me reconsider. The OOPM cap is applied to the member_responsibility. The member has room of 2439.04 under their individual OOPM. So the maximum member_responsibility for this claim is 2439.04.

But the coinsurance would be 2922.96. Since 2922.96 > 2439.04, the member pays only 2439.04, and the plan pays the rest.

member_responsibility = 2439.04
plan_paid = 14614.81 - 2439.04 = 12175.77

Accumulators after Line 5:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 595.50, OOPM 649.50
D: deductible 1500.00, OOPM 3560.96 + 2439.04 = 6000.00
Family: deductible 3000.00, OOPM 5174.96 + 2439.04 = 7614.00

**Line 6 — Claim 6 — 2026-03-11 — D (child)**
Service: Ambulatory surgery, in-network
Allowed: 5634.42

D's deductible is met. Family deductible is met.
deductible_applied = 0.00

D's OOPM is at 6000.00 (the individual in-network max). So D has reached the OOPM. Plan pays 100%.

member_responsibility = 0.00
plan_paid = 5634.42

Accumulators after Line 6:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00
C: deductible 595.50, OOPM 649.50
D: deductible 1500.00, OOPM 6000.00
Family: deductible 3000.00, OOPM 7614.00

**Line 7 — Claim 7 — 2026-03-25 — B (spouse)**
Service: Inpatient admission, in-network
Allowed: 20898.76

B's individual deductible remainder: 1500.00 - 0.00 = 1500.00
Family deductible remainder: 3000.00 - 3000.00 = 0.00 (already met)
Embedded: deductible_applied = min(1500.00, 0.00) = 0.00

Wait, the family deductible is already met. Under embedded, the deductible_applied is the lesser of individual remainder and family remainder. Since family remainder is 0, deductible_applied = 0.

Remaining allowed = 20898.76
Coinsurance at 20% = 20898.76 * 0.20 = 4179.752 → 4179.75

member_responsibility = 0.00 + 4179.75 = 4179.75

Check B's OOPM: 0.00 + 4179.75 = 4179.75 < 6000.00. OK.
Family OOPM: 7614.00 + 4179.75 = 11793.75 < 12000.00. OK.

plan_paid = 20898.76 - 4179.75 = 16719.01

Accumulators after Line 7:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 0.00 + 4179.75 = 4179.75
C: deductible 595.50, OOPM 649.50
D: deductible 1500.00, OOPM 6000.00
Family: deductible 3000.00, OOPM 7614.00 + 4179.75 = 11793.75

**Line 8 — Claim 8 — 2026-03-31 — D (child)**
Service: Inpatient admission, out-of-network
Allowed: 17086.02

Out-of-network. D's single deductible balance is 1500.00.
Out-of-network individual deductible threshold: 3000.00
D's out-of-network individual deductible remainder: 3000.00 - 1500.00 = 1500.00

deductible_applied = min(allowed, remainder) = min(17086.02, 1500.00) = 1500.00

Remaining allowed = 17086.02 - 1500.00 = 15586.02
Coinsurance at 40% (out-of-network) = 15586.02 * 0.40 = 6234.408 → 6234.41

member_responsibility before OOPM check = 1500.00 + 6234.41 = 7734.41

Now check D's out-of-network OOPM: 12000.00
D's OOPM balance is currently 6000.00. Wait, but D's OOPM balance includes both in-network and out-of-network spending?

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"

And from the accumulator 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."

So for out-of-network claims, the member is measured against the out-of-network individual OOPM of 12000.00.

D's current OOPM balance: 6000.00
D's out-of-network OOPM threshold: 12000.00
Room left: 12000.00 - 6000.00 = 6000.00

member_responsibility before cap: 7734.41
Since 7734.41 > 6000.00, cap at 6000.00.

member_responsibility = 6000.00
plan_paid = 17086.02 - 6000.00 = 11086.02

Wait, but how do the coinsurance and deductible break down when capped?
The deductible_applied is 1500.00. The remaining member responsibility after deductible would be 6000.00 - 1500.00 = 4500.00 (this is the coinsurance portion that the member actually pays).

Actually, for the final reporting, I think the deductible_applied stays as 1500.00, and the coinsurance_amount would be the actual coinsurance paid by the member which is 4500.00. But wait, the claim wasn't adjusted. Let me think about what the components are.

Actually, let me reconsider. When the OOPM caps the member responsibility, the deductible_applied is still the full amount applied to the deductible (1500.00), and the coinsurance_amount is the remainder of member_responsibility (6000.00 - 1500.00 = 4500.00).

Let me verify: member_responsibility = deductible_applied + copay_amount + coinsurance_amount
6000.00 = 1500.00 + 0.00 + 4500.00. Yes.

plan_paid = 17086.02 - 6000.00 = 11086.02

Accumulators after Line 8:
D's deductible balance: 1500.00 + 1500.00 = 3000.00
D's OOPM balance: 6000.00 + 6000.00 = 12000.00

Family deductible: 3000.00 + 1500.00 = 4500.00 (credits still accumulate to family balance)
Family OOPM: 11793.75 + 6000.00 = 17793.75

Wait, the addendum says: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So:
A: deductible 904.50, OOPM 964.50
B: deductible 0.00, OOPM 4179.75
C: deductible 595.50, OOPM 649.50
D: deductible 3000.00, OOPM 12000.00
Family: deductible 3000.00 + 1500.00 = 4500.00, OOPM 11793.75 + 6000.00 = 17793.75

**Line 9 — Claim 9 — 2026-04-12 — A (subscriber)**
Service: Primary care office visit, in-network
Allowed: 156.47

Primary care office visit → $30.00 copay.
- deductible_applied = 0.00
- copay_amount = 30.00
- coinsurance_amount = 0.00
- member_responsibility = 30.00
- plan_paid = 156.47 - 30.00 = 126.47

Accumulators after Line 9:
A: deductible 904.50, OOPM 964.50 + 30.00 = 994.50
B: deductible 0.00, OOPM 4179.75
C: deductible 595.50, OOPM 649.50
D: deductible 3000.00, OOPM 12000.00
Family: deductible 4500.00, OOPM 17793.75 + 30.00 = 17823.75

**Line 10 — Claim 10 — 2026-04-25 — B (spouse)**
Service: Specialist office visit, in-network
Allowed: 229.43

Specialist office visit → $60.00 copay.
- deductible_applied = 0.00
- copay_amount = 60.00
- coinsurance_amount = 0.00
- member_responsibility = 60.00
- plan_paid = 229.43 - 60.00 = 169.43

Accumulators after Line 10:
A: deductible 904.50, OOPM 994.50
B: deductible 0.00, OOPM 4179.75 + 60.00 = 4239.75
C: deductible 595.50, OOPM 649.50
D: deductible 3000.00, OOPM 12000.00
Family: deductible 4500.00, OOPM 17823.75 + 60.00 = 17883.75

**Line 11 — VOID of Claim 7 — 2026-04-29 — B (spouse)**

Claim 7 was for B, inpatient admission, in-network, allowed 20898.76.
Original adjudication of Claim 7:
- deductible_applied = 0.00
- coinsurance_amount = 4179.75
- member_responsibility = 4179.75
- plan_paid = 16719.01

Unwind Claim 7's credits:
B's deductible: 0.00 - 0.00 = 0.00
B's OOPM: 4239.75 - 4179.75 = 60.00
Family deductible: 4500.00 - 0.00 = 4500.00
Family OOPM: 17883.75 - 4179.75 = 13704.00

Void means nothing replaces it.

Accumulators after Line 11:
A: deductible 904.50, OOPM 994.50
B: deductible 0.00, OOPM 60.00
C: deductible 595.50, OOPM 649.50
D: deductible 3000.00, OOPM 12000.00
Family: deductible 4500.00, OOPM 13704.00

**Line 12 — Claim 12 — 2026-05-11 — C (child)**
Service: Inpatient admission with surgery, in-network
Allowed: 14567.47

C's individual deductible remainder: 1500.00 - 595.50 = 904.50
Family deductible remainder: 3000.00 - 4500.00 = negative... 

Wait, the family deductible is 4500.00 which is already above 3000.00. So family deductible is met.
Family deductible remainder = max(0, 3000.00 - 4500.00) = 0.00

Embedded: deductible_applied = min(individual remainder, family remainder) = min(904.50, 0.00) = 0.00

So deductible_applied = 0.00.

Remaining allowed = 14567.47
Coinsurance at 20% = 14567.47 * 0.20 = 2913.494 → 2913.49

member_responsibility = 0.00 + 2913.49 = 2913.49

Check C's OOPM: 649.50 + 2913.49 = 3562.99 < 6000.00. OK.
Family OOPM: 13704.00 + 2913.49 = 16617.49

Wait, family OOPM is already above 12000.00. Let me re-read the rules.

The family OOPM is 12000.00 (in-network). But it's already at 13704.00. Does the family OOPM cap apply?

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 family OOPM balance can exceed 12000.00 due to out-of-network claims. But does the family OOPM cap still protect in-network members?

Let me think about this. The family OOPM of 12000.00 is the in-network family OOPM. Once total family spending reaches 12000.00, all family members should have 100% coverage for in-network services.

But wait, D's out-of-network claim pushed the family balance past 12000.00. The out-of-network claim was measured against D's out-of-network OOPM of 12000.00 (individual), not the family OOPM.

Now for C's in-network claim, we need to check: has the family OOPM been met? The family OOPM balance is 13704.00 which is > 12000.00. So the family OOPM is met.

But wait, does the family OOPM being met mean C gets 100% coverage? Let me think...

Actually, I think the family OOPM works like the family deductible in embedded structure. Under embedded, once the family deductible is met, all members have their deductible satisfied for in-network purposes (or rather, the family remainder is 0, so deductible_applied is 0 for any member whose individual deductible is also met, but for a member whose individual deductible isn't met, the embedded rule says deductible_applied = min(individual remainder, family remainder) = min(X, 0) = 0).

Wait, that's what happened above with C - the family deductible was met, so C's deductible_applied was 0 even though C's individual deductible wasn't fully met.

Similarly for OOPM, if the family OOPM is met, does the member get 100% coverage?

Actually, looking at the plan document again: "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." It doesn't explicitly say the family OOPM triggers 100% for all members. But in typical embedded OOPM structures, once the family OOPM is met, all members get 100% coverage.

Hmm, but the plan document says: "Once a member reaches the out-of-pocket maximum..." This seems to be about individual members.

Actually, let me reconsider. The family OOPM is 12000.00. The individual in-network OOPM is 6000.00. With embedded structure, once a member's individual OOPM reaches 6000.00, that member gets 100%. Once the family total reaches 12000.00, all members get 100% (even if their individual hasn't reached 6000.00).

But here the family OOPM balance is 13704.00, which exceeds 12000.00 because of D's out-of-network claim. The out-of-network credits pushed it past.

For C's in-network claim, we should check if the family OOPM (in-network) has been met. Since the family balance is 13704.00 > 12000.00, the family OOPM is met. So C should get 100% coverage.

Wait, but I need to be more careful. The out-of-network claim added 6000.00 to the family OOPM. Is the family OOPM limit applied to the total of all member responsibilities (including out-of-network)?

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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So the family amounts do NOT limit an out-of-network claim. But the credits still accumulate to the family balance.

So the family OOPM balance is 13704.00. The family in-network OOPM threshold is 12000.00. Since 13704.00 > 12000.00, the family OOPM is met.

For C's in-network claim, the family OOPM has been met. So C should have 0 member responsibility? 

Actually, I need to think about this differently. Under embedded OOPM, a member's cost share is capped by the lesser of their individual OOPM remainder and the family OOPM remainder. If the family OOPM is met (remainder = 0), then the member's cost share for in-network is capped at 0.

So for C:
C's individual OOPM remainder: 6000.00 - 649.50 = 5350.50
Family OOPM remainder: 12000.00 - 13704.00 = negative, so 0.

Member's OOPM room = min(5350.50, 0) = 0.

So member_responsibility = 0.00 (capped by family OOPM being met).
plan_paid = 14567.47

Hmm, but this seems like the family OOPM was exceeded by out-of-network spending. Does the family OOPM really protect in-network members from cost sharing once exceeded by out-of-network spending?

Let me reconsider. The plan says the family OOPM is 12000.00 (in-network). The out-of-network individual OOPM is 12000.00. There is no out-of-network family OOPM listed.

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 when D had the out-of-network claim, it was measured against D's out-of-network individual OOPM of 12000.00. The family OOPM (12000.00 in-network) did NOT limit D's out-of-network claim. But the credits accumulated to the family balance.

Now for C's in-network claim, the family OOPM is 12000.00. The family balance is 13704.00, which exceeds 12000.00. So the family OOPM is met, and C should get 100% coverage.

Actually, wait. I'm not sure this is right. Let me reconsider the whole OOPM structure.

In typical health plans with embedded OOPM:
- Each member has an individual OO

Let me process this step by step.

**Plan Document Summary:**
- Plan year: 2026-01-01 through 2026-12-31
- Deductible: Individual (in-network) = 1500.00, Family (in-network) = 3000.00
- Structure: EMBEDDED
- Out-of-network (individual) = 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- OOPM: Individual (in-network) = 6000.00, Family (in-network) = 12000.00, Individual (out-of-network) = 12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Primary care office visit: 30.00 copay
- Specialist office visit: 60.00 copay
- Urgent care: 75.00 copay
- Emergency room: 400.00 copay, WAIVED if inpatient admission
- Generic retail pharmacy: 15.00 copay
- Copays do NOT credit the deductible. Copays always credit the OOPM.
- Preventive care in-network: 100% paid, no cost share, no deductible, no copay.
- Member cost share calculated from ALLOWED amount.

**Accumulator Rules:**
- deductible_applied = LESSER of allowed amount and room left under deductible threshold
- in-network: smaller of member's individual remainder and family remainder (embedded)
- out-of-network: out-of-network individual remainder, measured against member's same single deductible balance
- Once applicable threshold is met, deductible_applied = 0.00
- Balance = running total of deductible_applied (for deductible) or member_responsibility (for OOPM)
- Out-of-network claims measured against out-of-network individual thresholds only; family amounts don't limit out-of-network claims
- Credits from out-of-network claims still accumulate to member's balance and family balance

Let me process each line:

**Initial State:**
- A: deductible = 0.00, OOPM = 0.00
- B: deductible = 0.00, OOPM = 0.00
- C: deductible = 0.00, OOPM = 0.00
- D: deductible = 0.00, OOPM = 0.00
- E: deductible = 0.00, OOPM = 0.00
- Family: deductible = 0.00, OOPM = 0.00

**Line 1 — Claim 1 — 2026-01-23 — D (child)**
- Service: Outpatient procedure, in-network
- Allowed: 9156.86
- D's individual deductible remainder: 1500.00
- Family deductible remainder: 3000.00
- deductible_applied = min(9156.86, min(1500.00, 3000.00)) = min(9156.86, 1500.00) = 1500.00
- Remaining allowed: 9156.86 - 1500.00 = 7656.86
- Coinsurance (in-network, after deductible): 20% of 7656.86 = 1531.37 (member), 6125.49 (plan)
- Member responsibility = 1500.00 + 1531.37 = 3031.37
- Plan paid = 6125.49
- D's deductible balance: 0 + 1500.00 = 1500.00 (individual deductible met)
- D's OOPM balance: 0 + 3031.37 = 3031.37
- Family deductible: 0 + 1500.00 = 1500.00
- Family OOPM: 0 + 3031.37 = 3031.37

Wait, let me re-check the coinsurance calculation.
7656.86 * 0.20 = 1531.372 → 1531.37
7656.86 * 0.80 = 6125.488 → 6125.49
Total: 1531.37 + 6125.49 = 7656.86 ✓
Member responsibility = 1500.00 + 1531.37 = 3031.37
Plan paid = 6125.49
Check: 3031.37 + 6125.49 = 9156.86 ✓

**Line 2 — Claim 2 — 2026-01-28 — E (child)**
- Service: Primary care office visit, in-network
- Allowed: 205.32
- Copay: 30.00
- Since this is a primary care office visit with a copay, does the deductible apply first?
- Let me re-read: "Copays do NOT credit the deductible."
- The plan document says: "Primary care office visit: 30.00 copay"
- I need to think about how copays interact with the deductible. Typically, if a service has a copay, the copay applies instead of deductible/coinsurance. Let me re-read the plan document.
- "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."
- This suggests copays might be subject to the deductible in some cases? But "Copays do NOT credit the deductible" is stated.
- Actually, I think the standard interpretation is: for services with a copay (like primary care visit), the member pays the copay, and the plan pays the rest. The copay doesn't go toward the deductible. Let me check if the deductible needs to be met first for copay services.
- The plan document doesn't explicitly say "copay services are exempt from deductible" but it says "Copays do NOT credit the deductible." This typically means the copay is a flat amount the member pays, and it doesn't count toward satisfying the deductible. But does the member need to satisfy the deductible before the copay applies?
- In many plans, copay services (like PCP visits) are available before the deductible is met. The plan says "Primary care office visit: 30.00 copay" without saying "after deductible." So I'll treat it as: member pays 30.00 copay, plan pays the rest (205.32 - 30.00 = 175.32). No deductible applied.
- Actually, wait. Let me re-read: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." This implies that a copay might otherwise credit the deductible, but the plan says copays do NOT credit the deductible. So the statement is saying: even if a copay would credit the deductible, once the deductible is met, deductible_applied is 0.00.
- I think the correct interpretation is: for copay services, the member pays the copay amount, and the deductible is NOT applied (deductible_applied = 0). The copay credits the OOPM.
- deductible_applied = 0.00
- copay_amount = 30.00
- coinsurance_amount = 0.00
- member_responsibility = 30.00
- plan_paid = 205.32 - 30.00 = 175.32
- E's deductible balance: 0.00
- E's OOPM balance: 0 + 30.00 = 30.00
- Family deductible: 1500.00 (unchanged)
- Family OOPM: 3031.37 + 30.00 = 3061.37

**Line 3 — Claim 3 — 2026-02-07 — B (spouse)**
- Service: Outpatient imaging, in-network
- Allowed: 1054.17
- B's individual deductible remainder: 1500.00
- Family deductible remainder: 3000.00 - 1500.00 = 1500.00
- deductible_applied = min(1054.17, min(1500.00, 1500.00)) = min(1054.17, 1500.00) = 1054.17
- Remaining allowed: 1054.17 - 1054.17 = 0.00
- Coinsurance: 0.00
- Member responsibility = 1054.17
- Plan paid = 0.00
- B's deductible balance: 0 + 1054.17 = 1054.17
- B's OOPM balance: 0 + 1054.17 = 1054.17
- Family deductible: 1500.00 + 1054.17 = 2554.17
- Family OOPM: 3061.37 + 1054.17 = 4115.54

**Line 4 — Claim 4 — 2026-02-22 — E (child)**
- Service: Inpatient admission with surgery, out-of-network
- Allowed: 16325.03
- Out-of-network
- E's single deductible balance: 0.00
- Out-of-network individual deductible: 3000.00
- E's out-of-network individual remainder: 3000.00 - 0.00 = 3000.00
- deductible_applied = min(16325.03, 3000.00) = 3000.00
- Remaining allowed: 16325.03 - 3000.00 = 13325.03
- Coinsurance (out-of-network): 40% member / 60% plan
- Member coinsurance: 13325.03 * 0.40 = 5330.012 → 5330.01
- Plan coinsurance: 13325.03 * 0.60 = 7995.018 → 7995.02
- Check: 5330.01 + 7995.02 = 13325.03 ✓
- Member responsibility = 3000.00 + 5330.01 = 8330.01
- Plan paid = 7995.02
- Check: 8330.01 + 7995.02 = 16325.03 ✓
- E's deductible balance: 0 + 3000.00 = 3000.00 (out-of-network individual deductible met)
- E's OOPM balance: 30.00 + 8330.01 = 8360.01
- Family deductible: 2554.17 + 3000.00 = 5554.17

Wait, let me re-read the accumulator rules:
"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."

So the out-of-network deductible credits DO accumulate to the family balance.
Family deductible: 2554.17 + 3000.00 = 5554.17

But wait, the family deductible is 3000.00. So the family deductible is already exceeded. Let me think about this.

Actually, the family deductible threshold is 3000.00. The family deductible balance is now 5554.17, which exceeds the threshold. That's fine - the balance can exceed the threshold. The threshold just determines when coinsurance kicks in for subsequent claims.

Actually wait, I need to reconsider. The family deductible is 3000.00. After Claim 1, family deductible was 1500.00. After Claim 3, family deductible was 2554.17. Now with Claim 4 (out-of-network), the deductible_applied is 3000.00.

But for the family deductible, the out-of-network claim's deductible credit still accumulates to the family balance. So family deductible becomes 2554.17 + 3000.00 = 5554.17.

Hmm, but the family deductible threshold is 3000.00 (in-network). The family deductible balance is now 5554.17, which is well above 3000.00.

Let me also check: does the family OOPM get credited?
"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 E's OOPM balance: 30.00 + 8330.01 = 8360.01
Family OOPM: 4115.54 + 8330.01 = 12445.55

Wait, the family OOPM threshold is 12000.00. The family OOPM balance is now 12445.55, which exceeds 12000.00. That's fine.

But wait - does the family OOPM being exceeded mean anything for subsequent in-network claims? 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."

This says "a member" - so it's individual. But there's also a family OOPM of 12000.00. I think the family OOPM works like the family deductible - once the family OOPM is met, all family members get 100% coverage for in-network services.

Actually, let me re-read the 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."

I think the same logic applies to the OOPM. Once the family OOPM is reached, all members get 100% coverage.

But wait, for the OOPM, the plan says:
"Out-of-pocket maximum
  Individual (in-network) ................ 6000.00
  Family (in-network) .................... 12000.00
  Individual (out-of-network) ............ 12000.00"

So there's an individual in-network OOPM of 6000.00, a family in-network OOPM of 12000.00, and an individual out-of-network OOPM of 12000.00.

For E, the OOPM balance is 8360.01. The individual in-network OOPM is 6000.00, and the individual out-of-network OOPM is 12000.00.

Wait, E's OOPM balance includes both in-network and out-of-network amounts. Let me think about how this works.

Actually, let me re-read: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

So the OOPM balance is just the running total of member_responsibility. For E, it's 8360.01.

But which OOPM threshold does this get measured against? The plan says:
- Individual (in-network) OOPM: 6000.00
- Individual (out-of-network) OOPM: 12000.00

I think the OOPM balance is a single balance (like the deductible), and it's measured against the applicable threshold depending on whether the service is in-network or out-of-network.

For E, the OOPM balance is 8360.01. If E has an in-network service, the threshold is 6000.00. Since 8360.01 > 6000.00, E has met the in-network OOPM. If E has an out-of-network service, the threshold is 12000.00. Since 8360.01 < 12000.00, E has NOT met the out-of-network OOPM.

OK, let me continue.

Family OOPM: 4115.54 + 8330.01 = 12445.55
Family deductible: 2554.17 + 3000.00 = 5554.17

**Line 5 — Claim 5 — 2026-03-03 — E (child)**
- Service: Outpatient rehabilitation, in-network
- Allowed: 2923.30
- E's individual deductible remainder (in-network): 1500.00 - 0.00 = 1500.00... wait, E's deductible balance is 3000.00. The in-network individual deductible is 1500.00. Since 3000.00 > 1500.00, E's in-network individual deductible is met. Remainder = 0.
- Family deductible remainder: 3000.00 - 5554.17 < 0, so remainder = 0.
- deductible_applied = 0.00
- Coinsurance (in-network): 20% of 2923.30 = 584.66 (member), 2338.64 (plan)
- But wait, E's OOPM balance is 8360.01, and the in-network OOPM threshold is 6000.00. Since 8360.01 >= 6000.00, E has met the in-network OOPM.
- So the plan pays 100% of the allowed amount.
- Member responsibility = 0.00
- Plan paid = 2923.30
- deductible_applied = 0.00

Wait, I need to think about this more carefully. The OOPM balance is 8360.01, which includes out-of-network amounts. Does the out-of-network amount count toward the in-network OOPM?

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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

This says the balances are not capped at the in-network amounts. So the balance can exceed the in-network threshold. But does the out-of-network member responsibility count toward the in-network OOPM?

I think the balance is a single running total, and it's measured against the applicable threshold. So if E's total member responsibility is 8360.01, and the in-network OOPM is 6000.00, then E has exceeded the in-network OOPM.

Actually, I think there might be separate in-network and out-of-network OOPM accumulators. Let me re-read.

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

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

I think there's a single OOPM balance per member, and it's measured against the applicable threshold. So for in-network services, the threshold is 6000.00, and for out-of-network services, the threshold is 12000.00.

But wait, the plan also says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This is explicitly stated for the deductible. Is the same true for the OOPM?

The plan doesn't explicitly say this for the OOPM, but I think the same logic applies. The OOPM balance is a single running total, measured against the applicable threshold.

So for E:
- OOPM balance: 8360.01
- In-network OOPM threshold: 6000.00
- Since 8360.01 >= 6000.00, E has met the in-network OOPM.
- Plan pays 100% of in-network allowed amount.
- Member responsibility = 0.00
- Plan paid = 2923.30

Wait, but should I also check the family OOPM? The family OOPM is 12445.55, and the family in-network OOPM threshold is 12000.00. Since 12445.55 >= 12000.00, the family OOPM is also met.

Actually, I think the embedded structure applies to the OOPM as well. So if either the individual or family OOPM is met, the member gets 100% coverage.

For E, both the individual in-network OOPM (6000.00) and the family in-network OOPM (12000.00) are met. So E gets 100% coverage.

Member responsibility = 0.00
Plan paid = 2923.30
E's OOPM balance: 8360.01 + 0.00 = 8360.01
Family OOPM: 12445.55 + 0.00 = 12445.55

**Line 6 — Claim 6 — 2026-03-08 — A (subscriber)**
- Service: Screening mammography, in-network
- Allowed: 1220.47
- This is a preventive service (screening mammography). In-network preventive services are paid at 100% with no cost share.
- deductible_applied = 0.00
- Member responsibility = 0.00
- Plan paid = 1220.47
- A's deductible balance: 0.00
- A's OOPM balance: 0.00
- Family deductible: 5554.17
- Family OOPM: 12445.55

**Line 7 — Claim 7 — 2026-03-18 — D (child)**
- Service: Inpatient admission, in-network
- Allowed: 19176.22
- D's individual deductible is met (balance = 1500.00, threshold = 1500.00).
- Family deductible is met (balance = 5554.17, threshold = 3000.00).
- deductible_applied = 0.00
- D's OOPM balance: 3031.37. In-network OOPM threshold: 6000.00. Room: 6000.00 - 3031.37 = 2968.63.
- Family OOPM balance: 12445.55. Family in-network OOPM threshold: 12000.00. Family OOPM is met.
- Since the family OOPM is met, D gets 100% coverage.

Wait, but D's individual OOPM is not met (3031.37 < 6000.00). Does the family OOPM being met mean D gets 100% coverage?

I think the embedded structure applies: "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."

By analogy, the family OOPM is also satisfied once total family credits reach the family amount. So if the family OOPM is met, all members get 100% coverage for in-network services.

Family OOPM balance: 12445.55 >= 12000.00. So the family OOPM is met.
D gets 100% coverage.
Member responsibility = 0.00
Plan paid = 19176.22
D's OOPM balance: 3031.37
Family OOPM: 12445.55

Hmm, but wait. Let me reconsider whether the family OOPM was really met. The family OOPM balance is 12445.55. But this includes out-of-network amounts from E's claim. Do out-of-network amounts count toward the family in-network OOPM?

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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

This says the balances are not capped at the in-network amounts. So the family balance can exceed the family in-network OOPM of 12000.00.

But does an out-of-network claim's member responsibility count toward the family in-network OOPM? I think it does, because the balance is a single running total.

Actually, wait. Let me re-read more carefully: "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 says the family amounts do not LIMIT an out-of-network claim. So when processing an out-of-network claim, we don't check if the family deductible or family OOPM is met. But the credits still accumulate to the family balance.

So the family balance includes out-of-network credits. And when processing an in-network claim, we check the family balance against the family in-network threshold.

Family OOPM balance: 12445.55 >= 12000.00. So the family in-network OOPM is met.

But wait, is the family OOPM balance really 12445.55? Let me recalculate.

After Claim 1 (D): Family OOPM = 3031.37
After Claim 2 (E): Family OOPM = 3031.37 + 30.00 = 3061.37
After Claim 3 (B): Family OOPM = 3061.37 + 1054.17 = 4115.54
After Claim 4 (E): Family OOPM = 4115.54 + 8330.01 = 12445.55

Yes, family OOPM is 12445.55.

So for Claim 7 (D, in-network), since the family OOPM is met, D gets 100% coverage.
Member responsibility = 0.00
Plan paid = 19176.22

**Line 8 — Claim 8 — 2026-03-28 — A (subscriber)**
- Service: Inpatient admission with surgery, in-network
- Allowed: 15812.18
- A's deductible balance: 0.00. In-network individual deductible: 1500.00. Room: 1500.00.
- Family deductible is met (5554.17 >= 3000.00). So family deductible remainder = 0.
- deductible_applied = min(15812.18, min(1500.00, 0)) = min(15812.18, 0) = 0.00

Wait, the family deductible is already met. So the family remainder is 0. Under embedded structure, deductible_applied = min(allowed, min(individual remainder, family remainder)) = min(15812.18, min(1500.00, 0)) = 0.00.

So deductible_applied = 0.00.

Now for coinsurance:
- A's OOPM balance: 0.00. In-network OOPM threshold: 6000.00. Room: 6000.00.
- Family OOPM is met (12445.55 >= 12000.00).
- Since the family OOPM is met, A gets 100% coverage.
- Member responsibility = 0.00
- Plan paid = 15812.18

Wait, but if A gets 100% coverage because the family OOPM is met, does A's OOPM balance change? No, because member responsibility is 0.00.

A's OOPM balance: 0.00
Family OOPM: 12445.55

**Line 9 — Claim 9 — 2026-04-05 — E (child)**
- Service: Inpatient admission with surgery, in-network
- Allowed: 23810.73
- E's individual deductible is met (3000.00 >= 1500.00).
- Family deduct

Let me process this ledger step by step. I need to track accumulators for each member and the family.

Plan details:
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Primary care office visit: 30.00 copay
- Specialist office visit: 60.00 copay
- Urgent care: 75.00 copay
- Emergency room: 400.00 copay, WAIVED if inpatient admission
- Generic retail pharmacy: 15.00 copay
- Copays do NOT credit the deductible. Copays always credit the OOPM.
- Preventive care in-network: 100% paid, no cost share, no deductible/coinsurance/copay

Let me set up initial accumulators:

Member A: deductible = 0.00, OOPM = 0.00
Member B: deductible = 0.00, OOPM = 0.00
Member C: deductible = 0.00, OOPM = 0.00
Member D: deductible = 0.00, OOPM = 0.00
Member E: deductible = 0.00, OOPM = 0.00
Family: deductible = 0.00, OOPM = 0.00

Now let me process each line:

**Line 1 — Claim 1 — 2026-01-13 — D (child)**
- Service: Inpatient admission, out-of-network
- Network: Out-of-network
- Allowed: 21121.93

Out-of-network service. The member's deductible balance is measured against the out-of-network individual threshold (3000.00).
D's deductible balance = 0.00. Out-of-network individual deductible = 3000.00.
Deductible remainder for D (out-of-network) = 3000.00 - 0.00 = 3000.00.

Wait, let me re-read the rules about deductible_applied for out-of-network:
"out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."

So for out-of-network claims, deductible_applied = lesser of allowed amount and (out-of-network individual threshold - member's single deductible balance).

D's single deductible balance = 0.00.
Out-of-network individual threshold = 3000.00.
Remainder = 3000.00.
Allowed = 21121.93.
deductible_applied = min(21121.93, 3000.00) = 3000.00.

After deductible, remaining allowed = 21121.93 - 3000.00 = 18121.93.
Coinsurance (out-of-network, 40% member) = 18121.93 * 0.40 = 7248.772 → 7248.77.

Wait, but I need to check OOPM. Out-of-network individual OOPM = 12000.00.
D's OOPM balance = 0.00.
Member responsibility so far = deductible_applied + coinsurance = 3000.00 + 7248.77 = 10248.77.
OOPM remainder = 12000.00 - 0.00 = 12000.00.
Since 10248.77 < 12000.00, no cap needed.

Member responsibility = 10248.77.
Plan paid = 21121.93 - 10248.77 = 10873.16.

Wait, let me reconsider. The coinsurance calculation: 18121.93 * 0.40 = 7248.772.
Round half up to the cent at the end: 7248.77.

member_responsibility = 3000.00 + 7248.77 = 10248.77
plan_paid = 21121.93 - 10248.77 = 10873.16

Update accumulators:
D's deductible balance: 0.00 + 3000.00 = 3000.00
D's OOPM balance: 0.00 + 10248.77 = 10248.77
Family deductible: 0.00 + 3000.00 = 3000.00
Family OOPM: 0.00 + 10248.77 = 10248.77

Wait - does the family deductible use the same single deductible balance? Let me re-read.

"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."

And for family deductible: "the family deductible is also satisfied once total family credits reach the family amount"

So the family deductible credits are the sum of all members' deductible credits. Since D's deductible_applied is 3000.00, the family deductible gets 3000.00 credited.

Family deductible = 3000.00. Family deductible threshold = 3000.00. So family deductible is satisfied!

Wait, but for 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 reaches 3000.00, it's satisfied. Now for in-network claims, the deductible_applied is the lesser of member's individual remainder and family remainder. Since family remainder = 0, deductible_applied for in-network would be 0.

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

So for out-of-network, it doesn't use the family deductible at all. It only uses the out-of-network individual threshold (3000.00) against the member's single deductible balance.

D's single deductible balance = 3000.00. This equals the out-of-network individual threshold (3000.00), so D's out-of-network deductible is satisfied too.

Actually wait, let me re-read: "The amount above is the threshold that balance is measured against when the service is out-of-network."

So the single deductible balance is compared against:
- 1500.00 for in-network services
- 3000.00 for out-of-network services

D's balance is 3000.00. For in-network, 3000.00 >= 1500.00, so in-network deductible is satisfied.
For out-of-network, 3000.00 >= 3000.00, so out-of-network deductible is satisfied.

OK, let me continue.

After Line 1:
A: ded=0.00, oopm=0.00
B: ded=0.00, oopm=0.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10248.77
E: ded=0.00, oopm=0.00
Family: ded=3000.00, oopm=10248.77

**Line 2 — Claim 2 — 2026-01-24 — B (spouse)**
- Service: Primary care office visit, in-network
- Allowed: 228.07

Primary care office visit = 30.00 copay.
Copays do NOT credit the deductible. Copays always credit the OOPM.

So member_responsibility = 30.00 (copay).
plan_paid = 228.07 - 30.00 = 198.07.
No deductible_applied.

Update accumulators:
B's OOPM: 0.00 + 30.00 = 30.00
Family OOPM: 10248.77 + 30.00 = 10278.77

After Line 2:
A: ded=0.00, oopm=0.00
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10248.77
E: ded=0.00, oopm=0.00
Family: ded=3000.00, oopm=10278.77

**Line 3 — Claim 3 — 2026-02-09 — E (child)**
- Service: Allergy testing, in-network
- Allowed: 2282.31

In-network service. E's deductible balance = 0.00.
For in-network, deductible_applied = lesser of member's individual remainder and family remainder (embedded).
E's individual remainder = 1500.00 - 0.00 = 1500.00.
Family remainder = 3000.00 - 3000.00 = 0.00.
So deductible_applied = min(2282.31, min(1500.00, 0.00)) = min(2282.31, 0.00) = 0.00.

Family deductible is already satisfied, so no deductible applies.

After deductible, remaining = 2282.31.
Coinsurance (in-network, 20% member) = 2282.31 * 0.20 = 456.462 → 456.46.

Check OOPM: E's OOPM = 0.00. In-network individual OOPM = 6000.00.
member_responsibility = 0.00 + 456.46 = 456.46.
OOPM remainder = 6000.00 - 0.00 = 6000.00.
456.46 < 6000.00, so no cap.

member_responsibility = 456.46
plan_paid = 2282.31 - 456.46 = 1825.85

Update accumulators:
E's OOPM: 0.00 + 456.46 = 456.46
Family OOPM: 10278.77 + 456.46 = 10735.23

After Line 3:
A: ded=0.00, oopm=0.00
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10248.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=10735.23

**Line 4 — Claim 4 — 2026-02-13 — D (child)**
- Service: Urgent care visit, in-network
- Allowed: 311.34

Urgent care = 75.00 copay.
Copays do NOT credit the deductible. Copays always credit the OOPM.

member_responsibility = 75.00 (copay).
plan_paid = 311.34 - 75.00 = 236.34.
No deductible_applied.

Update accumulators:
D's OOPM: 10248.77 + 75.00 = 10323.77
Family OOPM: 10735.23 + 75.00 = 10810.23

After Line 4:
A: ded=0.00, oopm=0.00
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=10810.23

**Line 5 — Claim 5 — 2026-02-20 — A (subscriber)**
- Service: Outpatient endoscopy, in-network
- Allowed: 2316.72

In-network. A's deductible balance = 0.00.
A's individual remainder = 1500.00 - 0.00 = 1500.00.
Family remainder = 3000.00 - 3000.00 = 0.00.
deductible_applied = min(2316.72, min(1500.00, 0.00)) = 0.00.

Family deductible already satisfied.

Remaining = 2316.72.
Coinsurance (20%) = 2316.72 * 0.20 = 463.344 → 463.34.

Check OOPM: A's OOPM = 0.00. In-network OOPM = 6000.00.
member_responsibility = 463.34.
463.34 < 6000.00, no cap.

member_responsibility = 463.34
plan_paid = 2316.72 - 463.34 = 1853.38

Update accumulators:
A's OOPM: 0.00 + 463.34 = 463.34
Family OOPM: 10810.23 + 463.34 = 11273.57

After Line 5:
A: ded=0.00, oopm=463.34
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=11273.57

**Line 6 — Claim 6 — 2026-02-26 — A (subscriber)**
- Service: Outpatient procedure, in-network
- Allowed: 8629.09

In-network. A's deductible balance = 0.00.
Family deductible already satisfied (remainder = 0).
deductible_applied = 0.00.

Remaining = 8629.09.
Coinsurance (20%) = 8629.09 * 0.20 = 1725.818 → 1725.82.

Check OOPM: A's OOPM = 463.34. In-network OOPM = 6000.00.
member_responsibility = 1725.82.
OOPM remainder = 6000.00 - 463.34 = 5536.66.
1725.82 < 5536.66, no cap.

member_responsibility = 1725.82
plan_paid = 8629.09 - 1725.82 = 6903.27

Update accumulators:
A's OOPM: 463.34 + 1725.82 = 2189.16
Family OOPM: 11273.57 + 1725.82 = 12999.39

After Line 6:
A: ded=0.00, oopm=2189.16
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=12999.39

Wait, family OOPM threshold is 12000.00. But the balance is 12999.39. 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 the family balances past the family amounts; the balances are not capped at the in-network amounts."

So the family OOPM balance can exceed 12000.00 because of out-of-network claims. D had an out-of-network claim that generated 10248.77 in OOPM. That's fine.

But wait, does the family OOPM cap affect in-network claims for other members? Let me think about this.

The family OOPM is 12000.00. Once reached, the plan pays 100% of allowed for covered in-network services. But D's out-of-network claim pushed the family OOPM past 12000.00 already. So for subsequent in-network claims, the family OOPM is already met.

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."

So it's about the member reaching their OOPM. The family OOPM of 12000.00 - how does that work?

Actually, I think the family OOPM works like the family deductible - once the total family OOPM credits reach 12000.00, all members get 100% coverage for in-network. But 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."

And:
"Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00"

So there's an individual OOPM and a family OOPM. I think the family OOPM works similarly to the embedded deductible - once the family total reaches 12000.00, all members are covered at 100% for in-network.

Actually wait, let me reconsider. The OOPM structure might also be embedded. Let me re-read.

The plan document says:
"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."

It doesn't explicitly say embedded or aggregate for OOPM. But the deductible is embedded. I think OOPM follows the same structure as the deductible by default in embedded plans.

Actually, looking at the accumulator rules: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."

For in-network claims, I think the member's OOPM is checked against the individual OOPM (6000.00). If the member's OOPM balance reaches 6000.00, they get 100% coverage.

But what about the family OOPM? If the family total reaches 12000.00, do all members get 100%?

I think yes, similar to the embedded deductible. Once family OOPM reaches 12000.00, all members are treated as having met their OOPM for in-network services.

So at this point, family OOPM = 12999.39, which exceeds 12000.00. So for all subsequent in-network claims, the family OOPM is met, and the plan pays 100%.

Wait, but I need to be more careful. Let me re-read the OOPM cap logic.

For an in-network claim, the member's cost share is capped by:
1. The member's individual OOPM remainder (6000.00 - member's OOPM balance)
2. The family OOPM remainder (12000.00 - family's OOPM balance)

The member's cost share for the claim is capped at the lesser of these two remainders.

Since family OOPM is already 12999.39 > 12000.00, the family OOPM remainder is 0 (or negative, treated as 0). So for any subsequent in-network claim, the member's cost share is capped at 0.

Hmm, but actually I need to think about whether the family OOPM being exceeded by out-of-network claims means the family OOPM is "met" for in-network purposes.

"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 balances can go past the in-network amounts. But does that mean the in-network thresholds are considered met? I think yes - if the balance exceeds the threshold, the threshold is met.

So family OOPM = 12999.39 > 12000.00, family OOPM is met for in-network.

Let me continue with this understanding.

**Line 7 — Claim 7 — 2026-03-13 — C (child)**
- Service: Outpatient rehabilitation, in-network
- Allowed: 9053.51

In-network. Family deductible is met (3000.00). C's individual deductible balance = 0.00.
Since family deductible is met, deductible_applied = 0.00.

Remaining = 9053.51.
Coinsurance (20%) = 9053.51 * 0.20 = 1810.702 → 1810.70.

Check OOPM: C's OOPM = 0.00. Individual OOPM = 6000.00.
Family OOPM = 12999.39, already exceeds 12000.00.

Since family OOPM is already met, the member's cost share is capped at 0 for in-network.

Wait, actually I need to think about this more carefully. The family OOPM was exceeded because of D's out-of-network claim. Does D's out-of-network OOPM count toward the family in-network OOPM?

Let me re-read: "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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So D's out-of-network claim credits DO accumulate to the family balance. The family OOPM balance is 12999.39, which exceeds the family in-network OOPM of 12000.00.

So yes, the family in-network OOPM is met. All members get 100% for in-network services.

member_responsibility = 0.00 (capped by family OOPM being met)
plan_paid = 9053.51

Wait, but is this right? Let me reconsider.

Actually, I think I need to be more careful about how the OOPM cap works. Let me think about it differently.

For an in-network claim:
1. Calculate deductible_applied
2. Calculate coinsurance on the remainder
3. member_cost_share = deductible_applied + coinsurance + copay
4. Check if member_cost_share would push the member's OOPM balance past the individual OOPM (6000.00) or the family OOPM balance past the family OOPM (12000.00)
5. If so, cap the member_cost_share so that neither is exceeded

For Claim 6 (Line 6), let me recheck:
Before Claim 6:
A's OOPM = 463.34
Family OOPM = 11273.57

Claim 6 coinsurance = 1725.82
If A pays 1725.82:
A's OOPM would be 463.34 + 1725.82 = 2189.16 (< 6000.00, OK)
Family OOPM would be 11273.57 + 1725.82 = 12999.39 (> 12000.00, NOT OK)

So the family OOPM cap would limit this!
Family OOPM remainder = 12000.00 - 11273.57 = 726.43.
So member_cost_share is capped at 726.43.

Let me redo Claim 6:
member_responsibility = 726.43 (capped by family OOPM)
plan_paid = 8629.09 - 726.43 = 7902.66

Update accumulators:
A's OOPM: 463.34 + 726.43 = 1189.77
Family OOPM: 11273.57 + 726.43 = 12000.00

After Line 6:
A: ded=0.00, oopm=1189.77
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=12000.00

OK, that makes more sense. The family OOPM is exactly 12000.00 now.

Now for Claim 7 (Line 7):
C's OOPM = 0.00. Family OOPM = 12000.00 (met).
Since family OOPM is met, member_cost_share = 0.00.
member_responsibility = 0.00
plan_paid = 9053.51

Update accumulators:
C's OOPM: 0.00 (no change)
Family OOPM: 12000.00 (no change)

After Line 7:
A: ded=0.00, oopm=1189.77
B: ded=0.00, oopm=30.00
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=3000.00, oopm=12000.00

**Line 8 — Claim 8 — 2026-03-28 — B (spouse)**
- Service: Outpatient procedure, out-of-network
- Allowed: 3428.25

Out-of-network. B's single deductible balance = 0.00.
Out-of-network individual threshold = 3000.00.
Remainder = 3000.00 - 0.00 = 3000.00.
deductible_applied = min(3428.25, 3000.00) = 3000.00.

Remaining = 3428.25 - 3000.00 = 428.25.
Coinsurance (out-of-network, 40%) = 428.25 * 0.40 = 171.30.

Check OOPM: B's OOPM = 30.00. Out-of-network individual OOPM = 12000.00.
member_responsibility = 3000.00 + 171.30 = 3171.30.
OOPM remainder = 12000.00 - 30.00 = 11970.00.
3171.30 < 11970.00, no cap from individual.

But what about family OOPM? Family OOPM = 12000.00 (already met for in-network).
Wait, for out-of-network claims, are they capped by the family OOPM?

"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 out-of-network claims are NOT capped by the family OOPM. They are only measured against the out-of-network individual OOPM (12000.00).

member_responsibility = 3171.30
plan_paid = 3428.25 - 3171.30 = 257.00 - wait, let me recalculate.
plan_paid = 3428.25 - 3171.30 = 256.95.

Update accumulators:
B's deductible balance: 0.00 + 3000.00 = 3000.00
B's OOPM: 30.00 + 3171.30 = 3201.30
Family deductible: 3000.00 + 3000.00 = 6000.00
Family OOPM: 12000.00 + 3171.30 = 15171.30

After Line 8:
A: ded=0.00, oopm=1189.77
B: ded=3000.00, oopm=3201.30
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=6000.00, oopm=15171.30

**Line 9 — Claim 9 — 2026-04-07 — A (subscriber)**
- Service: Inpatient admission with surgery, in-network
- Allowed: 25430.93

In-network. A's deductible balance = 0.00.
Family deductible is met (6000.00 > 3000.00).
deductible_applied = 0.00.

Remaining = 25430.93.
Coinsurance (20%) = 25430.93 * 0.20 = 5086.186 → 5086.19.

Check OOPM: A's OOPM = 1189.77. Individual OOPM = 6000.00.
Family OOPM = 15171.30, already exceeds 12000.00 (family in-network OOPM is met).

Since family OOPM is met, member_cost_share = 0.00 for in-network.

member_responsibility = 0.00
plan_paid = 25430.93

Update accumulators:
No change (member_responsibility = 0).

After Line 9:
A: ded=0.00, oopm=1189.77
B: ded=3000.00, oopm=3201.30
C: ded=0.00, oopm=0.00
D: ded=3000.00, oopm=10323.77
E: ded=0.00, oopm=456.46
Family: ded=6000.00, oopm=15171.30

**Line 10 — Claim 10 — 2026-04-20 — C (child)**
- Service: Primary care office visit, in-network
- Allowed: 228.88

Primary care office visit = 30.00 copay.
Copays do NOT credit the deductible. Copays always credit the OOPM.

But wait, family OOP

Let me carefully process each claim in order, tracking accumulators for each member and the family.

**Plan Details:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance in-network: 20% member / 80% plan
- Coinsurance out-of-network: 40% member / 60% plan
- Primary care copay: 30.00
- Specialist copay: 60.00
- Urgent care copay: 75.00
- ER copay: 400.00 (waived if inpatient admission)
- Generic retail pharmacy: 15.00
- Copays do NOT credit deductible. Copays always credit OOPM.
- Preventive care in-network: 100% paid, no cost share, no deductible, no copay.

**Accumulator rules:**
- deductible_applied = lesser of allowed amount and room left under deductible threshold
  - in-network: smaller of member's individual remainder and family remainder (embedded)
  - out-of-network: out-of-network individual remainder, measured against member's same single deductible balance
- Once applicable threshold is met, deductible_applied = 0.00
- Balance = running total of deductible_applied (for deductible) or member_responsibility (for OOPM)
- Out-of-network claims measured against out-of-network individual thresholds only; family amounts don't limit an out-of-network claim. Credits still accumulate to member's balance and family balance.

Wait, let me re-read the out-of-network rules carefully:
"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."

So for out-of-network:
- Deductible threshold is 3000.00 (out-of-network individual)
- The member's single deductible balance is measured against this 3000.00 threshold
- deductible_applied = lesser of allowed amount and (3000.00 - member's deductible balance)
- But wait, the family deductible is 3000.00 in-network. For out-of-network, we only look at the individual out-of-network threshold of 3000.00.
- The credits still go to the family balance.

Let me also note: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."

So each member has ONE deductible balance that accumulates both in-network and out-of-network deductible credits. When processing an in-network claim, the threshold is 1500.00 (individual) and 3000.00 (family). When processing an out-of-network claim, the threshold is 3000.00 (out-of-network individual).

Wait, but the family deductible is 3000.00. For embedded structure, an individual satisfies the individual deductible on their own. The family deductible is satisfied once total family credits reach 3000.00.

For out-of-network 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 out-of-network:
- deductible_applied = min(allowed, 3000 - member_deductible_balance)
- This deductible_applied credits the member's single deductible balance AND the family deductible balance
- But the family deductible (3000) doesn't cap the out-of-network claim's deductible application

Wait, I need to think about this more carefully. The family deductible is 3000.00 in-network. If family deductible is already met (>=3000), does that affect out-of-network claims?

"Out-of-network claims are measured against the out-of-network individual thresholds only" - so the family deductible being met doesn't affect out-of-network claims. Only the member's individual out-of-network threshold (3000) matters.

But the credits still accumulate to the family balance.

Let me also think about OOPM for out-of-network:
- Individual OOPM (out-of-network): 12000.00
- The member's OOPM balance is a single balance? Or separate?

Actually, re-reading: "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."

So there's a single member deductible balance and a single member OOPM balance. When processing:
- In-network claim: check if member deductible balance >= 1500 (individual threshold for in-network)
- Out-of-network claim: check if member deductible balance >= 3000 (individual threshold for out-of-network)

For OOPM:
- In-network claim: check if member OOPM balance >= 6000 (individual in-network OOPM)
- Out-of-network claim: check if member OOPM balance >= 12000 (individual out-of-network OOPM)

Wait, but what about family OOPM? Family OOPM is 12000.00 in-network. Does the family OOPM apply?

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."

For family OOPM, I think it works similarly to the family deductible - once total family OOPM credits reach 12000, all family members get 100% coverage for in-network. But for out-of-network, only the individual out-of-network OOPM of 12000 applies.

Actually, let me think about this more carefully. The plan document says:
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00

So for in-network claims, a member's cost share stops when:
- Their individual OOPM balance reaches 6000, OR
- The family OOPM balance reaches 12000

For out-of-network claims, a member's cost share stops when:
- Their individual OOPM balance reaches 12000

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."

OK let me also clarify: does the family OOPM being met affect out-of-network claims? I think not, based on "the family amounts, which are in-network amounts, do not limit an out-of-network claim."

Let me now process each claim.

**Initial Accumulators:**
- A: deductible=0, OOPM=0
- B: deductible=0, OOPM=0
- C: deductible=0, OOPM=0
- D: deductible=0, OOPM=0
- E: deductible=0, OOPM=0
- Family: deductible=0, OOPM=0

---

**Line 1 — Claim 1 — D (child) — Inpatient admission, out-of-network**
- Allowed: 21121.93
- Network: Out-of-network

D's deductible balance = 0. Out-of-network individual threshold = 3000.
deductible_applied = min(21121.93, 3000 - 0) = 3000.00

Remaining allowed after deductible = 21121.93 - 3000.00 = 18121.93

Now check OOPM. D's OOPM balance = 0. Out-of-network individual OOPM = 12000.
Coinsurance for out-of-network = 40% member.
Member coinsurance = 18121.93 * 0.40 = 7248.772

Total member responsibility so far = deductible_applied + coinsurance = 3000.00 + 7248.772 = 10248.772

But we need to check if this pushes D's OOPM past 12000.
D's OOPM balance = 0. Room under OOPM = 12000 - 0 = 12000.
10248.772 < 12000, so no cap needed.

Wait, let me reconsider. The member_responsibility includes deductible_applied + coinsurance. Let me check if the total member responsibility would exceed the OOPM limit.

Total member responsibility = 3000.00 + 7248.77 = 10248.77
D's OOPM balance after = 0 + 10248.77 = 10248.77. This is < 12000, so OK.

Actually wait, I need to round properly. Let me keep more precision and round at the end.

deductible_applied = 3000.00
Remaining after deductible = 21121.93 - 3000.00 = 18121.93
Coinsurance = 18121.93 * 0.40 = 7248.772 → 7248.77

Member responsibility = 3000.00 + 7248.77 = 10248.77
Plan paid = 21121.93 - 10248.77 = 10873.16

Wait, let me reconsider coinsurance rounding. 18121.93 * 0.40 = 7248.772.
Round half up to cent: 7248.77.

Member responsibility = 3000.00 + 7248.77 = 10248.77
Plan paid = 21121.93 - 10248.77 = 10873.16

Check: 10248.77 + 10873.16 = 21121.93 ✓

Update accumulators:
- D: deductible = 0 + 3000.00 = 3000.00, OOPM = 0 + 10248.77 = 10248.77
- Family: deductible = 0 + 3000.00 = 3000.00, OOPM = 0 + 10248.77 = 10248.77

Wait, the family deductible is 3000.00. After this claim, family deductible = 3000.00, which means the family deductible is met!

Also, D's individual deductible balance is 3000.00, which meets the out-of-network individual threshold of 3000.00. So D's deductible is satisfied for out-of-network. And since 3000 > 1500, D's deductible is also satisfied for in-network.

---

**Line 2 — Claim 2 — B (spouse) — Primary care office visit, in-network**
- Allowed: 228.07
- Network: In-network
- Service: Primary care office visit → copay = 30.00

Copays do NOT credit the deductible. Copays always credit the OOPM.

So for a primary care visit with a copay:
- Member pays copay = 30.00
- Does the deductible apply? The plan says "Primary care office visit ... 30.00 copay". This suggests the copay is the member's cost share for this service, and the deductible doesn't apply to copays.

Wait, let me re-read: "Copays do NOT credit the deductible." This means copays don't count toward the deductible. But does the deductible need to be met before copays apply?

Actually, typically in health plans, copays apply regardless of whether the deductible is met. The plan document lists copays as the member cost share for specific services. Let me assume copays apply without needing to meet the deductible first, since the plan lists them as specific cost shares.

Actually, I need to think about this. The plan says:
"Member cost share:
  Coinsurance after deductible, in-network ......... 20% member / 80% plan
  Primary care office visit ........................ 30.00 copay
  ..."

The coinsurance is "after deductible", but the copays are just listed as flat amounts. This suggests copays apply regardless of deductible status.

Also: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

This implies that normally a copay might credit the deductible, but this plan says "Copays do NOT credit the deductible." So deductible_applied = 0.00 for a copay service.

Wait, actually the statement "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible" is a general rule about what happens when the deductible is already met. It doesn't say copays normally credit the deductible. The plan explicitly says "Copays do NOT credit the deductible."

So for Claim 2:
- deductible_applied = 0.00 (copays don't credit deductible)
- copay_amount = 30.00
- coinsurance_amount = 0.00
- member_responsibility = 30.00
- plan_paid = 228.07 - 30.00 = 198.07

Update accumulators:
- B: deductible = 0, OOPM = 0 + 30.00 = 30.00
- Family: deductible = 3000.00 (no change), OOPM = 10248.77 + 30.00 = 10278.77

---

**Line 3 — Claim 3 — E (child) — Allergy testing, in-network**
- Allowed: 2282.31
- Network: In-network

E's deductible balance = 0. Individual in-network threshold = 1500.
Family deductible balance = 3000.00. Family threshold = 3000.00. Family deductible is MET.

For embedded structure: deductible_applied = smaller of member's individual remainder and family remainder.
- Member individual remainder = 1500 - 0 = 1500
- Family remainder = 3000 - 3000 = 0

So deductible_applied = min(2282.31, min(1500, 0)) = min(2282.31, 0) = 0.00

Wait, the family deductible is already met (3000.00). So the family remainder is 0. Under embedded structure, deductible_applied = smaller of individual remainder and family remainder = min(1500, 0) = 0.

So deductible_applied = 0.00.

Remaining after deductible = 2282.31 - 0 = 2282.31
Coinsurance = 2282.31 * 0.20 = 456.462 → 456.46

E's OOPM balance = 0. Individual in-network OOPM = 6000.
Room under OOPM = 6000 - 0 = 6000.
Member responsibility = 0 + 456.46 = 456.46 < 6000. OK.

Also check family OOPM: Family OOPM = 10278.77. Family OOPM threshold = 12000.
Room under family OOPM = 12000 - 10278.77 = 1721.23.
456.46 < 1721.23, so no cap from family OOPM either.

member_responsibility = 456.46
plan_paid = 2282.31 - 456.46 = 1825.85

Update accumulators:
- E: deductible = 0, OOPM = 0 + 456.46 = 456.46
- Family: deductible = 3000.00, OOPM = 10278.77 + 456.46 = 10735.23

---

**Line 4 — Claim 4 — D (child) — Urgent care visit, in-network**
- Allowed: 311.34
- Network: In-network
- Service: Urgent care → copay = 75.00

D's deductible balance = 3000.00. Individual in-network threshold = 1500. D's deductible is met.
Family deductible is met.

deductible_applied = 0.00
copay_amount = 75.00
coinsurance_amount = 0.00
member_responsibility = 75.00
plan_paid = 311.34 - 75.00 = 236.34

Update accumulators:
- D: deductible = 3000.00, OOPM = 10248.77 + 75.00 = 10323.77
- Family: deductible = 3000.00, OOPM = 10735.23 + 75.00 = 10810.23

---

**Line 5 — Claim 5 — A (subscriber) — Outpatient endoscopy, in-network**
- Allowed: 2316.72
- Network: In-network

A's deductible balance = 0. Individual in-network threshold = 1500.
Family deductible is met (3000.00).

For embedded: deductible_applied = smaller of individual remainder and family remainder.
- Individual remainder = 1500 - 0 = 1500
- Family remainder = 3000 - 3000 = 0

deductible_applied = min(2316.72, min(1500, 0)) = 0.00

Remaining after deductible = 2316.72
Coinsurance = 2316.72 * 0.20 = 463.344 → 463.34

A's OOPM = 0. Room = 6000.
Family OOPM = 10810.23. Room = 12000 - 10810.23 = 1189.77.
463.34 < 1189.77, so OK.

member_responsibility = 463.34
plan_paid = 2316.72 - 463.34 = 1853.38

Update accumulators:
- A: deductible = 0, OOPM = 0 + 463.34 = 463.34
- Family: deductible = 3000.00, OOPM = 10810.23 + 463.34 = 11273.57

---

**Line 6 — Claim 6 — A (subscriber) — Outpatient procedure, in-network**
- Allowed: 8629.09
- Network: In-network

A's deductible = 0. Family deductible met.
deductible_applied = 0.00

Remaining = 8629.09
Coinsurance = 8629.09 * 0.20 = 1725.818 → 1725.82

A's OOPM = 463.34. Room under individual OOPM = 6000 - 463.34 = 5536.66.
Family OOPM = 11273.57. Room under family OOPM = 12000 - 11273.57 = 726.43.

Member coinsurance = 1725.82, but family OOPM room is only 726.43.

So member_responsibility is capped at 726.43 (to not exceed family OOPM).

Wait, but does the family OOPM cap work this way? 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."

And the family OOPM is 12000. So once the family OOPM reaches 12000, all members get 100% coverage.

So for this claim:
- Uncapped member responsibility = 1725.82
- Family OOPM room = 726.43
- Capped member responsibility = min(1725.82, 726.43) = 726.43

Wait, I also need to check A's individual OOPM room: 6000 - 463.34 = 5536.66. So individual OOPM is not the limiting factor.

member_responsibility = 726.43
plan_paid = 8629.09 - 726.43 = 7902.66

Update accumulators:
- A: deductible = 0, OOPM = 463.34 + 726.43 = 1189.77
- Family: deductible = 3000.00, OOPM = 11273.57 + 726.43 = 12000.00

Family OOPM is now exactly 12000.00. Family OOPM is MET.

---

**Line 7 — Claim 7 — C (child) — Outpatient rehabilitation, in-network**
- Allowed: 9053.51
- Network: In-network

C's deductible = 0. Family deductible met.
deductible_applied = 0.00

Remaining = 9053.51
Coinsurance = 9053.51 * 0.20 = 1810.702 → 1810.70

Family OOPM is met (12000.00). So plan pays 100%.
member_responsibility = 0.00
plan_paid = 9053.51

Update accumulators:
- C: deductible = 0, OOPM = 0 (no change since member_responsibility = 0)
- Family: deductible = 3000.00, OOPM = 12000.00

---

**Line 8 — Claim 8 — B (spouse) — Outpatient procedure, out-of-network**
- Allowed: 3428.25
- Network: Out-of-network

B's deductible balance = 0. Out-of-network individual threshold = 3000.
deductible_applied = min(3428.25, 3000 - 0) = 3000.00

Remaining after deductible = 3428.25 - 3000.00 = 428.25
Coinsurance = 428.25 * 0.40 = 171.30

Total member responsibility = 3000.00 + 171.30 = 3171.30

B's OOPM = 30.00. Out-of-network individual OOPM = 12000.
Room = 12000 - 30.00 = 11970.00.
3171.30 < 11970.00, OK.

Wait, does the family OOPM being met affect out-of-network 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 family OOPM (which is an in-network amount) does NOT limit out-of-network claims. Only B's individual out-of-network OOPM of 12000 matters.

member_responsibility = 3171.30
plan_paid = 3428.25 - 3171.30 = 256.95

Update accumulators:
- B: deductible = 0 + 3000.00 = 3000.00, OOPM = 30.00 + 3171.30 = 3201.30
- Family: deductible = 3000.00 + 3000.00 = 6000.00, OOPM = 12000.00 + 3171.30 = 15171.30

Wait, the family deductible balance goes to 6000? But the family deductible threshold is 3000. The balance can exceed the threshold - it's just a running total.

And family OOPM balance goes to 15171.30. The balance is a running total and can exceed the threshold.

---

**Line 9 — Claim 9 — A (subscriber) — Inpatient admission with surgery, in-network**
- Allowed: 25430.93
- Network: In-network

A's deductible = 0. Family deductible met.
deductible_applied = 0.00

Family OOPM is met (12000.00 >= 12000.00). So plan pays 100% for in-network.
member_responsibility = 0.00
plan_paid = 25430.93

Update accumulators:
- A: deductible = 0, OOPM = 1189.77 (no change)
- Family: deductible = 6000.00, OOPM = 15171.30 (no change)

---

**Line 10 — Claim 10 — C (child) — Primary care office visit, in-network**
- Allowed: 228.88
- Network: In-network
- Service: Primary care → copay = 30.00

Family OOPM is met. Plan pays 100%.
Wait, does the copay still apply if the family OOPM is met?

"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 if the family OOPM is met, the plan pays 100% of the allowed amount. The member pays nothing, including no copay.

member_responsibility = 0.00
plan_paid = 228.88
deductible_applied = 0.00
copay_amount = 0.00
coinsurance_amount = 0.00

Update accumulators:
- C: deductible = 0, OOPM = 0
- Family: deductible = 6000.00, OOPM = 15171.30

---

**Line 11 — Claim 11 — A (subscriber) — Cardiac stress test, in-network**
- Allowed: 576.23
- Network: In-network

Family OOPM is met. Plan pays 100%.
member_responsibility = 0.00
plan_paid = 576.23

Update accumulators: no change.

---

**Line 12 — Claim 12 — A (subscriber) — Specialty pharmacy administration, in-network**
- Allowed: 9039.75
- Network: In-network

Family OOPM is met. Plan pays 100%.
member_responsibility = 0.00
plan_paid = 9039.75

Update accumulators: no change.

---

**Line 13 — Claim 13 — E (child) — Inpatient admission, in-network**
- Allowed: 22046.13
- Network: In-network

Family OOPM is met. Plan pays 100%.
member_responsibility = 0.00
plan_paid = 22046.13

Update accumulators: no change.

---

**Line 14 — ADJUSTMENT to Claim 5 — A (subscriber)**
- Original allowed: 2316.72
- Corrected allowed: 2664.23

First, unwind Claim 5's credits:
Claim 5 original: deductible_applied = 0.00, member_responsibility = 463.34

Remove from accumulators:
- A: deductible = 0 - 0 = 0, OOPM = 1189.77 - 463.34 = 726.43
- Family: deductible = 6000.00 - 0 = 6000.00, OOPM = 15171.30 - 463.34 = 14707.96

Now re-adjudicate Claim 5 at corrected values against current accumulators:
- Allowed: 2664.23
- A's deductible = 0. Family deductible = 6000.00. Family deductible threshold = 3000.00, already met.
- deductible_applied = 0.00 (family remainder = 0)

Remaining = 2664.23
Coi

Let me work through this step-by-step, processing each claim in order and tracking accumulators.

**Plan Rules Summary:**
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 5000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance in-network: 30% member / 70% plan
- Coinsurance out-of-network: 50% member / 50% plan
- Copays: PCP 25, Specialist 50, Urgent care 60, ER 300 (waived if admitted), Generic Rx 10
- Copays DO credit the deductible and OOPM
- Preventive in-network: 100% plan, no cost share

**Accumulator rules:**
- 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)
  - out-of-network: out-of-network individual remainder, measured against member's same single deductible balance
- Once applicable threshold is met, deductible_applied is 0.00
- Balance = running total of deductible_applied (for deductible) or member_responsibility (for OOPM)
- Out-of-network claims measured against out-of-network individual thresholds only; family amounts don't limit out-of-network claims
- Credits from out-of-network claims still accumulate to member's balance and family balance

Let me track accumulators for each member and family:

**Initial State:**
- A: ded=0.00, oopm=0.00
- B: ded=0.00, oopm=0.00
- C: ded=0.00, oopm=0.00
- D: ded=0.00, oopm=0.00
- Family: ded=0.00, oopm=0.00

---

**Line 1 — Claim 1 — A — Outpatient procedure, in-network — Allowed: 6138.52**

A's individual ded remainder: 2500.00 - 0.00 = 2500.00
Family ded remainder: 5000.00 - 0.00 = 5000.00
Embedded: min(2500.00, 5000.00) = 2500.00
deductible_applied = min(6138.52, 2500.00) = 2500.00

Remaining allowed after deductible: 6138.52 - 2500.00 = 3638.52
Coinsurance (30% member): 3638.52 * 0.30 = 1091.556 → 1091.56
Plan coinsurance: 3638.52 * 0.70 = 2546.964 → 2546.96

Wait, let me be more careful. member_responsibility + plan_paid = allowed amount.
deductible_applied = 2500.00
coinsurance_amount = (6138.52 - 2500.00) * 0.30 = 3638.52 * 0.30 = 1091.556
Rounding: I should round at the end. Let me keep full precision and round at the end.

member_responsibility = deductible_applied + coinsurance_amount + copay_amount
= 2500.00 + 1091.556 + 0 = 3591.556

plan_paid = allowed - member_responsibility = 6138.52 - 3591.556 = 2546.964

Round half up to cent at end:
member_responsibility = 3591.56
plan_paid = 6138.52 - 3591.56 = 2546.96
deductible_applied = 2500.00
coinsurance_amount = 1091.56
copay_amount = 0.00

Check: 3591.56 + 2546.96 = 6138.52 ✓

Update accumulators:
A: ded = 0 + 2500.00 = 2500.00 (individual met)
A: oopm = 0 + 3591.56 = 3591.56
Family: ded = 0 + 2500.00 = 2500.00
Family: oopm = 0 + 3591.56 = 3591.56

---

**Line 2 — Claim 2 — D — Ambulatory surgery, out-of-network — Allowed: 2734.12**

D's single deductible balance: 0.00
Out-of-network individual deductible threshold: 5000.00
D's out-of-network ded remainder: 5000.00 - 0.00 = 5000.00
deductible_applied = min(2734.12, 5000.00) = 2734.12

Remaining after deductible: 2734.12 - 2734.12 = 0
coinsurance_amount = 0
member_responsibility = 2734.12
plan_paid = 0.00

Update accumulators:
D: ded = 0 + 2734.12 = 2734.12
D: oopm = 0 + 2734.12 = 2734.12
Family: ded = 2500.00 + 2734.12 = 5234.12
Family: oopm = 3591.56 + 2734.12 = 6325.68

Wait - for out-of-network 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. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."

So D's deductible_applied is based on out-of-network individual threshold (5000), and the credits go to both D's balance and family balance.

D: ded = 2734.12
D: oopm = 2734.12
Family: ded = 2500.00 + 2734.12 = 5234.12
Family: oopm = 3591.56 + 2734.12 = 6325.68

---

**Line 3 — Claim 3 — A — Inpatient admission, in-network — Allowed: 11894.44**

A's individual ded remainder: 2500.00 - 2500.00 = 0 (already met)
Family ded remainder: 5000.00 - 5234.12 = 0 (already met, actually over)
Wait, family ded is 5000.00. Family ded balance is 5234.12. So family ded is met.

Since A's individual ded is met and family ded is met:
deductible_applied = 0.00

Remaining after deductible: 11894.44
coinsurance (30%): 11894.44 * 0.30 = 3568.332

member_responsibility = 0 + 3568.332 = 3568.332

But wait, check OOPM:
A's OOPM: 3591.56
A's in-network OOPM threshold: 5500.00
A's OOPM remainder: 5500.00 - 3591.56 = 1908.44

So member_responsibility can't exceed 1908.44 for this claim.
member_responsibility = min(3568.332, 1908.44) = 1908.44

Wait, but I need to think about this more carefully. The coinsurance is calculated, but the member's total responsibility is capped by the OOPM.

Actually, let me reconsider. The member pays deductible + coinsurance until OOPM is reached.

deductible_applied = 0.00
coinsurance calculated = 11894.44 * 0.30 = 3568.332
But A's OOPM room is 5500.00 - 3591.56 = 1908.44

So coinsurance_amount = min(3568.332, 1908.44) = 1908.44
member_responsibility = 0 + 1908.44 = 1908.44
plan_paid = 11894.44 - 1908.44 = 9986.00

Update accumulators:
A: ded = 2500.00 (no change)
A: oopm = 3591.56 + 1908.44 = 5500.00 (met!)
Family: ded = 5234.12 (no change)
Family: oopm = 6325.68 + 1908.44 = 8234.12

---

**Line 4 — Claim 4 — B — Ambulatory surgery, in-network — Allowed: 8808.44**

B's individual ded remainder: 2500.00 - 0.00 = 2500.00
Family ded remainder: 5000.00 - 5234.12 = 0 (already met)
Embedded: min(2500.00, 0) = 0
deductible_applied = 0.00

Wait, family deductible is already met (5234.12 > 5000.00). Under 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.

So if family deductible is met, does B still need to satisfy individual deductible?

"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."

So "whichever comes first" means: once the family deductible is met, all family members are past the deductible, even if their individual deductible isn't met.

So B's deductible_applied = 0.00 since family ded is met.

Remaining: 8808.44
Coinsurance (30%): 8808.44 * 0.30 = 2642.532

B's OOPM: 0.00
B's in-network OOPM threshold: 5500.00
B's OOPM room: 5500.00

coinsurance_amount = min(2642.532, 5500.00) = 2642.532
member_responsibility = 2642.532
plan_paid = 8808.44 - 2642.532 = 6165.908

Round:
member_responsibility = 2642.53
plan_paid = 8808.44 - 2642.53 = 6165.91
coinsurance_amount = 2642.53
deductible_applied = 0.00

Check: 2642.53 + 6165.91 = 8808.44 ✓

Update accumulators:
B: ded = 0.00
B: oopm = 0 + 2642.53 = 2642.53
Family: ded = 5234.12
Family: oopm = 8234.12 + 2642.53 = 10876.65

---

**Line 5 — Claim 5 — B — Specialist office visit, in-network — Allowed: 372.91**

Specialist copay: 50.00

Family ded is met, B's individual ded doesn't need to be met.
deductible_applied = 0.00 (since deductible is met)

Wait: "Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

So deductible_applied = 0.00
copay_amount = 50.00
coinsurance_amount = 0.00 (copay service, no coinsurance)
member_responsibility = 50.00
plan_paid = 372.91 - 50.00 = 322.91

Update accumulators:
B: ded = 0.00
B: oopm = 2642.53 + 50.00 = 2692.53
Family: ded = 5234.12
Family: oopm = 10876.65 + 50.00 = 10926.65

---

**Line 6 — Claim 6 — B — Outpatient infusion, out-of-network — Allowed: 722.55**

B's single deductible balance: 0.00
Out-of-network individual deductible threshold: 5000.00
B's OON ded remainder: 5000.00 - 0.00 = 5000.00
deductible_applied = min(722.55, 5000.00) = 722.55

Remaining: 0
coinsurance = 0
member_responsibility = 722.55
plan_paid = 0.00

Update accumulators:
B: ded = 0 + 722.55 = 722.55
B: oopm = 2692.53 + 722.55 = 3415.08
Family: ded = 5234.12 + 722.55 = 5956.67
Family: oopm = 10926.65 + 722.55 = 11649.20

---

**Line 7 — Claim 7 — B — Ambulatory surgery, in-network — Allowed: 7877.07**

B's individual ded remainder: 2500.00 - 722.55 = 1777.45

Wait, B's single deductible balance is 722.55. The in-network individual threshold is 2500.00. So B's individual ded remainder for in-network is 2500.00 - 722.55 = 1777.45.

Family ded remainder: 5000.00 - 5956.67 = 0 (met)
Embedded: min(1777.45, 0) = 0
deductible_applied = 0.00

Remaining: 7877.07
Coinsurance (30%): 7877.07 * 0.30 = 2363.121

B's OOPM: 3415.08
B's in-network OOPM threshold: 5500.00
B's OOPM room: 5500.00 - 3415.08 = 2084.92

coinsurance_amount = min(2363.121, 2084.92) = 2084.92
member_responsibility = 2084.92
plan_paid = 7877.07 - 2084.92 = 5792.15

Update accumulators:
B: ded = 722.55
B: oopm = 3415.08 + 2084.92 = 5500.00 (met!)
Family: ded = 5956.67
Family: oopm = 11649.20 + 2084.92 = 13734.12

---

**Line 8 — Claim 8 — C — Inpatient admission with surgery, in-network — Allowed: 14673.31**

C's individual ded: 0.00
C's individual ded remainder: 2500.00
Family ded remainder: 5000.00 - 5956.67 = 0 (met)
Embedded: min(2500.00, 0) = 0
deductible_applied = 0.00

Remaining: 14673.31
Coinsurance (30%): 14673.31 * 0.30 = 4401.993

C's OOPM: 0.00
C's in-network OOPM threshold: 5500.00
C's OOPM room: 5500.00

coinsurance_amount = min(4401.993, 5500.00) = 4401.993

member_responsibility = 4401.99 (rounding: 4401.993 → 4401.99)

Wait, 14673.31 * 0.30 = 4401.993. Round half up: 4401.99.

member_responsibility = 4401.99
plan_paid = 14673.31 - 4401.99 = 10271.32

Check: 4401.99 + 10271.32 = 14673.31 ✓

Update accumulators:
C: ded = 0.00
C: oopm = 0 + 4401.99 = 4401.99
Family: ded = 5956.67
Family: oopm = 13734.12 + 4401.99 = 18136.11

---

**Line 9 — Claim 9 — D — Inpatient admission with surgery, in-network — Allowed: 12574.38**

D's individual ded: 2734.12
D's individual ded remainder: 2500.00 - 2734.12 = 0 (already over 2500)

Wait, D's single deductible balance is 2734.12. The in-network individual threshold is 2500.00. So D's in-network individual ded is met (2734.12 > 2500.00).

Family ded is also met.
deductible_applied = 0.00

Remaining: 12574.38
Coinsurance (30%): 12574.38 * 0.30 = 3772.314

D's OOPM: 2734.12
D's in-network OOPM threshold: 5500.00
D's OOPM room: 5500.00 - 2734.12 = 2765.88

coinsurance_amount = min(3772.314, 2765.88) = 2765.88
member_responsibility = 2765.88
plan_paid = 12574.38 - 2765.88 = 9808.50

Update accumulators:
D: ded = 2734.12
D: oopm = 2734.12 + 2765.88 = 5500.00 (met!)
Family: ded = 5956.67
Family: oopm = 18136.11 + 2765.88 = 20901.99

---

**Line 10 — ADJUSTMENT to Claim 5 — B — Specialist office visit — Allowed corrected to 223.75**

Original Claim 5: deductible_applied = 0.00, member_responsibility = 50.00, copay = 50.00
Credits to unwind:
- B's ded: 0.00 (no change since deductible_applied was 0)
- B's oopm: 50.00 → remove 50.00
- Family ded: 0.00 (no change)
- Family oopm: 50.00 → remove 50.00

After unwinding:
B: ded = 722.55
B: oopm = 5500.00 - 50.00 = 5450.00
Family: ded = 5956.67
Family: oopm = 20901.99 - 50.00 = 20851.99

Now re-adjudicate Claim 5 at corrected allowed amount 223.75:
Specialist copay: 50.00

Family ded is met (5956.67 > 5000.00).
B's individual ded: not relevant since family met.
deductible_applied = 0.00

copay_amount = 50.00
coinsurance_amount = 0.00
member_responsibility = 50.00
plan_paid = 223.75 - 50.00 = 173.75

Update accumulators:
B: ded = 722.55
B: oopm = 5450.00 + 50.00 = 5500.00
Family: ded = 5956.67
Family: oopm = 20851.99 + 50.00 = 20901.99

So the adjustment to Claim 5 ends up with the same member_responsibility (50.00) and same accumulator impact. The only thing that changes is plan_paid goes from 322.91 to 173.75.

---

**Line 11 — Claim 11 — C — Inpatient admission, in-network — Allowed: 16484.33**

C's individual ded: 0.00
Family ded is met.
deductible_applied = 0.00

Remaining: 16484.33
Coinsurance (30%): 16484.33 * 0.30 = 4945.299

C's OOPM: 4401.99
C's in-network OOPM threshold: 5500.00
C's OOPM room: 5500.00 - 4401.99 = 1098.01

coinsurance_amount = min(4945.299, 1098.01) = 1098.01
member_responsibility = 1098.01
plan_paid = 16484.33 - 1098.01 = 15386.32

Update accumulators:
C: ded = 0.00
C: oopm = 4401.99 + 1098.01 = 5500.00 (met!)
Family: ded = 5956.67
Family: oopm = 20901.99 + 1098.01 = 22000.00

---

**Line 12 — Claim 12 — B — Specialty pharmacy administration, out-of-network — Allowed: 6655.34**

B's single deductible balance: 722.55
Out-of-network individual deductible threshold: 5000.00
B's OON ded remainder: 5000.00 - 722.55 = 4277.45
deductible_applied = min(6655.34, 4277.45) = 4277.45

Remaining: 6655.34 - 4277.45 = 2377.89
Coinsurance (50% OON): 2377.89 * 0.50 = 1188.945

B's OOPM: 5500.00 (already met in-network)

Wait, what about B's out-of-network OOPM? Individual OOPM (out-of-network): 11000.00.
B's OOPM balance is 5500.00. But wait - is the OOPM for out-of-network separate?

Let me re-read: "Out-of-pocket maximum: Individual (in-network) 5500.00, Family (in-network) 11000.00, Individual (out-of-network) 11000.00"

And: "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 there's a single OOPM balance per member, but different thresholds. For out-of-network claims, the threshold is 11000.00 (individual OON OOPM).

B's OOPM balance: 5500.00
B's OON OOPM threshold: 11000.00
B's OON OOPM room: 11000.00 - 5500.00 = 5500.00

Total member cost share calculated: deductible_applied + coinsurance = 4277.45 + 1188.945 = 5466.395

But wait, member_responsibility is capped by OOPM room:
member_responsibility = min(5466.395, 5500.00) = 5466.395

Hmm, but 5466.395 < 5500.00, so it's not capped.

Actually wait. Let me reconsider. The member_responsibility for this claim is deductible_applied + coinsurance. The OOPM caps the total member_responsibility.

deductible_applied = 4277.45
coinsurance calculated = (6655.34 - 4277.45) * 0.50 = 2377.89 * 0.50 = 1188.945

Total = 4277.45 + 1188.945 = 5466.395

B's OOPM room: 11000.00 - 5500.00 = 5500.00
5466.395 < 5500.00, so no capping needed.

member_responsibility = 5466.40 (rounding 5466.395 → 5466.40)

Wait, let me be more careful. 5466.395 rounds to 5466.40 (round half up: the third decimal is 5, so round up).

Actually, let me recalculate: 2377.89 * 0.50 = 1188.945
4277.45 + 1188.945 = 5466.395

Round half up to cent: 5466.40 (since 5466.395 → the digit after the cent position is 5, round up)

Wait, 5466.395: the cents are .39, and the next digit is 5. Round half up means .395 → .40.

member_responsibility = 5466.40
plan_paid = 6655.34 - 5466.40 = 1188.94

Let me verify: deductible_applied + coinsurance_amount = member_responsibility
4277.45 + 1188.95 = 5466.40? No, 4277.45 + 1188.95 = 5466.40. Wait:
4277.45 + 1188.95 = 5466.40. Yes.

But 1188.945 rounded is 1188.95 (round half up, since .945 → .95).

So coinsurance_amount = 1188.95
member_responsibility = 4277.45 + 1188.95 = 5466.40
plan_paid = 6655.34 - 5466.40 = 1188.94

Check: 5466.40 + 1188.94 = 6655.34 ✓

Update accumulators:
B: ded = 722.55 + 4277.45 = 5000.00 (OON ded met)
B: oopm = 5500.00 + 5466.40 = 10966.40
Family: ded = 5956.67 + 4277.45 = 10234.12
Family: oopm = 22000.00 + 5466.40 = 27466.40

---

**Line 13 — Claim 13 — A — Inpatient admission with surgery, in-network — Allowed: 14802.53**

A's OOPM: 5500.00 (already met)
A's individual ded: met
Family ded: met

deductible_applied = 0.00
coinsurance calculated = 14802.53 * 0.30 = 4440.759

But A's OOPM is met (5500.00). For in-network, once OOPM is met, plan pays 100%.
A's in-network OOPM room: 5500.00 - 5500.00 = 0

member_responsibility = 0.00
plan_paid = 14802.53

Update accumulators:
A: ded = 2500.00
A: oopm = 5500.00
Family: ded = 10234.12
Family: oopm = 27466.40

---

**Line 14 — Claim 14 — D — Ambulatory surgery, in-network — Allowed: 3531.74**

D's OOPM: 5500.00 (already met)
D's individual ded: met
Family ded: met

deductible_applied = 0.00
member_responsibility = 0.00 (OOPM met, plan pays 100%)
plan_paid = 3531.74

Update accumulators:
D: ded = 2734.12
D: oopm = 5500.00
Family: ded = 10234.12
Family: oopm = 27466.40

---

**Line 15 — Claim 15 — D — Cardiac stress test, out-of-network — Allowed: 988.74**

D's single deductible balance: 2734.12
OON individual ded threshold: 5000.00
D's OON ded remainder: 5000.00 - 2734.12 = 2265.88
deductible_applied = min(988.74, 2265.88) = 988.74

Remaining: 0
coinsurance = 0
member_responsibility = 988.74

D's OOPM balance: 5500.00
D's OON OOPM threshold: 11000.00
D's OON OOPM room: 11000.00 - 5500.00 = 5500.00
988.74 < 5500.00, so no capping.

member_responsibility = 988.74
plan_paid = 988.74 - 988.74 = 0.00

Wait, member_responsibility = deductible_applied + coinsurance = 988.74 + 0 = 988.74
plan_paid = 988.74 - 988.74 = 0.00

Update accumulators:
D: ded = 2734.12 + 988.74 = 3722.86
D: oopm = 5500.00 + 988.74 = 6488.74
Family: ded = 10234.12 + 988.74 = 11222.86
Family: oopm = 27466.40 + 988.74 = 28455.14

So for Claim 15:
claim_15_member_responsibility = 988.74
claim_15_plan_paid = 0.00
claim_15_deductible_applied = 988.74
claim_15_copay_amount = 0.00
claim_15_coinsurance_amount = 0.00

---

**Line 16 — Claim 16 — C — Generic retail pharmacy fill, in-network — Allowed: 27.12**

Generic retail pharmacy copay: 10.00

C's OOPM: 5500.00 (already met)
Family ded: met
C's individual ded: 0.00 but family met so deductible_applied = 0.00

"Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."

deductible_applied = 0.00

Now, C's OOPM is met. Does the copay still apply?
"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 if OOPM is met, member pays nothing. Plan pays 100%.
member_responsibility = 0.00
copay_amount = 0.00 (OOPM met)

Wait, but the copay is 10.00. If OOPM is met, the member doesn't pay the copay.

Actually, 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."

So member_responsibility = 0.00, plan_paid = 27.12.

copay_amount = 0.00 (since OOPM is met, no cost share)
coinsurance_amount = 0.00
deductible_applied = 0.00

Update accumulators: no change
C: ded = 0.00
C: oopm = 5500.00
Family: ded = 11222.86
Family: oopm = 28455.14

---

**Line 17 — Claim 17 — A — Cardiac stress test, in-network — Allowed: 2051.44**

A's OOPM: 5500.00 (met)
member_responsibility = 0.00
plan_paid = 2051.44
deductible_applied = 0.00
copay_amount = 0.00
coinsurance_amount = 0.00

Update accumulators: no change
A: ded = 2500.00
A: oopm = 5500.00
Family: ded = 11222.86
Family: oopm = 28455.14

---

**Line 18 — Claim 18 — D — Emergency department visit, in-network — Allowed: 2826.50 — Admitted as inpatient**

ER copay: 300.00, WAIVED if visit results in inpatient admission, in which case the visit is subject to the deductible and coinsurance.

So this is treated as a regular in-network service subject to deductible and coinsurance.

D's OOPM: 6488.74
D's in-network OOPM threshold: 5500.00

Wait, D's OOPM balance is 6488.74. But D's in-network OOPM threshold is 5500.00. D already exceeded the in-net

Let me work through this step by step.

**Starting Accumulators:**

| Member | Deductible | OOPM |
|--------|-----------|------|
| A | 60.69 | 60.69 |
| B | 383.93 | 924.55 |
| C | 1524.34 | 2116.83 |
| Family | 1968.96 | 3102.07 |

**Plan Rules:**
- Individual deductible (in-network): 2500.00
- Family deductible (in-network): 5000.00
- Embedded structure
- Out-of-network individual deductible: 5000.00
- Single deductible balance for in-network and out-of-network
- Individual OOPM (in-network): 5500.00
- Family OOPM (in-network): 11000.00
- Individual OOPM (out-of-network): 11000.00
- Coinsurance in-network: 30% member / 70% plan
- Coinsurance out-of-network: 50% member / 50% plan
- Specialist copay: 50.00
- Urgent care copay: 60.00
- Generic retail pharmacy copay: 10.00
- Copays DO credit the deductible and OOPM
- Once deductible threshold is met, deductible_applied is 0.00 (including for copays)

**Deductible applied rule:**
- In-network: lesser of (member's individual remainder, family remainder) [embedded]
- Out-of-network: out-of-network individual remainder, measured against member's same single deductible balance

Let me process each line.

---

**Line 1 — Claim 1 — 2026-01-14 — C (child)**
- Inpatient admission with surgery, in-network
- Allowed: 10074.70

C's deductible remainder (individual): 2500.00 - 1524.34 = 975.66
Family deductible remainder: 5000.00 - 1968.96 = 3031.04
Deductible applied = min(975.66, 3031.04) = 975.66

After deductible: 10074.70 - 975.66 = 9099.04
Coinsurance (30%): 9099.04 * 0.30 = 2729.712 → 2729.71
Member responsibility = 975.66 + 2729.71 = 3705.37
Plan paid = 10074.70 - 3705.37 = 7369.33

Wait, let me check: member_responsibility + plan_paid = allowed amount.
3705.37 + 7369.33 = 11074.70. That's wrong. Let me recalculate.

10074.70 - 975.66 = 9099.04
9099.04 * 0.30 = 2729.712 → 2729.71
9099.04 * 0.70 = 6369.328 → 6369.33

Member responsibility = 975.66 + 2729.71 = 3705.37
Plan paid = 6369.33
3705.37 + 6369.33 = 10074.70 ✓

C's OOPM check: C's OOPM was 2116.83. After adding 3705.37, it would be 5822.20.
Individual OOPM (in-network) is 5500.00. So we need to cap.

Wait, let me re-read the OOPM rules. "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 if C's OOPM would exceed 5500.00, we need to limit the member responsibility.

C's OOPM before: 2116.83
Room under OOPM: 5500.00 - 2116.83 = 3383.17

Member responsibility needed: 3705.37
But room is only 3383.17.

So member responsibility is capped at 3383.17.
Deductible applied = 975.66 (this all fits within the OOPM room since 975.66 < 3383.17)
Remaining room after deductible: 3383.17 - 975.66 = 2407.51
Coinsurance room: 2407.51
So coinsurance amount = 2407.51 (instead of 2729.71)
Plan paid = 10074.70 - 3383.17 = 6691.53

Let me verify: member_responsibility = deductible_applied + coinsurance_amount = 975.66 + 2407.51 = 3383.17
Plan paid = 10074.70 - 3383.17 = 6691.53
3383.17 + 6691.53 = 10074.70 ✓

Now update accumulators:
C deductible: 1524.34 + 975.66 = 2500.00
C OOPM: 2116.83 + 3383.17 = 5500.00
Family deductible: 1968.96 + 975.66 = 2944.62
Family OOPM: 3102.07 + 3383.17 = 6485.24

C has reached individual OOPM (5500.00) and individual deductible (2500.00).

---

**Line 2 — Claim 2 — 2026-01-22 — A (subscriber)**
- Specialty pharmacy administration, in-network
- Allowed: 4603.57

A's deductible remainder (individual): 2500.00 - 60.69 = 2439.31
Family deductible remainder: 5000.00 - 2944.62 = 2055.38
Deductible applied = min(2439.31, 2055.38) = 2055.38

Wait, but the family deductible is 5000.00. Let me think about this. Under embedded structure, the individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount.

So deductible applied for in-network = min(member individual remainder, family remainder).

A's individual remainder: 2500.00 - 60.69 = 2439.31
Family remainder: 5000.00 - 2944.62 = 2055.38
Deductible applied = min(2439.31, 2055.38) = 2055.38

After deductible: 4603.57 - 2055.38 = 2548.19
Coinsurance (30%): 2548.19 * 0.30 = 764.457 → 764.46
Plan coinsurance: 2548.19 * 0.70 = 1783.733 → 1783.73

Member responsibility = 2055.38 + 764.46 = 2819.84
Plan paid = 1783.73
2819.84 + 1783.73 = 4603.57 ✓

Check OOPM: A's OOPM before: 60.69
Room: 5500.00 - 60.69 = 5439.31
2819.84 < 5439.31, so no cap needed.

Update accumulators:
A deductible: 60.69 + 2055.38 = 2116.07
A OOPM: 60.69 + 2819.84 = 2880.53
Family deductible: 2944.62 + 2055.38 = 5000.00
Family OOPM: 6485.24 + 2819.84 = 9305.08

Family deductible is now met (5000.00).

---

**Line 3 — Claim 3 — 2026-02-06 — B (spouse)**
- Specialist office visit, in-network
- Allowed: 339.69
- Specialist copay: 50.00

Family deductible is met (5000.00). So deductible_applied = 0.00 for copays once deductible threshold is met.

Wait, let me re-read: "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 in-network is the smaller of individual remainder and family remainder. Since family remainder is 0, deductible_applied = 0.00.

So this is a copay service. The copay is 50.00.
Since deductible is met (family deductible met), deductible_applied = 0.00.

Member responsibility = copay = 50.00
Plan paid = 339.69 - 50.00 = 289.69

Check OOPM: B's OOPM before: 924.55
Room: 5500.00 - 924.55 = 4575.45
50.00 < 4575.45, no cap.

Update accumulators:
B deductible: 383.93 + 0 = 383.93
B OOPM: 924.55 + 50.00 = 974.55
Family deductible: 5000.00 + 0 = 5000.00
Family OOPM: 9305.08 + 50.00 = 9355.08

Wait, I need to think about this more carefully. The deductible for B hasn't been met individually (383.93 < 2500). But the family deductible IS met. Under embedded, deductible_applied = min(individual remainder, family remainder) = min(2116.07, 0) = 0. So deductible_applied = 0.

But wait, does B still have a deductible to meet? Under embedded, an individual satisfies the individual deductible on their own. But the family deductible being met means... hmm.

Let me re-read: "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."

And: "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)"

So for in-network, deductible_applied = min(allowed, min(individual remainder, family remainder)).

Since family remainder = 0, deductible_applied = 0 for all in-network claims now.

This means B doesn't need to meet their individual deductible anymore because the family deductible is met. The deductible_applied is 0.

OK so for Claim 3:
Deductible_applied = 0.00
Copay = 50.00
Member responsibility = 50.00
Plan paid = 289.69

Update:
B deductible: 383.93 (no change)
B OOPM: 924.55 + 50.00 = 974.55
Family deductible: 5000.00
Family OOPM: 9305.08 + 50.00 = 9355.08

---

**Line 4 — Claim 4 — 2026-02-12 — B (spouse)**
- Inpatient admission, out-of-network
- Allowed: 15484.21

Out-of-network. B's deductible balance is 383.93 (same single balance).
Out-of-network individual deductible threshold: 5000.00
Out-of-network individual remainder: 5000.00 - 383.93 = 4616.07

Deductible applied = min(15484.21, 4616.07) = 4616.07

After deductible: 15484.21 - 4616.07 = 10868.14
Coinsurance (50% out-of-network): 10868.14 * 0.50 = 5434.07
Plan coinsurance: 5434.07

Member responsibility = 4616.07 + 5434.07 = 10050.14
Plan paid = 5434.07
10050.14 + 5434.07 = 15484.21 ✓

Check OOPM: B's OOPM before: 974.55
Out-of-network individual OOPM: 11000.00
Room: 11000.00 - 974.55 = 10025.45

Wait, what OOPM threshold applies? The plan says:
- Individual OOPM (in-network): 5500.00
- Individual OOPM (out-of-network): 11000.00

For out-of-network claims, the OOPM threshold is 11000.00.

10050.14 < 10025.45? No, 10050.14 > 10025.45. So we need to cap.

Room under OOPM: 11000.00 - 974.55 = 10025.45
So member responsibility capped at 10025.45.

Deductible applied = 4616.07 (this fits in the room since 4616.07 < 10025.45)
Remaining room after deductible: 10025.45 - 4616.07 = 5409.38
Coinsurance amount = 5409.38 (instead of 5434.07)
Plan paid = 15484.21 - 10025.45 = 5458.76

Verify: 10025.45 + 5458.76 = 15484.21 ✓

Update accumulators:
B deductible: 383.93 + 4616.07 = 5000.00
B OOPM: 974.55 + 10025.45 = 11000.00
Family deductible: 5000.00 + 4616.07 = 9616.07
Family OOPM: 9355.08 + 10025.45 = 19380.53

B has reached out-of-network OOPM (11000.00).
B's deductible balance is now 5000.00.

Wait, the family OOPM is now 19380.53, which exceeds the family in-network OOPM of 11000.00. The instructions say: "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 family OOPM can go past 11000.00. OK.

---

**Line 5 — Claim 5 — 2026-02-26 — B (spouse)**
- Urgent care visit, in-network
- Allowed: 181.01
- Urgent care copay: 60.00

B's OOPM is 11000.00 (out-of-network threshold met). But wait, is B's OOPM met for in-network too?

B's OOPM balance is 11000.00. The in-network individual OOPM is 5500.00. Since 11000.00 >= 5500.00, B has also exceeded the in-network OOPM.

Actually wait. Let me re-read the OOPM rules. The plan has:
- Individual OOPM (in-network): 5500.00
- Individual OOPM (out-of-network): 11000.00

The OOPM balance is a single running total of member_responsibility. The threshold it's measured against depends on the service:
- For in-network service: threshold is 5500.00
- For out-of-network service: threshold is 11000.00

So B's OOPM balance is 11000.00. For an in-network service, the threshold is 5500.00. Since 11000.00 >= 5500.00, B has met the in-network OOPM.

So for this in-network urgent care visit, B's OOPM is met. Plan pays 100%.

Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00 (since OOPM is met, no cost share)
Coinsurance = 0.00
Plan paid = 181.01

Wait, actually, does the plan pay 100% of the allowed amount? "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 responsibility = 0.00, plan paid = 181.01.

Update accumulators:
B deductible: 5000.00 (no change)
B OOPM: 11000.00 (no change)
Family deductible: 9616.07 (no change)
Family OOPM: 19380.53 (no change)

---

**Line 6 — Claim 6 — 2026-03-10 — A (subscriber)**
- Urgent care visit, in-network
- Allowed: 213.67
- Urgent care copay: 60.00

A's deductible: 2116.07. Individual remainder: 2500.00 - 2116.07 = 383.93
Family deductible: 5000.00 (met). Family remainder: 0.

Deductible applied = min(213.67, min(383.93, 0)) = 0.00

Since family deductible is met, deductible_applied = 0.00.

This is a copay service (urgent care = 60.00).
Since deductible is met (family), deductible_applied = 0.00.

Member responsibility = copay = 60.00
Plan paid = 213.67 - 60.00 = 153.67

Check OOPM: A's OOPM before: 2880.53
Room: 5500.00 - 2880.53 = 2619.47
60.00 < 2619.47, no cap.

Update accumulators:
A deductible: 2116.07 (no change)
A OOPM: 2880.53 + 60.00 = 2940.53
Family deductible: 5000.00
Family OOPM: 19380.53 + 60.00 = 19440.53

---

**Line 7 — Claim 7 — 2026-03-22 — C (child)**
- Specialist office visit, in-network
- Allowed: 330.22
- Specialist copay: 50.00

C's OOPM is 5500.00 (met). In-network OOPM threshold is 5500.00. So C has met OOPM.

Plan pays 100%.
Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00
Coinsurance = 0.00
Plan paid = 330.22

Update accumulators:
C deductible: 2500.00 (no change)
C OOPM: 5500.00 (no change)
Family deductible: 5000.00 (no change)
Family OOPM: 19440.53 (no change)

---

**Line 8 — Claim 8 — 2026-04-02 — C (child)**
- Sleep study, out-of-network
- Allowed: 1805.31

C's OOPM is 5500.00. Out-of-network OOPM threshold is 11000.00.
Room: 11000.00 - 5500.00 = 5500.00

C's deductible balance is 2500.00. Out-of-network individual remainder: 5000.00 - 2500.00 = 2500.00.

Deductible applied = min(1805.31, 2500.00) = 1805.31

After deductible: 1805.31 - 1805.31 = 0
No coinsurance since entire allowed amount went to deductible.

Member responsibility = 1805.31
Plan paid = 0.00

Check OOPM: 1805.31 < 5500.00, no cap.

Update accumulators:
C deductible: 2500.00 + 1805.31 = 4305.31
C OOPM: 5500.00 + 1805.31 = 7305.31
Family deductible: 5000.00 + 1805.31 = 6805.31
Family OOPM: 19440.53 + 1805.31 = 21245.84

---

**Line 9 — ADJUSTMENT to Claim 6 — 2026-04-11 — A (subscriber)**
- Allowed amount corrected to 277.77

First, unwind Claim 6's original credits:
Original Claim 6: deductible_applied = 0.00, member_responsibility = 60.00

Remove from accumulators:
A deductible: 2116.07 - 0 = 2116.07
A OOPM: 2940.53 - 60.00 = 2880.53
Family deductible: 5000.00 - 0 = 5000.00
Family OOPM: 19440.53 - 60.00 = 19380.53

Now re-adjudicate Claim 6 with allowed = 277.77, urgent care copay = 60.00.

A's deductible: 2116.07. Individual remainder: 383.93
Family deductible: 5000.00 (met). Family remainder: 0.

Deductible applied = min(277.77, min(383.93, 0)) = 0.00

Copay = 60.00
Member responsibility = 60.00
Plan paid = 277.77 - 60.00 = 217.77

Check OOPM: A's OOPM is 2880.53. Room: 5500.00 - 2880.53 = 2619.47. 60.00 < 2619.47, no cap.

Update accumulators:
A deductible: 2116.07 + 0 = 2116.07
A OOPM: 2880.53 + 60.00 = 2940.53
Family deductible: 5000.00
Family OOPM: 19380.53 + 60.00 = 19440.53

So the adjustment didn't change anything for accumulators because deductible_applied was 0 and member_responsibility was 60.00 both times. The plan paid changes from 153.67 to 217.77.

Wait, but Claim 6 was adjusted again at Line 11 with the same values. Let me continue.

---

**Line 10 — Claim 10 — 2026-04-25 — C (child)**
- Ambulatory surgery, out-of-network
- Allowed: 8945.95

C's deductible balance: 4305.31. Out-of-network individual remainder: 5000.00 - 4305.31 = 694.69
C's OOPM: 7305.31. Out-of-network OOPM remainder: 11000.00 - 7305.31 = 3694.69

Deductible applied = min(8945.95, 694.69) = 694.69

After deductible: 8945.95 - 694.69 = 8251.26
Coinsurance (50%): 8251.26 * 0.50 = 4125.63

Member responsibility before cap = 694.69 + 4125.63 = 4820.32
Room under OOPM: 3694.69
4820.32 > 3694.69, so cap.

Member responsibility = 3694.69
Deductible applied = 694.69 (fits in room since 694.69 < 3694.69)
Remaining room: 3694.69 - 694.69 = 3000.00
Coinsurance amount = 3000.00
Plan paid = 8945.95 - 3694.69 = 5251.26

Verify: 3694.69 + 5251.26 = 8945.95 ✓

Update accumulators:
C deductible: 4305.31 + 694.69 = 5000.00
C OOPM: 7305.31 + 3694.69 = 11000.00
Family deductible: 6805.31 + 694.69 = 7500.00
Family OOPM: 19440.53 + 3694.69 = 23135.22

C has reached out-of-network OOPM (11000.00) and out-of-network deductible (5000.00).

---

**Line 11 — ADJUSTMENT to Claim 6 — 2026-05-11 — A (subscriber)**
- Allowed amount corrected to 277.77

This is the same correction as Line 9. Let me unwind the current Claim 6 values and re-adjudicate.

Current Claim 6 on books (from Line 9 adjustment): deductible_applied = 0.00, member_responsibility = 60.00

Unwind:
A deductible: 2116.07 - 0 = 2116.07
A OOPM: 2940.53 - 60.00 = 2880.53
Family deductible: 5000.00 - 0 = 5000.00
Family OOPM: 19440.53 - 60.00 = 19380.53

Re-adjudicate with allowed = 277.77, urgent care copay = 60.00.

Same calculation as before:
Deductible applied = 0.00
Copay = 60.00
Member responsibility = 60.00
Plan paid = 277.77 - 60.00 = 217.77

Update accumulators:
A deductible: 2116.07 + 0 = 2116.07
A OOPM: 2880.53 + 60.00 = 2940.53
Family deductible: 5000.00
Family OOPM: 19380.53 + 60.00 = 19440.53

So Claim 6 final values:
- deductible_applied: 0.00
- copay_amount: 60.00
- coinsurance_amount: 0.00
- member_responsibility: 60.00
- plan_paid: 217.77

---

**Line 12 — Claim 12 — 2026-05-23 — C (child)**
- Inpatient admission, in-network
- Allowed: 23123.73

C's OOPM is 11000.00. In-network OOPM threshold is 5500.00. Since 11000.00 >= 5500.00, C has met in-network OOPM too.

Plan pays 100%.
Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00
Coinsurance = 0.00
Plan paid = 23123.73

Update accumulators:
C deductible: 5000.00 (no change)
C OOPM: 11000.00 (no change)
Family deductible: 7500.00 (no change)
Family OOPM: 19440.53 (no change)

---

**Line 13 — Claim 13 — 2026-05-30 — A (subscriber)**
- Outpatient procedure, in-network
- Allowed: 5196.38

A's deductible: 2116.07. Individual remainder: 2500.00 - 2116.07 = 383.93
Family deductible: 5000.00 (met). Family remainder: 0.

Deductible applied = min(5196.38, min(383.93, 0)) = 0.00

After deductible: 5196.38
Coinsurance (30%): 5196.38 * 0.30 = 1558.914 → 1558.91

Member responsibility = 0 + 1558.91 = 1558.91
Plan paid = 5196.38 - 1558.91 = 3637.47

Verify: 1558.91 + 3637.47 = 5196.38 ✓

Check OOPM: A's OOPM before: 2940.53
Room: 5500.00 - 2940.53 = 2559.47
1558.91 < 2559.47, no cap.

Update accumulators:
A deductible: 2116.07 (no change)
A OOPM: 2940.53 + 1558.91 = 4499.44
Family deductible: 5000.00 (no change)
Family OOPM: 19440.53 + 1558.91 = 20999.44

---

**Line 14 — Claim 14 — 2026-06-13 — B (spouse)**
- Inpatient admission with surgery, in-network
- Allowed: 21835.03

B's OOPM is 11000.00. In-network OOPM threshold is 5500.00. Since 11000.00 >= 5500.00, B has met in-network OOPM.

Plan pays 100%.
Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00
Coinsurance = 0.00
Plan paid = 21835.03

Update accumulators:
B deductible: 5000.00 (no change)
B OOPM: 11000.00 (no change)
Family deductible: 7500.00 (no change)
Family OOPM: 20999.44 (no change)

---

**Line 15 — Claim 15 — 2026-06-17 — A (subscriber)**
- Routine immunisation, out-of-network
- Allowed: 839.74

This is a preventive service. "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount and are not subject to the deductible, coinsurance, or a copay."

But this is OUT-OF-NETWORK. "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 out-of-network deductible and coinsurance.

A's deductible balance: 2116.07. Out-of-network individual remainder: 5000.00 - 2116.07 = 2883.93
A's OOPM: 4499.44. Out-of-network OOPM threshold: 11000.00. Room: 11000.00 - 4499.44 = 6500.56

Deductible applied = min(839.74, 2883.93) = 839.74

After deductible: 839.74 - 839.74 = 0
No coinsurance.

Member responsibility = 839.74
Plan paid = 0.00

Check OOPM: 839.74 < 6500.56, no cap.

Update accumulators:
A deductible: 2116.07 + 839.74 = 2955.81
A OOPM: 4499.44 + 839.74 = 5339.18
Family deductible: 7500.00 + 839.74 = 8339.74
Family OOPM: 20999.44 + 839.74 = 21839.18

---

**Line 16 — Claim 16 — 2026-06-26 — C (child)**
- Inpatient admission with surgery, in-network
- Allowed: 10575.83

C's OOPM is 11000.00. In-network OOPM threshold is 5500.00. Met.

Plan pays 100%.
Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00
Coinsurance = 0.00
Plan paid = 10575.83

Update accumulators: no change.

---

**Line 17 — Claim 17 — 2026-07-03 — B (spouse)**
- Generic retail pharmacy fill, in-network
- Allowed: 38.18
- Generic retail pharmacy copay: 10.00

B's OOPM is 11000.00. In-network OOPM threshold is 5500.00. Met.

Plan pays 100%.
Member responsibility = 0.00
Deductible applied = 0.00
Copay = 0.00
Coinsurance = 0.00
Plan paid = 38.18

Update accumulators: no change.

---

Now let me compile the final results.

**Claim 6 (final, after Line 11 adjustment):**
- deductible_applied: 0.00
- copay_amount: 60.00
- coinsurance_amount: 0.00
- member_responsibility: 60.00
- plan_paid: 21